The origin of invasive carcinoma of the bladder

In Vitro and In Vivo Antitumor Efficacy of Hizikia fusiforme Celluclast Extract against Bladder Cancer

Various physiological benefits have been linked to Hizikia fusiforme (HF), an edible brown seaweed. Here, fucose-containing sulfated polysaccharides were extracted from celluclast-processed HF (SPHF) and their antitumor efficacy against bladder cancer was evaluated in vitro and in vivo. SPHF possesses high sulfated polysaccharide and fucose contents and free radical scavenging activities compared to those of celluclast-processed HF extracts (CHF). SPHF inhibited bladder cancer EJ cell proliferation via G1-phase cell cycle arrest. This was due to the induction of p21WAF1 expression associated with the downregulation of CDKs and cyclins. Moreover, JNK phosphorylation was identified as an SPHF-mediated signaling molecule. SPHF treatment also hindered the migration and invasion of EJ cells by inhibiting MMP-9 expression, which was attributed to the repression of transcriptional binding to NF-κB, AP-1, and Sp-1 in the MMP-9 promoter region. In an animal study, SPHF treatment suppressed EJ tumor growth in xenograft mice similarly to cisplatin. Furthermore, no toxicity signs were found after weight loss assessment, biochemical tests, and organ tissue immunostaining during oral administration of 20–200 mg/kg SPHF for 20 days. Therefore, our study demonstrates the antitumor efficacy of SPHF in vitro and in vivo, thus highlighting its potential for bladder cancer treatment development.

An improved mouse orthotopic bladder cancer model exhibiting progression and treatment response characteristics of human recurrent bladder cancer

Nonmuscle-invasive (superficial) bladder cancer is generally treated via surgical removal, followed by adjuvant therapy (bacillus Calmette-Guerin). However, bladder cancer can often recur, and in a substantial number of recurrent cases, the cancer progresses and metastasizes. Furthermore, residual microtumors following excision may lead to an increased risk of recurrence. An in vivo model mimicking the pattern of urinary bladder microtumor regrowth may provide an effective experimental system for improving postsurgical treatment outcomes. A mouse bladder cancer model established using orthotopic transplant of UM-UC-3 human urinary bladder carcinoma cells has been established, however, to the best of our knowledge, no report has investigated sequential histological changes, including early-phase changes and treatment responses in bladder cancer. In the present study, the efficiency of the model was optimized and the sequential changes were examined using histopathology and in situ imaging. The therapeutic effects of cisplatin (CDDP) and gemcitabine (GEM) were also examined, which are drugs that are often used for follow-up chemotherapy. Tumor-seeding efficiency reached 90-100%, with muscle layer and bladder lumen invasion occurring in ~21 days, using the following modifications: i) Shallow catheter insertion to mitigate bladder wall damage; ii) bladder pretreatment using prewarmed trypsin, followed by light urethral clamping and body temperature maintenance for more efficient removal of transitional epithelium; and iii) seeding with UM-UC-3 cells (rather than HT1376, 5637 or T24 tumor cells) in a medium supplemented with Matrigel. Transplant with UM-UC-3 cells resulted in isolated microlesions that progressed into tumors, invading the bladder lumen and muscle layer to the serosal surface. Tumor growth was markedly reduced by weekly intravenous injections of CDDP and partially suppressed by GEM. Therefore, this model is reliable, and pathological progression and treatment responses recapitulate the features of recurrent human bladder cancer.

Stem cell marker-positive stellate cells and mast cells are reduced in benign-appearing bladder tissue in patients with urothelial carcinoma

Survival after invasive bladder cancer has improved less than that of other common non-skin cancers. In many types of malignancy, treatment failure has been attributed to therapy-resistant stem-like cancer cells. Our aim was therefore to determine identities of stem cell marker-positive cells in bladder cancer tissue and to investigate possible associations between these cells and different forms of bladder neoplasia. We investigated tissue from 52 patients with bladder neoplasia and 18 patients with benign bladder conditions, from a cohort that had been previously described with regard to diagnosis and outcome. The samples were analysed immunohistologically for the stem cell markers aldehyde dehydrogenase 1 A1 (ALDH1) and CD44, and markers of cell differentiation. The majority of stem cell marker-positive cells were located in connective tissue, and a smaller fraction in epithelial tissue. Stem cell marker-positive cells exhibiting possible stem cell characteristics included cells in deeper locations of benign and malignant epithelium, and sub-endothelial cells in patients with or without neoplasia. Stem cell marker-positive cells with non-stem cell character included stellate cells, mast cells, endothelial cells, foamy histiocytes, and neurons. Significantly, ALDH1+ stellate cells and ALDH1+ mast cells were reduced in number in stroma of benign-appearing mucosa of bladder cancer patients. The stem cell markers ALDH1 and CD44 label several types of differentiated cells in bladder tissue. ALDH1+ stellate cells and mast cells appear to be reduced in stroma of normal-appearing mucosa of bladder cancer patients, and may be part of a "field effect" in cancer-near areas.

