Histological grading of papillary urothelial carcinoma of the bladder: prognostic value of the 1998 WHO/ISUP classification system and comparison with conventional grading systems

Outcome Analysis of a Series of Mixed-Grade, Non-muscle Invasive, Papillary Carcinomas of the Bladder

Introduction. Papillary urothelial carcinomas are currently graded as either low- or high-grade tumors based on World Health Organization (WHO) 2022 guidelines for genitourinary tumors. However, a minority of tumors are mixed-grade tumors, composed predominantly of low-grade cancer with a minor high-grade component. In the 2022 WHO these cancers are recognized as having outcomes comparable to low-grade cancers, although data to date has been limited. Methods. The pathology records of a large academic institution were searched for mixed-grade, non-muscle invasive papillary carcinomas of the bladder and ureter in order to characterize prognosis of these cancers. Results. Of 136 cancers, the majority (n = 104, 76.5%) were solitary, mixed-grade tumors, while 21 (15.4%) had a concurrent low-grade cancer and 11 (8.1%) had multiple mixed-grade tumors at the time of diagnosis. At follow-up (median 48.3 months, range = 1.3 months-18.1 years), 71 cancers recurred (52.2%): 52 (38.2%) as low- or mixed-grade cancers and 18 (13.2%) as high-grade cancers. There were no instances of stage-progression to >pT2. Conclusions. The clinical outcome of mixed-grade carcinomas was similar to what has been reported for low-grade carcinomas. Based on our results, and prior congruent studies of mixed-grade lesions, these lesions may be regarded as a distinct sub-category with a better prognosis than high-grade tumors.

Bladder cancer grading using the four-tier combination of the World Health Organization (WHO) 1973 and WHO 2004 classifications

OBJECTIVE

To investigate the impact of grading in urothelial bladder cancer (UBC) stages Ta and T1, comparing the World Health Organization (WHO) grading classifications of 1973 (WHO73) and 2004 (WHO04) and a combination of these (WHO73/04).

PATIENTS AND METHODS

All patients with primary Ta and T1 UBC in the Östergötland region, Sweden, between 1992 and 2007 were included. From 1992, we introduced a new programme for management and follow-up of UBC, including prospectively performed registration of all patients, a systematic description of the location and size of all tumours, primary resection and intravesical treatment in the case of recurrence. All tumour specimens were retrospectively reviewed in 2008 and graded according to the WHO73 and WHO04. A combination of WHO73/04, Grade 1 (G1), Grade 2 low grade (G2LG), Grade 2 high grade (G2HG) and Grade 3 (G3) was analysed in relation to clinical variables and outcomes.

RESULTS

There were 769 patients with a median age of 72 years and a median follow-up duration of 74 months. Recurrence was noted in 484 patients (63%) and progression in 80 patients (10%). Recurrence was more common in multiple tumours, larger tumours and in tumours of higher grade (G2LG, G2HG and G3). Progression was more common in tumours classified as larger, T1 and G2HG and G3. Notably, in tumours classified as G2HG, recurrence and progression were more common than in the G2LG group. Harrell's concordance index for the WHO73/04 was higher for recurrence and progression than in the WHO73 or WHO04.

CONCLUSION

In the four-tier combined WHO73/04 for urothelial cancer, we observed two G2 sub-groups, G2HG and G2LG. There was a better outcome in the latter group, and the importance of G1 and G3 tumours could be fully evaluated. The WHO73/04 had greater accuracy for recurrence and progression than either the WHO73 or WHO04.

Clinical Application of Circulating Tumor Cells and Circulating Endothelial Cells in Predicting Bladder Cancer Prognosis and Neoadjuvant Chemosensitivity

Purpose

To investigate the role of circulating rare cells (CRCs), namely, circulating tumor cells (CTCs) and circulating endothelial cells (CECs), in aiding early intervention, treatment decision, and prognostication in bladder cancer.

Methods

A total of 196 patients with pathologically confirmed bladder cancer, namely, 141 non-muscle invasive bladder cancer (NMIBC) and 55 muscle invasive bladder cancer (MIBC) patients. There were 32 patients who received cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC). Subtraction enrichment combined with immunostaining-fluorescence in situ hybridization (SE-iFISH) strategy was used for CTC/CEC detection. Kaplan–Meier analysis and Cox regression were used to evaluate the overall survival (OS) and recurrence-free survival (RFS). Receiver operator characteristic analysis was used to discriminate NAC sensitivity.

Results

CTCs and CECs were related to clinicopathological characteristics. Triploid CTCs, tetraploid CTCs, and total CECs were found to be higher in incipient patients than in relapse patients (P = 0.036, P = 0.019, and P = 0.025, respectively). The number of total CECs and large cell CECs was also associated with advanced tumor stage (P = 0.028 and P = 0.033) and grade (P = 0.028 and P = 0.041). Remarkably, tumor-biomarker-positive CTCs were associated with worse OS and RFS (P = 0.026 and P = 0.038) in NMIBC patients underwent TURBT. CECs cluster was an independent predictor of recurrence in non-high-risk NMIBC patients underwent TURBT (HR = 9.21, P = 0.040). For NAC analysis, pre-NAC tetraploid CTCs and small cell CTCs demonstrated the capability in discriminating NAC-sensitive from insensitive patients. Additionally, tetraploid CTCs and single CTCs elevated post-NAC would indicate chemoresistance.

Conclusion

CTCs and CECs may putatively guide in diagnosis, prognosis prediction, and therapeutic decision-making for bladder cancer.

Bladder cancer recurrence in papillary urothelial neoplasm of low malignant potential (PUNLMP) compared to G1 WHO 1999: a population-based study

OBJECTIVE

Papillary urothelial neoplasm of low malignant potential (PUNLMP) and stage TaG1 non-muscle invasive bladder cancer (NMIBC) represent separate categories in current WHO 1999 grade definitions. Similarly, PUNLMP and Ta low-grade are separate entities in the WHO 2004/2016 grading system. However, this classification is currently questioned by reports showing a similar risk of recurrence and progression for both categories.

