Prognostic Factors in Non–Muscle-Invasive Bladder Tumors

A Safer Method for Disinfection of Bacillus Calmette-Guerin-Containing Urine: A Prospective, Randomized Study

INTRODUCTION

The aim of the study was to examine whether disinfection of bacillus Calmette-Guerin-containing urine with etaprocohol® (ethanol 76.9-81.4 vol % and isopropanol as an additive) is safer than disinfection with sodium hypochlorite.

METHOD

In prospective research, safety and efficacy was analyzed in 5 patients in the etaprocohol® disinfection group and 5 patients in the sodium hypochlorite disinfection group. The primary endpoint was the temperature change after disinfection and the secondary endpoint was the unpleasantness of the odor caused by disinfection. Additionally, concentration of gas produced was also examined. Sensory tests were taken from staff who performed urine disinfection and the odor generated by disinfection was evaluated. As a safety protocol, post-BCG-treated urine is cultured to verify the negativity for mycobacteria.

RESULTS

Mycobacteria were disinfected in all cases. The temperature rise following disinfection was significantly higher in the sodium hypochlorite group. The sensory test outcomes were significantly worse in the group disinfected with sodium hypochlorite. The concentration of gas generated immediately after disinfection in both groups reached the maximum value and declined quickly.

CONCLUSIONS

Disinfection of bacillus Calmette-Guerin-containing urine with etaprocohol® was safer than disinfection with sodium hypochlorite, and an equivalent disinfection effect was achieved.

Prediction of the postoperative prognosis in patients with non-muscle-invasive bladder cancer based on preoperative serum surface-enhanced Raman spectroscopy

Non-muscle-invasive bladder cancer (NMIBC) is a common urinary tumor and has a high recurrence rate due to improper or inadequate conservative treatment. The early and accurate prediction of its recurrence can be helpful to implement timely and rational treatment. In this study, we explored a preoperative serum surface-enhanced Raman spectroscopy based prognostic protocol to predict the postoperative prognosis for NMIBC patients at the time even before treatment. The biochemical analysis results suggested that biomolecules related to DNA/RNA, protein substances, trehalose and collagen are expected to be potential prognostic markers, which further compared with several routine clinically used immunohistochemistry expressions with prognostic values. In addition, high prognostic accuracies of 87.01% and 89.47% were achieved by using the proposed prognostic models to predict the future postoperative recurrence and recurrent type, respectively. Therefore, we believe that the proposed method has great potential in the early and accurate prediction of postoperative prognosis in patients with NMIBC, which is with important clinical significance to guide the treatment and further improve the recurrence rate and survival time.

Progress in the development of tissue-based biomarkers for urothelial cancer

INTRODUCTION

As the understanding of molecular mechanisms of bladder cancer advances, molecularly-guided precision medicine becomes increasingly relevant. Biomarkers play a critical role in this setting, predicting treatment response and identifying candidates for targeted therapies.

AREAS COVERED

Current literature on biomarkers in their role in disease prognosis, and response to neoadjuvant and adjuvant therapies. In non-muscle invasive bladder cancer, particular focus is on markers of disease progression, and response to intravesical therapy. In muscle invasive and advanced bladder cancer, particular emphasis is on markers associated with neoadjuvant chemotherapy, as well as systemic immunotherapy. We discuss current shortcomings and pitfalls in contemporary markers, and future avenues of prospective research.

EXPERT OPINION

The focus on biomarkers has moved from immunohistochemical analysis and tumor-related phenotypic changes to examining genetic alterations. Single marker analysis has been shown to be insufficient in predicting both disease course and response to therapy, and studies have shifted towards examining marker combinations and genetic classifiers. Ultimately, significant progress in implementing biomarkers into clinical guidelines remains elusive, largely due to lack of prospective studies in well-defined patient cohorts and with clinically-meaningful endpoints. Until then, despite their promising value, tissue markers should be limited to experimental settings and clinical trials.

