Value of immunohistochemistry in staging T1 urothelial bladder carcinoma

Substaging of pT1 Urothelial Bladder Carcinoma Predicts Tumor Progression and Overall Survival

INTRODUCTION

Limitations in tumor staging and the heterogeneous natural evolution of pT1 urothelial bladder carcinoma (UBC) make the choice of treatment challenging. We evaluated if histopathological substaging (pT1a, pT1b, and pT1c) helps predict disease recurrence, progression, and overall survival following transurethral resection of the bladder (TURB).

METHODS

We included 239 consecutive patients diagnosed with pT1 UBC at TURB in a single institution since 2001. Each sample was interpreted by our specialized uropathologists trained to subclassify pT1 stage. Three groups were distinguished according to the degree of invasion: T1a (up to the muscularis mucosae [MM]), T1b (into the MM), and T1c (beyond the MM).

RESULTS

T1 substaging was possible in 217/239 (90%) patients. pT1a, b, and c occurred in 124 (57), 59 (27), and 34 (16%), respectively. The median follow-up was 3.1 years, with a cumulative recurrence rate of 52%, progression rate of 20%, and survival rate of 54%. Recurrence was not significantly associated with tumor substage (p = 0.61). However, the Kaplan-Meier survival analysis showed a significantly higher progression rate among T1b (31) and T1c (26%) tumors than T1a (13%) (log-rank test: p = 0.001) stages. In a multivariable model including gender, age, ASA score, smoking, tumor grade, and presence of carcinoma in situ, T1 substage was the single variable significantly associated with progression-free survival (HR 1.7, p = 0.005). Nineteen patients (9%) needed radical cystectomy; among them, 12/19 (63%) had an invasive tumor. Overall survival was significantly associated with tumor substaging (p = 0.001).

CONCLUSION

Histopathological substaging of pT1 UBC is significantly associated with tumor progression and overall survival and therefore appears to be a useful prognostic tool to counsel patients about treatment options.

Optimisation and validation of immunohistochemistry protocols for cancer research

BACKGROUND

Immunohistochemistry (IHC) has become a valuable laboratory technique for diagnosing, evaluating metastasis and informing treatment selection in several cancers. Standardization however remains a limiting factor in IHC. The main aim of this research study was to optimise, validate and standardize antibodies and IHC protocols for cancer research.

METHODS

Seven monoclonal mouse and rabbit antibodies were optimised using formalin-fixed paraffin embedded (FFPE) human tissue blocks. 4um sections of FFPE block were stained using the Roche Ventana XT or Ventana ULTRA IHC automated analysers. This study modified manufacturer recommended protocols by using a unique antigen retrieval method, adding an amplification step, varying primary antibody incubation times, as well as using the Roche Ventana Ultraview detection system.

RESULTS

Optimum antibody localisation was observed in modified IHC protocols in comparison with manufacturer recommended protocols for anti-CEACAM-1, anti-CD31, anti-COX-2, anti-HER-2/neu, anti-S100P, anti-thrombomodulin and anti-VEGFR-3. Majority of antibodies required more than one modification of the initial protocol. For anti-VEGFR-3 optimum staining was observed following 4 protocol modifications.

CONCLUSIONS

This study has optimised and standardized several tissue-based biomarkers that may be, in the future, used to screen, diagnose and monitor patients with certain cancer, such as bladder cancer. Accurate data on optimised protocols reduce time and resources wasted on experimental protocols, and ultimately help identify biomarkers or biomarker panels, which may be used to select treatment regimens for various cancers.

