201
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Canter D, Guzzo TJ, Resnick MJ, Brucker B, Vira M, Chen Z, Tomaszewski J, VanArsdalen K, Wein AJ, Malkowicz SB. Hydronephrosis Is an Independent Predictor of Poor Clinical Outcome in Patients Treated for Muscle-Invasive Transitional Cell Carcinoma With Radical Cystectomy. Urology 2008; 72:379-83. [DOI: 10.1016/j.urology.2008.03.053] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2007] [Revised: 03/10/2008] [Accepted: 03/11/2008] [Indexed: 12/27/2022]
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202
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Matsumoto K, Satoh T, Irie A, Ishii J, Kuwao S, Iwamura M, Baba S. Loss Expression of Uroplakin III is Associated with Clinicopathologic Features of Aggressive Bladder Cancer. Urology 2008; 72:444-9. [PMID: 18313120 DOI: 10.1016/j.urology.2007.11.128] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2007] [Revised: 11/12/2007] [Accepted: 11/26/2007] [Indexed: 11/16/2022]
Affiliation(s)
- Kazumasa Matsumoto
- Department of Urology, School of Medicine Kitasato University, Tokyo, Japan.
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203
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Abstract
Most cancerous lesions metastasize through the lymphatic system and the status of regional lymph nodes is the most important indicator of a patient's prognosis. The extent of lymph node involvement with cancer is also an important parameter used for determining treatment options. Although the importance of the lymphatic system for metastasis has been well recognized, traditionally, the lymphatic vessels have not been considered actively involved in the metastatic process. Recent evidence, however, indicates that the activation of the lymphatic system is an important factor in tumor progression to metastasis. Tumor lymphangiogenesis has been associated with increased propensity for metastasis, and lymphatic vessel density has emerged as another promising prognostic indicator. More recently, lymphangiogenesis in the sentinel lymph nodes has been shown to contribute to malignant progression. In addition to its role as a transport system for tumor cells, the lymphatic system may also be more actively involved in metastases by directly facilitating tumor cell recruitment into the lymphatic vessels. This review highlights recent advances in our understanding of the mechanisms by which lymphatic vessels participate in metastasis.
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Affiliation(s)
- Suvendu Das
- Department of Oncological Sciences, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1130, New York, NY 10029, USA
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204
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Herrmann E, Stöter E, van Ophoven A, Bierer S, Bolenz C, Hertle L, Wülfing C. The prognostic impact of pelvic lymph node metastasis and lymphovascular invasion on bladder cancer. Int J Urol 2008; 15:607-11. [PMID: 18462352 DOI: 10.1111/j.1442-2042.2008.02059.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Edwin Herrmann
- Department of Urology, University of Münster, Münster, Germany.
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205
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Walz J, Shariat SF, Suardi N, Perrotte P, Lotan Y, Palapattu GS, Gupta A, Bastian PJ, Rogers CG, Vazina A, Amiel GE, Sagalowsky AI, Schoenberg M, Lerner SP, Karakiewicz PI. Adjuvant chemotherapy for bladder cancer does not alter cancer-specific survival after cystectomy in a matched case-control study. BJU Int 2008; 101:1356-61. [PMID: 18454792 DOI: 10.1111/j.1464-410x.2008.07524.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effect of adjuvant chemotherapy (ACHT; methotrexate, vinblastine, adriamycin and cisplatin, MVAC, or gemcitabine/cisplatin, GC) on the rate of cancer-specific survival and overall survival, as the benefit of ACHT after radical cystectomy (RC) for bladder cancer is controversial. PATIENTS AND METHODS Within a study group of 958 patients treated with RC between 1984 and 2003, we identified 274 (29.0%) with a high risk of progression due to pT3 or pT4 and/or pN1-3 stages. Of these, 129 (46.6%) received ACHT (MVAC in 103, GC in 26). These patients were then matched with the remaining patients who were unexposed to ACHT. Exact matches were made for pT stage, tumour grade, pN stage and lymphovascular invasion. Age (+/-5 years) and year of surgery (+/-5 years) were calliper-matched. Matching resulted in 62 patients treated with RC/ACHT and 65 treated with RC alone. Kaplan-Meier, life-table and Cox regression analyses were used to assess cancer-specific and overall survival. RESULTS There was no statistically significant difference in cancer-specific survival probabilities at 5 years after RC between the two groups (relative risk 1.2; P = 0.5). There was also no difference in overall survival at 5 years (1.1; P = 0.7). In multivariable analyses the delivery of adjuvant chemotherapy was not an independent predictor for survival endpoints (P = 0.3 for cancer-specific and 0.3 for overall survival). CONCLUSIONS This matched case-control analysis showed that either MVAC or GC chemotherapy had no effect on cancer-specific or overall survival after RC in high-risk patients. Further randomized long-term studies are necessary to confirm these results.
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Affiliation(s)
- Jochen Walz
- Cancer Prgonosis and Health Outcomes Unit, University of Montreal, Montreal, Quebec, Canada
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206
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Akao J, Matsuyama H, Yamamoto Y, Hara T, Kawai Y, Sakano S, Ohmi C, Gondo T, Naito K. Clinical significance of lymphovascular invasion in upper urinary tract urothelial cancer. BJU Int 2008; 102:572-5. [PMID: 18485032 DOI: 10.1111/j.1464-410x.2008.07749.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To clarify the significance of lymphovascular invasion (LVI) in patients with pT3N0M0 upper urinary tract (UUT) urothelial carcinoma (UC) relative to prognosis in terms of disease-specific survival, as LVI, which implies both blood vessel and lymph vessel involvement, is reportedly a poor prognostic factor in patients with UUT-UC. PATIENTS AND METHODS The clinical records of 90 patients who had surgery for UUT-UC were reviewed retrospectively. The median patient age was 71 years and the median follow-up was 42 months. The prognostic significances of LVI (with vs without), T stage (< 1 vs 2-4), grade (1-2 vs 3), N stage (0 vs 1-2), age (< or = 70 vs > 70 years), gender and tumour location (renal pelvis vs ureter) for survival time were evaluated. RESULTS LVI of UUT-UC was found in 34 patients (37.8%). There were significantly higher frequencies of LVI with advancing stage and lymph node metastasis. Kaplan-Meier analysis showed that LVI was strongly associated with disease-specific survival in all patients (P < 0.001) and in patients with pT3N0M0 disease (P < 0.001). Univariate analyses showed that LVI, T stage, N stage and tumour grade were significantly related to disease-specific survival in all patients (P < 0.001, < 0.001, 0.003 and 0.007, respectively). Multivariate analysis using Cox proportional hazards model showed that LVI was the only prognostic factor with independent significance for disease-specific survival (P < 0.001). CONCLUSIONS LVI appears to be an important and independent prognostic factor for UUT-UC in patients treated by nephroureterectomy. Our data suggest that the LVI status might be a predictive marker for disease-specific survival in patients with T3N0M0 UTT-UC.
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Affiliation(s)
- Jumpei Akao
- Department of Urology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
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207
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Margulis V, Lotan Y, Montorsi F, Shariat SF. Predicting survival after radical cystectomy for bladder cancer. BJU Int 2008; 102:15-22. [PMID: 18325050 DOI: 10.1111/j.1464-410x.2008.07594.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Accurate prediction is essential for patient counselling, appropriate selection of treatments and determination of eligibility for clinical trials. In this review we assess the available determinants of oncological outcome after radical cystectomy (RC) for transitional cell carcinoma of the urinary bladder. We reviewed previous publications to provide guidelines in terms of criteria, limitations and clinical value of available tools for predicting patient outcome after RC. Our findings suggest that while individual surgical, patient and pathological features provide useful estimates of survival outcome, the inherent heterogeneity of tumour biology and patient characteristics leads to significant variation in outcome. By incorporating all relevant continuous predictive factors for individual patients, integrative predictive models, such as nomograms or artificial neural networks, provide more accurate predictions and generally surpass clinical experts at predicting outcomes. Nonetheless, there is a clear need for the development and validation of molecular biomarkers and their incorporation into multivariable predictive tools. Significant progress has been made in identifying important molecular markers of disease and the development of multifactorial tools for predicting the outcome after RC.
