Superficial papillary urothelial carcinomas in young and elderly patients: a comparative study

Survival and Analysis of Prognostic Factors for Bladder Malignancies in Children and Adolescents: A Population-based Study

OBJECTIVE

To explore the clinicopathological features and prognosis of pediatric patients with malignant bladder tumors in a population-based cohort.

METHODS

The database Surveillance, Epidemiology, and End Results was used to evaluate all pediatric patients diagnosed with malignant bladder tumors between 1975 and 2018. The log-rank test was used to compare survival curves. Kaplan-Meier estimations were used to create survival curves based on various parameters. The Cox proportional hazards model was utilized to determine the factors that were independently related to mortality.

RESULTS

A total of 263 children and adolescents with bladder malignancies were assessed. Papillary urothelial neoplasms of low malignant potential were the most frequent histologic subtype (35.1%), while embryonal rhabdomyosarcoma was more common during the first decade of life. Survival rates varied significantly by age at diagnosis, with older patients showing better outcomes. When compared to other subtypes, papillary urothelial neoplasms of low malignant potential had the highest overall survival rates (3- and 5-year were 99.2% and 98.3%, respectively). Multivariate analysis of the entire cohort showed that Surveillance, Epidemiology, and End Results stage and surgery were significant independent predictors of progression to disease-specific death in this model.

CONCLUSION

Bladder malignancies are rare in children and adolescents. The prognosis for them varies. The localized stage was independently associated with superior survival and surgery could extend survival time.

Tertiary experience of managing young bladder cancer patients

Objective:

Bladder cancer is rare in young patients and some authors have concluded that this group have a favourable outcome. We aimed to analyse our experience with such patients.

Patients and Methods:

Patients aged 50 years or younger were identified via a retrospective review of pathology samples between 2016 and 2020. Data regarding demographics, symptoms, stage, grade, size and multifocality at initial transurethral resection, recurrence rate and progression were analysed.

Results:

60 patients with an average age of 42 were identified. The majority of patients presented with intermediate-risk non-muscle invasive bladder cancer (NMIBC). Four patients presented with muscle invasive and three with metastatic disease. There were seven deaths. Forty-nine patients with NMIBC were followed-up for an average of 5 years and 2 months. 41% of our cohort did not have a recurrence and only four moved up the risk stratification. No patients under 40 presented with muscle invasive disease and the majority had intermediate risk NMIBC.

Conclusion:

Young patients typically present with intermediate-risk NMIBC which rarely progresses. Very high-risk disease and aggressive variants do occur and may benefit from upfront cystectomy. The rate of muscle-invasive disease increases with age and rarely occurs under 40. Until more data is readily available, the management of this cohort of patients should follow the well-established guidelines.

Level of evidence:

4 (case series)

Clinical behavior and survival outcome of urothelial bladder cancer in young adults

Background:

Bladder cancer (BC) is rare in young adults and therefore natural history of BC is still debatable. This study aimed to determine clinical behavior and prognosis of BC in patients <40 years.

Materials and Methods:

We reviewed patients (<40 years) managed with urothelial BC from 2003 to 2019. Patients with nonurothelial histology were excluded. Clinical behavior and prognosis such as recurrence, progression, and survival were assessed. The recurrence is defined as a newly diagnosed occurrence of BC at previous or new site(s). Cancer progression is defined as an increase in staging or grade.

Results:

Fifty-five patients inclusive of 45 males and 10 females with a median age of 30.0 (interquartile range [IQR] 25.0–33.0) years were included. The median follow-up was 3.5 (IQR: 1.5–7.0) years. Fifty-one (92.72%) patients were diagnosed with nonmuscle-invasive BC while four (7.27%) patients were diagnosed with muscle-invasive disease. Three out of four patients with muscle-invasive BC died of metastatic disease. According to stage and grade, there were 42 (76.36%) Ta, 9 (16.36%) T1 and 4 (7.27%) having T2 stage while 41 (74.54%) low grade and 14 (25.45%) were having high grade disease. Thirty-six (65.45%) patients remained stable, 13 (26.63%) patients progressed, and 6 (10.90%) patients regressed to lower stage and grade. Higher stage and grade (P = 0.0431) and tumor size >3 cm (P = 0.0454) were significant for recurrence, and higher stage and grade (P = 0.0012) and tumor size >3 cm (P = 0.0055) were associated with tumor progression.

Conclusion:

BC in younger adults is mostly low stage and low grade. We should be vigilant in patients with higher stage and grade as it is related with recurrence, progression, and metastatic disease.

Young age increases the risk of lymph node positivity but improves prognosis in patients with bladder cancer treated via cystectomy: a population-based study

Background

Age and lymph node positivity are significant prognostic indicators in patients with bladder cancer. This study aimed to investigate the impact of age on lymph node positivity and bladder cancer outcomes.

Methods

Patients with bladder cancer who underwent cystectomy with at least one lymph node examined between 2004 and 2015 were identified from the Surveillance, Epidemiology, and End Results database. Cochran-Armitage trend tests and logistic regression analyses were used to evaluate the association between age and lymph node positivity in all T stages. Multivariate Cox regression analysis was used to analyze the effect of age on overall survival (OS) and cancer-specific survival (CSS).

