The 3-month clinical response to intravesical therapy as a predictive factor for progression in patients with high risk superficial bladder cancer

[Early cystectomy-patient selection and technique]

Early radical cystectomy (RC) is a therapeutic option for non-muscle invasive bladder cancer (NMIBC). The 15-year overall survival after early RC in NMIBC patients is about 70%. Nevertheless, RC is associated with significant morbidity and mortality and therefore requires careful patient selection. The aim of the following review is to assess the selection process for early RC in NMIBC. Especially, the new European Association of Urology (EAU) risk calculator identifying NMIBC patients with very high risk for disease progression is described in detail. Furthermore, the technical aspects of the procedure are evaluated. A review of the current literature (PubMed) and national and international guideline recommendations was also conducted.

Integrative Transcriptome Profiling Reveals SKA3 as a Novel Prognostic Marker in Non-Muscle Invasive Bladder Cancer

Approximately 80% of all new bladder cancer patients are diagnosed with non-muscle invasive bladder cancer (NMIBC). However, approximately 15% of them progress to muscle-invasive bladder cancer (MIBC), for which prognosis is poor. The current study aimed to improve diagnostic accuracy associated with clinical outcomes in NMIBC patients. Nevertheless, it has been challenging to identify molecular biomarkers that accurately predict MIBC progression because this disease is complex and heterogeneous. Through integrative transcriptome profiling, we showed that high SKA3 expression is associated with poor clinical outcomes and MIBC progression. We performed RNA sequencing on human tumor tissues to identify candidate biomarkers in NMIBC. We then selected genes with prognostic significance by analyzing public datasets from multiple cohorts of bladder cancer patients. We found that SKA3 was associated with NMIBC pathophysiology and poor survival. We analyzed public single-cell RNA-sequencing (scRNA-seq) data for bladder cancer to dissect transcriptional tumor heterogeneity. SKA3 was expressed in an epithelial cell subpopulation expressing genes regulating the cell cycle. Knockdown experiments confirmed that SKA3 promotes bladder cancer cell proliferation by accelerating G2/M transition. Hence, SKA3 is a new prognostic marker for predicting NMIBC progression. Its inhibition could form part of a novel treatment lowering the probability of bladder cancer progression.

Glypican-1 as a target for fluorescence molecular imaging of bladder cancer

OBJECTIVES

To investigate whether anti-glypican-1 antibody Miltuximab conjugated with near-infrared dye IRDye800CW can be used for in vivo fluorescence imaging of urothelial carcinoma.

METHODS

The conjugate, Miltuximab-IRDye800CW, was produced and characterized by size exclusion chromatography and flow cytometry with glypican-1-expressing cells. Balb/c nude mice bearing subcutaneous urothelial carcinoma xenografts were intravenously injected with Miltuximab-IRDye800CW or control IgG-IRDye800CW and imaged daily by fluorescence imaging. After 10 days, tumors and major organs were collected for ex vivo study of the conjugate biodistribution, including its accumulation in the tumor.

RESULTS

The intravenous injection of Miltuximab-IRDye800CW to tumor-bearing mice showed its specific accumulation in the tumors with the tumor-to-background ratio of 12.7 ± 2.4, which was significantly higher than that in the control group (4.6 ± 0.9, P < 0.005). The ex vivo imaging was consistent with the in vivo findings, with tumors from the mice injected with Miltuximab-IRDye800CW being significantly brighter than the organs or the control tumors.

CONCLUSIONS

The highly specific accumulation and retention of Miltuximab-IRDye800CW in glypican-1-expressing tumors in vivo shows its high potential for fluorescence imaging of urothelial carcinoma and warrants its further investigation toward clinical translation.

Bladder preservation therapy in combination with atezolizumab and radiation therapy for invasive bladder cancer (BPT-ART) - A study protocol for an open-label, phase II, multicenter study

Radical cystectomy (RC) is recommended for muscle-invasive bladder cancer (MIBC) or highest-risk non-muscle-invasive bladder cancer (NMIBC). Trimodal therapy (TMT) is the most favorable strategy among bladder preservation therapies (BPT) for patients who are ineligible for or refuse RC. However, referrals for TMT, especially following chemotherapy, are limited by the patient's condition. Therefore, new BPT approaches are needed. Atezolizumab inhibits programmed death-ligand 1, is well-tolerated in patient populations heavily dominated by renal insufficiency, and is expected to have synergistic anti-tumor effects in combination with radiation therapy (RT). Therefore, we have conducted this open-label phase II multicenter study to evaluate the efficacy and safety of RT in combination with atezolizumab for T2-3 MIBC and highest-risk T1 NMIBC patients. This study was initiated in January 2019, and we aimed to enroll a total of 45 patients. The study is registered in the Japan Registry of Clinical Trials (Identifier: RCT2031180060).

