Surveillance of urothelial carcinoma: stage and grade migration, 1993-2005 and survival trends, 1993-2000

Unmarried Status Effect on Stage at Presentation and Treatment Patterns in Non-Metastatic Upper Tract Urothelial Carcinoma Patients

BACKGROUND

Unmarried status has been associated with higher proportions of locally advanced stage and lower treatment dose intensification rates in several urological and non-urological malignancies. However, no previous investigators focused on the association between unmarried status and advanced stage (T3-4N0-2) at presentation and lower nephroureterectomy (RNU) and systemic therapy (ST) rates in non-metastatic upper tract urothelial carcinoma (UTUC) patients.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database 2000-2020, all non-metastatic UTUC patients were identified. Multivariable logistic regression models (LRMs) tested for differences in stage at presentation and treatment (RNU and ST) according to marital status (married vs unmarried), in a sex-specific fashion.

RESULTS

Of all 8544 non-metastatic UTUC patients, 4748 (56%) were male vs 3190 (44%) were female. Of all 4748 male UTUC patients, 1191 (25%) were unmarried. Of all 3190 female UTUC patients, 1608 (50%) were unmarried. In multivariable LRMs predicting RNU, unmarried status was an independent predictor of lower RNU rates in male (Odds Ratio [OR]: 0.56; P < .001), but not in female (OR: 0.81; P = .1) non-metastatic UTUC patients. In multivariable LRMs predicting ST exposure, unmarried status was an independent predictor of lower ST rates in both male (OR:0.73; P = .03) and female (OR:0.64; P < .001) UTUC patients. In multivariable LRMs predicting locally advanced stage (T3-4N0-2), unmarried status was not associated with an increased risk of locally advanced stage at presentation in either male (OR: 0.95; P = .5) or female (OR: 0.99; P = .9) UTUC patients.

CONCLUSIONS

Unmarried male UTUC patients appear at risk of less being able to access RNU, relative to their married counterparts. Moreover, unmarried UTUC patients appear to less benefit from ST, regardless of sex. Conversely, unmarried status was not associated with an increased risk of locally advanced stage at presentation in either male or female UTUC patients.

Adjuvant Chemotherapy for Upper Tract Urothelial Carcinoma: A Real-World, Retrospective Study

PURPOSE

The aim of this retrospective study was to evaluate the efficacy of adjuvant cisplatin-based chemotherapy in patients with locally advanced upper tract urothelial carcinoma (UTUC), administered following radical nephroureterectomy.

MATERIALS AND METHODS

Patients with UTUC, arising from renal pelvis or ureter, staged pT3/T4 or N+ were treated with adjuvant chemotherapy following surgery. The chemotherapy consisted of gemcitabine 1,000 mg/m2 on days 1 and 8, cisplatin 70 mg/m2 on day 1. Treatment was repeated every 3 weeks for up to 4 cycles. Endpoints included disease-free survival (DFS), metastasis-free survival (MFS), and safety.

RESULTS

Among 89 eligible patients, 85 (95.5%) completed at least 3 cycles of adjuvant chemotherapy. Chemotherapy was well tolerated, the main toxicities being mild-to-moderate gastrointestinal toxic effects and pruritus. With a median follow-up of 37 months, median DFS was 30 months (95% confidence interval, 22 to 39), and the median MFS was not reached. The 3-year DFS and MFS were 44% and 56%, respectively. Multivariate analyses revealed that the main factor associated with DFS and MFS was the lymph node involvement, whereas age, T category, grade, or the primary site of UTUC were not significantly associated with DFS or MFS.

CONCLUSION

Adjuvant cisplatin-based chemotherapy after radical surgery of pT3/T4 or N+ UTUC was feasible and may demonstrate benefits in DFS and MFS. Whether novel agents added to the chemotherapy regimen, as a concurrent combination or maintenance, impacts on survival or reduces the development of metastases remains to be studied.

Intravesical Gemcitabine and Docetaxel Therapy for BCG-Naïve Patients: A Promising Approach to Non-Muscle Invasive Bladder Cancer

Bacillus Calmette-Guérin (BCG) therapy for patients with non-muscle invasive bladder cancer (NMIBC) faces limitations in efficacy and significant side effects, aggravated by a recent global shortage. In this prospective clinical study, we report the outcomes of sequential intravesical administration of gemcitabine and docetaxel (Gem/Doce) as a first-line treatment for BCG-naïve patients with high-risk NMIBC (HR NMIBC). From October 2019 until April 2022, we enrolled 52 patients and followed the treatment protocol set forth by the University of Iowa. Follow-up assessments were conducted every 3 months. In this cohort, 25 (48.1%) patients were diagnosed with high-grade T1 (T1HG) bladder cancer, 10 (19.2%) patients had carcinoma in situ (CIS), and 17 (32.7%) patients had a combination of T1HG+CIS. The median time to first recurrence in the T1HG, CIS, and T1HG+CIS groups was 11, 10.5, and 8.8 months, respectively. The recurrence-free survival was 98.1%, 94.2%, and 80.8% at 6, 9, and 12 months, respectively. The rate of progression-free survival was 100%, 98.1%, and 92.3% at 6, 9, and 12 months, respectively. We demonstrated the safety and efficacy of Gem/Doce therapy in BCG-naïve patients with HR NMIBC during a one-year follow-up. Further research with extended follow-ups, as well as direct comparisons of Gem/Doce with other anticancer agents, is essential.

Regional differences in upper tract urothelial carcinoma patients across the United States

BACKGROUND

It is unknown whether regional differences in patient, tumor, and treatment characteristics of upper tract urothelial carcinoma (UTUC) patients exist and may potentially result in regional overall mortality (OM) differences. We tested for inter-regional differences, according to Surveillance, Epidemiology, and End Results (SEER) registries.

METHODS

Using SEER database 2000 to 2016, patient (age, sex, race/ethnicity), tumor (location, grade) and treatment (nephroureterectomy, systemic therapy [ST]) characteristics of UTUC patients of all-stages were tabulated and graphically depicted in a stage-specific fashion (T1-2N0M0 vs. T3-4N0M0 vs. TanyN1-2M0/TanyNanyM1). Multivariable Cox regression (MCR) models tested for inter-regional differences in OM.

RESULTS

Regarding T1-2N0M0 patients, statistically significant differences existed for race/ethnicity (Caucasian 71 vs. 98%), location (renal pelvis: 55 vs. 67%), grade (high 60 vs. 83%) and ST (5.5 vs. 13.9%). In MCR models, registries 3 (Hazard ratio [HR]:1.39; P < 0.001) and 4 (HR:1.31; P = 0.01) independently predicted higher OM and Registry 8 (HR:0.64; P = 0.001) lower OM. Regarding T3-4N0M0 patients, statistically significant differences existed for race/ethnicity (Caucasian 70 vs. 98%), location (renal pelvis: 67 vs. 76%), grade (high 84 vs. 94%) and ST (18.7 vs. 29.5%). In MCR models, registries 3 (HR:1.42; P < 0.001) and 4 (HR:1.31; P = 0.009) independently predicted higher OM. Regarding TanyN1-2M0/TanyNanyM1 patients, statistically significant differences existed for location (renal pelvis: 63 vs. 82%), grade (high 92 vs. 98%) and ST (53.4 vs. 58.8%). In MCR models, Registry 3 (HR:1.37; P = 0.004) independently predicted higher OM and Registry 2, (HR:0.78; P = 0.02) lower OM.

CONCLUSIONS

Inter-regional differences were recorded in patients, tumor, and treatment characteristics. Even after adjustment for these characteristics, OM differences persisted which may be indicative of regional differences in quality of care or expertise in UTUC management.

A systematic review and meta-analysis on delaying surgery for urothelial carcinoma of bladder and upper tract urothelial carcinoma: Implications for the COVID19 pandemic and beyond

Purpose

The COVID-19 pandemic has led to competing strains on hospital resources and healthcare personnel. Patients with newly diagnosed invasive urothelial carcinomas of bladder (UCB) upper tract (UTUC) may experience delays to definitive radical cystectomy (RC) or radical nephro-ureterectomy (RNU) respectively. We evaluate the impact of delaying definitive surgery on survival outcomes for invasive UCB and UTUC.

