Multifocality of transitional cell carcinoma results from genetic instability of entire transitional epithelium

[An extremely rare case of multiple recurrences of urothelial carcinoma in an ileal neobladder: a case report and review of the literature]

In up to 18% of patients, recurrence is observed after curative radical cystectomy. Tumour recurrence occurs in most cases in the locoregional lymph node, as well as in the remaining urinary tract, but very rarely in the orthotopic neobladder. We report a case of multiple recurrence of urothelial carcinoma solely in the orthotopic neobladder of a male patient, 10 years after surgery, without involvement of the urethra or upper urinary tract. Therefore, the patient underwent resection of the neobladder with conversion to a sigmoid conduit. Nevertheless approximately 6 months later the patient developed widespread metastases and died a few months later. Currently, no guidelines are available for the treatment of these rare cases. We present our experience, together with revision of the current literature on this issue.

Transitional cell carcinoma recurrence impacting intestinal diversion after radical cystectomy. Oncologic outcomes of a rare site of recurrence

Introduction

Transitional cell carcinoma recurrence within an intestinal urinary diversion (TCCUD) after radical cystectomy (RC) is a rare condition with unknown origin, prognosis and treatment. The aim of this study was to describe treatment options and oncologic outcomes of this understudied site of recurrence in a multi-institutional case series.

Material and methods

TCCUD relapse cases after RC were investigated in a retrospective, multi-institutional study. Surgical approach and adjuvant chemotherapy were discussed. Early and late complications were described according to the Clavien-Dindo classification. Kaplan-Meier method was used to assess progression-free and cancer-specific survival.

Results

A total of 19 patients were selected. The most common presentation was gross hematuria. The median interval between RC and TCCUD was 51.2 months. Fifteen patients (78.9%) underwent surgical excision, and two underwent concomitant radical nephroureterectomy. In 12 (63.1%) cases the site of TCCUD was the uretero-ileal anastomosis. Tumor invading the muscularis of the intestinal diversion was described in 10 (52.6%) cases. Surgical complications occurred in 7/15 (46.6%) patients, of these two with Clavien-Dindo Grade III. Four patients (21.0%) underwent adjuvant chemotherapy and two (10.5%) both chemotherapy and radiation therapy. During follow-up 15 patients (78.9%) presented with other sites of recurrence, with lymph nodes (21.0%) and liver (15.7%) being the most common localizations. Recurrence free and overall survival rates were 36.8% and 15.8%, and 56.5% and 24.2%, respectively at 12 and 18 months.

Conclusions

Most patients with TCCUD have invasive disease and a substantial percentage experience upper tract cancer during their disease course. TCCUD is often the herald of advanced disease and systemic progression, with poor progression-free and overall survival rates.

The feasibility and safety of cryoablation as an adjuvant therapy with transurethral resection of bladder tumor: A pilot study

BACKGROUND

The potential for transurethral resection (TUR) to result in residual tumors in patients with muscle invasive or high-risk non-muscle invasive bladder cancer (NMIBC) may affect local recurrence or progression. This study attempted to evaluate the feasibility and safety of cryoablation as an adjuvant therapy with TUR to treat bladder tumor.

METHODS

Patients who met inclusion criteria between December 2014 and August 2015 in our institute was included. The inclusion criteria were as followed: 1) urothelial carcinoma; 2) non-muscle-invasive bladder cancer or 3) stage T2 muscle invasive bladder cancer meeting with the following two conditions, solitary and less than 3 cm in size. Ten patients underwent TUR followed by immediate transurethral cryoablation of the tumor resection bed. All patients underwent pathological re-evaluation during follow-up cystoscopy.

RESULTS

The cryoablation was successfully performed without bladder perforation during the procedures. No grade II-V complications were observed. Among these patients, two had T2a stage tumors, three had T1 stage tumors and five had Ta stage tumors. The median follow-up of cases was 9 months (range 9-14 months). During follow-up, tumor recurrence was observed in three patients. Only one recurrence occurred in the primary tumor site.

CONCLUSIONS

Cryoablation as an adjuvant therapy with TUR for bladder tumors was feasible and safe. The potential benefit was to eliminate the residual tumor to the greatest extent.

