Risk of concomitant carcinoma in situ determining biopsy candidates among primary non-muscle-invasive bladder cancer patients: Retrospective analysis of 173 Japanese cases

The diagnostic challenge of suspicious or positive malignant urine cytology findings when cystoscopy findings are normal: an outpatient blue-light flexible cystoscopy may solve the problem

PURPOSE

To investigate whether outpatient blue-light flexible cystoscopy could solve the diagnostic challenge of positive or suspicious urine cytology findings despite normal white-light flexible cystoscopy results and normal findings on computerized tomography urography, in patients investigated for urothelial cancer.

MATERIAL AND METHODS

In a multicentre study, a total of 70 examinations were performed with the use of blue-light flexible cystoscopy (photodynamic diagnosis) after intravesical instillation of the fluorescence agent hexaminolevulinate. The examination started with a conventional white-light flexible cystoscopy and then the settings were switched to use blue light. Suspicious lesions were biopsied. Afterwards, the patients were interviewed regarding their experience of the examinations.

RESULTS

Bladder cancer was diagnosed in 29 out of 70 (41%) cases, among them 14/29 (48%) had malignant lesions seen only in blue light. The majority had carcinoma in situ (21/29). Normal findings were seen in 41 cases that underwent BLFC. During the further course, malignancy of the bladder was detected in six cases (9%) and malignancy of the upper urinary tract was detected in one case (1%). The majority of patients (93%) preferred the blue-light flexible cystoscopy performed at the outpatient clinic instead of the transurethral resection under general anaesthesia.

CONCLUSION

Blue-light flexible cystoscopy at the outpatient clinic may be a useful tool to solve unclear cases of a malignant or suspicious urinary cytology suggestive of bladder cancer. The procedure was well tolerated by the patients.

Surgery for Bladder and Upper Tract Urothelial Cancer

The cornerstone for diagnosis and treatment of bladder and upper tract urothelial carcinoma involves surgery. Transurethral resection of bladder tumors forms the basis of further management. Radical cystectomy for invasive bladder carcinoma provides good oncologic outcomes. However, it can be a morbid procedure, and advances such as minimally invasive surgery and early recovery after surgery need to be incorporated into routine practice. Diagnostic ureteroscopy for upper tract carcinoma is needed in cases of doubt after cytology and imaging studies. Low-risk cancers can be managed with conservative endoscopic surgery without compromising oncological outcomes; however, high-risk disease necessitates radical nephroureterectomy.

European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and Carcinoma In Situ) - 2019 Update

CONTEXT

This overview presents the updated European Association of Urology (EAU) guidelines for non-muscle-invasive bladder cancer (NMIBC), TaT1, and carcinoma in situ (CIS).

OBJECTIVE

To provide practical recommendations on the clinical management of NMIBC with a focus on clinical presentation and recommendations.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines has been performed annually since the last published version in 2017. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned.

EVIDENCE SYNTHESIS

Tumours staged as Ta, T1, and/or CIS are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of the tissue obtained by transurethral resection (TURB) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TURB is essential for the patient's prognosis and correct diagnosis. Where the initial resection is incomplete, where there is no muscle in the specimen, or where a T1 tumour is detected, a second TURB should be performed within 2-6 wk. The risks of both recurrence and progression may be estimated for individual patients using the European Organisation for Research and Treatment of Cancer (EORTC) scoring system. Stratification of patients into low-, intermediate-, and high-risk groups is pivotal to the recommendation of adjuvant treatment. In patients with tumours presumed to be at a low risk and in those presumed to be at an intermediate risk with a low previous recurrence rate and an expected EORTC recurrence score of <5, one immediate chemotherapy instillation is recommended. Patients with intermediate-risk tumours should receive 1 yr of full-dose bacillus Calmette-Guérin (BCG) intravesical immunotherapy or instillations of chemotherapy for a maximum of 1 yr. In patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. In patients at the highest risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is recommended in BCG-unresponsive tumours. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/.

CONCLUSIONS

These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology Non-muscle-invasive Bladder Cancer (NMIBC) Panel has released an updated version of their guidelines, which contains information on classification, risk factors, diagnosis, prognostic factors, and treatment of NMIBC. The recommendations are based on the current literature (until the end of 2018), with emphasis on high-level data from randomised clinical trials and meta-analyses. Stratification of patients into low-, intermediate-, and high-risk groups is essential for deciding appropriate use of adjuvant intravesical chemotherapy or bacillus Calmette-Guérin (BCG) instillations. Surgical removal of the bladder should be considered in case of BCG-unresponsive tumours or in NMIBCs with the highest risk of progression.