Assessing treatment response after intravesical bacillus Calmette-Guerin induction cycle: are routine bladder biopsies necessary?

PURPOSE

To determine the need for routine bladder biopsies (BBs) in assessing response to the induction cycle of intravesical bacillus Calmette-Guérin (BCG) for high-risk non-muscle-invasive bladder cancer (NMIBC).

METHODS

Our prospectively maintained NMIBC database was queried to identify patients with high-risk disease (carcinoma in situ, high-grade Ta/T1) who underwent BBs after BCG induction cycle. Urine cytology, cystoscopy, and BBs findings were evaluated.

RESULTS

A total of 219 patients met the inclusion criteria. Urine cytology was positive in 20 patients and negative in 199; cystoscopy was positive in 35 patients, suspicious in 32 and normal in 152 patients. BBs yielded bladder cancer (BCa) in 43 (19.6%) patients, with a BCa rate of 9.3% in patients with negative cytology and cystoscopy as opposed to 38.0% in patients whereby one or both exams were suspicious/positive. The diagnostic accuracy of urine cytology, cystoscopy, and combined tests was 0.56, 0.70, and 0.71, respectively. The negative predictive value of combined tests was 90.7%. Performing BBs only in patients with positive cytology and/or positive/suspicious cystoscopy would have spared 140 (64%) patients to undergo this procedure while missing BCa in 13 (9.3%) of them, representing 30% of all BCa cases.

CONCLUSION

Performing BBs only in patients with positive cytology and suspicious/positive cystoscopy would spare 64% of un-necessary BBs but miss a non-negligible number of BCas. While no data are available regarding the potential consequences of missing such BCas, such information should be taken into account in patient's counselling.

ElectroMotive drug administration (EMDA) of Mitomycin C as first-line salvage therapy in high risk "BCG failure" non muscle invasive bladder cancer: 3 years follow-up outcomes

BACKGROUND

In case of high grade non-muscle invasive bladder cancer (HG-NMIBC), intravesical BCG represents the first-line treatment; despite the "gold" standard therapy, up to 50% of patients relapse, needing radical cystectomy. Hence, alternative therapeutic strategies have been developed. The aim of the study was to evaluate a first-line salvage treatment with EMDA®-MMC in patients with HGNMIBC unresponsive to BCG.

METHODS

We carried out a prospective, single-center, single-arm Phase II study in order to evaluate the efficacy (in terms of recurrence and progression) and the safety of the EMDA®-MMC treatment in 26 (21 male, 5 female) consecutive patients with "BCG refractory" HGNMIBC on a 3 years follow-up. EMDA®-MMC treatment consisted of 40 mg of MMC diluted in 100 ml of sterile water retained in the bladder for 30 min with 20 mA pulsed electric current. EMDA®-MMC regimen consisted of an induction course of 6 weekly instillations followed by a maintenance course of 6 monthly instillations. Follow-up was performed with systematic mapping biopsies of the bladder (with sampling in the prostatic urethra for men), voiding and washing urinary cytology, radiological study of the upper urinary tract. We performed Survival Kaplan-Meier curves and Log-rank test in order to analyze high grade disease-free survival.

RESULTS

At the end of follow-up, 16 patients (61.5%) preserved their native bladder; 10 patients (38.4%) underwent radical cystectomy, in 6 patients (23.1%) for recurrent HGNMIBC and in 4 patients (15.4%) for progression to muscle-invasive disease. At the end of follow-up, stratifying patients based on TNM classification (TaG3, T1G3, Cis, TaT1G3 + Cis), disease-free rates were 75, 71.4, 50 and 25%, respectively; survival curves showed statistically significant differences (p value < 0.05). Regarding toxicity, we reported severe adverse systemic event of hypersensitivity to the MMC in 3 patients (11.5%), and local side effects in 6 patients (26.1%).

CONCLUSIONS

In the field of alternative strategies to radical cystectomy, the EMDA®-MMC could be considered safe and effective in high-risk NMIBC unresponsive to BCG, as a "bladder sparing" therapy in selected patients. Multicenter studies with a larger number of patients and a longer follow-up might confirm our preliminary results.

TRIAL REGISTRATION

EudraCT2017-002585-43. 17 June 2017 (retrospectively registered).