The evaluation of the risk factors for non-muscle invasive bladder cancer (NMIBC) recurrence after transurethral resection (TURBt) in Chinese population

OBJECTIVE

The risk factors of bladder cancer recurrence after transurethral resection of bladder tumor (TURBt) were poorly understood, especially in Chinese population. This study evaluated the potential risk factors of recurrence based on a Chinese population.

MATERIALS AND METHODS

A total of 698 patients that received TURBt procedure in our institute from 2000 to 2012 were recruited in this study. Clinical information was collected. The patients were followed up according to the schedule recommended by Chinese guideline.

RESULTS

A total of 583 males (83.5%) and 115 females (16.5%) were enrolled in our study. The median follow-up duration was 51.5 months. Gender, chief complain, tumor size, number of lesions, histological grade and chemotherapeutic agents were found significantly associated with patients' short-term recurrence (less than 1 year) (All p<0.05). In the multivariate analysis, tumor size, number of lesions, histological grade and chemotherapeutic agents were significantly related to patients' short-term recurrence (less than 1 year) (All p<0.05). A multivariate model based on tumor size, number of lesions, histological grade and chemotherapeutic agents had an AUC of 0.697, which significantly improved the prediction utility for bladder cancer short-term recurrence (less than 1 year) than any single factor In the multivariate Cox regression, tumor size greater than 3 cm, multifocal lesions, worsen histological grade and non-urothelial carcinoma was related to time to recurrence (TR).

CONCLUSION

Patients with larger tumor size, multifocal number of lesions, higher tumor grade and who received chemotherapeutic agents other than Epirubicin and Pirarubicin might have higher risks of recurrence less than 1 year. Tumor size, number of lesions, pathology and histological grade might be associated with TR. As Bacille Calmette-Guerin (BCG) is currently not approved for bladder cancer in China, Epirubicin and Pirarubicin might be considered prior to other chemotherapy medications when providing post-operative instillation of chemotherapy.

Urothelial carcinoma recurrence in ileal orthotopic neobladder: urethrectomy and creation of ileal conduit

A patient who had previously undergone radical cystoprostatectomy and ileal neobladder with the Studer technique presented with a recurrence of urothelial carcinoma in the neobladder and urethra. Surgical treatment consisted of resection of the neobladder, urethrectomy, and creation of an ileal conduit using a separately isolated segment of ileum. Pathologic analysis revealed high-grade urothelial carcinoma implants to the Studer pouch and urethra, with spread to the mesenteric lymph nodes draining the pouch. Intraluminal tumor cell seeding appears to be an important mechanism of metachronous transitional cell carcinoma recurrence in the urethra and ileal mucosa of a neobladder.

On the origin of syn- and metachronous urothelial carcinomas

OBJECTIVE

To evaluate existing models for the origin of meta- and synchronous urothelial carcinomas in light of the accumulated genetic data.

METHODS

Published studies on the clonal origin and genetic relationships of syn- and metachronous tumors, genetic aberrations in normal and premalignant urothelial lesions, as well as histologic and genetic mapping studies of cystectomized bladder samples are reviewed.

RESULTS

The most common models for the origin of syn- and metachronous tumors are found to conform less well to the accumulated genetic data. A new model is proposed, the field-first-tumor-later model, in which aberrant cells with a stem cell, or stem cell-like, origin spread in the urothelium by cellular displacement, creating fields of premalignant cells. Tumor growth is suggested to be initiated by critical genetic events occurring in individual cells in such fields. Hence, recurring tumors are proposed to originate from a shared field of premalignant cells and not from previous overt tumors.

CONCLUSIONS

The proposed model can better account for the existing genetic and histological data on syn- and metachronous urothelial carcinomas.

Implants of noninvasive papillary urothelial carcinoma in peritoneum and ileocolonic neobladder: Support for “seed and soil” hypothesis of bladder recurrence

OBJECTIVES

To explore the underlying mechanism of tumor regrowth in cases of noninvasive urothelial carcinoma that recur in unusual anatomic locations.

