The Prostate Involvement As Prognostic Factor in Patients with Superficial Bladder Tumors

European Association of Urology Guidelines on Primary Urethral Carcinoma-2020 Update

CONTEXT

Primary urethral carcinoma (PUC) is a rare cancer accounting for <1% of all genitourinary malignancies.

OBJECTIVE

To provide updated practical recommendations for the diagnosis and management of PUC.

EVIDENCE ACQUISITION

A systematic search interrogating Ovid (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was performed.

EVIDENCE SYNTHESIS

Urothelial carcinoma of the urethra is the predominant histological type of PUC (54-65%), followed by squamous cell carcinoma (16-22%) and adenocarcinoma (10-16%). Diagnosis of PUC depends on urethrocystoscopy with biopsy and urinary cytology. Pathological staging and grading are based on the tumour, node, metastasis (TNM) classification and the 2016 World Health Organization grading systems. Local tumour extent and regional lymph nodes are assessed by magnetic resonance imaging, and the presence of distant metastases is assessed by computed tomography of the thorax/abdomen and pelvis. For all patients with localised distal tumours (≤T2N0M0), partial urethrectomy or urethra-sparing surgery is a valid treatment option, provided that negative intraoperative surgical margins can be achieved. Prostatic Ta-Tis-T1 PUC can be treated with repeat transurethral resection of the prostate and bacillus Calmette-Guérin. In prostatic or proximal ≥ T2N0 disease, neoadjuvant cisplatin-based chemotherapy should be considered prior to radical surgery. All patients with locally advanced disease (≥T3N0-2M0) should be discussed within a multidisciplinary team. In men with locally advanced squamous cell carcinoma, curative radiotherapy combined with radiosensitising chemotherapy can be offered for definitive treatment and genital preservation. In patients with local urethral recurrence, salvage surgery or radiotherapy can be offered. For patients with distant metastatic disease, systemic therapy based on tumour characteristics can be evaluated.

CONCLUSIONS

These updated European Association of Urology guidelines provide up-to-date guidance for the contemporary diagnosis and management of patients with suspected PUC.

PATIENT SUMMARY

Primary urethral carcinoma (PUC) is a very rare, but aggressive disease. These updated European Association of Urology guidelines provide evidence-based guidance for clinicians treating patients with PUC.

Primary urothelial carcinoma of the prostate: A rare case report

RATIONALE

Prostatic urothelial carcinoma is a rare disease. Medical misdiagnosis rates remain high because there are no specific clinical symptoms or imaging features, which decreases patient survival. We report a case of prostatic urethral cancer confirmed by transrectal ultrasound-guided prostate biopsy because of an abnormal digital rectal exam.

PATIENT CONCERNS

A 55-year-old man was referred to our hospital due to lower urinary tract symptoms that lasted for 5 years.

DIAGNOSES AND INTERVENTIONS

On digital rectal examination, a hard and enlarged prostate was detected. Computed tomography, bone scintigraphy, and magnetic resonance imaging indicated benign prostatic hyperplasia. The patient underwent transrectal ultrasound-guided prostate biopsy. From the histopathological examination and immunohistochemical markers, a diagnosis of high-grade prostatic urothelial carcinoma was made. We excluded the possibility of urothelial cancer originating in the bladder lining after transurethral resection of the bladder. Radical cystoprostatectomy was performed, followed by 6 cycles of cisplatin and gemcitabine chemotherapy. Postoperative pathology showed primary urothelial carcinoma of the prostate.

OUTCOMES

The patient recovered smoothly after surgery. After a 6-month follow-up, no evidence of local recurrence or metastatic disease was found.

LESSONS

This case reminds clinicians that, for middle-aged men with suspicious digital rectal examinations, a diagnosis of prostatic urothelial carcinoma should be considered. Initial radical surgery followed by combination chemotherapy is suggested for therapeutic management.

A prospective comparison of intra-arterial chemotherapy combined with intravesical chemotherapy and intravesical chemotherapy alone after transurethral resection with a thulium laser in high-risk non-muscle invasive bladder cancer

Objective To compare intra-arterial chemotherapy combined with intravesical chemotherapy with intravesical chemotherapy alone in the treatment of high-risk non-muscle invasive bladder cancer (HRBC) after thulium laser resection of a bladder tumor (TmLRBT).

