Positive urine cytology but negative white-light cystoscopy: an indication for fluorescence cystoscopy?

Photodynamic Diagnosis for the Identification of Intestinal-Type Gastric Cancers and High-Grade Adenomas

Gastric cancer is the second most common cancer in Japan. The incidence of gastric cancer remains high owing to the increase in the elderly population. Endoscopy outperforms radiography in identifying early gastric cancer (EGC). Furthermore, image-enhanced endoscopy (IEE) has been developed and implemented worldwide in clinical practice. Magnifying IEE images can help to visualize the microvascular pattern and microstructure architecture, which is used for the characterization of EGC. However, accurate endoscopic diagnosis requires the experience and skill of endoscopists, making an objective and simple diagnostic method desirable. In this retrospective study, we investigated the diagnostic yield of 5-aminolevulinic acid (5-ALA)-mediated photodynamic diagnosis (PDD) for identifying gastric cancers and high-grade adenomas. In total, 52 lesions from 43 patients were ultimately included in the study. We detected 5-ALA-mediated protoporphyrin IX fluorescence in 45 of the 52 lesions that were initially intended for PDD, resulting in a detection rate of 86.5%, whereas each signet ring cell carcinoma was negative using 5-ALA PDD. In eight of the patients with multiple lesions, 17 lesions were identified using 5-ALA PDD. Again, we took biopsies from six areas that we suspected as new lesions. While 4 lesions were gastric neoplasms resected by endoscopic submucosal dissection, two other lesions were normal. Preoperative 5-ALA-PDD could provide additional diagnostic yields to detect such multiple lesions simultaneously. No severe adverse events were observed. Prospective multicenter studies are warranted to confirm the usefulness of 5-ALA PDD for EGC identification.

Current Status of Photodynamic Diagnosis for Gastric Tumors

Although the recent development and widespread use of image-enhanced endoscopy and magnifying endoscopy have improved endoscopic diagnosis of gastric cancer, it is somewhat complicated, requires a higher level of expertise, and is still subjective. Photodynamic endoscopic diagnosis (PDED) is based on the fluorescence of photosensitizers that accumulate in tumors, which enables objective evaluation independent of the endoscopist’s experience, and is useful for tumor detection. The objective of this work was to perform a narrative review of PDED for gastric tumors and to introduce our approach to PDED in gastric tumors in our hospital. In our review there have been case reports of PDED for gastric cancer, but its usefulness has not been established because no prospective studies evaluating its usefulness have been performed. In our previous study, 85.7% (42/49) of gastric tumors exhibited fluorescence in PDED. PDED may be useful in the diagnosis of early gastric cancer. Our previous studies were pilot studies in cancer patients; therefore, future prospective studies are required to verify the usefulness of PDED.

A 25-year perspective on advances in an understanding of the biology, evaluation, treatment and future directions/challenges of urothelial cancer

The Urologic Oncology Journal was founded 25 years ago and we reviewed the literature since that time in the area of urothelial cancer to see the progress and pitfalls we have made over this time period. A comprehensive literature search was conducted by the authors involved who are all actively involved in research, clinical trials, and treatment for urothelial cancer and the results were summarized over the past 25 years. The field of urothelial cancer has evolved tremendously in the last 25 years with the incorporation of molecular subtyping, novel imaging, immunotherapy, and robotic surgery. However, treatments such as BCG and radical cystectomy have remained steadfast over the last 25 years. Although we have a better understanding of the biology of bladder cancer, we still have a long way from being able to cure patients with bladder cancer and eliminate morbidity from treatments. Nevertheless, considerable progress has been made since the founding of the Urologic Oncology Journal 25 years ago.

Shedding Light on Bladder Cancer Diagnosis in Urine

Blue light cystoscopy (BLC) is the most recent clinical approach in the detection and diagnosis of bladder cancer, a common type of cancer with a high rate of recurrence. Representing a significant advance over previous approaches, this photodynamic diagnostic technique uses a photosensitiser prodrug as an adjunct to white light cystoscopy to enhance the in vivo detection of malignant tissues in the bladder based on their distinctive fluorescence. Whilst it does improve detection rates, BLC remains an invasive and costly procedure. Meanwhile, a variety of noninvasive urine detection methods and related microdevices have been developed, none of which have yet entered routine clinical use due to unsatisfactory sensitivity. Following a brief description of the current approaches and their limitations, we provide here a systematic review of a newer niche research aiming to develop a noninvasive adaptation of photodynamic diagnosis. The research to date surrounding the ex situ use of photosensitiser prodrugs for urinary diagnosis of bladder cancer is also discussed.