The sensitivity of fluorescent-light cystoscopy for the detection of carcinoma in situ (CIS) of the bladder: a meta-analysis with comments on gold standard

What's known on the subject? and What does the study add? Fluorescent-light cystoscopy has a high sensitivity, relative to that of white light cystoscopy, for carcinoma in situ of the bladder. However, this systematic review reveals that the absolute sensitivity is unknown due to the absence of proper gold standard which is microscopic examination of whole bladders. •  A literature search was conducted to identify peer-reviewed study reports on the sensitivity of fluorescent-light cystoscopy (FLC) for the detection of carcinoma in situ (CIS) of the bladder. •  Data from 16 original studies comprising 1503 patients were pooled. •  The claimed sensitivity of FLC for detecting patients with CIS using the most commonly reported intravesical agents 5-aminolevulinic acid or hexaminolevulinic acid was 92.4%, while that of white-light cystoscopy (WLC) was 60.5%. The two agents did not differ significantly for sensitivity. •  It must be pointed out that a 'gold standard' is lacking in FLC studies. •  The occurrence of CIS of the bladder can only be established by the pathological examination of whole bladders. The true sensitivities of various modes of cystoscopy for detecting CIS can be revealed if patients scheduled for cystectomy are first examined with WLC, FLC, and optionally random biopsies. •  The absolute sensitivity of FLC for detecting CIS of the bladder is not yet known.

Bladder cancer in Sri Lanka: experience from a tertiary referral center

BACKGROUND

Bladder cancer is one of the most common malignancies occurring worldwide. No published data exists on bladder cancer in Sri Lanka. The objective of the study was to determine the clinicopathological characteristics of histologically confirmed transitional cell carcinoma (TCC) of the bladder in Sri Lanka.

METHODS

Three hundred and one patients were diagnosed with primary bladder cancer during a 7.5-year period from 1993 to 2000. Two hundred and eighty-one patients (239 men and 42 women; mean age, 66 years; range, 26-88) with TCC of the bladder were evaluated with regard to clinical presentation, cystoscopic findings and histopathological data.

RESULTS

Transitional cell carcinoma accounted for 93.4% of primary bladder cancer. There was a male predominance with a sex ratio of 6:1. The majority of patients (63.7%) were in the 7th and 8th decades of life. Painless hematuria was the most common presenting symptom (52.7%), followed by painful hematuria (39.2%). The median duration of hematuria for all TCC patients, as well as for muscle-invasive TCC patients, was 3 months. Papillary configuration at cystoscopy, was found in 89.7% of non-invasive urothelial tumors. In contrast, 77.8% of invasive TCC patients had a solid/mixed tumor configuration. One hundred and forty-five patients (51.6% of TCC) had non-invasive urothelial tumor and 136 patients (48.4%) had muscle-invasive disease. In the non-invasive urothelial tumor category, 61 patients (42.0%) had pTa tumors and 84 patients (58.0%) had pT1 tumors. Of newly diagnosed TCC cases, 5.3% were found to be T1G3 urothelial carcinomas. Fifty-six patients (38.6%) with non-invasive urothelial tumor had a tumor greater than 5 cm in size.

CONCLUSIONS

More than 90% of primary bladder tumors in Sri Lanka are TCC, with nearly half the patients having muscle-invasive diseases on initial presentation. Even in non-invasive urothelial tumors, the majority (58.0%) have lamina propria invasion.

Impaired Delta Np63 expression associates with reduced beta-catenin and aggressive phenotypes of urothelial neoplasms

p63, a homologue of the p53 gene, is considered to be essential for the normal development of stratified epithelia including urothelium. To examine possible roles of p63 in urothelial tumorigenesis, p63 expression was systematically examined in normal urothelium, low-grade papillary noninvasive (LPN) urothelial tumours, and high-grade or invasive carcinomas, using either an isoform-nonspecific or a Delta N-isoform-specific antibody. Expression profiles of p63 were also analysed in cultured cells. Immunoreactivity with the two antibodies was virtually identical in tissue samples examined. Basal and intermediate cell layers of normal urothelium showed intense nuclear p63 immunostaining. This normal staining pattern was preserved in a majority of LPN tumours, whereas it was frequently impaired in high-grade or muscle-invasive carcinomas. At the mRNA level, Delta Np63 expression predominated over TAp63, and amounts of Delta Np63 mRNA correlated with p63 immunoreactivity, confirming that Delta Np63 accounts for p63 expressed in urothelial tissues. In cultured cells, Delta Np63 was also expressed in low-grade tumour cells as well as normal urothelial cells, but undetectable in high-grade aggressive carcinoma cells. Interestingly, impaired Delta Np63 expression significantly associated with reduced beta-catenin expression that was possibly related to progression of urothelial neoplasms. Thus, impaired Delta Np63 expression characterises aggressive phenotypes of urothelial neoplasms.

