Significance of Positive Urine Cytology on Progression and Cancer-Specific Mortality of Non–Muscle-Invasive Bladder Cancer

Voided urine cytology is a useful tool predicting non-muscle-invasive bladder cancer risk before surgery

OBJECTIVE

To determine the accuracy of voided urinary cytology (VUC) in predicting of non-muscle-invasive bladder cancer (NMIBC) risk stratification before surgery.

METHODS

We prospectively collected data from all patients diagnosed with bladder cancer in our institution over 2 years. We have analyzed VUC accuracy of positive and suspicious VUC in the detection of high-risk tumors and negative and atypical VUC in the detection of low-risk tumors. To test this accuracy, we assessed sensitivity, specificity, positive (PPV) and negative predictive values (NPV), diagnostic odds ratio (DOR), and generated ROC curves (receiver operating characteristic curve).

RESULTS

With 224 patients included, the positive VUC subcategory showed a specificity of 92.4% (95%CI: 83.2%-97.5%) and a PPV of 91.4 (95%CI: 81%-97.1%). DOR in this subgroup was 6.81. In the suspicious VUC, specificity was 90.9% (95%CI: 81.3%-96.6%), PPV was 88% (95%CI: 75.7%-95.5%) and DOR was 4.23. Combined analysis of positive and suspicious cytologies for detecting high-risk NMIBC showed a sensitivity of 65% (95%CI: 57.3%-73.2%) and a DOR of 9.51. Negative VUC showed high specificity in detecting low-risk (93.2% [95%CI: 87.9%-96.7%]) and a DOR of 6.90 (95%CI: 3.07-15.46). Atypical VUC was the least accurate and had rather low specificity and predictive values.

CONCLUSIONS

VUC appears to be a good, inexpensive and easily available method to determine risk stratification before surgery. This can be useful in daily practice to determine which patients should receive a single instillation of MMC and to prioritize patients more likely to have a high- risk tumor.

Preoperative positive voided urine cytology predicts poor clinical outcomes in patients with upper tract urothelial carcinoma undergoing nephroureterectomy

BACKGROUND

Performance of urinary cytology is recommended as the part of a standard diagnostic workup and base surveillance regimens in upper tract urothelial carcinoma (UTUC). However, the effect of positive voided urine cytology (VUC) on UTUC prognosis, compared with negative VUC, has not been fully demonstrated. This study aimed to evaluate the impact of preoperative VUC on predicting intravesical recurrence, disease recurrence, and mortality in patients with UTUC who underwent nephroureterectomy (RNU).

METHODS

Clinicopathological information was collected from 315 UTUC patients treated with RNU. The association between VUC and oncological outcomes was analyzed using the Kaplan-Meier method with log-rank test and Cox proportional hazards regression models. Multiple logistic regression analysis was performed to identify the influence of VUC on tumor grade.

RESULTS

Preoperative positive VUC, presenting in 101 patients (32%), was significantly associated with tumor multifocality (P = 0.017) and higher tumor grade (P = 0.010). On multivariable Cox regression analyses, preoperative positive VUC was an independent prognostic factor of intravesical recurrence-free survival (RFS) (hazard ratio [HR] = 2.21, 95% confidence interval [CI] 1.06-4.64; P = 0.035), RFS (HR = 1.80, 95% CI 1.08-2.99; P = 0.023), and cancer-specific survival (CSS) (HR = 1.87, 95% CI 1.10-3.18; P = 0.020), but not overall survival (HR = 1.32, 95% CI 0.80-2.18; P = 0.28). Logistic regression analysis revealed that VUC was related to high tumor grade in UTUC (odds ratio = 2.23, 95%CI 1.15-4.52).

CONCLUSION

Preoperative positive VUC significantly increases the risk of intravesical recurrence in UTUC patients undergoing RNU. In addition, positive VUC is an adverse predictor of RFS and CSS, which might be due to the association between positive VUC and high tumor grade.

Significance of Bladder Neck Involvement in Risk Substratification of Intermediate-Risk Non-muscle-invasive Bladder Cancer

BACKGROUND

Intermediate-risk non-muscle-invasive bladder cancer (NMIBC) involves heterogeneous patients, resulting in uncertainty regarding its prognosis and the indication of adjuvant therapy. Previous studies suggested a correlation between tumor location, especially bladder neck involvement (BNI), and patient prognosis of NMIBC.

