Risk group stratification to predict recurrence after transurethral resection in Japanese patients with stage Ta and T1 bladder tumours: validation study on the European Association of Urology guidelines

Significant impact of a history of prior or concomitant upper urinary tract cancer on the recurrence and progression of non-muscle invasive bladder cancer

Background

The objective of the present study was to evaluate the prognostic impact of the upper urinary tract cancer status on recurrence-free survival and progression-free survival, and to develop risk stratification systems that include the upper urinary tract cancer status for patients with non-muscle invasive bladder cancer.

Patients and Methods

The present study included 40 (upper urinary tract cancer-non-muscle invasive bladder cancer group) and 285 (non-muscle invasive bladder cancer alone group) patients with and without a history of prior or concomitant upper urinary tract cancer, respectively. Nine clinicopathological findings between the two groups were compared, and risk stratification systems for the recurrence and progression of non-muscle invasive bladder cancer were developed.

Results

Recurrence-free survival and progression-free survival in the upper urinary tract cancer-non-muscle invasive bladder cancer group were significantly inferior to those in the NMIBC alone group (P < 0.001 and P = 0.006, respectively). Multivariate analyses identified the following independent prognosticators: multiplicity and upper urinary tract cancer status for recurrence-free survival, and pT category and upper urinary tract cancer status for progression-free survival. Significant differences were noted by the risk stratification systems based on the positive number of independent predictors of recurrence-free survival and progression-free survival (P < 0.001 and P = 0.007, respectively). The concordance indices of recurrence-free survival were 0.627, 0.588 and 0.499 in this study stratification, EORTC risk table and CUETO model, respectively. Those of progression-free survival were 0.752, 0.740 and 0.714, respectively.

Conclusion

The present results suggest the significant impact of a history of prior or concomitant UUTC on recurrence-free survival and progression-free survival in non-muscle invasive bladder cancer patients, and risk stratification systems that include the upper urinary tract cancer status for the recurrence and progression of non-muscle invasive bladder cancer are promising tools for predicting the outcomes of these patients.

Serum soluble B7-H3 is a prognostic marker for patients with non-muscle-invasive bladder cancer

Background

B7-H3 is a member of the B7 family of immune-regulatory ligands and is a costimulatory molecule promoting the T cell response in vitro. We herein investigated the clinical utility of serum soluble B7-H3 (sB7-H3) in patients with non-muscle invasive bladder cancer (NMIBC).

Methods

We analyzed 555 patients in whom NMIBC was diagnosed at Tokyo Metropolitan Tama Medical Center between 2008 and 2013. We measured the serum sB7-H3 (sB7-H3) level using the enzyme-linked immunosorbent assay (ELISA) and evaluated the utility of sB7-H3 as a prognostic biomarker for NMIBC. We used the Cox proportional hazards regression model to assess recurrence-free survival (RFS) and progression-free survival (PFS) with the sB7-H3 level.

Results

We detected high levels of sB7-H3 in the sera of 47% of patients with NMIBC versus only 8% in healthy donors. The increase of sB7-H3 was significantly associated with poor RFS and PFS. Multivariate analysis showed that elevated sB7-H3 was an independent prognostic factor of RFS and PFS. According to the European Organization for Research and Treatment of Cancer (EORTC), in intermediate-low and intermediate-high risk groups, the presence of sB7-H3 significantly determined the rate of recurrence and progression.

Conclusions

Our data suggested that evaluating serum sB7-H3 expression is a useful tool for predicting the prognosis of patients with NMIBC.

A new risk stratification model for intravesical recurrence, disease progression, and cancer-specific death in patients with non-muscle invasive bladder cancer: the J-NICE risk tables

BACKGROUND

The aim of this study is to establish new risk tables for the current clinical setting, enabling short- and long-term risk stratification for recurrence, progression, and cancer-specific death after transurethral resection in non-muscle invasive bladder cancer (NMIBC). Currently available risk tables lack input from the 2004 World Health Organization grading system and risk prediction for cancer-specific death.

