Pathologic evaluation of radical cystectomy specimens

Expression of Rab1A in bladder cancer and its clinical implications

Rab1A protein has been identified to be highly expressed in a number of malignant tumor tissues and to participate in the regulation of tumor development, but no data concerning bladder cancer have been described at present. The present study measured the expression of Rab1A in bladder cancer tissues and cell lines, and analyzed its clinical significance for patients with bladder cancer. A total of 153 pairs of bladder cancer tumor tissues and adjacent cancer healthy tissues were included in the present study. Western blot analysis and immunohistochemistry were used to measure the expression of Rab1A protein in normal bladder and bladder cancer cell line, and bladder cancer and normal adjacent tissues. SPSS 20.0 software was used for statistical analysis and mapping of survival curves in patients with bladder cancer. The expression levels of Rab1A protein in normal bladder cells and tissues was significantly decreased compared with that in bladder cancer cells and tissues, and it was significantly associated with tumor size, histological grade, tumor-node-metastasis (TNM) stage, lymph node metastasis and remote metastasis in 153 patients with bladder cancer. Cox regression analysis demonstrated that the expression of Rab1A protein in bladder cancer tissues was an independent risk factor for prognosis (overall risk=0.549; 95% confidence interval=0.139-0.916). The 5-year survival rate of patients with bladder cancer with high expression levels of Rab1A protein was 48.613%, which was significantly decreased compared with the rate of patients with low expression 75.31% (P<0.05). The expression of Rab1A in bladder cancer tissues and cell lines was upregulated, and its expression increased with increasing TNM stages. It was also associated with the metastasis of tumor cells and negatively affected the survival time of patients with bladder cancer.

Bladder Neck Urothelial Carcinoma: A Urinary Bladder Subsite Carcinoma With Distinct Clinicopathology

To evaluate the clinicopathology of carcinomas originating in the urinary bladder neck, 316 cystectomies for urinary bladder carcinoma performed between January 1, 2008, and December 31, 2013, were analyzed. Clinicopathological parameters were compared between bladder neck carcinomas (BNCs) and non-BNCs. Among the 316 cystectomies were 19 BNCs and 297 non-BNCs. BNCs accounted for 19/316 (6%) of all the cases, with a male-to-female ratio 18:1. Bladder neck location was significantly associated with advanced tumor stage. Ninety percent and 58% BNCs presented at stage ≥T2 and ≥T3, respectively, versus 62% and 38% non-BNCs at ≥T2 and ≥T3, respectively. Significantly higher percentage of lymphovascular invasion and lymph node metastasis were also seen in BNCs (68% and 47%, respectively) than in non-BNCs (29% and 17%, respectively). In conclusion, BNCs present with a significantly higher frequency of muscle invasion and advanced tumor stage, lymphovascular invasion, as well as local and distant metastasis at diagnosis compared with the non-BNCs group. Recognition of these unique clinicopathologic features with early detection and possibly more aggressive management of BNC can potentially have a significant impact on the patient's outcome.

Robotic-assisted laparoscopic radical cystectomy: history, techniques and outcomes

OBJECTIVE

Robotic-assisted radical cystectomy (RARC) is a less invasive means of performing the radical cystectomy operation, which holds promise for improved patient morbidity. We review the history, technique and current literature pertaining to RARC and place the current results in context with the open procedure.

METHODS

All articles regarding RARC found in PubMed after January 2000 were examined. We selected articles that appeared in high-impact journals, had large patient population size (>80 patients), or were novel in technique or findings. We chose key laparoscopic articles to give reference to the history in transition to robotic radical cystectomy. In addition, we chose classic articles from open radical cystectomy to give reference regarding the newer robotic perioperative outcomes.

RESULTS

Studies suggest that a 20-patient learning curve is needed to reach an operative time of 6.5 h, with 30 surgeries performed to reach lymph node counts in excess of 20 (International Robotic Cystectomy Consortium). The only randomized surgical trial comparing open and robotic techniques showed equivalent lymph node yield, which may be surgeon and volume dependent. Literature demonstrates lower estimated blood loss, transfusion rates, early return of bowel function and decreased complications in early small series.

CONCLUSION

RARC and urinary diversion are still early in development and limited to centers with extensive robotic experience and volume, although adoption of the robotic approach is becoming more common. Early studies have shown promise to reduce complications with equivalent oncologic results.

Pelvic lymphadenectomy during radical cystectomy: a review of the literature

Currently, radical cystectomy associated with pelvic lymph node dissection is the gold standard surgical treatment for muscle invasive bladder cancer. However, although there is consensus on the need for pelvic lymph node dissection, controversies still exist regarding its extent and exact role. Evidence from the literature is based on retrospective data from high volume, often multicentre studies. Different series report very different templates of lymphadenectomy, thereby complicating data analysis. Furthermore, morbidity related to lymphadenectomy does not seem to be influenced by the extent of the procedure. The role of the pathologist and the modality of node retrieval have a pivotal role in the quality of node assessment. Different prognostic factors regarding node status (number of nodes retrieved, lymphovascular invasion, lymph node density, extracapsular extension, gross node involvement, and extent of primary bladder tumour related to positive nodes) have been introduced and analysed, although the impact on staging and survival are still under investigation. The correct use and assessment of these prognostic factors should help to provide an accurate staging in order to identify those patients who need adjuvant therapy. Future studies should, therefore, be prospective and include all information achievable from a lymphadenectomy.