Contemporary surgical and technical aspects of transurethral resection of bladder tumor

To date, transurethral resection of bladder tumor (TURBT) remains the gold standard of staging urothelial cancer of the bladder and treating non-muscle invasive bladder cancer (NMIBC). The primary goal of the procedure includes a proper diagnosis, correct staging, and removal all lesions. Herein, we discuss major contemporary surgical and technical aspects of including en bloc resection, bipolar and laser resection as well as quality control of TURBT.

Clinical usefulness of random biopsies in diagnosis and treatment of non-muscle invasive bladder cancer: Systematic review and meta-analysis

INTRODUCTION AND OBJECTIVE

This systematic review of the literature has been focused on determining the clinical usefulness of random bladder biopsies (RB) in the diagnosis of carcinoma in situ. A meta-analysis was performed to establish the clinic and pathological factors associated to positive biopsies.

EVIDENCE ACQUISITION

A systematic review was performed using Pubmed/Medline database according to the PRISMA guidelines. Thirty-seven articles were included, recruiting a total of 12,657 patients, 10,975 were submitted to RB.

EVIDENCE SYNTHESIS

The overall incidence of positive RB was 21.91%. Significant differences were found in the incidence of positive RB when patients were stratified according to urine cytology result, tumor multiplicity, tumor appearance, stage and grade. The results of the meta-analysis revealed that the presence of positive cytology, tumor multiplicity, non-papillary appearance tumors, stage T1 and histological grades G2 and G3 represent the risk factors to predict abnormalities in RB.

CONCLUSIONS

The incidence of positive RB in patients with non-muscle invasive bladder cancer was 21.91%. The maximum usefulness of RB was observed when these are performed in a standardized way. The results of the meta-analysis showed that besides positive cytology and non-papillary appearance tumors, tumor multiplicity and histological grades G2 and G3 represent risk factors associated to positive RB, suggesting that the use of RB might be extensive to the intermediate risk group of the European Organization for Research and Treatment of Cancer (EORTC).

Clinical significance of random bladder biopsy in primary T1 bladder cancer

The clinical significance of random bladder biopsies in primary non-muscle-invasive bladder cancer is unclear. The present study investigated the significance of positive random bladder biopsies in primary T1 NMIBC. The present study retrospectively reviewed the records of 71 patients with primary pT1N0M0 bladder cancer who underwent transurethral resection of the bladder tumor (TURBT) and concomitant random bladder biopsy. A total of 12 patients who received cystectomy immediately following the TURBT were excluded, and the remaining 59 patients were included in the analysis. Random bladder biopsy was defined as a cold-cup biopsy of pre-specified normal-looking areas in the bladder. The association of clinicopathological factors, including random biopsy results, with intravesical recurrence were assessed by univariate and multivariate Cox proportional hazards analyses. Of the 59 patients, 15 (25%) demonstrated carcinoma in situ (CIS) lesions on random bladder biopsy: Five (33%) in biopsy specimens alone and the remaining 10 (67%) in biopsy and TUR specimens. Positive random biopsy was associated with preoperative positive urine cytology (P=0.011) and small size of the main tumor (P=0.008). Multivariate analysis demonstrated positive random biopsy as the sole independent poor prognostic factor for intravesical recurrence (hazard ratio: 4.69, P=0.014). The five patients who had CIS detected in biopsy specimens alone had worse, although non-significantly worse, recurrence-free survival compared with those with CIS detected in biopsy and TUR specimens (P=0.100). In conclusion, positive bladder random biopsy, equivalent to the presence of CIS, was an independent predictor of recurrence in primary T1 bladder cancer. Given that one-third of CIS lesions could not have been detected without biopsy, random bladder biopsy should be considered for patients with T1 tumors.

The management of non-muscle-invasive bladder cancer: A comparison of European and UK guidelines

Bladder cancer represents a significant health burden worldwide, with non-muscle-invasive tumours representing the majority of new bladder cancer diagnoses. Non-muscle-invasive bladder cancer (NMIBC) has a high prevalence and forms a large proportion of the caseload in urological practice, accounting for a significant cost in terms of urological healthcare. The last two decades have seen the development and refinement of guidelines from national and international organisations aiming to optimise management of NMIBC and bladder cancer in general. This review outlines the most recent European and United Kingdom guidelines on NMIBC, and in particular focuses on comparing and contrasting key recommendations from guidelines published by the European Association of Urology and the UK-based National Institute for Clinical Excellence.