METHODS

This was a multi-institutional database study of 1490 patients diagnosed with NMIBC (the development cohort). A multivariate Fine and Gray subdistribution hazard model was used to assess the prognostic impact of various factors. Patients were classified into low-, intermediate-, and high-risk groups according to a sum of the weight of selected factors, and predicted cumulative rates were calculated. Internal validation was conducted using 200 bootstrap resamples to assess the optimism for the c-index and estimate a bias-corrected c-index. External validation of the developed risk table was performed on an independent dataset of 91 patients.

RESULTS

The Japanese NIshinihon uro-onCology Extensive collaboration group (J-NICE) risk stratification table was derived from six, five, and two factors for recurrence, progression, and cancer-specific death, respectively. The internal validation bias-corrected c-index values were 0.619, 0.621, and 0.705, respectively. The application of the J-NICE table to an external dataset resulted in c-indices for recurrence, progression, and cancer-specific death of 0.527, 0.691, and 0.603, respectively.

CONCLUSIONS

We propose a novel risk stratification model that predicts outcomes of treated NMIBC and may overcome the shortcomings of existing risk models. Further external validation is required to strengthen its clinical impact.

Development and Validation of a Novel Recurrence Risk Stratification for Initial Non-Muscle Invasive Bladder Cancer in the Han Chinese Population

Background: Some classification models for determining the risk of recurrence after transurethral resection of bladder tumor (TURBT) in patients with non-muscle invasive bladder cancer (NMIBC) had some shortcomings in clinical applications. This study aimed to investigate whether the European Organization for Research and Treatment of Cancer (EORTC) risk stratification was useful to predict the recurrence of NMIBC in the Han Chinese population. In addition, we developed and validated a novel risk stratification method for recurrence prediction of NMIBC.

Methods: Excluding cases who do not meet the inclusion criteria, 606 patients with NMIBC from the First Affiliated Hospital of Zhengzhou University were included in the testing and validation groups. The recurrence-free survival (RFS) curve according to the EORTC risk classifications was calculated by the Kaplan-Meier and the log-rank test methods. Receiver operating characteristic (ROC) curve analysis was used to estimate the diagnosis value for recurrence. We built a logistic regression model for recurrence in NMIBC patients combining the independent recurrence prognostic factors. One external validation group including 166 patients with NMIBC from the Zhongnan Hospital of Wuhan University was also used to assess the logistic regression model.

Results: There was no significant difference in RFS rates between the groups grouped according to EORTC. We constructed a novel risk model to predict recurrence by classifying patients into two groups using ten independent prognostic factors [bladder cancer-specific nuclear matrix protein 4 (BLCA-4), bladder tumour antigen (BTA), nuclear matrix protein 22 (NMP22), carcinoembryonic antigen (CEA), body mass index, smoking, family history of bladder cancer, occupational exposure to aromatic amine chemicals, number of tumours, bladder instillation of chemotherapeutic agents] to predict tumour recurrence based on logistic regression analyses (testing group). According to the novel recurrence risk classification, there was a significant difference in 5-year RFS rates between the low-risk group and the high-risk group (Validation group and the external validation group).

Conclusions: Our novel classification model can be a useful tool to predict recurrence risk in the Han Chinese population with NMIBC.

Risk Stratification Tools and Prognostic Models in Non-muscle-invasive Bladder Cancer: A Critical Assessment from the European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel

CONTEXT

This review focuses on the most widely used risk stratification and prediction tools for non-muscle-invasive bladder cancer (NMIBC).

OBJECTIVE

To assess the clinical use and relevance of risk stratification and prediction tools to enhance clinical decision making and counselling of patients with NMIBC.

EVIDENCE ACQUISITION

The most frequent, currently used risk stratification tools and prognostic models for NMIBC patients were identified by the members of the European Association of Urology (EAU) Guidelines Panel on NMIBC.

