Recurrence, progression and survival in bladder cancer. A retrospective analysis of 232 patients with greater than or equal to 5-year follow-up

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.

Comparison of red and green light for treating non-muscle invasive bladder cancer in rats using singlet oxygen-cleavable prodrugs with PPIX-PDT

It has been 30 years since Photofrin-PDT was approved for the treatment of bladder cancer in Canada. However, Photofrin-PDT failed to gain popularity due to bladder complications. The PDT with red light and IV-administered Photofrin could permanently damage the bladder muscle. We have been developing a new combination strategy of PpIX-PDT with singlet oxygen-cleavable prodrugs for NMIBC with minimal side effects, avoiding damage to the bladder muscle layer. PpIX can be excited by either green (532 nm) or red (635 nm) light. Red light could be more efficacious in vivo due to its deeper tissue penetration than green light. Since HAL preferentially produces PpIX in tumors, we hypothesized that illuminating PpIX with red light might spare the muscle layer. PpIX-PDT was used to compare green and red laser efficacy in vitro and in vivo. The IC50 of in vitro PpIX-PDT was 18 mW/cm2 with the red laser and 22 mW/cm2 with the green laser. The in vivo efficacy of the red laser with 50, 75, and 100 mW total dose was similar to the same dose of green laser in reducing tumor volume. Combining PpIX-PDT with prodrugs methyl-linked mitomycin C (Mt-L-MMC) and rhodamine-linked SN-38 (Rh-L-SN-38) significantly improved efficacy (tumor volume comparison). PpIX-PDT or PpIX-PDT + prodrug combination did not cause muscle damage in histological analysis. Overall, a combination of PpIX-PDT and prodrug with 635 nm laser is promising for non-muscle invasive bladder cancer treatment.

Cyclophosphamide-associated bladder cancers and considerations for survivorship care: A systematic review

PURPOSE

We performed a systematic review to assess the clinical features of cyclophosphamide-associated bladder cancer.

MATERIALS AND METHODS

MEDLINE, Web of Science, and Cochrane Library were searched from inception to August 2020 according to PRISMA guidelines. Studies that associated bladder cancer with prior cyclophosphamide use on an individual level were included.

RESULTS

We identified 121 studies spanning over a 50-year period with 285 patients. The most common malignant indication for cyclophosphamide was lymphoma (25%), while the most common non-malignant indication was ANCA-associated vasculitides (26%). Hematuria and dysuria were the most prevalent symptoms prior to a cyclophosphamide-associated bladder cancer diagnosis, and median age at diagnosis was 55 years. Conventional urothelial carcinoma (UC) was the most common bladder-associated diagnosis (74%), although a broad range of cancer types were represented, notably leiomyosarcoma and squamous cell carcinoma. About half of bladder cancers were muscle invasive at diagnosis and median latency time was 10.0 years; 33% of patients had a bladder cancer related death.

CONCLUSIONS

We describe the largest pooled analysis of patients with cyclophosphamide-associated bladder cancer. These bladder cancers have a propensity for younger age at diagnosis, more advanced stage at diagnosis, and variant histology. There was a substantial number of patients with latency time of ≥20 years independent of cumulative cyclophosphamide dose. These findings support consideration of screening and long-term surveillance of cancer survivors with a history of cyclophosphamide therapy for bladder cancer.

Stage T1 bladder cancer: diagnostic criteria and pitfalls

Accurate pathological staging is crucial for patient management. Patients with T1 bladder cancer are at risk of recurrence, progression, and death of cancer. Recognition of early invasion (stage T1 disease) in urothelial carcinoma remains one of the most challenging areas in urological surgical pathology practice. A logical roadmap to T1 diagnosis would include careful evaluation of histological grade, stromal epithelial interface, characteristics of the invading epithelium, and the stroma associated responses. Tangential sectioning, crush and cautery artifacts, and associated inflammatory infiltrate are commonly encountered problems and the source of pitfalls. In this review, we outline diagnostic criteria, common pitfalls, and different histological patterns of invasion into the lamina propria. Current recommendations on reporting of biopsy and transurethral resection specimens, molecular biomarkers, clinical implications of T1 cancer diagnosis and recent developments on the T1 substaging are also discussed. Most T1 bladder cancer patients will benefit from conservative management after restaging transurethral resection of bladder and bacillus Calmette-Guérin maintenance. Patients with high risk features, such as concurrent urothelial carcinoma in situ, increased depth of invasion, lymphovascular invasion, and variant histology among others, should be considered for early cystectomy.