MATERIALS AND METHODS

From January 2009 to December 2013, 283 patients with HRBC were randomly assigned to the combined group (group A, n = 141) or intravesical chemotherapy-alone group (group B, n = 142) after TmLRBT. Intra-arterial chemotherapy was administered after initial TmLRBT, with 3 courses at 4-week intervals. Each course consisted of cisplatin (50 mg/m²) and epirubicin (30 mg/m²). Intravesical chemotherapy was administered in both groups, including an immediate 50 mg of epirubicin instillation after TmLRBT and weekly maintenance for 8 weeks, followed by monthly maintenance for 1 year.

RESULTS

The recurrence rate was 29.1% (41/141) in group A and 42.9% (61/142) in group B, with a significant difference (p = 0.01). The progression rate was 15.6% (22/141) in group A and 25.3% (36/142) in group B, with a significant difference (p = 0.039). Patients with concomitant carcinoma in situ (CIS) also had a lower recurrence rate and progression rate in group A compared to those in group B (p = 0.006 and p = 0.03, respectively). On univariate and multivariate logistic regression analyses, patients with low-grade histology had a higher reccurrence-free rate. Multivariate COX analysis of tumor-related factors suggested that concomitant CIS was the only significant prognostic factor associated with poorer recurrence-free survival and progression-free survival.

CONCLUSIONS

Intra-arterial chemotherapy combined with intravesical chemotherapy could reduce the risk of recurrence and progression compared to intravesical chemotherapy alone in HRBC.

EAU guidelines on primary urethral carcinoma

CONTEXT

The European Association of Urology (EAU) Guidelines Group on Muscle-Invasive and Metastatic Bladder Cancer prepared these guidelines to deliver current evidence-based information on the diagnosis and treatment of patients with primary urethral carcinoma (UC).

OBJECTIVE

To review the current literature on the diagnosis and treatment of patients with primary UC and assess its level of scientific evidence.

EVIDENCE ACQUISITION

A systematic literature search was performed to identify studies reporting urethral malignancies. Medline was searched using the controlled vocabulary of the Medical Subject Headings database, along with a free-text protocol.

EVIDENCE SYNTHESIS

Primary UC is considered a rare cancer, accounting for <1% of all malignancies. Risk factors for survival include age, tumour stage and grade, nodal stage, presence of distant metastasis, histologic type, tumour size, tumour location, and modality of treatment. Pelvic magnetic resonance imaging is the preferred method to assess the local extent of urethral tumour; computed tomography of the thorax and abdomen should be used to assess distant metastasis. In localised anterior UC, urethra-sparing surgery is an alternative to primary urethrectomy in both sexes, provided negative surgical margins can be achieved. Patients with locally advanced UC should be discussed by a multidisciplinary team of urologists, radiation oncologists, and oncologists. Patients with noninvasive UC or carcinoma in situ of the prostatic urethra and prostatic ducts can be treated with a urethra-sparing approach with transurethral resection and bacillus Calmette-Guérin (BCG). Cystoprostatectomy with extended pelvic lymphadenectomy should be reserved for patients not responding to BCG or as a primary treatment option in patients with extensive ductal or stromal involvement.

CONCLUSIONS

The 2013 guidelines document on primary UC is the first publication on this topic by the EAU. It aims to increase awareness in the urologic community and provide scientific transparency to improve outcomes of this rare urogenital malignancy.

Predictive factors for recurrence progression and cancer specific survival in high-risk bladder cancer

PURPOSE OF REVIEW

Despite standard treatment with transurethral resection (TUR) and adjuvant Bacillus Calmette-Guérin (BCG), a large percentage of high-risk bladder cancer (HRBC) recur, and some progress. On the basis of review of the current guidelines and literature, we have developed actualized clinical and molecular prognostic factors of recurrence, progression and cancer specific survival (CSS) in patients with HRBC.

RECENT FINDINGS

A Medline search was conducted to identify the current literature updating the most important clinic and pathological predictive factors published in the last years. Also, there have been reviewed the new molecular markers that can assess prognosis and BCG response.

