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Lokeshwar SD, Rahman SN, Press BH, Khan AI, Soloway MS. Surveillance and office management of low-grade Ta bladder tumors. Actas Urol Esp 2022; 46:613-618. [PMID: 35780050 DOI: 10.1016/j.acuroe.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/11/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Patients with low-grade (LG), grade 1-2, Ta bladder cancer (BC) will frequently have a "recurrence". However, they rarely progress in stage. Although current guidelines mention surveillance and office management for these new or recurrent tumors, transurethral resection (TURBT) is the most common treatment. The purpose of this study is to determine if surveillance and/or office cautery is safe. MATERIALS AND METHODS This study was conducted as a retrospective case series analysis of 45 patients who had recurrent LG Ta appearing bladder cancer (BC) and were managed primarily with surveillance and/or office cautery. Patients with carcinoma in-situ were excluded. The primary outcome was stage progression. RESULTS Median follow up was 62 months. 41 (91%) patients did not progress in stage. Three patients recurred with HG T1 BC; one is receiving systemic immunotherapy. One patient developed HG T2 BC and was treated with a bladder preservation protocol. 40 (89%) patients underwent office cauterization. Eleven received BCG and 26 received post-cautery intravesical chemotherapy. Five (11%) patients developed HG BC during follow up. No patients died. None of the 17 (38%) Hispanic patients had progression. CONCLUSIONS Active surveillance and/or office cautery for patients with small recurrent LG Ta bladder tumors is safe, reduces cost and improves quality of life by avoiding TURBTs.
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Affiliation(s)
- S D Lokeshwar
- Department of Urology, Yale University, New Haven, CT, USA.
| | - S N Rahman
- Department of Urology, Yale University, New Haven, CT, USA
| | - B H Press
- Department of Urology, Yale University, New Haven, CT, USA
| | - A I Khan
- Department of Urology, Yale University, New Haven, CT, USA
| | - M S Soloway
- Urologic Oncology, Memorial Physician Group, Division of Urology, Memorial Healthcare System, Aventura, FL, USA
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Lokeshwar S, Rahman S, Press B, Khan A, Soloway M. Vigilancia y manejo en consulta de los tumores de vejiga Ta de bajo grado. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bree KK, Shan Y, Hensley PJ, Lobo N, Hu C, Tyler DS, Chamie K, Kamat AM, Williams SB. Management, Surveillance Patterns, and Costs Associated With Low-Grade Papillary Stage Ta Non-Muscle-Invasive Bladder Cancer Among Older Adults, 2004-2013. JAMA Netw Open 2022; 5:e223050. [PMID: 35302627 PMCID: PMC8933744 DOI: 10.1001/jamanetworkopen.2022.3050] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Low-risk non-muscle-invasive bladder cancer (NMIBC) is associated with extremely low rates of progression and cancer-specific mortality; however, patients with low-risk NMIBC may often receive non-guideline-recommended and potentially costly surveillance testing and treatment. OBJECTIVE To describe current surveillance and treatment practices, cancer outcomes, and costs of care for low-grade papillary stage Ta (low-grade Ta) NMIBC and identify factors associated with increased cost of care. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study identified 13 054 older adults (aged 66-90 years) diagnosed with low-grade Ta tumors in the Surveillance, Epidemiology and End Results-linked Medicare database from January 1, 2004, through December 31, 2013. Medicare claims data through December 31, 2014, were also reviewed. Data were analyzed from April 1 to October 6, 2021. EXPOSURES Surveillance testing and treatment among patients with low-grade Ta NMIBC. MAIN OUTCOMES AND MEASURES The primary outcome was patterns in population-level surveillance and treatment practice over time among patients with low-grade Ta NMIBC. Secondary outcomes were recurrence (defined as receipt of subsequent transurethral resection of bladder tumor >3 months after index diagnosis of NMIBC and initial transurethral resection of bladder tumor), progression (defined as receipt of definitive treatment for bladder cancer), and costs of care. RESULTS Among 13 054 patients who met inclusion criteria, 9596 (73.5%) were male and 3458 (26.5%) were female, with a median age of 76 years (IQR, 71-81 years). A total of 403 patients (3.1%) were Black, 120 (0.9%) were Hispanic, 12 123 (92.9%) were White, and 408 (3.1%) were of other races and/or ethnicities. Rates of surveillance cystoscopy increased over the study period (from 79.3% in 2004 to 81.5% in 2013; P = .007), with patients receiving a median of 3.0 cystoscopies per year (IQR, 2.0-4.0 per year). Rates of upper tract imaging (particularly computed tomography or magnetic resonance imaging) also increased over the study period (from 30.4% in 2004 to 47.0% in 2013; P < .001), with most patients receiving a median of 2.0 imaging tests per year (IQR, 1.0-2.0 per year). The use of urine cytologic testing or other urine biomarker assessment also increased (from 44.8% in 2004 to 54.9% in 2013; P < .001). Rates of adherence to current guidelines were similar over time (eg, a median of 4398 patients [55.2%] received ≤2 cystoscopies per year in 2004-2008 vs a median of 2736 patients [53.8%] in 2009-2013; P = .11), suggesting overuse of all surveillance testing modalities. With regard to treatment, 2250 patients (17.2%) received intravesical bacillus Calmette-Guérin, and 792 patients (6.1%) received intravesical chemotherapy (excluding receipt of a single perioperative dose). Among all patients with low-grade Ta NMIBC, 217 (1.7%) experienced disease recurrence and 52 (0.4%) experienced disease progression. The total annual median costs of low-grade Ta surveillance testing and treatment increased by 60% (from $34 792 in 2004 to $53 986 in 2013), with higher 1-year median expenditures noted among those with disease recurrence ($76 669) vs no disease recurrence ($53 909) at the end of the study period. CONCLUSIONS AND RELEVANCE In this cohort study, despite low rates of disease recurrence and progression, rates of surveillance testing increased during the study period. The annual cost of care also increased over time, particularly among patients with recurrent disease. Efforts to improve adherence to current practice guidelines, with the focus on limiting overuse of surveillance testing and treatment, may mitigate associated increasing costs of care.