Level of evidence: Not applicable for this multicentre audit.

Clinical rationale and safety of restaging transurethral resection in indication-stratified patients with high-risk non-muscle-invasive bladder cancer

Background

Indications for restaging transurethral resection of the bladder tumor (reTURBT) in patients with non-muscle-invasive bladder cancer (NMIBC) remain controversial. This study was aimed at evaluation of clinical value and safety of reTURBT in different clinical indications.

Methods

This is a retrospective analysis of consecutive 141 patients who underwent TURBT followed by reTURBT in years 2011–2015 in a single department. Pathological results and surgical complications were analyzed in the whole study cohort and stratified by clinical stage (Ta, T1, Tx (no muscle in the specimen)) and grade (low-grade (LG), high-grade (HG)) of bladder cancer diagnosed at primary TURBT.

Results

Full data was available for 132 patients. Residual disease was found in 53 patients (40.2%) with highest rate for Ta-HG cases (57.1%) followed by T1-HG (51.4%), Tx-HG (45.2%), T1-LG (32.1%), and Tx-LG (25.8%). In the multivariate analysis, high grade (p = 0.02) was the only independent predictor of residual disease. Upstaging to muscle-invasive bladder cancer was noticed in 9 patients (6.8%). The rate of grade ≥ 2 Clavien-Dindo complications (1.5 vs. 5.3%) did not differ significantly between TURBT and reTURBT cases.

Conclusions

ReTURBT is a safe procedure that remains crucial for therapeutic and staging purposes in patients with T1, Tx, or high-grade bladder cancer found in the primary resection.

Nonmuscle-invasive bladder cancer: what's changing and what has changed

PURPOSE

Nonmuscle-invasive bladder cancer (NMIBC) is a challenging disease to manage primarily due to its varied clinical course. The management of NMIBC has witnessed a widespread change with respect to its diagnosis and treatment. Although transurethral resection (TUR) and adjuvant bacillus Calmette-Guerin (BCG) stills remain the cornerstone, newer protocols has come into vogue to achieve optimal care. On the basis of a literature review, we aimed to establish 'what changes has already occurred and what is expected in the future' in NMIBC.

METHODS

A Medline search was performed to identify the published literature with respect to diagnosis, treatment and future perspectives on NMIBC. Particular emphasis was directed to determinants such as the quality of TUR and the newer modifications, Re-TUR, current status of newer macroscopic and microscopic imaging, role of urinary biomarkers, clinical, histologic and molecular predictors of high-risk disease, administration of intravesical agents, salvage therapy in BCG recurrence and the current best practice guidelines were analyzed.

RESULTS AND CONCLUSIONS

Optimal TUR, restaging in select group, incorporation of newer endoscopic imaging and judicious administration of intravesical chemo-immunotherapeutic agents can contribute to better patient care. Although there is a plethora of urinary markers, there is insufficient evidence for their use in isolation. The future probably lies in identification of genetic markers to determine disease recurrence, nonresponders to standard treatment and early institution of alternative/targeted therapy.

Comparison of Guidelines on Non-Muscle Invasive Bladder Cancer (EAU, CUA, AUA, NCCN, NICE)

Background:

Non-muscle invasive bladder cancer (NMIBC) represents a considerably diverse patient group and the management of this complex disease is debatable. A number of panels from Europe and North America have convened on the topic and recently released guideline documents.

Objective:

The purpose was to compare and contrast the NMIBC guideline recommendations from the EAU (Europe), CUA (Canada), NCCN (United States), AUA (United States), and NICE (United Kingdom).

Methods:

All unabridged guideline documents were reviewed by the authors and comparisons were completed according to major topics in NMIBC.

Results:

Despite a paucity of high level evidence regarding the majority of management topics in NMIBC, there was general agreement among the various guideline panels. Differences mainly centered on the categories of evidence synthesized and grades of recommendations. Each document offers a unique presentation of the available literature and guideline recommendation.

Conclusions:

The guidelines for NMIBC from the EAU, CUA, AUA, NCCN, and NICE provide considerable consensus regarding the management of this often difficult disease. Clinicians are encouraged to familiarize themselves with all of the guidelines in order to determine which style of presentation would be most useful to their current practice.