SUMMARY

Despite different methodological bias, as short follow-up, a small number of patients and a different definition of prognostic factors, increased evidence supports sex, age, grade, stage, multifocality, history of previous recurrences, carcinoma in situ in the prostatic urethra and early recurrence as prognostic factors for recurrence, progression and CSS in nonmuscle invasive bladder cancer. Also lymphovascular invasion in TUR and new molecular markers (galectin-3, profilin-1, and combination of markers) are increasingly useful in predicting prognosis and BCG response. Moreover, there is enough evidence to consider the implementation of new specific risk tables for patients treated with BCG. In cases with poor prognostic factors after TUR in HRBC early cystectomy should be considered.

[Prostatic involvement by urothelial carcinoma in patients with bladder cancer and their implications in the clinical practice]

OBJECTIVES

Urothelial carcinoma (UC) is a multifocal disease that may develop in any location of the urinary tract, including the prostate. We analyze the types of prostate involvement due to UC, their diagnosis, risk factors and the clinical implications of this entity.

MATERIAL AND METHODS

Analysis of original, review articles and publications related to prostate involvement due to UC. The study included works published in the period of 1985-2011, most of which were obtained from the search in PubMed.

RESULTS

Prostate involvement due to UC has been observed frequently in both non-muscle invasive bladder cancer (NMIBC) series and prolonged follow-up (39%) as in radical cystectomy series (15-48%). Prostatic involvement may occur in the mucosa and ducts (superficial involvement) or prostate stroma (invasive involvement), a fact that has prognostic and therapeutic implications. Stromal involvement may have both a bladder and intraurethral origin. Carcinoma in situ, multifocality, bladder neck/trigone cancer, and previous history of tumor recurrence are the factors that have been m ore consistently associated to prostate involvement due to UC. The incidence of prostatic involvement by UC in patients with NMIBC increases over time when risk factors exist. In these cases, a prostatic urethral biopsy should be performed during the follow-up. Conservative treatment with transurethral resection and BCG is possible in case of superficial involvement of the prostatic urethra, assuming its risk of progression. Patients subjects to cystectomy and with prostate involvement due to UC have a greater risk of urethral recurrence. The elevated incidence of prostatic adenocarcinoma and prostatic involvement by UC in cystectomy specimens makes it necessary to be very selective when indicating prostate-sparing cystectomy. Chemotherapy may be an option in an attempt to improve survival of patients with prostatic stromal involvement.

CONCLUSIONS

Prostatic involvement by UC is not uncommon and it has important implications in the management of patients with NMIBC and in those who have an indication for or have undergone radical cystectomy.

Pathologic assessment and clinical significance of prostatic involvement by transitional cell carcinoma and prostate cancer

The prostate is commonly involved by transitional cell carcinoma (TCC) in patients with bladder cancer. A number of clinicopathologic factors including multifocal carcinoma in situ, tumor location, and tumor stage are associated with prostatic TCC (pTCC). In addition, the manner and extent of pathologic examination also makes a significant difference in the detection rate. Distinct patterns and extent of pTCC have been described and are associated with pathologic stage of the primary bladder tumor as well as prognosis. Preoperative transurethral biopsy of the prostatic urethra is a sensitive and accurate method to detect pTCC and is helpful for surgical planning. Given the high incidence of pTCC and prostatic adenocarcinoma, radical cystoprostatectomy is the treatment of choice for loco-regional control for patients with T4a disease. Further studies are necessary to establish the role of neoadjuvant and adjuvant therapy for patient with prostatic stroma invasion.

Clinical outcome of radical cystectomy for patients with pT4 bladder cancer

OBJECTIVE

The objective of this study was to analyze the outcomes of radical cystectomy for patients with pT4 bladder cancer.

METHODS

Between 1995 and 2003, 583 patients underwent radical cystectomy for bladder cancer at our institution and related hospitals, including 76 pathologically diagnosed as having pT4 disease. Of these 76, this study included 60 patients after excluding 16 with pT4Tis disease, and a retrospective review of their records was carried out.