Progression from superficial to invasive carcinoma of the bladder: genetic evidence of either clonal heterogeneous events

Until now, no definitive molecular evidence proving or disproving a true progression from superficial to invasive bladder tumors has been reported. A total of 36 lesions from 6 patients affected by invasive bladder cancer after multiple superficial recurrences were analyzed for loss of heterozygosity on 8 loci of chromosome 9 and 2 loci of chromosome 17. In addition, the clonal composition of the tumors from two female patients was examined using the human androgen receptor assay. Our data suggest that papillary bladder lesions can and sometimes do make a true progression into invasive life-threatening tumors; however, this progression is not an invariable sequence because it was definitely proven in 2 but not confirmed in 3 of the cases we examined.

Bladder. Risk and prognostic factors--a pathologist's perspective

Morphology remains a power tool to help predict the risk of recurrence, progression, and even response to therapy in bladder cancer. Nevertheless, more work is needed to refine and standardize criteria and terminology. Novel molecular tools may reveal prognostic factors, but these techniques must be compared with standard morphologic and clinical markers by performing multivariate analysis in a prospective fashion.

Diagnosis and grading of bladder cancer and associated lesions

Standardized classification and grading of urothelial carcinoma has now been achieved internationally. Uniformity of pathologic reporting should improve the comparability of different studies and therapies and provide more accurate information to urologists in managing patients.

The quality of medical textbooks: bladder cancer diagnosis as a case study

PURPOSE

This study was conducted to determine whether there is an inherent bias in medical texts that influences physicians to favor certain signs and symptoms over others when evaluating patients with bladder cancer.

MATERIALS AND METHODS

Numerous sources, primarily textbooks from various medical specialties, were reviewed (italics are added for emphasis). Attention was paid to the criteria the authors suggested for use in the diagnosis of bladder cancer.

RESULTS

Although most authors agree on a core of presenting signs and symptoms, some concentrate strongly on hematuria with the result of down playing the importance of other findings such as irritative voiding symptoms. The concern is that this approach may lead to delay in the diagnosis of tumors, some of which may be highly aggressive, which present with dysuria and pyuria but no hematuria.

CONCLUSIONS

Inconsistencies do exist in the literature regarding which diagnostic criteria to use in selecting those patients to be evaluated for bladder cancer. Recommendations are made for ways to improve standardization.

Fluorescence detection of flat transitional cell carcinoma after intravesical instillation of aminolevulinic acid

Carcinoma in situ (CIS) of the bladder is a confounding disease that is difficult to recognize endoscopically because it is a flat cancer. Many studies have suggested its relationship with subsequent invasive disease. Early recognition of CIS therefore is essential in offering the patient the most appropriate treatment and the highest cure rate. Because white light cystoscopic examination is not sufficient to reveal areas of dysplasia or CIS, random biopsies are recommended. The authors evaluate whether amino levulinic acid (ALA) fluorescence detection could be helpful in diagnosing CIS and if the specificity could be enhanced by reducing the ALA dose. Sixteen patients with papillary bladder cancer, and CIS and dysplasia were given low-dose ALA. Fluorescence detection of the metabolized ALA was performed 3 hours later, with the naked eye, after blue light illumination. Carcinoma in situ or dysplasia was found in 50 biopsies. The sensitivity for detecting CIS was 94% with a specificity of 54%. Carcinoma in situ can be diagnosed with a very high accuracy through fluorescence detection after ALA instillation. Fluorescence detection can be achieved with the naked eye and does not necessitate either complex equipment or specially trained personnel.

Bladder cancer in patients with multiple sclerosis treated with cyclophosphamide

PURPOSE

We define the risk of bladder cancer in multiple sclerosis related to the use of indwelling catheters and cyclophosphamide administered as an immunomodulating agent.

MATERIALS AND METHODS

We retrospectively reviewed the records of 2,351 patients with multiple sclerosis referred to the National Center for Multiple Sclerosis.

RESULTS

Of the 2,351 patients 2 women and 5 men (0.29%) had bladder cancer. Of the 850 chronically catheterized patients the incidence was 0.7%. One patient with cancer performed intermittent catheterization for a rate of 0.23% in this group. In a subgroup of 70 patients treated with cyclophosphamide 5 chronically catheterized patients (5.7%) had bladder cancer. Hematuria was the most common presenting symptom. These data were compared with those in the literature on bladder cancer in spinal cord injury.

