Carcinoma-in-Situ of the Urothelium

[Clinical experience with transurethral resection of bladder tumor (TUR-Bt) guided by photodynamic diagnosis (PDD)]

PURPOSE

To report our clinical experience regarding transurethral resection of bladder tumor (TUR-Bt) guided by photodynamic diagnosis (PDD) with intravesical instillations of 5-aminolevulinic acid (ALA) and to assess the usefulness of the therapeutic method.

MATERIALS AND METHODS

TUR-Bt guided by PDD was performed in 57 patients of which 47 were men and 10 women with a median age of 74.3 years (range 45-90), 36 were primary cases and 21 were recurrent cases with non-muscle invasive bladder cancer. Two to two and half hours prior to endoscopy 1.5 g ALA dissolved in 50 ml of 8.4% sodium hydrogen carbonate (NaHCO3) solution was instilled intravesically. For fluorescence excitation a blue light source (D-LIGHT System, Karl Storz Endoscopy Japan K.K.) was used. The tumorous lesions under white light guidance and the lesion with fluorescent excitation under blue (fluorescence) light guidance were taken by cold cup as a biopsy and also resected sequentially. To evaluate the accuracy of PDD, the levels in images of the ALA-induced fluorescence were compared with the pathological results. To evaluate the availability of TUR-Bt guided by PDD, survival Analysis regarding vesical recurrence was retrospectively examined compared to the cases underwent conventional TUR-Bt under white light guidance. Moreover, in these cases, multivariate analysis using Cox proportional-hazards model was performed to detect the clinico-pathological factor independently contribute to improving prognosis. (Results) In the 301 specimens obtained from 57 patients, the sensitivity and specificity of PDD were 92.5% and 60.1%, whereas the sensitivity and specificity of conventional endoscopic examination under white light guidance were 81.6% and 79.5%, respectively. Median follow-up period was 19.1 (range 8.6-49.9) months in 57 patients underwent TUR-Bt guided by PDD. Eight of 57 patients recurred and recurrence-free survival rate was 88.2 +/- 0.1% (at 12 months) and 76.2 +/- 0.1% (24-48 months). Median follow-up period was 49.9 (5.0-145.0) months in 149 patients underwent conventional TUR-Bt. Ninety-nine of 149 patients recurred and recurrence-free survival rate was 60.3 +/- 0.0% (12 months) and 31.6 +/- 0.0% (24-48 months). There was statistical significance in recurrence-free survival rate between these 2 therapeutic groups (p < 0.001). Moreover, multivariate analysis revealed the independent factor contribute to improving prognosis was only TUR-Bt guided by PDD (hazard ratio 0.279, p = 0.001).

CONCLUSION

It was suggested that TUR-Bt guided by PDD might reduce the risk of vesical recurrence in the early stage after operation of non-muscle invasive bladder cancer.

Determination of hypericin in human plasma by high-performance liquid chromatography after intravesical administration in patients with transitional cell carcinoma of the bladder

In the present study, the systemic absorption of hypericin was investigated after intravesical instillation of the compound in nine patients with superficial transitional cell carcinoma (TCC) bladder tumors. Hypericin (8 microM) was instilled in the bladder for 2-3 h before photodynamic diagnosis of bladder tumors. Blood was then collected from a peripheral vein 1 h after termination of the instillation. Solid phase extraction with ammonium acetate buffer and methanol was used to extract hypericin from the plasma. A reversed-phase high performance liquid chromatographic method with fluorescence detection was used to identify and quantify hypericin in the extracts from plasma samples. Analysis of standard plasma samples, which were spiked with known amounts of hypericin, indicated that the pH of the buffer was a determining factor in the extraction yield. The results obtained using ammonium buffer (pH 3.5) and methanol showed the mean extraction recovery of hypericin to be 64% (RSD=12%, n=6). The limits of detection and quantification were 6 and 20 nM, respectively. Extraction and analysis of the plasma of patients after intravesical administration showed hypericin concentrations below the detection limit (<6 nM). In addition, photodynamic treatment of in vitro cultured HeLa cells incubated with 1-100 nM hypericin concentrations showed that lower concentrations (1-20 nM) of hypericin do not induce significant photocytotoxic effects. Taken together, these results imply that photosensitization or other systemic side effects in patients are not to be expected after photodynamic diagnosis of TCC bladder tumors with hypericin.