Expression of OCT4A: the first step to the next stage of urothelial bladder cancer progression

OCT4 (octamer-binding transcription factor) is a transcription factor responsible for maintaining the pluripotent properties of embryonic stem cells. In this paper, we present the results of studies to investigate the role of the OCT4 splicing variant in urothelial bladder cancer and the relationship between the OCT4 phenotype and the morphological parameters of tumor malignancy. Ninety patients who received a cystectomy for bladder cancer were enrolled. The expression of OCT4 protein was analyzed by immunohistochemistry. The ratio of OCT4-positive cells was the lowest in pT1 (pathological assessment (p)--tumor extent confined to mucosa (T1)) tumors and the highest in pTis (non-papillary tumor extent confined to urothelium) and pT2 (tumor extent including muscularis propria) tumors. Information about the percentage of OCT4A-positive tumor cells could facilitate choosing the treatment mode in borderline pTis-pT1 (crossing the border of the basement membrane; the first stage of progression) and pT1-pT2 (crossing the border of the muscularis propria; the second stage of progression) cases: a higher percentage of OCT4A-positive cells should support more radical therapy. A significantly higher percentage of cases with moderate OCT4 intensity was found in metastasizing (the third stage of progression) cases with >2 positive lymph nodes. The percentage of OCT4-positive cells was significantly higher for cancers with a high grade, higher non-classic differentiation number and greater aggressiveness of invasion. The differentiation, maturation and aggressiveness of tumor invasion appear to depend on the expression of the OCT4 phenotype in cancer cells, similar to the successive stages of malignancy progression in urothelial cancer.

The value of bladder mapping and prostatic urethra biopsies for detection of carcinoma in situ (CIS)

It is well known that CIS is a major risk factor for muscle-invasive bladder cancer and that this entity can be difficult to diagnose. Taking cold-cup mapping biopsies from different areas of the bladder (BMAP) is commonly used in patients at risk of harbouring CIS. The diagnostic accuracy of this approach has not been assessed until now. By using the CIS found in the cystoprostatectomy specimen as an indicator of the true occurrence of CIS and comparing that with the findings of BMAP, it is clear that the sensitivity of BMAP to detect CIS when present is low and that negative findings should be considered unreliable.

OBJECTIVES

To assess the value of bladder mapping and prostatic urethra biopsies for detection of urothelial carcinoma in situ (CIS). CIS of the urinary bladder is a flat high-grade lesion of the mucosa associated with a significant risk of progression to muscle-invasive disease. CIS is difficult to identify on cystoscopy, and definite diagnosis requires histopathology. Traditionally, if CIS is suspected, multiple cold-cup biopsies are taken from the bladder mucosa, and resection biopsies are obtained from the prostatic urethra in males. This approach is often called bladder mapping (BMAP). The accuracy of BMAP as a diagnostic tool is not known.

PATIENTS AND METHODS

Male patients with bladder cancer scheduled for cystectomy underwent cold-cup bladder biopsies (sidewalls, posterior wall, dome, trigone), and resection biopsies were taken from the prostatic urethra. After cystectomy, the surgical specimen was investigated in a standardised manner and subsequently compared with the BMAP biopsies for the presence of CIS.

RESULTS

The histopathology reports of 162 patients were analysed. CIS was detected in 46% of the cystoprostatectomy specimens, and multiple (≥2) CIS lesions were found in 30%. BMAP (cold-cup bladder biopsies + resection biopsies from the prostatic urethra) provided sensitivity of 51% for any CIS, and 55% for multiple CIS lesions. The cold-cup biopsies for CIS in the bladder mucosa showed sensitivity and specificity of 46% and 89%, respectively.

CONCLUSION

Traditional cold-cup biopsies are unreliable for detecting CIS in bladder mucosa and negative findings must be interpreted with caution.

New Italian guidelines on bladder cancer, based on the World Health Organization 2004 classification

OBJECTIVE To provide evidence-based recommendations on bladder cancer management METHODS A multidisciplinary guideline panel composed of urologists, medical oncologists, radiotherapists, general practitioners, radiologists, epidemiologists and methodologists conducted a structured review of previous reports, searching the Medline database from 1 January 2004 to 31 December 2008. The milestone papers published before January 2004 were accepted for analysis. The level of evidence and the grade of the recommendations were established using the GRADE system. RESULTS In all, 15 806 references were identified, 1940 retrieved, 1712 eliminated (specifying the reason for their elimination) and 971 included in the analysis, as well as 241 milestone reports. A consensus conference held to discuss the discrepancies between the scientific evidence and the clinical practice was then attended by 122 delegates of various specialities. CONCLUSION Recommendations on bladder cancer management are provided.