High-Risk Non-Muscle-Invasive Bladder Cancer-Therapy Options During Intravesical BCG Shortage

Bladder cancer is the second commonest urinary tract malignancy with 70–80 % being non-muscle invasive (NMIBC) at diagnosis. Patients with high-risk NMIBC (T1/Tis, with high grade/G3, or CIS) represent a challenging group as they are at greater risk of recurrence and progression. Intravesical Bacilli Calmette-Guerin (BCG) is commonly used as first line therapy in this patient group but there is a current worldwide shortage. BCG has been shown to reduce recurrence in high-risk NMIBC and is more effective that other intravesical agents including mitomycin C, epirubicin, interferon-alpha and gemcitabine. Primary cystectomy offers a high change of cure in this cohort (80–90 %) and is a more radical treatment option which patients need to be counselled carefully about. Bladder thermotherapy and electromotive drug administration with mitomycin C are alternative therapies with promising short-term results although long-term follow-up data are lacking.

Papillary Recurrence of Bladder Cancer at First Evaluation after Induction Bacillus Calmette-Guérin Therapy: Implication for Clinical Trial Design

BACKGROUND

Recurrence with papillary tumor(s) by 3-mo after induction bacillus Calmette-Guérin (BCG) is historically believed to be a poor prognostic indicator in patients with high-risk non-muscle invasive bladder cancer. However, the impact of a clinical Ta (cTa) papillary recurrence at 3 mo after BCG is often debated.

OBJECTIVE

To evaluate the prognostic implications of cTa papillary recurrence found 3 mo after induction BCG therapy and to evaluate its significance in clinical trial design.

DESIGN, SETTING, AND PARTICIPANTS

We reviewed our database of 917 patients who underwent transurethral resection and induction of BCG from 1995 to 2012. Clinical characteristics were compared between 3-mo recurrence stages.

INTERVENTION

Transurethral resection of bladder tumor and intravesical therapy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Chi-square analysis and Student t test were used to compare clinical characteristics between 3-mo recurrence stages. Kaplan-Meier method was used to determine bladder-preservation time, progression-free survival, and disease-specific survival.

RESULTS AND LIMITATIONS

We identified 84 patients who met the study criteria (66 patients with cTa and 18 patients with clinical T1 [cT1]). The median follow-up for the entire cohort was 74 mo. Of the patients with cTa recurrence, 60 continued with bladder-sparing therapy. Patients with a high-grade cTa recurrence who continued bladder-sparing therapy had a 17% incidence of disease progression and a 62% incidence of recurrence within 1 yr. No patients with low-grade cTa recurrence (n=13) developed disease progression or underwent radical cystectomy. Patients with an initial cTa at diagnosis had a higher 5-yr bladder preservation rate than those with an initial cT1 diagnosis (84% vs 61%; p=0.041). Patients with high-grade cTa recurrence and those with cT1 recurrence had similar outcomes with respect to death rates over the entire follow-up period (11% and 15%, respectively), as well as 5-yr progression-free survival (77% vs 83%). Limitations include using a single institution and a retrospective review.

CONCLUSIONS

Patients with low-grade cTa papillary recurrence 3 mo after induction of BCG can safely continue with bladder-sparing therapy. Patients with high-grade cTa papillary recurrence at that time have risks of recurrence and progression similar to those of patients with cT1 recurrence. These are important factors to consider during clinical trial design.

PATIENT SUMMARY

Low-grade clinical Ta papillary recurrence following induction of bacillus Calmette-Guérin therapy can be safely managed conservatively, although a high-grade clinical Ta recurrence should be treated similar to a clinical T1 recurrence due to its comparable progression rates.

Recommendations for the improvement of bladder cancer quality of care in Canada: A consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015

This initiative was undertaken in response to concerns regarding the variation in management and in outcomes of patients with bladder cancer throughout centres and geographical areas in Canada. Population-based data have also revealed that real-life survival is lower than expected based on data from clinical trials and/or academic centres. To address these perceived shortcomings and attempt to streamline and unify treatment approaches to bladder cancer in Canada, a multidisciplinary panel of expert clinicians was convened last fall for a two-day working group consensus meeting. The panelists included urologic oncologists, medical oncologists, radiation oncologists, patient representatives, a genitourinary pathologist, and an enterostomal therapy nurse. The following recommendations and summaries of supporting evidence represent the results of the presentations, debates, and discussions. Methodology

Risk Factors Predictive of Recurrence and Progression for Patients Who Suffered Initial Recurrence After Transurethral Resection of Stage pT1 Bladder Tumor in Chinese Population: A Retrospective Study