Methods

We searched for all studies investigating delayed urologic cancer surgery in Medline and Embase up to June 2020. A systematic review and meta-analysis was performed.

Results

We identified a total of 30 studies with 32,591 patients. Across 13 studies (n = 12,201), a delay from diagnosis of bladder cancer/TURBT to RC was associated with poorer overall survival (HR 1.25, 95% CI: 1.09–1.45, p = 0.002). For patients who underwent neoadjuvant chemotherapy before RC, across the 5 studies (n = 4,316 patients), a delay between neoadjuvant chemotherapy and radical cystectomy was not found to be significantly associated with overall survival (pooled HR 1.37, 95% CI: 0.96–1.94, p = 0.08). For UTUC, 6 studies (n = 4,629) found that delay between diagnosis of UTUC to RNU was associated with poorer overall survival (pooled HR 1.55, 95% CI: 1.19–2.02, p = 0.001) and cancer-specific survival (pooled HR of 2.56, 95% CI: 1.50–4.37, p = 0.001). Limitations included between-study heterogeneity, particularly in the definitions of delay cut-off periods between diagnosis to surgery.

Conclusions

A delay from diagnosis of UCB or UTUC to definitive RC or RNU was associated with poorer survival outcomes. This was not the case for patients who received neoadjuvant chemotherapy.

Site-specific Risk Stratification Models for Postoperative Recurrence and Survival Prediction in Patients with Upper Tract Urothelial Carcinoma Undergoing Radical Nephroureterectomy: Better Stratification for Adjuvant Therapy

Background

Site-specific postoperative risk models for localized upper tract urothelial carcinoma (UTUC) are unavailable.

Objective

To create specific risk models for renal pelvic urothelial carcinoma (RPUC) and ureteral urothelial carcinoma (UUC), and to compare the predictive accuracy with the overall UTUC risk model.

Design, setting, and participants

A multi-institutional database retrospective study of 1917 UTUC patients who underwent radical nephroureterectomy (RNU) between 2000 and 2018 was conducted.

Outcome measurements and statistical analysis

A multivariate hazard model was used to identify the prognostic factors for extraurinary tract recurrence (EUTR), cancer-specific death (CSD), and intravesical recurrence (IVR) after RNU. Patients were stratified into low-, intermediate-, high-, and highest-risk groups. External validation was performed to estimate a concordance index of the created risk models. We investigated whether our risk models could aid decision-making regarding adjuvant chemotherapy (AC) after RNU.

Results and limitations

The UTUC risk models could stratify the risk of cumulative incidence of three endpoints. The RPUC- and UUC-specific risk models showed better stratification than the overall UTUC risk model for all the three endpoints, EUTR, CSD, and IVR (RPUC: concordance index, 0.719 vs 0.770, 0.714 vs 0.794, and 0.538 vs 0.569, respectively; UUC: 0.716 vs 0.767, 0.766 vs 0.809, and 0.553 vs 0.594, respectively). The UUC-specific risk model can identify the high- and highest-risk patients likely to benefit from AC after RNU. A major limitation was the potential selection bias owing to the retrospective nature of this study.

Conclusions

We recommend using site-specific risk models instead of the overall UTUC risk model for better risk stratification and decision-making for AC after RNU.

Patient summary

Upper tract urothelial carcinoma comprises renal pelvic and ureteral carcinomas. We recommend using site-specific risk models instead of the overall upper tract urothelial carcinoma risk model in risk prediction and decision-making for adjuvant therapy after radical surgery.

Evaluating the efficacy of secondary transurethral resection of the bladder for high-grade Ta tumors

PURPOSE

The need for secondary transurethral resection of the bladder (re-TURB) in patients with high-grade Ta tumors has not been assessed. This study aimed to compare the outcomes of patients with high-grade Ta tumors who did and did not undergo re-TURB.

MATERIALS AND METHODS

This study used data from the Seoul National University Prospectively Enrolled Registry for Urothelial Cancer-Transurethral Bladder Tumor Resection (SUPER-UC-TURB). Patients with high-grade Ta tumors who underwent TURB between March 2016 and December 2019 were included. Following the initial TURB, if the pathology results showed a tumor grade higher than high-grade Ta, re-TURB was performed according to the surgeon's recommendation. The recurrence-free survival rate was assessed by Kaplan-Meier analysis and Cox regression analysis between patients who did and did not undergo re-TURB.

RESULTS

In total, 187 patients with high-grade Ta who underwent initial TURB were included, of whom 115 underwent re-TURB and 72 did not. Patients in the re-TURB group had a significantly higher 2-year recurrence-free survival rate than did those in the no re-TURB group (81.3% vs. 60.1%; p=0.005). Whether patients underwent re-TURB was a significant predictor of the risk of bladder cancer recurrence in both the univariate (HR, 0.52; 95% CI, 0.27-0.98; p=0.044) and multivariate (HR, 0.41; 95% CI, 0.19-0.97; p=0.041) analysis.

CONCLUSIONS

The risk for bladder cancer recurrence was increased, and the 2-year recurrence-free survival was significantly decreased, in patients with high-grade Ta tumors who did not undergo re-TURB. Thus, re-TURB is beneficial in patients with high-grade Ta bladder cancer.

Uptake and outcomes of small intestinal and urinary tract cancer surveillance in Lynch syndrome

BACKGROUND

Lynch syndrome (LS) is a hereditary cancer predisposition syndrome associated with increased risk of multiple cancers. While colorectal cancer surveillance decreases mortality in LS and is recommended by guidelines, there is lack of evidence for the efficacy of surveillance for extra-colonic cancers associated with LS, including small intestinal cancer (SIC) and urinary tract cancer (UTC). Given the limited evidence, guidelines do not consistently recommend surveillance for SIC and UTC, and it remains unclear how often individuals will choose to undergo and follow through with extra-colonic surveillance recommendations.

AIM

To study factors associated with SIC and UTC surveillance uptake and outcomes in LS.

METHODS

This is an IRB-approved retrospective analysis of individuals with LS seen at a tertiary care referral center. Included individuals had a pathogenic or likely pathogenic variant in MLH1, MSH2, MSH6, PMS2, or EPCAM, or were a confirmed obligate carrier, and had at least one documented visit to our center. Information regarding SIC and UTC surveillance was captured for each individual, and detailed personal and family history was obtained for individuals who had an initial LS management visit in our center’s dedicated high-risk LS clinic between January 1, 2017 and October 29, 2020. During these initial management visits, all patients had in-depth discussions of SIC and UTC surveillance with 1 of 3 providers experienced in LS management to promote informed decision-making about whether to pursue SIC and/or UTC surveillance. Statistical analysis using Pearson’s chi-squared test and Wilcoxon rank-sum test was completed to understand the factors associated with pursuit and completion of SIC and UTC surveillance, and a P value below 0.05 was deemed statistically significant.

RESULTS

Of 317 individuals with LS, 86 (27%) underwent a total of 105 SIC surveillance examinations, with 5 leading to additional work-up and no SICs diagnosed. Additionally, 99 (31%) patients underwent a total of 303 UTC surveillance examinations, with 19 requiring further evaluation and 1 UTC identified. Of 155 individuals who had an initial LS management visit between January 1, 2017 and October 29, 2020, 63 (41%) chose to undergo SIC surveillance and 58 (37%) chose to undergo UTC surveillance. However, only 26 (41%) and 32 (55%) of those who initially chose to undergo SIC or UTC surveillance, respectively, successfully completed their surveillance examinations. Individuals with a pathogenic variant in MSH2 or EPCAM were more likely to initially choose to undergo SIC surveillance (P = 0.034), and older individuals were more likely to complete SIC surveillance (P = 0.007). Choosing to pursue UTC surveillance was more frequent among older individuals (P = 0.018), and females more frequently completed UTC surveillance (P = 0.002). Personal history of cancer and family history of SIC or UTC were not significantly associated with electing nor completing surveillance. Lastly, the provider discussing SIC/UTC surveillance was significantly associated with subsequent surveillance choices.

CONCLUSION

Pursuing and completing SIC/UTC surveillance in LS is influenced by several factors, however broad incorporation in LS management is likely unhelpful due to low yield and frequent false positive results.

