Does the presence of muscularis propria on transurethral resection of bladder tumour specimens affect the rate of upstaging in cT1 bladder cancer?

Recent Advances in the Management of Patients with Non-Muscle-Invasive Bladder Cancer Using a Multidisciplinary Approach: Practical Recommendations from the Spanish Oncology Genitourinary (SOGUG) Working Group

Simple Summary

This report presents clinically relevant advances in the management of non-muscle-invasive bladder cancer, which have been the focus of discussion of expert members of the Spanish Oncology Genitourinary (SOGUG) Multidisciplinary Working Group in the framework of the Genitourinary Alliance project (12GU), designed as a space for the integration of novel information in the care of bladder cancer patients. The present study is focused on different aspects regarding the evaluation of hematuria, assessment of second (or repeated) transurethral resection of bladder cancer, histopathological diagnosis and problems with tumor grading, importance of histological variants, shortage of drug supply, and the current role and influence of immunotherapy and biological markers on the oncological outcome of patients. All proposals and recommendations have a multidisciplinary practical approach and are intended to help clinicians in shared decision making for patients with non-muscle-invasive urothelial cancer.

Abstract

On the basis of the discussion of the current state of research on relevant topics of non-muscle-invasive bladder cancer (NMIBC) among a group of experts of the Spanish Oncology Genitourinary (SOGUG) Working Group, recommendations were proposed to overcome the challenges posed by the management of NMIBC in clinical practice. A unified definition of the term ‘microhematuria’ and the profile of the patient at risk are needed. Establishing a ‘hematuria clinic’ would contribute to a centralized and more efficient evaluation of patients with this clinical sign. Second or repeated transurethral resection (re-TUR) needs to be defined, including the time window after the first procedure within which re-TUR should be performed. Complete tumor resection is mandatory when feasible, with specification of the presence or absence of muscle. Budding should be used as a classification system, and stratification of T1 tumors especially in extensive and deep tumors, is advisable. The percentage of the high-grade component should always be reported, and, in multiple tumors, grades should be reported separately. Luminal and basal subtypes can be identified because of possibly different clinical outcomes. Molecular subtypes and immunotherapy are incorporated in the management of muscle-invasive bladder cancer but data on NMIBC are still preliminary.

Early recurrence and the need for re-resection following Photodynamic diagnosis–assisted Transurethral Resection of Bladder Tumours: Multi-centre real-world experience of the UK PDD Users Group

Objective:

This study aimed to investigate the association between Photodynamic Diagnosis (PDD) with hexaminolevulinate (HAL) and the rate of complete resection and disease persistence at first follow-up cystoscopy for non-muscle-invasive bladder cancer (NMIBC) in UK real-world practice.

Methods:

Audit data were pooled from six UK centres where HAL PDD was used in patients with a new NMIBC diagnosis undergoing transurethral resection of bladder tumours (TURBT) since 2008. Patients received adjunctive intra-vesical therapy and surveillance in line with European and UK guidelines, including early re-resection in high-grade NMIBC.

Results:

PDD-assisted TURBT was done in 837 patients with new NMIBC. The detrusor muscle was present in 69.4% of cases. At early re-TURBT in 207 high-risk patients, 13.0% had residual disease. Multifocal disease was the most significant factor in increasing the rate of residual disease (odds ratio excluding cases of CIS=4.1; 95% confidence interval 1.5–11.3). The recurrence rate at first follow-up cystoscopy (RRFFC) was 10.6% (8.9% in patients with complete initial TURBT). In the historical cohort undergoing good-quality white-light TURBT, RRFFC was 31%; 40.5% of high-risk patients had residual disease at early re-TURBT.

Conclusion:

HAL PDD may increase the rates of complete resection, reducing the risk of early recurrence and the need for routine re-resection in high-grade NMIBC.

Level of evidence:

2b.

Optimal treatment of non-muscle invasive urothelial carcinoma including perioperative management revisited

Non-muscle invasive urothelial carcinoma is a heterogeneous disease that requires the practicing urologist to implement a variety of surgical and non-surgical treatment strategies. The disease course can range from recurrent low grade papillary disease to aggressive disease concerning for progression from initial presentation. Depending on the particular patient and goals of care, treatments similarly span the range from minimally invasive fulgurations to immediate radical cystectomy. For most patients some form of intravesical therapy will bridge the gap between transurethral resections (TUR) and radical surgery. Recent advances in the field continue to emphasize the importance of quality TUR and its strong impact on outcomes. In addition, continued research to optimize intravesical therapies has provided more information about how, when, and in whom these agents should be utilized to enhance their efficacy. This review covers the current state of NMIBC and the standards of care for the management of this disease.