EVIDENCE SYNTHESIS

The 2006 European Organization for Research and Treatment of Cancer (EORTC) risk tables are the most widely used and validated tools for risk stratification and prognosis prediction in NMIBC patients. The EAU risk categories constitute a simple alternative to the EORTC risk tables and can be used for comparable risk stratification. In the subgroup of NMIBC patients treated with a short maintenance schedule of bacillus Calmette-Guerin (BCG), the Club Urológico Español de Tratamiento Oncológico (CUETO) scoring model is more accurate than the EORTC risk tables. Both the EORTC risk tables and the CUETO scoring model overestimate the recurrence and progression risks in patients treated according to current guidelines. The new concept of conditional recurrence and progression estimates is very promising during follow-up but should be validated.

CONCLUSIONS

Risk stratification and prognostic models enable outcome comparisons and standardisation of treatment and follow-up. At present, none of the available risk stratification and prognostic models reflects current standards of treatment. The EORTC risk tables and CUETO scoring model should be updated with previously unavailable data and recalculated.

PATIENT SUMMARY

Non-muscle-invasive bladder cancer is a heterogeneous disease. A risk-based therapeutic approach is recommended. We present available risk stratification and prediction tools and the degree of their validation with the aim to increase their use in everyday clinical practice.

Outcomes of subsequent non-muscle-invasive bladder cancer treated with intravesical Bacillus Calmette-Guérin after radical nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVES

To describe the clinicopathological characteristics and prognosis of subsequent non-muscle-invasive bladder cancer (NMIBC) after radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC), and particularly its response to intravesical Bacillus Calmette-Guérin (BCG).

PATIENTS AND METHODS

An observational study was conducted in 1463 patients with UTUC who had undergone RNU and in 1555 patients with primary NMIBC. Of the 1463 patients with UTUC, 256 (17%) subsequently developed NMIBC (UTUC-NMIBC group) and were available for the analysis. The clinicopathological background and outcomes, including intravesical recurrence-free survival and bladder progression-free survival, were compared between the patients with UTUC-NMIBC and the patients with primary NMIBC treated with intravesical BCG. Propensity score matching was performed to adjust for the potential differences in the backgrounds of the two groups. To validate the utility of the CUETO scoring model in the UTUC-NMIBC group, risk scores were calculated and compared with the published probabilities for recurrence and progression.

RESULTS

Compared with the unadjusted primary NMIBC group (n = 352), the UTUC-NMIBC group (n = 75) were found to have a worse prognosis for intravesical recurrence and progression, before propensity score matching. After propensity score matching for potential confounding factors, however, a worse prognosis was observed only for intravesical recurrence. The validation test of the CUETO scoring model for the UTUC-NMIBC group showed a significant difference in the rate of intravesical recurrence and progression for the 0-4 and 5-6 score groups between the UTUC-NMIBC group and the CUETO risk table reference data.

CONCLUSION

Compared with the primary NMIBC group, the UTUC-NMIBC group had a worse prognosis after intravesical BCG, especially with regard to intravesical recurrence. This suggests that patients with UTUC-NMIBC are inherently poor responders to BCG exposure. An optimal treatment strategy and risk scoring model to select patients for adjuvant intravesical BCG, chemotherapy or immediate radical cystectomy should be established.

External validation of EORTC risk scores to predict recurrence after transurethral resection of brazilian patients with non -muscle invasive bladder cancer stages Ta and T1

Validate the EORTC risk tables in Brazilian patients with NMIBC.

METHODS

205 patients were analyzed. The 6 parameters analyzed were: histologic grading, pathologic stage, size and number of tumors, previous recurrence rate and concomitant CIS. The time for first recurrence (TFR), risk score and probability of re¬currence were calculated and compared to the probabilities obtained from EORTC risk tables. C-index was calculated and accuracy of EORTC tables was analyzed.