Bladder cancer is one of the most common malignancies worldwide and the stage pT1nonmuscle invasive bladder cancer (NMIBC) has a high probability of recurrence after initial diagnosis and treatment. However, risk factors predictive of repeated recurrence and progression of pT1 bladder tumors after primary relapse have not been uncovered. Thus, we conducted the retrospective study.A total of 418 patients who suffered initial recurrence after transurethral resection (TUR) of pT1 bladder tumor were selected for the analyses. Clinic information of the patients was retrieved from their medical records. Recurrence-free survival (RFS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Univariate and multivariate analyses were performed using a Cox proportional hazards regression model. The probability of recurrence and progression by multivariate analyses was used as a surrogate marker to construct receiver operating curve (ROC).Results showed that variables including time to prior recurrence time, prior treatment, number of tumor, tumor size, tumor grade, and time of instillation after surgery were associated with the repeated recurrence of pT1 bladder tumor (P < 0.05). The variables including time to prior recurrence time, tumor size, tumor grade, carcinoma in situ (CIS), and time of instillation after surgery were associated with progression of pT1 bladder tumor (P < 0.05). In the present study, the multivariate model showed an area under ROC (AUC) value of 0.754 and 0.798 for tumor recurrence and progression, respectively, which was more effective in prediction than a single risk factor.In conclusion, we have identified several risk factors relevant to RFS and PFS for patients who have had a history of recurrence of pT1 bladder tumor after TUR. These predictive factors may help urologists to stratify patients into distinct risk groups of recurrence and progression, which probably contributes to the individualized treatment for patients.

Non-muscle invasive bladder cancer risk stratification

INTRODUCTION

Non-muscle invasive bladder cancer (NMIBC) comprises about 70% of all newly diagnosed bladder cancer, and includes tumors with stage Ta, T1 and carcinoma in situ (CIS.) Since, NMIBC patients with progression to muscle-invasive disease tend to have worse prognosis than with patients with primary muscle-invasive disease, there is a need to significantly improve risk stratification and earlier definitive treatment for high-risk NMIBC.

MATERIALS AND METHODS

A detailed Medline search was performed to identify all publications on the topic of prognostic factors and risk predictions for superficial bladder cancer/NMIBC. The manuscripts were reviewed to identify variables that could predict recurrence and progression.

RESULTS

The most important prognostic factor for progression is grade of tumor. T category, tumor size, number of tumors, concurrent CIS, intravesical therapy, response to bacillus Calmette-Guerin at 3- or 6-month follow-up, prior recurrence rate, age, gender, lymphovascular invasion and depth of lamina propria invasion are other important clinical and pathological parameters to predict recurrence and progression in patients with NMIBC. The European Organization for Research and Treatment of Cancer (EORTC) and the Spanish Club UrológicoEspañol de Tratamiento Oncológico (CUETO) risk tables are the two best-established predictive models for recurrence and progression risk calculation, although they tend to overestimate risk and have poor discrimination for prognostic outcomes in external validation. Molecular biomarkers such as Ki-67, FGFR3 and p53 appear to be promising in predicting recurrence and progression but need further validation prior to using them in clinical practice.

CONCLUSION

EORTC and CUETO risk tables are the two best-established models to predict recurrence and progression in patients with NMIBC though they tend to overestimate risk and have poor discrimination for prognostic outcomes in external validation. Future research should focus on enhancing the predictive accuracy of risk assessment tools by incorporating additional prognostic factors such as depth of lamina propria invasion and molecular biomarkers after rigorous validation in multi-institutional cohorts.

The value of EORTC risk tables in evaluating recurrent non-muscle-invasive bladder cancer in everyday practice

Introduction

Due to the risk of recurrence and progression, patients with non–muscle–invasive bladder cancer have to be under observation. The aim of this study is the evaluation of early recurrence at the first control cystoscopy, as a prognostic factor for recurrence and progression based on EORTC risk tables.

Material and methods

This study analyzed 243 patients with non–muscle–invasive bladder cancer, with an average observation time of 46 months. Recurrence was observed in case of 99 patients. Among these patients, we selected 79 who had the first cystoscopy 3 months after the transurethral electroresection of the bladder tumor. Subsequently, 45 patients with early recurrence at the first control cystoscopy were compared with 34 patients whose cancer recurred at later control cystoscopies. The patients were compared with respect to the number of points assigned by EORTC tables.

Results

Those patients who had an early recurrence had a significantly higher score in the EORTC table in the progression scale (p = 0.017) but not in the recurrence scale (p = 0.11), as compared with patients who had a late recurrence.

Conclusions

Early recurrence that occurs within 3 months after TURBT indicates a higher risk of progression, as compared with a late recurrence. Patients who had an early recurrence had a significantly higher EORTC risk score for progression. Their EORTC risk score for recurrence was also higher, but the difference was not statistically significant. Every patient with an early recurrence has a worse prognosis and a higher risk of progression.