Results

Overall, 13,251 patients were identified, 648 of whom were under 50 years of age (4.89%). Lymph node positivity was negatively associated with increasing age in each stage except in non-invasive-muscular bladder cancer. In the multivariable analysis, age was an independent prognostic factor for OS and CSS in both the overall cohort and the lymph node positivity group.

Conclusions

In patients with bladder cancer undergoing cystectomy, young age at diagnosis is associated with a higher risk of lymph node positivity and superior outcomes. These findings may guide clinicians in selecting suitable treatments, determining the aggressiveness of lymph node involvement, and predicting survival outcomes in patients of different ages.

Young age increases the risk of lymph-node metastasis in patients with muscle-invasive bladder urothelial carcinoma

BACKGROUND

The risk of positive lymph nodes in patients with muscle-invasive bladder urothelial carcinoma (MIBC) can be used to guide treatment recommendations. However, little is known about the effect of age on lymph node positivity (LN+). This study aimed to evaluate the effect of age on LN+ in MIBC.

METHODS

We analyzed patients with stage T2-T4 bladder urothelial carcinoma who had not received preoperative radiotherapy, had at least one lymph node examined, and underwent cystectomy between 1998 and 2015. The Cochran-Armitage trend test and logistic univariate and multivariate analyses were used to evaluate the effect of age on LN+ in all T stages.

RESULTS

In total, 15,624 patients with MIBC were identified, including 747 patients aged ≤50 years (4.78%), 2614 patients aged 50-59 years (16.73%), 4914 patients aged 60-69 years (31.45%), 5225 patients aged 70-79 years old (33.44%), and 2124 patients aged > 80 years (13.59%). In T2-T4 staging, LN+ was negatively correlated with age. After adjustment for several covariates, multivariate logistic regression analysis revealed that age was an independent risk factor for LN+.

CONCLUSIONS

In this large SEER analysis, Young patients with MIBC have a higher risk of lymph node metastasis. This finding is worthy of further study and may eventually affect the treatment decisions of young patients.

Bladder cancer in patients younger than 40 years: outcomes from the National Cancer Database

PURPOSE

To evaluate the clinical, pathological, and survival outcomes of bladder cancer in patients aged 18-40 years.

METHODS

We identified 362,091 bladder cancer patients from the National Cancer Database between 2004-2013 and compared patients aged 18-40 years to those > 40 years of age with univariate analysis using Chi-square tests. A subset analysis was performed on patients who underwent cystectomy. Multivariable Cox regression was used for overall survival analysis.

RESULTS

Our final analysis included 314,177 patients with 3314 (1.1%) patients aged 18-40 years. Patients aged 18-40 years had a lower male-to-female ratio (2.4 versus 3.0), a greater proportion of low-grade tumors (72.7% versus 48.3%, p < 0.001), non-muscle invasive tumors (90.3% versus 81.2%, p < 0.001), and variant histology (4.0% versus 3.3%, p < 0.001). Similar trends were observed at cystectomy including lower male-to-female ratio in the 18-40 years group (1.7 versus 3.1), a greater proportion of variant histology (25.0% versus 10.0%, p < 0.001); and 53.3% of those younger patients with variant histology were women. Patients aged 18-40 years who underwent cystectomy had a higher proportion of locally advanced disease (pT4 19.2% versus 14.6%, p = 0.004). Multivariable analyses in both cohorts demonstrated that variant histology was a predictor of worse overall survival.

CONCLUSION

The majority of patients aged 18-40 years with bladder cancer present with low-grade, non-muscle-invasive disease associated with better survival. However, a subset of younger patients with a higher proportion of women presents with aggressive bladder cancer which may be partly explained by a higher prevalence of variant histology.

Relapsed papillary urothelial neoplasm of low malignant potential (PUNLMP) of the young age: a case report and a review of the literature

Background

Papillary Urothelial Neoplasm of Low Malignant Potential (PUNLMP) are exceptionally rare in the first decade of life (mostly if multifocal) and there is a lack of standardized recommendations for the pediatric age.

Case presentation

We describe the case of a 9-year-old boy with a diagnosis of PUNLMP, who underwent to cystoscopic lesion removal and later to endoscopic lesion removal and intra-bladder Mitomycin-c (MMC) instillations for relapsed disease. Follow-up investigations at five years showed disease negativity.

Conclusions

Intra-bladder MMC instillation may allow obtaining the complete remission with bladder-sparing for paediatric patients with a high-risk relapsed PUNLMP.

Urothelial papilloma: a rare cause of gross haematuria in childhood

Bladder urothelial papilloma is extremely rare in the paediatric population. It usually presents as painless gross haematuria and its diagnosis implies a high index of suspicion as other causes of haematuria predominate in this age range. We describe a 9-year-old boy with two episodes of gross haematuria occurring 1 year apart with spontaneous resolution after 2 days. Bladder ultrasound revealed an endovesical papillary lesion of 24×24 mm suggestive of bladder tumour. The diagnosis was confirmed by histopathological examination of the specimen obtained by cystoscopy with transurethral resection. After 3 years of follow-up with ultrasound and cystoscopy, there are no signs of recurrence. Due to the low prevalence of urothelial papilloma, paediatric guidelines for appropriate management and follow-up are unavailable, making this a challenging entity.