RESULTS

pTa was presented in 91 (44.4%) patients and pT1 in 114 (55.6%). Ninety-seven (47.3%) patients had solitary tumor, and 108 (52.7%) multiple tumors. One hundred and three (50.2%) patients had tumors smaller than 3 cm and 102 (40.8%) had bigger than 3 cm. Concomitant CIS was observed in 21 (10.2%) patients. Low grade was presented in 95 (46.3%) patients, and high grade in 110 (53.7%). Intravesical therapy was utilized in 105 (56.1%) patients. Recurrence was observed in 117 (57.1%) patients and the mean TFR was 14,2 ± 7,3 months. C-index was 0,72 for 1 year and 0,7 for 5 years. The re¬currence risk was 28,8% in 1 year and 57,1% in 5 years, independently of the scoring risk. In our population, the EORTC risk tables overestimated the risk of recurrence in 1 year and underestimated in 5 years.

CONCLUSION

The validation of the EORTC risk tables in Brazilian patients with NMIBC was satisfactory and should be stimulated to predict recurrence, although these may overestimated the risk of recurrence in 1 year and underestimated in 5 years.

Development and Validation of a Novel Recurrence Risk Stratification for Initial Non-muscle Invasive Bladder Cancer in Asia

BACKGROUND

Some risk classifications to determine prognosis of patients with non-muscle invasive bladder cancer (NMIBC) have disadvantages in the clinical setting. We investigated whether the EORTC (European Organization for Research and Treatment of Cancer) risk stratification is useful to predict recurrence and progression in Japanese patients with NMIBC. In addition, we developed and validated a novel, and simple risk classification of recurrence.

METHODS

The analysis was based on 1085 patients with NMIBC at six hospitals. Excluding recurrent cases, we included 856 patients with initial NMIBC for the analysis. The Kaplan-Meier method with the log-rank test were used to calculate recurrence-free survival (RFS) rate and progression-free survival (PFS) rate according to the EORTC risk classifications. We developed a novel risk classification system for recurrence in NMIBC patients using the independent recurrence prognostic factors based on Cox proportional hazards regression analysis. External validation was done on an external data set of 641 patients from Kyorin University Hospital.

FINDINGS

There were no significant differences in RFS and PFS rates between the groups according to EORTC risk classification. We constructed a novel risk model predicting recurrence that classified patients into three groups using four independent prognostic factors to predict tumour recurrence based on Cox proportional hazards regression analysis. According to the novel recurrence risk classification, there was a significant difference in 5-year RFS rate between the low (68.4%), intermediate (45.8%) and high (33.7%) risk groups (P<0.001).

INTERPRETATION

As the EORTC risk group stratification may not be applicable to Asian patients with NMIBC, our novel classification model can be a simple and useful prognostic tool to stratify recurrence risk in patients with NMIBC.

FUNDING

None.

Exploration of risk factors predicting outcomes for primary T1 high-grade bladder cancer and validation of the Spanish Urological Club for Oncological Treatment scoring model: Long-term follow-up experience at a single institute

OBJECTIVE

To determine the prognostic factors of primary T1 high-grade bladder cancer and to validate the Spanish Urological Club for Oncological Treatment model in Japanese patients with T1 high-grade bladder cancer treated at a single institution.

METHODS

Records of 106 patients with T1 high-grade bladder cancer treated from 1998 to 2013 were retrospectively reviewed. Variables included various clinicopathological parameters, including lymphovascular invasion and tumor growth pattern at the invasion front. Recurrence-free survival and progression-free survival were analyzed. Multivariate Cox proportional regression analysis was used to verify the prognostic significance of the variables. Scores for recurrence and progression were calculated using the Spanish Urological Club for Oncological Treatment model.

RESULTS

Of 106 patients, 44 (42%) had recurrence and 16 (15%) developed progression after a median (interquartile range) follow-up period of 54 months (range 32-81 months). Non-papillary shape was the only independent predictor for recurrence, while broad-based tumor stalk and infiltrative tumor growth pattern at the invasion front were determined to be independent predictors for progression. Stratification of patients according to the number of progression risk factors yielded hazard ratios of 10.1 and 13.1 in patients having one and two risks, respectively, compared with those without any risks. The Spanish Urological Club for Oncological Treatment model successfully stratified our patients with a trend toward different probabilities of recurrence and progression.