EORTC risk tables - their usefulness in the assessment of recurrence and progression risk in non-muscle-invasive bladder cancer in Polish patients

INTRODUCTION

The assessment of risk of recurrence and progression of bladder cancer (BC) is still rather difficult. We decided to check the rates of the changes mentioned above in the group of the Polish patients after a year-long observation and next to compare them with the results calculated in the European Organisation of Research and Treatment of Cancer (EORTC) risk tables.

METHODS

The tested group consisted of 91 patients who underwent transurethral resection of bladder tumour (TURBT). When being diagnosed, 60 cases were in the pTa clinical stage, whereas 30 cases were in T1. The coexisting carcinoma in situ (CIS) was observed in four cases. On the basis of the scores obtained from the EORTC tables, the patients were divided into the groups of low, intermediate or high risk of disease recurrence and progression.

RESULTS

Recurrence was noticed in 23 patients (25%), while progression was observed in 11 patients (12.1%). The rate of the observed recurrences proved to be lower than it had been predicted in all the groups, except for one of the intermediate-risk group (score 1- 4). Moreover, the rate of the progressions predicted according to the EORTC risk tables was higher in all the risk groups.

CONCLUSIONS

It can be noticed that the rate of real recurrences is lower than expected, whereas the rate of the observed progressions is overestimated. Partly, it could be the result of using a relatively small group of patients for observation and applying a different method of treatment.

Best practice in the treatment of nonmuscle invasive bladder cancer

Bladder carcinoma is the most common malignancy of the urinary tract. Approximately 75-85% of patients with bladder cancer present with a disease that is confined to the mucosa (stage Ta, carcinoma in situ) or submucosa (stage T1). These categories are grouped as nonmuscle invasive bladder cancer (NMIBC). Although the management of NMIBC tumours has significantly improved during the past few years, it remains difficult to predict the heterogeneous outcome of such tumours, especially if high-grade NMIBC is present. Transurethral resection is the initial treatment of choice for NMIBC. However, the high rates of recurrence and significant risk of progression in higher-grade tumours mandate additional therapy with intravesical agents. We discuss the role of various intravesical agents currently in use, including the immunomodulating agent bacillus Calmette-Guérin (BCG) and chemotherapeutic agents. We also discuss the current guidelines and the role of these therapeutic agents in the context of higher-grade Ta and T1 tumours. Beyond the epidemiology, this article focuses on the risk factors, classification and diagnosis, the prediction of recurrence and progression in NMIBC, and the treatments advocated for this invasive disease.

[Recurrent bladder cancer after BCG instillation therapy. Local therapy options?]

Patients with a so-called BCG failure (Bacillus Calmette-Guérin) constitute an inhomogeneous group of patients. Patients with BCG recurrence or BCG refractive tumors are real BCG failures. Therapeutic options are radical cystectomy and a conservative approach, depending on the individual risk of recurrence and progression. Intravesical chemotherapy with docetaxel or gemcitabine after BCG failure shows some promise whereas second line immunotherapy, the combination of BCG and interferon (INF)-α, is an effective regimen but results need to be confirmed. Device-assisted intravesical strategies, such as mitomycin-EMDA or chemohyperthermia are candidates to keep in mind for the near future. Finally, cystectomy results in the best disease-specific survival in patients with BCG failure.

Survival after primary and deferred cystectomy for stage T1 transitional cell carcinoma of the bladder

Context:

The optimal time of cystectomy for nonmuscle invasive bladder cancer (NMIBC) is controversial.

Aim:

This study aims at comparing cancer-specific survival in primary versus deferred cystectomy for T1 bladder cancer.

Settings and Design:

Between 1990 and 2004, a retrospective cohort of 204 patients was studied.

Materials and Methods:

Primary cystectomy at the diagnosis of NMIBC was performed in 134 patients (group 1) and deferred cystectomy was done after failed conservative treatment in 70 (group 2) Both groups were compared regarding patient and tumor characteristics and cancer-specific survival.

Statistical Analysis Used:

Cancer-specific survival was calculated using the Kaplan-Meier method.

Results:

Mean follow-up was 79 and 66 months, respectively, in the two groups. Tumor multiplicity was more frequent in group 2; otherwise, both groups were comparable in all characteristics. The definitive stage was T1 in all patients. Although the 3-year (84% in group 1 vs. 79% in group 2), 5-year (78% vs. 71%) and 10-year (69% vs. 64%) cancer-specific survival rates were lower in the deferred cystectomy group, the difference was not statistically significant. In group 2, survival was significantly lower in cases undergoing more than three transurethral resections of bladder tumors (TURBT) than in cases with fewer TURBTs.