Ocular Metastasis in Elderly Male Bladder Cancer Patients: Potential Risk Factors

Bladder cancer is a common type of tumor among elderly male population; it causes intraocular metastasis (IOM). The study investigated the differences between elderly male bladder cancer patients with and without IOM, and identified risk factors for IOM. In this study, 749 elderly male patients (aged ≥50 years) with bladder cancer were included from November 2003 to December 2016. Differences between the IOM and non-IOM (NIOM) groups were evaluated by chi-square test and Student’s t-test. The binary logistic regression analysis calculates the risk factors. Receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic value of IOM in elderly male patients with bladder cancer.

The incidence of IOM in patients with bladder cancer was 1.7%. No significant differences were detected in age and histopathology between the IOM and NIOM groups. According to the study, the IOM group had higher ALP and Cyfra21-1. Binary logistic regression indicated that ALP and Cyfra21-1 were risk factors for IOM in elderly male bladder cancer patients (p < .05). ROC curve analysis revealed area under the curve values for ALP and Cyfra21-1 of 0.913 and 0.814, using cutoff values of 9.65 and 83.5 U/L, respectively. The sensitivity and specificity values for ALP were 61.5% and 95.8%, respectively, while those for Cyfra21-1 were 84.6% and 73.3%.

The investigation indicates that ALP and Cyfra21-1 are risk factors for IOM in elderly male patients with bladder cancer and ALP is more reliable at distinguishing IOM from NIOM in elderly male patients with bladder cancer.

Bladder cancer trends in Latvia during 1990-2017: incidence, mortality, and survival rates

Introduction

The aim of this article was to evaluate bladder cancer (BC) incidence, mortality and survival trends in Latvia over the past 28 years.

Material and methods

Our study included patients diagnosed with BC between 1990 and 2017. The data were obtained from the national population-based cancer registry. Joinpoint regression analysis was used to identify points where a significant change in incidence and mortality trends occurred, accordingly with the patient’s gender and age. Relative survival (RS) was estimated by Ederer I and II methods.

Results

Altogether, 9589 patients with initial BC diagnosis were included in the study. The age-standardised (ASR) incidence rates (per 100,000) increased from 6.8 in 1990 to 12.5 in 2014 followed by a statistically insignificant decrease continuing up to 2017. The ASR BC mortality rates (per 100,000) also rose from 3.9 in 1990 to 4.4 in 2017. However, there was a decline in BC mortality trends in the age-group 40–59 with annual percentage change (APC) -1.1%. RS rates increased from 55.0 % in 1990–2000 to 59.0% in years 2013–2017.

Conclusions

This study revealed that the incidence and mortality rates have been gradually increasing over the past 28 years. The exception being cancer-specific mortality in the age group 40–59, which tends to decrease. Although the 5-year RS rates improved over the reviewed period, there is still plenty of room for improvement.

Stage Migration for Upper Tract Urothelial Cell Carcinoma

INTRODUCTION

Upper tract urothelial carcinomas (UTUCs) account for 5% to 10% of urothelial cancers. The phenomenon of stage migration in tumors has been evident with increased use and higher resolution of cross-sectional imaging. Using the National Cancer Database, we analyzed trends in stage at presentation and overall survival for UTUCs.

PATIENTS AND METHODS

We analyzed UTUCs in the renal pelvis or ureter from 2004 to 2016. Pathologic tumor stage data were available for 71.3% of patients and clinical tumor staging were available for 28.7% of patients. Five-year overall survival was analyzed comparing patients between 2004-2007 and 2008-2011. Tumor stage was categorized as early (0-1), intermediate (2-3), or late (4) for survival analyses. Linear regression and Kaplan-Meier analyses were utilized.

RESULTS

A total of 37,210 renal pelvic and 23,200 ureteral origin UTUC cases were evaluated. Stage migration toward stage 0 and stage 4 was observed. There was a significant increase in proportion of stage 0 Ta/Tis (22.8%-33.4%, R² = 0.86, P < .001) and stage 4 (22.3%-26.4%, R² = 0.57, P = .003) disease for renal pelvic tumors, and a significant decrease in stages 1, 2, and 3. For UTUCs of ureteral origin, diagnosis at stage 0 Ta/Tis (37.6%-44.7%, R² = 0.53, P = .005) and stage 4 (10.9%-14.6%, R² = 0.63, P = .001) increased significantly, with significant reductions in stage 1 and 2. There was no difference in 5-year overall survival for ureteral or renal pelvic UTUCs for patients during 2004-2007 versus 2008-2011 when stratified by early, intermediate, or late stage.

CONCLUSION

There is a stage migration toward stage 0 and stage 4 disease for UTUC. Five-year survival data from 2004 to 2011 remained stable across early, intermediate, and late stage groups.

Novel treatment of upper tract urothelial carcinoma in situ with docetaxel in BCG refractory patients

INTRODUCTION

Patients with upper-tract carcinoma in situ (UT-CIS) that have failed treatment with BCG are recommended for radical nephroureterectomy (RNU). We describe a cohort of patients with BCG-refractory UT-CIS that were treated with docetaxel, a novel agent in the approach to topical therapy.

METHODS

Patients with pathologically proven UT-CIS from 2012 to 2020 with an imperative indication for organ preservation and history of BCG-refractory disease were included. Each patient underwent ureteroscopy with biopsy and selective cytology pre- and postinduction, and after each maintenance course. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology, and absence of clinical progression. No response (NR) was defined as persistence of lesions after induction or absence of visualized lesions with persistently positive cytology.

RESULTS

Seven patients and 10 renal units were treated. Six of the 10 renal units had initial CR (60%). Three patients with NR went on to have RNU, one of which subsequently died due to cancer-specific mortality. One patient with bilateral disease had NR in 10 renal unit and cure in the other. This patient subsequently developed recurrence in his remaining renal unit. A second patient had CR in both kidneys for 6 years, but 1 year after finishing maintenance regimen developed HG disease in 1 ureter. Average follow-up was 33 months.

CONCLUSION

This study demonstrates efficacy of docetaxel as a treatment option for patients with UT-CIS with a contraindication to RNU after failing BCG. Response rates of 60% appear to be similar to those of BCG-refractory bladder CIS.

An evaluation of UGN-101, a sustained-release hydrogel polymer-based formulation containing mitomycin-C, for the treatment of upper urothelial carcinomas

INTRODUCTION

The treatment of low-grade upper tract urothelial carcinomas (UTUCs) after either surgery, or nephron-sparing techniques remains an unmet need in Genitourinary (GU) Oncology. UGN-101 is a novel drug in development for the treatment of UTUCs; it is composed of a sustained-release hydrogel polymer-based formulation containing the antitumor antibiotic mitomycin-C (MM-C); cold UGN-101 is liquid, but at body temperature, it becomes a gel, and thus, when administered through a ureteral catheter, it sticks to the upper tract urothelium, slowly releasing MM-C.

AREAS COVERED

Here, the authors review the preclinical rationale for the development of UGN-101, as well as presently available clinical results for the treatment of low-grade UTUCs.

EXPERT OPINION

The positive results of the recently completed OLYMPUS trial suggest the feasibility, activity (59% of complete responses, with just 6 of these complete responders on follow-up who recurred), and safety (68% of patients experiencing mild to moderate urinary adverse events) of UGN-101 instillations into the upper urinary tract. Our expectations are that UGN-101 will soon become a standard of treatment for low-grade UTUC at risk of relapse after either surgery, or nephron-sparing techniques.

Bladder cancer in patients younger than 40 years: outcomes from the National Cancer Database

PURPOSE

To evaluate the clinical, pathological, and survival outcomes of bladder cancer in patients aged 18-40 years.

METHODS

We identified 362,091 bladder cancer patients from the National Cancer Database between 2004-2013 and compared patients aged 18-40 years to those > 40 years of age with univariate analysis using Chi-square tests. A subset analysis was performed on patients who underwent cystectomy. Multivariable Cox regression was used for overall survival analysis.

