Advances in the Etiology of Urothelial Cancer

Targeted therapy of cancer stem cells: inhibition of mTOR in pre-clinical and clinical research

Cancer stem cells (CSCs) are a type of stem cell that possesses not only the intrinsic abilities of stem cells but also the properties of cancer cells. Therefore, CSCs are known to have self-renewal and outstanding proliferation capacity, along with the potential to differentiate into specific types of tumor cells. Cancers typically originate from CSCs, making them a significant target for tumor treatment. Among the related cascades of the CSCs, mammalian target of rapamycin (mTOR) pathway is regarded as one of the most important signaling pathways because of its association with significant upstream signaling: phosphatidylinositol 3‑kinase/protein kinase B (PI3K/AKT) pathway and mitogen‑activated protein kinase (MAPK) cascade, which influence various activities of stem cells, including CSCs. Recent studies have shown that the mTOR pathway not only affects generation of CSCs but also the maintenance of their pluripotency. Furthermore, the maintenance of pluripotency or differentiation into specific types of cancer cells depends on the regulation of the mTOR signal in CSCs. Consequently, the clinical potential and importance of mTOR in effective cancer therapy are increasing. In this review, we demonstrate the association between the mTOR pathway and cancer, including CSCs. Additionally, we discuss a new concept for anti-cancer drug development aimed at overcoming existing drawbacks, such as drug resistance, by targeting CSCs through mTOR inhibition.

Recent advances in upper tract urothelial carcinomas: From bench to clinics

Urothelial carcinoma in the upper tract is rare and often discussed separately. Many established risk factors were identified for the disease, including genetic and external risk factors. Radiographic survey, endoscopic examination and urine cytology remained the most important diagnostic modalities. In localized upper tract urothelial carcinomas, radical nephroureterectomy with bladder cuff excision are the gold standard for large, high-grade and suspected invasive tumors of the renal pelvis and proximal ureter, whereas kidney-sparing surgeries should be considered in patients with low-risk disease. Advances in technology have given endoscopic surgery an important role, not only in diagnosis, but also in treatment. Although platinum-based combination chemotherapy is efficacious in advanced or metastatic disease, current established chemotherapy regimens are toxic and lack a sustained response. Immune checkpoint inhibitors have led to a new era of treatment for advanced or metastatic urothelial carcinomas. The remarkable results achieved thus far show that immunotherapy will likely be the future treatment paradigm. The combination of immune checkpoint inhibitors and other agents is another inspiring avenue to explore that could benefit even more patients. With respect to the high incidence rate and different clinical appearance of upper tract urothelial carcinomas in Taiwan, a possible correlation exists between exposure to certain external risk factors, such as arsenic in drinking water and aristolochic acid in Chinese herbal medicine. As more gene sequencing differences between upper tract urothelial carcinomas and various disease causes are detailed, this has warranted the era of individualized screening and treatment for the disease.

Bladder metastasis presenting as neck, arm and thorax pain: a case report

BACKGROUND

A case of metastatic carcinoma secondary to urothelial carcinoma presenting as musculoskeletal pain is reported. A brief review of urothelial and metastatic carcinoma including clinical presentation, diagnostic testing, treatment and chiropractic considerations is discussed.

CASE PRESENTATION

This patient presented in November 2014 with progressive neck, thorax and upper extremity pain. Computed tomography revealed a destructive soft tissue mass in the cervical spine and additional lytic lesion of the 1st rib. Prompt referral was made for surgical consultation and medical management.

CONCLUSION

Distant metastasis is rare, but can present as a musculoskeletal complaint. History of carcinoma should alert the treating chiropractic physician to potential for serious disease processes.