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Affiliation(s)
- Kelly K. Bree
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston
| | - Yong Shan
- Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Patrick J. Hensley
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston
| | - Niyati Lobo
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston
| | - Chengrui Hu
- Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Douglas S. Tyler
- Department of Surgery, University of Texas Medical Branch, Galveston
| | - Karim Chamie
- Department of Urology, University of California, Los Angeles, Los Angeles
| | - Ashish M. Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston
| | - Stephen B. Williams
- Division of Urology, Department of Surgery, University of Texas Medical Branch, Galveston
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Han DS, Lynch KE, Chang JW, Sirovich B, Robertson DJ, Swanton AR, Seigne JD, Goodney PP, Schroeck FR. Overuse of Cystoscopic Surveillance Among Patients With Low-risk Non-Muscle-invasive Bladder Cancer - A National Study of Patient, Provider, and Facility Factors. Urology 2019; 131:112-119. [PMID: 31145947 DOI: 10.1016/j.urology.2019.04.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/05/2019] [Accepted: 04/06/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To understand cystoscopic surveillance practices among patients with low-risk non-muscle-invasive bladder cancer (NMIBC) within the Department of Veterans Affairs (VA). METHODS Using a validated natural language processing algorithm, we included patients newly diagnosed with low-risk (ie low-grade Ta) NMIBC from 2005 to 2011 in the VA. Patients were followed until cancer recurrence, death, last contact, or 2 years after diagnosis. Based on guidelines, surveillance overuse was defined as >1 cystoscopy if followed <1 year, >2 cystoscopies if followed 1 to <2 years, or >3 cystoscopies if followed for 2 years. We identified patient, provider, and facility factors associated with overuse using multilevel logistic regression. RESULTS Overuse occurred in 75% of patients (852/1135) - with an excess of 1846 more cystoscopies performed than recommended. Adjusting for 14 factors, overuse was associated with patient race (odds ratio [OR] 0.49, 95% confidence interval [CI]: 0.28, 0.85 unlisted race vs White), having 2 comorbidities (OR 1.60, 95% CI: 1.00, 2.55 vs no comorbidities), and earlier year of diagnosis (OR 2.50, 95% CI: 1.29, 4.83 for 2005 vs 2011, and OR 2.03, 95% CI: 1.11, 3.69 for 2006 vs 2011). On sensitivity analyses assuming all patients were diagnosed with multifocal or large low-grade tumors (ie, intermediate-risk), overuse would have still occurred in 45% of patients. CONCLUSION Overuse of cystoscopy among patients with low-risk NMIBC was common, raising concerns about bladder cancer surveillance cost and quality. However, few factors were associated with overuse. Further qualitative research is needed to identify other determinants of overuse not readily captured in administrative data.
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Affiliation(s)
- David S Han
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH
| | - Kristine E Lynch
- VA Salt Lake City Health Care System and the Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Ji Won Chang
- VA Salt Lake City Health Care System and the Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Brenda Sirovich
- The White River Junction VA Medical Center, White River Junction, VT
| | | | - Amanda R Swanton
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - John D Seigne
- Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- The White River Junction VA Medical Center, White River Junction, VT
| | - Florian R Schroeck
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH; The White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
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Peyton CC, Azizi M, Sexton WJ. Understanding risk and refining surveillance following tumor resection for low grade non-muscle invasive bladder cancer. Transl Androl Urol 2018; 7:987-989. [PMID: 30505739 PMCID: PMC6256040 DOI: 10.21037/tau.2018.07.07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Charles C Peyton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mounsif Azizi
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Schroeck FR, Smith N, Shelton JB. Implementing risk-aligned bladder cancer surveillance care. Urol Oncol 2018; 36:257-264. [PMID: 29395957 DOI: 10.1016/j.urolonc.2017.12.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/04/2017] [Accepted: 12/24/2017] [Indexed: 11/18/2022]
Abstract
Implementation science is a rapidly developing field dedicated to the scientific investigation of strategies to facilitate improvements in healthcare delivery. These strategies have been shown in several settings to lead to more complete and sustained change. In this essay, we discuss how refined surveillance recommendations for non-muscle-invasive bladder cancer, which involve a complex interplay between providers, healthcare facilities, and patients, could benefit from use of implementation strategies derived from the growing literature of implementation science. These surveillance recommendations are based on international consensus and indicate that the frequency of surveillance cystoscopy should be aligned with each patient's risk for recurrence and progression of disease. Risk-aligned surveillance entails cystoscopy at 3 and 12 months followed by annual surveillance for low-risk cancers, with surveillance every 3 months reserved for high-risk cancers. However, risk-aligned care is not the norm. Implementing risk-aligned surveillance could curtail overuse among low-risk patients, while curbing underuse among high-risk patients. Despite clear direction from respected and readily available clinical guidelines, there are multiple challenges to implementing risk-aligned surveillance in a busy clinical setting. Here, we describe how implementation science methods can be systematically used to understand determinants of care and to develop strategies to improve care. We discuss how the tailored implementation for chronic diseases framework can facilitate systematic assessment and how intervention mapping can be used to develop implementation strategies to improve care. Taken together, these implementation science methods can help facilitate practice transformation to improve risk-aligned surveillance for bladder cancer.