Immunohistochemical and molecular characterizations in urothelial carcinoma of bladder in patients less than 45 years

Bladder tumours in early-onset patients are rare and seem to exhibit unique clinicopathological features. Only few studies have investigated somatic alterations in this specific age of onset group and evidence is accumulating of a distinct molecular behaviour of early-onset bladder tumours. We collected the largest cohort of early-onset tumours of patients 45 years old or younger and aimed to test genomic alterations typically found in bladder cancer. Tumours of 118 early-onset patients were compared with a consecutive group of 113 cases. Immunohistochemistry of TP53, CK20 and Ki-67 was carried out. Molecular analysis was conducted to test for loss of heterozygosity of chromosome 9 and 17, as well as TP53 and FGFR3 mutations. Fisher´s exact and chi-squared test were appropriately used. No differences in grade/stage characteristics were observed. Overexpressed TP53 was differentially distributed between the two groups. TP53 nuclear accumulation was significantly more frequent in early-onset papillomas, PUNLMPs and pTa low-grade tumours compared to the consecutive cohort (p=0.005). Moreover, chromosome 9 deletions (29.5% vs. 44.6%) and FGFR3 mutations (34.5% vs. 63.7%) were less often detected in early-onset patients (p=0.05 and p<0.0001). By comparing the largest cohort of early-onset bladder cancer patients with an unselected group, we demonstrated that the typical molecular features are not independent of age at diagnosis. Our study supports the hypothesis of a distinct biological behaviour in early-onset tumours.

Clinical Behavior of Bladder Urothelial Carcinoma in Young Patients: A Single Center Experience

Background. There is not enough evidence about clinical behavior of bladder cancer in younger patients. Objective. We aimed to evaluate the clinical characteristics and prognosis of bladder urothelial carcinoma patients under the age of 40 years. Methods. Medical records of patients listed in our cancer database were retrospectively reviewed. A total of 40 patients who were initially diagnosed with bladder urothelial carcinoma at the age less than 40 years were included in the study. Patients' records were reviewed for recurrence and progression rates, demographic data, medical history, and treatment modalities. Results. Pathological results revealed 33 (82.5%) Ta low-grade, 6 (15%) T1 high-grade, and 1 (2.5%) T2 high-grade urothelial carcinomas. Recurrence was detected in 14/39 (35.9%) patients but progression was not observed in any patients. The mean age of recurrent patients was significantly higher than nonrecurrent patients (34.8 versus 28.5 years; p < 0.05). Besides, recurrence was detected in only 1 patient with the age under 30 years (6.2%) and 13 patients (54.1%) between 30 and 40 years old, respectively (p < 0.05). Conclusion. Bladder urothelial carcinoma diagnosed at young age tends to be a low pathologic stage, with relatively low rate of recurrence and progression.

[Not Available]

But : Les tumeurs urothéliales de la vessie sont rares chez le jeune adulte. Leur profil évolutif et leur pronostic restent matière à controverse. Nous rapportons notre expérience à propos de 54 patients.Méthodologie : Entre 1990 et 2010, 54 patients de moins de 40 ans au moment du diagnostic ont été traités pour carcinome à cellules transitionnelles de la vessie. Nous avons étudié le profil évolutif de ces tumeurs en séparant les patients en deux groupes (moins de 30 ans, et 30 à 40 ans). Résultats : La tumeur n’infiltrait pas le muscle vésical dans 37 cas et l’infiltrait dans 17 cas. Pour les tumeurs n’infiltrant pas le muscle vésical, elles étaient de stade Ta dans 20 cas et de grade I-II dans 36 cas. Le pronostic de ces tumeurs était meilleur avant l’âge de 30 ans avec un taux de récidive de 15,3 % sans progression. Pour les patients de 30 à 40 ans, le taux de récidive était de 33,3 %, et 25 % des tumeurs qui ont récidivé ont présenté une progression du stade. Pour les tumeurs infiltrant le muscle vésical, le pronostic était sombre (localement avancées dans neuf cas et métastatiques d’emblée dans cinq cas).Conclusion : Le profil évolutif des tumeurs n’infiltrant pas le muscle vésical a semblé meilleur avant l’âge de 30 ans. Entre 30 et 40 ans, le profil évolutif s’est approché de celui des sujets âgés. Les tumeursinfiltrantes étaient souvent évoluées et agressives, évoquant un potentiel évolutif particulier.

H-RAS mutation is a key molecular feature of pediatric urothelial bladder cancer. A detailed report of three cases

INTRODUCTION

Urothelial carcinoma (UC) of the bladder is a rare entity in the pediatric population, with an incidence of less than 0.4% in patients younger than 20 years. These patients overwhelmingly present with non-muscle-invasive low-grade disease and an indolent behavior.