Stage T1 bladder cancer: diagnostic criteria and pitfalls

Accurate pathological staging is crucial for patient management. Patients with T1 bladder cancer are at risk of recurrence, progression, and death of cancer. Recognition of early invasion (stage T1 disease) in urothelial carcinoma remains one of the most challenging areas in urological surgical pathology practice. A logical roadmap to T1 diagnosis would include careful evaluation of histological grade, stromal epithelial interface, characteristics of the invading epithelium, and the stroma associated responses. Tangential sectioning, crush and cautery artifacts, and associated inflammatory infiltrate are commonly encountered problems and the source of pitfalls. In this review, we outline diagnostic criteria, common pitfalls, and different histological patterns of invasion into the lamina propria. Current recommendations on reporting of biopsy and transurethral resection specimens, molecular biomarkers, clinical implications of T1 cancer diagnosis and recent developments on the T1 substaging are also discussed. Most T1 bladder cancer patients will benefit from conservative management after restaging transurethral resection of bladder and bacillus Calmette-Guérin maintenance. Patients with high risk features, such as concurrent urothelial carcinoma in situ, increased depth of invasion, lymphovascular invasion, and variant histology among others, should be considered for early cystectomy.

Staging of bladder cancer

Urothelial carcinoma of the urinary bladder is a heterogeneous disease with multiple possible treatment modalities and a wide spectrum of clinical outcome. Treatment decisions and prognostic expectations hinge on accurate and precise staging, and the recently published American Joint Committee on Cancer (AJCC) Staging Manual, 8th edition, should be the basis for staging of urinary bladder tumours. It is unfortunate that the International Union Against Cancer (UICC) 8th edition failed to incorporate new data which is considered in the AJCC 8th edition. Thus, the AJCC 8th edition is the focus of this review. Several critical changes and clarifications are made by the AJCC 8th edition relative to the 7th edition. Although the most obvious changes in the 8th edition are in the N (i.e. perivesical lymph node involvement now classified as N1) and M (i.e. M1 is subdivided into M1a and M1b) categories, several points are clarified in the T category (e.g. substaging of pT1 should be attempted). Further optimisation, however, is required. No particular method of substaging pT1 is formally recommended. In this review, these modifications are discussed, as well as points, which require further study and optimisation.

Morphological and Immunohistochemical Biomarkers in Distinguishing Prostate Carcinoma and Urothelial Carcinoma: A Comprehensive Review

The differential diagnosis between high-grade prostate carcinoma and infiltrating urothelial carcinoma (UC) in transurethral resection prostate specimens as well as cystoprostatectomy specimens may often be challenging due to morphologic and clinical overlap of the 2 entities. Such distinction has critical therapeutic and staging consequences, yet it is hampered by both issues in morphology and by the low accuracy rates of single immunohistochemical markers, as reported in literature. This review aims to provide a comprehensive analysis of the available morphological and immunohistochemical parameters, which may allow to discriminate between prostate carcinoma and urothelial carcinoma in the proper clinical context and to discuss their diagnostic applications in daily practice.

Practical Applications of Immunohistochemistry in the Diagnosis of Genitourinary Tumors

Context.—

Pathologic diagnosis of tumors in the genitourinary system can be challenging based on morphology alone, particularly when diagnostic material is limited, such as in core biopsies. Immunohistochemical stain can be a useful tool to aid in the diagnosis.

Objective.—

To provide an update on practical applications and interpretation of immunohistochemical stains in the diagnosis of tumors in prostate, kidney, bladder, and testis. We particularly focus on difficult differential diagnoses, providing our insights in frequently encountered challenging situations. Commonly used immunohistochemical panels are discussed.

Data Sources.—

Review of literature and our own experience.

Conclusion.—

Immunohistochemical stain is a valuable tool in the diagnosis of genitourinary tumors when appropriately used.

Stalk versus base invasion in pT1 papillary cancers of the bladder: improved substaging system predicting the risk of progression

AIMS

Pathological stage pT1 bladder cancers constitute a clinically heterogeneous group. However, current staging guidelines for superficially invasive cancers do not acknowledge the variability in type and extent of lamina propria invasion in papillary urothelial carcinomas (PUCs), and historically proposed substaging systems showed either high interobserver variation or limited value in predicting patient outcomes. The aim of this study was to reappraise pT1 PUC substaging, with the objective of identifying a novel scheme that is reproducible and prognostically meaningful.