Photodynamic diagnosis and therapy for urothelial carcinoma and prostate cancer: new imaging technology and therapy

Photodynamic technology using light-sensitive and fluorescent substances has an important role in an accurate diagnosis for a variety of malignancies, including bladder cancer and prostate cancer. Light-sensitive and fluorescent substances accumulate specifically in tumor cells compared to normal tissue, and by light irradiation and excitation at each specific wavelength, tumor lesion, blood flow, lymph node and so on show fluorescence. 5-Aminolevulinic acid (ALA) is converted to protoporphyrin IX (PpIX) into mitochondria. PpIX is excited by blue light, red fluorescence is emitted in the mitochondria. This phenomenon is the mechanism of ALA-mediated photodynamic diagnosis (ALA-PDD). ALA-PDD has made it possible to visualize smaller lesions and flat lesions that were previously difficult to visualize by endoscope using a white-light source. So accurate diagnosis and complete resection become possible during operation. The accumulation of PpIX in the mitochondria also induces direct mitochondrial damage and subsequent cell death by red and green light. This biological reaction is the ALA-mediate photodynamic therapy (ALA-PDT). ALA-PDT has been developed as a modality for minimum invasive cancer treatment that utilizes low-energy light and photosensitizer. Vascular-activated photosensitizer induces rapid tumor ablation by PDT involving direct tumor cell killing as well as damage to the exposed microvasculature. We summarize the clinical outcomes of PDD and PDT for urothelial carcinoma and prostate cancer.

Probing Hexaminolevulinate Mediated PpIX Fluorescence in Cancer Cell Suspensions in the Presence of Chemical Adjuvants

Exogenous administration of hexaminolevulinate (HAL) induces fluorescent protoporphyrin IX (PpIX) accumulation preferentially in cancer cells. However, the PpIX fluorescence intensities between noncancer and cancer cells are highly variable. The contrast between cancer and noncancer cells may be insufficient to reliably discriminate, especially at the single cell level in cancer diagnostics. This study examines the use of the chemical adjuvants dimethylsulphoxide (DMSO) or deferoxamine (DFO) to enhance the HAL induced PpIX accumulation in cancer cells. Our results showed that in some of the incubation conditions tested, the addition of DFO with HAL significantly increased PpIX 21 fluorescence of adherent monolayer cancer cells, but this was never the case for cells in suspension. Permeabilisation with DMSO did not increase PpIX fluorescence. Cell-to-cell interaction may well play an important role in the PpIX accumulation when suspended cells are treated in HAL and adjuvant chemicals.

5-aminolevulinic acid-mediated photodynamic diagnosis using fluorescence ureterorenoscopy for urinary upper tract urothelial carcinoma ∼Preliminary prospective single centre trial∼

OBJECTIVE

To investigate the diagnostic accuracy of 5- aminolevulinic acid-mediated photodynamic diagnosis (ALA-PDD) for upper urinary tract tumor (UTUC) including carcinoma in situ (CIS) lesions using flexible fluorescence ureterorenoscopy.

METHODS

A solution of ALA was orally administrated at 20 mg/kg body weight at 3 h prior to surgery. Fluorescence observation was carried out with IMAGE1S OPAL1 PDD system. Positive lesions that were identified as abnormal changes under white light and/or blue light were biopsied, followed by cold-cup biopsy of negative lesions that were normal-looking mucosa under white light and/or blue light. Diagnostic accuracy was analysed by comparing ureterorenoscopic observations under white light or blue light with pathological analysis results.

RESULTS

A total of 31 biopsy specimens were obtained from 10 patients. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for PDD to detect UTUC was 100 %, 50 %, 52.4 % and 100 %, respectively. The sensitivity of PDD ureterorenoscopy was significantly higher than that of white light ureterorenoscopy by statistics (p < 0.05). Especially, 5 CIS lesions were detected only by ALA-PDD ureterorenoscopy (p < 0.05). Of 10 patients, one patient (10 %) experienced hypotension during the ALA-PDD.

CONCLUSIONS

ALA-PDD for UTUC is a feasible and safe techniques with acceptable adverse events. Additional advantage of ALA-PDD for UTUC is the high sensitivity to detect CIS lesions with blue light mode.

ICUD-SIU International Consultation on Bladder Cancer 2017: management of non-muscle invasive bladder cancer

PURPOSE

To provide a summary of the Third International Consultation on Bladder Cancer recommendations for the management of non-muscle invasive bladder cancer (NMIBC).