OBJECTIVE

The aim was to determine the source of the different natural history between pediatric population and adults; we hypothesized that pediatric bladder cancer may stem from different molecular pathways. Our objective with this descriptive case series was to study the main genes involved in pediatric urothelial bladder carcinoma using immunohistochemical (IHC) and mutational analysis. By studying the genetic alterations and immunophenotype of the most commonly altered genes in bladder urothelial cancer in three pediatric tumors we could gain better understanding of the molecular pathogenesis in this rare disease.

STUDY DESIGN

Formalin-fixed paraffin-embedded (FFPE) tissue slides of urothelial bladder tumors from three pediatric patients were retrospectively identified at Columbia University pathology archives (1990-2011) and re-evaluated. FGFR3, H-RAS, and PI3K hotspots mutational analyses were conducted by polymerase chain reaction amplification and Sanger sequencing from the FFPE tissue blocks. IHC analysis was conducted using antibodies against p53, PTEN, RB, EGFR, and HER2. Proliferative rate was assessed by Ki-67 expression.

RESULTS

Two patients had low-grade Ta disease, whereas the other tumor was classified as a papillary urothelial neoplasm of low malignant potential. None of the lesions recurred. Notably, all specimens showed H-RAS G12V mutation, whereas they were characterized by wild-type FGFR3 and PI3K. Nuclear p53 was not detected, whereas PTEN and RB expression were maintained. EGFR was expressed in the three cases and HER2 was negative. The proliferation rate was very low in all cases.

DISCUSSION

It is difficult to draw strong conclusions from the study of three tumors treated at the same institution and from the same referral population, and a multicentric study should be performed to confirm these preliminary results. However, we propose that H-RAS mutation analysis could be performed on urothelial bladder tumors of pediatric patients. The knowledge in the molecular basis of urothelial bladder tumors in children opens a promising field which could lead us to establish different guidelines for surveillance and follow-up of pediatric urothelial bladder cancer patients.

CONCLUSION

Pediatric tumors are characterized by a consistent H-RAS mutation status, whereas FGFR3 and p53 pathways are not involved in this tumor initiation. These results may explain the few recurrences seen in this population.

Transitional Cell Carcinoma in the Pediatric Patient: A Review of the Literature

Transitional cell carcinoma (TCC) is extremely rare in children, with fewer than 30 cases reported in patients under 10 years old. It is thought that pediatric TCC is fundamentally different than TCC in adults; however, there are no specific guidelines for management or surveillance. Furthermore, the addition of papillary urothelial neoplasm of low malignant potential as a diagnosis has changed the management of lesions previously considered malignant. This review aims to investigate the difference between TCC in adults and children, to report current strategies for management of pediatric TCC, and to analyze the effects of the new grading system.

Bladder urothelial neoplasms in pediatric age: experience at three tertiary centers

INTRODUCTION

Urothelial bladder neoplasms (UBN) typically occur in patients in their sixth or seventh decade of life while they are infrequent in children and young adults. They occur in 0.1-0.4% of the population in the first two decades of life. Their management is controversial and paediatric guidelines are currently unavailable.

OBJECTIVE

To further expound the available data on the outcome of patients younger than 18 year old diagnosed with UBN.

STUDY DESIGN

We retrospectively reviewed the files of all the consecutive paediatric patients with UBN treated in three tertiary paediatric urology units from January 1999 to July 2013. Lesions were classified according to the 2004 WHO/ISUP criteria as urothelial papillomas (UP), papillary urothelial neoplasm of low malignant potential (PUNLMP), low-grade urothelial carcinoma (LGUC), and high-grade urothelial carcinoma (HGUC).

RESULTS

The table shows the results. Management after TURB varied among centres. One centre recommended only follow-up US at increasing intervals whereas another follow-up US plus urine cytologies and endoscopies, every three months in the first year, and at increasing intervals thereafter. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed disease recurrence or progression.

DISCUSSION

UBN is an uncommon condition in children and adolescents and, unlike in adults, its incidence, follow-up and outcome still controversial. Paediatric guidelines are currently lacking and management varies among centres. Gross painless haematuria is the most common presenting symptom. Therefore, this symptom should never be underestimated. US is generally the first investigation and additional imaging seems unnecessary. TURB often allows for complete resection. Lesions are generally solitary, non-muscle invasive, and low-grade (mainly UP and PUNLMP). Ideal follow-up protocol is the most controversial point. Reportedly, recurrence or progression during follow-up is uncommon in patients under 20 years, recurrence rate 7% and a single case of progression reported so far. Accordingly, a follow-up mainly based on serial US might be considered in this age group compared to adults where also serial endoscopies and urine cytologies are recommended. In the selection of the follow-up investigations, it should also be taken into consideration that urine cytology has a low sensibility in the detection of low-grade lesions while cystoscopy in young patients requires a general anaesthesia and hospitalization, and carries an increased risk of urethral manipulation.

CONCLUSION

UBN is a rare condition in children. Ultrasound is generally accurate in order to visualize the lesion, and TURB can treat the condition. Lesions are generally low-grade and non-muscle invasive, but high-grade lesions can also be detected. In present series, after TURB, follow-up US monitoring at increasing intervals was used at all centres, follow-up cystoscopies were added in two centres, but with different schedules. Urine cytologies were considered only at one centre. After a median follow-up of 5 years (range 9 months-14.5 years), none of the patients showed recurrence or progression of the disease.