RESULTS

Our final analysis included 314,177 patients with 3314 (1.1%) patients aged 18-40 years. Patients aged 18-40 years had a lower male-to-female ratio (2.4 versus 3.0), a greater proportion of low-grade tumors (72.7% versus 48.3%, p < 0.001), non-muscle invasive tumors (90.3% versus 81.2%, p < 0.001), and variant histology (4.0% versus 3.3%, p < 0.001). Similar trends were observed at cystectomy including lower male-to-female ratio in the 18-40 years group (1.7 versus 3.1), a greater proportion of variant histology (25.0% versus 10.0%, p < 0.001); and 53.3% of those younger patients with variant histology were women. Patients aged 18-40 years who underwent cystectomy had a higher proportion of locally advanced disease (pT4 19.2% versus 14.6%, p = 0.004). Multivariable analyses in both cohorts demonstrated that variant histology was a predictor of worse overall survival.

CONCLUSION

The majority of patients aged 18-40 years with bladder cancer present with low-grade, non-muscle-invasive disease associated with better survival. However, a subset of younger patients with a higher proportion of women presents with aggressive bladder cancer which may be partly explained by a higher prevalence of variant histology.

Lymphoepithelioma-like carcinoma of the upper urinary tract: A systematic review of case reports

BACKGROUND

Lymphoepithelioma-like carcinomas (LELCs) are rare, malignant epithelial tumors, generally considered a subtype of squamous cell carcinoma. LELCs are undifferentiated and can occur in multiple tissues, although LELCs in the urinary tract are extremely rare. As such, evidence does not provide clinicians with guidelines for the best practices. Even though this is a rare disease, it is associated with high morbidity and mortality. Therefore, we must learn to differentiate LELC types and identify risk factors for early identification.

AIM

To develop an evidence base to guide clinicians treating primary LELCs of the upper urinary tract (UUT-LELC).

METHODS

We performed a systematic review of all reports on UUT-LELC from the first published case in 1998 until October 2019, according to the PRISMA. A database was then developed by extracting data from previously published reports in order to analyze interactions between clinical characteristics, pathological features, interventions and outcomes. Survival was analyzed using Kaplan–Meier estimates, which were compared using log rank tests.

RESULTS

A total of 28 previously published cases were identified for inclusion. The median age was 72 years with a male to female ratio of 4:3. Pure type LELCs were most common with 48.3% (n = 14), followed by 37.9% (n = 11) predominant LELCs and 3.4% (n = 1) focal LELCs. Epstein-Barr virus testing was negative in all cases. Fourteen patients received radical nephroureterectomy (RNU)-based intervention. Twenty-three patients survived with no evidence of further metastasis, although six died before the median 18 mo follow-up point. Survival analysis suggests pure histological subtypes, and patients who receive complete tumor resection have more favorable prognoses. As always in cancer care, early identification generally increases the probability of interventional success.

CONCLUSION

The most effective treatment for UUT-LELC is RNU-based therapy. Since cases are few in number, case reporting must be enhanced and publishing encouraged to both save and prolong lives.

Bladder Cancer Stage Development, 2004-2014 in Europe Compared With the United States: Analysis of European Population-based Cancer Registries, the United States SEER Database, and a Large Tertiary Institutional Cohort

BACKGROUND

The purpose of this study was to analyze trends of bladder cancer (BC) stages and incidence in Europe and the United States (US).

MATERIALS AND METHODS

Tumor stages after radical cystectomy were assessed in a monocentric cohort from 2006 to 2016. BC incidence was assessed between 2004 and 2014 based on the German Center for Cancer Registry Data dataset at the Robert Koch Institute (n = 111,002), the Netherland Cancer Registry (n = 64,226), cancer registration statistics of England (n = 179,883), and the pooled data from the Scandinavian cancer registries, NORDCAN (n = 77,585) and the SEER (Surveillance, Epidemiology, and End Results) database (n = 184,519) for the complete populations and gender-specific subgroups. The average annual percent changes (AAPC) were used for statistical evaluation.

RESULTS

Non-muscle-invasive BC (NMIBC) and muscle-invasive BC (MIBC) did not change in the institutional cohort at the point of radical cystectomy. The incidence of total BC (AAPC, -0.3), NMIBC (AAPC, -0.1), and non-metastasized MIBC (AAPC, 0.1) did not change in Germany during the time period under survey. BC total incidence in the Netherlands did not change significantly. In England and the Nordic countries, the incidence of total BC increased (AAPC, 0.8 and 0.5, respectively). In contrast, both the incidence of total BC (AAPC, -1.4), NMIBC (AAPC, -1.6), and non-metastasized MIBC (AAPC, -1.6) significantly decreased in the US.

CONCLUSIONS

Between 2004 and 2014 the incidence of BC was significantly sinking in the US, was stable in Germany and the Netherlands, and increased in England and the Nordic countries. Predominantly, differences in the smoking prevalence within the last decades but also gender-specific factors might be responsible for this discrepancy.

Genomic distinctions between metastatic lower and upper tract urothelial carcinoma revealed through rapid autopsy

BACKGROUND

Little is known about the genomic differences between metastatic urothelial carcinoma (LTUC) and upper tract urothelial carcinoma (UTUC). We compare genomic features of primary and metastatic UTUC and LTUC tumors in a cohort of patients with end stage disease.

METHODS

We performed whole exome sequencing on matched primary and metastatic tumor samples (N=37) from 7 patients with metastatic UC collected via rapid autopsy. Inter- and intra-patient mutational burden, mutational signatures, predicted deleterious mutations, and somatic copy alterations (sCNV) were analyzed.

RESULTS

We investigated 3 patients with UTUC (3 primary samples, 13 metastases) and 4 patients with LTUC (4 primary samples, 17 metastases). We found that sSNV burden was higher in metastatic LTUC compared to UTUC. Moreover, the APOBEC mutational signature was pervasive in metastatic LTUC and less so in UTUC. Despite a lower overall sSNV burden, UTUC displayed greater inter- and intra-individual genomic distances at the copy number level between primary and metastatic tumors than LTUC. Our data also indicate that metastatic UTUC lesions can arise from small clonal populations present in the primary cancer. Importantly, putative druggable mutations were found across patients with the majority shared across all metastases within a patient.

CONCLUSIONS

Metastatic UTUC demonstrated a lower overall mutational burden but greater structural variability compared to LTUC. Our findings suggest that metastatic UTUC displays a greater spectrum of copy number divergence from LTUC. Importantly, we identified druggable lesions shared across metastatic samples, which demonstrate a level of targetable homogeneity within individual patients.

Outcomes of stage II-IV upper-tract urothelial carcinoma and adjuvant chemotherapy for locally advanced cancer

The present retrospective study aimed to examine the outcomes of stage II-IV upper-tract urothelial carcinoma (UTUC) and determine whether adjuvant chemotherapy is a beneficial treatment for patients with locally advanced UTUC (specifically, stage III-IV). The analysis included 126 patients with muscle-invasive UTUC who were treated between June 2003 and June 2012. All patients underwent laparoscopic or open nephroureterectomy and bladder cuff excision. Overall survival (OS), disease-free survival (DFS), distant metastasis-free survival (DMFS) and locoregional recurrence-free survival (LRFS) were assessed. Outcomes were compared between groups of patients with stage II (high-stage localized) disease, stage III-IV (high-stage locally advanced) disease treated with chemotherapy, and stage III-IV disease not treated with chemotherapy. Among patients with high-stage locally advanced UTUC (stage III-IV), those who received adjuvant chemotherapy had significantly better rates of OS (67.1 vs. 33.7%; P=0.004), DFS (70.2 vs. 46.0%; P=0.030) and DMFS (86.3 vs. 65.2%; P=0.048) at 5-years compared with those who did not undergo adjuvant chemotherapy. However, there was no significant difference between the 5-year LRFS rates in these two groups (78.2 vs. 62.5%; P=0.525). Importantly, the survival curve of patients with high-stage UTUC who received adjuvant chemotherapy was similar to that of patients with low-stage UTUC who underwent surgery only. Multivariate analysis revealed that adjuvant chemotherapy was an independent risk factor for OS [without adjuvant chemotherapy vs. with adjuvant chemotherapy: Hazard ratio (HR), 0.29; 95% confidence interval (CI), 0.129-0.654; P=0.003] and DFS (without adjuvant chemotherapy vs. with adjuvant chemotherapy: HR, 0.381; 95% CI, 0.168-0.865; P=0.021). In conclusion, adjuvant chemotherapy may improve the outcome for patients with high-stage locally advanced UTUC.