PATIENTS AND METHODS

In this population-based study, risk estimates were evaluated in patients diagnosed with PUNLMP (n = 135) or stage TaG1 (n = 2176) NMIBC 2004-2008 with 5-year follow-up registration in the nation-wide Bladder Cancer Data Base Sweden (BladderBaSe). The risk of recurrence was assessed using multivariable Cox regression with adjustment for multiple confounders (age, gender, marital status, comorbidity, educational level, and health care region).

RESULTS

At five years, 28/135 (21%) patients with PUNLMP and 922/2176 (42%) with TaG1 had local recurrence. The corresponding progression rates were 0.7% (1/135) and 4.0% (86/2176), respectively. A higher relative risk of recurrence was detected in patients with TaG1 tumours compared to PUNLMP (Hazard Ratio 1.6, 95% CI 1.2-2.0) at 5-year follow-up, while progression events were too few to compare.

CONCLUSIONS

The difference in risk of recurrence between primary stage TaG1 and PUNLMP stands in contrast to the recently adapted notion that treatment and follow-up strategies can be merged into one low-risk group of NMIBC.

Tumour Behaviour of Low-Grade Papillary Urothelial Carcinoma: A Single-Centre Retrospective Study

Background and objective

Carcinoma of the urinary bladder is the most common urological cancer, and it accounts for 3.9% of all cancer cases in men. Patients with the subset of noninvasive low-grade papillary urothelial carcinoma (LG-UrCa) are at higher risk for tumour recurrence. In this study, we aimed to analyse the histopathological features of LG-UrCa and to correlate those with recurrence potential as well as disease stage and grade progression.

Materials and methods

We conducted a retrospective study from January 2016 to December 2018. All cases with presenting biopsy initially reported as LG-UrCa were included in the study. All cases with initial biopsy reported as high-grade papillary urothelial carcinoma (HG-UrCa) were excluded from the study. We used the 2016 World Health Organization/International Society of Urological Pathology (WHO/ISUP) guidelines for the classification of papillary urothelial neoplasm.

Results

A total of 48 initially diagnosed cases of LG-UrCa were identified. Two out of 48 cases were reclassified as high-grade urothelial carcinoma and were excluded from the study. The mean age of patients at presentation was 56.7 years. The mean duration of follow-up was 19.8 months. The mean size of initial tumours was 3.4 cm. Tumour recurrence was encountered in 14 (30.4%) of 46 patients. Out of the four patients who had high-grade progression (8.7%), two also developed TNM stage progression. These two patients eventually underwent radical cystectomy. Patients with larger initial tumour sizes were found to have an increased tumour recurrence rate (p=0.009). Patients with multiple lesions at initial diagnosis had a significantly higher tumour recurrence rate than those with a single tumour (p=0.02). There was no significant difference with regard to intravesical Bacillus Calmette-Guérin (BCG) and tumour recurrence (p=0.065). None of the clinicopathological parameters were significantly associated with the grade and/or stage progression.

Conclusion

Based on our findings, patients with larger initial tumour size and tumour multiplicity at presentation had an increased tumour recurrence rate.

Prognostic Value of the WHO1973 and WHO2004/2016 Classification Systems for Grade in Primary Ta/T1 Non-muscle-invasive Bladder Cancer: A Multicenter European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel Study

BACKGROUND

In the current European Association of Urology (EAU) non-muscle-invasive bladder cancer (NMIBC) guideline, two classification systems for grade are advocated: WHO1973 and WHO2004/2016.

OBJECTIVE

To compare the prognostic value of these WHO systems.

DESIGN, SETTING, AND PARTICIPANTS

Individual patient data for 5145 primary Ta/T1 NMIBC patients from 17 centers were collected between 1990 and 2019. The median follow-up was 3.9 yr.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Univariate and multivariable analyses of WHO1973 and WHO2004/2016 stratified by center were performed for time to recurrence, progression (primary endpoint), cystectomy, and duration of survival, taking into account age, concomitant carcinoma in situ, gender, multiplicity, tumor size, initial treatment, and tumor stage. Harrell's concordance (C-index) was used for prognostic accuracy of classification systems.

RESULTS AND LIMITATIONS

The median age was 68 yr; 3292 (64%) patients had Ta tumors. Neither classification system was prognostic for recurrence. For a four-tier combination of both WHO systems, progression at 5-yr follow-up was 1.4% in low-grade (LG)/G1, 3.8% in LG/G2, 7.7% in high grade (HG)/G2, and 18.8% in HG/G3 (log-rank, p < 0.001). In multivariable analyses with WHO1973 and WHO2004/2016 as independent variables, WHO1973 was a significant prognosticator of progression (p <  0.001), whereas WHO2004/2016 was not anymore (p =  0.067). C-indices for WHO1973, WHO2004, and the WHO systems combined for progression were 0.71, 0.67, and 0.73, respectively. Prognostic analyses for cystectomy and survival showed results similar to those for progression.

CONCLUSIONS

In this large prognostic factor study, both classification systems were prognostic for progression but not for recurrence. For progression, the prognostic value of WHO1973 was higher than that of WHO 2004/2016. The four-tier combination (LG/G1, LG/G2, HG/G2, and HG/G3) of both WHO systems proved to be superior, as it divides G2 patients into two subgroups (LG and HG) with different prognoses. Hence, the current EAU-NMIBC guideline recommendation to use both WHO classification systems remains correct.

PATIENT SUMMARY

At present, two classification systems are used in parallel to grade non-muscle-invasive bladder tumors. Our data on a large number of patients showed that the older classification system (WHO1973) performed better in terms of assessing progression than the more recent (WHO2004/2016) one. Nevertheless, we conclude that the current guideline recommendation for the use of both classification systems remains correct, since this has the advantage of dividing the large group of WHO1973 G2 patients into two subgroups (low and high grade) with different prognoses.

