Importance of red patches diagnosed in cystoscopy for haematuria and lower urinary tract symptoms

The feasibility of multimodal fiber optic spectroscopy analysis in bladder cancer detection, grading, and staging

OBJECTIVE

To prove the feasibility of Multimodal Fiber Optic Spectroscopy (MFOS) analysis in bladder cancer (BCa) detection, grading, and staging.

MATERIALS AND METHODS

Bladder specimens from patients underwent TURBT or TURP were recorded and analyzed with MFOS within 30 min from excision. In detail, our MFOS combined fluorescence, Raman spectroscopy, and diffuse reflectance. We used these optical techniques to collect spectra from bladder biopsies, then we compared the obtained results to gold standard pathological analysis. Finally, we developed a classification algorithm based on principal component analysis-linear discriminant analysis.

RESULTS

A total of 169 specimens were collected and analyzed from 114 patients, 40 (23.7%) healthy (from TURP), and 129 (76.3%) with BCa. BCa specimens were divided according to their grade-34 (26.4%) low grade (LG) and 95 (73.6%) high grade (HG) BCa-and stage-64 (49.6%) Ta, 45 (34.9%) T1, and 20 (15.5%) T2. MFOS-based classification algorithm correctly discriminated healthy versus BCa with 90% accuracy, HG versus LG with 83% accuracy. Furthermore, it assessed tumor stage with 75% accuracy for Ta versus T1, 85% for T1 versus T2, and 86% for Ta versus T2.

CONCLUSIONS

Our preliminary results suggest that MFOS could be a reliable, fast, and label-free tool for BCa assessment, providing also grading and staging information. This technique could be applied in future for in vivo inspection as well as of ex vivo tissue biopsies. Thus, MFOS might improve urothelial cancer management. Further studies are required.

Isolated Red Patches Seen During Endoscopic Surveillance of Bladder Cancer: Incidence of Malignancy and When Should We Biopsy?

OBJECTIVE

To establish whether the regular biopsy of red patches (RPs) seen during endoscopic surveillance for bladder cancer is worthwhile and determine a suitable time frame for repeat biopsy of prior histologically benign persistent RPs in patients on endoscopic surveillance for bladder cancer.

PATIENTS AND METHODS

Four thousand eight hundred five flexible cystoscopy (FC) reports over a 12-month period were retrospectively reviewed at a United Kingdom tertiary teaching hospital and those undergoing cystoscopic surveillance for bladder cancer and found to have solitary RPs at FC were included in the study. A proportion of these cases had biopsies taken for histopathologic analysis.

RESULTS

Two hundred forty-one FC performed on 183 patients on endoscopic surveillance for bladder cancer had RPs and 120 (49.8%) of them had previous intravesical Bacillus Calmette-Guerin therapy. Eighty-five patients (35.3%) underwent biopsy of the RP. Malignancy was found in 20 biopsies (23.5%), of which, 11 out of 20 (55%) were carcinoma in-situ. Sixteen of these recurrences were biopsied previously, of which 11 (68.8%) were benign at last biopsy, 6 of which were in the last 12 months. The remaining four recurrences had no previous biopsy. No cases of malignancy were identified in patients with low-risk bladder cancer.

CONCLUSION

We recommend the biopsy of all RPs found during endoscopic surveillance of patients with intermediate-/high-risk bladder cancer due to the significant incidence of malignant recurrence identified, particularly if no biopsy has been performed within the previous 12 months. This is independent of previous biopsy histology.

Flexible cystoscopy findings in patients investigated for profound lower urinary tract symptoms, recurrent urinary tract infection, and pain

BACKGROUND AND PURPOSE

The National Institute of Clinical Excellence published guidelines in 2010 recommending the use of cystoscopy to investigate profound lower urinary tract symptoms (pLUTS), recurrent urinary tract infection (rUTI), and pain in men. Currently, there are no equivalent guidelines for women. We aimed to examine the diagnostic performance of flexible cystoscopy (FC) when it is used in this context in both men and women.

PATIENTS AND METHODS

Results of all outpatient FCs undertaken in our department between April 2009 and March 2010 were examined retrospectively. Patients undergoing FC for the investigation of pLUTS, rUTI, or pain were included. Diagnostic performance was calculated, which was defined as the number of patients receiving a diagnosis of a clinically relevant abnormality at FC divided by the total number of patients undergoing FC for this indication.

RESULTS

Of the 1809 patients who underwent FC during the study period, 113 underwent FC to investigate pLUTS, rUTI, or pain. Diagnostic performance was 11.5% (n=13), being 11.4%, 19.2%, and 0% in those with pLUTS, rUTI, and pain, respectively. Bladder cancer was diagnosed in one (0.9%) patient who underwent FC to investigate pLUTS but also had nonvisible hematuria. Urethral stricture was diagnosed in nine (8.0%) cases and intravesical calculi in four (3.5%) cases.

CONCLUSION

Clinically relevant abnormalities were found in 11.5% of patients with pLUTS, rUTI, or pain, supporting recently published NICE guidelines recommending cystoscopy in patients with pLUTS or rUTI. Of the 17 patients who were investigated for pain, none was found to have clinically relevant abnormalities; further studies are needed to define the clinical utility of FC in these cases.

Diagnosis, evaluation and treatment of carcinoma in situ of the urinary bladder: the state of the art

Urothelial carcinoma in situ (CIS) is regarded as a precursor of invasive bladder carcinoma. Although relatively uncommon as a primary entity, CIS is frequently seen in conjunction with other bladder tumors and represents a significant source of difficulty for surveillance of patients with known bladder cancer. CIS lesions are difficult to detect by cystoscopic examination or by currently available screening markers. Urothelial CIS is infrequently reported in the literature as a primary process; however, a wide variety of emerging methodologies are becoming available for screening and follow-up of bladder cancer. Most new methods demonstrate sensitivity and specificity similar to the current standard of urine cytology and cystoscopy. Detection of high-grade lesions such as CIS by these methods appears generally better than detection of low-grade lesions. Current molecular evidence suggests that a spectrum of genetic aberrations including p53 mutations are strongly associated with the potentially invasive CIS phenotype in contrast to low-grade papillary and hyperplastic lesions. These low-grade lesions frequently recur but infrequently become invasive. Patients with high-grade lesions including CIS and high-grade papillary tumors warrant aggressive treatment and life-long surveillance.