Automated Detection and Grading of Non-Muscle-Invasive Urothelial Cell Carcinoma of the Bladder

Accurate grading of non-muscle-invasive urothelial cell carcinoma is of major importance; however, high interobserver variability exists. A fully automated detection and grading network based on deep learning is proposed to enhance reproducibility. A total of 328 transurethral resection specimens from 232 patients were included, and a consensus reading by three specialized pathologists was used. The slides were digitized, and the urothelium was annotated by expert observers. The U-Net-based segmentation network was trained to automatically detect urothelium. This detection was used as input for the classification network. The classification network aimed to grade the tumors according to the World Health Organization grading system adopted in 2004. The automated grading was compared with the consensus and individual grading. The segmentation network resulted in an accurate detection of urothelium. The automated grading shows moderate agreement (κ = 0.48 ± 0.14 SEM) with the consensus reading. The agreement among pathologists ranges between fair (κ = 0.35 ± 0.13 SEM and κ = 0.38 ± 0.11 SEM) and moderate (κ = 0.52 ± 0.13 SEM). The automated classification correctly graded 76% of the low-grade cancers and 71% of the high-grade cancers according to the consensus reading. These results indicate that deep learning can be used for the fully automated detection and grading of urothelial cell carcinoma.

Consultation on UTUC, Stockholm 2018 aspects of diagnosis of upper tract urothelial carcinoma

Purpose

To summarize knowledge on upper urinary tract carcinoma (UTUC) regarding diagnostic procedures, risk factors and prognostic markers.

Methods

A scoping review approach was applied to search literature in Pubmed, Web of Science, and Embase. Consensus was reached through discussions at Consultation on UTUC in Stockholm, September 2018.

Results

Tumor stage and grade are the most important prognostic factors. CT urography (CTU) including corticomedullary phase is the preferred imaging modality. A clear tumor on CTU in combination with high-grade UTUC in urine cytology identifies high-risk UTUC, and in some cases indirect staging can be obtained. Bladder urine cytology has limited sensitivity, and in most cases ureterorenoscopy (URS) with in situ samples for cytology and histopathology are mandatory for exact diagnosis. Image-enhancing techniques, Image S1 and narrow-band imaging, may improve tumor detection at URS. Direct confocal laser endomicroscopy may help to define grade during URS. There is strong correlation between stage and grade, accordingly correct grading is crucial. The correlation is more pronounced using the 1999 WHO than the 2004 classification: however, the 1999 system risks greater interobserver variability. Using both systems is advisable. A number of tissue-based molecular markers have been studied. None has proven ready for use in clinical practice.

Conclusions

Correct grading and staging of UTUC are mandatory for adequate treatment decisions. Optimal diagnostic workup should include CTU with corticomedullary phase, URS with in situ cytology and biopsies. Both WHO classification systems (1999 and 2004) should be used to decrease risk of undergrading or overtreatment.

Application of fluorescence in situ hybridization in the detection of bladder transitional-cell carcinoma: A multi-center clinical study based on Chinese population

Objective

To evaluate the diagnostic value of fluorescence in situ hybridization (FISH) in bladder cancer.

Methods

We enrolled healthy volunteers and patients who were clinically suspected to have bladder cancer and conducted FISH tests and cytology examinations from August 2007 to December 2008. Receiver operating characteristic (ROC) curve analysis was performed and the area under curve (AUC) values were calculated for both the FISH and urine cytology tests.

Results

A cohort of 988 healthy volunteers was enrolled to establish a reference range for the normal population. A total of 4807 patients with hematuria were prospectively, randomly enrolled for the simultaneous analysis of urine cytology, FISH testing, and a final diagnosis as determined by the pathologic findings of a biopsy or a surgically-excised specimen. Overall, the sensitivity of FISH in detecting transitional-cell carcinoma was 82.7%, while that of cytology was 33.4% (p < 0.001). The sensitivity values of FISH for non-muscle invasive and muscle invasive bladder transitional-cell carcinoma were 81.7% and 89.6%, respectively (p = 0.004). The sensitivity values of FISH for low and high grade bladder cancer were 82.6% and 90.1%, respectively (p = 0.002).