METHODS

A detailed review of the literature was performed focusing on original articles for the management of NMIBC. An international committee assessed and graded the articles based on the Oxford Centre for Evidence-based Medicine system. The entire spectrum of NMIBC was covered such as prognostic factors of recurrence and progression, risk stratification, staging, management of positive urine cytology with negative white light cystoscopy, indications of bladder and prostatic urethral biopsies, management of Ta low grade (LG) and high risk tumors (Ta high grade [HG], T1, carcinoma in situ [CIS]), impact of BCG strain and host on outcomes, management of complications of intravesical therapy, role of alternative therapies, indications for early cystectomy, surveillance strategies, and new treatments. The working group provides several recommendations on the management of NMIBC.

RESULTS

Recommendations were summarized with regard to staging; management of primary and recurrent LG Ta and high risk disease, positive urine cytology with negative white light cystoscopy and prostatic urethral involvement; indications for timely cystectomy; and surveillance strategies.

CONCLUSION

NMIBC remains a common and challenging malignancy to manage. Accurate staging, grading, and risk stratification are critical determinants of the management and outcomes of these patients. Current tools for risk stratification are limited but informative, and should be used in clinical practice when determining diagnosis, surveillance, and treatment of NMIBC.

Diagnostic Accuracy of Hexaminolevulinate in a Cohort of Patients Undergoing Radical Cystectomy

PURPOSE

To compare the accuracy of white light cystoscopy (WLC) and blue light cystoscopy (BLC) in a cohort of patients undergoing radical cystectomy (RC) for previously resected urothelial bladder cancer.

PATIENTS AND METHODS

A cohort of patients undergoing RC received WLC and BLC prior radical surgery. To evaluate the residual tumor rate, the bladder was inspected after its removal and normal appearing mucosa sampled for histologic analysis. Lesions detected under WLC, BLC, or both, and biopsy samples from normal appearing mucosa, were all recorded separately.

RESULTS

Starting 2011, 64 patients underwent WLC and BLC prior cystectomy. Overall, 540 tissue samples were collected during cystoscopy and from normal appearing mucosa. Residual disease was found in 31/64 (48.4%) patients, including 27 (42.1%) cases of carcinoma in situ (CIS). The accuracy of BLC was much higher than WLC, both in the diagnosis of any residual disease (87.1% vs 32.3%, and 87.9% vs 51.5%, for sensitivity and specificity, respectively), as of CIS only (92.6% vs 29.6% and 83.8% vs 51.4%). We further evaluated the diagnostic accuracy as a result of the analysis on all specimens collected during the study. A total of 535 specimens were analyzed, and 58 specimens with residual disease were found, including 48 CIS foci. Again, detection rates and measures of accuracy were much better for BLC vs WLC, both overall (86.2% vs 31%, and 98.3% vs 93.3%, for sensitivity and specificity, respectively), and when CIS only was considered (89.6% vs 31.2% and 96.9% vs 92.8%).

CONCLUSIONS

Although BLC missed 12.9% of positive patients, and 7.4% of those with CIS, the agreement between BLC diagnostic accuracy and the definitive pathology was very robust.

Molecular targets in urothelial cancer: detection, treatment, and animal models of bladder cancer

Bladder cancer remains one of the most expensive cancers to treat in the United States due to the length of required treatment and degree of recurrence. In order to treat bladder cancer more effectively, targeted therapies are being investigated. In order to use targeted therapy in a patient, it is important to provide a genetic background of the patient. Recent advances in genome sequencing, as well as transcriptome analysis, have identified major pathway components altered in bladder cancer. The purpose of this review is to provide a broad background on bladder cancer, including its causes, diagnosis, stages, treatments, animal models, as well as signaling pathways in bladder cancer. The major focus is given to the PI3K/AKT pathway, p53/pRb signaling pathways, and the histone modification machinery. Because several promising immunological therapies are also emerging in the treatment of bladder cancer, focus is also given on general activation of the immune system for the treatment of bladder cancer.

Follow-up in non-muscle-invasive bladder cancer-International Bladder Cancer Network recommendations

OBJECTIVE

Non-muscle-invasive bladder cancer (NMIBC) comprises a wide spectrum of tumors with different behaviors and prognoses. It follows that the surveillance for these tumors should be adapted according to the risks of recurrence and progression and should be dynamic in design.

