Transitional cell carcinoma of bladder with lamina propria invasion in a 10-year-old boy

Management of High-grade, Nonmuscle Invasive Urothelial Carcinoma in a Prepubertal Patient With TURBT and Intravesical BCG

High-grade urothelial carcinoma of the bladder is rare in the pediatric population with no established guidelines for management. We treated a single female patient, 10 years of age, who was found to have high-grade, nonmuscle invasive urothelial carcinoma endoscopically and with intravesical bacille calmette guerin (BCG). Given the child's age, no local adult institution could provide BCG therapy. Utilizing the experience of the local adult institutions, we developed a comprehensive protocol for first-time delivery of BCG at a free-standing children's hospital. The patient has undergone successful induction and maintenance BCG for 7 cycles without disease recurrence and minimal side effects.

Urothelial carcinoma in children: A case series

OBJECTIVE

To report a series of 5 patients with urothelial bladder cancer (UBC) three of them with a history of exposure to amines and only two with gross hematuria.

MATERIALS AND METHODS

After obtaining ethical and legal authorization, we performed a restrospective monocentric study. We collected information of patients with UBC over a period of 10 years. We recorded: age, sex, reason for presentation, familial history and risk factors, preoperative assessment, surgical details, histological type and grade, follow-up.

RESULTS

2 children came to our attention for hematuria and 3 for incidental bladder mass finding, at a median age of 11.8 years. We performed microscopically complete transurethral resection of the tumor (TURB). Median tumor size was 1.8cm. No further therapy was required. All cancers belonged to NMIBC (Non-muscle-invasive Bladder Cancer) considering the 2004 WHO classification: 2 urothelial papillomas, 2 papillary tumors with low grade malignancy (PUN-LPM) and 1 papillary urothelial carcinoma of low histological grade (LG-PUC Ta, N0, M0). There was not any complications and no relapse occurred during follow-up (median 30 months).

CONCLUSIONS

In this study, UBCs presenting at a young age were low-grade and have not recurred in follow-up. This confirms the results of other series reported in Literature. Therefore there might be the space to perform a follow-up dedicated to children.

[Urothelial tumors in children]

Urothelial tumors are very rare in children (to date, only about 150 cases have been reported worlwide). Only 20% occur before the age of ten. The aim of this study is to specify the clinicopathologic features of urothelial tumor in young patients, which require a slightly different approach to treatment. On the basis of the WHO/ISUP (World Health Organisation/International Society of Urological Pathology) consensus classification report, these lesions are usually low-grade lesions, non invasive, and rarely recurrent. The sex ratio is three boys to one girl. These tumors are located preferentially in the low urinary tract, especially in the bladder. The main symptom is the macroscopic hematuria, which requires ultrasound examination in all cases. Cystoscopy is indicated in case of lesion of the bladder wall, or in case of persistent or recurrent hematuria, to obtain definitive diagnosis and biopsies. The tumors are mainly located on the posterior or lateral bladder wall above the trigone or near the ureteral orifices. Treatment is based on the transurethral resection of the lesion. The subsequent monitoring is sparsely codified, due to the exceptional occurrence of these tumors in the paediatric age group. These patients are likely to have better outcome than older patients, but it is due to the predominance of noninvasive papillary urothelial tumors. Tumor recurrences are not uncommon. In case of invasive, high-grade urothelial carcinomas, metastases or even lethal outcome may occur in rare cases.

Transitional Cell Carcinoma in the Pediatric Patient: A Review of the Literature

Transitional cell carcinoma (TCC) is extremely rare in children, with fewer than 30 cases reported in patients under 10 years old. It is thought that pediatric TCC is fundamentally different than TCC in adults; however, there are no specific guidelines for management or surveillance. Furthermore, the addition of papillary urothelial neoplasm of low malignant potential as a diagnosis has changed the management of lesions previously considered malignant. This review aims to investigate the difference between TCC in adults and children, to report current strategies for management of pediatric TCC, and to analyze the effects of the new grading system.

Management and follow-up of urothelial neoplasms of the bladder in children: a report from the TREP project

BACKGROUND

Urothelial neoplasms of the bladder (UNB) are rare in patients under 20 years of age, and even rarer in the first decade of life. The present series was investigated to provide recommendations on patient management in terms of therapeutic strategy and follow-up.

PROCEDURE

This is a retrospective analysis on 12 patients with UNB under 18 years of age. Data were extracted from the national database of the TREP (Tumori Rari in Età Pediatrica) Project.