Recent advances in upper tract urothelial carcinomas: From bench to clinics

Urothelial carcinoma in the upper tract is rare and often discussed separately. Many established risk factors were identified for the disease, including genetic and external risk factors. Radiographic survey, endoscopic examination and urine cytology remained the most important diagnostic modalities. In localized upper tract urothelial carcinomas, radical nephroureterectomy with bladder cuff excision are the gold standard for large, high-grade and suspected invasive tumors of the renal pelvis and proximal ureter, whereas kidney-sparing surgeries should be considered in patients with low-risk disease. Advances in technology have given endoscopic surgery an important role, not only in diagnosis, but also in treatment. Although platinum-based combination chemotherapy is efficacious in advanced or metastatic disease, current established chemotherapy regimens are toxic and lack a sustained response. Immune checkpoint inhibitors have led to a new era of treatment for advanced or metastatic urothelial carcinomas. The remarkable results achieved thus far show that immunotherapy will likely be the future treatment paradigm. The combination of immune checkpoint inhibitors and other agents is another inspiring avenue to explore that could benefit even more patients. With respect to the high incidence rate and different clinical appearance of upper tract urothelial carcinomas in Taiwan, a possible correlation exists between exposure to certain external risk factors, such as arsenic in drinking water and aristolochic acid in Chinese herbal medicine. As more gene sequencing differences between upper tract urothelial carcinomas and various disease causes are detailed, this has warranted the era of individualized screening and treatment for the disease.

The global epidemiology of bladder cancer: a joinpoint regression analysis of its incidence and mortality trends and projection

We tested the hypotheses that the global incidence of bladder cancer was increasing but its mortality was reducing and its incidence was positively correlated with country-specific socioeconomic development. We retrieved data on age-standardized incidence and mortality rates/100,000 from the GLOBOCAN database in 2012. Temporal patterns were examined for 39 countries from the Cancer Incidence in Five Continents volumes I-X and other national registries. We evaluated the correlation between the incidence/mortality rates and Human Development Index (HDI)/ logarithmic values of Gross Domestic Product per capita (GDP). The average annual percent change of the incidence and mortality rates in the most recent 10 years was examined by joinpoint regression analysis. The highest incidence rates were observed in Southern Europe, Western Europe and North America. The mortality rates were the highest in Western Asia and Northern Africa. The incidence was positively correlated with HDI (r = 0.66 [men]; r = 0.50 [women]) and to a lesser extent logarithmic values of GDP per capita (r = 0.60 [men]; r = 0.50 [women], all p < 0.01). Many European countries experienced incidence rise. A substantial mortality reduction was observed in most countries, yet increases in mortality rates were observed in the Philippines and Iceland. These findings identified countries where more preventive actions are required.

Lower tract neoplasm: Update of imaging evaluation

Cancers of the lower urinary tract can arise from the bladder, urachus or urethra. Urothelial carcinoma of the bladder (UCB) is the most common of these. The presentation of bladder, urachal and urethral cancers can differ but many result in hematuria as an initial indication. The diagnosis and staging of these cancers often necessitate radiologic imaging often in the form of cross-section CT urography or MR urography. The following article reviews the specific nature of lower tract cancers and their imaging.

Preclinical Evaluation of Intravesical Cisplatin Nanoparticles for Non-Muscle-Invasive Bladder Cancer

Purpose: Prior clinical trials evaluating cisplatin for non-muscle-invasive bladder cancer (NMIBC) were stopped due to local and systemic toxicity. Currently, there is still a need for improved intravesical therapies, and nanoparticle-based CDDP may be efficacious without the toxicity of free cisplatin observed in the past.Experimental Design: Cisplatin nanoparticles (CDDP NPs) were developed using biocompatible poly(l-aspartic acid sodium salt; PAA), both with and without low and high grafting density of methoxy-polyethylene glycol (PEG). In vitro cytotoxicity studies confirmed activity of CDDP NPs and CDDP solution against a papillary bladder cancer cell line. Local toxicity was assessed by three weekly intravesical administrations of CDDP formulations. CDDP NPs and CDDP solution were evaluated for bladder absorption in murine models 1 and 4 hours after intravesical administration. In vivo efficacy was evaluated in an immunocompetent carcinogen model of NMIBC.Results: CDDP NPs showed decreased local toxicity, as assessed by bladder weight, compared with CDDP solution. Furthermore, >2 μg/mL of platinum was observed in mouse serum after intravesical administration of CDDP solution, whereas serum platinum was below the limit of quantification after intravesical administration of CDDP NPs. CDDP NPs provided significantly increased (P < 0.05) drug levels in murine bladders compared with CDDP solution for at least 4 hours after intravesical administration. In vivo, CDDP NPs reduced cancer cell proliferation compared with untreated controls, and was the only treatment group without evidence of invasive carcinoma.Conclusions: Cisplatin-loaded PAA NPs have the potential to improve intravesical treatment of NMIBC while reducing local and systemic side effects. Clin Cancer Res; 23(21); 6592-601. ©2017 AACR.

A critical prognostic analysis of neutrophil-lymphocyte ratio for patients undergoing nephroureterectomy due to upper urinary tract urothelial carcinoma

BACKGROUND

To determine preoperative serum complete blood count parameters that affects survival of patients who underwent surgery for upper urinary tract urothelial cancer (UUT-UC).

METHODS

Since 1990, 150 patients underwent nephroureterectomy with bladder cuff excision for UUT-UC at Hacettepe University. Patients with a history of muscle-invasive bladder cancer, adjuvant chemotherapy or metastasis at the time of diagnosis were excluded. One hundred and thirteen patients without infective symptoms and with a full set of serum data were evaluated retrospectively. Effects of the neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), and leukocyte count on disease-free survival (DFS) and progression-free survival (PFS) were investigated. Threshold values for each parameter to predict PFS were calculated.

RESULTS

The mean age and median follow-up were 63.7 ± 11.1 years and 34 (3-186) months, respectively. Male to female ratio was 86/27. The 5-years PFS (bladder recurrence was excluded) and DFS were 59.6 and 38.4%, respectively. In multivariate analysis, NLR was independent prognostic factor for PFS and DFS (p = 0.006 and p = 0.021, respectively) while LMR was prognostic only for PFS (p = 0.037).

CONCLUSION

For UUT-UC, NLR is a prognostic factor for PFS and DFS, while LMR is a prognostic indicator for PFS in present series.

Upper tract urothelial carcinomas: frequency of association with mismatch repair protein loss and lynch syndrome

Increased risk for upper tract urothelial carcinoma is described in patients with Lynch syndrome, caused by germline mutations in mismatch repair genes. We aimed to identify the frequency of mismatch repair protein loss in upper tract urothelial carcinoma and its potential for identifying an association with Lynch syndrome. We queried our database to identify upper tract urothelial carcinomas. Patients were cross-referenced for history of colorectal carcinoma or other common Lynch syndrome-associated neoplasms to enrich for potential Lynch syndrome cases. Tumor histopathologic characteristics were reviewed and each case was analyzed for loss of mismatch repair proteins, MLH1, MSH2, MSH6, and PMS2, by immunohistochemistry. Of 444 patients with upper tract urothelial carcinoma, a subset of 215 (encompassing 30 with upper tract urothelial carcinoma and another common Lynch syndrome-associated neoplasm) was analyzed for loss of mismatch repair protein expression. Of 30 patients with Lynch syndrome-associated neoplasms, six had documented Lynch syndrome, including two with Muir-Torre syndrome. Mismatch repair protein loss was identified in 7% of total upper tract urothelial carcinomas and 30% of patients with Lynch syndrome-associated neoplasms (including all patients with Lynch syndrome/Muir-Torre syndrome). Of patients without history of Lynch syndrome-associated neoplasms, 5 of 184 (2.7%) had loss of mismatch repair protein expression. Twelve cases with mismatch repair protein loss demonstrated loss of MSH2 and MSH6, and 2 had isolated loss of MSH6. MLH1 and PMS2 expression were consistently retained. Although increased intratumoral lymphocytes, inverted growth, pushing tumor-stromal interface, and lack of nuclear pleomorphism were more commonly seen in cases with mismatch repair protein loss, only intratumoral lymphocytes and presence of pushing borders were statistically significant. MLH1 and PMS2 testing appear to have little utility in upper tract urothelial carcinoma; however, mismatch repair protein loss of MSH2 and/or MSH6 by immunohistochemistry seems relatively sensitive and specific for identifying patients with potential Lynch syndrome.