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Affiliation(s)
- Florian R Schroeck
- VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT; Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH; Norris Cotton Cancer Center, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH.
| | | | - Jeremy B Shelton
- Department of Urology, UCLA, Los Angeles, CA; Greater Los Angeles VA Medical Center, Los Angeles, CA
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Morales Á. Administration of Mycobacterium phlei cell wall-nucleic acid complex in the immediate postoperative period for the treatment of non-muscle-invasive bladder cancer. Can Urol Assoc J 2016; 10:328-332. [PMID: 27800054 DOI: 10.5489/cuaj.3568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This review sought to investigate the safety of intravesical administration of Mycobacterium phlei cell wall-nucleic acid (MCNA) in the immediate postoperative period after biopsy/resection for non-muscle-invasive bladder cancer (NMIBC). METHODS Patients with NMIBC who failed bacillus Calmette-Guérin (BCG) therapy and at high risk of recurrence and progression participated in this study. Treatment involved an induction phase of six weeks and maintenance of three weekly instillations every six months for two years. Biopsies were mandatory at six months and resections/biopsies as indicated. Of the 129 patients enrolled, 18 (14%) received one or more instillations of MCNA within 24 hours of an endoscopic procedure for a total of 32 instillations. RESULTS Fourteen patients (78%) received MCNA in the immediate postoperative period. Two (11%) received treatment the day after surgery, but a second treatment immediately after a transurethral resection of the bladder tumour (TURBT). The remaining two patients received an instillation each the day after surgery. Adverse events (AEs) occurred in 31.3% of those treated immediately after the procedure; they were mild, limited to the lower urinary tract, and not drug-related. Only one patient experienced systemic symptoms of moderate severity. None of the AEs resulted in postponement of treatment. There were no AEs among those receiving MCNA the day after surgery. CONCLUSIONS The dual mechanism of action of MCNA suggests that early treatment would take advantage of its chemotherapeutic (pro-apoptotic) activity. Concerns about early administration due to the presence of live bacteria are circumvented with this sterile preparation. These preliminary results warrant further investigation to confirm the safety of perioperative administration of MCNA.
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Miyake M, Fujimoto K, Hirao Y. Active surveillance for nonmuscle invasive bladder cancer. Investig Clin Urol 2016; 57 Suppl 1:S4-S13. [PMID: 27326406 PMCID: PMC4910757 DOI: 10.4111/icu.2016.57.s1.s4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 04/22/2016] [Indexed: 01/05/2023] Open
Affiliation(s)
- Makito Miyake
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Yoshihiko Hirao
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan.; Department of Urology, Osaka Gyoumeikan Hospital, Konohana-ku, Osaka, Japan
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Puntoni M, Petrera M, Campora S, Garrone E, Defferrari C, Torrisi R, Johansson H, Bruno S, Curotto A, DeCensi A. Prognostic Significance of VEGF after Twenty-Year Follow-up in a Randomized Trial of Fenretinide in Non-Muscle-Invasive Bladder Cancer. Cancer Prev Res (Phila) 2016; 9:437-44. [PMID: 27045034 DOI: 10.1158/1940-6207.capr-15-0345] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 03/25/2016] [Indexed: 11/16/2022]
Abstract
Non-muscle-invasive bladder cancer (NMIBC) may progress to muscle-invasive disease, but no effective preventive treatments are available. In addition, no reliable prognostic biomarkers have been identified. We assessed the long-term effect of the oral retinoid fenretinide and the prognostic value of circulating VEGF levels. We updated through the Tumor Registry the vital status of 99 patients with resected Ta/T1 bladder tumors who were recruited in a randomized trial of 2 years of fenretinide or no treatment in 1993-1994. Serum VEGF levels measured at baseline and 12 months were available in a subgroup of 62 patients. After a median of 20.5 years, 54 subjects died, 35 of any cancer and 14 of bladder cancer. Neither overall survival (OS), nor cancer survival (CS) or bladder cancer survival (BCS) was affected by fenretinide (log-rank P ≥ 0.2). DNA aneuploidy in bladder washing was associated with shorter OS (P = 0.02), CS (P = 0.05), and BCS (P = 0.09). Subjects with baseline VEGF levels in the top quintile (≥350 pg/mL) had a significantly shorter OS (P = 0.01), CS (P = 0.02), and BCS (P = 0.008). The trend across quintiles of VEGF was significant for BCS (P = 0.007). Multivariate analyses showed that, in addition to smoking status, VEGF level in the top quintile was an independent prognostic factor for OS (HR = 2.7; 95% CI, 1.1-6.5), CS (HR = 3.3; 95% CI, 1.1-9.4) and BCS (HR = 8.9; 95% CI,1.3-61). Fenretinide did not affect the long-term outcome of patients with NMIBC. High serum VEGF level was a significant predictor of overall and cancer death and may help to identify high-risk subjects who may benefit from a preventive therapy. Cancer Prev Res; 9(6); 437-44. ©2016 AACR.
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Affiliation(s)
- Matteo Puntoni
- Clinical Trial Unit, Scientific Direction, E.O. Ospedali Galliera, Genoa, Italy
| | | | - Sara Campora
- Medical Oncology Unit, E.O. Ospedali Galliera, Genoa, Italy
| | - Elsa Garrone
- Liguria Region Mortality Registry, IRCCS AOU San Martino-IST, Genoa, Italy
| | | | - Rosalba Torrisi
- Department of Oncology and Hematology, Humanitas Cancer Center, Humanitas Clinical and Research Hospital, Rozzano (Milan), Italy
| | - Harriet Johansson
- Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy
| | - Silvia Bruno
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Antonio Curotto
- University Urology Clinic, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Andrea DeCensi
- Medical Oncology Unit, E.O. Ospedali Galliera, Genoa, Italy. Division of Cancer Prevention and Genetics, European Institute of Oncology, Milan, Italy. Wolfson Institute of Preventive Medicine, Queen Mary University of London, UK.