Urothelial tumors of the urinary bladder in young patients: a clinicopathologic study of 59 cases

CONTEXT

Urothelial tumors are rare in young patients. Because of their rarity, the natural history of the disease in young patients remains poorly understood.

OBJECTIVE

To understand the pathologic and clinical features of urothelial tumors of the urinary bladder in young patients.

DESIGN

We identified 59 young patients with urothelial tumors of the urinary bladder treated at our institution and analyzed the tumors' pathologic features and the patients' clinical outcomes.

RESULTS

All patients were 30 years or younger, with a mean age of 23.5 years (range, 4-30). Thirty-eight patients (64%) were male, and 21 (36%) were female. Most tumors were noninvasive, papillary urothelial tumors (49 of 59; 83%), including papillary urothelial neoplasms of low malignant potential (7 of 49; 14%), low-grade papillary urothelial carcinomas (38 of 49; 78%), and high-grade papillary urothelial carcinomas (4 of 49; 8%). Only a few (n=10) of the urothelial tumors were invasive, invading the lamina propria (n=5; 50%), muscularis propria (n=4; 40%), or perivesical soft tissue (n=1; 10%). Clinical follow-up information was available for 41 patients (69%), with a mean follow-up time of 77 months. Of 31 patients with noninvasive papillary urothelial tumors, only 1 patient (3%) later developed an invasive urothelial carcinoma and died of the disease, and 30 of these patients (97%) were alive at the end of follow-up, although 10 (32%) had local tumor recurrences. In the 10 patients with invasive urothelial carcinomas, 3 patients (30%) died of the disease and 5 others (50%) were alive with metastases (the other 2 [20%] were alive with no recurrence).

CONCLUSION

Urothelial tumors in young patients are mostly noninvasive, papillary carcinomas and have an excellent prognosis; however, a small subset of patients may present with high-grade invasive urothelial carcinomas that result in poor clinical outcomes.

Hypermethylation of the polycomb group target gene PCDH7 in bladder tumors from patients of all ages

PURPOSE

Bladder tumors in patients younger than 20 years show a low incidence of the genetic and epigenetic aberrations typically found in older patients. One of the most common epigenetic aberrations in human malignancies is DNA hypermethylation. Polycomb group complexes have an important role during lineage choices in embryogenesis and their target genes are 12 times more likely to be methylated than nonpolycomb group target genes. We hypothesized that methylation of polycomb group target genes is an early event in urothelial carcinogenesis and thus might be observed in young patients.

MATERIALS AND METHODS

We stratified 167 patients by age into 4 groups, including age less than 20 years in 14, 20 to 40 in 48, 40 to 60 in 47 and greater than 60 in 58. Five previously identified polycomb group target genes (MEIS1, ONECUT2, OTX1, PCDH7 and SOX21) were selected for methylation analysis. Methylation ratios were calculated by using the unmethylated and methylated signal. The outcome represented the fraction of methylated cells within one tumor. Genes with similar methylation ratios in all age groups were considered as potential bladder cancer initiating candidates.

RESULTS

Three genes showed higher methylation ratios in tumors from older patients, including ONECUT2, SOX21 and OTX1 (each p <0.001). MEIS1 showed a similar methylation ratio in all groups but the median methylation ratio was low. PCDH7 showed a similar median methylation percent in all age categories, ie 54% at less than 20, 59% at 20 to 40, 59% at 40 to 60 and 67% at greater than 60 years (p = 0.1).

CONCLUSIONS

Tumors from young patients showed less methylation for most markers. PCDH7 showed high methylation ratios in all age categories. Therefore, it could have an important role in early urothelial carcinogenesis.

Urothelial bladder carcinoma in young patients is characterized by a relatively good prognosis

INTRODUCTION AND AIM

Urothelial bladder carcinoma (UBC) is a very rare condition in patients aged below 50 years. The aim of the study was to answer the question whether the characteristics of cancer in this group of patients differ from general UBC features.

MATERIAL AND METHODS

Altogether 2160 patients treated with primary transurethral resection due to a bladder tumor were included in the study. The mean age of the cohort was 69.1 years (range 11-100). Patients were divided into three subgroups depending on age: age <41 years (group 1), age 41-50 years (group 2), age >50 years (group 3). Sex ratio, tumor grade, and stage of disease were recorded.

RESULTS

Women constituted 18.5%, 19.2%, and 25.8% of the patients in groups 1, 2, and 3, respectively (P < 0.05). WHO grade 3 tumors were diagnosed in 0%, 8.5%, and 17.2%, respectively (P < 0.05). Non-invasive papillary carcinoma was found in 100.0%, 76.7%, and 62.7%, respectively (P < 0.05). The incidence of muscle-invasive bladder cancer was 0%, 11.0%, and 15.6%, respectively (P < 0.05).

CONCLUSIONS

Pathological characteristics of UBC are dependent on the patients' age. Being a very rare condition, UBC in young patients is characterized by a relatively good prognosis.