OBJECTIVE

We investigated the role of BNI in risk substratification of intermediate-risk NMIBC patients.

DESIGN, SETTING, AND PARTICIPANTS

This single-institutional study included 436 primary or recurrent intermediate-risk NMIBC patients based on risk stratification in the European Association of Urology guidelines.

INTERVENTION

All patients underwent transurethral resection of the bladder tumor.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary and secondary endpoints were progression and recurrence, respectively. The associations of BNI with the endpoints were examined using the Kaplan-Meier method and the Cox proportional hazards model.

RESULTS AND LIMITATIONS

Overall, 205 (47%) patients had multiple tumors and 276 (63%) underwent intravesical therapy. BNI was observed in 53 (12%) patients. During the median follow-up of 42 mo, 12 (3%) and 211 (48%) patients experienced progression and recurrence, respectively. Multivariate analysis showed that BNI was an independent predictor for both progression (hazard ratio 10.98, p < 0.001) and recurrence (hazard ratio 2.12, p < 0.001). The progression rate was significantly higher in patients with BNI compared with those without BNI (13% vs 1% at 3 yr and 20% vs 1% at 6 yr; p < 0.001). Analogous findings were observed for recurrence. The progression rate was more remarkably stratified by BNI in 103 recurrent cases (17% vs 3% at 3 yr and 34% vs 3% at 6 yr in patients with vs without BNI; p < 0.001). A limitation of this study was its retrospective nature.

CONCLUSIONS

BNI substratified intermediate-risk NMIBC patients well regarding their risks of progression and recurrence, which could help determine follow-up and therapeutic strategies for these patients.

PATIENT SUMMARY

The associations of bladder neck involvement with progression and recurrence were evaluated in patients with intermediate-risk non-muscle-invasive bladder cancer. We found that bladder neck involvement was a good factor for substratifying patients based on their risks of progression and recurrence. Bladder neck involvement can be useful in determining follow-up and therapeutic strategies for intermediate-risk non-muscle-invasive bladder cancer.

Prediction models for progression of non-muscle-invasive bladder cancer: A review

An accurate prediction of progression is critically important in the management of non-muscle-invasive bladder cancer. At present, three risk models are widely known for prediction of the risk of tumor recurrence and progression of non-muscle-invasive bladder cancer: the European Organization for Research and Treatment of Cancer, Club Urológico Español de Tratamiento Oncológico, and new European Organization for Research and Treatment of Cancer models. Bladder neck involvement has been shown to be one of the significant predictors for progression in non-muscle-invasive bladder cancer, and a new scoring model (Tokyo Medical and Dental University model) consisting of bladder neck involvement, tumor grade, and stage has been developed and externally validated. However, the predictive abilities of these models are still unsatisfactory, and more precise models are necessary for accurate individual prediction of prognosis. Until now, time-fixed analysis has been used for most studies predicting the prognosis and outcome of non-muscle-invasive bladder cancer patients. In order to predict progression more precisely, time-dependent models should be developed using multiple-event analytical techniques, as non-muscle-invasive bladder cancer often progresses to muscle-invasive bladder cancer after multiple recurrences and changes in tumor characteristics over a long natural history. Integration of molecular markers is also a promising approach. A validated model that accurately predicts the risk of progression would help urologists and patients decide whether and when to choose radical cystectomy on an individual basis.

Dose, duration and strain of bacillus Calmette-Guerin in the treatment of nonmuscle invasive bladder cancer: Meta-analysis of randomized clinical trials

BACKGROUND

Intravesical bacillus Calmette-Guerin (BCG) instillation is widely used as an adjuvant therapy after transurethral resection of bladder tumor (TURBT) in patients with intermediate- and high-risk nonmuscle invasive bladder cancer (NMIBC). However, the effective dose, duration, and strain of BCG have not yet been clearly determined. We aimed to elucidate the relationship between dose, duration, and strain of BCG and clinical outcomes in NMIBC patients treated with TURBT.

METHODS

We conducted a literature search in Embase, Scopus, and PubMed databases for all relevant articles published up to October 2016 in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. The relative risks of clinical outcomes, including recurrence, progression, cancer-specific mortality, and all-cause mortality according to dose (standard vs low), duration (induction vs maintenance), and strain of BCG were presented as the pooled risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Nineteen studies meeting the inclusion criteria were finally selected in this meta-analysis. The risk of recurrence was significantly highly observed in case of low-dose BCG (RR, 1.17; 95% CI 1.06-1.30) and induction BCG (RR, 1.33; 95% CI 1.17-1.50) only group without heterogeneity among the included studies. Although there were no significant differences between dose or duration and other clinical outcomes. On direct comparison in each study comparing BCG strains, the Tice stain showed a relatively high probability of recurrence compared with the Connaught (RR, 1.29; 95% CI 1.01-1.64) and RIVM (RR, 2.04, 95% CI 1.28-3.25) strains. Funnel plot testing revealed no significant publication bias.