CONCLUSIONS

These data suggest a possible synergistic role of cyclophosphamide and chronic catheterization in the induction of secondary bladder cancer. Regular cystoscopy is warranted in these patients to allow early detection of bladder tumors. Nitric oxide metabolism may be an important factor in the carcinogenesis of this type of bladder cancer.

Bladder cancer in patients with multiple sclerosis treated with cyclophosphamide

PURPOSE

We define the risk of bladder cancer in multiple sclerosis related to the use of indwelling catheters and cyclophosphamide administered as an immunomodulating agent.

MATERIALS AND METHODS

We retrospectively reviewed the records of 2,351 patients with multiple sclerosis referred to the National Center for Multiple Sclerosis.

RESULTS

Of the 2,351 patients 2 women and 5 men (0.29%) had bladder cancer. Of the 850 chronically catheterized patients the incidence was 0.7%. One patient with cancer performed intermittent catheterization for a rate of 0.23% in this group. In a subgroup of 70 patients treated with cyclophosphamide 5 chronically catheterized patients (5.7%) had bladder cancer. Hematuria was the most common presenting symptom. These data were compared with those in the literature on bladder cancer in spinal cord injury.

CONCLUSIONS

These data suggest a possible synergistic role of cyclophosphamide and chronic catheterization in the induction of secondary bladder cancer. Regular cystoscopy is warranted in these patients to allow early detection of bladder tumors. Nitric oxide metabolism may be an important factor in the carcinogenesis of this type of bladder cancer.

Urothelial transitional cell carcinoma with endophytic growth patterns: a discussion of patterns of invasion and problems associated with assessment of invasion in 18 cases

Most papillary transitional cell carcinomas (TCC) are characterized architecturally by an exophytic growth of fingerlike papillae, but some exhibit a prominent endophytic growth pattern resulting in considerable difficulty in assessing invasion. We report on 18 cases of TCC (17 urinary bladder, one pelvicalyceal system) in which endophytic growth was evident either as interanastomosing cords and columns of urothelium, often with a striking resemblance to inverted papilloma (inverted papilloma-like pattern), or as broad, pushing bulbous invaginations into the lamina propria (broad-front pattern). The mean age of the patients was 68 years (range, 32-94 years), with a male preponderance (3.5:1). In four cases, the endophytic pattern was exclusively inverted papilloma-like, 10 cases had only the broad-front pattern, and four cases showed both patterns. Exophytic papillary TCC of the usual type was present in all but two cases, varying from focal (five cases) to moderate (five cases) to extensive (six cases). In spite of the extensive incursion into the lamina propria resulting from the inverted growth, only nine cases (50%) had unequivocal destructive invasion (lamina propria invasion, eight cases; muscularis propria invasion, one case). Follow-up data, available in 14 cases (1-48 months; mean, 15.5 months), revealed one patient alive with disease, 11 patients with no evidence of disease, and two patients dead of other causes. The limited follow-up does not permit evaluation of the impact of the endophytic patterns on outcome. Because the phenomenon of endophytic growth in TCC has received little attention, we present detailed morphologic descriptions of our cases and review the problems associated with assessment of invasion and the different patterns of invasion by TCC.

The proliferation index of MIB-1 as a prognostic factor for patients with transitional cell carcinoma of the upper urinary tract

BACKGROUND

Recently, several reports have shown that immunohistochemical analysis using MIB-1 antibody, which recognizes Ki-67 (a human nuclear antigen expressed of proliferating cells), is a useful method for determining the proliferative activity of various cancers. In this study, the authors evaluated the prognostic usefulness of the proliferation index using MIB-1 antibody in transitional cell carcinoma of the upper urinary tract.

METHODS

Proliferation activity was investigated immunohistochemically using monoclonal antibody MIB-1 in formalin fixed, paraffin embedded tissues obtained from 67 specimens of renal pelvic and ureteral cancer. The MIB-1 proliferation index values were calculated from each sample as the percentage of positive nuclei expressed in tumor cells and the clinicopathologic correlation evaluated.

RESULTS

The MIB-1 proliferation index values were correlated with prognostic parameters such as pathologic stage ( < or = pT1 vs. > or = pT2, P < 0.0005), histologic grade (G1 vs. G2, P < 0.01; G1 vs. G3, P < 0.0001; G2 vs. G3, P < 0.001), and prognosis (P < 0.0001). When patients were subgrouped using index values, patients with higher indices ( > or = 24%) had significantly poorer survival (P < 0.0001). This was especially observed in the G2 group, in which 9 of 10 patients in the higher indices subgroup had a high incidence of recurrence and died. In contrast, only 2 of 29 patients in the lower indices subgroup died. The higher indices subgroup had significantly worse cause specific survival (P < 0.0001). Furthermore, with regard to the muscle invasive tumors ( > or = pT2), the higher indices subgroup also had significantly worse cause specific survival (P < 0.0001).