Management of non-muscle-invasive (superficial) bladder cancer

Non-muscle-invasive (superficial) bladder cancer (NMIBC) represents 80% of incident cases of bladder cancer, and is characterized by a generally good prognosis, with a tendency to remain localized. Only 10%-20% of cases progress to invasion and/or metastasis. The biggest problem in management is the potential for local recurrence, and this will occur with relatively predictable prognostic determinants. Gene expression and other cell surface determinant are associated with outcome. In most cases, successful management is predicated on careful history taking and physical assessment, meticulous endoscopic assessment, and transurethral resection of bladder tumor tissue where indicated. Histology determines the potential for recurrence. Options of treatment include repeat resection, immunologic therapy via intravesical instillation, and the use of intravescally administered cytotoxic agents, including mitomycin C, doxorubicin, gemcitabine, and selected investigational compounds. Of importance, as some cases have the potential to invade and metastasize, timing of cystectomy for recurrent, high-risk tumors is important to avoid unnecessary morbidity and mortality.

Association of BLCA-4 hypomethylation in blood leukocyte DNA and the risk of bladder cancer in a Chinese population

Global DNA hypomethylation has been associated with increased risk for cancers of the colorectum, bladder, breast, head and neck, and testicular germ cells. The aim of this study was to examine whether global hypomethylation measured at BLCA-4 repeat regions through bisulfite pyrosequencing in blood leukocyte DNA is associated with the risk of bladder cancer(BC). A total of 312 bladder cancer patients and 361 healthy control subjects were included in Chongqing, China. Global methylation in blood leukocyte DNA was estimated by analyzing BLCA-4 repeats using bisulfite-polymerase chain reaction (PCR) and pyrosequencing. The median methylation level in BC cases (percentage of 5-methylcytosine (5 mC) = 75.7 %) was significantly lower than that in controls (79.7 % 5 mC) (P = 0.002, Wilcoxon rank-sum test). The odds ratios (ORs) of BC for individuals in the third, second, and first (lowest) quartiles of BLCA-4 methylation were 1.2 (95 % confidence interval (CI) 0.8-1.9), 1.6 (95 % CI 1.1-2.3), and 2.7 (95 % CI 1.5-3.8) (P for trend <0.001), respectively, compared to individuals in the fourth (highest) quartile. A 2.1-fold (95 % CI 1.5-2.8) increased risk of BC was observed among individuals with BLCA-4 methylation below the median compared to individuals with higher (>median) BLCA-4 methylation. Our results demonstrate for the first time that individuals with global hypomethylation measured in BLCA-4 repeats in blood leukocyte DNA have an increased risk for BC. Our data provide the evidence that BLCA-4 hypomethylation may be a useful biomarker for poor prognosis of patients with BC.

Combined effects of GSTO1 and SULT1A1 polymorphisms and cigarette smoking on urothelial carcinoma risk in a Taiwanese population

BACKGROUND/PURPOSE

Cigarette smoking is the main risk factor for urothelial carcinoma of the bladder (UCB). Glutathione S-transferase omega 1 (GSTO1) and sulfotransferase 1A1 (SULT1A1) have been reported to be associated with the metabolism of polycyclic aromatic hydrocarbons (PAHs) and aromatic amines. The aim of the present study was to investigate the combined effects of polymorphisms in GSTO1 and SULT1A1 genes and cigarette smoking on UCB risk in a Taiwanese population.

METHODS

A total of 300 patients with histopathologically confirmed UCB and 233 cancer-free controls were recruited from the Department of Urology of Tung's Taichung Metro Harbor Hospital and Taipei Medical University Hospital. A comprehensive interview was conducted to collect personal information, including demographic characteristics and cigarette smoking status. A multivariate-adjusted logistic regression was performed to estimate the risk of UCB.

RESULTS

A significantly increased risk of UCB was observed in ever smokers [odds ratio (OR) = 2.3]. The Ala/Ala genotype of the GSTO1 gene and the Arg/Arg genotype of the SULT1A1 gene were associated with a significantly increased risk of UCB, with ORs of 1.8 [95% confidence interval (CI) = 1.2-2.6] and 2.1 (95% CI = 1.6-4.5), respectively. Significantly increased UCB risks were found in heavy smokers with the Ala/Ala genotype of the GSTO1 gene (OR = 4.2) and the Arg/Arg genotype of the SULT1A1 gene (OR = 6.8). Furthermore, a significant synergistic effect in an additive model (OR = 3.5) between the GSTO1 Ala/Ala genotype and the SULT1A1 Arg/Arg genotype on UCB risk was observed.

