Treatment and management of high-grade T1 bladder cancer: what should we do after second TUR?

Amide Proton Transfer-Weighted Imaging in Assessing the Aggressive and Proliferative Potential of Bladder Cancer

BACKGROUND

Ki-67 and human epidermal growth factor receptor 2 (HER2) are known oncogenes involved in bladder cancer (BCa) patient risk stratification. Preoperative assessment of their expression level can assist in clinical treatment decision-making. Recently, amide proton transfer-weighted (APTw) MRI has shown promising potential in the diagnosis of several malignancies. However, few studies reported the value of APTw imaging in evaluating Ki-67 and HER2 status of BCa.

PURPOSE

To investigate the feasibility of APTw MRI in assessing the aggressive and proliferative potential regarding the expression levels of Ki-67 and HER2 in BCa.

STUDY TYPE

Retrospective.

SUBJECTS

114 patients (mean age, 64.78 ± 11.93 [SD] years; 97 men) were studied.

FIELD STRENGTH/SEQUENCE

APTw MRI acquired by a three-dimensional fast-spin-echo sequence at 3.0 T MRI system.

ASSESSMENT

Patient pathologic findings, included histologic grade and the expression status of Ki-67 and HER2, were reviewed by one uropathologist. The APTw values of BCa were independently measured by two radiologists and were compared between high-/low-tumor grade group, high-/low-Ki-67 expression group, and high-/low-HER2 expression group.

STATISTICAL TESTS

The interclass correlation coefficient, independent sample t-test, Mann-Whitney U test, Spearman's rank correlation, and receiver operating characteristic curve (ROC) analysis were used. P < 0.05 was considered statistically significant.

RESULTS

Significantly higher APTw values were found in high-grade BCa patients (7.72% vs. 4.29%, P < 0.001), high-Ki-67 expression BCa patients (8.40% vs. 3.25%, P < 0.001) and HER2 positive BCa patients (8.24% vs. 5.40%, P = 0.001). APTw values were positively correlated with Ki-67 (r = 0.769) and HER2 (r = 0. 356) expression status. The area under the ROC curve of the APTw values for detecting Ki-67 and HER2 expression status were 0.883 (95% CI: 0.790-0.945) and 0.713 (95% CI: 0.592-0.816), respectively.

DATA CONCLUSIONS

APTw MRI is a potential method to assess the biological and proliferation potential of BCa.

LEVEL OF EVIDENCE: 4

TECHNICAL EFFICACY

Stage 2.

Clinicohistopathological Correlation and Prognostic Significance of Molecular Biomarkers in Urinary Bladder Neoplasms: A Comprehensive Analysis

BACKGROUND

Urinary bladder neoplasms constitute a heterogeneous group of tumors with diverse clinical behaviors and outcomes. Understanding the correlation between clinicopathological characteristics and the prognostic significance of molecular biomarkers in bladder cancer is vital for personalized treatment strategies and improved patient outcomes.

OBJECTIVE

This prospective observational study aimed to comprehensively investigate the clinicopathological correlations and prognostic significance of molecular biomarkers in urinary bladder neoplasms.

METHODS

A cohort of 174 patients diagnosed with urinary bladder neoplasm participated in this study. Clinicopathological data, including demographic information, medical history, imaging findings, and histopathological reports, were collected from the patient records. Tissue samples obtained from transurethral resection or biopsy were subjected to molecular biomarker analysis using immunohistochemistry (IHC), fluorescence in situ hybridization (FISH), and molecular profiling techniques. Longitudinal follow-up assessments were conducted to monitor disease progression, recurrence, and overall survival.

RESULT

Out of 174 patients diagnosed with bladder neoplasms, the mean age of the patients was 62.4 years (±8.7), indicating that the study cohort primarily comprised elderly individuals. The majority of patients were male (126, 72.4%), reflecting the higher prevalence of bladder cancer among men compared to women. Preliminary analysis revealed significant associations between clinicopathological parameters, molecular biomarker expression profiles, and clinical outcomes in patients with urinary bladder neoplasms. Elevated expression levels of specific biomarkers such as tumor protein p53 (p53), Ki-67, and estimated glomerular filtration rate (EGFR) were observed in advanced tumor stages (p < 0.001) and higher histological grades (p < 0.05), indicating their potential prognostic significance. Furthermore, genetic alterations detected using molecular profiling techniques, including chromosomal gains and losses, were significantly correlated with aggressive disease phenotypes and increased recurrence risk (p < 0.01). Longitudinal follow-up data demonstrated that patients with elevated biomarker expression levels or genetic alterations had poorer treatment responses and shorter overall survival durations than those with lower biomarker expression levels.