Expression of regulatory proteins and proliferative activity in relation to phenotypic characteristics of upper urothelial carcinoma

BACKGROUND/AIM

Deregulation of the normal cell cycle is common in upper urothelial carcinoma (UUC). The aim of this study was to investigate the expression of regulatory proteins of the cell cycle (p53, p16, cyclin D1, HER-2) and proliferative Ki-67 activity in UUC, and to determine their interaction and influence on the phenotypic characteristics of UUC.

METHODS

In 44 patients with UUC, histopathological and immunohistochemical analyses (p53, p16, cyclin D1, HER-2, and Ki-67) of tumors were done.

RESULTS

Overexpression/altered expression of p53, p16, cyclin D1 or HER-2 was detected in 20%, 57%, 64%, and 57% of tumors, respectively. Eleven (25%) UUC had a high proliferative Ki-67 index. Forty patients (91%) had at least one marker altered, while four (9%) tumors had a wild-type status. Analysis of relationship between expressions of molecular markers showed that only high expression of p53 was significantly associated with altered p16 activity (p < 0.05). High Ki-67 index was associated with the high stage (p < 0.005), solid growth (p < 0.01), high grade (p < 0.05), and multifocality p < 0.05) of UUC, while high expression of p53 was associated with the solid growth (p < 0.05). In regression models that included all molecular markers and phenotypic characteristics, only Ki-67 correlated with the growth (p < 0.0001), stage (p < 0.01), grade (p < 0.05) and multifocality (p < 0.05) of UCC; (Ki-67 and HER-2 expression correlated with the lymphovascular invasion (p < 0.05).

CONCLUSIONS

This investigation showed that only negative regulatory proteins of the cell cycle, p53 and p16, were significantly associated in UUC, while proliferative marker Ki-67 was in relation to the key phenotypic characteristics of UUC in the best way.

Impact of diabetes mellitus on recurrence and progression in patients with non-muscle invasive bladder carcinoma: a retrospective cohort study

OBJECTIVE

The aim of the present study was to investigate the relationship between diabetes mellitus (DM) and tumor features in patients with non-muscle invasive bladder cancer (NMIBC).

METHODS

Data from 251 patients who underwent transurethral resection (TUR) for NMIBC from January 2000 to June 2010 were analyzed retrospectively. Patients were divided into two groups: Group I, 159 patients (63%) who did not have DM at the time of surgery; and (ii) Group II, 92 patients (37%) who had DM at the time of surgery. Recurrence- and progression-free survival was assessed in both groups. Preoperative HbA1c levels, as parameter of glycemic control, were determined in Group II patients, with patients divided into two subgroups: (i) HbA1c ≥ 7.0%; and (ii) HbA1c <7.0%. The clinical features of the bladder tumor were compared in these two subgroups.

RESULTS

Compared with Group I, Group II patients were older and had a higher rate of hypertension, recurrence, and progression (P < 0.05). Univariate survival analysis showed that gender, DM, smoking, and serum creatinine were associated with recurrence-free survival (P < 0.05), whereas DM, stage, grade, intravesical instillation, and serum creatinine were associated with progression-free survival. In multivariate survival analysis, DM was found to be an independent factor for recurrence- (hazard ratio [HR] 2.11; 95% confidence interval [CI] 1.4-3.2; P = 0.001) and progression-free survival (HR 9.35; 95% CI 3.1-28.6; P = 0.001). Furthermore, patients with HbA1c ≥ 7.0% exhibited a significantly higher rate of multiplicity (P = 0.001), tumor grade (P = 0.03), and intravesical treatment (P = 0.04).

CONCLUSIONS

In conclusion, DM seems to be an independent predictor of recurrence- and progression-free survival in NMIBC patients. Further prospective studies are needed to establish the prognostic significance of postoperative glycemic control in this patient population.

Urothelial neoplasms of the urinary bladder occurring in young adult and pediatric patients: a comprehensive review of literature with implications for patient management