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Affiliation(s)
- Vitaly Margulis
- Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX 77030, USA.
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208
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Abstract
Tumour angiogenesis is a fast growing domain in tumour biology. Many growth factors and mechanisms have been unravelled. For almost 30 years, the sprouting of new vessels out of existing ones was considered as an exclusive way of tumour vascularisation. However, over the last years several additional mechanisms have been identified. With the discovery of the contribution of intussusceptive angiogenesis, recruitment of endothelial progenitor cells, vessel co-option, vasculogenic mimicry and lymphangiogenesis to tumour growth, anti-tumour targeting strategies will be more complex than initially thought. This review highlights these processes and intervention as a potential application in cancer therapy. It is concluded that future anti-vascular therapies might be most beneficial when based on multimodal anti-angiogenic, anti-vasculogenic mimicry and anti-lymphangiogenic strategies.
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Affiliation(s)
- Femke Hillen
- Angiogenesis Laboratory, Research Institute for Growth and Development (GROW), Department of Pathology, Maastricht University & University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Arjan W. Griffioen
- Angiogenesis Laboratory, Research Institute for Growth and Development (GROW), Department of Pathology, Maastricht University & University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
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209
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Colombo R. Re: Lymphatic Invasion is a Prognostic Factor for Bladder Cancer Treated with Radical Cystectomy. Eur Urol 2007; 52:1797-8. [DOI: 10.1016/j.eururo.2007.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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210
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Saito K, Kawakami S, Fujii Y, Sakura M, Masuda H, Kihara K. Lymphovascular Invasion is Independently Associated With Poor Prognosis in Patients With Localized Upper Urinary Tract Urothelial Carcinoma Treated Surgically. J Urol 2007; 178:2291-6; discussion 2296. [DOI: 10.1016/j.juro.2007.08.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Indexed: 11/25/2022]
Affiliation(s)
- Kazutaka Saito
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoru Kawakami
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mizuaki Sakura
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hitoshi Masuda
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazunori Kihara
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
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211
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Lotan Y, Svatek RS. Cost-effectiveness of bladder cancer screening. Expert Rev Pharmacoecon Outcomes Res 2007; 7:627-32. [PMID: 20528324 DOI: 10.1586/14737167.7.6.627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bladder cancer is the fourth most common cancer in men and 25% of patients present with advanced disease resulting in a poor prognosis. Urine-based tests, including evaluation for blood in the urine or tumor markers, may allow early detection of cancer with resultant improved survival. Studies need to be performed to evaluate the feasibility and cost-effectiveness of screening high-risk populations such as smokers.
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Affiliation(s)
- Yair Lotan
- Assistant Professor of Urology, Department of Urology, The University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110, USA.
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212
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Lotan Y, Svatek RS, Malats N. Screening for bladder cancer: a perspective. World J Urol 2007; 26:13-8. [PMID: 18030473 DOI: 10.1007/s00345-007-0223-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2007] [Accepted: 10/14/2007] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yair Lotan
- Department of Urology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110, USA.
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213
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Bastian PJ, Hutterer GC, Shariat SF, Rogers CG, Palapattu GS, Lotan Y, Vazina A, Amiel GE, Gupta A, Sagalowsky AI, Lerner SP, Schoenberg MP, Karakiewicz PI. Macroscopic, but not microscopic, perivesical fat invasion at radical cystectomy is an adverse predictor of recurrence and survival. BJU Int 2007; 101:450-4. [PMID: 17850359 DOI: 10.1111/j.1464-410x.2007.07213.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine whether the presence of microscopic (pT3a) or macroscopic (pT3b) disease worsens the prognosis relative to pT2 disease at radical cystectomy, as the prognostic significance of pT3a vs pT3b perivesical fat invasion (pT3) is controversial. PATIENTS AND METHODS In all, 242 patients with pT3 disease (pT3a in 88, pT3b in 121) had radical cystectomy and bilateral pelvic lymphadenectomy for transitional cell carcinoma of the urinary bladder; they were compared with 172 who had organ-confined muscle-invasive disease (pT2). For the analyses we used univariable and multivariable Cox regression models of recurrence and cancer-specific survival, adjusted for age, tumour grade, lymphovascular invasion and the presence of lymph node metastases. RESULTS In multivariable analyses, microscopic perivesical fat extension (pT3a) was not associated with higher recurrence (P = 0.3) or the mortality rate (P = 0.06) vs pT2 disease. Conversely, the presence of deep perivesical fat extension (pT3b) was associated with 1.8 times the rate of recurrence (P = 0.002) and with twice the rate of death (P = 0.001) vs pT2 disease. CONCLUSION These findings imply that a detailed assessment of the cystectomy specimen for the presence of microscopic perivesical fat invasion might not be necessary, as the presence of pT3a disease has no strong effect on recurrence or mortality. Moreover, patients with pT3a disease might not require more aggressive therapy than their counterparts with pT2 disease. However, further validation of our data is required.
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Affiliation(s)
- Patrick J Bastian
- The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, MD, USA
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214
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Lotan Y. Editorial comment on: Prognostic implications of lymphangiogenesis in muscle-invasive transitional cell carcinoma of the bladder. Eur Urol 2007; 53:579-80. [PMID: 17804152 DOI: 10.1016/j.eururo.2007.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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215
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Joudi FN. Editorial comment on: Prognostic implications of lymphangiogenesis in muscle-invasive transitional cell carcinoma of the bladder. Eur Urol 2007; 53:579. [PMID: 17804153 DOI: 10.1016/j.eururo.2007.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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216
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Türkölmez K, Tokgöz H, Reşorlu B, Köse K, Bedük Y. Muscle-Invasive Bladder Cancer: Predictive Factors and Prognostic Difference Between Primary and Progressive Tumors. Urology 2007; 70:477-81. [PMID: 17905100 DOI: 10.1016/j.urology.2007.05.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Revised: 03/14/2007] [Accepted: 05/14/2007] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To establish whether a difference in the clinical outcomes of patients with progressive and primary muscle-invasive bladder cancer exists. METHODS The records of patients who had undergone radical cystectomy for bladder urothelial carcinoma from 1990 to 2005 were reviewed. According to our inclusion criteria, 109 patients with primary muscle-invasive tumor (group 1) and 45 patients with progressive tumors were selected (group 2). The correlation of clinical and pathologic variables with survival was investigated using the Cox proportional hazards test. The Kaplan-Meier method was used to estimate progression rates. Multivariate analysis was performed using the Cox regression survival method to investigate possible predictive factors. RESULTS The 2, 3, and 5-year cancer-specific survival rate was 72%, 61%, and 43% for patients with progressive tumor and 75%, 62%, and 54% for patients with primary tumor, respectively (P >0.05). For lymph node-negative tumors (pN0), the corresponding rates were 77%, 64%, and 56% in group 1 and 73%, 60%, and 39% in group 2 (P >0.05). On multivariate analysis, lymphovascular invasion and pT stage of the primary tumor remained significant independent prognostic factors for cancer-specific survival. The detection of local and/or distant metastasis during follow-up significantly shortened the cancer-specific survival of patients with muscle-invasive bladder cancer. CONCLUSIONS The results of our study have shown that patients with progressive muscle-invasive urothelial tumors do not have a worse prognosis than do those with primary tumors. During the early postoperative years, even patients with progressive tumors had better disease-specific survival rates. For both groups, pT stage and lymphovascular invasion seemed to be independent predictors of decreased cancer-specific survival.