CONCLUSION

This study highlights the importance of integrating clinicopathological parameters and molecular biomarker data for the risk stratification, treatment selection, and prognostic assessment of urinary bladder neoplasms.

Risk stratification and management of non-muscle-invasive bladder cancer: A physician survey in six Asia-Pacific territories

OBJECTIVES

Multiple clinical practice guidelines, conflicting evidence, and physician perceptions result in variations in risk stratification among patients with non-muscle-invasive bladder cancer (NMIBC). This study aims to describe the extent of this variation and its impact on management approaches in the Asia-Pacific region.

METHODS

We conducted a cross-sectional survey involving 32 urologists and seven medical oncologists with ≥8 years of experience managing early-stage bladder cancer patients across Australia, Hong Kong, Japan, South Korea, Singapore, and Taiwan. The physicians completed an anonymous questionnaire that assessed their risk stratification and respective management approaches, based on 19 NMIBC characteristics. For each NMIBC characteristic, they were required to select one risk group, and their most preferred management approach.

RESULTS

Our results demonstrated a higher consensus on risk classification versus management approaches. More than 50% of the respondents agreed on the risk classification of all NMIBC characteristics, but 42% or fewer chose the same treatment option as their preferred choice for all but two characteristics-existence of variant histology (55%) and persistent high-grade T1 disease on repeat resection (52%). Across territories, there was the greatest variation in preferred treatment options (i.e., no treatment, intravesical chemotherapy, or Bacillus Calmette-Guérin [BCG] treatment) for intermediate-risk patients and the highest consensus on the treatment of very high-risk patients, namely radical cystectomy.

CONCLUSIONS

Our study revealed considerable variation in risk stratification and management of NMIBC in the region. It is critical to develop practical algorithms to facilitate the recognition of NMIBC and standardize the treatment of NMIBC patients.

Improving compliance with guidelines may lead to favorable clinical outcomes for patients with non-muscle-invasive bladder cancer: A retrospective multicenter study

OBJECTIVES

Clinical guidelines recommend that patients with non-muscle-invasive bladder cancer (NMIBC) should be treated with appropriate adjuvant therapy. However, compliance with guideline recommendations is insufficient, and this may lead to unfavorable outcomes. We aimed to investigate the level of adherence to guideline recommendations in patients with NMIBC and evaluate the outcomes of those who did and did not receive guideline-recommended therapies.

METHODS

We performed a retrospective analysis of patients with histologically diagnosed NMIBC. The percentage of patients with intermediate- and high-risk tumors who received adjuvant intravesical therapy or second transurethral resection (TUR) was calculated. Recurrence-free survival was assessed in patients who did and did not receive the therapies. We conducted a propensity score-matched analysis to compare outcomes between patients with intermediate-risk and T1 NMIBC who did and did not undergo guideline-recommended therapies.

RESULTS

Overall, 1204 patients from the Tohoku Urological Evidence-Based Medicine Study Group and Kyoto University Hospital were included. Of patients with intermediate- and high-risk tumors, 91.0% and 74.0% did not receive maintenance bacillus Calmette-Guérin (BCG), respectively. In both groups, significantly better recurrence-free survival was found for patients treated with maintenance BCG. Among patients with T1 NMIBC, only 16.7% underwent guideline-recommended therapies, that is, a second TUR and maintenance BCG. Significantly greater recurrence-free survival was observed in patients who received guideline-recommended therapies compared with propensity-matched patients who did not.

CONCLUSIONS

Guideline-recommended therapies may contribute to improvements in outcomes for patients with NMIBC, suggesting that improvements in adherence to clinical guidelines may lead to favorable outcomes.