CONCLUSION

The present study provided epidemiological evidence for a significantly increased risk of UCB in ever smokers with the Ala/Ala genotype of the GSTO1 gene and the Arg/Arg genotype of the SULT1A1 gene.

Pathobiology and chemoprevention of bladder cancer

Our understanding of the pathogenesis of bladder cancer has improved considerably over the past decade. Translating these novel pathobiological discoveries into therapies, prevention, or strategies to manage patients who are suspected to have or who have been diagnosed with bladder cancer is the ultimate goal. In particular, the chemoprevention of bladder cancer development is important, since urothelial cancer frequently recurs, even if the primary cancer is completely removed. The numerous alterations of both oncogenes and tumor suppressor genes that have been implicated in bladder carcinogenesis represent novel targets for therapy and prevention. In addition, knowledge about these genetic alterations will help provide a better understanding of the biological significance of preneoplastic lesions of bladder cancer. Animal models for investigating bladder cancer development and prevention can also be developed based on these alterations. This paper summarizes the results of recent preclinical and clinical chemoprevention studies and discusses screening for bladder cancer.

Occupational exposure to polycyclic aromatic hydrocarbons influenced neither the frequency nor the spectrum of FGFR3 mutations in bladder urothelial carcinoma

Occupational exposure to polycyclic aromatic hydrocarbons (PAH) is associated with an increased risk of urothelial carcinoma (UC). FGFR3 is found mutated in about 70% of Ta tumors, which represent the major group at diagnosis. The influence of PAH on FGFR3 mutations and whether it is related to the emergence or shaping of these mutations is not yet known. We investigated the influence of occupational PAH on the frequency and spectrum of FGFR3 mutations. We included on 170 primary urothelial tumors from five hospitals from France. Patients (median age, 64 yr) were interviewed to gather data on occupational exposure to PAH, revealing 104 non- and possibly PAH exposed patients, 66 probably and definitely exposed patients. Tumors were classified as follows: 75 pTa, 52 pT1, and 43 > or =pT2. Tumor grades were as follows: 6 low malignant potential neoplasms (LMPN) and 41 low-grade and 123 high-grade carcinomas. The SnaPshot method was used to screen for the following FGFR3 mutations: R248C, S249C, G372C, Y375C, A393E, K652E, K652Q, K652M, and K652T. Occupational PAH exposure was not associated with a particular stage or grade of tumors. Thirty-nine percent of the tumors harbored FGFR3 mutations. After adjustment for smoking, occupational exposure to PAH did not influence the frequency [OR, 1.10; 95% CI, 0.78-1.52], or spectrum of FGFR3 mutations. Occupational exposure to PAH influenced neither the frequency nor the spectrum of FGFR3 mutations and there was no direct relationship between these mutations and this occupational hazard.

RETRACTED: Highly specific urine-based marker of bladder cancer

OBJECTIVES

Bladder cancer represents a major health problem throughout the world, but advances in tumor biomarker development are revolutionizing how physicians diagnose the disease. We previously used an indirect immunoassay to demonstrate that the bladder cancer specific biomarker, BLCA-4, is present in urine samples from patients with bladder cancer, but not in samples from healthy individuals. In this study, a sandwich immunoassay was used to measure BLCA-4 in urine samples from patient populations with various urologic conditions and healthy individuals.

METHODS

Urine was collected from healthy individuals and from patients with bladder cancer, benign urologic conditions, or prostate cancer. BLCA-4 levels were evaluated by a sandwich immunoassay using two antibodies directed against distinct epitopes on BLCA-4.

RESULTS

Using a prospectively determined cutoff of an absorbance unit (OD) of 0.04, 67 of the 75 samples from patients with bladder cancer were positive for BLCA-4, resulting in an assay sensitivity of 89%. Also, 62 of the 65 samples from individuals without bladder cancer were negative for BLCA-4, resulting in an assay specificity of 95%.

CONCLUSIONS

The high sensitivity and specificity of the sandwich BLCA-4 immunoassay may allow for earlier detection and treatment of disease, thus greatly improving patient care.