RESULTS

Pathological examinations demonstrated that seven (11.6%) and 53 (88.4%) patients were Grades 2 and 3, respectively, and 48 (80.0%), 38 (63.4%), 10 (16.7%) and 30 (50.0%) were positive for lymphatic invasion, microvenous invasion, surgical margin and lymph node metastasis, respectively. During the observation period of this study (median, 24.5 months; range, 2-89 months), disease recurrence occurred in 38 (63.3%), and the median time to recurrence after radical cystectomy was 7.0 months (range, 1-38 months). One-, 3- and 5-year cancer-specific survival rates of the 60 patients were 68.8%, 48.5% and 23.9%, respectively. Univariate analysis identified lymph node metastasis, lymphatic invasion, microvenous invasion and positive surgical margin as significant predictors for cancer-specific survival; however, only lymph node metastasis was shown to be independently associated with cancer-specific survival by multivariate analysis.

CONCLUSIONS

The prognosis of patients with pT4 bladder cancer is generally poor, particularly for those with nodal involvement. Therefore, it would be potentially important to carry out careful follow-up for such patients following radical cystectomy and, if necessary, to consider a multimodal therapeutic approach in an adjuvant setting.

Prostatic transitional cell carcinoma: pathologic features and clinical management

Prostatic involvement by transitional cell carcinoma (pTCC) in patients with bladder cancer is a frequent finding, particularly in patients with high-grade invasive tumor and urothelial carcinoma in situ. Various patterns and levels of prostatic involvement have been described, and their impact in patients' management and their prognosis recognized. The role of prostatic urethral biopsy and intraoperative frozen section in the management of bladder cancer, tailoring to the bladder tumor stage is still not well defined and universally accepted. This review discusses the current understanding of the biology and histological patterns of pTCC and their clinical significance and management options. A rational approach for management of pTCC in patients with bladder cancer will be proposed on the basis of our experience and our review of literature.

Urothelial carcinoma in the prostatic urethra and prostate: current controversies

We reviewed the literature on urothelial carcinoma in the prostatic urethra and prostate. We concluded that the incidence of urothelial carcinoma in the prostatic urethra and prostate is probably underestimated. This fact warrants thorough follow-up of patients with high-risk bladder cancers and also whole-mount examination of the prostate after cystectomy to recognize the true incidence and extent of such tumor involvement. Resectoscope loop biopsy is the method of choice to detect urothelial carcinoma in the prostatic urethra/prostate and such biopsies should include the area around the verumontanum to ensure optimal sensitivity. Carcinoma in situ in the prostatic urethra should be treated with intravesical Bacillus Calmette-Guérin and a transurethral resection of the prostate prior to that treatment might increase the contact of Bacillus Calmette-Guérin with the prostatic urethra, improve staging and in itself treat the prostatic involvement. Conservative treatment of carcinoma in situ in the prostatic ducts is an option, although radical surgery is probably best for treating extensive intraductal involvement, since data on the former strategy are inconclusive. Patients with stromal invasion should undergo radical surgery. It is necessary to take the route of prostatic involvement into account when estimating prognosis in each individual patient, since contiguous growth into the prostate is associated with worse prognosis. Prospective studies using a whole-mount technique to investigate the prostate are needed to clarify both the role of different routes of prostate invasion and the prognostic significance of different degrees of prostate invasion. At cystectomy, when urothelial carcinoma is present in the prostatic urethra and/or prostate, it is necessary to balance the risk of urethral recurrence and decreased sexual function against opinion and expectations expressed by the patient during preoperative counseling regarding urinary diversion and primary urethrectomy.