CONCLUSIONS

The results of the evaluation of prognostic parameters indicate that the MIB-1 proliferation index is a useful prognostic factor and may enhance the accuracy of conventional morphologic grading and pathologic staging systems.

Tavola Rotonda su: “Fattori prognostici e markers nel carcinoma della vescica”. Aspetti generali e introduttivi: Round Table on: “Prognostic factors and markers in bladder carcinoma”. General and introductory aspects

Bladder tumours are generally grouped as superficial or invasive because of their different therapeutical regimens. Superficial tumours still cause uncertainties in choosing the best treatment due to their heterogeneity and different behaviour. In the prevision of these tumours it is important to consider all the factors that could influence the prognosis: tumoral characteristics, grading and staging mistakes, effects of the therapy and immunological response. Moreover it is important for clinical studies to have appropriate end points. Prognostic factors and markers with high predictive value can allow specific treatment for the individual cases to be planned.

A comparison of direct and liposomal antibody conjugates of sulfonated aluminum phthalocyanines for selective photoimmunotherapy of human bladder carcinoma

There is a need to improve the selectivity of photodynamic therapy and for better targeting of tumor cells within specific tumor compartments. Selective in vitro phototoxicity of a human bladder carcinoma cell line 647V has been achieved by targeting sulfonated aluminum phthalocyanines (AlSPc) with monoclonal antibodies. Aluminum tetra-3 sulfonyl chloride phthalocyanine (PC) or rhodamine sulfonyl chloride were directly coupled to antibodies by a sulfonamide linkage and AlSPc or carboxyfluorescein were encapsulated in liposomes of the small unilamellar vesicle type (SUV) bearing antibody. Antibody E7 (IgM subclass), which recognized an antigenic determinant expressed on 647V but was absent on T24 a control human bladder carcinoma cell line, and a control IgM antibody were used. The effects of the two types of conjugate were compared. Immunofluorescence studies on living cells demonstrated specific cell surface localization of conjugates at 4 degrees C and internalization at 37 degrees C. Phototoxicity was measured by 3-(4,5-dimethylthiazol-2-5-diphenyltetrazolium) bromide assay after exposing AlSPc-sensitized cells to red light. Significant AlSPc dose-dependent phototoxicity of the order 4 degrees C < 4 degrees C plus 37 degrees C < 37 degrees C was observed with E7-SUV and E7-PC in the range 1-8 microM AlSPc. At equimolar AlSPc doses absolute toxicity was similar for the two conjugate types, but at equimolar antibody doses, the liposomal conjugate was more effective by up to 13-fold. Addition of urine during illumination decreased toxicity, which was attributed to the presence of protective elements. The results suggest that photosensitizers such as AlSPc could be used for antibody-directed therapy and in particular for selectively damaging tumor cells of the epithelial cell compartment in bladder carcinoma by intrabladder administration. The therapeutic ratio, which takes into account both specific and nonspecific toxicity, was greater for the liposome conjugate than for the direct conjugate indicating their greater suitability for in vivo instillation.

Bladder tumours in Chinese: a 6 year study

Specimens from 334 Chinese patients who underwent surgical treatment for bladder tumours over a 6 year period were studied retrospectively. Transitional cell carcinoma (TCC) accounted for 91.3% of all the bladder tumours. The male to female ratio was 3:1 and the mean age was 69 years. Papillary TCC, which represented 67.5% of all TCC, were more often of a lower grade compared to non-papillary tumours. The staging of tumours was done for the 102 cystectomy specimens with TCC only. Among these, 28% were superficial while 72% were muscle-invasive and the papillary TCC usually presented at an earlier stage. Infiltration into the prostate gland was identified in 11% of male patients while coexisting adenocarcinoma of the prostate was observed in another 4.2%. Other types of carcinoma were uncommon. Squamous cell carcinoma, adenocarcinoma and small cell carcinoma accounted for 2.7, 1.8 and 0.6% of all bladder tumours, respectively. A rare case of sarcomatoid carcinoma was also found, but no true sarcoma was documented in this series. Benign lesions included five inverted papillomas, three nephrogenic adenomas, two paragangliomas and one haemangioma.

