Optimised photodynamic diagnosis for transurethral resection of the bladder (TURB) in German clinical practice: results of the noninterventional study OPTIC III

Diagnostic performance of photodynamic diagnosis with oral 5-aminolevulinic acid for upper tract- and bladder urothelial carcinoma: a single-centre, retrospective analysis

PURPOSE

To compare the diagnostic performance of photodynamic diagnosis (PDD) enhanced with oral 5-aminolaevulinic acid between the suspected upper tract urothelial carcinoma (UTUC) and bladder urothelial carcinoma (BUC) cases.

METHODS

This retrospective study included 18 patients with suspected UTUC who underwent ureteroscopy (URS) with oral 5-ALA in the PDD-URS cohort between June 2018 and January 2019; and 110 patients with suspected BUC who underwent transurethral resection of bladder tumour (TURBT) in the PDD-TURBT cohort between January 2019 and March 2023. Sixty-three and 708 biopsy samples were collected during diagnostic URS and TURBT, respectively. The diagnostic accuracy of white light (WL) and PDD in the two cohorts was evaluated, and false PDD-positive samples were pathologically re-evaluated.

RESULTS

The area under the receiver operating characteristic curve (AUC) of PDD was significantly superior to that of WL in both cohorts. The per biopsy sensitivity, specificity, and positive and negative predictive values of PDD in patients in the PDD-URS and PDD-TURBT cohorts were 91.2 vs. 71.4, 75.9 vs. 75.3, 81.6 vs. 66.3, and 88.0 vs. 79.4%, respectively. The PDD-URS cohort exhibited a higher AUC than did the PDD-TURBT cohort (0.84 vs. 0.73). Seven of four false PDD-positive samples (57.1%) in the PDD-URS cohort showed potential precancerous findings compared with eight of 101 (7.9%) in the PDD-TURBT cohort.

CONCLUSION

The diagnostic performance of PDD in the PDD-URS cohort was at least equivalent to that in the PDD-TURBT cohort.

Hysteroscopic Photodynamic Diagnosis Using 5-Aminolevulinic Acid: A High-Sensitivity Diagnostic Method for Uterine Endometrial Malignant Diseases

STUDY OBJECTIVE

To examine the diagnostic accuracy of hysteroscopic photodynamic diagnosis (PDD) using 5-aminolevulinic acid (5ALA) in patients with endometrial cancer and premalignant atypical endometrial hyperplasia.

DESIGN

A single-center, open-label, exploratory intervention study.

SETTING

University Hospital in Japan.

PATIENTS

Thirty-four patients who underwent hysteroscopic resection in the Department of Obstetrics and Gynecology at Keio University Hospital.

INTERVENTIONS

Patients were given 5ALA orally approximately 3 hours before surgery and underwent observation of the uterine cavity and endometrial biopsy using 5ALA-PDD during hysteroscopic resection. Specimens were diagnosed histopathologically and the diagnostic sensitivity and specificity of hysteroscopic 5ALA-PDD for malignancy in the uterine cavity was determined. Red (R), blue (B), and green (G) intensity values were determined from PDD images, and the relationships of histopathological diagnosis with these values were used to develop a model for objective diagnosis of uterine malignancy.

MEASUREMENTS AND MAIN RESULTS

Three patients were excluded from the study because of failure of the endoscope system. A total of 113 specimens were collected endoscopically. The sensitivity and specificity of 5ALA-PDD for diagnosis of malignancy in the uterine cavity were 93.8% and 51.9%, respectively. The R/B ratio in imaging analysis was highest in malignant lesions, followed by benign lesions and normal uterine tissue, with significant differences among these groups (p <.05). The R/B and G/B ratios were used in a formula for prediction of malignancy based on logistic regression and the area under the receiver operating characteristic curve for this formula was 0.838. At a formula cutoff value of 0.220, the sensitivity and specificity for diagnosis of malignant disease were 90.6% and 65.4%, respectively.

CONCLUSION

To our knowledge, this is the first study of the diagnostic accuracy of 5ALA-PDD for malignancies in the uterine cavity. Hysteroscopic 5ALA-PDD had higher sensitivity and identifiability of lesions. These findings suggest that hysteroscopic 5ALA-PDD may be useful for diagnosis of minute lesions.

Shedding Light on Bladder Cancer Diagnosis in Urine

Blue light cystoscopy (BLC) is the most recent clinical approach in the detection and diagnosis of bladder cancer, a common type of cancer with a high rate of recurrence. Representing a significant advance over previous approaches, this photodynamic diagnostic technique uses a photosensitiser prodrug as an adjunct to white light cystoscopy to enhance the in vivo detection of malignant tissues in the bladder based on their distinctive fluorescence. Whilst it does improve detection rates, BLC remains an invasive and costly procedure. Meanwhile, a variety of noninvasive urine detection methods and related microdevices have been developed, none of which have yet entered routine clinical use due to unsatisfactory sensitivity. Following a brief description of the current approaches and their limitations, we provide here a systematic review of a newer niche research aiming to develop a noninvasive adaptation of photodynamic diagnosis. The research to date surrounding the ex situ use of photosensitiser prodrugs for urinary diagnosis of bladder cancer is also discussed.