Transitional Cell Carcinoma of the Prostate

Transitional cell carcinoma of the prostate (TCCP) has become a well recognized entity, showing an increasing incidence due to the growing research awareness. TCCP is part of the well known pan-urothelial disease: the urologist, therefore, is strongly recommended to consider the prostate at any time in the management of superficial and invasive bladder cancer. Several cases are diagnosed in association with bladder cancer (secondary TCCP): primary prostatic transitional cell carcinoma arises ‘de novo’ as first tumour of the prostate urothelium and is rare. Prognosis depends on the prostate invasion degree. No reliable staging systems are presently available. Non-invasive TCCP can be successfully treated with conservative means (TUR +/- BCG), whereas stromal invasive TCCP must be aggressively treated with radical cystectomy. TCCP can interphere with surgeon's decisions about urinary diversion in patients undergoing radical cystectomy for urothelial cancer. (Urologia 2007; 74: 15–21)

Urothelial Carcinoma of the Prostate

This study was conducted to explore the diagnosis and management of urothelial carcinoma of the prostate in superficial disease and carcinoma in situ, stromal invasion, primary urothelial carcinoma, and urethral recurrence after radical surgery. A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) reviewed the diagnosis and management of urothelial carcinoma of the bladder. English-language literature about urothelial carcinoma of the prostate was identified and reviewed. Evidence-based recommendations for the diagnosis and management of urothelial carcinoma were made. Many recommendations were level 3 or 4 citations involving the diagnosis and management of superficial urothelial carcinoma; a few were level 2 citations. Level 1 citations related only to chemotherapy and radiotherapy in patients with stromal invasion, although these were not related specifically to invasive prostatic involvement. More than 130 reviewed citations are summarized in this review. Published reports on the diagnosis and treatment of superficial urothelial disease of the prostate primarily consist of short case series from individual centers. Prospective and multicenter trials are needed to identify the real incidence and the best management of these patients. In invasive disease of the prostate, the only large series were designed to investigate invasive bladder cancer.

Prostatic involvement by transitional cell carcinoma in patients with bladder cancer and its prognostic significance

To study the importance of prostatic involvement by transitional cell carcinoma (TCC) in patients with bladder cancer, we examined the entire prostates by whole-mount sections from 214 radical cystoprostatectomy specimens for detailed patterns of involvement by TCC and correlated the results with lymph node metastasis and patients' survival. Prostatic involvement by TCC was detected in 69 (32%) of 214 cases. Among them, 30 (43%) patients had carcinoma in situ (CIS) and the other 39 (57%) were invasive TCC. Carcinoma in situ occurred in either prostatic urethra (n = 6, 20%) or, more commonly, in prostatic ducts/acini (n = 14, 47%), and in a combination of prostatic urethra and ducts (n = 10, 33%). Ten (26%) of the invasive TCC resulted from direct penetration from the primary tumor in the bladder, and the remaining 29 (72%) cases arose from prostatic urethra/ducts, of which 11, 13, and 5 invaded the lamina propria, prostatic stroma, and periprostatic or seminal vesical tissue, respectively. Both prostatic TCC involvement and nodal metastasis were highly significant prognostic factors for patients' survival and the survival significance of prostatic TCC involvement still existed regardless of lymph node status. Furthermore, the presence of prostatic CIS and degrees of prostatic invasion are associated with nodal metastasis and survival. Patients with prostatic CIS or urethral lamina propria invasion had a similar, but higher incidence of lymph node metastasis and lower long-term and 5-year survival than those patients without prostatic involvement. Similarly, prostatic stromal invasion and periprostatic/seminal vesical invasion had a similar, but much higher nodal metastasis and worse survival than patients with only prostatic CIS or urethral lamina propria invasion. In summary, presence of prostatic TCC involvement and levels of involvement are significant prognostic factors in patients with bladder cancer.

Risk assessment for occult malignancy in the prostate before radical cystectomy

OBJECTIVES

To assess our clinical ability to predict prostate involvement by transitional cell carcinoma (PI-TCC) or occult prostate cancer (CAP) in patients undergoing radical cystectomy (RCx).

METHODS

We retrospectively analyzed 70 male patients undergoing RCx for TCC of the bladder between 1995 and 2003, focusing on preoperative factors to predict PI-TCC or CAP.

RESULTS

Of 70 RCx patients, 30 (43%) had PI-TCC (14) or CAP (16). Risk factors for PI-TCC included carcinoma in situ, multifocal TCC, and bladder neck involvement (P <0.05 for all three analyses). All 14 patients with PI-TCC had one or more risk factors, and none of 40 patients without these risk factors had PI-TCC (P <0.001). Risk factors for CAP included elevated prostate-specific antigen level, abnormal results on digital rectal examination, and age more than 65 years. Of 16 patients with CAP, 14 had one or more of these risk factors (P <0.05). Sixteen of the seventy patients in this series (22.9%) had no risk factors for PI-TCC or CAP, and none of these had prostatic involvement with either malignancy (P <0.05).