CONCLUSION

The use of standard dose and maintenance BCG instillation may be effective to reduce recurrence rate after TURBT for NMIBC. Further large scale, well-designed, and prospective studies, with stratification of the patients into risk group at randomization, will be required to determine the optimal guideline of BCG use to improve clinical outcomes in NMIBC.

Prognostic Factors for Recurrence and Progression in Korean Non-Muscle-Invasive Bladder Cancer Patients: A Retrospective, Multi-Institutional Study

PURPOSE

To identify the prognostic factors related to tumor recurrence and progression in Korean patients with non-muscle-invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

Data were collected and analyzed for 2412 NMIBC patients from 15 centers who were initially diagnosed after transurethral resection of bladder tumor (TURBT) from January 2006 to December 2010. Using univariable and multivariable Cox proportional hazards models, the prognostic value of each variable was evaluated for the time to first recurrence and progression.

RESULTS

With a median follow-up duration of 37 months, 866 patients (35.9%) experienced recurrence, and 137 (5.7%) experienced progression. Patients with recurrence had a median time to the first recurrence of 10 months. Multivariable analysis conducted in all patients revealed that preoperative positive urine cytology (PUC) was independently associated with worse recurrence-free survival [RFS; hazard ratio (HR) 1.56; p<0.001], and progression-free survival (PFS; HR 1.56; p=0.037). In particular, on multivariable analysis conducted for the high-risk group (T1 tumor/high-grade Ta tumor/carcinoma in situ), preoperative PUC was an independent predictor of worse RFS (HR 1.73; p<0.001) and PFS (HR 1.96; p=0.006). On multivariable analysis in patients with T1 high-grade (T1HG) cancer (n=684), better RFS (HR 0.75; p=0.033) and PFS (HR 0.33; p<0.001) were observed in association with the administration of intravesical Bacillus Calmette-Guérin (BCG) induction therapy.

CONCLUSION

A preoperative PUC result may adversely affect RFS and PFS, particularly in high-risk NMIBC patients. Of particular note, intravesical BCG induction therapy should be administered as an adjunct to TURBT in order to improve RFS and PFS in patients with T1HG cancer.

Prognostic and Prediction Tools in Bladder Cancer: A Comprehensive Review of the Literature

CONTEXT

This review focuses on risk assessment and prediction tools for bladder cancer (BCa).

OBJECTIVE

To review the current knowledge on risk assessment and prediction tools to enhance clinical decision making and counseling of patients with BCa.

EVIDENCE ACQUISITION

A literature search in English was performed using PubMed in July 2013. Relevant risk assessment and prediction tools for BCa were selected. More than 1600 publications were retrieved. Special attention was given to studies that investigated the clinical benefit of a prediction tool.

EVIDENCE SYNTHESIS

Most prediction tools for BCa focus on the prediction of disease recurrence and progression in non-muscle-invasive bladder cancer or disease recurrence and survival after radical cystectomy. Although these tools are helpful, recent prediction tools aim to address a specific clinical problem, such as the prediction of organ-confined disease and lymph node metastasis to help identify patients who might benefit from neoadjuvant chemotherapy. Although a large number of prediction tools have been reported in recent years, many of them lack external validation. Few studies have investigated the clinical utility of any given model as measured by its ability to improve clinical decision making. There is a need for novel biomarkers to improve the accuracy and utility of prediction tools for BCa.

CONCLUSIONS

Decision tools hold the promise of facilitating the shared decision process, potentially improving clinical outcomes for BCa patients. Prediction models need external validation and assessment of clinical utility before they can be incorporated into routine clinical care.

PATIENT SUMMARY

We looked at models that aim to predict outcomes for patients with bladder cancer (BCa). We found a large number of prediction models that hold the promise of facilitating treatment decisions for patients with BCa. However, many models are missing confirmation in a different patient cohort, and only a few studies have tested the clinical utility of any given model as measured by its ability to improve clinical decision making.