METHODS AND MATERIALS

Medline search was conducted from 1980 to 2016 using a combination of MeSH and keyword terms. The highest available evidence was reviewed to define different risk groups in NMIBC. The performance of different follow-up tools such as urine cytology, cystoscopy, and upper tract imaging in detecting bladder carcinoma was assessed. Different commercially available urinary markers were investigated to determine whether such markers would contribute to the surveillance of patients with NMIBC. A follow-up scheme based on the early evidence is proposed.

RESULTS

A risk-based approach is paramount. Cystoscopy and cytology are recommended to be done at 3 months following transurethral resection of bladder tumor. For low-risk tumors, annual cystoscopy alone is sufficient; no upper tract evaluations or cytology is needed except at diagnosis. High-risk tumors should be followed up with a more intense schedule: cystoscopy every 3 months for 2 years, 6 months for 2 years, and then annually, with cytology at frequent intervals, and imaging for upper tract evaluation at 1 year and then every 2 years. Intermediate-risk tumors should be subclassified as per the International Bladder Cancer Group recommendations and when associated with 3 or more of the following findings (multiple tumors, size≥3cm, early recurrence<1 year, frequent recurrences>1 per year) then a surveillance strategy similar to that of high risk should be followed. Several urine markers were more sensitive than cytology in the detection of NMIBC; however, these tests are still costly, require specialized laboratories, and do not replace cystoscopy. Until better and cheaper markers are available, their routine use has not been integrated in the follow-up recommendation of current guidelines.

CONCLUSIONS

Surveillance of NMIBC should follow a risk-adapted approach, with a combination of cystoscopy, cytology, and upper tract imaging. The aim of this approach is to minimize the therapeutic burden of a disease with high recurrence rates without missing progressing tumors. When designing a diagnostic pathway, first-line diagnostic imaging tests should have high sensitivity to ensure disease positives are included in the test population for further investigation. Second-line investigations should be highly specific, to ensure false-positives are minimized.

Clinical and cost effectiveness of hexaminolevulinate-guided blue-light cystoscopy: evidence review and updated expert recommendations

CONTEXT

Non-muscle-invasive bladder cancer (NMIBC) is associated with a high recurrence risk, partly because of the persistence of lesions following transurethral resection of bladder tumour (TURBT) due to the presence of multiple lesions and the difficulty in identifying the exact extent and location of tumours using standard white-light cystoscopy (WLC). Hexaminolevulinate (HAL) is an optical-imaging agent used with blue-light cystoscopy (BLC) in NMIBC diagnosis. Increasing evidence from long-term follow-up confirms the benefits of BLC over WLC in terms of increased detection and reduced recurrence rates.

OBJECTIVE

To provide updated expert guidance on the optimal use of HAL-guided cystoscopy in clinical practice to improve management of patients with NMIBC, based on a review of the most recent data on clinical and cost effectiveness and expert input.

EVIDENCE ACQUISITION

PubMed and conference searches, supplemented by personal experience.

EVIDENCE SYNTHESIS

Based on published data, it is recommended that BLC be used for all patients at initial TURBT to increase lesion detection and improve resection quality, thereby reducing recurrence and improving outcomes for patients. BLC is particularly useful in patients with abnormal urine cytology but no evidence of lesions on WLC, as it can detect carcinoma in situ that is difficult to visualise on WLC. In addition, personal experience of the authors indicates that HAL-guided BLC can be used as part of routine inpatient cystoscopic assessment following initial TURBT to confirm the efficacy of treatment and to identify any previously missed or recurrent tumours. Health economic modelling indicates that the use of HAL to assist primary TURBT is no more expensive than WLC alone and will result in improved quality-adjusted life-years and reduced costs over time.

CONCLUSIONS

HAL-guided BLC is a clinically effective and cost-effective tool for improving NMIBC detection and management, thereby reducing the burden of disease for patients and the health care system.

PATIENT SUMMARY

Blue-light cystoscopy (BLC) helps the urologist identify bladder tumours that may be difficult to see using standard white-light cystoscopy (WLC). As a result, the amount of tumour that is surgically removed is increased, and the risk of tumour recurrence is reduced. Although use of BLC means that the initial operation costs more than it would if only WLC were used, over time the total costs of managing bladder cancer are reduced because patients do not need as many additional operations for recurrent tumours.