Conclusion

FISH is significantly more sensitive than voided urine cytology for detecting bladder cancer in patients evaluated for gross hematuria at all cancer grades and stages. Higher sensitivity using FISH was obtained in high grade and muscle invasive tumors.

Neuroendocrine bladder cancer: oncological emergency?

Neuroendocrine bladder cancer is extremely rare, with an estimated incidence of 0.5%- 0.7%. In bladder cancers there is no evident connection between the neuroendocrine phenotypic expression and the clinical history. However, prognosis is usually poor and the survival rate at 5 years does not exceed 8%, if untreated.

Methods.

We are here describing three case reports of bladder carcinoma with neuroendocrine differentiation, which is extremely aggressive and leads rapidly to death. At the present time, the local control of these tumors is achieved by radical cystectomy and radiotherapy; they can be both associated to chemotherapy. However, since these lesions are fairly rare, there is no gold standard therapy and there are no prospective studies on the management of these tumors.

Conclusions.

Considering the quick evolution and progression of any variant of the neuroendocrine tumors of the bladder, urologists and anesthetists should see them as real oncological emergencies. A prompt intervention through radical surgery with cystectomy and linfadenectomia, and the anathomo-pathologist's systematic investigation of the scraps could make the approach therapeutic and not only palliative. Prospective studies on neo-adjuvant chemotherapy as well as experimental studies about target therapies may yield new guidelines on the tumor management.

A Review of Outcomes for Stage Ta Bladder Tumors

OBJECTIVES

Using data from former reports, this study reviews and analyzes the outcomes of tumor recurrence, tumor progression, and tumor-specific survival of patients with stage Ta bladder tumors.

METHODS

Data were collected from 19 longitudinal studies of outcomes after the first diagnosis of tumor and collected as individual patient results, that is, as failure times from the first tumor to any of the three outcomes. Altogether, there were 14,252 patients, including 4,050 for the outcome of tumor recurrence, 2,937 for the outcome of tumor progression, and 11,595 for the outcome of disease-specific survival (some patients were available for more than one outcome).

RESULTS

In these data, the mean time to additional tumors was 7.8 years, the mean time to an invasive tumor was 19.5 years, and the mean tumor-specific survival time was 27.2 years. All three outcomes were significantly related to the 2004 World Health Organization (WHO) tumor grades.

CONCLUSIONS

Although greater than 50% of those with stage Ta bladder tumors have additional bladder tumors, approximately 80% appear to follow a benign course without developing invasive tumors or dying of bladder cancer. The 2004 WHO grading scheme accounts for some but not all of the prognostic information.

Do African American Patients Treated with Radical Cystectomy for Bladder Cancer have Worse Overall Survival? Accounting for Pathologic Staging and Patient Demographics Beyond Race Makes a Difference

Background: It is estimated that 74,000 men and women in the United States will be diagnosed with bladder cancer and 16,000 will die from the disease in 2015. The incidence of bladder cancer in Caucasian males is double that of African American males, but African American men and women have worse survival. Although factors contributing to this disparity have been analyzed, there is still great uncertainty as to why this disparity exists.

Objective: To evaluate whether the disparities in bladder cancer survival after radical cystectomy for transitional cell carcinoma (TCC) of the bladder amongst African American (AA) and Caucasian patients is attributable to patient demographics, year of diagnosis, and/or tumor characteristics.

Methods: Using Surveillance, Epidemiology, and End Results Program (SEER) data from 1973–2011, African American and Caucasian patients treated with a radical cystectomy for TCC of the bladder were identified. Primary outcomes were all-cause and cancer-specific mortality. Differences in survival between African Americans and Caucasian patients were assessed using chi-square tests for categorical variables and Student’s t-tests for continuous variables. Cox proportional hazards regression was used to measure the hazard ratio for African Americans compared to Caucasians for all-cause and cancer-specific mortality. In addition, coarsened matching techniques within narrow ranges, were used to match African American and Caucasian patients on the basis of age, sex, and cancer stage. Following matching, differences in all-cause and cancer-specific mortality were again assessed using a stratified Cox proportional hazards model, using the matching strata for the regression strata.