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Affiliation(s)
- Kadir Türkölmez
- Department of Urology, Ankara University School of Medicine, Ankara, Turkey
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217
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Huang HY, Shariat SF, Sun TT, Lepor H, Shapiro E, Hsieh JT, Ashfaq R, Lotan Y, Wu XR. Persistent uroplakin expression in advanced urothelial carcinomas: implications in urothelial tumor progression and clinical outcome. Hum Pathol 2007; 38:1703-13. [PMID: 17707461 PMCID: PMC2778836 DOI: 10.1016/j.humpath.2007.04.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 04/02/2007] [Accepted: 04/03/2007] [Indexed: 10/22/2022]
Abstract
As the terminal differentiation products of human urothelium, uroplakins (UPs) would be expected to diminish during urothelial tumorigenesis. Surprisingly, recent studies found UPs to be retained even by well-advanced urothelial carcinomas, suggesting that the loss of UPs does not strictly parallel urothelial transformation. Little is known, however, about whether the status of UPs is associated with a particular pathologic parameter, the tumor's biological behavior, or patient outcome. Here we assessed UP expression by immunohistochemistry on tissue arrays from 285 patients with bladder urothelial carcinomas or nontumor conditions. UPs were expressed in all 9 normal urothelial specimens, 63 of 74 (85%) patients with non-muscle-invasive urothelial carcinomas on transurethral resection, 104 of 202 (51.5%) patients who underwent radical cystectomy for advanced urothelial carcinomas, and 33 of 50 (66%) lymph node metastases. Normally associated with urothelial apical surface, UPs were localized aberrantly in tumors, including microluminal, basal-laminal, cytoplasmic, or uniform patterns. In non-muscle-invasive diseases, there was no association between UP expression and disease recurrence, progression, or mortality. In contrast, in invasive diseases, absent UP expression was significantly associated with advanced pathologic stage, lymph node metastases, disease recurrence, and bladder cancer-specific mortality (P = .042, P = .035, P = .023, and P = .022, respectively) in univariate analyses. Furthermore, UP status was independent of key cell-cycle regulators, including p53, pRb, p27, and cyclin D1, thus excluding a functional link between these 2 groups of proteins. Our data demonstrate for the first time that persistent UP expression is associated with a favorable clinical outcome and that UPs may be used as adjunct markers for predicting the prognoses of patients with invasive and metastatic bladder carcinomas. Our results also suggest that UP-positive and -negative carcinomas have different clonal origins or may be derived from different cancer stem cells.
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Affiliation(s)
- Hong-Ying Huang
- Department of Urology, NYU Cancer Institute, New York University School of Medicine, New York, NY 10016, USA
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218
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Park J, Park S, Song C, Doo C, Cho YM, Ahn H, Kim CS. Effectiveness of Adjuvant Chemotherapy in Transitional Cell Carcinoma of the Urinary Bladder with Lymph Node Involvement and/or Lymphovascular Invasion Treated by Radical Cystectomy. Urology 2007; 70:257-62. [PMID: 17826485 DOI: 10.1016/j.urology.2007.03.054] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Revised: 02/26/2007] [Accepted: 03/16/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To assess the effect of adjuvant chemotherapy on the postoperative survival of patients with transitional cell carcinoma of the bladder and lymph node involvement and/or lymphovascular invasion (LVI). METHODS We retrospectively analyzed the data from 260 patients who had undergone radical cystectomy for transitional cell carcinoma of the bladder. Of these 260 patients, 85 (33%) had nodal involvement and 125 (48%) had LVI. Chemotherapy, consisting of three to six cycles of either methotrexate, vinblastine, cisplatin, and doxorubicin or gemcitabine and cisplatin, was administered to 17 (26.6%) of 64 patients with pT3-4N0 disease and 43 (50.6%) of 85 patients with node-positive disease. We determined the factors influencing cancer-specific survival and the effect of chemotherapy according to pathologic stage, LVI, and nodal status. The mean follow-up was 43.8 months (range, 3 to 180; median 33.6). RESULTS The overall 5-year cancer-specific survival rate was 65.6%. When we considered nodal involvement and LVI simultaneously, the 5-year survival rate was 92.2% for the node and LVI-negative patients, 60.7% for the node-negative but LVI-positive patients, and 32.5% for the node-positive patients. Chemotherapy was beneficial in the node-positive patients (5-year survival rate of 37.4% versus 26.9%; P = 0.0035) but not beneficial in the node-negative patients, regardless of LVI status. When subclassifying node-positive patients with regard to N stage or LVI status, the effect of chemotherapy was limited to those with Stage N2 (P = 0.002) or LVI-positive status (P = 0.001). CONCLUSIONS Adjuvant chemotherapy would be beneficial in patients with node-positive transitional cell carcinoma, especially those with a high nodal disease burden (Stage N2) or LVI, after radical cystectomy.
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Affiliation(s)
- Jinsung Park
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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219
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Shariat SF, Ashfaq R, Karakiewicz PI, Saeedi O, Sagalowsky AI, Lotan Y. Survivin expression is associated with bladder cancer presence, stage, progression, and mortality. Cancer 2007; 109:1106-13. [PMID: 17311310 DOI: 10.1002/cncr.22521] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The purpose was to compare the differential expression of Survivin in normal bladder tissue, bladder transitional cell carcinoma (TCC) of different stages, and to determine whether expression of Survivin is associated with TCC clinical outcomes. METHODS Immunohistochemical staining for Survivin was carried out on archival bladder specimens from 9 normal controls and 222 consecutive patients who underwent radical cystectomy and bilateral lymphadenectomy. Lymph node tissue involved with TCC from 50 of the 222 cystectomy patients was also evaluated. RESULTS Survivin was expressed in none of the normal bladder specimens, 64% of the cystectomy specimens, and 94% of the malignant lymph nodes. Multivariable analyses performed in the cystectomy patients revealed that Survivin expression was associated with disease recurrence (P = .040), disease-specific mortality (P = .037), and all-cause mortality (P = .044). CONCLUSIONS The findings of the study provide a rationale for further evaluation of Survivin and its downstream signaling pathways in bladder cancer and raise the potential for Survivin-targeted therapy for bladder cancer.
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Affiliation(s)
- Shahrokh F Shariat
- Department of Urology, University of Texas Southwestern Medical Center at Dallas, Texas 75390-9110, USA.
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220
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Horikawa Y, Kumazawa T, Narita S, Inoue T, Yuasa T, Matsuura S, Nanjo H, Satoh S, Tsuchiya N, Habuchi T. Lymphatic invasion is a prognostic factor for bladder cancer treated with radical cystectomy. Int J Clin Oncol 2007; 12:131-6. [PMID: 17443281 DOI: 10.1007/s10147-006-0637-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2006] [Accepted: 11/07/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND We aimed to elucidate the significance of pathological prognostic factors in patients with bladder cancer treated with radical cystectomy and pelvic lymphadenectomy focusing on the association between lymphatic invasion and disease recurrence. METHODS Ninety-one patients with ladder cancer who had undergone radical cystectomy were examined retrospectively. Clinicopathological findings and clinical outcomes were analyzed. Patients who received palliative cystectomy or neoadjuvant chemotherapy and patients who did not receive lymphadenectomy owing to a poor general condition or far advanced local disease status were excluded. RESULTS Lymphatic invasion and lymph node involvement were present in 45.1% and 23.1% of patients, respectively. Multivariate analyses, using the Cox proportional hazards model, indicated that lymphatic invasion (hazard ratio [HR], 5.30; P = 0.007) and lymph node involvement (HR = 3.05; P = 0.016) were independent prognostic factors for disease-specific survival. Of the 91 patients, 29 (31.9%) had recurrent disease during the follow-up period. The rate of recurrence in patients with lymphatic invasion and without lymph node involvement was 50% (11/22), which was not significantly different from that in patients with both lymphatic invasion and lymph node involvement (73.7%; 14/19; P = 0.121), indicating a high risk of disease recurrence in patients with bladder cancer with lymphatic invasion even in the absence of the lymph node involvement. CONCLUSION In patients with bladder cancer treated with radical cystectomy, lymphatic invasion is an independent prognostic factor for disease-specific and disease-free survival. Patients with lymphatic invasion have a high risk of disease recurrence after radical cystectomy even in the absence of lymph node involvement.