METHODS

The pathology files of our institution and the consult service of one of us were searched for cases of noninvasive nonmetastatic urothelial carcinoma with involvement of unusual anatomic sites. Cases in which the mode of spread included direct spread to the adjacent tissue and lymphovascular metastases were excluded. Medical history, including presenting symptoms, and follow-up data were obtained.

RESULTS

Two cases of noninvasive urothelial carcinoma were identified. One had presented as an implant in the peritoneal investment of the bladder dome and the other as multiple implants growing on the benign surface of the colonic mucosa of an orthotopic neobladder distant from the anastomosis site. Both cases had initially presented as noninvasive papillary urothelial carcinoma of the renal pelvis. Although the urinary bladder was free of neoplastic changes at nephroureterectomy, both patients also developed several papillary tumors within the bladder shortly after the removal of the kidney.

CONCLUSIONS

After clinicopathologic correlation, the mode of tumor spread in these cases was best explained by the "seeding/implantation" theory. The urothelial tumor cells in each of these cases demonstrated the ability to implant themselves not only in the urothelium of the bladder but also in the colonic mucosa of a constructed neobladder and on the peritoneal surface.

Bladder cancer, a two phased disease?

The processes of intraepithelial migration, intraluminal seeding, and field cancerization as models for initiation, spread, and recurrences of urothelial cell carcinoma (UCC) are reviewed in light of recent molecular investigations. The accumulated molecular data on synchronous and metachronous tumors indicate that the majority of recurrent and multiple tumors are monoclonal. Molecular data has also shown the presence of chromosomal and genetic changes in precursor lesions as well as in normal urothelial cells. Genetic-histological mapping of cystectomized bladders has shown that overt tumors occur as local events in areas of genetically altered urothelium. A model is put forward in which the tumor process is initiated by genetically altered but histologically normal cells that produce fields of altered cells by intraepithelial displacement. By the accumulation of further genetic changes the fields of altered urothelium reaches a state of criticality, which locally may produce frank tumors.

Chaotic Genomes Make Chaotic Cells: The Mutator Phenotype Theory of Carcinogenesis Applied to Clinicopathological Relationships of Solid Tumors

Abnormalities of cell morphology and chromosomes have been identified as features of the pathology of tumors for more than 100 years. However, no theory of carcinogenesis until recently has provided a basis for relating them either to each other or to the clinical behavior of individual tumors in many patients. The mutator phenotype theory is based on large numbers of mutations occurring chaotically (randomly, unpredictably, and variably from cell to cell) in individual tumors. Chaotic mutation clearly parallels both the often-observed chaotic morphology of tumors and the frequently unpredictable relationship of these morphologies to clinical behavior. Possible implications of this concept for staging, grading, multifocality, and therapy of cancers are discussed.

Oligoclonality in bladder cancer: the implication for molecular therapies

PURPOSE

There is conflicting evidence in the published literature regarding the clonal or oligoclonal origin of bladder cancer.

MATERIALS AND METHODS

A MEDLINE search of articles on the clonality, genetic, epigenetic and tumor microenvironment of bladder cancer cells was done. Laboratory and clinical studies were included and relevant articles were selected if tumor cell clonality was part of the study. We reviewed this published evidence.

RESULTS

Current thinking proposes 2 main theories. 1) In the clonogenic theory multifocal and recurrent tumors evolve from a single transformed cell and, hence, all progeny share a number of identical genetic mutations. 2) The field change theory assumes a global change in the urothelium with multiple transformed cells evolving into mature tumors independently. The evidence for and against each theory is compelling. Of equal importance are the parallel epigenetic modifications and changes in the cellular microenvironment that permit tumor evolution.

CONCLUSIONS

The presence of oligoclonality has implications for the potential efficacy of novel molecular therapeutic agents for bladder cancer. The molecular targets for such therapies must be widely sampled in a tumor population to assess expression in separate clones.