The predictive value of the ratio of the product of neutrophils and hemoglobin to lymphocytes in non-muscular invasive bladder cancer patients with postoperative recurrence

PURPOSE

The purpose of this study was to explore the predictive value of the ratio of the product of neutrophils and hemoglobin to lymphocytes (NHL) in patients with non-muscular invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

We retrospectively collected clinical and pathological data of patients with NMIBC who underwent transurethral resection of bladder tumor (TURBT) at our hospital between 2013 and 2018. The ratio of neutrophils to lymphocytes (NLR), the Systemic Immune Inflammation Index (SII), and NHL were obtained based on routine blood settlement within a week before surgery. The receiver operating characteristic curve was used to determine the optimal cutoff value of each index, and different groups were grouped accordingly. Kaplan-Meier survival curve and Cox regression model were used to study the factors affecting the prognosis of NMIBC patients.

RESULTS

There was significant difference in recurrence-free survival (RFS) rate between the high NLR group and the low NLR group, the high SII group and the low SII group, and the high NHL group and the low NHL group. Cox univariate regression analysis showed that tumor number, tumor size, tumor pathological grade, tumor pathological stage, NLR, SII, and NHL were related to postoperative RFS in patients with NMIBC. The tumor number, tumor pathological grade, SII, and NHL were independent predictors of RFS in multivariate analysis.

CONCLUSIONS

The preoperative clinical inflammatory indexes NLR, SII, and NHL have certain predictive value for postoperative RFS in NMIBC patients.

[Interest of reTURB for pTa high grade bladder urothelial carcinoma]

INTRODUCTION

Second look TURB (Transurethral Resection of Bladder Tumor) is recommended for high-risk pT1 tumors. It is well acquired for tumors classified pT1 high grade but its interest is still discussed for high-grade pTa tumors in the absence of high level of evidence. We evaluated the impact of second-look resection for the high-grade pTa bladder tumor.

METHODS

We performed a retrospective study in 2 centers from 2007 to 2016. We included all urothelial tumors classified pTa high grade. We studied the anatomopathological findings of reTURB and its consequences on survival without recurrence and progression.

RESULTS

Eighty-four patients were included. Thirty-five patients (41.7%) had reTURB and residual tumor was found in 42.9% of cases. The anatomopathology of reTURB was in 20% of cases high grade pTa, in 14.3% of cases pTis, and in 8.6% of cases pT1. Forty-three patients had recurrence, 13 reTURB patients (30.2%). In the patients who had a reTURB, 12 had recurrence (34.3%) against 31 without reTURB, (63.3%). After the first TURB, 45 patients (53.6%) had bladder instillation: 38 received BCG (45.2%) and 7 ametycin (8.3%). The main factor decreasing recurrence was BCG adjuvant therapy (HR=0.4 [0.2-0.9], P=0.02). The absence of reRTUV appeared to be a recurrence factor, but the result was not statistically significant (HR=1.4 [0.7-3], P=0.3).

CONCLUSION

reTURB confirms that residual tumor is often found. His interest in survival without recurrence remains to be proved by a prospective study with a larger number of patients.

LEVEL OF EVIDENCE

3.

New and contemporary markers of prognosis in nonmuscle invasive urothelial cancer

Nonmuscle invasive (NMI) urothelial cancer (UC) is associated with varied biological potential. It is characterized by frequent recurrence and progression, which thus worsens the oncological outcome. Nearly three-quarters of NMI UCs recur within 5 years, whereas half can progress during follow-up. Progression is particularly seen in T1 and carcinoma in situ (CIS). Undoubtedly, NMI UC is one of the most expensive cancers to manage. The European Organisation for Research and Treatment of Cancer (EORTC) risk calculator is a commonly used tool for assessing the recurrence and progression potential of a newly diagnosed cancer. The parameters used in the assessment are tumor size and number, pathological stage and grade of the cancer, presence of CIS, and prior recurrence rate. The main advantages of the EORTC tool are its ease of use and the lack of need to run expensive molecular tests. However, reproducibility of pathologic stage and grade is modest, which is a concern to clinicians. Molecular markers have potential for predicting the clinical outcome of NMI UC, given that clinico-pathologic variables are not sufficient for prediction of prognosis in an individual. Significant work has been done in the past 2 decades in understanding the molecular biology of bladder cancer; however, the translational value of this knowledge remains poor. The role for molecular markers in predicting recurrence seems limited because multifocal disease and incomplete treatment are probably more important for recurrence than the molecular features of a resected tumor. Urinary markers have very limited value in prognostication of bladder cancer and are used (mainly as an adjunct to cytology) for detection and surveillance of urothelial cell cancer recurrence. Prediction of progression with molecular markers holds considerable promise. Nevertheless, the contemporary value of molecular markers over clinico-pathologic indexes is limited.