Reappraisal of the papillary urothelial neoplasm of low malignant potential (PUNLMP)

Although the papillary urothelial neoplasm of low malignant potential (PUNLMP) diagnostic category was retained in the updated 2016 World Health Organisation (WHO) classification of tumours of the urinary system, there still exists a great deal of controversy regarding the biological behaviour of these tumours. We review PUNLMP tumours and histological grading with an emphasis on the histomorphological, genetic and clinical similarities between PUNLMP and low-grade non-invasive papillary urothelial carcinoma. A literature search using PubMed was performed. All relevant literature concerning PUNLMP and the grading of urothelial tumours was reviewed. PUNLMPs cannot be reliably distinguished from low-grade non-invasive papillary urothelial carcinomas based on the histomorphological criteria outlined in the WHO 2004/2016 classification system. PUNLMPs and low-grade non-invasive papillary urothelial carcinomas are not only morphologically similar, but also share similar molecular genetic alterations and a similar risk of recurrence and progression. In addition, there are no consensus recommendations for a different method of treatment and follow-up for these two tumour types. Attempting to distinguish PUNLMP from low-grade papillary urothelial carcinoma adds an unnecessary level of complexity to the grading and classification of urothelial tumours. We feel that PUNLMP terminology should be abandoned and that all such tumours should be classified as low-grade carcinomas until more objective determinants of clinical outcome can be established.

ARID1A upregulation predicts better survival in patients with urothelial bladder carcinoma

Objective

AT-rich interactive domain-containing protein 1A (ARID1A) is frequently mutated or deficient in various types of tumors. However, the role of ARID1A in bladder cancer remains unclear. We aimed to evaluate ARID1A expression and its biological role and correlation with prognosis in patients with urothelial bladder carcinoma (BUC).

Methods

ARID1A expression levels in BUC and normal tissues were assessed by immunohistochemistry and correlated with clinicopathological characteristics and patient outcomes. Downregulation of ARID1A was mimicked by transfection with small interfering RNA in T24 bladder cancer cells, and the effects on cell proliferation and migration were evaluated.

Results

ARID1A expression was significantly reduced in BUC tissues and was significantly associated with T stage and AJCC stage. Upregulation of ARID1A predicted a better prognosis in BUC patients. ARID1A expression and lymph node status were identified as independent prognostic factors for overall survival. Silencing of ARID1A promoted the proliferation of BUC cells.

Conclusions

ARID1A may represent a novel diagnostic and prognostic biomarker in patients with BUC.

Deletion/duplication mutation screening of TP53 gene in patients with transitional cell carcinoma of urinary bladder using multiplex ligation-dependent probe amplification

Bladder cancer is a molecular disease driven by the accumulation of genetic, epigenetic, and environmental factors. The aim of this study was to detect the deletions/duplication mutations in TP53 gene exons using multiplex ligation-dependent probe amplification (MLPA) method in the patients with transitional cell carcinoma (TCC). The achieved formalin-fixed paraffin-embedded tissues from 60 patients with TCC of bladder were screened for exonal deletions or duplications of every 12 TP53 gene exons using MLPA. The pathological sections were examined by three pathologists and categorized according to the WHO scoring guideline as 18 (30%) grade I, 22 (37%) grade II, 13 (22%) grade III, and 7 (11%) grade IV cases of TCC. None mutation changes of TP53 gene were detected in 24 (40%) of the patients. Furthermore, mutation changes including, 15 (25%) deletion, 17 (28%) duplication, and 4 (7%) both deletion and duplication cases were observed among 60 samples. From 12 exons of TP53 gene, exon 1 was more subjected to exonal deletion. Deletion of exon 1 of TP53 gene has occurred in 11 (35.4%) patients with TCC. In general, most mutations of TP53, either deletion or duplication, were found in exon 1, which was statistically significant. In addition, no relation between the TCC tumor grade and any type of mutation were observed in this research. MLPA is a simple and efficient method to analyze genomic deletions and duplications of all 12 exons of TP53 gene. The finding of this report that most of the mutations of TP53 occur in exon 1 is in contrast to that of the other reports suggesting that exons 5-8 are the most (frequently) mutated exons of TP53 gene. The mutations of exon 1 of TP53 gene may play an important role in the tumorogenesis of TCC.

Invasive low-grade papillary urothelial carcinoma: an immunohistochemical study of 26 cases

Invasive low-grade papillary urothelial carcinoma (LGPUC) is rare. We studied the immunohistochemical (IHC) expressions of CK20, p53, E-cadherin, phosphatase and tension homolog (PTEN), and Ki-67 in both noninvasive and invasive components in 26 cases. In the noninvasive component of LGPUC, 81% showed CK20 expression, and 50% showed p53 labeling. There was a wide range of Ki-67 labeling from less than 5% to 70%. All cases had intact PTEN except 1 that showed focal clonal PTEN loss in both noninvasive and subjacent invasive components. All cases had preserved strong and diffuse E-cadherin expression in both noninvasive and invasive components. There was no significant change between the noninvasive and invasive components in the IHC labeling of these markers, although 7 (33%) of 21 cases showed decreased CK20 expression to a certain extent in the invasive component. Only 2 cases showed significant increase of p53 expression in the invasive component compared with the noninvasive component. Two cases showed increase of Ki-67 labeling from less than 5% in the noninvasive to 20% and 40%, respectively, in the invasive component. High Ki-67 labeling was present in a significant portion of invasive LGPUC cases in both noninvasive and invasive components, much higher than in previous studies of noninvasive LGPUC. Whether higher Ki-67 in these cases is associated with more aggressive disease warrants further study. In general, it is not very helpful to use immunostains in diagnosis and predicting prognosis. This is the largest series to study the IHC characteristics of this entity.