Survival Outcome of Partial Cystectomy versus Transurethral Bladder Tumor Resection in T1 High-Grade Bladder Cancer Patients: A Propensity Score Matching Study

Purpose

Partial cystectomy was investigated as a method of bladder preservation with better disease outcomes than transurethral bladder tumor resection in T1 high-grade bladder cancer patients. Method and materials. The national Surveillance, Epidemiology, and End Results database (SEER) (2004-2015) were used to obtain patients diagnosed with T1 high-grade bladder cancer, and finally, 25263 patients were enrolled in our study. The Kaplan-Meier method with the log-rank test was performed to analyze the outcome of overall survival (OS) and cancer-specific survival (CSS) between patients undergoing partial cystectomy (PC), transurethral resection of bladder tumor (TURBT), or radical cystectomy (RC). Moreover, the propensity score matching (PSM) and multivariable Cox proportional hazard model were also utilized in the study.

Results

Ultimately, 24635 patients were undergoing TURBT, while 190 and 438 patients were, respectively, assigned to the PC and RC groups. Compared with patients with TURBT, a tendency of a higher proportion of higher older and male patients was observed in the PC group. When matching with RC patients, patients in the PC group were commonly older and had bigger tumor sizes and single tumors (All P < 0.05). After 1 : 1 PSM, 190 patients with TURBT and 160 patients receiving PC were selected. In survival analysis, the patients in the PC group had a higher survival probability of both OS and CSS before and after PSM compared with those in the TURBT group. Meanwhile, no significant differences were observed between the RC and PC groups in OS and CSS analysis. Moreover, multivariable Cox regression showed that PC was a protective factor for overall mortality (ACM) and cancer-specific mortality (CSM) compared with TURBT in T1 high-grade patients (All P < 0.05).

Conclusion

Patients undergoing partial cystectomy were shown to have a better outcome compared with those with transurethral bladder tumor resection in T1 high-grade bladder cancer patients. Partial cystectomy could be the more worthwhile choice for bladder preservation in T1 high-grade bladder cancer patients.

Upstaging and Survival Outcomes for Non-Muscle Invasive Bladder Cancer After Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

INTRODUCTION

We sought to describe the incidence, risk factors, and survival outcomes associated with pathological upstaging from non-muscle invasive bladder cancer (NMIBC) to muscle invasive bladder cancer (MIBC) after robot-assisted radical cystectomy (RARC).

METHODS

We reviewed the International Robotic Cystectomy Consortium database between 2004 and 2020. Upstaging was defined as ≥pT2 or pN+ at final pathology from clinical <T2N0M0. Descriptive statistics were used to summarize data. Cochran-Armitage test was used to depict upstaging trend over time. Multivariate regression models were used to depict variables associated with upstaging. Kaplan Meier curves were used to describe disease-specific (DSS), recurrence-free (RFS), and overall survival (OS).

RESULTS

463 patients underwent RARC for NMIBC. Upstaging occurred in 145 (31%) patients. Upstaged patients were older (70 vs 67 years, p <0.01), more likely to have American Society of Anesthesiologists score (≥3) (55% vs 44%, p=0.04) and had higher rate of preoperative hydronephrosis (26% vs 10%, p <0.01). They were more likely to have positive surgical margins (10% vs 3%, p= 0.01), recurrences (28% vs 9%, p<0.01), and to receive adjuvant/salvage treatment (26% vs none, p <0.01). On multivariate analysis, upstaging was associated with older age (OR 1.04; CI 1.01-1.07, p<0.01), cT1 vs cTis (OR 4.25; CI 1.57-11.48, p <0.01), cT1 vs cTa (OR 2.92; CI 1.40-6.06, p<0.01), and preoperative hydronephrosis (OR 3.18; CI 1.60-6.32, p<0.01). Upstaged patients had worse 5-year RFS (53 % vs 85%, log rank p<0.01), DSS (66% vs 93%, log rank p<0.01), and OS (49% vs 74%, log rank p<0.01). The rate of upstaging did not significantly change over time (38% in 2004 to 27% in 2019, p=0.17).

CONCLUSION

Upstaging to MIBC occurred in a significant proportion of patients after RARC for NMIBC and was associated with worse survival outcomes. Older patients, those with cT1 disease and hydronephrosis were more likely to upstage.