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.

Carcinoma in situ of the urinary bladder. Clues to host involvement in human carcinogenesis

BACKGROUND

Carcinoma in situ (CIS) of the urinary bladder is a neoplasm of uncertain biologic behavior. It rarely occurs as the primary disease and exists most often in association with high grade, invasive tumors. The unfavorable prognosis ascribed to CIS may not be due to tumor-related factors but to low host resistance or to host-tumor relationships established for previous or co-incident invasive cancers. The scant available evidence indicates that a large proportion of patients with primary CIS have a low frequency of muscle invasion and death from disease.

METHODS

Of 2000 patients with bladder neoplasms in our pathology files and tumor registry, 102 had CIS confirmed on histologic review. There were 29 cases of primary CIS and 73 cases of secondary CIS. These cases were compared, with an emphasis on patient outcome.

RESULTS

The data indicate that primary and secondary CIS are histologically identical lesions whose effect on patients is related mainly to the presence of multifocal disease, often associated with previous or coincident invasive cancers. Progression or death from disease is unusual among patients presenting with primary CIS but common among individuals with CIS associated with other bladder cancers.

CONCLUSION

The authors suggest that the appearance of urothelial CIS identifies patients with at least localized resistance to the development of invasive bladder cancer. The degree of patient resistance to carcinogenic events leading to bladder carcinoma is manifested by the type, grade, and stage of their initial neoplasms.

Pathology of carcinoma in situ of the urinary bladder and related lesions

In the United States, nearly all cases of bladder cancer are of the transitional cell type, and epidemiological evidence indicates that among these, approximately 80% present initially as more or less well-differentiated, superficial papillary neoplasms with a tendency for multifocal or diffuse involvement of the urothelial surface and/or recurrent tumor episodes, but with limited potential for invasive growth or a lethal outcome. Bladder tumors with lethal potential generally begin as poorly differentiated, sessile growths that are usually invasive at first diagnosis. Carcinoma in situ is a change that must be elicited among intact surface cells before progressive proliferation results in a tumor mass. Evidence for such an association is both temporal and spatial. Since most transitional cell carcinomas begin as well-differentiated tumors, i.e., resembling normal urothelium, recognition of early neoplastic alteration before a papillary structure forms is unlikely and most of the evidence is spatial based upon urothelial changes adjacent to papillary tumors. The morphologic definition of carcinoma in situ is arbitrary and generally defined as a total replacement of the urothelial surface by cells which bear morphologic features of carcinoma, but which lack architectural alteration other than an increase in the number of cell layers, i.e., a flat lesion. The Union Internationále Contra Cancer/American Joint Committee on Cancer (UICC/AJCC) staging scheme for bladder cancer distinguishes non-invasive papillary growths as Ta and carcinoma in situ as Tis. Because detection of carcinoma in situ, either by cytology or biopsy, depends upon recognizable malignant morphologic characteristics, studies of the lesion tend to be limited to the higher grade or more anaplastic examples.(ABSTRACT TRUNCATED AT 250 WORDS)

Conservative treatment of diffuse carcinoma in situ of the bladder with repeated courses of intravesical therapy