CONCLUSIONS

Our findings suggest that a well-defined subset of patients undergoing RCx might be at low risk for malignancy in the prostate. However, further evaluation of these risk factors in a prospective setting will be required to substantiate these findings and guide clinical decision making in this controversial field.

Cystectomy in patients with high risk superficial bladder tumors who fail intravesical BCG therapy: pre-cystectomy prostate involvement as a prognostic factor

PURPOSE

To review understaging and outcome of patients who underwent radical cystectomy (RC) for high risk superficial bladder cancer after bacillus Calmette-Guérin (BCG) failure.

PATIENTS AND METHODS

We carried out a retrospective study of 62 cases in which RC was indicated for clinical stage Tis, Ta, T1 transitional cell bladder tumors that failed transurethral resection (TUR) and BCG treatment. We used BCG (81 mg/Connaught BCG) in patients with superficial grade 3 tumors and CIS. We considered BCG failure a high-grade recurrence at 3 months of the first BCG course or after 2 courses. RC indications, correlation between their clinical and pathological stage and the ensuing progress were analyzed. We assessed the existence of any pre-cystectomy clinical or pathological factor related to understaging and survival.

RESULTS

RC was performed in 22 patients with carcinoma in situ (CIS) (35%), 7 with Ta (11,2%), 31 with T1 (50%), and 2 with Tx tumors (3%). All 62 but one were high-grade tumors (grade 3 and/or CIS). Tumor was clinically understaged with stages pT2 or greater on the RC specimen in 17 patients (27%). The presence of tumor in the prostatic urethra at the moment of endoscopic staging before RC was the only factor associated with clinical understaging (p=0.003) and shorter survival (p<0.0002). Five-year disease-specific survival rate was significantly lower in understaged (38%) as compared with not-understaged patients (90%) after a median follow-up of 40-months (range 1-142) (p=0.006). Overall five-year disease-specific survival was 79%.

CONCLUSIONS

RC should be performed prior to progression in high risk superficial tumors that fail after TUR and BCG. In patients with clinical and pathological nonmuscle invasive disease, RC provides an excellent disease-free survival. One third of patients with HRSBT who underwent RC after BCG failure were understaged and had a shorter survival. Tumor in the prostatic urethra at endoscopic staging was the only factor associated to understaging and shorter survival.

The optimum timing of radical cystectomy for patients with recurrent high-risk superficial bladder tumour

OBJECTIVE

To establish the optimum time of radical cystectomy (RC) for patients with recurrent high-risk superficial bladder tumours after the failure of intravesical therapy.

PATIENTS AND METHODS

Among 318 patients with transitional cell carcinoma treated with RC and with no neoadjuvant therapy, there were 46 with clinical stage Ta, T1 or Tis refractory to transurethral resection associated with intravesical therapy. These patients had at least one of: (i) high-risk superficial bladder tumours after failure of two consecutive induction courses of intravesical therapy; (ii) superficial bladder tumours with prostatic stromal invasion; (iii) superficial bladder tumours with mucosa/ducts involvement after failure of one course of intravesical therapy; (iv) uncontrolled superficial tumours with transurethral resection associated or not with intravesical therapy. Progression and cause-specific survival of these patients were compared to those with muscle-invasive tumours. Univariate and multivariate analyses of predictive factors for cause-specific survival were also used in patients with superficial tumours. The incidence of significant prognostic factors was compared in both superficial and muscle-invasive tumours, as were the progression pattern and survival.

RESULTS

The progression-free and cause-specific survival of patients with superficial tumours was 54% and 67%, respectively, with no significant difference from those with muscle-invasive tumours. In multivariate analysis, positive lymph-nodes and prostatic stromal invasion were significant and independent variables for survival. The incidence of positive lymph nodes was 15% vs 30% (P < 0.05) and of stromal invasion was 32% vs 1.5% (P < 0.001) in patients with superficial and muscle-invasive tumours, respectively. Accounting for the progression pattern in patients with superficial tumours, extravesical urothelial recurrence prevailed over local or distant recurrences (30% vs 15%), whereas in patients with muscle-invasive tumours the opposite occurred (5% vs 33%, respectively). The cause-specific survival of patients with superficial tumour and prostatic stromal invasion was one of three, and in those who developed extravesical urothelial recurrence was 28.5%.