Effect of contrast media on urinary cytopathology specimens

INTRODUCTION

Urological dogma dictates that washings collected from the urinary tract for cytological assessment must be performed without interference from contrast agents that may alter cellular integrity and diagnostic interpretation. In practice, the initial contrast used to outline the upper tracts is commonly discarded with subsequent saline washings sent for cytology. We hypothesize that contrast washings do not affect the morphology of urothelial carcinoma cells or the integrity of cytology interpretation.

METHODS

Samples obtained from (1) human bladder cell lines; (2) urine from a human xenograft bladder cancer model using UC-3 cells; and (3) patients with urothelial carcinoma were subjected to various experimental solutions (water, saline, urine, and dilutions of contrast media) for different exposure times. After exposure to various different solutions, samples underwent cytological analysis to assess morphologic and degenerative changes.

RESULTS

No cytological differences were seen when cells were exposed to ionic, hyperosmolar, or non-ionic low-osmolar contrast agents for any exposures up to five minutes. Cells exposed to mixtures of contrast agents and urine also demonstrated no evidence of degenerative change. Cells exposed to water for greater than one minute demonstrated significant hydropic degeneration impacting cytological interpretation. At 40 minutes or later, all reagents caused severe degeneration when evaluating urine samples from the mouse bladder cancer model and from patients undergoing urothelial carcinoma.

CONCLUSIONS

Commonly used contrast agents have no effect on urinary cytology up to five minutes. Contrast washings of the urinary tract should not be discarded and can be sent for cytological diagnosis if fixed within this time period.

Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline

PURPOSE

Although associated with an overall favorable survival rate, the heterogeneity of non-muscle invasive bladder cancer (NMIBC) affects patients' rates of recurrence and progression. Risk stratification should influence evaluation, treatment and surveillance. This guideline attempts to provide a clinical framework for the management of NMIBC.

MATERIALS AND METHODS

A systematic review utilized research from the Agency for Healthcare Research and Quality (AHRQ) and additional supplementation by the authors and consultant methodologists. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions.(1) RESULTS: A risk-stratified approach categorizes patients into broad groups of low-, intermediate-, and high-risk. Importantly, the evaluation and treatment algorithm takes into account tumor characteristics and uniquely considers a patient's response to therapy. The 38 statements vary in level of evidence, but none include Grade A evidence, and many were Grade C.

CONCLUSION

The intensity and scope of care for NMIBC should focus on patient, disease, and treatment response characteristics. This guideline attempts to improve a clinician's ability to evaluate and treat each patient, but higher quality evidence in future trials will be essential to improve level of care for these patients.

Comparison of clinicopathological features in metastatic upper tract urothelial carcinoma and urothelial bladder cancer

PURPOSE

To compare the characteristics of primary tumors, sites distribution of metastases and the metastasis-free interval (MFI) between metastatic upper tract urothelial carcinoma (UTUC) and urothelial bladder cancer (UBC), and evaluate the clinicopathological factors associated with MFI.

METHODS

We retrospectively reviewed 153 metastatic urothelial carcinoma patients consecutively registered at our hospital from 1997 to 2015, including 71 UTUC and 82 UBC, with a median follow-up of 18.3 months. MFI indicators were assessed by univariate and multivariate logistic regression analysis.

RESULTS

There were significant differences in median age at metastatic disease (p = 0.016), gender (p = 0.018), primary tumor size (p = 0.003), growth pattern (p < 0.001), grade (p < 0.001) and stage (p < 0.001) between metastatic UTUC and UBC. The median MFI of UTUC was dramatically shorter than that of UBC (6.1 vs. 17.4 months, p < 0.001). Univariate analysis revealed pathological stage was the only factor associated with the MFI of UTUC. Multivariate analysis showed that primary tumor grade was an independent inferior predictor for the MFI of UBC (HR 6.384, 95% CI 3.21-12.69, p < 0.001), while recurrence was an independent favorable factor for the MFI of UBC (HR 0.384, 95% CI 0.18-0.82, p = 0.014).

CONCLUSIONS

Compared to metastatic UBC, the primary tumors of metastatic UTUC were more invasive and the MFI was significantly shorter. Pathological stage was the only factor associated with the MFI in UTUC, while primary tumor grade and recurrence were independent factors for the MFI of UBC.

Pleomorphic giant cell carcinoma of the urinary bladder: an extreme form of tumour de-differentiation

AIMS

Vesical pleomorphic giant cell carcinoma (PGCC) is a variant of urothelial carcinoma (UC) characterized by highly pleomorphic tumour with giant cells. Fewer than 10 cases have been reported, and our aim was to determine the clinical and pathological features of a series of tumours from a specialized uropathology laboratory.

METHODS AND RESULTS

Thirteen cases of PGCC of the bladder were identified. There were nine males and four females, ranging in age from 53 to 92 years (mean 72 years). Associated conventional high-grade UC was seen in eight cases, while three cases also had micropapillary UC and one plasmacytoid UC. UC in situ (CIS) was present in five cases and occasional bizarre cells were seen in both UC and CIS. The proportion of PGCC present varied from 40% to 100% of tumour. Immunostaining performed on 10 cases showed uniform positivity for CK 8/18 and AE1/AE3, while most tumours were positive for CK7, CK20, uroplakin III and GATA binding protein 3 (GATA3). β-human chorionic gonadotrophin (β-hCG) was negative. Of 10 patients with follow-up, five died within 1 year and four are alive with tumour.

CONCLUSIONS

The association of PGCC with UC and an overlap in immunoexpression suggests that PGCC represents an extreme form of UC de-differentiation.

The Prognostic Significance of Inflammation-Associated Blood Cell Markers in Patients with Upper Tract Urothelial Carcinoma

BACKGROUND

Inflammation-related parameters based on blood cells, including white blood cell (WBC) count, neutrophil-lymphocyte ratio, platelet count, and red cell distribution width (RDW), have been shown to be associated with prognosis in many cancers. However, no previous study evaluated these inflammation-associated markers simultaneously in upper tract urothelial carcinoma (UTUC).

METHODS

A total of 195 patients with UTUC who received radical nephroureterectomy between 2005 and 2010 were included retrospectively as the derivation cohort to investigate the impact of inflammation markers on overall survival (OS) and cancer-specific survival (CSS). In turn, another independent set of 225 patients were used for validation. Finally, we performed survival analysis in the combined cohort consisting of 420 UTUC patients.

RESULTS

The predictive value of RDW and WBC count on outcome was replicable in different cohorts. Multivariate analysis showed high RDW was independently associated with poor OS (P < 0.001), and WBC count was a significant prognosticator for both OS and CSS (both P < 0.001). In subgroup analysis, we found the prognostic significance of RDW for OS was limited in organ-confined disease (≤pT2 without pN+). More importantly, a clear survival difference can be demonstrated by combining RDW and WBC count with other known prognostic factors in the risk stratification model.

CONCLUSIONS

RDW and WBC count have the advantage of their common accessibility and are useful markers to predict outcome of UTUC in the preoperative setting. RDW and WBC count could provide additional prognostic value and help physicians identify patients at high risk for mortality and formulate individualized treatment strategy.

Expression of bone morphogenetic protein-2 and -7 in urinary bladder cancer predicts time to tumor recurrence

INTRODUCTION

Urinary bladder cancer patients who have undergone transurethral resection of bladder tumor (TURBT) are at risk of recurrence. This study aims to correlate the level of bone morphogenetic protein (BMP) expression with urothelial carcinoma invasiveness, TNM stage and time to recurrence after TURBT.

MATERIAL AND METHODS

In 33 specimens of healthy transitional epithelium and 42 of urothelial carcinoma, BMP2, BMP4 and BMP7 expression was determined by real-time polymerase chain reaction. Patients who underwent TURBT were followed up for 1 year.