Results: The study cohort consisted of 21,406 African American and Caucasian patients treated with radical cystectomy for bladder urothelial cancer, with 6.2% being African American and 73.9% male. African American patients had worse all-cause and cancer-specific mortality in the univariable analysis (all-cause: HR: 1.23; 95% CI 1.15–1.32, p <  0.001); bladder-cancer specific: HR 1.21; 95% CI 1.11–1.33; p <  0.001). However, after accounting for sex, age, year of diagnosis, marital status, region of treatment, and stage at cystectomy, all-cause mortality was significant (HR 1.20; 95% CI 1.12–1.29; p <  0.0001), but not bladder-cancer specific mortality (HR 1.09; 95% CI 1.00–1.20; p <  0.053). Predictors of bladder cancer specific mortality were age, sex, stage of disease, and marital status. The matched analysis yielded a roughly 1 : 15 match, with 22,511 Caucasians being matched to 1,509 African American patients. In the matched analysis, African Americans had increased all-cause mortality (HR 1.17; 95% CI 1.09–1.26; p <  0.0001), but bladder-cancer specific mortality was no longer significant (HR 1.08; 95% CI 0.99–1.18; p <  0.102).

Conclusions: African Americans who undergo a cystectomy are more likely to die, but not necessarily solely because of bladder cancer. Although African American patients have worse all-cause and cancer-specific mortality in univariable models, after controlling for sex, age, year of diagnosis, marital status, region of treatment, and stage at cystectomy, African American patients still have worse overall survival, but equivalent bladder-cancer specific survival. Differences in age, sex, and stage at diagnosis explain some, but not all of the differences in survival.

BRD4 Regulates EZH2 Transcription through Upregulation of C-MYC and Represents a Novel Therapeutic Target in Bladder Cancer

People who develop bladder cancer frequently succumb to the intractable disease. Current treatment strategies are limited presumably due to the underlying molecular complexity and insufficient comprehension. Therefore, exploration of new therapeutic targets in bladder cancer remains necessary. Here, we identify that bromodomain-4 protein (BRD4), an important epigenome reader of bromodomain and extraterminal domain (BET) family member, is a key upstream regulator of enhancer of zeste homologue 2 (EZH2), and represents a novel therapeutic target in bladder cancer. We found that BRD4 was significantly overexpressed in bladder cancer cells and tissues. Inhibition of BRD4 decreased bladder cancer cell proliferation concomitantly with the accumulation of cell apoptosis in vitro and suppressed tumor growth in vivo We further found that suppression of BRD4 decreased the mRNA and protein levels of EZH2, which was reversed by ectopic expression of C-MYC In particular, individual silencing of BRD4 using shRNA or the BET inhibitor JQ1 strikingly diminished the recruitment of C-MYC to EZH2 promoter in bladder cancer. Briefly, our research reveals that BRD4 positively regulates EZH2 transcription through upregulation of C-MYC, and is a novel promising target for pharmacologic treatment in transcriptional program intervention against this intractable disease. Mol Cancer Ther; 15(5); 1029-42. ©2016 AACR.

Molecular and clinical support for a four-tiered grading system for bladder cancer based on the WHO 1973 and 2004 classifications

