Office evaluation and management of bladder neoplasms

Office-based Bladder Tumor Fulguration and Surveillance: Indications and Techniques

This article summarizes the current literature on office-based management of low-grade, noninvasive bladder cancer. Discussion includes differences in recurrence and progression rates between neoplasm grades and stages, role of visual grading for diagnosis, cost advantages of treatment outside the operating room, and a step-by-step description of office-based procedures.

Diagnosis and treatment of bladder cancer: how can we improve?

The majority of patients with bladder cancer will be diagnosed following an episode of hematuria. With few exceptions, these patients should be referred for a complete urologic evaluation, including a history and physical examination, flexible cystoscopy, imaging of the upper urinary tract, and optional urine cytology. Those found to have a bladder tumor should undergo transurethral resection for the combined purposes of initial staging and treatment. Delays in diagnosing invasive bladder cancer are associated with adverse outcomes. In this review, we cover the diagnosis and management of bladder cancer. In addition, we discuss ways to improve outcomes through increased public awareness, improvements in tumor detection, accurate staging, and regimented patient surveillance.

Economic aspects of bladder cancer: what are the benefits and costs?

OBJECTIVE

Bladder cancer (BC) has the highest lifetime treatment costs per patient of all cancers. The high recurrence rate and ongoing invasive monitoring requirement are the key contributors to the economic and human toll of this disease. The purpose of this paper was to utilize the recent literature to identify opportunities for improving the benefits and costs of BC care.

METHODS

A PubMed search was performed of recent publications concerning (BC) cost-effectiveness. We reviewed studies, reviews, opinion papers and cost-effectiveness analyses, focusing primarily on non-muscle-invasive bladder cancer (Ta/T1; NMIBC).

RESULTS

New diagnostic tools such as urine markers may assist in more cost-effectively detecting BC at an earlier stage, however, these markers cannot replace the cystoscopy, which is the current standard of care. A photodynamic diagnostic tool (PDD) using hexylaminolevulinate (Hexvix) enhances tumor visibility and improves transurethral resection of bladder cancer (TURB) results, potentially reducing recurrence rates and lowering treatment costs. While the importance of BC research has been acknowledged, research investment has been continuously reduced during the last 5 years.

CONCLUSIONS

The economic burden of BC is well-characterized in the literature. This study suggests that new technologies (i.e., urine-based tests, PDD) and therapeutic regimes (intravesical chemotherapy, adjuvant immunotherapy) have significant potential to improve the diagnosis, treatment and on-going monitoring of BC patients, with potential improvements in clinical outcomes and concurrent cost-savings. A renewed interest and investment in BC research are required to ensure future advancements.

Detection of circulating tumor cells in bladder cancer patients

The methods employed for the detection of circulating bladder cancer cells (CBCs) and their use as a molecular staging tool in clinical settings are thoroughly reviewed. CBC isolation and enrichment methods are discussed according to their advantages and pitfalls along with the clinical data of PCR-based techniques used for CBC detection. In addition, we review the specificity of molecular markers that have been proposed so far for CBC identification, and we comment on the controversial clinical data, proposing laboratory approaches which may improve the clinical significance of CBC detection in bladder cancer.

[Clinical-pathology relationship in bladder cancer]

OBJECTIVES

Analyze the role of the Computerized Axial Tomography (TAC) like image study of pre-surgery stadification, in the subjected patients to radical cystectomy, for the treatment of muscle infiltrate bladder cancer.

METHODS

Retrospective study of cohorts on 63 subjected patients to radical cystectomy for bladder cancer, in oneself service, between january of 1995 and december of 2.005. The capacity of the TAC was determined for the stadification bladder (pT), node (pN) and the results were compared, with the obtained ones in the pathological anatomy after the radical cystectomy, acording to TNM clasification. The possible impact of this image technique was evaluated in the change of surgical attitude in these patients.