Conclusions:

Cancer-specific survival is statistically comparable for primary and deferred cystectomy in T1 bladder cancer, although there is a non-significant difference in favor of primary cystectomy. In the deferred cystectomy group, the number of TURBTs beyond three is associated with lower survival. Conservative treatment should be adopted for most cases in this category.

Urothelial carcinoma of the bladder: definition, treatment and future efforts

The identification of patients with high-risk bladder cancer is important for the timely and appropriate treatment of this lethal disease. The understanding of the natural history of bladder cancer has improved; however, the criteria used to define high-risk disease and the relevant treatment strategies have remained the same for the past several decades, despite multiple large, randomized, prospective clinical trials that have evaluated the use of intravesical, surgical and systemic therapies. The genetic signature of high-risk bladder cancer has been a focus of investigation and has led to the discovery of potential molecular targets for disease identification, risk stratification and therapy. These advances, combined with a comprehensive risk assessment profile that incorporates available pathological and clinical characteristics, might improve the diagnosis and treatment of patients with bladder cancer.

Contemporary management of patients with high-risk non-muscle-invasive bladder cancer who fail intravesical BCG therapy

It is advocated that patients with high-risk non-muscle-invasive bladder cancer (NMIBC) receive an adjuvant course of intravesical Bacille Calmette-Guerin (BCG) as first-line treatment. However, a substantial proportion of patients will 'fail' BCG, either early with persistent (refractory) disease or recur late after a long disease-free interval (relapsing). Guideline recommendation in the 'refractory' setting is radical cystectomy, but there are situations when extirpative surgery is not feasible due to competing co-morbidity, a patient's desire for bladder preservation or reluctance to undergo surgery. In this review, we discuss the contemporary management of NMIBC in patients who have failed prior BCG and are not suitable for radical surgery and highlight the potential options available. These options can be categorised as immunotherapy, chemotherapy, device-assisted therapy and combination therapy. However, the current data are still inadequate to formulate definitive recommendations, and data from ongoing trials and maturing studies will give us an insight into whether there is a realistic efficacious second-line treatment for patients who fail intravesical BCG but are not candidates for definitive surgery.

Contemporary management of low-risk bladder cancer

Bladder cancer comprises a heterogeneous group of tumors, the majority of which are non-muscle-invasive bladder cancer (NMIBC) at initial presentation. Low-risk bladder cancer--defined as pTa low-grade papillary tumors--is the type of NMIBC with the most favorable oncologic outcome. Although the risk of progression is less than 1% in 5 years, almost 15% will recur after 1 year, and 32% after 5 years. A complete transurethral resection, followed by an immediate single postoperative instillation of chemotherapy will reduce the risk of recurrence for the first 2 years. Follow-up cystoscopy is required to detect recurrence; in the vast majority of cases the recurrent tumor is of the same stage and grade as the primary tumor. The first follow-up visit, 3 months after surgery, is the most important in predicting risk of recurrence for the future. Recent developments in profiling urine and cancer tissue make it possible to better predict risk of progression and recurrence. In the future this profiling will play an important role in the timing and the choice of treatment, as well as guiding follow-up procedures.

The efficacy of the EORTC scoring system and risk tables for the prediction of recurrence and progression of non-muscle-invasive bladder cancer after intravesical bacillus calmette-guerin instillation

PURPOSE

The European Organization for Research and Treatment of Cancer (EORTC) scoring system and risk table were introduced in the 2008 European Association of Urology guidelines on TaT1 bladder cancer. We compared the recurrence and progression rate between EORTC risk tables and author's patients who underwent transurethral resection of bladder cancer (TURB) following intravesical Bacillus Calmette-Guerin (BCG) instillation.

MATERIALS AND METHODS

The medical records of 251 patients who underwent TURB and were diagnosed with non-muscle-invasive bladder cancer from l993 to 2007 were analyzed. The patients were divided into 2 groups: the recurrence group and the progression group. According to the EORTC scoring system, the patients in each group were categorized in terms of number of tumors, tumor size, prior recurrence rate, T category, carcinoma in situ, and pathologic grade and the scores were summed. According to the summed scores, the recurrence group and the progression group were divided into 3 subgroups: low, intermediate, and high risk, respectively. The recurrence rate and progression rate of each group were compared with the EORTC risk tables.

RESULTS

The recurrence rate and progression rate were almost similar to the EORTC risk tables. However, the recurrence rate was low in the intermediate-risk group.

CONCLUSIONS

Clinical utilization of the EORTC scoring system and risk tables is very effective in predicting the recurrence and progression of non-muscle-invasive bladder cancer and in selecting treatment.