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Han KS, You D, Jeong IG, Kwon T, Hong B, Hong JH, Ahn H, Ahn TY, Kim CS. Is intravesical Bacillus Calmette-Guérin therapy superior to chemotherapy for intermediate-risk non-muscle-invasive bladder cancer? An ongoing debate. J Korean Med Sci 2015; 30:252-8. [PMID: 25729246 PMCID: PMC4330478 DOI: 10.3346/jkms.2015.30.3.252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/13/2014] [Indexed: 11/24/2022] Open
Abstract
The objective of this study was to evaluate the risk of recurrence in patients with intermediate-risk non-muscle-invasive bladder cancer (NMIBC) after intravesical instillation with chemotherapeutic agents or Bacillus Calmette-Guérin (BCG) therapy. A cohort of 746 patients with intermediate-risk NMIBC comprised the study group. The primary outcome was time to first recurrence. The recurrence rates of the transurethral resection (TUR) alone, chemotherapy, and BCG groups were determined using Kaplan-Meier analysis. Risk factors for recurrence were identified using Cox regression analysis. In total, 507 patients (68.1%), 78 patients (10.5%), and 160 (21.4%) underwent TUR, TUR+BCG, or TUR+chemotherapy, respectively. After a median follow-up period of 51.7 months (interquartile range=33.1-77.8 months), 286 patients (38.5%) developed tumor recurrence. The 5-yr recurrence rates for the TUR, chemotherapy, and BCG groups were 53.6%±2.7%, 30.8%±5.7%, and 33.6%±4.7%, respectively (P<0.001). Chemotherapy and BCG treatment were found to be predictors of reduced recurrence. Cox-regression analysis showed that TUR+BCG did not differ from TUR+chemotherapy in terms of recurrence risk. Adjuvant intravesical instillation is an effective prophylactic that prevents tumor recurrence in intermediate-risk NMIBC patients following TUR. In addition, both chemotherapeutic agents and BCG demonstrate comparable efficacies for preventing recurrence.
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Affiliation(s)
- Kyung-Sik Han
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dalsan You
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Gab Jeong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Teakmin Kwon
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bumsik Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hanjong Ahn
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tai Young Ahn
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Choung-Soo Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kamat AM, Witjes JA, Brausi M, Soloway M, Lamm D, Persad R, Buckley R, Böhle A, Colombel M, Palou J. Defining and treating the spectrum of intermediate risk nonmuscle invasive bladder cancer. J Urol 2014; 192:305-15. [PMID: 24681333 DOI: 10.1016/j.juro.2014.02.2573] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE Low, intermediate and high risk categories have been defined to help guide the treatment of patients with nonmuscle invasive bladder cancer (Ta, T1, CIS). However, while low and high risk disease has been well classified, the intermediate risk category has traditionally comprised a heterogeneous group that does not fit into either of these categories. As a result, many urologists remain uncertain about the categorization of patients as intermediate risk as well as the selection of the most appropriate therapeutic option for this patient population. We review the current literature and clinical practice guidelines on intermediate risk nonmuscle invasive bladder cancer and, based on our findings, provide urologists with a better understanding of this heterogeneous risk group as well as practical recommendations for the treatment of intermediate risk patients. MATERIALS AND METHODS The IBCG analyzed published clinical trials, meta-analyses and current clinical practice guidelines on intermediate risk nonmuscle invasive bladder cancer available as of September 2013. The definitions of intermediate risk, patient outcomes and guideline recommendations were considered, as were the limitations of the available literature and additional parameters that may be useful in guiding treatment decisions in intermediate risk patients. RESULTS Current definitions and management recommendations for intermediate risk nonmuscle invasive bladder cancer vary. The most simple and practical definition is that proposed by the IBCG and the AUA of multiple and/or recurrent low grade Ta tumors. The IBCG suggests that several factors should be considered in clinical decisions in intermediate risk disease, including number (greater than 1) and size (greater than 3 cm) of tumors, timing (recurrence within 1 year) and frequency (more than 1 per year) of recurrence, and previous treatment. In patients without these risk factors a single, immediate instillation of chemotherapy is advised. In those with 1 to 2 risk factors adjuvant intravesical therapy (intravesical chemotherapy or maintenance bacillus Calmette-Guérin) is recommended, and previous intravesical therapy should be considered when choosing between these adjuvant therapies. For those patients with 3 to 4 risk factors, maintenance bacillus Calmette-Guérin is recommended. It is also important that all intermediate risk patients are accurately risk stratified at initial diagnosis and during subsequent followup. This requires appropriate transurethral resection of the bladder tumor, vigilance to rule out carcinoma in situ or other potential high risk tumors, and review of histological material directly with the pathologist. CONCLUSIONS Intermediate risk disease is a heterogeneous category, and there is a paucity of independent studies comparing therapies and outcomes in subgroups of intermediate risk patients. The IBCG has proposed a management algorithm that considers tumor characteristics, timing and frequency of recurrence, and previous treatment. Subgroup analyses of intermediate risk subjects in pivotal EORTC trials and meta-analyses will be important to validate the proposed algorithm and support clear evidence-based recommendations for subgroups of intermediate risk patients.