Concurrent mutations of coding and regulatory sequences of the Ha-ras gene in urinary bladder carcinomas

This report concerns the study of Ha-ras gene mutations and ras p21 expression in primary tumors of the urinary bladder. Polymerase chain reaction-based techniques and computerized image analysis were used. The data obtained were related to tumor grade, DNA ploidy, and tumor invasion. A point mutation (G-->T) at Ha-ras codon 12 was found in 30 of 67 tumors. The mutation frequency was greater in grade III (65%) than in grade II (44%) tumors; no mutations were observed in grade I tumors. The mutation was observed more often in aneuploid (58%) than in diploid (28%) tumors. No other substitution at codon 12 was seen and no codon 61 mutation was detected. The tumors were also tested for the A-->G mutation at position 2719 of Ha-ras intron D. Concurrent codon 12 and intron D mutations were identified in seven high-grade aneuploid tumors; six were invasive. The levels of the ras gene product p21 were approximately 10 times higher in tumors with intron D mutation than in those without. These findings confirm on human bladder tumors the observations of the effect of synchronous exon-intron mutations reported on the bladder cancer cell line T24. Our results are the first demonstration of Ha-ras intron D alterations in human tumor tissues and suggest that concurrent mutations at codon 12 and intron D of this gene within the same tumor may contribute to the aggressive behavior of human bladder carcinomas.

Prognostic factors in bladder carcinoma: histologic parameters and expression of a cell cycle-related nuclear antigen (Ki-67)

A total of 316 biopsies from patients with bladder carcinoma who entered a trial of the genito-urinary group of the European Organization for Research and Treatment of Cancer (EORTC) were reviewed. The histological data were subsequently correlated with the clinical course. A strong correlation between the number of mitoses and the time of first recurrence, muscle invasion, and death was noted. Next the expression of Ki-67 in frozen sections from 49 transitional cell carcinomas (TCCs) and the DNA content of the tumour cells were determined. The frequency of Ki-67-positive tumour cells increased with tumour grade and stage. Grade II TCCs and superficially infiltrating TCCs showed a wide range of Ki-67 scores. There was a significant difference in Ki-67 score between non-infiltrating (Ta) and superficially infiltrating (T1) grade II TCCs. All DNA-aneuploid carcinomas but also 15 out of 36 DNA-diploid tumours contained more than 10 per cent Ki-67-positive cells. Only some of these tumours were DNA-aneuploid or -tetraploid. The results indicate that the number of Ki-67-positive cells in grade II tumours may be a useful aid in separating grade II TCCs with a favourable prognosis from those with a poor clinical outcome.

Papillary tumors of the bladder

The most common neoplasms of the urinary bladder are papillary tumors that vary histologically and cytologically from very well differentiated to highly anaplastic patterns. Biologic behavior of these tumors is closely correlated with morphology, so that cytologically benign tumors (papillomas) are benign in behavior, and increasing anaplasia is associated with increasing clinical aggressiveness. By this definition, 20% or more of bladder tumors should be classified as papillomas. The development of carcinoma occurs in a series of steps, progressing through atypia and carcinoma in situ to invasion. Finally, evidence is presented to show that invasive carcinoma often begins from areas of flat carcinoma in situ associated with, but not within, co-existing papillary tumors.

Bladder cancer from a perspective of 40 years

The key events leading to a better understanding of the natural history of urothelial tumors of the bladder are summarized. These were: the recognition of flat carcinoma in situ and related lesions (intraurothelial neoplasia) as principal sources of invasive cancer; identification of the unique structure of the urothelium; analysis of DNA content and the recognition of two pathways of urothelial tumors. A brief comment on the current status of immunologic and molecular genetic markers is appended.

Pathology of carcinoma in situ of the urinary bladder and related lesions

In the United States, nearly all cases of bladder cancer are of the transitional cell type, and epidemiological evidence indicates that among these, approximately 80% present initially as more or less well-differentiated, superficial papillary neoplasms with a tendency for multifocal or diffuse involvement of the urothelial surface and/or recurrent tumor episodes, but with limited potential for invasive growth or a lethal outcome. Bladder tumors with lethal potential generally begin as poorly differentiated, sessile growths that are usually invasive at first diagnosis. Carcinoma in situ is a change that must be elicited among intact surface cells before progressive proliferation results in a tumor mass. Evidence for such an association is both temporal and spatial. Since most transitional cell carcinomas begin as well-differentiated tumors, i.e., resembling normal urothelium, recognition of early neoplastic alteration before a papillary structure forms is unlikely and most of the evidence is spatial based upon urothelial changes adjacent to papillary tumors. The morphologic definition of carcinoma in situ is arbitrary and generally defined as a total replacement of the urothelial surface by cells which bear morphologic features of carcinoma, but which lack architectural alteration other than an increase in the number of cell layers, i.e., a flat lesion. The Union Internationále Contra Cancer/American Joint Committee on Cancer (UICC/AJCC) staging scheme for bladder cancer distinguishes non-invasive papillary growths as Ta and carcinoma in situ as Tis. Because detection of carcinoma in situ, either by cytology or biopsy, depends upon recognizable malignant morphologic characteristics, studies of the lesion tend to be limited to the higher grade or more anaplastic examples.(ABSTRACT TRUNCATED AT 250 WORDS)

ras gene alterations in invasive and non-invasive rat bladder carcinomas induced by N-methyl-N-nitrosourea