Bladder papilloma in a 12-year-old girl

Epithelial bladder tumours are rare in childhood. A case of bladder papilloma in a 12-year-old girl is reported. Emphasis is given to the important role of ultrasound in diagnosis. Endoscopic treatment was successful and no evidence of recurrence was found at 5-year follow-up. Exposure to a chemical environmental factor (volatile shoe adhesives) is suggested as a possible cause of the tumour.

Glutathione S-transferase (GST) M1, T1 and N-acetyltransferase 2 (NAT2) polymorphisms and urothelial cancer risk with tobacco smoking

The objective of this study was to examine the association between the genetic polymorphism of glutathione S-transferase (GST) M1, T1 and N-acetyltransferase 2 (NAT2) genes and urothelial cancer risk in relation to smoking status. In this study, 325 Japanese patients with urothelial transitional cell carcinoma and 325 healthy controls were compared for frequencies of GSTM1, T1 and NAT2 genotypes. The frequencies of GSTM1 null genotype and NAT2 slow genotype were significantly higher in the cases than in the controls (adjusted odds ratio (OR) 1.37, 95% confidence interval (CI) 1.01-1.87, adjusted OR 3.09, 95% CI 1.69-5.63, individually). Furthermore, the risk of GSTM1 null genotype and NAT2 slow genotype was higher among smokers (adjusted OR 1.48, 95% CI 1.01-2.15, adjusted OR 4.28, 95% CI 1.96-9.36, individually). The regression analysis of cancer risk as a function of the amount of smoking showed that the susceptibility of people who had GSTM1 null genotype increased from 45 pack-years, while the susceptibility of people with NAT2 intermediate or slow genotype increased rapidly from 25 pack-years, compared with non-smokers. A multiplicative interaction between NAT2 intermediate or slow genotype and pack-years of smoking was found (P<0.001), but GSTM1 null genotype was not (P=0.06). Our results indicate that the GSTM1 null genotype and NAT2 intermediate or slow genotype are associated with an increased risk of urothelial cancer in relation to smoking amounts. Furthermore, the interaction between NAT2 intermediate or slow genotype and pack-years of smoking has a strong impact on urothelial cancer.

Cyclophosphamide is contraindicated in patients with a history of transitional cell carcinoma

Cyclophosphamide is a urotoxic agent that increases the incidence of malignant neoplasms of the urinary tract. The aim of this study was to evaluate the long-term impact of cyclophosphamide on patients with a history of superficial bladder cancer. Between July 1986 and January 1988, 58 consecutive patients with primary superficial transitional cell carcinoma of the bladder were included in this study. All patients had a transurethral R0 resection. Then 6 weekly intravesical instillations of 120 mg bacillus Calmette-Guérin (BCG) were performed. Until June 1987, 22 consecutive patients (group A) received an additional intravenous application of 700 mg/m(2) cyclophosphamide prior to the BCG immunotherapy, while from July 1987 36 patients were treated without cyclophosphamide. Survival was calculated using the Kaplan-Meier method and comparison of survival using the log rank test. Tumor staging, grading, and size were equally distributed in both groups. No significant difference could be observed regarding the 10-year overall survival rate (group A: 59%, group B: 58%), the 10-year tumor-specific survival rate (89 vs 94%), and the 10-year progression-free survival rate (85 vs 97%). There was a statistically significant deterioration of the 10-year recurrence-free survival rate in the cyclophosphamide group (44 vs 70%, log rank test: p < 0.05). Whereas there were no recurrences in the upper urinary tract among the patients of group B, 2 of the 22 patients from group A developed cancer of the renal pelvis. In patients with a history of superficial bladder cancer, a single dose of cyclophosphamide poses a significantly increased risk of tumor recurrence in the lower and in the upper urinary tract as well.

[Neoplastic pathology of the urothelium]

Bladder cancer is one of the most common diseases treated by urologists. In this article, we will try to review some of the controversies and all the available data which come from the systematic review and meta-analysis.

Racial variation in the incidence of squamous cell carcinoma of the bladder in the United States

PURPOSE

Racial differences in the incidence of squamous cell carcinoma of the bladder may provide insight into the pathogenesis of this disease. We determined the incidence of squamous cell carcinoma of the bladder according to race in the United States.