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Affiliation(s)
- Yohei Horikawa
- Department of Urology, Akita University School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan
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221
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Kassouf W, Spiess PE, Brown GA, Munsell MF, Grossman HB, Siefker-Radtke A, Dinney CP, Kamat AM. P0 stage at radical cystectomy for bladder cancer is associated with improved outcome independent of traditional clinical risk factors. Eur Urol 2007; 52:769-74. [PMID: 17434254 PMCID: PMC2691552 DOI: 10.1016/j.eururo.2007.03.086] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Accepted: 03/16/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Final pathologic specimen free of detectable disease (P0) is not uncommon in patients undergoing cystectomy for bladder cancer, especially in the era of neoadjuvant chemotherapy. To improve our understanding of its significance in a contemporary series, we performed an outcomes analysis of this cohort of patients. METHODS Over the last 15 yr, 1104 patients with bladder cancer underwent radical cystectomy at our institution. Of these, 120 (11%) were pT0N0M0 (P0) in the surgical specimen and form the basis of this report. Survival data were estimated by method of Kaplan and Meier, with Cox proportional hazards regression model used to evaluate associations between survival and variables studied. RESULTS Clinical stages were cT1, 21 patients; cT2, 65; cT3b, 20; cT4a, 11; and cT4b, 3. The 5-yr estimates of overall (OS), disease-specific (DSS), and recurrence-free survival (RFS) rates were 84%, 88%, and 84%, respectively. With mean follow-up of 43 mo, 11 patients developed recurrences, 9 of whom died of disease. Median time to recurrence was 7.7 mo (range: 2.2-45 mo). On multivariate analysis, presence of lymphovascular invasion and concomitant carcinoma in situ on the transurethral resection of the bladder tumor specimen were the only significant prognostic factors associated with shorter OS (p = 0.04) and RFS (p = 0.049), respectively. Notably, patients who received preoperative chemotherapy (n = 77) had 5-yr survival rates similar to those of patients who did not. CONCLUSION Although patients who are P0 at cystectomy have a good prognosis, not all can be considered cured. The favorable prognosis conferred by a P0 state appears to be independent of whether this is achieved by neoadjuvant chemotherapy or by thorough transurethral resection before cystectomy.
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Affiliation(s)
- Wassim Kassouf
- Division of Urology, McGill University Health Center, Montreal, Canada
| | - Philippe E. Spiess
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Gordon A. Brown
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Mark F. Munsell
- Department of Biostatistics and Applied Mathematics, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - H. Barton Grossman
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Arlene Siefker-Radtke
- Department of Genitourinary Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Colin P.N. Dinney
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
- Department of Cancer Biology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Ashish M. Kamat
- Department of Urology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
- Department of Cancer Biology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
- Correspondence: Ashish M. Kamat, Department of Urology, Unit 1373, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA, Tel: 713-792-3250, Fax: 713-794-4824, E-mail:
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Margulis V, Shariat SF, Ashfaq R, Thompson M, Sagalowsky AI, Hsieh JT, Lotan Y. Expression of Cyclooxygenase-2 in Normal Urothelium, and Superficial and Advanced Transitional Cell Carcinoma of Bladder. J Urol 2007; 177:1163-8. [PMID: 17296438 DOI: 10.1016/j.juro.2006.10.033] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Indexed: 12/21/2022]
Abstract
PURPOSE We compared the differential expression of cyclooxygenase-2 in normal bladder tissue, primary bladder transitional cell carcinoma and transitional cell carcinoma metastases to lymph nodes, and determined whether cyclooxygenase-2 expression is associated with molecular alterations commonly found in bladder transitional cell carcinoma and clinical outcomes after radical cystectomy. MATERIALS AND METHODS Immunohistochemical staining for cyclooxygenase-2, survivin (Novus Biologicals, Littleton, Colorado), p21, p27, pRB, p53, MIB-1, Bax, Bcl-2, cyclin D(1) (Dakotrade mark), cyclin E (Oncogene, Cambridge, Massachusetts) and caspase-3 (Cell Signaling, Beverley, Massachusetts) was performed on archival bladder specimens from 9 subjects who underwent cystectomy for benign causes, 21 patients who underwent transurethral resection and 157 consecutive patients after radical cystectomy, and on 41 positive lymph nodes. RESULTS Cyclooxygenase-2 was expressed in none of the 9 normal bladder specimens (0%), 52% of transurethral resection specimens, 62% of cystectomy specimens and 80% of lymph nodes involved with transitional cell carcinoma. Cyclooxygenase-2 expression was associated with higher pathological stage, lymphovascular invasion and metastases to lymph nodes (p=0.001, 0.045 and 0.002, respectively). Cyclooxygenase-2 expression was associated with altered expression of p53 (p=0.039), pRB (p=0.025), cyclin D1 (p=0.034) and caspase-3 (p=0.014). On univariate analysis cyclooxygenase-2 expression was associated with an increased risk of disease recurrence and bladder cancer specific mortality (p=0.0189 and 0.0472, respectively). However, on multivariate analysis only pathological stage and metastases to lymph nodes were associated with disease recurrence (p<0.001 and <0.001) and survival (p<0.001 and 0.015, respectively). CONCLUSIONS Cyclooxygenase-2 is not expressed in normal bladder urothelium. Cyclooxygenase-2 over expression is associated with pathological and molecular features of biologically aggressive disease, suggesting a role for cyclooxygenase-2 in bladder cancer development and invasion.
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Affiliation(s)
- Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9110, USA
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223
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Thalmann GN. Prognostic Markers for Bladder Cancer – Are We There Yet? Eur Urol 2007; 51:591-2. [PMID: 17174022 DOI: 10.1016/j.eururo.2006.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2006] [Accepted: 12/04/2006] [Indexed: 10/23/2022]
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Abstract
PURPOSE OF REVIEW Lymphovascular invasion has been correlated with the metastatic ability of the cancer. It has been studied in urological tumours at every location, but it has only been included as a prognostic factor in the TNM (tumour, lymph nodes and metastasis) classification of germ cell testicular tumours. The purpose of this evaluation is to look into the predictive value of lymphovascular invasion in locally advanced bladder cancer. RECENT FINDINGS Studies carried out in patients who underwent cystectomy report a lymphovascular invasion incidence of 30-50% of the cases. All of them agree that there is a correlation between the presence of lymphovascular invasion and disease evolution, but some authors consider that only blood vessel invasion is a statistically significant independent prognostic factor, and others find that this happens only in lymph node-negative cases. SUMMARY All papers stress the prognostic value of lymphovascular invasion, most of them as an independent factor, but there are still some doubts as to its use in clinical decision making, owing to the poor diagnosis reproducibility. This is why it would be necessary to reach a consensus on strict diagnostic criteria as soon as possible to be able to incorporate this prognostic factor in clinical practice.