RESULTS

The estimate of bladder affectation with TAC was correct in 28.6%, sub-estadificate in 50.8%, and up-estadificate in 20.6%. The TAC for the bladder possesses a lower sensibility the more outpost it is this affectation. It specificity is higher the more advanced locally is the cancer, oscillating among 44% in the pT2 and 94% in the pT4. Regarding the estadification node, it is correct in 73.5% of all cases, although this percentage depends almost exclusively on the patients with negative node (N -). These data offer us a sensibility of 28%, specificity of 55%, positive predictive value of 68% and negative predictive of 67%.

SUMMARY

The impact of the TAC in the clinical estadification of the infiltrate bladder cancer is relatively low. The biggest benefit is obtained in patient with suspicion of advanced illness. Its limitation to this group would suppose a significant reduction of costs, with low risk of an inappropriate surgical handling.

Contemporary diagnosis of bladder cancer

BACKGROUND

Early diagnosis of bladder cancer is mandatory, as a delay in treatment has been shown to affect prognosis. The current diagnostic standard of cystoscopy and cytology is costly, invasive and inconvenient, whereas advances in molecular biology have resulted in the evolvement of several markers.

OBJECTIVE

To review diagnostic considerations in the use of old and new technical modalities and tests for the detection of bladder cancer.

METHODS

A PubMed search of the literature concerning bladder cancer diagnosis was performed. Reviews are included on certain topics to avoid extensive reference to separate studies.

CONCLUSION

Recent technical advances have an impact on the management of patients with suspected bladder cancer. Cytology is still an important adjunct in the diagnostic work-up, whereas urine-bound tests may have a role in screening and surveillance. However, cystoscopy is the standard of care for the detection of bladder cancer. Fluorescence cystoscopy is an adjunctive tool, especially for the prompt identification of carcinoma in situ.

Muscle-invasive urothelial cell carcinoma of the human bladder: multidirectional differentiation and ability to metastasize

Few published studies have addressed the correlation between multidirectional differentiation in muscle-invasive bladder cancer and its ability to metastasize. We demonstrated that histologic differentiation within a single tumor affects lymph node metastasis. We examined cystectomy specimens from 93 bladder tumors and 1085 lymph nodes. In this study, urothelial cell carcinomas (UCCs) with divergent differentiation, excluding pure divergent patterns such as squamous cell carcinoma and adenocarcinoma that tend toward a distinct biologic behavior, were subjected to histopathologic estimation. The positive lymph node ratio increased with the nonconventional differentiation number (NDN) within a tumor from 8.7% for an NDN of 0 (pure conventional UCCs) to 35.5% for an NDN of 2 or higher (mixed conventional and nonconventional [NC] UCCs showing >2 NC patterns). The positive lymph node number (PLN) was more than twice as high for an NDN of 3 or higher as compared with cases with an NDN of 0. Lymph node positivity (LP) was associated with the presence of micropapillary, lymphoma-like, plasmacytoid, giant cell, or clear cell-type tumors, and increasing PLN was associated with the presence of glandular, nested, lymphoma-like, plasmacytoid, or undifferentiated types in the primary tumor. By multivariate analysis, NDN status was determined to be an independent predictor of PLN (P = .032). Tumor stage had impact on LP (P = .002); however, in cases with a PLN of 4 or higher, the NDN became the only predictor of further dissemination (P = .016). No significant tumor grade impact on LP or PLN was found. Our results indicate that NC differentiation in the primary tumor is a good predictor of lymph node dissemination.

The diagnosis and staging of bladder cancer: From RBCs to TURs

Timely and accurate diagnosis and staging of bladder cancer is critical for the successful management of patients with this disease. We review the literature on screening, signs and symptoms, cystoscopic evaluation, diagnostic tests, transurethral resection, and imaging. We highlight emerging areas, such as markers and fluorescence cystoscopy. Suspicion, accuracy, and technologic advances are key factors in ensuring the best outcomes for patients with bladder cancer.

[Is there a place for randomized biopsies in the follow up of superficial transitional cell carcinoma of the urinary bladder?]