Bladder urothelial carcinoma is typically a disease of older individuals and rarely occurs below the age of 40 years. There is debate and uncertainty in the literature regarding the clinicopathologic characteristics of bladder urothelial neoplasms in younger patients compared with older patients, although no consistent age criteria have been used to define "younger" age group categories. Use of the World Health Organization 2004/International Society of Urological Pathology 1998 grading nomenclature and recent molecular studies highlight certain unique features of bladder urothelial neoplasms in young patients, particularly in patients below 20 years of age. In this meta-analysis and review, the clinical, pathologic, and molecular features and risk factors of bladder urothelial neoplasms in patients 40 years or less are presented and analyzed according to decades of presentation. Similar to older patients, bladder urothelial neoplasms in patients 40 years or younger occur more common in male patients, present mainly with gross painless hematuria, and are more commonly located at bladder trigone/ureteral orifices, but in contrast have a greater chance for unifocality. Delay in diagnosis of bladder urothelial neoplasms seems not to be uncommon in younger patients probably because of its relative rarity and the predominance of benign causes of hematuria in this age group causing hesitancy for an aggressive work-up. Most tumors in patients younger than 40 years were low grade. The incidence of low-grade tumors was the lowest in the first 2 decades of life, with incremental increase of the percentage of high-grade tumors with increasing age decades. Classification according to the World Health Organization 2004/International Society of Urological Pathology grading system identified papillary urothelial neoplasms of low malignant potential to be relatively frequent among bladder tumors of young patients particularly in the teenage years. Similar to grade, there was marked predominance of low stage tumors in the first 2 decades of life with gradual inclusion of few higher stage and metastatic tumors in the 2 older decades. Bladder urothelial neoplasms occurring in patients <20 years of age lack or have a much lower incidence of aberrations in chromosome 9, FGFR3, p53, and microsatellite instability and have fewer epigenetic alterations. Tumor recurrence and deaths were infrequent in the first 2 decades and increased gradually in each successive decade, likely influenced by the increased proportion of higher grade and higher stage tumors. Our review of the literature shows that urothelial neoplasms of the bladder occurring in young patients exhibit unique pathologic and molecular features that translate to its more indolent behavior; this distinction is most pronounced in patients <20 years. Our overall inferences have potential implications for choosing appropriate noninvasive diagnostic and surveillance modalities, whenever feasible, and for selecting suitable treatment strategies that factor in quality of life issues vital to younger patients.

In-depth investigation of the molecular pathogenesis of bladder cancer in a unique 26-year old patient with extensive multifocal disease: a case report

Background

The molecular characteristics and the clinical disease course of bladder cancer (BC) in young patients remain largely unresolved. All patients are monitored according to an intensive surveillance protocol and we aim to gain more insight into the molecular pathways of bladder tumors in young patients that could ultimately contribute to patient stratification, improve patient quality of life and reduce associated costs. We also determined whether a biomarker-based surveillance could be feasible.

Case Presentation

We report a unique case of a 26-year-old Caucasian male with recurrent non-muscle invasive bladder tumors occurring at a high frequency and analyzed multiple tumors (maximal pTaG2) and urine samples of this patient. Analysis included FGFR3 mutation detection, FGFR3 and TP53 immunohistochemistry, mircosatellite analysis of markers on chromosomes 8, 9, 10, 11 and 17 and a genome wide single nucleotide polymorphism-array (SNP). All analyzed tumors contained a mutation in FGFR3 and were associated with FGFR3 overexpression. None of the tumors showed overexpression of TP53. We found a deletion on chromosome 9 in the primary tumor and this was confirmed by the SNP-array that showed regions of loss on chromosome 9. Detection of all recurrences was possible by urinary FGFR3 mutation analysis.

Conclusions

Our findings would suggest that the BC disease course is determined by not only a patient's age, but also by the molecular characteristics of a tumor. This young patient contained typical genetic changes found in tumors of older patients and implies a clinical disease course comparable to older patients. We demonstrate that FGFR3 mutation analysis on voided urine is a simple non-invasive method and could serve as a feasible follow-up approach for this young patient presenting with an FGFR3 mutant tumor.

Bladder malignancies in children aged <18 years: results from the Surveillance, Epidemiology and End Results database

OBJECTIVE

To present descriptive statistics for bladder tumours in children, calculated from the Surveillance, Epidemiology and End Results (SEER) database, as bladder malignancies are relatively uncommon in children, causing difficulty in understanding their incidence and survival.

PATIENTS AND METHODS

The SEER database was interrogated to report the incidence of bladder malignancies in children from birth to 18 years old. Race and sex differences were assessed. The 5-year survival by disease stage at diagnosis and 5-year conditional survival after surviving for 1-3 years is reported for 1973-2003. The incidence and survival rates for bladder embryonal rhabdomyosarcoma were further characterized.

RESULTS

We identified 140 cases of bladder cancers in the selected cohort. Papillary urothelial neoplasm of low malignant potential (PUNLMP) and rhabdomyosarcoma comprised 50.7% and 36.4% of the tumours, respectively. The incidence of bladder malignancies significantly increased between 1973 and 2003. Conditional survival calculated for 1 and 2 years after disease diagnosis was 93.6% and 97.5%. Fifty-one cases of embryonal rhabdomyosarcoma were identified. The male to female incidence ratio was approximately 2:1 for these tumours. The 5-year survival rates were 50-80% over the past three decades.

CONCLUSIONS

We present the most contemporary survey of the SEER database for the incidence and survival for bladder tumours in children. Depending on the patient's age, PUNLMP and rhabdomyosarcoma predominated in different proportions. The 2-3-year conditional survival and overall survival were excellent. We also identified improving survival for embryonal bladder rhabdomyosarcoma with time.