The role of urine markers, white light cystoscopy and fluorescence cystoscopy in recurrence, progression and follow-up of non-muscle invasive bladder cancer

Non-muscle invasive bladder cancer (NMIBC) accounts for approximately 70 % of all bladder cancer cases and represents a heterogeneous pathological entity, characterized by a variable natural history and oncological outcome. The combination of cystoscopy and urine cytology is considered the gold standard in the initial diagnosis of bladder cancer, despite the limited sensitivity. The first step in NMIBC management is transurethral resection of the bladder tumour (TURBT). This procedure is marked by a significant risk of leaving residual disease. The primary landmark in NMIBC is the high recurrence rate. Fluorescence cystoscopy improves the bladder cancer detection rate, especially for flat lesions, and improves the recurrence-free survival by decreasing residual tumour. Progression to muscle invasive tumours constitutes the second important landmark in NMIBC evolution. Stage, grade, associated CIS and female gender are the major prognostic factors in this regard. The evolution to MIBC has a major negative impact upon the survival rate and quality of life of these patients. Fluorescence cystoscopy improves the detection rate of bladder cancer but does not improve the progression-free survival. Urine markers such as ImmunoCyt and Uro Vysion (FISH) have also limited additional value in diagnosis and prognosis of NMIBC patients. Major drawbacks are the requirement of a specialized laboratory and the additional costs. In this review, the risks of recurrence and progression are analysed and discussed. The impact of white light cystoscopy, fluorescence cystoscopy and urine markers is reviewed. Finally, the means and recommendations regarding follow-up are discussed.

Value of fluorescence cystoscopy in high risk non-muscle invasive bladder cancer

Photodynamic Diagnosis (PDD), an adjunct to white light cystoscopy, has been shown to improve detection and thoroughness of resection of bladder cancer by enhancing visualisation of malign lesions during transurethral resection of bladder tumours (TURBT) compared to the sole use of standard white light cystoscopy. The PDD also has been shown to improve recurrence of free survival in non-muscle invasive bladder cancer. Little data on its impact on outcome in non-muscle invasive bladder cancer of high risk of progression is available however. The few trials and studies available demonstrate improved accuracy of diagnosis especially of flat malign lesions. In addition, improved recurrence rates have been suggested without an impact on progression rates in early invasive bladder cancer indicating little influence of thoroughness of resection on the tumour biology in those tumour stages. While no specific and larger data on impact of PDD on cancer specific survival exist to date and the few long-term data suggest little impact, improved accuracy of diagnosis is suggested to be beneficial for clinical decision making and thus a value of PDD is postulated in the management of high-risk non-muscle invasive bladder cancer.

Hexyl aminolevulinate-guided fluorescence cystoscopy in the diagnosis and follow-up of patients with non-muscle-invasive bladder cancer: a critical review of the current literature

CONTEXT

Controversy exists regarding the therapeutic benefit and cost effectiveness of photodynamic diagnosis (PDD) with 5-aminolevulinic acid (5-ALA) or hexyl aminolevulinate (HAL) in addition to white-light cystoscopy (WLC) in the management of non-muscle-invasive bladder cancer (NMIBC).

OBJECTIVE

To systematically evaluate evidence regarding the therapeutic benefits and economic considerations of PDD in NMIBC detection and treatment.

EVIDENCE ACQUISITION

We performed a critical review of PubMed/Medline, Embase, and the Cochrane Library in October 2012 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Identified reports were reviewed according to the Consolidated Standards of Reporting Trials (CONSORT) and Standards for the Reporting of Diagnostic Accuracy Studies (STARD) criteria. Forty-four publications were selected for inclusion in this analysis.

EVIDENCE SYNTHESIS

Included reports used 5-ALA (in 26 studies), HAL (15 studies), or both (three studies) as photosensitising agents. PDD increased the detection of both papillary tumours (by 7-29%) and flat carcinoma in situ (CIS; by 25-30%) and reduced the rate of residual tumours after transurethral resection of bladder tumour (TURBT; by an average of 20%) compared to WLC alone. Superior recurrence-free survival (RFS) rates and prolonged RFS intervals were reported for PDD, compared to WLC in most studies. PDD did not appear to reduce disease progression. Our findings are limited by tumour heterogeneity and a lack of NMIBC risk stratification in many reports or adjustment for intravesical therapy use in most studies. Although cost effectiveness has been demonstrated for 5-ALA, it has not been studied for HAL.

CONCLUSIONS

Moderately strong evidence exists that PDD improves tumour detection and reduces residual disease after TURBT compared with WLC. This has been shown to improve RFS but not progression to more advanced disease. Further work to evaluate cost effectiveness of PDD is required.