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Affiliation(s)
- Ferran Algaba
- Section of Pathology, Fundació Puigvert, Department of Morphology, Medicine School, Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
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225
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Ferguson JL, Smart JM, Geldart TR, Mead GM, Tung KT. Bladder carcinoma recurrence post-cystectomy simulating rectal carcinoma. Clin Radiol 2007; 62:177-80. [PMID: 17207702 DOI: 10.1016/j.crad.2006.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Revised: 08/31/2006] [Accepted: 09/10/2006] [Indexed: 11/28/2022]
Affiliation(s)
- J L Ferguson
- Department of Radiology, Southampton University Hospitals NHS Trust, Hampshire, UK
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Van der Auwera I, Cao Y, Tille JC, Pepper MS, Jackson DG, Fox SB, Harris AL, Dirix LY, Vermeulen PB. First international consensus on the methodology of lymphangiogenesis quantification in solid human tumours. Br J Cancer 2006; 95:1611-25. [PMID: 17117184 PMCID: PMC2360768 DOI: 10.1038/sj.bjc.6603445] [Citation(s) in RCA: 156] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Revised: 09/18/2006] [Accepted: 09/26/2006] [Indexed: 02/07/2023] Open
Abstract
The lymphatic system is the primary pathway of metastasis for most human cancers. Recent research efforts in studying lymphangiogenesis have suggested the existence of a relationship between lymphatic vessel density and patient survival. However, current methodology of lymphangiogenesis quantification is still characterised by high intra- and interobserver variability. For the amount of lymphatic vessels in a tumour to be a clinically useful parameter, a reliable quantification technique needs to be developed. With this consensus report, we therefore would like to initiate discussion on the standardisation of the immunohistochemical method for lymphangiogenesis assessment.
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Affiliation(s)
- I Van der Auwera
- Translational Cancer Research Group Antwerp, Laboratory of Pathology, University of Antwerp/University Hospital Antwerp, Edegem 2650, Belgium; Oncology Centre, General Hospital Sint-Augustinus, Wilrijk 2610, Belgium
| | - Y Cao
- Laboratory of Angiogenesis Research, Microbiology and Tumor Biology Center, Karolinska Institutet, Stockholm 171 77, Sweden
| | - J C Tille
- Department of Microbiology, Laboratory of Angiogenesis Research, Tumor and Cell Biology, Karolinska Institutet, Stockholm 171 77, Sweden
| | - M S Pepper
- NetCare Molecular Medicine Institute, Unitas Hospital and Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria 0002, South Africa
| | - D G Jackson
- Medical Research Council Human Immunology Unit, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford OX3 9DS, UK
| | - S B Fox
- Department of Pathology, Peter MacCallum Cancer Centre, Victoria 8006, Australia
| | - A L Harris
- Cancer Research UK Molecular Oncology Laboratories, Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DS, UK
| | - L Y Dirix
- Translational Cancer Research Group Antwerp, Laboratory of Pathology, University of Antwerp/University Hospital Antwerp, Edegem 2650, Belgium; Oncology Centre, General Hospital Sint-Augustinus, Wilrijk 2610, Belgium
| | - P B Vermeulen
- Translational Cancer Research Group Antwerp, Laboratory of Pathology, University of Antwerp/University Hospital Antwerp, Edegem 2650, Belgium; Oncology Centre, General Hospital Sint-Augustinus, Wilrijk 2610, Belgium
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227
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Shariat SF, Karakiewicz PI, Palapattu GS, Lotan Y, Rogers CG, Amiel GE, Vazina A, Gupta A, Bastian PJ, Sagalowsky AI, Schoenberg MP, Lerner SP. Outcomes of Radical Cystectomy for Transitional Cell Carcinoma of the Bladder: A Contemporary Series From the Bladder Cancer Research Consortium. J Urol 2006; 176:2414-22; discussion 2422. [PMID: 17085118 DOI: 10.1016/j.juro.2006.08.004] [Citation(s) in RCA: 487] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE We present the characteristics and outcomes of a large, contemporary, consecutive series of patients treated with radical cystectomy and pelvic lymphadenectomy for transitional cell carcinoma of the bladder. MATERIALS AND METHODS We developed a multi-institutional database and collected retrospective and prospective data on 888 consecutive patients with bladder transitional cell carcinoma who were treated with radical cystectomy and pelvic lymphadenectomy at 3 academic centers in the United States between 1984 and 2003. RESULTS Of the patients 25% had extravesical tumor extension with negative lymph nodes and 23% had lymph node metastasis. The rate of lymph node involvement increased with advancing pathological stage. Mean recurrence-free and bladder cancer specific survival +/- SE was 58% +/- 2% and 66% +/- 2% at 5 years, respectively. On preoperative multivariate analysis clinical tumor stage and neoadjuvant systemic chemotherapy were associated with cancer recurrence, while more advanced age, clinical tumor stage and preoperative carcinoma in situ were associated with bladder cancer specific mortality. On postoperative multivariate analysis pathological tumor stage, lymph node metastasis, lymphovascular invasion, adjuvant radiotherapy and adjuvant chemotherapy were associated with cancer recurrence, while higher pathological tumor stage, more advanced age, lymph node metastasis, lymphovascular invasion and adjuvant radiotherapy were associated with disease specific survival. Patients with metastasis to regional lymph nodes (pT any N1-3) were at significantly higher risk for bladder cancer recurrence and death than patients with extravesical tumor extension (pT3N0), who in turn were at significantly higher risk than patients with organ confined disease (pT2 N0 or less). CONCLUSIONS The results of this large, contemporary, multi-institutional series show that radical cystectomy and pelvic lymphadenectomy provide durable local control and disease specific survival in patients with localized invasive transitional cell carcinoma.
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Affiliation(s)
- Shahrokh F Shariat
- Department of Urology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Shariat SF, Ashfaq R, Sagalowsky AI, Lotan Y. Correlation of cyclin D1 and E1 expression with bladder cancer presence, invasion, progression, and metastasis. Hum Pathol 2006; 37:1568-76. [PMID: 16949911 DOI: 10.1016/j.humpath.2006.05.017] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2006] [Revised: 05/19/2006] [Accepted: 05/31/2006] [Indexed: 10/24/2022]
Abstract
The objective of this study was to determine the correlation of the expression of cyclin D1 and E1 with the expression of commonly altered cell cycle regulators and bladder cancer presence, staging, and clinical outcomes. We performed immunohistochemical staining for cyclin D1, cyclin E1, p53, p21, p27, and retinoblastoma protein (pRB) on serial cuts from normal urothelium from 9 controls, radical cystectomy specimens from 226 consecutive patients with advanced transitional cell carcinoma, and lymph nodes with metastasis from 50 of the 226 cystectomy patients. Cyclin D1 and E1 immunoreactivity were considered low when samples demonstrated less than 10% and 30% nuclear reactivity, respectively. Normal bladder urothelium from all 9 control patients showed uniformly intense expression of cyclin D1 and E1. Cyclin D1 expression was low in 99 (43.8%) of 226 cystectomy specimens and 25 (50.0%) of 50 metastatic lymph node specimens. Cyclin D1 immunoreactivity was not associated with any pathologic characteristics or clinical outcomes. Cyclin E1 expression was low in 125 (55.3%) of 226 cystectomy specimens and 22 (44.0%) of 50 metastatic lymph node specimens. Low cyclin E1 expression was significantly associated with advanced pathologic stage, lymphovascular invasion, and lymph node metastases. In multivariate analyses, low cyclin E1 expression was significantly associated with bladder cancer-specific mortality (P = .048), but not disease recurrence (P = .056). Low cyclin E1 expression was significantly associated with altered expression of pRB, p27, and cyclin D1. Low cyclin D1 expression was significantly associated with altered expression of pRB, p21, and cyclin E1. Cyclin E1 expression stratifies patients with bladder transitional cell carcinoma into those with more "indolent" behavior and those with features of biologically and clinically aggressive disease.