We have established a reliable method to induce invasive and non-invasive carcinomas in the heterotopically transplanted urinary bladder of rats by repeated injection of N-methyl-N-nitrosourea (MNU), and examined the alterations of the ras oncogenes and ras oncogene product (p21) in the induced tumours. The incidence of muscle-invasive carcinomas was proportional to the total dose of MNU. When 5, 6 or 12 doses of MNU were used, muscle invasive carcinomas developed in 22, 58 or 45% of animals, respectively, after a mean observation period, respectively, of 54 +/- 9, 45 +/- 13 and 38 +/- 3 weeks. Whereas activated H-ras gene was detected in only one non-invasive carcinoma by DNA transfection assay, seven of 18 non-invasive and invasive carcinomas showed activated ras p21 when examined by immunoblot analysis. Amplification or rearrangement of myc or epidermal growth factor (EGF) receptor gene was not observed. The results indicate that alterations of ras gene may be involved in the development of rat bladder carcinomas but not of invasiveness.

Time- and dose-dependent induction of invasive urinary bladder cancers by N-ethyl-N-(4-hydroxybutyl)nitrosamine in B6C3F1 mice

A sequential investigation of N-ethyl-N-(4-hydroxybutyl)nitrosamine (EHBN) bladder carcinogenesis was performed in male B6C3F1 mice maintained ad libitum on tap water containing 0.025% EHBN for 4, 12, 20, 28 and 36 weeks. A total of 81 invasive tumors, comprising 55 squamous cell carcinomas (SCCs) (68%), 25 transitional cell carcinomas (TCCs) (31%) and 1 adenocarcinoma (1%) were found. Of these, 23 (22 SCCs and 1 TCC) demonstrated invasion to the prostate, 3 metastasized to the lung, and 2 spread by peritoneal seeding. The anaplastic grade and extent of invasion of the SCCs significantly exceeded those of the TCCs. The results suggested a histogenetic pathway from simple dysplasia through papillary or nodular dysplasia and/or carcinoma in situ to eventual development of invasive carcinomas.

Urothelial cancer in white and Japanese patients in Hawaii: pathology

The sites, growth patterns, histological grades and degrees of invasion of urothelial tumors were assessed among white and Japanese patients in Hawaii. Tissues were available from 225 white and 164 Japanese patients, representing virtually all of the urothelial tumors from these races entered into the Hawaii Tumor Registry for Oahu island between 1977 and 1986. No statistically significant interracial differences emerged from the analysis. Grade 1 papillary tumors were the most numerous types encountered, consisting of 43% of the urothelial tumors in men of both races, and 37.5% in white and 31% in Japanese women. Recently, observed increasing incidence trends of urothelial tumors among white men in the United States are associated with a synchronous decrease in mortality trends. Our analysis indicates that these diverging trends cannot be accounted for by increased numbers of noninvasive papillary tumors.

The dangers of a long urological waiting list

Statistics on urological waiting lists suggest that there is considerable regional variation in delay before treatment. This clearly depends on many factors but is unlikely to indicate significant variation in morbidity either at presentation or during subsequent admission for surgery. Managers and politicians should be extremely wary if encouraged to base major changes in distribution of funding and equipment on a casual examination of waiting list figures. It is doubtful if delay in diagnosis or treatment seriously influences morbidity and mortality from urological illness.

Muscle-invasive bladder cancer: does it arise de novo or from pre-existing superficial disease?

This study examines the clinical and pathologic features of 20 consecutive patients with muscle-invasive bladder cancer diagnosed between January 1, 1983, and December 31, 1984, at The Mount Sinai Hospital. On retrospective analysis, 18 patients (90%) had muscle-invasive bladder cancer at their initial presentation. The interval between onset of symptoms and histologic documentation of cancer was less than two months in 14 cases (78%), and in the remaining 22 per cent, the intervals of six, six, twelve, and twenty-four months were attributable to delay in seeking medical attention or delay in biopsy. In contrast, in the 2 patients who had presented with superficial tumors, the intervals were thirteen and one hundred eighty months. It therefore appeared that most patients with invasive bladder cancer had no therapeutically significant prior clinical or symptomatic history of superficial disease, and that invasion either was already present when symptoms had begun, or occurred rapidly after symptoms had initially appeared. These findings confirm the broad applicability of this pattern of bladder cancer in the general population, thereby complementing similar findings reported in recent years by secondary referral centers.

Can cytomorphometry replace histomorphometry for grading of bladder tumours?