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Affiliation(s)
- Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, Texas.
| | - J Alfred Witjes
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | - Mark Soloway
- Department of Urology, University of Miami School of Medicine, Miami, Florida
| | - Donald Lamm
- Department of Surgery, University of Arizona, and BCG Oncology, Phoenix, Arizona
| | - Raj Persad
- Department of Urology/Surgery, Bristol Royal Infirmary & Bristol Urological Institute, Bristol, United Kingdom
| | - Roger Buckley
- Department of Urology, North York General Hospital, Toronto, Ontario, Canada
| | - Andreas Böhle
- Department of Urology, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany
| | - Marc Colombel
- Department of Urology, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
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Oosterlinck W, Decaestecker K. Current strategies in the treatment of non-muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2014; 12:1097-106. [DOI: 10.1586/era.12.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kausch I, Doehn C, Jocham D. Recent improvements in the detection and treatment of nonmuscle-invasive bladder cancer. Expert Rev Anticancer Ther 2014; 6:1301-11. [PMID: 17020462 DOI: 10.1586/14737140.6.9.1301] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In total, 70-80% of newly diagnosed bladder cancers are confined to the mucosa and staged as Ta, T1 or carcinoma in situ according to the 2002 tumor, lymph nodes and metastasis classification. The standard treatment for these nonmuscle-invasive bladder cancers is transurethral tumor resection with or without adjuvant intravesical chemotherapy or intravesical immunotherapy and subsequent follow-up. Diagnosis and follow-up of nonmuscle-invasive bladder cancer offers two main problems. First, approximately 10-20% of all tumors are not seen in standard cystoscopy. Additionally, frequently repeated follow-up cystoscopies are bothersome for the patient. As an adjunct to standard cystoscopy, fluorescence-guided cystoscopy has demonstrated significantly higher tumor detection rates and optimized patient treatment in recent Phase III studies. Second, routinely performed urine cytology is characterized by high specificity but low sensitivity. Today, several urine tests are available that may increase diagnostic accuracy and potentially prolong intervals of follow-up cystocopy. Owing to rather high recurrence rates after transurethral tumor resection in most tumors and high progression rates in poorly differentiated tumors, adjuvant intravesical chemotherapy or intravesical immunotherapy has gained widespread use in patients with nonmuscle-invasive bladder cancer. Only a few further immunomodulatory drugs, such as recombinant cytokines, have shown significant clinical effectiveness. Additional approaches, such as photodynamic therapy with different photosensitizers and thermotherapy in combination with intravesical chemotherapy, have been evaluated in Phase III studies.
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Affiliation(s)
- Ingo Kausch
- Department of Urology, University of Lubeck Medical School, Ratzeburger Allee 160, 23538 Lubeck, Germany.
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Follow-up After Surgical Treatment of Bladder Cancer: A Critical Analysis of the Literature. Eur Urol 2012; 62:290-302. [DOI: 10.1016/j.eururo.2012.05.008] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Accepted: 05/03/2012] [Indexed: 11/18/2022]
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Abstract
Transurethral resection is an effective therapy for non-muscle-invasive bladder cancer. However, the high rates of recurrence and significant risk of progression in higher grade tumors mandates additional therapy with intravesical agents. In this review we discuss the role of various intravesical agents currently in use including the immunomodualtory agent BCG and chemotherapeutic agents. We discuss the current guidelines and the role of these therapeutic agents in the context of higher grade Ta and T1 tumors.
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Affiliation(s)
- M Manoharan
- Department of Urology, University of Miami, Miami, FL, USA
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Brausi M, Witjes JA, Lamm D, Persad R, Palou J, Colombel M, Buckley R, Soloway M, Akaza H, Böhle A. A review of current guidelines and best practice recommendations for the management of nonmuscle invasive bladder cancer by the International Bladder Cancer Group. J Urol 2011; 186:2158-67. [PMID: 22014799 DOI: 10.1016/j.juro.2011.07.076] [Citation(s) in RCA: 196] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Indexed: 11/26/2022]
Abstract
PURPOSE Although the European Association of Urology, First International Consultation on Bladder Tumors, National Comprehensive Cancer Network and American Urological Association guidelines all provide an excellent evidence-based framework for the management of nonmuscle invasive bladder cancer, these guidelines vary with respect to important issues such as risk level definitions and management strategies for these risk categories. Therefore, we built on the existing framework provided by current guidelines, and provide consensus on the definitions of low, intermediate and high risk nonmuscle invasive bladder cancer, as well as practical recommendations for the treatment of patients in each of these risk categories. MATERIALS AND METHODS An international committee of experts on bladder cancer management identified and analyzed the European Association of Urology, First International Consultation on Bladder Tumors, National Comprehensive Cancer Network and American Urological Association guidelines as well as the published English language literature related to the treatment and management of nonmuscle invasive bladder cancer available as of April 2010. RESULTS Based on review of the current guidelines and literature, the International Bladder Cancer Group developed practical recommendations for the management of nonmuscle invasive bladder cancer. CONCLUSIONS Complete transurethral bladder tumor resection is recommended for all patients with nonmuscle invasive bladder cancer. For low risk disease a single, immediate chemotherapeutic instillation after transurethral bladder tumor resection is recommended. For intermediate or high risk disease there is no significant benefit from an immediate, postoperative chemotherapeutic instillation. For intermediate risk disease intravesical bacillus Calmette-Guérin with maintenance or intravesical chemotherapy is recommended. For high risk disease bacillus Calmette-Guérin induction plus maintenance is recommended. The appropriate management of recurrence depends on the patient level of risk as well as previous treatment, while the management of treatment failure depends on the type of failure as well as the level of risk for recurrence and disease progression.