Stratification based on methylation of TBX2 and TBX3 into three molecular grades predicts progression in patients with pTa-bladder cancer

The potential risk of recurrence and progression in patients with non-muscle-invasive bladder cancer necessitates followup by cystoscopy. The risk of progression to muscle-invasive bladder cancer is estimated based on the European Organisation of Research and Treatment of Cancer score, a combination of several clinicopathological variables. However, pathological assessment is not objective and reproducibility is insufficient. The use of molecular markers could contribute to the estimation of tumor aggressiveness. We recently demonstrated that methylation of GATA2, TBX2, TBX3, and ZIC4 genes could predict progression in Ta tumors. In this study, we aimed to validate the markers in a large patient set using DNA from formalin-fixed and paraffin-embedded tissue. PALGA: the Dutch Pathology Registry was used for patient selection. We included 192 patients with pTaG1/2 bladder cancer of whom 77 experienced progression. Methylation analysis was performed and log-rank analysis was used to calculate the predictive value of each methylation marker for developing progression over time. This analysis showed better progression-free survival in patients with low methylation rates compared with the patients with high methylation rates for all markers (P<0.001) during a followup of ten-years. The combined predictive effect of the methylation markers was analyzed with the Cox-regression method. In this analysis, TBX2, TBX3, and ZIC4 were independent predictors of progression. On the basis of methylation status of TBX2 and TBX3, patients were divided into three new molecular grade groups. Survival analysis showed that only 8% of patients in the low molecular grade group progressed within 5 years. This was 29 and 63% for the intermediate- and high-molecular grade groups. In conclusion, this new molecular-grade based on the combination of TBX2 and TBX3 methylation is an excellent marker for predicting progression to muscle-invasive bladder cancer in patients with primary pTaG1/2 bladder cancer.

Recurrence and progression of disease in non-muscle-invasive bladder cancer: from epidemiology to treatment strategy

CONTEXT

This review focuses on the prediction of recurrence and progression in non-muscle invasive bladder cancer (NMIBC) and the treatments advocated for this disease.

OBJECTIVE

To review the current status of epidemiology, recurrence, and progression of NMIBC and the state-of-the art treatment for this disease.

EVIDENCE ACQUISITION

A literature search in English was performed using PubMed and the guidelines of the European Association of Urology and the American Urological Association. Relevant papers on epidemiology, recurrence, progression, and management of NMIBC were selected. Special attention was given to fluorescent cystoscopy, the new World Health Organisation 2004 classification system for grade, and the role of substaging of T1 NMIBC.

EVIDENCE SYNTHESIS

In NMIBC, approximately 70% of patients present as pTa, 20% as pT1, and 10% with carcinoma in situ (CIS) lesions. Bladder cancer (BCa) is the fifth most frequent type of cancer in western society and the most expensive cancer per patient. Recurrence (in < or = 80% of patients) is the main problem for pTa NMIBC patients, whereas progression (in < or = 45% of patients) is the main threat in pT1 and CIS NMIBC. In a recent European Organisation for Research and Treatment of Cancer analysis, multiplicity, tumour size, and prior recurrence rate are the most important variables for recurrence. Tumour grade, stage, and CIS are the most important variables for progression. Treatment ranges from transurethral resection (TUR) followed by a single chemotherapy instillation in low-risk NMIBC to, sometimes, re-TUR and adjuvant intravesical therapy in intermediate- and high-risk patients to early cystectomy for treatment-refractory high-risk NMIBC.

CONCLUSIONS

NMIBC is a heterogeneous disease with varying therapies, follow-up strategies, and oncologic outcomes for an individual patient.