RESULTS

BMP2 and BMP7 were downregulated in infiltrating urothelial carcinoma, the relative expression being 0.76 (p = 0.04) and 0.28 (p = 0.025) respectively, while BMP4 was downregulated in non-invasive tumors. High expression of BMP2 and BMP7 correlated with prolonged time to recurrence (log-rank: p = 0.01 and p = 0.03 respectively).

CONCLUSIONS

Low expression of BMP2 and BMP7 is associated with shorter time to recurrence. The BMP expression levels are not indicative of tumor stage.

Ureterorenoscopy for upper tract urothelial carcinoma: how often are we missing lesions?

OBJECTIVE

To determine the ability of ureterorenoscopy (URS) to identify the precise number and location of all lesions as compared with pathologic review of nephroureterectomy specimens, which have not been previously determined. Upper tract urothelial carcinoma (UTUC) comprises 5% of all urothelial malignancies in the United States. With advances in endoscopic equipment, there has been a move toward using flexible ureteroscopes to perform URS as part of the diagnostic evaluation and management.

METHODS

We identified patients who had undergone URS with biopsy before radical nephroureterectomy for UTUC. Operative reports for each procedure were reviewed and compared with the surgical pathology reports.

RESULTS

URS correctly identified the number and location of lesions in 57 of 76 patients (75%). The most common locations for missed lesions were in the ureter (9 patients) and renal pelvis (8 patients). Carcinoma in situ was missed on the initial biopsy for 9 patients. Three of 11 patients (27%) with a solitary lesion in the distal ureter visualized by URS had a missed lesion in the renal pelvis. URS with biopsy accurately predicted the grade of UTUC lesions in 79% of cases, whereas 65% of patients were upstaged on final pathology.

CONCLUSION

URS with biopsy can accurately map UTUC in the majority of patients. However, up to 25% of patients will have missed lesions, and nearly 50% of these patients will have a missed carcinoma in situ lesion. Undergrading and understaging of UTUC lesions remain shortcomings with potentially severe consequences.

Sex differences in bladder cancer pathology and survival: analysis of a population-based cancer registry

Sex differences in bladder cancer pathology and epidemiology have been the focus of recent research. We investigated the epidemiological characteristics and compared bladder cancer pathology and survival between men and women in Japan. A total of 13,184 patients with primary bladder cancer diagnosed from 1954 to 2010 were identified in a large-scale cancer registry database in Kanagawa Prefecture. Using this database, we compared the odds ratios (ORs) for nonurothelial carcinoma (non-UC) using a multiple logistic regression model adjusted for age and diagnosis periods. We also compared hazard ratios (HRs) for overall death and cancer-specific death using a Cox proportional hazards model adjusted for non-UC, age, and diagnosis period. The proportion of non-UC was significantly higher in female compared with male patients (OR = 2.14, 95% confidence interval [CI]: 1.81-2.52). Furthermore, survival was significantly poorer in female patients than in male patients after adjusting for UC or non-UC (HR for overall death = 1.15, 95% CI: 1.06-1.23; HR for cancer-specific death = 1.39, 95% CI: 1.28-1.52). Sex differences exist in the epidemiological characteristics of bladder cancer in Japan, with female patients having less favorable pathology and poorer survival compared with male patients.

Urothelial cancer of bladder in young versus older adults: clinical and pathological characteristics and outcomes

Bladder urothelial carcinoma is rare in young adults and occurs more commonly in older individuals. The aim of this study was to compare the clinical behavior, pathologic characteristics, and prognosis of urothelial carcinoma of urinary bladder in young versus older adults. A retrospective review of our records between 2007 and 2013 identified 56 patients (42 males and 14 females) with transitional cell carcinoma of the bladder who were less than 40 years old. Clinical and pathological parameters of patients who were less than 40 years of age were compared with those of a series of patients older than 40 years of age (the control group) during the same period. A survival analysis was performed using the Kaplan-Meier method and log-rank test, and Cox regression was performed to identify clinical parameters that affected the clinical outcomes. The mean age was 29.21 years (range, 5-40 years) for patients less than 40 years old and 61.66 years (range, 41-75) for those older than 40 years. The mean follow-up was 40.26 months (range, 12-65 months) for young patients and 42.57 months (range, 12-72 months) for the older patients. Young bladder cancer patients had smaller-sized tumors (less than 3 cm), less high-grade cancers, higher papillary urothelial neoplasms of low malignant potential, and low-grade tumors than patients older than 40 years. Multivariate logistic regression analysis predicted tumor recurrence in young patients with high-grade tumors [odds ratio (OR), 1.959; 95% confidence interval (CI), 1.235-2.965; p = 0.046] and tumors larger than 3 cm (OR, 1.772; 95% CI, 1.416-1.942; p = 0.032). The 5-year overall survival rate was 100% for young patients and 88.1% for older patients. No difference was observed in the recurrence-free (p = 0.321) and progression-free (p = 0.422) survival rates between the two groups. We concluded that although the clinical stage distribution, natural history, and outcomes of bladder urothelial cancer in young adults are similar to those in their older counterparts, clinicians must be aware that patients under 40 years of age presented with higher-grade and larger (>3 cm) tumors and are more likely to experience tumor recurrence.

Emerging drugs for urothelial carcinoma

INTRODUCTION

Advanced urothelial carcinoma is associated with a poor prognosis. In the metastatic setting, the response rate to first-line, cisplatin-containing chemotherapy is high, but survival is poor. Second-line treatment options are limited. Advanced age at diagnosis and the presence of comorbidities often preclude treatment with cisplatin-containing regimens.

AREAS COVERED

This review addresses the current therapy of urothelial carcinoma, the unmet needs in treatment and the status of drug development in this disease. The molecular targets identified and efforts to incorporate targeted agents into therapy will be addressed.

EXPERT OPINION

There have been no major advances in the treatment of urothelial carcinoma in three decades. Despite high response rates in the first-line setting, survival is limited. Major impediments to improved outcomes include poor durability of response to first-line chemotherapy and lack of second-line treatments. Better understanding in tumor biology has identified multiple targets in urothelial carcinoma; however, such discoveries have yet to lead to the incorporation of targeted agents into the routine treatment of urothelial carcinoma. Multiple ongoing clinical trials are investigating the use of targeted agents in urothelial carcinoma. Continued efforts are underway to better understand the molecular drivers of disease and such efforts are likely to identify additional therapeutic targets.

Trends in stage-specific incidence rates for urothelial carcinoma of the bladder in the United States: 1988 to 2006

BACKGROUND

Bladder cancer is notable for a striking heterogeneity of disease-specific risks. Among the approximately 75% of incident cases found to be superficial to the muscularis propria at the time of presentation (non-muscle-invasive bladder cancer), the risk of progression to the lethal phenotype of muscle-invasive disease is strongly associated with stage and grade of disease. Given the suggestion of an increasing percentage of low-risk cases in hospital-based registry data in recent years, the authors hypothesized that population-based data may reveal changes in the stage distribution of early-stage cases.

METHODS

Surveillance, Epidemiology, and End Results (SEER) data were used to examine trends for the stage-specific incidence of bladder cancer between 1988 and 2006, adjusted for age, race, and sex, using Joinpoint and nonparametric tests.

RESULTS

The adjusted incidence rate of papillary noninvasive (Ta) predominantly low grade (77%) disease was found to increase from 5.52 to 9.09 per 100,000 population (P < .0001), with an average annual percentage change of +3.3. Over the same period, concomitant, albeit smaller, decreases were observed for flat in situ (Tis) and lamina propria-invasive (T1) disease (2.57 to 1.19 and 6.65 to 4.61 per 100,000 population [both P < .0001]; average annual percent change of -5.0 and -1.6, respectively). The trend was most dramatic among patients in the oldest age strata, suggesting a previously unappreciated cohort phenomenon.

CONCLUSIONS

The findings of the current study should motivate further epidemiological investigations of differential associations of genetic and environmental factors with different bladder cancer phenotypes as well as further scrutiny of clinical practice guideline recommendations for the growing subgroup of predominantly older patients with lower-risk disease.