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Shang PF, Kwong J, Wang ZP, Tian J, Jiang L, Yang K, Yue ZJ, Tian JQ. Intravesical Bacillus Calmette-Guérin versus epirubicin for Ta and T1 bladder cancer. Cochrane Database Syst Rev 2011:CD006885. [PMID: 21563157 DOI: 10.1002/14651858.cd006885.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Bladder cancer accounts for approximately 4.4% of adult malignancies, and approximately 80% of bladder cancer presents initially as transitional cell carcinoma that is confined to the urothelium (stage Ta) or lamina propria (stage T1). Intravesical administration of Bacillus Calmette-Guérin (BCG) and epirubicin (EPI) has been proven to reduce tumour recurrence and prevent or delay progression to muscle invasion and metastases. However, comparison of the effectiveness and safety of intravesical BCG and EPI in bladder cancer has yet to be explored. OBJECTIVES To compare the effectiveness and safety of BCG with EPI in the treatment of Ta and T1 bladder cancer. SEARCH STRATEGY A comprehensive search of MEDLINE (1966 to April 2010), EMBASE (1980 to April 2010), Health Services Technology, Administration, and Research (HealthSTAR), the Cochrane Central Register of Controlled Trials (CENTRAL), CancerLit, and Database of Abstracts of Reviews of Effectiveness (DARE), was performed, and handsearching of relevant journals was undertaken. SELECTION CRITERIA All randomised or quasi-randomised trials (in which allocation was obtained by alternation - e.g., alternate medical records, date of birth, or other predictable methods) in patients with Ta or T1 bladder cancer that compared intravesical BCG with EPI were included. No language restrictions were applied. DATA COLLECTION AND ANALYSIS Trial eligibility, methodological quality and data extraction were assessed independently by two reviewers. We compared dichotomous outcomes (frequency of tumour recurrence, progressive disease by stage, mortality, distant metastases, local and systemic adverse effects, treatment delayed or stopped due to adverse effects) using risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Five trials of 1111 participants were included in this review. For BCG, 549 patients were treated, and 562 with EPI. Of the evaluated patients, 35.5% (195/549) in the BCG group and 51.4% (289/562) in the EPI group had tumour recurrence (P < 0.05). For disease progression (BCG, 44/549; EPI, 58/562) and distant metastases (BCG, 23/487; EPI, 31/495), there were no significant differences (P = 0.19 and P = 0.29, respectively). Only two trials, including 769 patients, had sufficient data for us to analyze disease-specific (BCG, 22/383; EPI, 26/386) and overall mortality (BCG, 125/383; EPI, 147/386). Neither comparison was significant (P = 0.93 and P = 0.12, respectively). In four studies reporting toxicity, BCG was associated with significantly more drug-induced cystitis [BCG, 54.1% (232/429); EPI, 31.7% (140/441)] and haematuria [BCG, 30.8% (132/429); EPI, 16.1% (71/440)]. Similarly, in three studies reporting systemic toxicity, BCG had significantly higher toxicity than the EPI (34.8% (134/385) versus 1.3% (5/393), respectively). In a meta-analysis comparing 'treatment delayed or stopped' (BCG, 40/431; EPI, 33/441), there was no significant difference between BCG and EPI treatments (P = 0.82). AUTHORS' CONCLUSIONS The data from the present meta-analysis indicate that intravesical BCG treatment is more efficacious than EPI in reducing tumour recurrence for Ta and T1 bladder cancer. However, BCG appears to be associated with a higher incidence of adverse effects, such as drug-induced cystitis, haematuria and systemic toxicity, than EPI. The overall quality of the evidence is rather low. Well-designed, high quality randomised controlled trials with good allocation concealment are required.
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Affiliation(s)
- Pan Feng Shang
- Department of Urology, Second Hospital of Lanzhou University, No. 82, Cui Ying Men Street, Lanzhou City, Gansu, China, 730030
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Brausi MA. Challenging the EAU Guidelines on Non–Muscle-Invasive Bladder Cancer (NMIBC): Single Instillation of Chemotherapy After Transurethral Resection of NMIBC and Chemotherapy Versus Bacillus Calmette-Guérin in Treatment of Intermediate-Risk Tumours. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.eursup.2010.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Antonio Lopez-Beltran
- Unit of Anatomic Pathology, Department of Surgery, Faculty of Medicine, Cordoba University Medical School, Cordoba, Spain
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Miyamoto H, Miller JS, Fajardo DA, Lee TK, Netto GJ, Epstein JI. Non-invasive papillary urothelial neoplasms: the 2004 WHO/ISUP classification system. Pathol Int 2010; 60:1-8. [PMID: 20055945 DOI: 10.1111/j.1440-1827.2009.02477.x] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The classification and grading of papillary urothelial neoplasms has been a long-standing subject of controversy. Previously, numerous diverse grading schemes for bladder tumor, including the 1973 World Health Organization (WHO) classification, existed whereby one of the major limitations was poor inter-observer reproducibility among pathologists. The WHO/International Society of Urological Pathology (ISUP) consensus classification system of urothelial neoplasms of the urinary bladder was developed in 1998 and was revised most recently in 2003 (published in 2004). Importantly, the current classification system provides detailed histological criteria for papillary urothelial lesions and allows for designation of a lesion (papillary urothelial neoplasm of low malignant potential) with a negligible risk of progression. Thus, the latest system is designed to be a universally acceptable one for bladder tumors that not only could be effectively used by pathologists, urologists, and oncologists, but also stratifies the tumors into prognostically significant categories. This article outlines the 2004 WHO/ISUP classification system regarding the specific histological criteria for non-invasive papillary urothelial neoplasms and the clinical significance of each category.
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Affiliation(s)
- Hiroshi Miyamoto
- Department of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.