GSTP1 and GSTO1 single nucleotide polymorphisms and the response of bladder cancer patients to intravesical chemotherapy

SNPs may restrict cell detoxification activity and be a potential risk factor for cancer chemosensitivity. We evaluated the predictive value of these polymorphisms on the sensitivity of bladder cancer patients to epirubicin and mitomycin chemotherapy instillation as well as their toxicities. SNPs were analyzed by TaqMan genotyping assays in 130 patients treated with epirubicin and 114 patients treated with mitomycin. Recurrence-free survival (RFS) was estimated by the Kaplan-Meier method, and hazard ratios (HRs) and 95% confidence intervals (CIs) of the HRs were derived from multivariate Cox proportional hazard models. GSTP1 rs1695 and GSTO1 rs4925 were also associated with RFS in the epirubicin group. Patients carrying the GSTP1 AG+GG and GSTO1 AC+AA genotypes had an unfavorable RFS. Patients with the GSTP1 AA and GSTO1 CC genotypes had a reduced risk of recurrence after the instillation of epirubicin. In addition, patients with the GSTP1 rs1695 AA genotype had an increased risk of irritative voiding symptoms; while patients with the GSTO1 rs4925 CC genotype had a decreased risk of hematuria. Our results suggest that GSTP1 and GSTO1 polymorphisms are associated with epirubicin treatment outcomes as well as with epirubicin-related toxicity.

Surgical pathology in cancer diagnosis: implications for quaternary prevention

Surgical pathology is the medical specialty in charge of cancer diagnosis. Although very important since oncology development, its link with overdiagnosis and overtreatment remains understudied. Despite big mediatisation, molecular biology has not brought much progress to tumour classifications. On the contrary, the silent apparition of immunohistochemistry at the end of the 1980's improved much of tumour classifications so significantly that it could cast doubts in some trials’ results of that period. This article discusses how the booming and abuse of immunohistochemistry might have led to overdiagnosis. It also highlights that the ISO 15189 standardization, as well as the tumour classification complexity, might function to induce overtreatment. In summary, critical reading and understanding of pathology reports by general practitioners are essential. Therefore, family doctors should not hesitate to discuss the cancer diagnosis with the pathologist, and in some cases also question the oncologist decision. This approach can be considered a quaternary prevention action which can prevent overtreatment.

Bladder papillary urothelial neoplasm of low malignant potential in Chinese: a clinical and pathological analysis

Papillary urothelial neoplasm of low malignant potential (PUNLMP) had the incidence of low and definitive recurrence. Therefore, few studies showed that the relationship between pathological factors and the prognosis of patients with PUNLMP. The aim of this study assessed the linkage of pathological factors and prognosis of patients with PUNLMP including the presence or absence of mitoses and the thickness of urothelium. A retrospective analysis of 71 patients with PUNLMP was enrolled between January 2007 and June 2013. The clinicopathological factors consisting of tumor diameter, multifocality, the presence or absence of mitoses and cell thickness of urothelium were retrieved, Log-rank test and Cox proportional hazards regression models were used for univariate and multivariate analyses to evaluate the associations of these factors with recurrence-free survival (RFS) and progression-free survival (PFS).The incidence of recurrence and progression for PUNLMP was 19.7% and 16.9%, respectively. Patients with grade progression represented 85.7% in the recurrent patients. No patients had stage progression and no cases died from invasive urothelial carcinoma. Univariate analysis showed that the presence of mitoses, tumor diameter greater than or equal to 0.8 cm, multifocality were significantly correlated with worse RFS (P<0.05) and PFS (P<0.05). Multivariate analysis demonstrated that the presence of mitoses, tumor multifocality were significantly independent biomarkers for worse RFS (P<0.05) and PFS (P<0.05). Although the rare and infrequent mitoses were found for PUNLMP, the presence of mitoses and tumor multifocality were still the independent and poor predictors for the prognosis of PUNLMP. In addition, once the PUNLMP appeared to the recurrence, the inevitable grade progression could be determined, herein, long-term follow-up was necessary to be warranted, especially for patients with multiple lesions and the presence of mitoses.

Histopathological evaluation of urothelial carcinomas in transurethral resection urinary bladder tumor specimens: eight years of single center experience

BACKGROUND

Urothelial carcinoma (UC) is a malignant neoplasm that most commonly occurs in the urinary bladder. The primary aim of this study was to evaluate the clinicopathologic features, recurrence and progression in patients with bladder urothelial cancer.

MATERIALS AND METHODS

The medical records of patients diagnosed with UC in the state pathology laboratory between January 2006 and July 2014 were retrospectively included. Carcinomas were categorized according to age, gender, histologic grade, tumor configuration, pathologic staging, recurrence status, and progression.

RESULTS

A total of 125 (113 men, 12 women) patients were examined. The mean age was 65.9 years and the male-to-female urothelial cancer incidence ratio was 9.4:1. Low-grade UCs were observed in 85 (68%) and high-grade in 40 (32%). A papillary tumor pattern was observed in 67.2% of the UCs. Cases were classified with the following pathological grades: 34 (27.2%) cases of pTa, 70 (56%) of pT1, and 21 (16.8%) of pT2. Recurrence occurred in 27 (21.6%) patients. Ten progressed to a higher stage (pT1 to pT2), and three cases to higher grade (low to high). We also analyzed the results separately for 70 (56%) patients 65 years of age and older.

CONCLUSIONS

With early detection and diagnosis of precursor lesions in older patients, by methods such as standard urologic evaluation, urinary cytology, ultrasound scanning and contrast urography, and cystoscopy, in addition to coordinated efforts between pathologists and urologists, early diagnosis may reduce the morbidity and mortality of patients with urothelial carcinoma.

Long-term outcome of primary Papillary Urothelial Neoplasm of Low Malignant Potential (PUNLMP) including PUNLMP with inverted growth

BACKGROUND

Few larger studies have evaluated the long-term outcome after a diagnosis of papillary urothelial neoplasm of low malignant potential (PUNLMP), demonstrating a broad range of recurrence and progression rates. Additionally, no study has addressed the outcome of PUNLMP exhibiting inverted growth. We evaluated the long term clinical outcome of primary papillary urothelial neoplasm of low malignant potential (PUNLMP), including PUNLMP with inverted growth in a large single center study.