MATERIALS AND METHODS

Data obtained from the Surveillance, Epidemiology and End Results program from 1973 to 1997 were analyzed to determine the incidence of squamous cell carcinoma of the bladder in individuals 35 to 84 years old. Incidence rates by race and gender were then adjusted to the age distribution of the 1970 American population.

RESULTS

The average annual incidence of squamous cell carcinoma of the bladder was 1.20/100,000 in black and 0.60/100,000 in white Americans (relative risk 2.0, 95% CI 1.74 to 2.29). Black men were at increased risk compared with white men and black women were at increased risk compared with white women. The higher incidence in black versus white individuals existed in all age groups beyond 45 years and was present throughout the study period.

CONCLUSIONS

Squamous cell carcinoma of the bladder appears to be twice as common in black as in white individuals in the United States.

Survey of incidence of urological cancer in South Korea: a 15-year summary

BACKGROUND

Although the pattern of cancer incidence in South Korea is not the same as that of western countries, urological cancer will become one of the major cancers in South Korea in the near future. The pattern of cancer in South Korea is becoming steadily similar to that in western countries. It is, therefore, important to understand the epidemiological features of cancer. Surveillance of cancer incidence and mortality trends provides clues to etiology and helps to assess the effects of improved diagnostic, screening and intervention measures.

METHODS

The subjects of the study were 13,208 patients living in South Korea, newly diagnosed with urological cancer during the period of 1985-1999. The data were analyzed by age, sex, geography and period of diagnosis (1985-1989; 1990-1994; 1995-1999).

RESULTS

Bladder cancer was the most common urological cancer in South Korea (6,867 cases, 52.0%). The incidence of prostate cancer and renal cell carcinoma was similar. Male patients outnumbered female patients by a ratio of 5.4 : 1. In both sexes, the peak incidence of urological cancer in South Korea was noted in the 70+ age group. The geographic distribution of urological cancer across seven residential areas was similar. The incidence rate of all urological cancer (except urethral and penile cancer) had increased remarkably, especially in the last several years. The crude incidence rate of urological cancer among Koreans in South Korea was estimated to be 46.55 per 100,000 males, 8.64 per 100,000 females and 27.67 per 100,000 across both sexes.

CONCLUSION

Although this survey is not definitive, these data should be useful in showing general patterns or changes of incidence of urological cancer in South Korea. The elevated incidence of urological cancer noted in our survey also indicates the need for continued promotion of urological cancer screening programs. Moreover, these results may be useful in indicating directions for future research of urological cancer.

Incidence of urogenital cancers in Gunma Prefecture, Japan: a 10-year summary

BACKGROUND

Although the incidence of urogenital cancers in Japan is lower than that of other cancers, it is increasing steadily. Thus, an epidemiologic study was necessary to determine the measures that would decrease the mortality rate associated with these cancers.

METHODS

The subjects were 4759 patients with urogenital cancer who were living in Gunma Prefecture and who were newly diagnosed between 1985 and 1994. The data were analyzed by year and by patients' ages. The incidence rates of each disease were expressed as the number of cases per 100,000/year, and age-adjusted rates were adjusted to the world population.

RESULTS

The number of males and females afflicted by urogenital cancers increased over the 10-year period. The increase in age-adjusted incidence rates was sharpest for prostate, renal cell, and testicular cancers among males, and for renal cell, renal pelvic and ureter cancers among females. When age-specific rates were plotted against age on double logarithmic scales, the cancers were classified as type 1 (linear), type 2 (linear until a certain age, then flattening out or decreasing), or type 3 (irregular) based on the slope of the line. The magnitude of increase in the age-specific incidence rates of type 1 cancers with age was on the order of the 12th power for prostate cancer and the 5th power for bladder cancer. When the 10 years were divided into 2 periods (earlier and later), the age-specific incidence rates of prostate and renal cell cancers increased in all age groups, whereas the age-specific incidence rates of cancers that increased less sharply remained stable or even declined in some age groups.

CONCLUSION

These epidemiologic data should be useful in reducing the mortality rates associated with these cancers.