Currently, the use of two classification systems for bladder cancer grade is advocated in clinical guidelines because the WHO2004 classification has not been sufficiently validated with biological markers and follow-up. The slides of 325 primary non-muscle invasive bladder cancers from three hospitals were reviewed by one uro-pathologist in two separate sessions for the WHO1973 (G1, G2 and G3) and 2004 (papillary urothelial neoplasm of low malignant potential (LMP), low-grade (LG) and high-grade (HG)) classifications. FGFR3 status was examined with PCR-SNaPshot analysis. Expression of Ki-67, P53 and P27 was analyzed by immuno-histochemistry. Clinical recurrence and progression were determined. We performed validation and cross-validation of the two systems for grade with molecular markers and clinical outcome. Multivariable analyses were done to predict prognosis and pT1 bladder cancer. Grade review resulted in 88 G1, 149 G2 and 88 G3 lesions (WHO1973) and 79 LMP, 101 LG and 145 HG lesions (WHO2004). Molecular validation of both grading systems showed that FGFR3 mutations were associated with lower grades whereas altered expression (Ki-67, P53 and P27) was found in higher grades. Clinical validation showed that the two classification systems were both significant predictors for progression but not for recurrence. Cross-validation of both WHO systems showed a significant stepwise increase in biological (molecular markers) and clinical (progression) potential along the line: G1-LG-G2-HG-G3. The LMP and G1 categories had a similar clinical and molecular profile. On the basis of molecular biology and multivariable clinical data, our results support a four-tiered grading system using the 1973 and 2004 WHO classifications with one low-grade (LMP/LG/G1) category that includes LMP, two intermediate grade (LG/G2 and HG/G2) categories and one high-grade (HG/G3) category.

Update for the practicing pathologist: The International Consultation On Urologic Disease-European association of urology consultation on bladder cancer

The International Consultations on Urological Diseases are international consensus meetings, supported by the World Health Organization and the Union Internationale Contre le Cancer, which have occurred since 1981. Each consultation has the goal of convening experts to review data and provide evidence-based recommendations to improve practice. In 2012, the selected subject was bladder cancer, a disease which remains a major public health problem with little improvement in many years. The proceedings of the 2nd International Consultation on Bladder Cancer, which included a 'Pathology of Bladder Cancer Work Group,' have recently been published; herein, we provide a summary of developments and consensus relevant to the practicing pathologist. Although the published proceedings have tackled a comprehensive set of issues regarding the pathology of bladder cancer, this update summarizes the recommendations regarding selected issues for the practicing pathologist. These include guidelines for classification and grading of urothelial neoplasia, with particular emphasis on the approach to inverted lesions, the handling of incipient papillary lesions frequently seen during surveillance of bladder cancer patients, descriptions of newer variants, and terminology for urine cytology reporting.

Incidence and predictors of understaging in patients with clinical T1 urothelial carcinoma undergoing radical cystectomy

OBJECTIVE

To evaluate predictors of understaging in patients with presumed non-muscle-invasive bladder cancer (NMIBC) identified on transurethral resection of bladder tumour (TURBT) who underwent radical cystectomy (RC) with attention to the role of a restaging TURBT.

PATIENTS AND METHODS

We retrospectively evaluated 279 consecutive patients with clinically staged T1 (cT1) disease after TURBT who underwent RC at our institution from April 2000 to July 2011. In all, 60 of these cT1 patients had undergone a restaging TURBT before RC. The primary outcome measure was pathological staging of ≥T2 disease at the time of RC.

RESULTS

In all, 134 (48.0%) patients were understaged. Of the 60 patients who remained cT1 after a restaging TURBT, 28 (46.7%) were understaged. Solitary tumour (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.25-0.76, P = 0.004) and fewer prior TURBTs (OR 0.84, 95% CI 0.71-1.00, P = 0.05) were independent risk factors for understaging.

CONCLUSIONS

Despite the overall improvement in staging accuracy linked to restaging TURBTs, the risk of clinical understaging remains high in restaged patients found to have persistent T1 urothelial carcinoma who undergo RC. Solitary tumour and fewer prior TURBTs are independent risk factors for being understaged. Incorporating these predictors into preoperative risk stratification may allow for augmented identification of those patients with clinical NMIBC who stand to benefit most from RC.

Recent improvements in the detection and treatment of nonmuscle-invasive bladder cancer