We present a series of 13 patients with diffuse carcinoma in situ (CIS) of the bladder who failed an initial induction course of intravesical therapy with Mitomycin C, thiotepa, doxorubicin or Bacillus Calmette Guérin (BCG). Cystectomy, although indicated, was, for various reasons, not performed after the first failure of intravesical therapy and all patients were subsequently treated topically with the same or different agents. Of the 7 patients treated with 2 induction courses, 6 showed a complete response during a follow-up period of 24 to 42 months. Although 1 patient initially responded completely, he developed invasive transitional cell carcinoma (TCC) Grade IV 30 months later. Among the 3 patients who underwent 3 induction courses, 2 had a complete response at 42 and 60 months of follow-up and 1 developed TCC Grade IV with muscle invasion 18 months later. Two of the 3 patients treated with 4 induction courses are free of disease at 48 and 57 months; the third developed low grade, low stage TCC. This experience suggests that the majority of patients with CIS who fail initial treatment usually respond to further treatment with the same or a different drug. The question as to whether a second course of intravesical therapy, subsequent to failure of the first course, should be given before cystectomy requires further investigation.

The outcome of conservative treatment of carcinoma in situ of the bladder

We treated 52 patients with carcinoma in situ by transurethral resection, thiotepa and other intravesical chemotherapeutic agents. All patients underwent standard initial and subsequent evaluative procedures and the average followup was 62 months. Half of the patients had a history of stage Ta and/or T1 transitional cell carcinoma. The remainder had carcinoma in situ when first diagnosed (10 had carcinoma in situ only). Of 12 patients treated by transurethral resection alone 1 reached 60 months without radical cystectomy or disease progression. There were 18 patients who had a complete response following chemotherapy, 11 had a partial response (positive cytology) and 11 failed (persistent carcinoma in situ). Patients with a history of transitional cell carcinoma had a statistically significantly greater probability of achieving a complete response. Despite other types of treatments only 2 of 22 patients (partial response and failure) achieved a lasting complete response. Persistent partial response and failure resulted in progressive transitional cell carcinoma (stage T2 or greater, prostatic involvement and metastases) and only 1 of these survived for more than 5 years without cystectomy. None of our patients received bacillus Calmette-Guerin because it was not available during the time most of the patients were treated. While the lives and bladders in some patients may be spared by its use, failure to achieve a complete response indicates impending disaster and cystectomy should be considered seriously.

The significance of urothelial dysplasia as diagnosed by cup biopsies

A prospective study was carried out in which four quadrant cold cup biopsies of the bladder were taken from patients with either a bladder tumour (57) or irritative bladder symptoms (44), and a control group (23). Five histopathological patterns were recognized: normal urothelium, mild, moderate and severe dysplasia, and carcinoma in situ (CIS). In the control group, 22 of the 23 patients had normal urothelium, giving a 4% incidence of mild dysplasia. Of the 57 patients with all stages and grades of transitional cell carcinoma, 38 (67%) had dysplastic urothelium. This association is significant (P less than 0.01, chi-squared). Thirty-seven patients had Ta or T1 tumours, and 24 (65%) of these had dysplasia, including four (11%) with CIS. Twenty patients had T2-T4, Grade 111 tumours and 14 (70%) of these had dysplasia, including five (25%) with CIS. There was no statistical difference between these two groups. The recurrence rate was evaluated for all patients presenting with a first bladder tumour. Seventy-three percent of patients with normal cup biopsies remained recurrence free during a mean follow-up of 3 years (s.d. 1.15 years). Of patients with dysplastic urothelium, 72% remained recurrence free over a mean follow-up of 3.25 years (s.d. 1.23 years). Hence, the presence of dysplasia did not predict the likelihood of tumour recurrence. Thirty patients had dysuria or suprapubic pain for which there was no explanation. Sixteen (53%) had dysplasia on cup biopsy including three (10%) with CIS (P less than 0.01, chi-squared). It seems clear, therefore, that the dysplasia was the cause of these symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoma in situ of the urinary bladder with and without associated vesical neoplasms