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Affiliation(s)
- Shahrokh F Shariat
- Department of Urology, University of Texas Southwestern Medical Center at Dallas, TX 75390-9110, USA.
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229
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Shariat SF, Karakiewicz PI, Palapattu GS, Amiel GE, Lotan Y, Rogers CG, Vazina A, Bastian PJ, Gupta A, Sagalowsky AI, Schoenberg M, Lerner SP. Nomograms Provide Improved Accuracy for Predicting Survival after Radical Cystectomy. Clin Cancer Res 2006; 12:6663-76. [PMID: 17121885 DOI: 10.1158/1078-0432.ccr-06-0372] [Citation(s) in RCA: 195] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS To develop multivariate nomograms that determine the probabilities of all-cause and bladder cancer-specific survival after radical cystectomy and to compare their predictive accuracy to that of American Joint Committee on Cancer (AJCC) staging. METHODS We used Cox proportional hazards regression analyses to model variables of 731 consecutive patients treated with radical cystectomy and bilateral pelvic lymphadenectomy for bladder transitional cell carcinoma. Variables included age of patient, gender, pathologic stage (pT), pathologic grade, carcinoma in situ, lymphovascular invasion (LVI), lymph node status (pN), neoadjuvant chemotherapy (NACH), adjuvant chemotherapy (ACH), and adjuvant external beam radiotherapy (AXRT). Two hundred bootstrap resamples were used to reduce overfit bias and for internal validation. RESULTS During a mean follow-up of 36.4 months, 290 of 731 (39.7%) patients died; 196 of 290 patients (67.6%) died of bladder cancer. Actuarial all-cause survival estimates were 56.3% [95% confidence interval (95% CI), 51.8-60.6%] and 42.9% (95% CI, 37.3-48.4%) at 5 and 8 years after cystectomy, respectively. Actuarial cancer-specific survival estimates were 67.3% (62.9-71.3%) and 58.7% (52.7-64.2%) at 5 and 8 years, respectively. The accuracy of a nomogram for prediction of all-cause survival (0.732) that included patient age, pT, pN, LVI, NACH, ACH, and AXRT was significantly superior (P=0.001) to that of AJCC staging-based risk grouping (0.615). Similarly, the accuracy of a nomogram for prediction of cancer-specific survival that included pT, pN, LVI, NACH, and AXRT (0.791) was significantly superior (P=0.001) to that of AJCC staging-based risk grouping (0.663). CONCLUSIONS Multivariate nomograms provide a more accurate and relevant individualized prediction of survival after cystectomy compared with conventional prediction models, thereby allowing for improved patient counseling and treatment selection.
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Affiliation(s)
- Shahrokh F Shariat
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, and The Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, MD, USA
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230
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Nielsen ME, Shariat SF, Karakiewicz PI, Lotan Y, Rogers CG, Amiel GE, Bastian PJ, Vazina A, Gupta A, Lerner SP, Sagalowsky AI, Schoenberg MP, Palapattu GS. Advanced age is associated with poorer bladder cancer-specific survival in patients treated with radical cystectomy. Eur Urol 2006; 51:699-706; discussion 706-8. [PMID: 17113703 DOI: 10.1016/j.eururo.2006.11.004] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Accepted: 11/02/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Bladder cancer (BCa) is a disease of older persons, the incidence of which is expected to increase as the population ages. There is controversy, however, regarding the outcomes of radical cystectomy (RC), the gold standard treatment of high-risk BCa, in patients of advanced chronological age. The aim of our study was to assess the impact of patient age on pathological characteristics and recurrence-free and disease-specific survival following RC. METHODS The records of 888 consecutive patients who underwent RC for transitional cell carcinoma (TCC) were reviewed. Age at RC was analyzed both as a continuous (yr) and categorical (< or =60 yr old, n=240; 60.1-70 yr old, n=331; 70.1-80 yr old, n=266; >80 yr old, n=51) variable. Logistic regression and survival analyses were performed. RESULTS Higher age at RC, analyzed as a continuous or categorical variable, was associated with extravesical disease and pathological upstaging (all p<0.02). Older patients were less likely to receive postoperative chemotherapy (< or =60 yr: 32% vs. >80 yr: 14%, p=0.008). In both pre- and postoperative multivariate models, higher age at RC as a categorical variable was associated with BCa-specific survival (p<0.05). Patients >80 yr old had a significantly greater risk of disease recurrence than patients aged < or =60 yr (p<0.05). CONCLUSION Greater patient age at the time of RC for BCa is independently associated with adverse outcomes. Better understanding of factors associated with postoperative outcomes in this growing segment of the population is necessary. Prospective corroboration and further refinement of similar analyses in other large datasets is needed.
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Affiliation(s)
- Matthew E Nielsen
- The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland, USA.
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231
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Abstract
Bladder cancer is a common genitourinary malignancy that demonstrates a great variation in risk of tumor recurrence and progression following treatment. The dramatic differences in clinical behavior dictate vastly differing treatments, which may range from simple surveillance to combination radical surgery with systemic chemotherapy. For non-muscle invasive bladder cancer prediction of the risk of recurrence and progression is necessary to assess the need for intravesical therapy and possible early cystectomy. In contrast, prediction of advanced disease response to primary treatment such as cystectomy and the response to systemic chemotherapy plays an important role in treatment assignment for patients with muscle invasive disease. To estimate these risk traditional risk grouping schemes such as the present TNM staging system has been used to guide patient treatment. More recently, improved prognostic tools such as nomograms have been developed to provide a more accurate assessment of outcomes. Clinicians are enthusiastically working to utilize these statistical methods in bladder cancer. We summarize the current status of outcome predictive models for bladder cancer; and focus particularly on the ability of nomograms to predict disease recurrence, progression, and patient survival.
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Affiliation(s)
- Ahmad Shabsigh
- Division of Urology, Memorial Sloan Kettering Cancer Center, Kimmel Center for Prostate and Urologic Cancers, 353 E. 68th Street, New York, NY 10021, USA
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232
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Thomas CY, Theodorescu D. Molecular markers of prognosis and novel therapeutic strategies for urothelial cell carcinomas. World J Urol 2006; 24:565-78. [PMID: 17063322 DOI: 10.1007/s00345-006-0119-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Christopher Y Thomas
- Department of Hematology and Oncology, UVA HSC, P.O. Box 800716, Charlottesville, VA 22908, USA
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233
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Lotan Y, Svatek RS, Sagalowsky AI. Should we screen for bladder cancer in a high-risk population?: A cost per life-year saved analysis. Cancer 2006; 107:982-90. [PMID: 16862567 DOI: 10.1002/cncr.22084] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The U.S. Food and Drug Administration recently approved screening high-risk patients for bladder cancer using urine-based markers. The cost and life-years saved associated with bladder cancer screening were evaluated. METHODS A Markov model was created to estimate cumulative cancer-related costs and efficacy of screening (vs. no screening) of a high-risk population for bladder cancer using a urine-based tumor marker over a 5-year period. Assumptions were based on literature review of survival and progression rates for patients with bladder cancer and costs associated with different bladder cancer disease states. RESULTS Screening for bladder cancer in a population with a 4% incidence of bladder cancer resulted in a gain of 3.0 life years per 1000 subjects at a cost savings of $101,000 for the population, assuming a 50% downstaging in the screened population from muscle-invasive to nonmuscle-invasive disease. One-way sensitivity analyses found that screening is the most cost-effective strategy if cancer incidence is >1.6%, tumor marker costs <$126, marker sensitivity is >26%, marker specificity is >54%, downstaging with screening is >20%, and office cystoscopy costs <$694. Varying costs of cystectomy, transurethral resection of bladder tumor (TURBT), chemotherapy, end-of-life care, costs of metastatic disease, and a computed tomography scan over a wide range did not affect the superiority of screening. CONCLUSIONS The model found that urine-based markers are cost-effective in a high-risk population. Prospective randomized trials in a completely asymptomatic high-risk cohort are indicated before bladder cancer screening can be recommended.