Cytomorphometry, using various cytopreparatory techniques on bladder washings and histomorphometry on the resected bladder tumours, was used in an attempt to answer the question: Can cytomorphometry replace histomorphometry for grading of bladder tumours? For the analysis of quantitative data, a probit model was used. Three out of the four cytomorphometric methods provided data supportive to the histomorphometry. Using one of the four cytomorphometric methods was sufficient to enhance grading accuracy and all were equally good. Two cases of high grade carcinoma in situ were properly identified by cytomorphometry (as judged on the follow-up data) but the concurrent resected papillary tumours were low grade. These findings indicate that cytomorphometry is a useful method in bladder tumour grading. In some cases it is preferable to histomorphometry.

Transitional cell neoplasms of the urinary bladder. Can biologic potential be predicted from histologic grading?

The concept that most transitional cell neoplasms of the urinary bladder exist as either nonaggressive lesions of low cytologic grade or aggressive anaplastic cancers is gradually gaining acceptance. The extent to which the biological potential of these neoplasms is revealed in their pathologic features is the subject of this article. Using guidelines developed in experimental models, a series of 400 transitional cell neoplasms selected for long-term follow-up were classified into the WHO system. The results indicate that (1) almost all transitional cell tumors can be grouped into low and high grades at initial presentation; (2) the low grade lesions (usually designated transitional cell carcinoma, Grade I) are benign and should be called papillomas rather than carcinomas; (3) the risk of progression is not a function of the number of recurrences for these noninvasive, low-grade, papillary tumors; (4) the high-grade neoplasms are aggressive whether papillary or nodular and account for greater than 93% of tumor-related deaths; (5) patients with high-grade lesions have a reduced life expectancy even if progression does not occur; (6) depth of invasion and growth pattern are limited as predictive factors compared with histologic grade; (7) histologic grading of the initial tumor tissue can be highly predictive of outcome.

Prostatic involvement in bladder cancer. Prostate mapping in 20 cystoprostatectomy specimens

Twenty prostate glands from patients with either high-grade papillary tumors (19 patients, 15 of whom also had peripheral carcinoma in situ) or multifocal carcinoma in situ (1 patient) of the bladder who underwent cystoprostatectomy were studied histologically by mapping. Prostatic duct involvement by urothelial carcinoma was noted in nine patients, two with extensive involvement and seven with focal involvement confined to periurethral ducts. Carcinoma in situ of the bladder was observed in each of the nine patients and intraepithelial permeation appeared to be the predominant manner of spread of cancer cells into the prostate. The prostatic involvement was clinically silent and it may be a potential source of failure of conservative modalities of treatment of high-grade bladder cancer. A routine diagnostic transurethral prostatic biopsy may be recommended in the workup of patients with carcinoma in situ and high-grade carcinomas of the bladder. An incidental observation was the presence of 14 occult prostatic adenocarcinomas.

Strain differences in mice with invasive bladder carcinomas induced by N-butyl-N-(4-hydroxybutyl)nitrosamine

Papillary superficial and nonpapillary invasive bladder carcinomas of humans are two disease entities exhibiting completely different biological behavior. Studies were performed on the susceptibilities of various strains of mice to induction of bladder carcinomas by N-butyl-N-(4-hydroxybutyl)nitrosamine (BHBN), and the type of carcinomas that developed. BHBN at concentrations of 0.05% and 0.01% in drinking water was given to female mice of strains A/Jax, AKR/Jax, C3H/He, DBA/2, and C57BL/6 for 22 weeks. The incidence of nonpapillary invasive bladder carcinomas in these strains was 40%, 100%, 100%, 89%, and 89%, respectively, in groups treated with 0.05% BHBN and 30%, 60%, 60%, 90%, and 40%, respectively, in groups treated with 0.01% BHBN. At both levels BHBN and in all strains the bladder carcinomas induced were of the nonpapillary invasive type.

Connective tissue stroma in bladder papillary transitional cell carcinoma, carcinoma in situ and benign cystitis

The stromal characteristics in papillary and non-papillary tumours of the urinary bladder were investigated in an attempt to improve the accuracy of histopathological diagnosis. It appeared to be possible to differentiate true papillary tumours from pseudopapillary structures lined by carcinoma in situ. Stromal differences were not found in cases of carcinoma in situ accompanied by denuding cystitis and cystitis due to other aetiological factors. It is concluded that histopathological examination of the stroma of bladder tumours improves diagnostic accuracy.

Urothelial dysplasia and carcinoma in situ of the bladder

Urothelial cells were pepsin-extracted from paraffin-embedded specimens taken from human nontumorous bladder mucosa, dysplasia, and carcinoma in situ. After Feulgen staining for DNA, nuclei were measured with an integrating microdensitometer. The measurements show that normal urothelium consists mostly of diploid nuclei. Dysplasia means that there is a predominance of tetraploid DNA values, whereas carcinoma in situ is characterized by a high percentage of aneuploid cells. In both dysplasia and carcinoma in situ there is a considerable percentage of diploid nuclei. Thus, DNA cytophotometry can be used for standardization of preneoplastic and early stages of tumor development in bladder cancer.