INTRODUCTION

Transitional cell carcinoma of the bladder represents a disease of entire urothelial tract. The follow up is very important to detect any lesion that might represent a progression or a local recurrence. Some authors recommend randomized biopsies as a routine workup, others recommend cystoscopies and urinary cytology as the main part of superficial bladder cancer follow up.

PATIENTS AND METHODS

Forty nine patients with superficial bladder cancer were followed up during a ten-year period. Randomized biopsies and urinary cytology were harvested according to the international cancer protocol on bladder cancer.

RESULTS

15 (1%) out of 1.489 randomized biopsies found to be positive to transitional cell carcinoma. Four out (10.5%) of 35 biopsies targeted to suspicious areas were positive to transitional cell carcinoma. 50 (17.4%) out of 288 cystoscopies with urinary cytology found to be positive to transitional cell carcinoma. Sensitivity and Specificity of biopsies (including randomized and targeted) were 31% and 85.2% respectively. Sensitivity and specificity of cystoscopies with urinary cytology were 48% and 86.5% respectively.

CONCLUSION

Randomized biopsies did not show to detect more local recurrence or progression when compared to the urinary cytology. Cystoscopies with urinary cytology have good sensitivity and specificity for detection of tumor recurrence during follow up of transitional cell carcinoma.

Expectant management of small, recurrent, noninvasive papillary bladder tumors

PURPOSE

The majority of patients with stage Ta or T1 bladder cancer will have a subsequent tumor. Many of these patients invariably undergo multiple transurethral resections to manage small subsequent tumors or recurrences. We report our experience monitoring patients whose subsequent tumors appear to be small, low grade and papillary.

MATERIALS AND METHODS

A total of 32 patients with small, papillary, low grade appearing tumors and a history of Ta or T1 transitional cell carcinoma were monitored. The decision to delay resection or fulguration and observe these tumors was based on bladder cancer history, endoscopic appearance of the tumor and presence or lack of symptoms. All patients had a previous Ta tumor, and the tumor being observed was always papillary and appeared to be low grade. The decision to resect the tumor(s) was based on change in appearance (size or configuration) at followup endoscopy or hematuria. Patient records were reviewed, and bladder cancer history and tumor observation periods were recorded. Several patients underwent a number of observation periods. Tumor grade and stage before the observation interval were compared to the pathology of the observed tumor(s) after eventual resection. Tumor growth rate was calculated based on estimated tumor size documented at each interval.

RESULTS

Mean patient age was 72 years (range 39 to 88). Mean time since diagnosis of bladder cancer (initial urothelial tumor event) was 71 months (range 12 to 139). Mean number of subsequent tumor episodes or recurrences per patient was 3.8 (range 1 to 10). Mean number of transurethral resections was 3.8. Mean tumor-free interval before development of a subsequent tumor or mean time to recurrence was 13.4 months based on 104 tumor episodes. Not all tumor recurrences were observed. Mean number of tumor observation periods per patient was 1.8 (range 1 to 5) with a mean duration of 10.09 months per period based on 56 observation intervals. Mean time since the beginning of the initial observation period was 38 months (range 6 to 126). Mean tumor growth rate for 37 tumors was 1.77 mm per month (range 0 to 5.8). Only 3 of 45 (6.7%) patients had tumor progression from a pre-observation, low grade, noninvasive (TaG1 to 2) to a high grade Ta or T1 tumor. In the 3 observation periods in which the patient's most recent tumor was T1, 2 (67%) patients had TaG1 on resection after observation. Every patient with a T1 tumor before observation of a small new tumor had a history of a Ta tumor. No disease progressed to muscle invasion.

CONCLUSIONS

Small, recurrent, low grade appearing bladder tumors are slow growing and pose minimal risk. Therefore, as an alternative to in office fulguration to minimize morbidity and cost associated with repeat transurethral resection it may not be necessary to remove these tumors promptly at new tumor occurrence or recurrence.