Genomic aberrations are rare in urothelial neoplasms of patients 19 years or younger

Urothelial neoplasms in patients 19 years of age or younger are rare, and the data regarding clinical outcome are conflicting. Molecular data are not available. Urothelial tumours from 14 patients aged 4 to 19 years were analysed, including FGFR3 and TP53 mutation screening, comparative genomic hybridization (CGH), UroVysion FISH analysis, polymerase chain reaction for human papillomavirus (HPV), microsatellite analysis using the NIH consensus panel for detection of microsatellite instability (MSI) and six markers for loss of heterozygosity on chromosome arms 9p, 9q, and 17p and immunohistochemistry for TP53, Ki-67, CK20 and the mismatch repair proteins (MRPs) hMSH2, hMLH1, and hMSH6. Based on the 2004 WHO classification, one urothelial papilloma, seven papillary urothelial neoplasms of low malignant potential (PUNLMPs), five low-grade, and one high-grade papillary urothelial carcinoma were included. No multifocal tumours were found and recurrence was seen in only one patient with a urothelial papilloma. All patients were alive with no evidence of disease at a median follow-up of 3.0 years. We found no mutations in FGFR3, deletions of chromosome arms 9p, 9q or 17p, MSI or MRP loss, or HPV positivity in any of the patients. Three cases showed chromosome alterations in CGH analyses, urothelial dedifferentiation with CK20 overexpression, or aneuploidy, and one TP53 mutation with TP53 overexpression was found. Urothelial neoplasms in people younger than 20 years are predominantly low grade and are associated with a favourable clinical outcome. Genetic alterations frequently seen in older adults are extremely rare in young patients. Urothelial neoplasms in children and young adults appear to be biologically distinct and lack genetic instability in most cases.

Transitional cell carcinoma of bladder with lamina propria invasion in a 10-year-old boy

Transitional cell carcinoma of the bladder is a rare entity in childhood. We report on a 10-year-old boy with transitional cell carcinoma of the bladder who presented with gross hematuria. Ultrasonography revealed a papillary lesion in the bladder. Cystoscopic evaluation showed a papillary lesion with a thick stalk located just above the right ureteral orifice. Because the lesion was suspicious for at least lamina propria invasion, a single dose of mitomycin C was instilled after resection. Pathologic evaluation of the specimen was reported as grade 2 transitional cell carcinoma of the bladder with lamina propria invasion. Immunohistochemical staining with p53 and Ki-67 was performed for further evaluation.

A single-nucleotide polymorphism in the XPG gene, and tumour stage, grade, and clinical course in patients with nonmuscle-invasive neoplasms of the urinary bladder

OBJECTIVE

To evaluate whether the single nucleotide polymorphism (SNP), Asp1104His (G3507C), in the XPG gene affects malignant phenotypes of nonmuscle-invasive urinary bladder neoplasms (NIBN), by investigating associations between the SNP and clinicopathological variables in patients with NIBN.

PATIENTS AND METHODS

The 233 patients constituted newly diagnosed cases of primary NIBN in the Stockholm area. The Asp1104His polymorphism in the XPG gene was genotyped using a polymerase chain reaction-restriction fragment length polymorphism technique.

RESULTS

The GC + CC genotypes were more frequent in stage pT1 tumours at initial diagnosis than pTa (odds ratio 1.9, 95% confidence interval 1.0-3.5, P = 0.048). The difference was larger in the young group (4.6, 1.9-11.8, P = 0.001). In the young group, the GC + CC genotypes were significantly more frequent in high-grade than in low-grade tumours (3.1, 1.5-6.8, P = 0.004) whereas in the older group the genotypes were less frequent in high-grade tumours (0.3, 0.1-0.7, P = 0.007). The XPG genotypes were not associated with tumour recurrence, stage progression or survival.

CONCLUSION

These results suggest that the SNP in the XPG gene might be related to tumour invasiveness in NIBN.

UROTHELIAL NEOPLASMS IN PATIENTS 20 YEARS OR YOUNGER: A CLINICOPATHOLOGICAL ANALYSIS USING THE WORLD HEALTH ORGANIZATION 2004 BLADDER CONSENSUS CLASSIFICATION

PURPOSE

Urothelial neoplasms in patients younger than 20 years are rare, with conflicting data regarding clinical outcomes.

MATERIALS AND METHODS

We identified 23 patients 4 to 20 years old with urothelial neoplasms, reclassified the microscopic diagnoses using the 2004 WHO/International Society of Urologic Pathology grading classification and collected data on presentation, risk factors and outcomes.

RESULTS

Pathological grading revealed 2 urothelial papillomas, 10 papillary urothelial neoplasms of low malignant potential (PUNLMPs), and 8 low grade and 3 high grade papillary urothelial cancers, all without invasion. Mean patient age was 13.2 years (range 4 to 20), 19 patients were male and 19 presented with gross hematuria. All lesions were solitary and measured 0.1 to 6 cm. One patient had a history of smoking and 1 had parents who smoked. Three patients (13%) had recurrences classified as either urothelial papilloma (1) or PUNLMP (2). All patients were alive with no evidence of disease after a mean followup of 4.5 years (range 6 months to 13 years).

CONCLUSIONS

Urothelial neoplasms in individuals younger than 20 years more commonly occur in males and are predominantly low grade with a favorable clinical outcome. Before the current classification system the 10 patients with a diagnosis of PUNLMP would have been classified as having papillary carcinoma. Thus, the diagnostic category of PUNLMP allowed 43.5% of patients in this series to avoid being labeled with "cancer" at a young age.