CONCLUSIONS

The results of the present study might be helpful for counseling certain patients towards intensive treatment, such as radical cystectomy and/or platinum-based systemic chemotherapy. In addition, the Spanish Urological Club for Oncological Treatment model might be applicable to Japanese patients with T1 high-grade bladder cancer.

Prognostic and Prediction Tools in Bladder Cancer: A Comprehensive Review of the Literature

CONTEXT

This review focuses on risk assessment and prediction tools for bladder cancer (BCa).

OBJECTIVE

To review the current knowledge on risk assessment and prediction tools to enhance clinical decision making and counseling of patients with BCa.

EVIDENCE ACQUISITION

A literature search in English was performed using PubMed in July 2013. Relevant risk assessment and prediction tools for BCa were selected. More than 1600 publications were retrieved. Special attention was given to studies that investigated the clinical benefit of a prediction tool.

EVIDENCE SYNTHESIS

Most prediction tools for BCa focus on the prediction of disease recurrence and progression in non-muscle-invasive bladder cancer or disease recurrence and survival after radical cystectomy. Although these tools are helpful, recent prediction tools aim to address a specific clinical problem, such as the prediction of organ-confined disease and lymph node metastasis to help identify patients who might benefit from neoadjuvant chemotherapy. Although a large number of prediction tools have been reported in recent years, many of them lack external validation. Few studies have investigated the clinical utility of any given model as measured by its ability to improve clinical decision making. There is a need for novel biomarkers to improve the accuracy and utility of prediction tools for BCa.

CONCLUSIONS

Decision tools hold the promise of facilitating the shared decision process, potentially improving clinical outcomes for BCa patients. Prediction models need external validation and assessment of clinical utility before they can be incorporated into routine clinical care.

PATIENT SUMMARY

We looked at models that aim to predict outcomes for patients with bladder cancer (BCa). We found a large number of prediction models that hold the promise of facilitating treatment decisions for patients with BCa. However, many models are missing confirmation in a different patient cohort, and only a few studies have tested the clinical utility of any given model as measured by its ability to improve clinical decision making.

Selection of adjuvant intravesical therapies using the European Organization for Research and Treatment of Cancer scoring system in patients at intermediate risk of non-muscle-invasive bladder cancer

PURPOSE

We investigated whether the European Organization for Research and Treatment of Cancer (EORTC) scoring system can be used for the selection of adjuvant intravesical therapies for individual patients who undergo transurethral resection (TURB) for non-muscle-invasive bladder cancer (NMIBC).

METHODS

We retrospectively analyzed the data of 469 TURB cases for NMIBC. Clinical and pathological variables were compared using univariate and multivariate Cox proportional hazards regression analyses. The recurrence-free survival (RFS) rate was estimated by the Kaplan-Meier method, and the log-rank test was used to compare groups divided according to EORTC score or type of adjuvant therapy.

RESULTS

The overall RFS rate at 1 and 3 years was 59.1 and 40.3%, respectively. Of the total, 424 TURB cases (90.4%) had an EORTC score of 1-9. Tumor number, size, and grade were significant predictors of time to recurrence. The EORTC score was a significant predictor of RFS according to multivariate analysis, and the hazard ratios increased according to each EORTC score in multivariate analysis of a combination of EORTC score and adjuvant therapies. In groups with intermediate recurrence risk as defined by the European Association of Urology guidelines, the recurrence prevention effects in patients with an EORTC score of ≥ 5 were significantly greater with intravesical Bacillus Calmette-Guérin therapy than with weekly intravesical chemotherapy.

CONCLUSION

The EORTC scoring system provides useful information for the selection of adjuvant therapies for patients at intermediate risk of NMIBC recurrence.

Predicting recurrence and progression in Chinese patients with nonmuscle-invasive bladder cancer using EORTC and CUETO scoring models

OBJECTIVE

To validate the European Organization for Research and Treatment of Cancer (EORTC) model and the Spanish Urological Club for Oncological Treatment (CUETO) model in Chinese patients with nonmuscle-invasive bladder cancer (NMIBC).