Micronuclei kinetics of exfoliated urothelial cells

Micronuclei observed in exfoliated cells result from DNA-damage of basal epithelium's cells by mutagens. Exfoliated urothelial cells can be collected by non-invasive procedure and may be used as target site to identify genotoxic effects of chemicals. Kinetic studies are important for any biomarker, especially those in which tissue differentiation and maturation processes will heavily influence the time between induction of damage and collection of damaged cells for analysis. This manuscript details the result of a longitudinal study of micronuclei induction in cells isolated from urine samples of 4 healthy women over 6 consecutive days. Three of them were former smokers. Results suggested that micronucleated cell rates were not influenced neither by the day nor by the time of sampling.

Human papillomavirus infection and transitional cell carcinoma of the bladder. Immunohistochemistry and in situ hybridization

The aim of the present research was to investigate human papillomavirus (HPV) infection by means of immunohistochemistry and in situ hybridization in 76 bladder cancer specimens. A biotinylated DNA probe that recognizes HPV 6/11, HPV 16/18 and HPV 31/33/35 was used for in situ hybridization. A polyclonal antibody recognizing HPV capsid antigen (HPVcAg) was used for immunohistochemistry. In situ hybridization and immunohistochemistry were developed by alkaline phosphatase and immunogold-silver techniques respectively. Our results showed that 25 (32.8%) out of 76 bladder carcinoma specimens reacted with HPVcAg. Twelve (15.7%) out of 76 cases were positive for HPV 16/18-DNA using non-isotopic in situ hybridization. Sixteen cases had koilocytosis. No positive signals were found for HPV 6/11 or 31/33/35-DNA probes.

Detection of human papillomavirus DNA sequences in cancer of the urinary bladder by in situ hybridisation and polymerase chain reaction

OBJECTIVE

To evaluate the prevalence of "high risk" human papillomavirus type 16 (HPV 16) in transitional cell carcinoma of the urinary bladder.

MATERIALS AND METHODS

The study included 10 biopsy specimens from male patients of transitional cell carcinoma of the urinary bladder for the detection of HPV DNA sequences. Specimens were collected from the Urology Clinic of the K.G. Medical College Hospital, Lucknow, India. Detection of HPV DNA was carried out by tissue in situ hybridisation (a single copy gene localisation method) using 3H-labelled HPV DNA probe and also by polymerase chain reaction (PCR) techniques using primers to HPV 16 upstream regulatory region (URR).

RESULTS

Out of 10 cases of transitional cell carcinoma of the urinary bladder, "high risk" HPV 16 DNA was detected only in one (10%) by using in situ hybridisation whereas two cases (20%) were found to be positive by polymerase chain reaction.

CONCLUSION

Our results suggest that the rare occurrence of HPV in bladder carcinoma may not have a causal relation with the viral infection.

Detection of human papillomavirus DNA in cancer of the urinary bladder by in situ hybridisation

The association of the human papillomavirus (HPV) with cancer of the urinary bladder was assessed by in situ hybridisation using probes selective for HPV types 6/11 and 16/18 DNA. No hybridisation signal was detected with the type 6/11 probe on 100 formalin-fixed, paraffin-embedded bladder tumours sampled. However, when the same samples were hybridised with the HPV type 16/18 DNA probe, 11 of 66 (16.6%) papillary and 1 of 10 (10%) solid transitional cell carcinomas gave positive signals. These results suggest the involvement of HPV in cancer of the bladder, although the frequency of multiple HPV types in these tumours is uncertain.

Bladder cancer. What's new in diagnosis and treatment?

Advances in diagnosis and treatment have improved survival rates, bladder preservation, and quality of life in patients with bladder cancer. Flow cytometry and flexible endoscopy have enhanced early diagnosis, and intravesical use of BCG vaccine has decreased the rate of recurrence and progression of superficial bladder cancer. Systemic chemotherapy is effective in patients with invasive and metastatic bladder cancer. Although these advances are encouraging, continued investigation is required to further improve bladder preservation and survival rates, and clinical application of laser therapy and phototherapy needs to be fully developed.