A comparison of patient and tumour characteristics in two UK bladder cancer cohorts separated by 20 years

OBJECTIVES

To compare patient and tumour characteristics at presentation from two large bladder cancer cohorts, with recruitment separated by 15-20 years To identify significant differences in the West Midlands' urothelial cancer of the bladder (UCB) population during this period.

PATIENTS AND METHODS

Data were collected prospectively from 1478 patients newly diagnosed with UCB in the West Midlands from January 1991 to June 1992 (Cohort 1), and from 1168 patients newly diagnosed with UBC within the same region from December 2005 to April 2011 (Cohort 2). Gender, age, smoking history, and tumour grade, stage, type, multiplicity and size at presentation were compared using a Pearson chi-square test or Cochran-Armitage trend test, as appropriate.

RESULT

Cohort 2 had a higher proportion of male patients (P = 0.021), elderly patients (P < 0.001), grade 3 tumours (P < 0.001), Ta/T1 tumours (P = 0.008), multiple tumours (P < 0.001), and tumours of ≤2 cm in diameter (P < 0.001).

CONCLUSIONS

There were significant differences between the cohorts. These differences are potentially explained by an ageing population, changes in grading practices, improved awareness of important symptoms, improved cystoscopic technology, and reductions in treatment delays. Regional cohorts remain important for identifying changes in tumour and patient characteristics that may influence disease management in the UK and beyond.

Restaging transurethral resection for non-muscle invasive bladder cancer: who, why, when, and how?

The rate of clinical understaging in non-muscle invasive bladder cancer (NMIBC) after an initial transurethral resection (TUR) is significant, particularly for high-grade disease, and this has a major impact on prognosis. A repeat TUR, 2 to 6 weeks following the initial resection, is recommended in appropriately selected cases to avoid diagnostic inaccuracy and improve treatment allocation. This article summarizes the rationale and indications for performing a repeat TUR in NMIBC and also provides information regarding patient selection and technique.

Preoperative prognostic factors after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma

PURPOSE

To evaluate the clinical significance of preoperative biomarkers such as laboratory data, Eastern Cooperative Oncology Group Performance Status (ECOG PS) and clinicopathological factors in patients undergoing radical nephroureterectomy for upper urinary tract urothelial carcinoma.

METHODS

Between 1995 and 2011, a total of 99 patients treated at our institution for upper urinary tract urothelial carcinoma were enrolled in this study. The prognostic significance of various preoperative data and clinicopathological factors were analyzed. Univariate and multivariate analyses were performed using the Kaplan-Meier method with the log-rank test and a Cox proportional hazards regression model.

RESULTS

Median patient age was 73 years (range 44-86 years), and the median follow-up period after radical nephroureterectomy was 37.9 months (range 6.6-171.4 months). The 5-year intravesical recurrence-free survival and cancer-specific survival estimates were 47.1 and 70.0 %, respectively. On multivariate analysis, concomitant bladder carcinoma was an independent predictor of intravesical recurrence (hazard ratio 3.689; P = 0.002), and infiltration (hazard ratio 14.842; P = 0.002), preoperative serum creatinine level (hazard ratio 9.992; P = 0.005), preoperative serum hemoglobin level (hazard ratio 6.370; P = 0.018) and ECOG PS (hazard ratio 4.326; P = 0.037) were associated with worse cancer-specific survival. This study is limited by biases associated with its retrospective design.

CONCLUSIONS

This study indicates that not only clinicopathological factors, but also preoperative biomarkers, such as serum creatinine and hemoglobin levels and ECOG PS, predict a poor survival in patients with upper urinary tract urothelial carcinoma.

The contemporary role of lymph node dissection during nephroureterectomy in the management of upper urinary tract urothelial carcinoma: the Canadian experience

OBJECTIVE

To investigate the association between lymph node dissection (LND) and survival among patients undergoing nephroureterectomy for upper urinary tract urothelial cell carcinoma (UTUC).

METHODS

This study includes 1029 patients from 10 Canadian institutions who underwent nephroureterectomy between 1990 and 2010. Disease-specific survival (DSS), overall survival (OS), and recurrence-free survival (RFS) were compared for patients with a node-negative LND (N0), node-positive LND (N+), or no LND (Nx) using Kaplan-Meyer analysis and Cox regression analysis. The association between survival and number of positive nodes, number of nodes removed, and ratio of positive nodes to nodes removed was also investigated.

RESULTS

The median follow-up for the entire cohort was 19.8 months (interquartile range = 7.2-53.8). LND was performed in 276 (26.8%) patients, and 77 (27.9%) had N+ disease. Patients with N+ disease had significantly shorter OS, DSS, and RFS compared with N0 and Nx patients(P < .01). No differences were identified between N0 and Nx patients in any survival categories (P > .05). A ratio of positive nodes to nodes removed ≥ 20% had a per annum hazard ratio of 2.24 (95% confidence interval [CI] 1.18-4.65) for OS, 2.70 (95% CI = 1.25-5.83) for DSS, and 1.94 (95% CI = 1.13-3.32) for RFS. The number of positive nodes and the number of nodes removed were not associated with survival in any survival category (P > .05).

CONCLUSION

LND during nephroureterectomy provides more accurate staging and prediction of survival; however, it remains uncertain whether LND independently improves survival in patients with UTUC.

Analysis of the Distribution and Temporal Trends of Grade and Stage in Urothelial Bladder Cancer in Northern New England from 1994 to 2004

We investigate the distribution of bladder tumor category and stage in Northern New England by geographic region, smoking status and over time. 1091 incident bladder cancer cases from the New England Bladder Cancer Study (NEBCS), a large population-based case-control study carried out in Maine, New Hampshire and Vermont (2001-2004), and 680 bladder cancer cases from previous case-control studies in New Hampshire (1994-2000) were used in the analysis. Of 1091 incident bladder cancer cases from the NEBCS, 26.7% of tumors were papillary urothelial neoplasms of low malignant potential (PUNLMP), 26.8% low-grade papillary urothelial carcinomas (PUC-LG), 31.3% high-grade papillary urothelial carcinomas (PUC-HG), 9.1% non-papillary urothelial carcinomas (non-PUC), and 4.3% carcinoma in situ (CIS). Approximately 70% of cases were non-invasive (Tis/Ta), and all PUNLMP cases were of the Ta category. By contrast, half of all PUC-HG carcinomas were invasive. Short-term time trend analysis within the NEBCS (2001-2004) indicated an increase in the percentage of PUNLMP (p-trend<0.0001) paralleled by a decrease in PUC-LG (p-trend=0.02), and for PUC-LG an increase in the percentage of non-invasive tumors (p-trend 0.04). Our findings suggest possible short-term trends with an increase in the percentage of PUNLMP and a change in the percentage of PUC-LG towards non-invasive disease.

Transitional cell carcinoma of the bladder: racial and gender disparities in survival (1993 to 2002), stage and grade (1993 to 2007)

PURPOSE

Bladder cancer survival is consistently lower in female and black patients than in male and white patients. We compared trends and differences according to clinical, demographic and facility characteristics by patient race and gender to identify the impact of these characteristics on survival.

MATERIALS AND METHODS

We identified bladder transitional cell carcinoma cases diagnosed in 1993 to 2007 from the National Cancer Data Base. Trends in grade and stage distribution between 1993 and 2007 were analyzed. Survival differences by race and gender were compared using 5-year relative survival and multivariate Cox regression.

RESULTS

There were 310,257 white male, 102,345 white female, 13,313 black male and 7,439 black female patients. Black and female patients had a higher proportion of muscle invasive tumors than white and male patients, and black patients had a larger proportion of higher grade tumors. The incidence of stage 0a and of high grade tumors significantly increased with time. Multivariate analysis showed a significantly lower HR in white females than in white males (HR 0.9) but a significantly higher HR in black males and females (HR 1.2). The higher mortality risk in black males and females was primarily limited to late stage disease (HR 1.3).

CONCLUSIONS

Survival differences by race and gender are partially explained by differences in tumor and demographic characteristics in black males and females, and fully explained by these characteristics in white females. Treatment delays and under treatment due to comorbid conditions, age and other factors may also contribute to these disparities.