Restaging transurethral resection for non-muscle invasive bladder cancer: who, why, when, and how?

The rate of clinical understaging in non-muscle invasive bladder cancer (NMIBC) after an initial transurethral resection (TUR) is significant, particularly for high-grade disease, and this has a major impact on prognosis. A repeat TUR, 2 to 6 weeks following the initial resection, is recommended in appropriately selected cases to avoid diagnostic inaccuracy and improve treatment allocation. This article summarizes the rationale and indications for performing a repeat TUR in NMIBC and also provides information regarding patient selection and technique.

[A second transurethral resection could be not necessary in all high grade non-muscle-invasive bladder tumors]

OBJECTIVES

Evaluate the rate of residual tumor, understaging and perioperative complications in patients with high grade non-muscle-invasive bladder cancer who underwent second transurethral resection (re-TUR).

MATERIAL AND METHODS

A retrospective review of 47 patients with high grade non-muscle-invasive bladder cancer who underwent second TUR from January 2007 to December 2009 at our institution. We evaluated the rate of residual tumor and understaging detected by re-TUR, complications, and the cost of the surgery.

RESULTS

Twenty-two patients underwent second TUR because of the absence of muscle in the initial resection specimen (cTx). We observed residual disease in 8/47 patients (17%) and understaging in 2 cases (4.2%), the only 2 patients understaged muscularis propria was not present in the sample of initial TUR. The other 20 cTx (90%) were cT0 in the re-TUR. We did not identify any case of cT1 understaged in the re-TUR (≥cT2). Six patients (12.6%) reported complications related with the second TUR (one urethral stricture, two patients required reintervention because of bleeding, one febrile urinary infection and two bladder perforations).

CONCLUSIONS

Our findings show that the absence of muscle in the initial resection specimen is the only risk factor for understaging. Therefore, we consider re-TUR is mandatory in these cases. On the other hand, when complete TUR has been performed and the muscularis propria is present and tumor free (cTa-T1), we consider systematic re-TUR is not necessary and only indicated in selected patients, even more if we consider that re-TUR is not exempt from complications.

Immediate radical cystectomy vs conservative management for high grade cT1 bladder cancer: is there a survival difference?

OBJECTIVE

To determine whether a survival difference exists between patients with high grade (HG) cT1 urothelial cell carcinoma (UCC) receiving immediate radical cystectomy (IRC) as opposed to those choosing bladder-sparing therapy.

PATIENTS AND METHODS

Between January 1990 and August 2010, 349 patients were retrospectively identified with a diagnosis of HG cT1 UCC of the bladder. Patients were divided into two groups: those who underwent IRC and those treated with conservative management (CM), consisting of transurethral resection of the bladder tumour (TURBT) and intravesical therapy. IRC was defined as surgery within 90 days of HG cT1 diagnosis with no intervening transurethral resection (TUR) or intravesical therapy (IVT). Trends in patient selection and cancer-specific survival (CSS) were analyzed over consecutive decades. The primary outcome was to compare CSS among patients during consecutive decades whereby management paradigms shifted from IRC to CM. The secondary outcome was to examine whether patient selection changed over time for each respective intervention.

RESULTS

One hundred and thirteen patients underwent IRC and 236 had CM. From 1990 to 1999, only 90 patients were diagnosed with HG cT1 disease, and a majority of patients (n= 54) underwent IRC. From 2000 to 2010, only 23% (59/259) of the patients with HG cT1 underwent IRC. Despite 42.3% more patients successfully maintaining their bladder in the long-term, no difference in 5 year bladder CSS was noted between decades (77% vs 80% consecutively, P= 0.566). A subset analysis of risk factors for bladder cancer progression/recurrence demonstrated more patients with lymphovascular invasion (LVI) on TUR underwent IRC in the current era (13/59 (22.0%) vs 13/200 (6.5%), P < 0.001). These findings remain to be validated in prospective work at other institutions.

CONCLUSION

Conservative management strategies are a viable treatment option within a well selected subset of patients with HG cT1 UCC.

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

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