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Affiliation(s)
- Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA.
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234
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Karakiewicz PI, Shariat SF, Palapattu GS, Gilad AE, Lotan Y, Rogers CG, Vazina A, Gupta A, Bastian PJ, Perrotte P, Sagalowsky AI, Schoenberg M, Lerner SP. Nomogram for Predicting Disease Recurrence After Radical Cystectomy for Transitional Cell Carcinoma of the Bladder. J Urol 2006; 176:1354-61; discussion 1361-2. [PMID: 16952631 DOI: 10.1016/j.juro.2006.06.025] [Citation(s) in RCA: 165] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Indexed: 11/16/2022]
Abstract
PURPOSE American Joint Committee on Cancer staging represents the gold standard for prediction of recurrence after radical cystectomy in patients with invasive bladder cancer. We tested the hypothesis that American Joint Committee on Cancer stage based predictions may be improved when pathological tumor and node stage information is combined with additional clinical and pathological variables within a prognostic nomogram. MATERIALS AND METHODS We used Cox proportional hazards regression analysis to model variables of 728 patients with transitional cell carcinoma of the bladder treated with radical cystectomy and bilateral pelvic lymphadenectomy at 1 of 3 participating institutions. Standard predictors, pT and pN, were complemented by age, gender, tumor grade at cystectomy, presence of lymphovascular invasion, presence of carcinoma in situ in the cystectomy specimen, neoadjuvant chemotherapy, adjuvant chemotherapy and adjuvant radiotherapy. The concordance index was used to quantify the accuracy of regression coefficient based nomograms. A total of 200 bootstrap resamples were used to reduce overfit bias and for internal validation. Calibration plots were used to graphically explore the performance characteristics of the multivariate nomogram. RESULTS Followup ranged from 0.1 to 183.4 months (median 24.9, mean 36.4). Recurrence was recorded in 249 (34.2%) patients with a median time to recurrence of 108 months (range 0.8 to 131.9). Actuarial recurrence-free probabilities were 69.6% (95% CI 65.8%-73.0%), 60.2% (55.8%-64.3%) and 52.9% (47.3%-58.1%) at 2, 5 and 8 years after cystectomy, respectively. Two-hundred bootstrap corrected predictive accuracy of American Joint Committee on Cancer stage based predictions was 0.748. Accuracy increased by 3.2% (0.780) when age, lymphovascular invasion, carcinoma in situ, neoadjuvant chemotherapy, adjuvant chemotherapy and adjuvant radiotherapy were added to pathological stage information and used within a nomogram. CONCLUSIONS A nomogram predicting bladder cancer recurrence after cystectomy is 3.2% more accurate than American Joint Committee on Cancer stage based predictions. Moreover, a nomogram approach combines several advantages such as easy and precise estimation of individual recurrence probability at key points after cystectomy, which all patients deserve to know and all treating physicians need to know.
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Affiliation(s)
- Pierre I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, University of Montreal, Montreal, Quebec, Canada
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235
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Donat SM. Staged based directed surveillance of invasive bladder cancer following radical cystectomy: valuable and effective? World J Urol 2006; 24:557-64. [PMID: 17009050 DOI: 10.1007/s00345-006-0117-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- S Machele Donat
- Department of Urology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021, USA.
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236
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Shariat SF, Palapattu GS, Amiel GE, Karakiewicz PI, Rogers CG, Vazina A, Schoenberg MP, Lerner SP, Sagalowsky AI, Lotan Y. Characteristics and outcomes of patients with carcinoma in situ only at radical cystectomy. Urology 2006; 68:538-42. [PMID: 16979748 DOI: 10.1016/j.urology.2006.03.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2005] [Revised: 02/06/2006] [Accepted: 03/15/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe the cancer-specific outcomes of patients with pathologic carcinoma in situ (CIS) only at radical cystectomy. METHODS The records of 812 consecutive patients who underwent radical cystectomy and pelvic lymphadenectomy for bladder transitional cell carcinoma at three U.S. academic centers were reviewed. Of the 812 patients, 99 (12%) had CIS only at radical cystectomy. RESULTS The distribution of clinical stage for the 99 patients with CIS only at radical cystectomy was as follows: 47% of patients had CIS only, 8% had cT1, 15% had cT1 plus CIS, 10% had cT2, 13% had cT2 plus CIS, 6% had cTa, and 1% had Ta plus CIS. Two patients had lymphovascular invasion in the radical cystectomy specimen, and three had metastases to the lymph nodes. The actuarial recurrence-free survival estimates were 89.8% (95% confidence interval [CI] 83.0% to 96.6%) at 3 years and 83.0% (95% CI 73.2% to 92.8%) at 5 and 7 years after radical cystectomy. Six patients (6%) had died of bladder cancer at analysis and 13 (13%) had died of other causes without evidence of disease recurrence. The actuarial disease-specific survival estimates were 95.8% (95% CI 91.2% to 99.9%) at 3 years, 90.7% (95% CI 82.4% to 98.9%) at 5 years, and 87.2% (95% CI 76.8% to 97.5%) at 7 years after surgery. On univariate Cox regression analyses, only metastasis to lymph nodes was associated with bladder cancer recurrence and death (P <0.001). CONCLUSIONS Disease control seemed durable for patients with pathologic CIS only at radical cystectomy in the absence of metastases to the lymph nodes, even in the case of failure after intravesical therapy.
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Affiliation(s)
- Shahrokh F Shariat
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9110, USA
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Bibliography. Current world literature. Bladder cancer. Curr Opin Urol 2006; 16:386-9. [PMID: 16905987 DOI: 10.1097/01.mou.0000240314.93453.d4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mitra AP, Almal AA, George B, Fry DW, Lenehan PF, Pagliarulo V, Cote RJ, Datar RH, Worzel WP. The use of genetic programming in the analysis of quantitative gene expression profiles for identification of nodal status in bladder cancer. BMC Cancer 2006; 6:159. [PMID: 16780590 PMCID: PMC1550424 DOI: 10.1186/1471-2407-6-159] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2006] [Accepted: 06/16/2006] [Indexed: 11/30/2022] Open
Abstract
Background Previous studies on bladder cancer have shown nodal involvement to be an independent indicator of prognosis and survival. This study aimed at developing an objective method for detection of nodal metastasis from molecular profiles of primary urothelial carcinoma tissues. Methods The study included primary bladder tumor tissues from 60 patients across different stages and 5 control tissues of normal urothelium. The entire cohort was divided into training and validation sets comprised of node positive and node negative subjects. Quantitative expression profiling was performed for a panel of 70 genes using standardized competitive RT-PCR and the expression values of the training set samples were run through an iterative machine learning process called genetic programming that employed an N-fold cross validation technique to generate classifier rules of limited complexity. These were then used in a voting algorithm to classify the validation set samples into those associated with or without nodal metastasis. Results The generated classifier rules using 70 genes demonstrated 81% accuracy on the validation set when compared to the pathological nodal status. The rules showed a strong predilection for ICAM1, MAP2K6 and KDR resulting in gene expression motifs that cumulatively suggested a pattern ICAM1>MAP2K6>KDR for node positive cases. Additionally, the motifs showed CDK8 to be lower relative to ICAM1, and ANXA5 to be relatively high by itself in node positive tumors. Rules generated using only ICAM1, MAP2K6 and KDR were comparably robust, with a single representative rule producing an accuracy of 90% when used by itself on the validation set, suggesting a crucial role for these genes in nodal metastasis. Conclusion Our study demonstrates the use of standardized quantitative gene expression values from primary bladder tumor tissues as inputs in a genetic programming system to generate classifier rules for determining the nodal status. Our method also suggests the involvement of ICAM1, MAP2K6, KDR, CDK8 and ANXA5 in unique mathematical combinations in the progression towards nodal positivity. Further studies are needed to identify more class-specific signatures and confirm the role of these genes in the evolution of nodal metastasis in bladder cancer.