Growth pattern in superficial urothelial bladder carcinomas. Histological review and clinical relevance

INTRODUCTION

The question of when an intraepithelial urothelial carcinoma becomes invasive into the lamina propria of the urinary bladder is an unresolved issue. Our objective was to analyse a series of consecutive superficial carcinomas to assess the importance of growth pattern in tumour recurrence and progression.

MATERIALS AND METHODS

The pathological staging of 200 superficial (pTa/pT1) bladder carcinomas was reviewed. Non-invasive lesions and tumours invading the lamina propria were distinguished. Both infiltrating and pushing patterns of growth were regarded as lamina propria invasion.

RESULTS

A total of 35 (17.5%) pTa and 165 (82.5%) pT1 tumours were identified. Among pT1 tumours, 39 (23.6%) displayed the infiltrating pattern of invasion and 126 (76.4%) the pushing pattern. Differences in five-year recurrence-free (P = 0.01) and progression-free (P = 0.001) survival were demonstrated between pTa and pT1 tumours, and between pT1 infiltrating and pT1 pushing subcategories. Invasive growth pattern has a 1.86 times higher risk of tumour recurrence and 3.01 times higher risk of progression.

CONCLUSIONS

The pT1 category of bladder carcinoma should include a group of tumours defined by its pushing pattern of growth. Some cases may have been previously considered pTa, but follow an intermediate clinical course between pTa and pT1 tumours with infiltrating growth pattern.

Failure to achieve a complete response to induction BCG therapy is associated with increased risk of disease worsening and death in patients with high risk non-muscle invasive bladder cancer

PURPOSE

The Southwest Oncology Group conducted a randomized trial of induction bacillus Calmette-Guérin (BCG) with or without maintenance BCG. In these additional retrospective analyses, our goal was to evaluate the association of a complete response (CR) or remaining with no evidence of disease (NED) vs. no CR during induction therapy with subsequent survival after adjusting for other potential confounders. Among all patients randomized to maintenance treatment, we also wanted to identify combinations of baseline covariates in order to define prognostic groups for subsequent worsening-free survival.

METHODS

Outcome measures of worsening-free and overall survival were assessed using Kaplan Meier estimates and proportional hazards regression models. For the classification and regression tree (CART) analysis, 434 patients randomized to maintenance vs. no therapy with complete covariate information were included.

RESULTS

Of the 593 evaluable patients, 341 were not randomized to maintenance BCG. Patients who achieved a prior complete response during induction BCG had a 5-year survival probability of 77% compared with 62% for patients who did not [hazard ratio (HR) 0.60; 95% confidence interval (CI) 0.44, 0.81; P = 0.0008]. Prior CR retained significance when adjusted for age, gender, prior intravesical chemotherapy, and papillary disease versus CIS (HR = 0.63; 95% CI: 0.46, 0.86; P = 0.003). CART analysis identified 4 prognostic groups. Older patients (> or =62 years old) previously treated with intravesical chemotherapy who failed to achieve a CR had a 5-fold higher risk of a worsening event relative to those who are younger (<67 years old) and achieve a CR (HR = 5.09; 95% CI: 3.37, 7.68; P < 0.0001).

CONCLUSION

Failure to achieve a complete response after induction BCG is associated with a significant risk of a worsening event and death for patients with CIS or Ta or T1 bladder cancer at increased risk of recurrence.

The increasing use of intravesical therapies for stage T1 bladder cancer coincides with decreasing survival after cystectomy

OBJECTIVE

Intravesical therapy (IVT), chemo and immunotherapy, has made conservative, bladder-sparing strategies a viable option for managing patients with high grade T1 bladder cancer. However, many of these patients will have recurrence and occasionally progression, questioning delayed intervention. This study examines the patterns of use of IVT in high-grade T1 bladder cancer and the subsequent impact on survival for patients ultimately proceeding to radical cystectomy (RC).

PATIENTS AND METHODS

Between 1990 and 2005, 104 patients were identified with T1 high-grade transitional cell carcinoma (TCC) and who underwent RC. Patients were divided into two groups; those having RC before 1998 (median year of surgery) and those after 1998. Trends in time from diagnosis to RC, courses of IVT, recurrence and pathological stage were analysed using two-sample t-tests with 95% confidence intervals. Kaplan-Meier analysis was used to determine the disease-free and overall survival rates.

RESULTS

Before 1998, 28 of 38 patients (74%) proceeded directly to RC with no IVT, vs 20 of 47 (43%) after 1998 (P = 0.004). The mean number of IVT courses per patient was 0.53 before 1998 and 1.2 afterward (P = 0.016). Patients who had RC before 1998 had a 69.7% disease-free survival at 5 years, vs 39.6% for those after 1998 (P = 0.05).