METHODS

We evaluated 189 primary PUNLMP (177 exophytic, 12 inverted), diagnosed from January 1, 2000 to December 31, 2009, in a centralized uropathology practice. We excluded PUNLMP diagnosed after a previous or with a concurrent urothelial neoplasm. Recurrence was defined as any subsequent urothelial neoplasm, regardless of the grade. Progression was defined as any subsequent higher-grade or invasive urothelial neoplasm. Recurrence and progression were established only if documented on a subsequent biopsy. Descriptive statistical analysis was performed using Microsof Excel software package.

RESULTS

The location of PUNLMP included bladder (187) and renal pelvis and ureter (1 each). After a median follow-up of 61 months (range, 9-128 months), 20.1% patients developed a recurrence. Recurrence with PUNLMP only was found in 9% of patients. Subsequent low-grade urothelial carcinoma was documented in 9.5% of patients. Progression to high-grade urothelial carcinoma was found in 1.6% patients (1% with muscle invasion). No patients with recurrent PUNLMP or subsequent low-grade carcinoma demonstrated invasion. All patients with PUNLMP exhibiting an inverted growth had no recurrence or progression on follow-up.

CONCLUSION

In this study, primary PUNLMP recurred primarily either as PUNLMP or low grade urothelial carcinoma. Primary PUNLMP rarely progressed to high grade or invasive carcinoma on long term follow-up. No recurrence or progression was documented on follow-up for PUNLMP that demonstrated exclusively inverted growth.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1332825572154074.

Role of morphometry and proliferative parameters in grading of urothelial neoplasms

INTRODUCTION

Mean nuclear area of 10 nuclei (MNA-10), mitotic activity index (MAI) and Ki-67 are highly reproducible and can be routinely used as adjuncts to histopathological grading in classifying tumors. Assays of these biomarkers are non-invasive, rapid, easy to perform, more objective and accurate, with high sensitivity and specificity, and correlate well with tumor grade.

MATERIAL AND METHODS

This study was conducted at the Department of Pathology PGIMS, Rohtak on 50 cases, of which 25 cases were high-grade, 15 low-grade, 6 Papillary Urothelial Neoplasm of Low Malignant Potentialand 4 reactive lesions as per the 2004 ISUP/WHO classification. MNA-10, MAI and Ki-67 immunoquantitation were performed on stained sections.

RESULTS

The age of the patients varied from 35 to 87 years. Male: female ratio was 3.5:1. The mean MNA-10 (μm(2)) for High Grade Malignant Potential was 104.52 ±25.64 μm(2), which was significantly higher than in PUNLMP (47.64 ±10.23) and LMP (51.57 ±15.66). MAI (/10 HPF) showed an increasing trend from reactive lesions to HMP, with a mean of (3 ±1.16)/10 HPF to (21.36 ±5.31)/10 HPF respectively. Ki-67 labelling index, a proliferative marker, revealed increasing trend lowest with reactive lesions (10 ±2.83%) and highest in high grade tumors (65.96 ±14.44). Spearman's correlation showed maximum correlation between MAI and Ki-67 and the increasing grade of tumor.

CONCLUSIONS

MNA-10 in combination with Ki-67 and MAI was found to be stronger than MNA-10 alone. MAI has high reproducibility in differentiating low and high grade, with simple assessment in paraffin embedded sections allowing adequate histopathological analysis and visualization of proliferating cells simultaneously. This multivariate grading model should be applied in routine grading to overcome interobserver variability and to increase reproducibility of grading.

[Clinical practice and adherence to the diagnosis and treatment of NMIBC guidelines: a report of a recognition based clinical cases study]

For non-muscle invasive bladder cancer, a disease with a considerable epidemiological and socio-economic impact, the introduction of the Guidelines has always evoked as a tool for the resolution of long-standing disputes in terms of diagnosis and therapy. Check the degree of routine clinical practice adherence to the Recommendations is for this disease, more than for other uro-oncology pathology, an urgent need felt by the urological community. To assess the level of Guidelines adherence's, and study issues related to the paths of diagnosis and treatment of non-muscle invasive bladder cancer, and identifying the processes actually implemented in daily clinical practice, a series of case studies has submitted to a group of experts. The acknowledgement study allowed testing the impact of the current Evidence Based Medicine Recommendations in the everyday clinical practice identifying strengths and weaknesses. Questions Responses Analysis' of 5 clinical cases (Ta low grade, T1 low grade, T1 high grade, T1 high grade + CIS, Ta low-grade multiple recurrence) showed a moderate amendment to the European Association of Urology (EAU)-Guidelines. On the other hand, it was emphasized that there are clear discrepancies between what should be done, in accordance with the Evidence Based Medicine Recommendations, and what is actually do in everyday clinical practice. The most common reason for the low Recommendations adherences are structural and organizational practical limitations.

ARID1A immunohistochemistry improves outcome prediction in invasive urothelial carcinoma of urinary bladder

AT-rich interactive domain 1A (ARID1A) is tumor suppressor gene that interacts with BRG1 adenosine triphosphatase to form a SWI/SNF chromatin remodeling protein complex. Inactivation of ARID1A has been described in several neoplasms, including epithelial ovarian and endometrial carcinomas, and has been correlated with prognosis. In the current study, ARID1A expression in urothelial carcinoma (UC) of the bladder and its association with clinicopathological parameters and outcome are addressed. Five tissue microarrays were constructed from 136 cystectomy specimens performed for UC at our institution. Nuclear ARID1A staining was evaluated using immunohistochemistry. An H-score was calculated as the sum of the products of intensity (0-3) multiplied by extent of expression (0%-100%). Average H-score per case was used for statistical analysis. ARID1A expression was categorized in low and high using Youden index to define the cut point. ARID1A expression significantly increased from normal to noninvasive UC to invasive UC. For both tumor progression and cancer death, Youden index yielded an H-score of 288 as the optimal cut point for ARID1A expression. Low ARID1A expression showed a tendency for lower risk of tumor progression and cancer mortality. Adding ARID1A expression to pathologic features offers a better model for predicting outcome than pathologic features alone. Low ARID1A expression was more frequently seen in earlier stage disease. There was a tendency for low ARID1A expression to predict better outcome. More importantly, the findings indicate that adding ARID1A expression to pathologic features increases the goodness of fit of the predictive model.