CONCLUSION

In patients with recurrent high-risk superficial bladder cancer after intravesical therapy, our criteria for RC were inappropriate, and patients had a survival rate similar to those with muscle-invasive tumours. RC might have been used too late, as there was a high incidence of prostatic stromal invasion and extravesical urothelial recurrence after RC. Both events seem to be responsible of the low cause-specific survival. Predictive factors for progression are needed to indicate early RC in patients with recurrent high-risk superficial tumours. From a previous analysis the pathological pattern of the clinical lack of response (T1, G3, bladder carcinoma in situ and prostate involvement) to intravesical therapy evaluated at 3 months might be important for predicting progression, and an early RC at that time might be useful.

Conservative Management of Mucosal Prostatic Urethral Involvement in Patients with Superficial Transitional Cell Carcinoma of the Bladder

OBJECTIVE

Treatment of patients with mucosal prostatic urethral transitional cell carcinoma (TCC) is controversial. In this study, we evaluated the outcome of patients with mucosal prostatic urethral TCC who were managed conservatively.

METHODS

The data of 290 consecutive male patients with superficial TCC of the bladder who were treated at our institution were reviewed. Median age was 63 years and median follow-up was 63 months. Initially, all patients with mucosal PU involvement without evidence of ductal and/or stromal involvement underwent intravesical BCG or Epirubicin therapy.

RESULTS

Nineteen patients (6.6%) had mucosal involvement of the prostatic urethra (PU) and concomitant multifocal TCC of the bladder. Of those, 12 patients (12/19, 4.2%) had macroscopic mucosal involvement of the PU, while the other 7 patients (7/19, 2.4%) had microscopic PU tumor. Seven of 12 patients who were treated with BCG and 2 of 7 patients who were treated with Epirubicin achieved complete response. Progression occurred in 3 patients who received BCG and no patients progressed in the Epirubicin group.

CONCLUSIONS

Prostatic urethral sampling should be considered necessary in intermediate and high risk patients with superficial TCC of the bladder. Intravesical therapy, especially with BCG seems to be an effective treatment alternative in the management of mucosal PU involvement.

Prognostic impact of extensive parenchymal invasion pattern in pT3 renal pelvic transitional cell carcinoma

BACKGROUND

Pathologic T3 renal pelvic transitional cell carcinoma exhibits various patterns of invasion. The authors investigated the prognostic impact of three patterns of invasion of pT3 renal pelvic transitional cell carcinoma.

METHODS

Of 212 patients who underwent surgery for renal pelvic transitional cell carcinoma, 70 with pT3 disease were eligible for the main analyses. The candidate predictors of prognosis included patient age, gender, lesion laterality, tumor grade, perioperative cisplatin-based systemic chemotherapy, lymph node involvement, vascular involvement, and patterns of invasion. Invasion patterns were classified as fat invasion, ductal involvement, or parenchymal invasion.

RESULTS

Mean postoperative followup was 33.5 months (range, 1-136 months). On univariate analysis, gender, lymph node involvement, vascular involvement, and extensive parenchymal invasion each had a significant impact on the cause specific survival rate. A multivariate analysis using Cox stepwise regression revealed that extensive parenchymal involvement was the strongest prognostic predictor (P = 0.0004, hazard ratio = 5.59). Lymph node involvement (P = 0.0175, hazard ratio = 3.14) and gender (P = 0.0361, hazard ratio = 2.42) were other weaker predictors. Statistically, pT3 disease without extensive parenchymal invasion had a prognosis similar to that of lower stage disease, and pT3 disease with extensive parenchymal invasion had a prognosis similar to that of pT4 disease.

CONCLUSIONS

Extensive parenchymal invasion has a strong prognostic impact in renal pelvic transitional cell carcinoma. pT3 disease should be subclassified into two separate entities, that with and that without extensive parenchymal invasion, in view of prognosis.