CONCLUSION

In the past 15 years, our experience indicates that patients having RC for T1 high-grade TCC after 1998 were more likely to receive IVT. These same patients had a worsening disease-free survival. In very few other cancers has disease-free survival decreased over time. We postulate that the decrease in survival might be related to an increased use of IVT.

Institutional variability in the accuracy of urinary cytology for predicting recurrence of transitional cell carcinoma of the bladder

OBJECTIVE

To assess the contemporary inter-institutional accuracy of urinary cytology in predicting the recurrence of transitional cell carcinoma (TCC) of the bladder, in a large multi-institutional cohort from four continents, as cystoscopy and urinary cytology represent the 'gold standards' for surveillance of TCC recurrences, but the ability of cytology to predict recurrence varies.

PATIENTS AND METHODS

Ten institutions contributed 2542 patients with a history of superficial TCC, of whom 898 had TCC recurrence. Age- and gender-adjusted logistic regression models were used to evaluate the association between urine cytology and TCC recurrence. The predictive accuracy derived from the logistic regression model was tested using the area under the receiver operating characteristic curve. The resulting predictive accuracy estimates were internally validated with 200 bootstrap re-samples.

RESULTS

The mean (range across institutions) age of the patients was 65 (48-69) years and 75 (67-87)% were men. Cytology was positive in 19 (10-38)% of patients; recurrence was identified in 35 (27-54)% of patients. The sensitivity was 38-65% across institutions. Urinary cytology varied significantly in its ability to predict recurrence of bladder cancer. Institution-specific predictive accuracy adjusted for gender and age was 0.627-0.893. Stratifying by grade and stage only partly attenuated the discrepancies between centres.

CONCLUSIONS

The variability of urinary cytology results was very appreciable among the 10 centres and ranged from poor (63%) to excellent (89%).

The optimum timing of radical cystectomy for patients with recurrent high-risk superficial bladder tumour

OBJECTIVE

To establish the optimum time of radical cystectomy (RC) for patients with recurrent high-risk superficial bladder tumours after the failure of intravesical therapy.

PATIENTS AND METHODS

Among 318 patients with transitional cell carcinoma treated with RC and with no neoadjuvant therapy, there were 46 with clinical stage Ta, T1 or Tis refractory to transurethral resection associated with intravesical therapy. These patients had at least one of: (i) high-risk superficial bladder tumours after failure of two consecutive induction courses of intravesical therapy; (ii) superficial bladder tumours with prostatic stromal invasion; (iii) superficial bladder tumours with mucosa/ducts involvement after failure of one course of intravesical therapy; (iv) uncontrolled superficial tumours with transurethral resection associated or not with intravesical therapy. Progression and cause-specific survival of these patients were compared to those with muscle-invasive tumours. Univariate and multivariate analyses of predictive factors for cause-specific survival were also used in patients with superficial tumours. The incidence of significant prognostic factors was compared in both superficial and muscle-invasive tumours, as were the progression pattern and survival.

RESULTS

The progression-free and cause-specific survival of patients with superficial tumours was 54% and 67%, respectively, with no significant difference from those with muscle-invasive tumours. In multivariate analysis, positive lymph-nodes and prostatic stromal invasion were significant and independent variables for survival. The incidence of positive lymph nodes was 15% vs 30% (P < 0.05) and of stromal invasion was 32% vs 1.5% (P < 0.001) in patients with superficial and muscle-invasive tumours, respectively. Accounting for the progression pattern in patients with superficial tumours, extravesical urothelial recurrence prevailed over local or distant recurrences (30% vs 15%), whereas in patients with muscle-invasive tumours the opposite occurred (5% vs 33%, respectively). The cause-specific survival of patients with superficial tumour and prostatic stromal invasion was one of three, and in those who developed extravesical urothelial recurrence was 28.5%.

CONCLUSION

In patients with recurrent high-risk superficial bladder cancer after intravesical therapy, our criteria for RC were inappropriate, and patients had a survival rate similar to those with muscle-invasive tumours. RC might have been used too late, as there was a high incidence of prostatic stromal invasion and extravesical urothelial recurrence after RC. Both events seem to be responsible of the low cause-specific survival. Predictive factors for progression are needed to indicate early RC in patients with recurrent high-risk superficial tumours. From a previous analysis the pathological pattern of the clinical lack of response (T1, G3, bladder carcinoma in situ and prostate involvement) to intravesical therapy evaluated at 3 months might be important for predicting progression, and an early RC at that time might be useful.