RESULTS

Ten of the 12 patients presented with a single episode of hematuria, while the discovery of the lesion was incidental in two. Eleven of the 12 lesions were G1 and one was G2/G3; none of the lesions invaded the lamina propria. All lesions were removed completely by transurethral resection. No further treatment was administered in nine children but three received a single dose of intravesical chemotherapy (epirubicin in 2, mitomycin in 1). Only one patient experienced a recurrence and all patients are alive in complete remission with a median follow-up of 30 months (range 4-112). Follow-up investigations varied at the different centers and included abdominal ultrasound in nine patients, cystoscopy in seven, and additional radiological investigations in a few cases.

CONCLUSIONS

UNB in children seems to be a low-grade, scarcely aggressive disease with an excellent prognosis. The role of intravesical chemotherapy is debatable. Follow-up can be based on ultrasound. The adoption of shared recommendations should enable unnecessary treatment and invasive investigations to be avoided.

Urothelial carcinoma of the urinary bladder in pediatric patients: a long-term follow-up

OBJECTIVES

To report our experience and long-term follow-up data on pediatric patients with urothelial carcinoma (UC) of the urinary bladder.

METHODS

In this retrospective study, perioperative and long-term follow-up data of nine pediatric patients with neoplasms of urothelial origin within the urinary bladder between 1980 and 2014 were analyzed. Cystoscopy was performed under general anesthesia, and transurethral resection of the bladder tumors was carried out in the same session. Adult follow-up protocols were used for all patients.

RESULTS

Urothelial carcinoma of the urinary bladder was histologically verified in five male (66%) and three female (33%) patients. In one patient, papillary urothelial neoplasm of low malignant potential was detected. Median patient age at the time of diagnosis was 12 years (4-18 years). Mean tumor size was 2.2 cm (1.5-4 cm). After a median follow-up of 60 months (10-121 months), no recurrence was observed among our patients.

CONCLUSION

Urothelial carcinoma of the urinary bladder in pediatric patients is a rare condition. Due to lack of substantial data, it is difficult to establish tailored management strategies. Most patients present with low-grade, low-stage disease. Being the most common symptom, macroscopic hematuria should be clarified with cystoscopy in pediatric age group.

Bladder urothelial neoplasms in pediatric age: experience at three tertiary centers

INTRODUCTION

Urothelial bladder neoplasms (UBN) typically occur in patients in their sixth or seventh decade of life while they are infrequent in children and young adults. They occur in 0.1-0.4% of the population in the first two decades of life. Their management is controversial and paediatric guidelines are currently unavailable.

OBJECTIVE

To further expound the available data on the outcome of patients younger than 18 year old diagnosed with UBN.

STUDY DESIGN

We retrospectively reviewed the files of all the consecutive paediatric patients with UBN treated in three tertiary paediatric urology units from January 1999 to July 2013. Lesions were classified according to the 2004 WHO/ISUP criteria as urothelial papillomas (UP), papillary urothelial neoplasm of low malignant potential (PUNLMP), low-grade urothelial carcinoma (LGUC), and high-grade urothelial carcinoma (HGUC).

RESULTS

The table shows the results. Management after TURB varied among centres. One centre recommended only follow-up US at increasing intervals whereas another follow-up US plus urine cytologies and endoscopies, every three months in the first year, and at increasing intervals thereafter. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed disease recurrence or progression.

DISCUSSION

UBN is an uncommon condition in children and adolescents and, unlike in adults, its incidence, follow-up and outcome still controversial. Paediatric guidelines are currently lacking and management varies among centres. Gross painless haematuria is the most common presenting symptom. Therefore, this symptom should never be underestimated. US is generally the first investigation and additional imaging seems unnecessary. TURB often allows for complete resection. Lesions are generally solitary, non-muscle invasive, and low-grade (mainly UP and PUNLMP). Ideal follow-up protocol is the most controversial point. Reportedly, recurrence or progression during follow-up is uncommon in patients under 20 years, recurrence rate 7% and a single case of progression reported so far. Accordingly, a follow-up mainly based on serial US might be considered in this age group compared to adults where also serial endoscopies and urine cytologies are recommended. In the selection of the follow-up investigations, it should also be taken into consideration that urine cytology has a low sensibility in the detection of low-grade lesions while cystoscopy in young patients requires a general anaesthesia and hospitalization, and carries an increased risk of urethral manipulation.

CONCLUSION

UBN is a rare condition in children. Ultrasound is generally accurate in order to visualize the lesion, and TURB can treat the condition. Lesions are generally low-grade and non-muscle invasive, but high-grade lesions can also be detected. In present series, after TURB, follow-up US monitoring at increasing intervals was used at all centres, follow-up cystoscopies were added in two centres, but with different schedules. Urine cytologies were considered only at one centre. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed recurrence or progression of the disease.