Relationship of PCNA, C-erbB2 and CD44s expression with tumor grade and stage in urothelial carcinomas of the bladder

In the present study, the intention was to reveal the relationship of histological grade and stage with c-erbB2, CD44s, and PCNA immunoreactivity in bladder urothelial carcinomas (UC). In our study, we evaluated 46 items of transurethral resection material of patients submitted by YYU Faculty of Medicine, Main Department of Pathology, with a mass revealed in their bladder after clinical and radiological studies at our laboratories and who were diagnosed with urothelial carcinomas. PCNA, c-erbB2, and CD44s were applied in an immunohistochemical manner comprised from nine low-malignant potential papillary urothelial neoplasia, 23 low-grade papillary urothelial carcinoma, and 14 high-grade papillary urothelial carcinoma. Immunostaining was scored according to the percentage of positive cells. The immunohistochemical study demonstrated that the c-erbB2 and PCNA staining ratio increased when an increase occurred in stage and grade. The CD44s staining ratio decreased. C-erbB2, PCNA, and CD44s appear to be a useful marker in the assessment of the prognosis and treatment options in urothelial carcinomas.

Differences in Expression of Uroplakin III, Cytokeratin 7, and Cyclooxygenase-2 in Canine Proliferative Urothelial Lesions of the Urinary Bladder

The expression of immunohistochemical markers that have been used in diagnosis and/or prognostication of urothelial tumors in humans (uroplakin III [UPIII], cytokeratin 7 [CK7], cyclooxygenase-2 [COX-2], and activated caspase 3) was evaluated in a series of 99 canine proliferative urothelial lesions of the urinary bladder and compared to the lesion classification and grade as defined by the World Health Organization / International Society of Urologic Pathology consensus system. There were significant associations between tumor classification and overall UPIII pattern ( P = 1.49 × 10–18), loss of UPIII ( P = 1.27 × 10–4), overall CK7 pattern ( P = 4.34 × 10–18), and COX-2 pattern ( P = 8.12 × 10–25). In addition, there were significant associations between depth of neoplastic cell infiltration into the urinary bladder wall and overall UPIII pattern ( P = 1.54 × 10–14), loss of UPIII ( P = 2.07 × 10–4), overall CK7 pattern ( P = 1.17 × 10–13), loss of CK7 expression ( P = .0485), and COX-2 pattern ( P = 8.23 × 10–21). There were no significant associations between tumor classification or infiltration and caspase 3 expression pattern.

TERT promoter mutations occur early in urothelial neoplasia and are biomarkers of early disease and disease recurrence in urine

Activating mutations occur in the promoter of the telomerase reverse transcriptase (TERT) gene in 66% of muscle-invasive urothelial carcinomas. To explore their role in bladder cancer development and to assess their utility as urine markers for early detection, we sequenced the TERT promoter in 76 well-characterized papillary and flat noninvasive urothelial carcinomas, including 28 pTa low-grade transitional cell carcinomas (TCC), 31 pTa high-grade TCCs, and 17 pTis carcinoma in situ lesions. We also evaluated the sequence of the TERT promoter in a separate series of 14 early bladder neoplasms and matched follow-up urine samples to determine whether urine TERT status was an indicator of disease recurrence. A high rate of TERT promoter mutation was observed in both papillary and flat lesions, as well as in low- and high-grade noninvasive urothelial neoplasms (mean: 74%). In addition, among patients whose tumors harbored TERT promoter mutations, the same mutations were present in follow-up urines in seven of eight patients that recurred but in none of the six patients that did not recur (P < 0.001). TERT promoter mutations occur in both papillary and flat lesions, are the most frequent genetic alterations identified to date in noninvasive precursor lesions of the bladder, are detectable in urine, and seem to be strongly associated with bladder cancer recurrence. These provocative results suggest that TERT promoter mutations may offer a useful urinary biomarker for both early detection and monitoring of bladder neoplasia.

Profile of lesions in cystoscopic bladder biopsies: a histopathological study

Aim and Introduction: Urinary bladder lesions, non-neoplastic and neoplastic, are collectively responsible for significant morbidity and mortality throughout the world. The present study aimed to study the histopathology of various lesions of the bladder through cystoscopic biopsies.

MATERIAL AND METHODS

The present prospective study aimed to study the histopathology of various lesions of the urinary bladder through cystoscopic biopsies. All patients who visited Urology Outpatients Department for haematuria and dysuria were subjected to cystoscopy.

RESULTS

Histopathological examinations revealed an equal share of non neoplastic lesions and neoplastic lesions. Amongst the non neoplastic lesions, 84% were inflammatory lesions. Urothelial tumours (96%) formed the bulk amongst neoplastic lesions.

CONCLUSION

This article has stressed upon the importance of histopathological examinations in evaluating bladder pathologies.