[Hexaminolevulinate photodynamic diagnosis in non-muscle invasive bladder cancer: experience of the BLUE group]

OBJECTIVES

Photodynamic diagnosis (PDD) with hexaminolevulinate has been recently used to improve detection of non-muscle invasive bladder cancer. Our main purpose was to quantify the benefit of PDD vs. conventional white light cystoscopy (WL) in our area.

MATERIAL AND METHODS

Fluorescence-guided cystoscopy using hexaminolevulinate was performed at the time of the transurethral resection (TUR) in 305 patients from 7 Spanish hospitals. All lesions found with WL and PDD were numbered and recorded in an online database. Each lesion was sent separately for pathology analysis. Random biopsies were also obtained in 148 patients.

RESULTS

A total of 1659 lesions were biopsied: 522 were identified with PDD and WL, 237 only with PDD, 19 only with WL and 881 random biopsies. Of the 600 tumors, PDD detected 563, WL 441 and random biopsies 29 (20 CIS). The mean overdetection rate for PDD over WL was 31.9% for all types of lesions, but it was 209% for carcinoma in situ (CIS). Sensitivity was 93.8% for PDD and 78.2% for WL. Specificity was 81.5% for PDD and 90.5% for WL. In 23% of patients, PDD detected at least one additional neoplastic lesion compared to WL.

CONCLUSIONS

Hexaminolevulinate fluorescence cystoscopy improves detection and resection of non-muscle invasive bladder cancer, especially of CIS. Sensitivity of PDD is higher than WL, but specificity is lower. In our study, random biopsies were able to detect some CIS not visible under PDD.

[Photodynamic diagnosis (PDD) in non-muscle invasive bladder cancer. Literature review]

Non-muscle invasive bladder cancer is one of the most prevalent and incident neoplastic conditions in the Western world. Its clinical management involves significant costs for health systems. Diagnosis and treatment are based on direct visualization of the disease and on detection of flat forms having no specific morphology and which are sometimes overlooked. Prognosis of NMIBC often depends on quality of transurethral resection and on early detection of undifferentiated flat forms. Cystoscopy using photosensitive substances such as 5-aminolevulinic acid (5-ALA) or hexyl aminolevulinic acid (HAL) achieves overdetection rates of 29 % for bladder neogrowths and 59% for carcinoma in situ. This overdetection ability results in an increased disease-free survival and a longer time to the first relapse. Increased costs resulting from use of these resources are compensated by a lower number of or delayed performance of cystectomies, resections, and instrumentations. It is concluded that PDD should be universally used, rather than in high risk patients only.that has been shown in both animal studies and human tumors.

Recurrence and progression of disease in non-muscle-invasive bladder cancer: from epidemiology to treatment strategy

CONTEXT

This review focuses on the prediction of recurrence and progression in non-muscle invasive bladder cancer (NMIBC) and the treatments advocated for this disease.

OBJECTIVE

To review the current status of epidemiology, recurrence, and progression of NMIBC and the state-of-the art treatment for this disease.

EVIDENCE ACQUISITION

A literature search in English was performed using PubMed and the guidelines of the European Association of Urology and the American Urological Association. Relevant papers on epidemiology, recurrence, progression, and management of NMIBC were selected. Special attention was given to fluorescent cystoscopy, the new World Health Organisation 2004 classification system for grade, and the role of substaging of T1 NMIBC.

EVIDENCE SYNTHESIS

In NMIBC, approximately 70% of patients present as pTa, 20% as pT1, and 10% with carcinoma in situ (CIS) lesions. Bladder cancer (BCa) is the fifth most frequent type of cancer in western society and the most expensive cancer per patient. Recurrence (in < or = 80% of patients) is the main problem for pTa NMIBC patients, whereas progression (in < or = 45% of patients) is the main threat in pT1 and CIS NMIBC. In a recent European Organisation for Research and Treatment of Cancer analysis, multiplicity, tumour size, and prior recurrence rate are the most important variables for recurrence. Tumour grade, stage, and CIS are the most important variables for progression. Treatment ranges from transurethral resection (TUR) followed by a single chemotherapy instillation in low-risk NMIBC to, sometimes, re-TUR and adjuvant intravesical therapy in intermediate- and high-risk patients to early cystectomy for treatment-refractory high-risk NMIBC.

CONCLUSIONS

NMIBC is a heterogeneous disease with varying therapies, follow-up strategies, and oncologic outcomes for an individual patient.