Urothelial bladder tumour in childhood: A report of two cases and a review

Urothelial bladder tumour in childhood is extremely rare, and almost all the reported cases have been low-grade tumours with a favourable outcome. Here we review 57 reports comprising 127 cases, and we report two new cases.

Long-term follow-up of transitional cell carcinoma of the bladder in childhood

BACKGROUND

Bladder tumours are rare in children, with only 0.38% of cases occurring in the first two decades of life.

OBJECTIVE

To describe a long-term follow-up series of nine urothelial bladder tumours in children.

PATIENTS AND METHODS

We carried out a retrospective study covering the period from 1988 until 2005. We found that during this time, urothelial tumours had been diagnosed at our centre in eight patients (9 tumours) younger than 18 years old who reported an episode of haematuria. Diagnosis was attained through renal and bladder ultrasound in 85% of patients, and through cystoscopy under anaesthesia in 15%. All cases were treated by means of transurethral resection of the bladder, with ensuing follow-up using renal and bladder ultrasound and urinary cytology.

MEASUREMENTS

Patients characteristics and outcome are evaluated.

RESULTS

Single exophytic tumours were present in seven (87.5%) of the patients, located either in the lateral wall or in the trigone; one patient showed two small tumours. The pathology was as follows: two G1Ta, one G1T1, one G2T1, and five G2Ta. There were no recurrences.

CONCLUSIONS

Transitional cell carcinoma in childhood is of low grade and low aggressiveness. It has a good prognosis and recurrences are infrequent. We suggest performing a urinary cytology/cystoscopy every 6 months the first 2 years and urinary cytology/bladder ultrasound once a year.

Urothelial neoplasms of the urinary bladder occurring in young adult and pediatric patients: a comprehensive review of literature with implications for patient management

Bladder urothelial carcinoma is typically a disease of older individuals and rarely occurs below the age of 40 years. There is debate and uncertainty in the literature regarding the clinicopathologic characteristics of bladder urothelial neoplasms in younger patients compared with older patients, although no consistent age criteria have been used to define "younger" age group categories. Use of the World Health Organization 2004/International Society of Urological Pathology 1998 grading nomenclature and recent molecular studies highlight certain unique features of bladder urothelial neoplasms in young patients, particularly in patients below 20 years of age. In this meta-analysis and review, the clinical, pathologic, and molecular features and risk factors of bladder urothelial neoplasms in patients 40 years or less are presented and analyzed according to decades of presentation. Similar to older patients, bladder urothelial neoplasms in patients 40 years or younger occur more common in male patients, present mainly with gross painless hematuria, and are more commonly located at bladder trigone/ureteral orifices, but in contrast have a greater chance for unifocality. Delay in diagnosis of bladder urothelial neoplasms seems not to be uncommon in younger patients probably because of its relative rarity and the predominance of benign causes of hematuria in this age group causing hesitancy for an aggressive work-up. Most tumors in patients younger than 40 years were low grade. The incidence of low-grade tumors was the lowest in the first 2 decades of life, with incremental increase of the percentage of high-grade tumors with increasing age decades. Classification according to the World Health Organization 2004/International Society of Urological Pathology grading system identified papillary urothelial neoplasms of low malignant potential to be relatively frequent among bladder tumors of young patients particularly in the teenage years. Similar to grade, there was marked predominance of low stage tumors in the first 2 decades of life with gradual inclusion of few higher stage and metastatic tumors in the 2 older decades. Bladder urothelial neoplasms occurring in patients <20 years of age lack or have a much lower incidence of aberrations in chromosome 9, FGFR3, p53, and microsatellite instability and have fewer epigenetic alterations. Tumor recurrence and deaths were infrequent in the first 2 decades and increased gradually in each successive decade, likely influenced by the increased proportion of higher grade and higher stage tumors. Our review of the literature shows that urothelial neoplasms of the bladder occurring in young patients exhibit unique pathologic and molecular features that translate to its more indolent behavior; this distinction is most pronounced in patients <20 years. Our overall inferences have potential implications for choosing appropriate noninvasive diagnostic and surveillance modalities, whenever feasible, and for selecting suitable treatment strategies that factor in quality of life issues vital to younger patients.

Transitional cell carcinoma of the bladder in first decade of life

This report describes two rare cases of well-differentiated, non-invasive transitional cell carcinomas in children (Grade 1 Stage pTa). One was 8-year-old girl with a polypoid lesion and the other 9-year-old girl with kissing bilateral paraureteral lesions. The initial presentation was haematuria and symptoms of urinary tract infection. Subsequent course and investigation confirmed the diagnosis. Complete resection of the lesion and follow-up with urine cytology, vesical ultrasound and check cystoscopy at 4 years has showed no evidence of recurrence.