Reproductibilité des classifications OMS 1973 et OMS 2004 des tumeurs urothéliales papillaires de la vessie

RéSUMé: OBJECTIF : Déterminer les taux d'accord et la reproductibilité intra et inter-observateurs des classifications OMS 1973 et OMS 2004 des tumeurs urothéliales papillaires de la vessie. MATéRIEL ET MéTHODES : Cent deux cas de tumeurs urothéliales papillaires de stade pTa/pT1 ont été étudiés. Deux pathologistes ont revu les lames et ont établi le grade tumoral selon les deux classifications OMS 1973 et OMS 2004. En cas de désaccord, les deux évaluateurs ont procédé à une lecture commune au microscope en double tête afin d'aboutir à un grade consensuel selon les deux classifications. La variabilité intra-observateur a été étudiée chez l'un des deux évaluateurs qui a procédé à la relecture des lames un mois après sa première lecture. Les taux d'accord entre les deux pathologistes pour chaque catégorie de grade ont été déterminés et la reproductibilité des deux classifications a été évaluée à l'aide du coefficient kappa. Une valeur de 0 à 0,2 était interprétée comme un désaccord absolu, de 0,21 à 0,4, un accord faible, de 0,41 à 0,6, un accord modéré, de 0,61 à 0,8, un accord considérable, et de 0,8 à 1, un accord absolu. RéSULTATS : Selon la classification OMS 1973, les proportions des grades G1, G2 et G3 étaient respectivement de 40,2 %, 50 % et 9,8 %. Selon la classification OMS 2004, les proportions respectives des tumeurs de faible potentiel de malignité, des carcinomes de bas grade et des carcinomes de haut grade de malignité étaient de 23,5 %, 60,8 % et 15,7 %. La reproductibilité intra-observateur était excellente pour les deux classifications (accord absolu). Les taux d'accord entre les deux pathologistes étaient meilleurs pour la classification OMS 2004 (kappa = 0,7) que pour la classification OMS 1973 (kappa = 0,51).

CONCLUSIONS

La reproductibilité entre observateurs de la classification OMS 2004 est supérieure à celle de 1973. La reproductibilité intra-observateur est excellente pour les deux classifications.

The 1973 WHO Classification is more suitable than the 2004 WHO Classification for predicting prognosis in non-muscle-invasive bladder cancer

Background

Predicting the recurrence and progression of Non-muscle-invasive bladder cancer(NMIBC) is critical for urologist. Histological grade provides significant prognostic information, especially for prediction of progression. Currently, the 1973 and the 2004 WHO classification co-exist. Which system is better for predicting rumor recurrence and progression still a matter for debate.

Methodology/Principal Findings

348 patients diagnosed with Non-muscle invasive bladder cancer were enrolled in our retrospective study. Paraffin sections were assessed by an experienced urological pathologist according to both the 1973 and 2004 WHO classifications. Tumor recurrence and progression was followed-up in all patients. During follow-up, corresponding 5-year recurrence-free survival rates of G1, G2 and G3 were 82.1%, 55.9%, 32.1% and the 5-year progression-free survival rates were 95.9%, 84.4% and 43.3%, respectively. The 5-year recurrence-free survival rates of papillary urothelial neoplasm of low malignant potential (PUNLMP), low-grade papillary urothelial carcinoma(LGPUC) and high-grade papillary urothelial carcinoma (HGPUC) were 69.8%, 67.1% and 42.0% respectively and the 5-year progression-free survival rates were 100%, 90.9% and 54.8% respectively. In multivariate analysis, the 1973 WHO classification significantly associated with both tumor recurrence and progression(p = 0.010 and p = 0.022, respectively); the 2004 WHO classification correlated with tumor progression(p = 0.019), while was not proved to be a variable that can predict the risk of recurrence(p = 0.547). Kaplan-Meier plots showed that both the 1973 WHO and the 2004 WHO classifications were significantly associated with progression-free survival (p<0.0001, log-rank test). For prediction of recurrence, significant differences were observed between the tumor grades classified using the 1973 WHO grading system (p<0.0001, log-rank test), while a significant overlap was observed between PUNLMP and LG plots using the 2004 WHO grading system(p = 0.616, log-rank test).

Conclusion/Significance

Both the 1973 WHO and the 2004 WHO Classifications are effective in predicting tumor progression in Non-muscle invasive bladder cancer, while the 1973 WHO Classification is more suitable for predicting tumor recurrence.

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.

High-grade papillary urothelial carcinoma of the urinary tract: a clinicopathologic analysis of a post-World Health Organization/International Society of Urological Pathology classification cohort from a single academic center

About one half of all bladder neoplasms are noninvasive, and in those, the histologic grade is a crucial prognosticator. Few single-center studies have assessed the recurrence, progression, and cancer-related mortality rates of noninvasive high-grade papillary urothelial carcinomas. With this aim, we evaluated the clinicopathologic and outcome features of 85 patients with high-grade papillary urothelial carcinoma. Median age was 68 years, and 80.5% were men. Tumor size ranged from 0.3 to 13.0 cm (median, 1.6 cm). Recurrence was found in 36.5% of the patients, whereas tumor progression, defined as invasion of lamina propria or beyond, was identified in 40% of all cases. When present, lesion reappearance involved mostly 1 to 2 episodes. Metastasis appeared in 20% of the patients, and 15% died of disseminated bladder cancer. All cancer-related deaths occurred in the group of patients with progression, whereas patients with recurrence showed similar outcomes to those with no recurrence. For patients with tumor progression, clinical stage was significantly associated with outcome (P = .002). As for prognosis, tumor size was strongly associated with progression (P < .01). In conclusion, recurrence, progression, and cancer-specific mortality rates were 36.5%, 40%, and 15%, respectively. All the patients who died of cancer had a history of tumor progression. Patients with recurrences showed similar outcomes to those with no recurrence. Tumor size was strongly associated with tumor progression and cancer-specific survival, whereas clinical stage was significantly associated with outcome in the progression group. In light of the high recurrence and progression rates of high-grade papillary urothelial carcinoma, strict clinical surveillance aimed to detect early recurrent lesions, especially in patients with larger tumors, is warranted.

Low-grade papillary urothelial carcinoma of the urinary bladder: a clinicopathologic analysis of a post-World Health Organization/International Society of Urological Pathology classification cohort from a single academic center

CONTEXT

Few large cohort studies have addressed outcome in patients with noninvasive low-grade papillary urothelial carcinoma (LG-UrCa) following implementation of the 2004 World Health Organization/International Society of Urological Pathology (WHO/ISUP) consensus classification.

OBJECTIVE

To evaluate our cohort of LG-UrCa cases classified according to 2004 WHO/ISUP to reassess outcome and interobserver agreement.