METHODS AND RESULTS

pT1 PUCs diagnosed during 1999-2015 were retrospectively reviewed and characterized as focal invasion confined to the papillary stalk, focal invasion of the tumour base, or extensive invasion of the tumour base. Cases with concurrent flat carcinoma in situ, angiolymphatic invasion, absent muscularis propria or clinically advanced disease were excluded. We calculated cumulative incidence rates of recurrence, progression and death by tumour subtype, and evaluated differential risks by using log-rank tests and Kaplan-Meier curves stratified by type and extent of invasion. Among 62 patients satisfying the inclusion criteria, 22 of 29 patients with base-extensive invasion progressed, whereas four of 13 with base-focal and none of 20 with stalk-only invasion progressed. There was strong evidence that base-extensive patients had a higher risk of progression and death resulting from bladder cancer than base-focal or stalk-only patients (P < 0.0001). However, tumour subtype was not significantly associated with risk of recurrence (P = 0.21).

CONCLUSIONS

We propose an innovative substaging approach for reporting the site and extent of lamina propria invasion in patients with pT1 PUC, allowing patient stratification for risk of progression.

Prognostic Significance of Substaging according to the Depth of Lamina Propria Invasion in Primary T1 Transitional Cell Carcinoma of the Bladder

Purpose

To evaluate the prognostic significance of the depth of lamina propria invasion in primary T1 transitional cell carcinoma (TCC) of the bladder.

Materials and Methods

We retrospectively reviewed the medical records of 183 patients with primary T1 TCC of the bladder who had undergone transurethral resection (TUR) at our institution. Substaging was defined according to the depth of lamina propria invasion as follows: T1a, superficial invasion of lamina propria; T1b, invasion into the muscularis mucosa (MM); T1c, invasion beyond the MM but not to the muscularis propria. The prognostic significance of various clinicopathological variables for recurrence and progression was analyzed.

Results

Of the 183 patients, substaging was T1a in 119, T1b in 57, and T1c in 7 patients. The recurrence rate was 32.8% for T1a and 40.6% for T1b/c, but there was no significant difference between the two groups. The progression rate was significantly different between the two groups: 5.8% in T1a and 21.9% in T1b/c (p=0.003). The cancer-specific mortality rate was also significantly different: 4.2% in T1a and 14.0% in T1b/c (p=0.036). In the univariate analysis, microscopic tumor architecture was the only significant prognostic factor for recurrence. In the univariate and multivariate analysis concerning progression, depth of lamina propria invasion and concomitant carcinoma in situ were significant prognostic factors.

Conclusions

Substaging according to the depth of lamina propria invasion in primary T1 TCC of the bladder was an independent prognostic factor for progression. This suggests that substaging would be helpful for guiding decisions about adjuvant therapies and follow-up strategies.

The WHO classification of 1973 is more suitable than the WHO classification of 2004 for predicting survival in pT1 urothelial bladder cancer

OBJECTIVE

To ascertain which of the currently defined World Health Organization (WHO) grading classifications of pT1 urothelial bladder cancer (BC), published in 1973 and 2004, is more suitable for predicting outcome.

PATIENTS AND METHODS

Transurethral resection of the bladder (TURB) specimens of 310 patients with first diagnosis of initial pT1 BC were reassessed by three urological pathologists according to the WHO classifications of 1973 and 2004. The TURB procedure was followed by either immediate cystectomy or adjuvant bacille Calmette-Guérin (BCG) instillations. Kaplan-Meier analysis was used to compare survival rates of the different tumour grades (mean follow-up was 57 months).

RESULTS

According to the 1973 WHO classification, none of the pT1 BC specimens were graded as G1, while 36% were graded as G2 and 64% were graded as G3. Histological reassessment according to the 2004 WHO classification highlighted only 4% low-grade and 96% high-grade tumours. The 10-year cancer-specific survival rates of high-grade tumours (85%) were intermediate between G2 (96%) and G3 (78%).

CONCLUSIONS

The results of the present study support the presumption that the 1973 WHO classification is more suitable for predicting outcome for pT1 tumours, by defining at least two prognostic groups. A new classification should revise the definition of low- and high-grade pT1 BC to preserve the prognostic value of tumour grading.