The risk of subsequent primary malignant diseases after cancers of the colon and rectum. A nationwide cohort study

The occurrence of a second primary malignant disease was analyzed in 38,166 patients with cancer of the colon and 23,603 patients with rectal cancer reported to the Swedish Cancer Registry between 1960 and 1981. The overall relative risk (RR) of developing a second primary malignant disease was significantly (P less than 0.05) increased both after cancer of the colon (women, RR = 1.4; men, RR = 1.3) and rectum (women, RR = 1.4; men, RR = 1.3). Besides confirming an increased risk of metachronous colorectal cancer this study suggests that cancer of the small intestine, breast, endometrium, and possibly of the ovary and prostate may have etiologic factors in common with cancer of the large bowel, notably those located in the colon.

Urinary tract cancers found by homescreening with hematuria dipsticks in healthy men over 50 years of age

In a homescreening study 235 asymptomatic men, 50 years of age and older without known causes of hematuria, tested their urine each week with a chemical reagent strip for the presence of blood for 1 year. Forty-four men had hematuria at least once, and 31 had a full urologic evaluation. Of these, eight were found to have urinary cancers and seven had nonmalignant diseases warranting immediate treatment. In six of these 15 men (only two with cancer) hematuria occurred in over 1/3 of the testings, and in four hematuria was found on microscopic urinalysis at the time of urologic evaluation. The degree of hematuria was unrelated to the seriousness of its cause. We conclude that in this population hematuria occurs intermittently and when found, regardless of quantity or symptoms, serious underlying pathology must be ruled out. Furthermore, regular hematuria home testing offers a promising means of detecting urinary cancers and other diseases that warrant therapy in asymptomatic men 50 years of age and older.

Treatment alternatives for invasive bladder cancer

Radical cystectomy remains the gold standard in the treatment of patients with muscle invasive bladder cancer. However, the specter of high failure rates coupled with morbid treatment methods has caused urologists, oncologists, and radiotherapists to explore modifications in, and alternatives to, the traditional treatments for invasive bladder cancer. The identification of the active methotrexate-platinum-based combination chemotherapy regimens heralds a new era in our ability to treat advanced disease effectively. Patients with less extensive muscle invasive tumors may be efficiaciously treated using conservative surgical excision, either alone or in combination with adjunctive treatments. In addition, definitive radiation therapy, given via the interstitial route or in combination with radiosensitizers, may result in long-term survival and preservation of bladder function. Progress has been made on multiple fronts in our ability to improve overall survival rates while allowing for the preservation of bladder function. The ability of these new mixed multimodality treatment initiatives to produce viable statistics equal to that of radical exenteration is an important landmark on the route towards an ideal treatment for invasive bladder cancer.

Smoking and bladder cancer. The modifying effect of cigarettes on other factors

A population-based, incidence case-control study was used to assess the effect of cigarette smoking on other risk factors for the development of bladder cancer. White men (n = 332) between the ages of 21 and 84 with bladder cancer were compared with 686 population-based controls. Cigarette smokers were classified by current smoking status as well as by amount, duration, inhalation patterns, age at first having smoked, and years since having stopped smoking. These variables were associated with a change in the risk for bladder cancer. The population-attributable risk associated with cigarette smoking was 48.5%. Risks from the use of other tobacco products such as cigars, pipes, snuff, and chewing tobacco, and from caffeinated coffee, tea, and alcoholic beverages were evaluated in light of cigarette smoking status. Cigarette smoking was shown to be both a confounder and an effect modifier. Risk estimates for bladder cancer associated with caffeinated coffee and alcoholic beverages were decreased after controlling for the effects of cigarette smoking. However, an increased risk of developing bladder cancer from cigar smoking (Odds ratio [OR] = 2.46) and tea drinking (OR = 3.14) was only seen in men who never smoked cigarettes. An increased but not significant risk was also seen for pipe, snuff, and chewing tobacco use in noncigarette smokers. The population-attributable risk from cigars and tea in the population of white men who had never smoked was 6.3% and 18.9%, respectively. Our results suggest that cigarette smoking may obscure other risk factors unless those who never smoked are separately studied.