DESIGN

Files were searched for all patients diagnosed with LG-UrCa between 1998 and 2008. All sections were reevaluated for accuracy of classification.

RESULTS

A total of 112 cases initially diagnosed as LG-UrCa were identified. Of those, 8 of 55 cases (15%) initially diagnosed by nonurologic pathologists were reclassified as high-grade papillary urothelial carcinoma and were excluded. The mean length of follow-up was 40.1 months (range, 2-113 months). Tumor recurrence was encountered in 56 of 104 patients (53.8%), including 37 (35.6%) with LG-UrCa or lower-grade tumors and 19 (18.3%) with high-grade papillary urothelial carcinoma. Of the 19 patients demonstrating grade progression, 7 (37%) also developed stage progression (invasive carcinoma, n = 5; metastatic carcinoma, n = 2). Seven patients eventually underwent radical cystectomy. None of the 104 patients died of bladder cancer. The mean number of recurrence episodes was 3.11. The mean durations of time to first recurrence and time to grade progression were 13.9 months and 25.1 months, respectively. The mean size of initial tumors was 1.73 cm. There was no significant correlation between tumor size, patient age, sex, or smoking history and the likelihood for recurrence or grade progression. A significantly higher rate of recurrence was seen in patients with multiple tumors at initial diagnosis (P = .04).

CONCLUSIONS

A tendency to underdiagnose high-grade papillary urothelial carcinoma continues to exist. More than half (53.8%) of patients with LG-UrCa developed recurrence, with an 18.3% incidence of grade progression and a 6.7% incidence of stage progression. Patients with multiple initial tumors had significantly higher risk of developing recurrence.

Prognostic significance of the 2004 WHO/ISUP classification for prediction of recurrence, progression, and cancer-specific mortality of non-muscle-invasive urothelial tumors of the urinary bladder: a clinicopathologic study of 1,515 cases

To verify prognostic significance of the 2004 World Health Organization (WHO)/International Society of Urological Pathology (ISUP) grading systems, we retrospectively studied the tumors of 1,515 patients who underwent transurethral resection of primary non-muscle-invasive urothelial tumors (pTa, 1,006 patients; pT1, 509 patients) confined to the bladder. Cases were classified according to the 2004 WHO/ISUP systems as 212 cases of papillary urothelial neoplasm of low malignant potential (PUNLMP), 706 low-grade papillary urothelial carcinomas (LPUCs), and 597 high-grade papillary urothelial carcinomas (HPUCs). PUNLMP showed the statistically significantly lowest recurrence cumulative incidence compared with the other tumor types. There were significant differences and trends for higher progression and cancer-specific mortality cumulative incidence in the following order: PUNLMP, LPUC, pTa HPUC, and pT1 HPUC. No differences of progression and cancer-specific mortality cumulative incidence were found between pTa and pT1 LPUC. Our study validates the usefulness of the 2004 WHO/ISUP system to classify urothelial tumors into prognostically distinct categories that would contribute to the design of therapeutic and monitoring strategies for patients with non-muscle-invasive bladder urothelial tumors.

Non-invasive papillary urothelial neoplasms: the 2004 WHO/ISUP classification system

The classification and grading of papillary urothelial neoplasms has been a long-standing subject of controversy. Previously, numerous diverse grading schemes for bladder tumor, including the 1973 World Health Organization (WHO) classification, existed whereby one of the major limitations was poor inter-observer reproducibility among pathologists. The WHO/International Society of Urological Pathology (ISUP) consensus classification system of urothelial neoplasms of the urinary bladder was developed in 1998 and was revised most recently in 2003 (published in 2004). Importantly, the current classification system provides detailed histological criteria for papillary urothelial lesions and allows for designation of a lesion (papillary urothelial neoplasm of low malignant potential) with a negligible risk of progression. Thus, the latest system is designed to be a universally acceptable one for bladder tumors that not only could be effectively used by pathologists, urologists, and oncologists, but also stratifies the tumors into prognostically significant categories. This article outlines the 2004 WHO/ISUP classification system regarding the specific histological criteria for non-invasive papillary urothelial neoplasms and the clinical significance of each category.

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

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

The current classification of urothelial neoplasms

The classification of urothelial neoplasms has been a subject of significant controversy and debate over the last decade. Only recently has a general level of agreement developed on the utility of the classification first proposed by the World Health Organization and the International Society of Urologic Pathology in 1998. Recent adoption of this scheme in therapeutic guidelines indicates the clinical utility of the system. In this review a brief historical perspective is presented, followed by a review of the classification system, the histological criteria for the specific categories and the clinical significance of these diagnoses.

Growth pattern in superficial urothelial bladder carcinomas. Histological review and clinical relevance

INTRODUCTION

The question of when an intraepithelial urothelial carcinoma becomes invasive into the lamina propria of the urinary bladder is an unresolved issue. Our objective was to analyse a series of consecutive superficial carcinomas to assess the importance of growth pattern in tumour recurrence and progression.

MATERIALS AND METHODS

The pathological staging of 200 superficial (pTa/pT1) bladder carcinomas was reviewed. Non-invasive lesions and tumours invading the lamina propria were distinguished. Both infiltrating and pushing patterns of growth were regarded as lamina propria invasion.

RESULTS

A total of 35 (17.5%) pTa and 165 (82.5%) pT1 tumours were identified. Among pT1 tumours, 39 (23.6%) displayed the infiltrating pattern of invasion and 126 (76.4%) the pushing pattern. Differences in five-year recurrence-free (P = 0.01) and progression-free (P = 0.001) survival were demonstrated between pTa and pT1 tumours, and between pT1 infiltrating and pT1 pushing subcategories. Invasive growth pattern has a 1.86 times higher risk of tumour recurrence and 3.01 times higher risk of progression.

CONCLUSIONS

The pT1 category of bladder carcinoma should include a group of tumours defined by its pushing pattern of growth. Some cases may have been previously considered pTa, but follow an intermediate clinical course between pTa and pT1 tumours with infiltrating growth pattern.