Of 99 patients who had carcinoma-in situ (TIS) at least once between 1970 and 1980, 84 were subjected to detailed analysis and pathologic review. They may be classified into four groups: (Group 1) 14 patients, who presented with invasive bladder carcinoma (TCC) associated with TIS; (Group 2) 15 patients who, subsequent to the diagnosis of TIS with or without another superficial TCC developed muscle invasion (12 patients) or metastases without muscle invasion (three patients); (Group 3) 29 patients who underwent cystectomy for superficial TCC (Ta or T1, or TIS alone). Twenty (69%) had extravesical superficial extension. Two patients developed metastases subsequent to undergoing cystectomy; and (Group 4) 26 patients with TIS proven at least once who have not developed muscle invasion, metastases nor have undergone cystectomy. Nineteen had previous non-TIS superficial TCC. All patients in Groups 2 and 4 were treated conservatively (TUR +/- intravesical chemotherapy) when the initial diagnosis of TIS was made. Twelve patients in Group 3 underwent cystectomy within a month of the diagnosis of TIS. When 38 patients found to have TIS in association with the first diagnosis of superficial transitional cell carcinoma of the bladder were compared with 32 patients who had TIS diagnosed subsequent to their initial diagnosis of transitional cell carcinoma, the former group fared significantly worse (P less than 0.01) in regard to muscle invasion, metastases, or clinical indications for cystectomy.

Urothelial dysplasia in random mucosal biopsies from patients with bladder tumours

A prospective study of the incidence of urothelial dysplasia in random mucosal biopsies from cystoscopically normal appearing mucosa was carried out in 90 patients with bladder tumours at the initial diagnosis. More than 50% of invasive bladder tumours were accompanied by wide-spread urothelial dysplasia, in half of these cases characterized as carcinoma in situ supporting the idea that bladder cancer is a diffuse urothelial disease. Although suggesting an early radical treatment of invasive bladder cancer, such action should not be taken before a careful follow-up study of these patients have provided information on the natural history of diffuse urothelial dysplasia associated with bladder tumours.

Pre-clinical cytological diagnosis of bladder cancer

The records of 100 recent urology service patients with bladder neoplasms were evaluated for correlation of cytological findings with clinical and histological diagnoses. At the time of diagnosis 83 patients had synchronous positive biopsies and cytologies, 3 had negative cytologies (even though urothelial cancer was present) and the remaining 14 had abnormal cytologies but clinical examination was negative. Of these 14 patients invasive cancer has been identified subsequently in 11, while 3 have not yet returned for clinical followup. Analysis of the 11 patients in whom cancer was proved eventually reveals 14 distinct periods, ranging from 1 to 37 months, in which cytologies were abnormal and concurrent clinical examinations and histological diagnoses were negative. Ten of these periods preceded tumor recurrence and the other 4 antedated the first occurrence of cancer. A relationship was found between a cytological diagnosis of carcinoma in situ or severe dysplasia and the presence or future appearance of low grade clinical cancer. Cytologies containing overtly malignant cells more commonly were associated with or preceded the appearance of high grade cancers. In these 11 patients the sensitivity of a single spontaneously voided urine specimen was 97 per cent but the sensitivity was 100 per cent when 2 or more specimens were submitted per patient. Bladder barbotages were 100 per cent sensitive.

En bloc transpubic urethrectomy in conjunction with radical cystectomy for bladder carcinoma in males

A technique for en bloc transpubic urethrectomy and radical cystectomy in the male is described and compared with commonly employed means of urethrectomy. Although this technique has been performed in a limited number of cases, this report is warranted because of the following advantages: en bloc resection is achieved at one operation without compromised positioning or need to reposition; the risk of transecting tumor in the urethra or leaving tumor behind in the urethra is avoided; the contamination inherent with a perineal incision and the resulting increase in morbidity are avoided, yet the mobilization of the urethra and prostate is comparable to that achieved transperineally; the exposure with this technique equals or excels that achieved by other approaches; although thirty minutes are required to perform pubectomy and urethrectomy, this is comparable to the time required to expose and close the perineum; and usually time is saved because of the improved exposure.