Evaluation of autofluorescence and photodynamic diagnosis in assessment of bladder lesions

The ability to detect and diagnose bladder cancer early and precisely is crucial for effective treatment. The aim of this study is to assess the utility of optical biopsy performed with autofluorescence cystoscopy (AFC) using the Onco-LIFE system with numerical color values (NCVs) and by ALA/PDD. Histopathological examination of material obtained during TURBT and/or biopsy of the bladder was carried out in 251 patients. In the case of 35 patients, the selection of the specimen collected for histopathological examination was based using ALA/PDD. In the remaining 216 patients, tissue was collected based on the findings of AFC with NCV. Using AFC, the observed NCV ranged from 0 to 3.86; the highest mean NCV was observed in neoplastic muscle invasive lesions and was equal to 3.18. Furthermore, non-muscle invasive tumors were characterized by a mean NCV equal to 1.54. Tissue with inflammation, metaplasia, and healthy tissue demonstrated significantly lower mean NCV values. The presence of a muscle-invasive tumor increased the NCV by approximately 2.86 compared to healthy tissue. The rates of postoperative complications depend on the examining operator and are observed more often, as much as 65.7 % during ALA/PDD. AFC with NCV using the Onco-LIFE system, as well as ALA/PDD are helpful tools for early diagnosis of bladder precancerous and cancer lesions and for performing targeted biopsies. A significant correlation was found between lesion NCV index and the grade of dysplasia or tumor malignancy. Tissue with inflammation, metaplasia, and healthy tissue demonstrated significantly lower mean NCV values. AFE with NCV have a significantly higher sensitivity than specificity. Low rates of postoperative complications are correlated to the experience of the endoscopist and with AFE/NCV in comparison of ALA/PDD.

Application of nomograms in the prediction of overall survival and cancer-specific survival in patients with T1 high-grade bladder cancer

To predict survival outcomes for individual patients with clinical T1 high-grade (T1HG) bladder cancer (BC), data from the Surveillance Epidemiology and End Results (SEER) database were analyzed in the present study. The data of 6,980 cases of T1HG BC between 2004 and 2014 were obtained from the SEER database. Uni- and multivariate Cox analyses were performed to identify significant prognostic factors. Subsequently, prognostic nomograms for predicting 3- and 5-year overall survival (OS) and cancer-specific survival (CSS) rates were constructed based on the SEER database. Clinical information from the SEER database was divided into internal and external groups and used to validate the nomograms. In addition, calibration plot diagrams and concordance indices (C-indices) were used to verify the predictive performance of the nomogram. A total of 6,980 patients were randomly allocated to the training cohort (n=4,886) or the validation cohort (n=2094). Univariate and multivariate Cox analyses indicated that age, ethnicity, tumor size, marital status, radiation and surgical status were independent prognostic factors. These characteristics were used to establish nomograms. The C-indices for OS and CSS rate predictions for the training cohort were 0.707 (95% CI, 0.693–0.721) and 0.700 (95% CI, 0.679–0.721), respectively. Internal and external calibration plot diagrams exhibited an excellent consistency between actual survival rates and nomogram predictions, particularly for 3- and 5-year OS and CSS. The significant prognostic factors in patients with T1HG BC were age, ethnicity, marital status, tumor size, status of surgery and use of radiation. In the present study, a nomogram was developed that may serve as an effective and convenient evaluation tool to help surgeons perform individualized survival evaluations and mortality risk determination for patients with T1HG BC.

Molecular Progression Risk Score for Prediction of Muscle Invasion in Primary T1 High-Grade Bladder Cancer

BACKGROUND

Pathologic T1 high-grade (pT1HG) bladder cancer (BC) is characterized by a high progression rate and constitutes an important clinical challenge; however, there is no consensus on the prediction of progression in pT1HG BC. The purpose of this study was to validate previously published molecular progression risk score (MoPRS) for predicting muscle-invasive disease in pT1HG BC.

MATERIALS AND METHODS

The expression of an 8-gene progression-related classifier identified from microarray data was analyzed by real-time PCR, and the MoPRS was calculated in 121 newly recruited patients with pT1HG BC. Progression was defined as muscle invasion or metastasis.