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Affiliation(s)
- Anirban P Mitra
- Department of Pathology, University of Southern California Keck School of Medicine, 2011 Zonal Avenue, HMR 312, Los Angeles CA 90033, USA
| | - Arpit A Almal
- Genetics Squared Inc., 210 South 5th Avenue, Suite A, Ann Arbor MI 48104, USA
| | - Ben George
- Department of Internal Medicine, Gundersen Lutheran Medical Center, 1900 South Avenue, La Crosse WI 54601, USA
| | - David W Fry
- Genetics Squared Inc., 210 South 5th Avenue, Suite A, Ann Arbor MI 48104, USA
| | - Peter F Lenehan
- Genetics Squared Inc., 210 South 5th Avenue, Suite A, Ann Arbor MI 48104, USA
| | - Vincenzo Pagliarulo
- Dipartimento Emergenza e Trapianti d'Organo, Sezione di Urologia, Università di Bari, Piazza G. Cesare 11, Bari 70124, Italy
| | - Richard J Cote
- Department of Pathology, University of Southern California Keck School of Medicine, 2011 Zonal Avenue, HMR 312, Los Angeles CA 90033, USA
| | - Ram H Datar
- Department of Pathology, University of Southern California Keck School of Medicine, 2011 Zonal Avenue, HMR 312, Los Angeles CA 90033, USA
| | - William P Worzel
- Genetics Squared Inc., 210 South 5th Avenue, Suite A, Ann Arbor MI 48104, USA
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Rogers CG, Palapattu GS, Shariat SF, Karakiewicz PI, Bastian PJ, Lotan Y, Gupta A, Vazina A, Gilad A, Sagalowsky AI, Lerner SP, Schoenberg MP. Clinical Outcomes Following Radical Cystectomy for Primary Nontransitional Cell Carcinoma of the Bladder Compared to Transitional Cell Carcinoma of the Bladder. J Urol 2006; 175:2048-53; discussion 2053. [PMID: 16697800 DOI: 10.1016/s0022-5347(06)00317-x] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Indexed: 11/22/2022]
Abstract
PURPOSE The effect of bladder cancer histological subtypes other than transitional cell carcinoma (nonTCC) on clinical outcomes remains uncertain. We conducted a multi-institutional retrospective study of patients with bladder cancer treated with radical cystectomy to assess the impact of nonTCC histology on bladder cancer specific outcomes. MATERIALS AND METHODS A total of 955 consecutive patients underwent radical cystectomy with bilateral pelvic lymphadenectomy for bladder cancer at 3 academic institutions. TCC was present in the radical cystectomy specimen in 888 patients (93%). NonTCC histology was present in 67 patients (7%), including squamous cell carcinoma in 26, adenocarcinoma in 13, small cell carcinoma in 10 and other nonTCC subtypes (ie spindle cell carcinoma, carcinosarcoma and undifferentiated carcinoma) in 18. For patients alive at last followup median followup was 39 and 23 months for patients with TCC and nonTCC histologies, respectively. Bladder cancer specific progression and survival were assessed using Kaplan-Meier and multivariate Cox proportional hazards analyses. RESULTS Bladder cancer specific progression and mortality did not differ significantly between patients with SCC and TCC histologies. Patients with nonTCC and nonSCC bladder cancer were at significantly increased risk for progression and death compared to patients with TCC or SCC (p <0.001). This association remained statistically significant in patients with organ confined disease (stage pT2 or lower) and patients with nonorgan confined disease (stage pT3 or higher) (p <0.001). In a multivariate analysis nonTCC and nonSCC histology was associated with an increased risk of bladder cancer progression and death (OR 2.272 and 2.585, respectively, p <0.001), even after adjusting for final pathological stage, lymph node status, lymphovascular invasion and neoadjuvant or adjuvant treatments. CONCLUSIONS NonTCC and nonSCC histological subtype is an independent predictor of bladder cancer progression and mortality in patients undergoing radical cystectomy for bladder cancer. Patients with bladder TCC and SCC share similar stage specific clinical outcomes.
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Affiliation(s)
- Craig G Rogers
- Bladder Cancer Research Consortium, James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland 21287-2101, USA
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Cohen SM, Goel A, Phillips J, Ennis RD, Grossbard ML. The Role of Perioperative Chemotherapy in the Treatment of Urothelial Cancer. Oncologist 2006; 11:630-40. [PMID: 16794242 DOI: 10.1634/theoncologist.11-6-630] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Cancer of the urothelium is the fourth most common malignancy in men in the U.S. and the ninth most common in women. More than 63,000 Americans will be diagnosed with bladder cancer this year (47,010 men and 16,200 women), and more than 13,000 (8,970 men and 4,210 women) can expect to die of their disease. The approximate 5:1 ratio of incidence to mortality roughly parallels the frequency of superficial to invasive disease. Efforts to improve this ratio have generated a potential paradigm shift in the treatment of urothelial cancer, incorporating increasingly active chemotherapy into treatment regimens for high-risk tumors in both the pre-and postoperative settings. This review summarizes the evolution of chemotherapeutic treatment of urothelial cancer and the rationale for its perioperative administration and addresses the future directions of clinical research in this field.
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Affiliation(s)
- Seth M Cohen
- Department of Medicine, Division of Hematology/Oncology, St. Luke's-Roosevelt Hospital Center, New York, New York 10019, USA.
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Abstract
Pathologists play an important role in the management of urinary bladder cancer by making a careful morphologic assessment of the primary tumor and its relation to adjacent structures. Ideally, evaluation of the primary site will segregate patients into groups with distinct clinical features, biologic behavior, and response to therapy. Traditionally, to accomplish this goal, pathologists have relied on factors such as histologic tumor type, grade, depth of invasion, and presence or absence of vascular invasion. Recently, in an effort to enhance our ability to subclassify these patients, we have introduced new modalities, such as flow cytometry, monoclonal antibodies, assessment of proliferative rate, and cytogenetics and molecular genetics. Without question we are advancing into an era in which tumors will be classified based on their molecular "fingerprint." Nevertheless, at this time, morphology remains the "gold standard" and, consequently, the best tool to assess the biologic potential of early bladder cancer. Despite this undeniable fact, there are many problems with the pathologic evaluation of these tumors, mostly because of the inherent subjectivity of the field and the lack of universal, standardized criteria for the evaluation of the above-mentioned morphologic parameters. Publications in peer-reviewed journals and the proliferation of educational opportunities by way of seminars, conferences, and web-based tutorials play an important role in keeping the practicing pathologist informed and up to date. As novel concepts and modern techniques are reported, their clinical value must be validated prospectively. Expert pathology review and establishment of exportable practice standards play an important role in the process.
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Affiliation(s)
- Victor E Reuter
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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Reuter VE. Lymphovascular Invasion As an Independent Predictor of Recurrence and Survival in Node-Negative Bladder Cancer Remains to Be Proven. J Clin Oncol 2005; 23:6450-1. [PMID: 16129842 DOI: 10.1200/jco.2005.05.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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