MATERIALS AND METHODS

A retrospective study was performed of 363 Chinese patients with NMIBC treated at our hospital from January 2003 to September 2010. Most of these patients had undergone intravesical chemotherapy after transurethral resection of the bladder tumor. The scores for recurrence and progression were calculated using the 2 models. Next, all the patients were divided into 4 risk groups according to their scores. The Kaplan-Meier method was used to estimate the probabilities of recurrence and progression according to both models. Discrimination was assessed using the concordance index.

RESULTS

The EORTC model successfully stratified our patients into 4 groups with statistically significant different probabilities of recurrence. For progression, only the intermediate- and high-risk groups could be reasonably distinguished using the EORTC model. The CUETO model stratified neither the recurrence nor the progression risks. The concordance index using the EORTC and CUETO model was 0.711 and 0.663 for recurrence and 0.768 and 0.741 for progression, respectively.

CONCLUSION

Compared with the CUETO risk tables, the EORTC model showed more value in predicting recurrence and progression in Chinese patients with NMIBC, most of whom received intravesical chemotherapy after transurethral resection of the bladder tumor. Prospective multicenter studies should be performed of large cohorts to construct an ideal prognostic model for Chinese patients with NMIBC.

Pyuria predicts poor prognosis in patients with non-muscle-invasive bladder cancer

BACKGROUND

To evaluate the significance of inflammation in non-muscle-invasive bladder cancer (NMIBC), we assessed the presence of pyuria at time of diagnosis.

PATIENTS AND METHODS

A cohort of 805 patients with newly diagnosed NMIBC between 1994 and 2007 at the Tokyo Metropolitan Tama Medical Center were enrolled in this retrospective study. Pyuria was defined as urine containing ≥ 10 white blood cells (WBCs) per high power field (HPF).

RESULTS

One hundred ninety-nine (24%) of the patients with NMIBC had pyuria. The 3-year recurrence-free survival rates of patients with and without pyuria were 10.9 vs. 45.0%, respectively. The 5-year progression-free survival rates of patients with and without pyuria were 72.3% and 95.7%, respectively. Multivariate Cox proportional hazards regression models indicated that pyuria was an independent predictor of disease recurrence and progression. After dividing the sample according to the European Organization for Research and Treatment of Cancer (EORTC) risk tables, we further classified patients into subgroups according to the presence of pyuria. The recurrence-free survival rates were higher in the pyuria-negative subgroups of the low, intermediate-low, intermediate-high, and high risk for recurrence groups. Similarly, the progression-free survival rates at 5 years were higher in the pyuria-negative subgroups of the low, intermediate-low, and intermediate-high risk for progression groups.

CONCLUSION

Patients with inflammatory NMIBC exhibited poor clinical outcomes.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

DDX39 acts as a suppressor of invasion for bladder cancer

The object of the present study was to identify markers for predicting urinary bladder cancer progression by comparative proteome analysis of bladder cancers and paired normal mucosas. We found that DDX39 was overexpressed in four of six bladder cancers examined compared with respective control tissues. Immunohistochemical analysis using 303 bladder cancer specimens revealed that DDX39 was inversely correlated to pT stage and histological grade progression. The incidence of DDX39(high) tumors (positive cells ≥50%) was 68.6%, 43.5%, 20.0%, and 5.3% in pTa, pT1, pTis, and ≥pT2 tumors, respectively, and 65.2%, 60.7%, and 19.6% in G1, G2, and G3 tumors, respectively. The incidence of DDX39(high) tumors was significantly lower in pT1 and ≥pT2 compared to pTa tumors, and also significantly lower in G3 compared to G1 and G2 tumors. Follow-up analysis (n = 105) revealed that DDX39(low) tumors (positive cells <50%) were associated with disease progression (hazard ratio 7.485; P = 0.0083). Furthermore, DDX39-knockdown bladder cancer cells increased their invasion ability compared to negative control cells. These results suggest that DDX39 is a suppressor of invasion and loss of its function predicts disease progression in bladder cancers.