Staging and reporting of urothelial carcinoma of the urinary bladder

Significant progress has been made in the standardization of bladder neoplasm classification and reporting. Accurate staging using the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) TNM system is essential for patient management, and has been reinforced by clinical evidence in recent years. It is now recognized that 'superficial' bladder carcinomas are a heterogenous group of tumors with diverse biological and clinical manifestations. The term 'superficial,' therefore, is no longer used for bladder tumor nomenclature. Recognition of diagnostic pitfalls associated with lamina propria invasion is critical for the evaluation of bladder tumor specimens. Neither the 1973 nor the 2004 WHO grading system appears to be useful for predicting the clinical outcome of invasive urothelial carcinoma. This review will discuss recent progress and controversial issues on the staging and substaging of bladder carcinomas. Essential elements for handling and reporting of bladder tumor specimens will also be discussed.

Predicting outcome in minimally invasive (T1a and T1b) urothelial bladder carcinoma using a panel of biomarkers: a high throughput tissue microarray analysis

OBJECTIVE

To evaluate the protein expression of fibroblast growth factor receptor-3 (FGFR3), hamartin, 14-3-3sigma, Aurora-A, and E-cadherin using immunohistochemistry (IHC) in a series of human bladder carcinomas and to evaluate their value in distinguishing T1a from T1b tumours and in predicting their behaviour, as T1 urothelial bladder tumours present great diagnostic and therapeutic challenges to pathologists and clinicians.

PATIENTS, MATERIALS AND METHODS

Tissue microarrays were constructed from 94 patients (Ta 20, T1a 31, T1b 14, and T2 29 patients) using tissue obtained at first disease presentation.

RESULTS

FGFR3 and 14-3-3sigma were the only markers that were significantly associated with tumour grade and 14-3-3sigma was significantly associated with tumour stage. Furthermore, none of these markers could help in distinguishing T1a from T1b tumours. After adjusting for the E-cadherin expression, FGFR3 expression was a significant factor in predicting the time to recurrence in T1a/T1b. Furthermore, among all the clinical variables, grade and depth of invasion were the only ones that had a significant value in predicting T1a/T1b tumour progression.

CONCLUSIONS

Even though the staging of T1 to T1a/T1b is not a common practice and it is not included in the Tumour-Node-Metastasis classification, our data clearly confirmed the importance of a proper sub-staging of T1 tumours whenever feasible.

Handling and pathology reporting of specimens with carcinoma of the urinary bladder, ureter, and renal pelvis

OBJECTIVE

Pathologists play a pivotal role in the diagnosis and in the report of the pathological features related to prognosis.

METHODS

To meet these endpoints, the following issues must be accomplished: adequate information about the patient history, proper handling of the specimens, identification of the reliable histopathological techniques necessary to reach the more detailed diagnostic information and evaluate the prognostic variables, and a standardized pathological report.

RESULTS

Recent efforts to standardize the histopathological evaluation have generated significant confusion among the urological and pathological communities as well. No consensus has been achieved about the optimal pathological grading of urothelial tumors, to date.

CONCLUSION

A proposal for standardization of sampling and reporting of the urothelial tissues achieved within Uropathology follows. The urologists have a great role in assisting pathologists in the proper examination by providing them with clinical information.

Stage pT1 bladder carcinoma: diagnostic criteria, pitfalls and prognostic significance

Recognition of early invasion (stage pT1) in urothelial neoplasia is one of the most challenging areas in bladder pathology, and reproducibility between pathologists is a major issue. This fact, together with the proposal by some urologists to treat early invasive tumours more aggressively, makes the accurate detection of pT1 lesions even more relevant in clinical practice. In recent years, the morphologic features and patterns of invasion of tumour into the lamina propria have been more accurately characterised and standardised, and although some of the features are subtle, they can be of great utility in the accurate assessment of pT1 staging. Histologic grade, changes at the stroma-epithelial interface, the characteristics of the invading epithelium, and the stroma-associated response are among the most important clues for appropriate pT1 staging and these are discussed in this review. Common problems in stage pT1 disease evaluation include, tangential sectioning--due to an inability to orient transurethral resection specimens--crush and cautery artefacts, and a streaking inflammatory infiltrate. With few exceptions, the criteria discussed in this review allow pathologists to separate superficial bladder tumours consistently and reproducibly into non-invasive (pTa) tumours and tumours that have invaded the lamina propria (pT1), the latter having a significantly poorer prognosis. This review is intended to assist the surgical pathologist by presenting appropriate diagnostic criteria, by describing common pitfalls and by outlining the different histologic patterns of invasion of urothelial carcinoma into the lamina propria. The value of pT1 tumour substaging, as a predictor of bladder cancer progression is also discussed.