Ras oncogene mutations in urine sediments of patients with bladder cancer

Early detection of bladder cancer is particularly important since it dramatically affects the survival rates. However, neither urinary cytology nor tumor markers that are currently used are sensitive enough for the early detection of bladder cancer or recurrent disease. The ras genes are frequently mutated in cancer. In this study, we investigated the diagnostic potential of ras mutation analysis in urinary sediments of patients with bladder cancer using a single-strand conformation polymorphism analysis and polymerase chain reaction. Mutation in codon 12 of the H-ras gene was observed in 39% of the patients. Our results indicate that this approach may significantly improve diagnostic sensitivity in detecting bladder tumors.

Teaching transurethral resection of the bladder: still a challenge?

OBJECTIVES

To report on our 2-year experience in teaching transurethral resection (TUR) of bladder tumors to five trainees. We analyzed their problems, as well as those of the teachers, and present our solutions.

METHODS

Between April 2000 and March 2002, five residents and three members of the staff took part in a training program to teach TUR of the bladder. From a total of 692 patients with bladder tumors admitted for treatment to our department, 417 were selected for the study. These 417 had papillary tumors of small to medium size (maximum 25 mm in diameter). The mean patient age was 61 years (range 32 to 92) for men (n = 322; 77%) and 68.4 years (range 48 to 91) for women (n = 95; 33%).

RESULTS

A total of 417 teaching TURs were performed during a 24-month period. A total of 65 complications (16%) occurred and were analyzed from the database. The most common complication was postoperative bleeding, occurring in 33 cases (8%), followed by extraperitoneal perforation, which occurred in 16 cases (4%).

CONCLUSIONS

Despite careful patient selection and the use of video-assisted equipment and permanent supervision by an experienced resectionist, a significant number of complications occurred. The question: "How to teach the teacher to teach TUR of the bladder?" remains open.

The health economics of bladder cancer: a comprehensive review of the published literature

The aim of this paper was to conduct a critical systematic review of the available literature on the clinical and economic burden of bladder cancer in developed countries, with a focus on the cost effectiveness of interventions aimed at reducing that burden.Forty-four economic studies were included in the review. Because of long- term survival and the need for lifelong routine monitoring and treatment, the cost per patient of bladder cancer from diagnosis to death is the highest of all cancers, ranging from 96000-187000 US dollars (2001 values) in the US. Overall, bladder cancer is the fifth most expensive cancer in terms of total medical care expenditures, accounting for almost 3.7 billion US dollars (2001 values) in direct costs in the US. Screening for bladder cancer in the general population is currently not recommended. The economic value of relatively new and less expensive urine assays and molecular urinary tumour markers has not been assessed. However, the literature suggests that screening patients suspected of having bladder cancer and using less invasive diagnostic procedures is cost effective. Very few cost-effectiveness studies have evaluated intravesical therapies such as bacillus Calmette-Guérin and mitomycin in the management of superficial disease and no robust recommendations can be drawn. Economic analyses suggest that non-surgical treatment strategies for the management of invasive disease aiming at bladder preservation may not be cost effective, because they have not consistently demonstrated survival benefits and do not eliminate the need for subsequent radical cystectomy. The literature suggests that the current conventional frequent follow-up and monitoring of patients can be cost effectively replaced by less frequent and less invasive monitoring, and should rely more heavily on intravesical chemotherapy to reduce the need for cystoscopies. Bladder cancer is a fairly common and costly malignancy. Nevertheless, the existing literature only contributes marginally to our knowledge concerning the burden of bladder cancer and the economic value of various interventions. The limited value of the literature in this area may be attributed to (i) being published as abstracts rather than full peer-reviewed evaluations; (ii) employing questionable methodologies; and (iii) being in many cases nearly obsolete, rendering them less relevant to, if not in conflict with, current clinical practice. Consequently, opportunities exist to conduct meaningful economic research in all areas of the management of bladder cancer, including screening, diagnosis, follow-up and treatment, especially with respect to new and innovative pharmaceutical and other technologies.