Standardization of radical cystectomy and pelvic lymph node dissection for bladder cancer: a collaborative group report

PURPOSE

We propose standards for radical cystectomy and pelvic lymph node dissection in the surgical treatment of patients with invasive bladder cancer.

MATERIALS AND METHODS

We compiled the consecutive cystectomy experience of 16 experienced surgeons during the last 3 years (2000 to 2002) from 4 institutions. We evaluated patient, tumor and surgical variables of margin status, extent of pelvic node dissection, number of nodes examined and surgeon volume associated with bladder cancer outcomes.

RESULTS

A total of 1,091 cystectomy cases were evaluated. Surgical margins and number of nodes retrieved correlated with patient age, prior treatments, pathological tumor stage and extent of node dissection, but not surgeon volume.

CONCLUSIONS

Standards for radical cystectomy can be established and achieved by experienced surgeons operating on patients presenting with diverse clinical situations.

Extended Radical Lymphadenectomy in Patients With Urothelial Bladder Cancer:: Results of a Prospective Multicenter Study

PURPOSE

Previous studies demonstrate a positive correlation between postoperative survival and the extent of pelvic lymphadenectomies in patients with bladder cancer. However, the distribution of nodal metastases has not been examined in sufficient detail. Therefore, we conducted a comprehensive prospective analysis of lymph node metastases to obtain precise knowledge about the pattern of lymphatic tumor spread.

MATERIALS AND METHODS

Between 1999 and 2002 we performed 290 radical cystectomies and extended lymphadenectomies. Cranial border of the lymphadenectomy was the level of the inferior mesenteric artery, lateral border was the genitofemoral nerve and caudal border was the pelvic floor. We made every effort to excise and examine microscopically all lymph nodes from 12 well-defined anatomical locations.

RESULTS

Mean total number and standard deviation of lymph nodes removed was 43.1 +/- 16.1. Nodal metastases were present in 27.9% of patients. The percentage of metastases at different sites ranged from 14.1% (right obturator nodes) to 2.9% (right paracaval nodes above the aortic bifurcation). By studying cases of unilateral primary tumors or with only 1 metastasis we observed a preferred pattern of metastatic spread. However, there were many exceptions to the rule and we did not identify a well-defined sentinel lymph node.

CONCLUSIONS

We strongly recommend extended radical lymphadenectomy to all patients undergoing radical cystectomy for bladder cancer to remove all metastatic tumor deposits completely. The operation can be conducted in routine clinical practice and our data may serve as a guideline for future standardization and quality control of the procedure.

Pathologic evaluation of radical cystectomy specimens

BACKGROUND

The authors evaluated the pathology of radical cystectomy and pelvic lymph node specimens from patients with bladder carcinoma who were enrolled in a cooperative group trial. Their objective was to determine whether current practices conform to suggested pathology practice guidelines for reporting on radical cystectomy and pelvic lymph node specimens.

METHODS

Overall, 268 patients underwent radical cystectomy with pelvic lymph node dissection over 11 years in a total of 109 diverse geographic locations and types of institutions. Institutions included 50 community hospitals, 36 academic hospitals, and 23 Veterans Administration (VA)/military hospitals, which evaluated 84, 137, and 47 patients, respectively. The quality of pathology examination was assessed based on the original pathology reports of specimens that were submitted according to published practice guidelines.

RESULTS

Among all types of institutions, pathologic evaluation of radical cystectomy specimens generally was complete for tumor histology, grade, size, location, pathologic stage, lymph node status, prostate involvement, and associated mucosal abnormalities, including ureters and urethra. Perivesical fat (soft tissue) margins were not recorded in 10% of specimens, and 18% of patients did not mention either the presence or the number of lymph nodes. These deficiencies were observed primarily at community and VA hospitals.

CONCLUSIONS

The overall quality of pathologic examination of radical cystectomy specimens is high. Better reporting of soft tissue margin status and pelvic lymph node counts is needed to achieve compliance with the standards published by evolving practice protocols. Standardized pathologic evaluation and reporting of radical cystectomy specimens will optimize important prognostic information and foster better communication between the pathologist, surgeon, and interested oncologists to benefit patients.

The role of lymphadenectomy in renal cell carcinoma

The standard of care for localized and metastatic renal cell carcinoma includes a nephrectomy. The potential benefits for lymphadenectomy include more accurate staging, decreased risk of local recurrence, and improved survival. However, the benefits of lymph node dissection have not been proven.