Expression of cell cycle proteins in T1a and T1b urothelial bladder carcinoma and their value in predicting tumor progression

BACKGROUND

Cell cycle proteins are important markers in predicting tumor behavior in urothelial carcinoma of the bladder. The objectives of this study were 1) to determine the expression levels of some of those markers in a series of patients with bladder carcinoma, 2) to define their value in distinguishing T1a (minimally invasive) from T1b (invasive) tumors, and 3) to evaluate their use as predictive factors in the progression of T1a and T1b tumors.

METHODS

Tumor specimens from 101 patients were included (22 Ta specimens, 34 T1a specimens, 15 T1b specimens, and 30 T2 specimens). A tissue microarray from the 101 paraffin embedded tissue blocks was constructed. Immunohistochemistry for p16, p27, p21, p53, cyclin D1, and Ki-67 were performed. To evaluate T1a and T1b tumor progression, clinical and follow-up data were available for all 49 patients.

RESULTS

Cyclin D1 and p27 were the only markers that showed a significant association with tumor stage and tumor grade (cyclin D1: P = 0.002 and P > 0.00, respectively; p27: P = 0.024 and P = 0.031, respectively). The results indicated that a combination of p21 (odds ratio, 5.7; 95% confidence interval [95% CI], 1.3-24.8 [P = 0.022]) and p16 (odds ratio, 3.7; 95% CI, 0.8-16.5 [P = 0.081]) may have potential use in distinguishing T1b tumors from T1a tumors. Finally, none of the markers examined were found to have predictive value for T1a and T1b tumor progression.

CONCLUSIONS

The expression of cyclin D1 and p27 was associated with the most important prognostic factors (tumor stage and grade). The combination of p21 and p16 may have value in distinguishing T1b tumors from T1a tumors, although this finding must be evaluated in much larger series. Finally, none of the markers studied appeared to have predictive value for disease progression in patients with T1a and T1b urothelial bladder tumors.

New diagnostic strategies in the detection and staging of bladder cancer

PURPOSE OF REVIEW

Bladder cancer is a very frequent disease and represents the second most common genitourinary neoplasm. The most prevalent form of the disease, superficial bladder cancer, can recur in more than 70% of cases, despite correct management. Any way to improve our disease diagnostic and treatment policy is therefore welcome.

RECENT FINDINGS

This review covers the following topics: (1). endoscopic tools: standard cystoscopy versus fluorescence cystoscopy and virtual endoscopy; (2). bladder cancer staging: histopathological analysis developments and imaging techniques (positron emission tomography, magnetic resonance imaging, computed tomography); (3). cytology and ancillary procedures (ImmunoCyt and fluorescence in-situ hybridization test, and others); (4). first-generation (bladder tumour antigen, nuclear matrix protein 22, telomerase repeat amplification protocol) and second-generation (loss of heterozygosity, minichromosome maintenance 5, DNA methylation, microsatellite) urine and serum markers.

SUMMARY

New diagnostic and therapeutic (endoscopic) tools in superficial bladder cancer should eventually modify our disease management policy. Fluorescence cystoscopy detects carcinoma in situ with a high accuracy, and seems to have a positive impact on reducing residual tumour and recurrence rate. A more specific staining of tissue specimens facilitates histological analysis and helps achieve better staging, especially in T1 diseases. Improving the sensitivity of cytology for low-grade diseases, ancillary procedures to classic cytology such as fluorescence in-situ hybridization and ImmunoCyt tests, may reduce the number of unpleasant cystoscopies in surveillance protocols of selected groups of patients. Second-generation urine markers such as loss of heterozygosity, microsatellite, minichromosome maintenance 5, with a high level of accuracy, show great potential for influencing bladder cancer detection and screening policy.