Demonstration of papillomavirus structural antigen in human urinary bladder neoplasia

Clear cells showing characteristic features of koilocytotic atypia were found in 41 (82%) of 50 paraffin sections of urinary bladder tumour. Papillomavirus common structural antigen was detected in seven (14%) of the samples using an avidin-biotin peroxidase staining technique. The results suggest a role for the human papillomavirus in the aetiology of urinary bladder neoplasia.

Relationship of blood groups and bladder cancer. A retrospective study

A retrospective study to evaluate the relationship of blood groups of 96 patients with transitional cell carcinoma of the bladder in Israeli population, reports that patients with blood group O had higher grade tumors and higher recurrence rates than the other blood groups, without a difference in the mortality rates.

The role of staging in urologic cancer. Physical assessment and risk factors

Patients with urologic cancer may have improved survival if their diagnosis is made early. This task begins in the primary care physician's office through patient education on prevention and early detection procedures. A thorough history which provides for risk factor evaluation including life-style and environmental factors, a careful family history, past personal history, and finally, symptoms of current and past illness is the keystone of prevention and early diagnosis. The general physical examination as well as a specific examination of the scrotum and its contents, the penis, the prostate, and the kidney carefully done by an experienced examiner may improve chances for survival. The office urinalysis which should be available in every primary care physician's office is evaluated for its usefulness in early diagnosis. This report relates urologic cancer and its precursors to the history and physical examination with the urinalysis which in turn may be associated with morbidity and mortality.

Epidemiology and environmental factors in urologic cancer

Urologic cancers include malignancies of the genital and the urinary organs of men, and the urinary organs of women. For men in the United States, urologic cancers account for about 25% of all new cases of cancer and about 15% of cancer deaths. For women, cancers of the urinary organs account for 4% of all new cases of cancer and 3% of cancer deaths. Of urologic cancers, bladder cancer has been the most intensively studied epidemiologically. Cigarette smoking is the most important known preventable cause of the disease. Occupational exposures continue to come under suspicion. It appears that neither coffee drinking nor use of artificial sweeteners are important risk factors. Current questions in the etiology of prostate cancer concern its relationships to benign prostatic hypertrophy, to components of the diet and to hormone metabolism. Little is known of the etiology of kidney cancer other than probable associations of the disease with cigarette smoking and exposure to asbestos. Testicular cancer is associated with undescended testis and possibly other urogenital anomalies. The relationships of testicular cancer to pesticide exposure, in utero estrogen exposure, and infection are current research issues.

The significance of asymptomatic microhematuria in men 50 or more years old: findings of a home screening study using urinary dipsticks

In an ongoing home screening study 231 men 50 or more years old without known causes of hematuria have tested their urine each week with a chemical reagent strip for the presence of blood. After 3 months of testing 23 patients have had hematuria at least once. Of these men 5 have had urinary cancers and 5 have had other serious underlying diseases requiring immediate treatment. In only 3 of these 10 men (only 1 with cancer) did hematuria occur in more than a third of the testings or on subsequent microscopic urinalysis. The degree of hematuria was unrelated to the seriousness of its cause. We conclude that in this population hematuria occurs so intermittently that when found on routine urinalysis, regardless of quantity, serious underlying pathological conditions must be ruled out aggressively. Furthermore, regular hematuria home testing appears to offer promise as an economical means to detect urinary cancers and other serious diseases in asymptomatic men 50 or more years old.

The impact of cigarette smoking on stage, grade and number of recurrences of transitional cell carcinoma of the bladder

The records of 386 patients with diagnosed transitional cell carcinoma of the bladder were reviewed to determine a correlation between smoking history, and stage, grade and number of recurrences of transitional cell carcinoma. A significant association was detected between smoking history and all 3 variables. Within this military population 79 per cent of the patients were noted to have a smoking history, which is higher than most previously studied groups. These data further confirm the association between cigarette smoking and transitional cell carcinoma of the bladder, and suggest that cigarette smoking within the military population may portend a much higher cancer risk in this group.

Relationship of blood groups and bladder cancer

A retrospective study correlating the blood groups of 141 patients with bladder cancer showed that patients with blood group A had lower grade tumors with lower mortality rates, and those with blood group O(H) had higher grade tumors and higher mortality rates.