Guidelines on bladder cancer

OBJECTIVES

On behalf of the European Association of Urology (EAU) guidelines for diagnosis, therapy and follow-up of bladder cancer patients were established. Criteria for recommendations were evidence based, and included aspects of cost-effectiveness and clinical feasibility.

METHOD

A systematic literature research using Medline Services was conducted. References were weighted by a panel of experts.

RESULTS

TNM 1997 classification and WHO grading 1998 are recommended. Recommendations are developed for diagnosis for bladder cancer in general, treatment of superficial and infiltrative bladder cancer, and follow-up after different types of treatment modalities, such as intravesical instillations, radical cystectomy, urinary diversions, radiotherapy and chemotherapy.

Prospective registration of all patients in a geographical region with newly diagnosed bladder carcinomas during a two-year period

OBJECTIVE

To report the age, stage and grade of all patients with newly diagnosed bladder carcinoma in a well-defined geographical region and to compare this cohort with previous reports which come mainly from large referral centres.

MATERIAL AND METHODS

All newly diagnosed bladder carcinoma patients (n = 701) in Western Sweden were prospectively registered during a 2-year period (1987-88). The histopathological material was re-examined by a reference pathologist. All the original clinical records were reviewed by one urologist 5-7 years after diagnosis. Demographic data, tumor grade, stage, multiplicity, presence of carcinoma in situ and lymphatic invasion are presented.

RESULTS

The mean age at diagnosis was 70.5 years. Grade and stage increase with age. The proportion of non-invasive tumors (55%) is higher than in any previous Scandinavian report. The age-standardized incidence in bladder carcinoma among men in the largest city (Göteborg) is 55% higher than in the rest of the region (p<0.0001). Deviations between the primary pathologist and the reviewer with regard to tumor grade were particularly seen in tumors of grades I and II.

CONCLUSIONS

Differences in mean age, stage and grade distribution were found between the present report, which included all patients with newly diagnosed bladder carcinoma in a geographical area, and other reports, which mainly comprised patients from large treatment centres. These differences can probably and mainly be explained by selection factors such as various degrees of inclusion of low-grade papillary tumors.

Diagnosis and grading of bladder cancer and associated lesions

Standardized classification and grading of urothelial carcinoma has now been achieved internationally. Uniformity of pathologic reporting should improve the comparability of different studies and therapies and provide more accurate information to urologists in managing patients.

Upper urinary tract involvement in patients with bladder carcinoma in situ (Tis): its impact on management

OBJECTIVES

To analyze the biologic behavior and etiologic mechanism of upper-tract involvement in patients with bladder cancer in situ (Tis) and its impact on management of these patients.

METHODS

One hundred thirty-eight patients with bladder Tis, 786 with superficial bladder cancer, and 179 patients with invasive bladder cancer treated by cystectomy were studied: 34 (24.6%), 18 (2.3%), and 7 (3.9%) developed upper-tract involvement in each group, respectively. Sixty-three patients with primary urothelial upper-tract tumors were also studied. Taking progression-free survival as an end point, univariate and multivariate analyses were performed.

RESULTS

The upper-tract recurrence rate was significantly higher in patients with bladder Tis than in patients with superficial bladder tumors (P <0.001); it was also significantly higher in patients treated with cystectomy because of bladder Tis compared with those treated because of invasive tumors (P <0.01). Patients with bladder Tis and upper-tract involvement showed high rates of upper-tract bilaterality (32.3%) and prostate involvement (67.4%). On pathologic examination, the upper tract showed predominantly superficial (Ta-T1-Tis) tumors (67.4%) and distal ureter location as the only finding (47%). In patients with bladder Tis, upper-tract involvement alone does not have a negative impact on the survival rate according to univariate and multivariate analysis (P = NS).

CONCLUSIONS

In patients with bladder Tis, upper-tract involvement represents a diffuse process; therefore, a close evaluation of both the prostate and the upper tract is recommended. Upper-tract involvement has no impact on bladder-preservation strategy. Many of these patients could also be offered a conservative management for the involved upper tract.