Genetic instability in superficial bladder cancer and adjacent mucosa: an interphase cytogenetic study

A systematic analysis of both tumors and the surrounding urothelium to help identify what lies behind the mechanism of multifocal tumor development has not yet been performed. In this study we investigated chromosome 1, 7, 9, and 17 aneusomy in 25 superficial papillary carcinomas and in 51 tissue samples taken from sites of macroscopically uninvolved urothelium surrounding the tumors, using the fluorescence in situ hybridization method. Our data demonstrated a close genetic relationship between all examined tumors and normal-appearing mucosa. Numeric aberrations of chromosomes 1, 7, 9, and 17 were found to exhibit similar patterns in all analyzed specimens, although with different frequencies.

Clonality of multifocal urothelial carcinomas: 10 years of molecular genetic studies

Multifocal occurrence and frequent recurrence are characteristic features of urothelial carcinomas of both the urinary bladder and the upper urinary tract. To describe the clonal nature of these tumors, 2 theories have been proposed. The monoclonality hypothesis describes the multiple tumors as descendants of a single genetically transformed cell spreading throughout the urothelium. In contrast, field cancerization caused by carcinogen exposure of the urothelium may lead to independent development of synchronous or metachronous nonrelated tumors at different sites of the urothelial tract. In the last 10 years, a multitude of molecular genetic studies have investigated the clonality of multifocal urothelial carcinomas. The majority of studies revealed a monoclonal origin of the multiple tumors. However, most of these studies investigated advanced invasive carcinomas. A small but significant proportion of multifocal urothelial carcinomas appear to arise from different clones, supporting the field-cancerization hypothesis. Oligoclonal tumors might be more common in precursor lesions and early tumor stages. The frequent monoclonality found in patients with advanced tumors could be due to outgrowth of 1 tumor cell clone with specific genetic alterations. Two important mechanisms appear to be important for the spread of malignant cells: intraluminal seeding and intraepithelial migration. Investigation of the entire urothelial lining in patients with urothelial tumors should provide further insight into the development of multifocal urothelial carcinomas.

Multivariate analysis of survival, recurrence, progression and development of mestastasis in T1 and T2a transitional cell bladder carcinoma

BACKGROUND

Determination of prognosis factors associated with survival, recurrence, progression, and development of metastasis in T1 and T2a transitional cell carcinoma (TCC) of the bladder is discussed.

METHODS

A study was conducted of a group of 210 patients with primary bladder TCC at classification T1 (n = 175) and T2aN0M0 (n = 35). A total of 177 variables were studied in each patient. The monoclonal antibodies used were the following: DO7 (p53) and MIB-1 (Ki-67). Prognosis was obtained using Kaplan-Meier methodology and Cox proportional hazards model.

RESULTS

The average follow-up period was 6.7 years. Cancer-related survival rates at 5 and 10 years were 82.96% and 74.78%, respectively. The independent survival variables were the following: age and expression of p53. Recurrence free survival at 5 and 10 years stood at 51.80% and 42.71%, respectively. The independent recurrence variables were T2a classification, tumor multifocality, tumor size of greater than 3 cm, carcinoma in situ in random biopsy, and expression of Ki-67. Progression free survival rates at 5 and 10 years were 75.31% and 69.16%, respectively. The independent progression variables were age, T2a classification, and expression of p53. Metastasis free survival rates at 5 and 10 years stood at 87.23% and 84.55%, respectively. The expression of p53 was the sole variable to provide an independent prediction of metastasis.

CONCLUSIONS

The expression of p53 clearly has an independent effect on the prediction of survival, progression and development of metastasis, showing a dose-response effect. Tumor multifocality and T2a classification are the variables that best predict recurrence.

Progression from superficial to invasive carcinoma of the bladder: genetic evidence of either clonal heterogeneous events

Until now, no definitive molecular evidence proving or disproving a true progression from superficial to invasive bladder tumors has been reported. A total of 36 lesions from 6 patients affected by invasive bladder cancer after multiple superficial recurrences were analyzed for loss of heterozygosity on 8 loci of chromosome 9 and 2 loci of chromosome 17. In addition, the clonal composition of the tumors from two female patients was examined using the human androgen receptor assay. Our data suggest that papillary bladder lesions can and sometimes do make a true progression into invasive life-threatening tumors; however, this progression is not an invariable sequence because it was definitely proven in 2 but not confirmed in 3 of the cases we examined.