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Singh V, Sinha RJ, Sankhwar S. Outcome of Simultaneous Transurethral Resection of Bladder Tumor and Transurethral Resection of the Prostate in Comparison with the Procedures in Two Separate Sittings in Patients with Bladder Tumor and Urodynamically Proven Bladder Outflow Obstruction. J Endourol 2009; 23:2007-11. [DOI: 10.1089/end.2009.0009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Vishwajeet Singh
- Department of Urology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, India
| | - Rahul J. Sinha
- Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, India
| | - S.N. Sankhwar
- Department of Urology, Chhatrapati Shahuji Maharaj Medical University, Lucknow, India
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Rao PK, Stephen Jones J. Routine perioperative chemotherapy instillation with initial bladder tumor resection. Cancer 2009; 115:997-1004. [DOI: 10.1002/cncr.24104] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Han KS, Joung JY, Cho KS, Seo HK, Chung J, Park WS, Lee KH. Results of Repeated Transurethral Resection for a Second Opinion in Patients Referred for Nonmuscle Invasive Bladder Cancer: The Referral Cancer Center Experience and Review of the Literature. J Endourol 2008; 22:2699-704. [DOI: 10.1089/end.2008.0281] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kyung Seok Han
- Urology Oncology Clinic, Center for Specific Organ Cancer, National Cancer Center, Goyang, Korea
| | - Jae Young Joung
- Urology Oncology Clinic, Center for Specific Organ Cancer, National Cancer Center, Goyang, Korea
| | - Kang Su Cho
- Urology Oncology Clinic, Center for Specific Organ Cancer, National Cancer Center, Goyang, Korea
| | - Ho Kyung Seo
- Urology Oncology Clinic, Center for Specific Organ Cancer, National Cancer Center, Goyang, Korea
| | - Jinsoo Chung
- Urology Oncology Clinic, Center for Specific Organ Cancer, National Cancer Center, Goyang, Korea
| | - Won Seo Park
- Department of Pathology, Center for Specific Organ Cancer, National Cancer Center, Goyang, Korea
| | - Kang Hyun Lee
- Urology Oncology Clinic, Center for Specific Organ Cancer, National Cancer Center, Goyang, Korea
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Lamm D, Colombel M, Persad R, Soloway M, Böhle A, Palou J, Witjes JA, Akaza H, Buckley R, Brausi M. Clinical Practice Recommendations for the Management of Non–Muscle Invasive Bladder Cancer. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.eursup.2008.07.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Persad R, Lamm D, Brausi M, Soloway M, Palou J, Böhle A, Colombel M, Akaza H, Buckley R, Witjes JA. Current Approaches to the Management of Non-Muscle Invasive Bladder Cancer: Comparison of Current Guidelines and Recommendations. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.eursup.2008.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Herr HW, Donat SM, Reuter VE. Management of Low Grade Papillary Bladder Tumors. J Urol 2007; 178:1201-5; discussion 1205. [PMID: 17698090 DOI: 10.1016/j.juro.2007.05.148] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Indexed: 11/28/2022]
Abstract
PURPOSE We evaluated the management and treatment outcomes of low grade papillary bladder tumors. MATERIALS AND METHODS We evaluated 215 patients diagnosed with low grade and noninvasive papillary bladder tumors, and followed them every 6 months with flexible cystoscopy for 6 to 10 or more years. Tumor recurrence was treated with transurethral resection or outpatient cystoscopic fulguration. RESULTS Of the 215 patients 143 (67%) had at least 1 recurrence (positive cystoscopy). With a median followup of 8 years tumor recurrences averaged 6.2 (range 1 to 19) requiring 0.34 transurethral resections per year or 1 transurethral resection every 3 years, or 0.61 fulgurations or 1 fulguration approximately every 2 years. There were 17 patients (8%) who had progression in grade or stage and 1 patient (0.5%) died of bladder cancer. Patients most likely to have recurrence had multiple tumors, low grade (TaLG) carcinoma or tumor at first followup cystoscopy. CONCLUSIONS Surveillance cystoscopy at 6-month intervals coupled with outpatient fulguration controls recurrent tumors and reduces the therapeutic burden for patients diagnosed with low grade papillary bladder tumors.
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Affiliation(s)
- Harry W Herr
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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Soloway MS. It is time to abandon the "superficial" in bladder cancer. Eur Urol 2007; 52:1564-5. [PMID: 17681680 DOI: 10.1016/j.eururo.2007.07.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2007] [Accepted: 07/08/2007] [Indexed: 11/25/2022]
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Ugurlu O, Gonulalan U, Adsan O, Kosan M, Oztekin V, Cetinkaya M. Effects of Simultaneous Transurethral Resection of Prostate and Solitary Bladder Tumors Smaller Than 3 cm on Oncologic Results. Urology 2007; 70:55-9. [PMID: 17656208 DOI: 10.1016/j.urology.2007.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2006] [Revised: 01/27/2007] [Accepted: 03/02/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To investigate the effect on the oncologic outcomes of treatment with transurethral resection of patients with a solitary bladder tumor smaller than 3 cm with a superficial appearance and benign prostatic hyperplasia. METHODS The follow-up data from 34 men (group 1) who had undergone transurethral bladder tumor resection alone and 31 men who had undergone both transurethral prostate resection and transurethral bladder tumor resection at the same operation (group 2) in our clinic from 1996 to 2004 were retrospectively examined. The groups were also compared with each other. The recurrence and progression rates, elapsed time to recurrence, and the recurrence rates in the bladder neck and prostatic urethra were determined and compared. Statistical analysis was performed using the Mann-Whitney U and chi-square tests. RESULTS The patients were followed up for at least 12 months (mean 28.9, range 12 to 98). The average follow-up period for group 1 was 27.4 months (range 12 to 91) and was 30.5 months (range 12 to 98) for group 2. The recurrence and progression rates for groups 1 and 2 were 41.2% and 8.8% and 35.5% and 9.7%, respectively. Recurrence in the bladder neck and/or prostatic urethra developed in 1 patient in each group. No statistically significant differences were found between groups in terms of follow-up time, recurrence, progression, recurrence in the prostatic urethra and/or bladder neck, and elapsed time to recurrence. CONCLUSIONS According to our results, transurethral prostate resection can be safely performed with transurethral bladder tumor resection simultaneously in selected patients with severe lower urinary tract symptoms and a superficial solitary tumor smaller than 3 cm.
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Affiliation(s)
- Ozgur Ugurlu
- Department of 2nd Urology, Ankara Numune Education and Research Hospital, Ankara, Turkey.