In total, 70-80% of newly diagnosed bladder cancers are confined to the mucosa and staged as Ta, T1 or carcinoma in situ according to the 2002 tumor, lymph nodes and metastasis classification. The standard treatment for these nonmuscle-invasive bladder cancers is transurethral tumor resection with or without adjuvant intravesical chemotherapy or intravesical immunotherapy and subsequent follow-up. Diagnosis and follow-up of nonmuscle-invasive bladder cancer offers two main problems. First, approximately 10-20% of all tumors are not seen in standard cystoscopy. Additionally, frequently repeated follow-up cystoscopies are bothersome for the patient. As an adjunct to standard cystoscopy, fluorescence-guided cystoscopy has demonstrated significantly higher tumor detection rates and optimized patient treatment in recent Phase III studies. Second, routinely performed urine cytology is characterized by high specificity but low sensitivity. Today, several urine tests are available that may increase diagnostic accuracy and potentially prolong intervals of follow-up cystocopy. Owing to rather high recurrence rates after transurethral tumor resection in most tumors and high progression rates in poorly differentiated tumors, adjuvant intravesical chemotherapy or intravesical immunotherapy has gained widespread use in patients with nonmuscle-invasive bladder cancer. Only a few further immunomodulatory drugs, such as recombinant cytokines, have shown significant clinical effectiveness. Additional approaches, such as photodynamic therapy with different photosensitizers and thermotherapy in combination with intravesical chemotherapy, have been evaluated in Phase III studies.

Relevance of the mammalian target of rapamycin pathway in the prognosis of patients with high-risk non-muscle invasive bladder cancer

High-risk non-muscle invasive bladder cancer (NMIBC) is associated with higher rates of recurrence and progression. Molecular markers within aberrant signaling pathways in cancer need further evaluation of their role as prognostic indicators and potential future targets for prevention of recurrence. Our objective was to investigate the role of the mammalian target of rapamycin (mTOR) signaling pathway on the stage and outcome of patients with high-risk NMIBC. Tissue microarrays were built from archival bladder tumor specimens (n = 142). Various clinicopathologic variables were collected retrospectively from patients treated with transurethral resection. Immunohistochemical staining was performed for phosphatase and tensin homolog, phosphorylated Akt, phosphorylated mTOR, phosphorylated S6 (p-S6), eukaryotic translation initiation factor 4E-binding protein-1, and p27. Multivariate analysis using Cox regression models addressed recurrence-free survival (RFS), progression-free survival, and worsening-free survival. In multivariate analysis, p-S6 was an independent predictor of shorter RFS (hazard ratio, 3.55; 95% CI, 1.31-9.64). Expression of p27 was inversely correlated with RFS (hazard ratio, 0.27; 95% CI, 0.10-0.74). Low levels of phosphatase and tensin homolog expression were associated with worsening-free survival (P < .03). None of the markers showed correlation with progression-free survival. Our results demonstrate that activation of the mTOR pathway, as assessed by p-S6 and expression of p27, might be used to provide prognostic information, particularly as a predictor of recurrence among patients with high-risk NMIBC.

Cancer-specific survival after radical nephroureterectomy for upper urinary tract urothelial carcinoma: proposal and multi-institutional validation of a post-operative nomogram

Background:

Owing to the scarcity of upper urinary tract urothelial carcinoma (UUT-UC) it is often necessary for investigators to pool data. A patient-specific survival nomogram based on such data is needed to predict cancer-specific survival (CSS) post nephroureterectomy (NU). Herein, we propose and validate a nomogram to predict CSS post NU.

Patients and methods:

Twenty-one French institutions contributed data on 1120 patients treated with NU for UUT-UC. A total of 667 had full data for nomogram development. Study population was divided into the nomogram development cohort (397) and external validation cohort (270). Cox proportional hazards regression models were used for univariate and multivariate analyses and to build a nomogram. A reduced model selection was performed using a backward step-down selection process, and Harrell's concordance index (c-index) was used for quantifying the nomogram accuracy. Internal validation was performed by bootstrapping and the reduced nomogram model was calibrated.

Results:

Of the 397 patients in the nomogram development cohort, 91 (22.9%) died during follow-up, of which 66 (72.5%) died as a consequence of UUT-UC. The actuarial CSS probability at 5 years was 0.76 (95% CI, 71.62-80.94). On multivariate analysis, T stage (P<0.0001), N status (P=0.014), grade (P=0.026), age (P=0.005) and location (P=0.022) were associated with CSS. The reduced nomogram model had an accuracy of 0.78. We propose a nomogram to predict 3 and 5-year CSS post NU for UUT-UC.

Conclusion:

We have devised and validated an accurate nomogram (78%), superior to any single clinical variable or current model, for predicting 5-year CSS post NU for UUT-UC.