T1 bladder cancer: current considerations for diagnosis and management

Stage T1 bladder cancers invade the lamina propria of the bladder and, despite sharing many of the genetic features of muscle-invasive bladder cancers, are classified as non-muscle-invasive or 'superficial' tumours. Yet, patients with T1 bladder cancer have an overall mortality of 33% and a cancer-specific mortality of 14% at three years after diagnosis, suggesting that these patients have a high risk of progression and, accordingly, require meticulous surgery, endoscopic surveillance and clinical decision-making. We hypothesize that the variability in the outcomes of patients with T1 bladder cancer is a result of both tumour heterogeneity and pathological staging, as well as inconsistencies in risk stratification, endoscopic resection and schedules of delivery of BCG. Owing to limitations in clinical staging, patients with T1 bladder cancer are at risk of both undertreatment with persistent use of BCG despite recurrence, and overtreatment with early cystectomy. Understanding the molecular features of T1 bladder cancers and how they respond to BCG therapy could improve biomarkers for risk stratification to align therapy with biological risk.

[Supplementary optical techniques for the detection of nonmuscle invasive bladder cancer]

White light cystoscopy (WL) is the gold standard for the detection of bladder cancer. It can be performed using a rigid or flexible urethrocystoscope. With the more recent introduction of high definition (HD) techniques, WL cystoscopy has been decisively improved. Supplementary optical techniques are also used to improve the detection of bladder cancer. Among these are photodynamic diagnosis (PDD), narrow-band imaging (NBI), S‑technologies of IMAGE1 S, optical coherence tomography (OCT), confocal laser endomicroscopy (CLE), and Raman spectroscopy. The aim of the present work is to introduce the techniques and to discuss their current role and future potential in the detection of bladder cancer.

Current concept of transurethral resection of bladder cancer: from re-transurethral resection of bladder cancer to en-bloc resection

PURPOSE OF REVIEW

Transurethral resection of bladder cancer (TURB) is the critical step in the management of nonmuscle invasive bladder cancer (NMIBC). This review presents new improvements in the strategy and technique of TURB as well as in technological developments used for tumour visualization and removal.

RECENT FINDINGS

The goal of TURB is to perform complete resection of NMIBC. Tumor visualization during procedure can be improved by enhanced optical technologies. Fluorescence-guided photodynamic diagnosis (PDD) and narrow-band imaging (NBI) used during TURB can improve tumour detection and potentially reduce recurrence rate, their influence on progression, however, remains controversial. TURB can be performed using monopolar or bipolar electrocautery without significant differences in results or safety. To overcome limitations of traditional TURB, the technique of en-bloc resection was introduced to improve the quality of tumour removal. In selected cases, an early re-resection (re-TURB) within 2-6 weeks after initial procedure is recommended.

SUMMARY

TURB is a fundamental step in diagnosis and treatment of NMIBC. Urologists should be aware of promising innovations including new imaging and surgical techniques and their potential benefits. Hopefully, new technologies and performance of TURB bring improved outcomes, which can alter the indication criteria for re-TURB.

Enhanced Endoscopy in Bladder Cancer

PURPOSE OF REVIEW

Endoscopy coupled with targeted resections represents a cornerstone in the diagnosis, staging, and treatment of patients with bladder cancer. Direct visualization can be challenging and imprecise due to patient-, tumor-, and surgeon-specific factors. We will review contemporary endoscopic technologies and techniques used to improve our ability to safely identify and resect malignant lesions in patients with bladder cancer.

RECENT FINDINGS

Enhanced endoscopic imaging technology may improve detection rates for bladder cancer throughout the upper and lower urinary tract, which may lead to improvements in recurrence and progression rates for non-muscle invasive bladder cancer (NMIBC). New techniques including narrow-band imaging (NBI), photodynamic diagnosis (PDD), Storz Professional Image Enhancement System (SPIES), optical coherence tomography (OCT), and others have shown benefit and may further improve our ability to detect and stage bladder tumors. Enhanced endoscopy technologies have already demonstrated value in improving the sensitivity of bladder cancer detection and early results suggest they may improve short- and long-term oncologic outcomes.

Hexvix plus Chemo

While photodynamic diagnosis during transurethral resection of bladder tumor seems warranted only in seemingly high-risk cases, early intravesical instillation of chemotherapy is warranted in all low-risk cases. According to the latest randomized controlled trial, data may make sense also in intermediate- and high-risk cases.

The Impact of Blue Light Cystoscopy on the Diagnosis and Treatment of Bladder Cancer

Photodynamic diagnostic technique with blue light cystoscopy (BLC) takes advantage of the preferential uptake and accumulation of protoporphyrins in neoplastic tissue which emit a red fluorescence when illuminated with blue light (360-450 nm wavelengths). This allows enhanced visualization of small papillary tumors and flat carcinoma in situ lesions that might have been missed on white light cystoscopy (WLC). There is compelling evidence that the ability of BLC to detect these additional tumors translates into improved recurrence rates compared to WLC. However, the impact of BLC with regard to progression rates and in patients who are managed with intravesical therapy is not yet known. Further work is required to optimize the integration of BLC into clinical practice, but the future for BLC appears promising.