RESULTS

Overall, the disease of 28 patients (23.1%) progressed to muscle-invasive BC during the median follow-up of 63.7 (interquartile range, 17.6-96.4) months. The MoPRS was significantly higher in 1973 World Health Organization grade 3 than grade 2 tumors (P = .004). Early development of invasive BC was more prevalent in the highest quartile MoPRS group than in the lowest to 75th percentile MoPRS groups according to Kaplan-Meier analysis. Multivariate Cox regression analysis revealed that the MoPRS was an independent predictor of invasive BC, either as a continuous variable (hazard ratio, 1.624; 95% confidence interval, 1.266-2.082; P < .001) or as a categorical variable (hazard ratio, 3.089; 95% confidence interval, 1.335-7.150; P = .008).

CONCLUSION

The MoPRS was an independent prognostic factor for identifying patients at high risk of invasive BC in patients with pT1HG BC. This scale may help identify patients who could benefit from more aggressive therapeutic intervention such as early cystectomy.

Clinical predictors for high-grade bladder cancer before first-time transurethral resection of the bladder tumor: a retrospective cohort study

The aim of this study was to identify the clinical predictors related to the risk of high-grade bladder cancer before first-time transurethral resection of the bladder tumor (TUR-Bt) and to externally validate the accuracy of Shapur's nomogram predicting the risk of high-grade bladder cancer in Japanese patients. As a result, episode of gross hematuria (odds ratio: 2.68, P = 0.02), larger tumor size (odds ratio: 1.89, P < 0.01) and positive urinary cytology (odds ratio: 8.34, P < 0.01) were found to be significant predictors for high-grade bladder cancer. Furthermore, the nomogram showed a high predictive accuracy in our Japanese population (area under the curve: 0.79). Clinicians will be able to predict high-grade bladder cancer using the common factors in Shapur's study and ours, such as tumor size and urinary cytology, and gross hematuria as the additional factor first identified here to decide priorities for the treatment of patients diagnosed with bladder cancer.

How do we manage high-grade T1 bladder cancer? Conservative or aggressive therapy?

High-grade T1 bladder cancer has a poor prognosis due to a higher incidence of recurrence and progression than other nonmuscle invasive bladder cancer; thus patients with high-grade T1 have to be carefully monitored and managed. If patients are diagnosed with high-grade T1 at initial transurethral resection (TUR), a second TUR is strongly recommended regardless of whether muscle layer is present in the specimen because of the possibility of understating due to incomplete resection. Since high-grade T1 disease shows diverse clinical courses, individual approaches are recommended for treatment. In cases with low risk of progression, cystectomy could represent overtreatment and deteriorate quality of life irreversibly, while, in those with high risk, bacillus Calmette-Guérin (BCG) therapy may worsen survival by delaying definitive therapy. Therefore, a strategy for predicting prognosis based on the risk of progression is needed for managing high-grade T1 disease. Molecular risk classifiers predicting the risk of progression and response to BCG may help identify the optimal management of high-grade T1 disease for each individual.

Metformin for the Prevention of Bladder Cancer Recurrence: Is it Effective?

Background

Many methods have been used for preventing and reducing recurrences of bladder cancers. In recent years, some investigators have examined the use of metformin for this purpose. First lines of evidence have shown that metformin inhibits cancer cell growth and prevents cancer occurrence in patients with type 2 diabetes.

Objectives

This study is designed to assess metformin usage in the prevention of bladder cancer recurrence after the trans-urethral resection of a bladder tumor (TUR-T).

Patients and Methods

In the present study, metformin was administered in the treatment of 32 patients with a history of bladder cancer, and their results were compared with those of 33 patients with bladder cancer recurrence (placebo group). Patients in the metformin group received 1000 mg metformin (2 tablets 500 mg) for 1 year. Frequency of tumor recurrence was calculated and compared with the placebo group.

Results

There was no statistical difference between the 2 groups with respect to the recurrence rate (P > 0.05). Although the recurrence interval was longer for the metformin group, this increase was not statistical significant (P > 0.05). Furthermore, tumor recurrence had no correlation with sex or the grade of the tumors.

Conclusions

According to our findings, it seems that metformin has no considerable inhibitory effect on the recurrence rate of bladder cancer, but that it can delay tumor recurrence.