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31
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Kawanishi H, Takahashi T, Ito M, Matsui Y, Watanabe J, Ito N, Kamoto T, Kadowaki T, Tsujimoto G, Imoto I, Inazawa J, Nishiyama H, Ogawa O. Genetic analysis of multifocal superficial urothelial cancers by array-based comparative genomic hybridisation. Br J Cancer 2007; 97:260-6. [PMID: 17579624 PMCID: PMC2360305 DOI: 10.1038/sj.bjc.6603850] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The purpose of this study was to investigate the accumulation of genetic alterations during metachronous and/or synchronous development of multifocal low-grade superficial urothelial tumours in the same patient, by using array-based comparative genomic hybridisation (array-CGH) and FGFR mutation analysis. We analysed 24 tumours (pTa-1 G1-2) from five patients. We had previously identified a clonal relationship among the tumours of each patient by microsatellite analysis. This time, unsupervised hierarchical cluster analysis revealed that the tumours from each patient were clustered together independently of the tumours from the other patients. All of the tumours from a single patient showed a set of 2–7 identical regional or whole-arm chromosomal changes. In addition, several individual alterations were also found. Cladistic diagrams revealed that the accumulation of genetic alterations could not be explained by a linear model, and the existence of a hypothetical precursor cell was assumed in four patients. In some cases, FGFR mutation seemed to occur later during multifocal tumour development. Taken together, these findings suggest that low-grade superficial urothelial tumours accumulate minor genetic alterations during multifocal development, although these tumours are genetically stable.
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Affiliation(s)
- H Kawanishi
- Department of Urology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - T Takahashi
- Department of Urology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - M Ito
- Department of Urology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - Y Matsui
- Department of Urology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - J Watanabe
- Department of Urology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - N Ito
- Department of Urology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - T Kamoto
- Department of Urology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - T Kadowaki
- Department of Genomic Drug Discovery Science, Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshida-Shimo-Adachi-cho, Sakyo-ku, Kyoto 606-8501, Japan
- Eisai Co. Ltd., 5-1-3 Tokodai, Tsukuba, Ibaraki 300-2635, Japan
| | - G Tsujimoto
- Department of Genomic Drug Discovery Science, Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshida-Shimo-Adachi-cho, Sakyo-ku, Kyoto 606-8501, Japan
| | - I Imoto
- Department of Molecular Cytogenetics, Medical Research Institute and School of Biomedical Science, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
- Core Research for Evolutional Science and Technology of Japan Science and Technology Corporation, 4-1-8 Honcho Kawaguchi, Saitama 332-0012, Japan
| | - J Inazawa
- Department of Molecular Cytogenetics, Medical Research Institute and School of Biomedical Science, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
- Core Research for Evolutional Science and Technology of Japan Science and Technology Corporation, 4-1-8 Honcho Kawaguchi, Saitama 332-0012, Japan
- 21st Century Center of Excellence (COE) Program for Molecular Destruction and Reconstitution of Tooth and Bone, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - H Nishiyama
- Department of Urology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
| | - O Ogawa
- Department of Urology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
- E-mail:
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Puntoni M, Zanardi S, Branchi D, Bruno S, Curotto A, Varaldo M, Bruzzi P, Decensi A. Prognostic Effect of DNA Aneuploidy from Bladder Washings in Superficial Bladder Cancer. Cancer Epidemiol Biomarkers Prev 2007; 16:979-83. [PMID: 17507625 DOI: 10.1158/1055-9965.epi-06-0538] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Superficial (papillary) bladder cancer is associated with progression and death from muscle-invasive bladder cancer, but no reliable predictors of the outcomes have been identified. METHODS We analyzed the long-term prognostic effect of DNA flow cytometry in bladder washings from 93 subjects with previously resected T(a) and T(1) bladder tumors who participated in a chemoprevention trial of the synthetic retinoid fenretinide. Kaplan-Meier analysis and Cox regression were used to determine the prognostic effect of DNA aneuploidy on cancer progression and mortality in conjunction with conventional clinical factors after a median of 11.5 years (interquartile range, 9.5-11.7 years). RESULTS Overall, 58 of 93 (62%) specimens were DNA aneuploid at baseline. Progression-free survival was significantly shorter in subjects with stage T(1) [hazard ratio (HR), 31.6; 95% confidence interval (95% CI), 2.6-386.1; P < 0.001] and in subjects with baseline DNA aneuploid washing (HR, 10.5; 95% CI, 1.1-126.1; P = 0.03). The risk of death was also greater for stage T(1) tumors (HR, 2.6; 95% CI, 1.04-6.7; P = 0.04). DNA aneuploidy was a significant prognostic factor also for overall survival (HR, 2.8; 95% CI, 1.0-9.0; P = 0.05). Fenretinide treatment had no significant effect on cancer progression and death. CONCLUSIONS DNA aneuploidy in washings from endoscopically normal bladder is a significant predictor of progression and death in addition to tumor stage. This biomarker may help to identify and monitor a high-risk group who may benefit from a chemoprevention intervention.
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Affiliation(s)
- Matteo Puntoni
- Division of Medical Oncology, E.O. Ospedali Galliera, Mura delle Cappuccine 14, 16128 Genoa, Italy
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Oosterlinck W. Repeat transurethral resection lowers recurrence rates in T1 bladder tumors, even after intravesical mitomycin C. ACTA ACUST UNITED AC 2006; 3:582-3. [PMID: 17088923 DOI: 10.1038/ncpuro0627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Accepted: 08/31/2006] [Indexed: 11/09/2022]
Affiliation(s)
- Willem Oosterlinck
- Department of Urology, Ghent University Hospital, DePintelaan 185, 9000 Ghent, Belgium.
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Oosterlinck W. Watchful waiting for low-grade Ta bladder tumours: the idea would have been unacceptable 30 years ago, but nowadays we are highly interested in the results of this study exploring it. Eur Urol 2006; 49:215-6. [PMID: 16426733 DOI: 10.1016/j.eururo.2005.12.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Revised: 12/04/2005] [Accepted: 12/05/2005] [Indexed: 11/15/2022]
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