Bladder cancer: epidemiology, diagnosis, and management

PURPOSE

The purpose of this article is to present an overview of the epidemiology diagnosis, and management of bladder cancer, with a focus on the early stage of this disease.

OVERVIEW

English-language articles published between 1990 and 2000, as well as selected abstracts published in non-English languages before 1990, were reviewed. Epidemiologic data clearly indicate that bladder cancer is much more common in men, White persons, and the elderly. Cigarette smoking appears to be the most significant environmental risk factor. Screening for the disease is currently not standard in the United States or Canada. Potential tests include urine cytology, hematuria dipstick, and the urinary biomarkers. Diagnosis is made most often on the basis of the findings of cystoscopy, tumor biopsy, and urine cytology. Transurethral resection (TUR) of the tumor is generally the first-line treatment for superficial disease. Cystectomy is the "gold standard" treatment for invasive disease in many countries, although trimodality therapy (TUR, radiation, systemic chemotherapy) has shown promise as a bladder-preserving strategy. Intravesical therapy is effective for preventing disease recurrence, although its role in slowing disease progression is uncertain. Chemotherapy and radiation also can be used with cystectomy to treat or prevent pelvic recurrence of invasive disease or to prolong life in patients with metastatic disease.

CLINICAL IMPLICATIONS

Bladder cancer is a commonly occurring disease. Prevention efforts must focus on the avoidance or cessation of cigarette smoking and on public education relating to known environmental risk factors. Patient and disease factors must be considered in making treatment decisions and determining prognosis. Careful follow-up after treatment is essential. It is hoped that ongoing research on potential tumor markers and tumor-specific therapies ultimately will result in improved clinical outcomes for patients with this malignancy.

Office-based cystoureteroscopy for assessment of the upper urinary tract

Nephron-sparing management of malignant or benign lesions of the upper tracts creates the need for surveillance. This usually requires serial endoscopic assessment in the operating room under general anesthesia. Herein is presented a novel alternative to follow selected patients in the office setting using readily available adult cystoscopic equipment.

Sensitive detection of transitional cell carcinoma of the bladder by microsatellite analysis of cells exfoliated in urine

Transitional cell carcinoma (TCC) is the most common bladder tumor. Urine cytology can identify most high-grade tumors but sensitivity is lower if one includes lesions of all grades. Microsatellite marker alterations have been found in many tumor types including bladder cancer and have been used to detect cancer cells in body fluids including urine. The aim of our study is to further evaluate feasibility and sensitivity of microsatellite analysis to detect bladder cancer cells in urine. We studied 55 individuals: 21 with symptoms suggestive of bladder cancer, 23 patients with previous history of TCC and 11 healthy subjects. Genomic DNA was extracted from blood lymphocytes, urine sediment, bladder washings and tumor or normal bladder mucosa. Twenty highly informative microsatellite markers were analyzed for loss of heterozigosity (LOH) and microsatellite instability (MIN) by polymerase chain reaction. Microsatellite analysis of urine identified 33 of 34 (97%) patients with either primary or tumor recurrence, whereas urine cytology identified 27 of 34 (79%) patients (p = 0.0001). Detection of microsatellite abnormalities improved the sensitivity of detecting low-grade and/or stage bladder tumor: from 75-95% for grades G1-G2 and from 75-100% for pTis-pTa tumors. Bladder washings from 25 patients were also analyzed, and in all cases results were identical to those obtained from voided urine. None of the 16 patients without evidence of TCC showed LOH and/or MIN in urine samples or bladder washings. Interestingly, in a patient with persistent bladder mucosa abnormalities, microsatellite alterations were demonstrated 8 months before the histopathologic diagnosis of tumor recurrence. These results further indicate that microsatellite marker analysis is more sensitive than conventional urine cytology in detecting bladder cancer cells in urine and represents a potential clinical tool for monitoring patients with low-grade/stage TCC.