Clinical implications and prognostic values of topoisomerase-II alpha expression in primary non-muscle-invasive bladder cancer

OBJECTIVES

To investigate the association between expression levels of topoisomerase-II alpha (TOP-2alpha) and prognosis in primary non-muscle-invasive bladder cancer (NMIBC). TOP-2alpha, a marker of cell proliferation, has been assessed as a prognostic indicator in several types of cancer. However, currently available data on the role of TOP-2alpha in prognosis are inconsistent.

METHODS

Top-2alpha messenger ribonucleic acid (mRNA) levels were examined in 103 tumor specimens from patients with primary NMIBC by real-time polymerase chain reaction. Immunohistochemical staining was performed on 39 matched tumor samples. The median follow-up period for all patients was 51.8 months (range, 3.2-137).

RESULTS

The mRNA expression levels of TOP-2alpha were significantly elevated in subjects with high-grade (P<.001) and high-stage (P=.041) tumors as compared with subjects with low-grade and low-stage tumors. Kaplan-Meier estimates revealed significant variation in tumor recurrence and progression depending on the level of TOP-2alpha expression (log-rank test, P<.05). Multivariate Cox regression analysis revealed that the level of TOP-2alpha expression is a strong predictor of recurrence (hazard ratio, 2.507; 95% confidence interval, 1.228-5.116; P=.012) and progression (hazard ratio, 4.192; 95% confidence interval, 1.002-17.536; P=.049) for NMIBC. The results of immunohistochemical staining generally correlated with mRNA expression levels.

CONCLUSIONS

Enhanced expression of TOP-2alpha is positively associated with a high rate of recurrence and progression in NMIBC. Thus, TOP-2alpha represents a promising marker of prognosis for NMIBC.

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.

Diagnosis of urothelial carcinoma from urine

Urine cytology is the most widely used noninvasive test to detect urothelial tumors. However, it is limited by its low sensitivity. On the other hand, cystoscopy is the gold standard procedure to follow patients with a history of bladder cancer but this test is invasive and costly. Therefore, there is a real need to develop new tests that can be used in bladder cancer surveillance. Several soluble and cell-based markers have been developed and most of them improve the sensitivity of cytology but the specificity is invariably decreased. Of the cell-based tests, two obtained Food and Drug Administration approval. ImmunoCyt/uCyt is a fluorescent test that uses three monoclonal antibodies and UroVysion is an in situ hybridization test, which uses four different probes to different chromosomes. Both tests have a high sensitivity to detect cancer cells and can help to predict urothelial cancer recurrence. ImmunoCyt/uCyt is somewhat better at detecting low-grade tumors but UroVysion is not affected by prior BCG treatment. However, both tests use fluorescent dyes, are time-consuming and require trained personnel. Because of their high negative predictive value, both tests may help the urologist to postpone a number of cystoscopies, especially in patients with low-risk urothelial cancer.

Relationship of Ki67, TP53, MDM-2 and BCL-2 expressions with WHO 1973 and WHO/ISUP grades, tumor category and overall patient survival in urothelial tumors of the bladder

Using the 1998 World Health Organization/International Society of Urological Pathology (WHO/ISUP) (2004 WHO), 1999 WHO/ISUP, and 1973 WHO classifications, we examined Ki67, BCL-2, TP53, and MDM-2 expressions in invasive and noninvasive urothelial neoplasias of the bladder of 72 patients, and compared the results regarding tumor category and grade with clinical outcome to determine the clinicopathological relevance of these classifications. Ki67 and TP53 expressions were correlated with tumor grades of the 1973 WHO classification, and they also distinguished "papillary urothelial neoplasm with low malignant potential" from other WHO/ISUP grades (p < 0.05). No difference was observed for Ki67 and TP53 expressions between the other WHO/ISUP grades (p > 0.05). Neither tumor grade nor tumor category correlated with MDM-2 or BCL-2 expressions (p > 0.05). WHO/ISUP classifications are obviously not superior to the 1973 WHO classification for grading urothelial neoplasia of the bladder. However, if the "papillary urothelial neoplasm with low malignant potential" is distinguished from grade 1 tumors of the 1973 WHO classification, more precise prognostic information may be obtained.

Polymorphisms in NQO1 and the clinical course of urinary bladder neoplasms

OBJECTIVE

Urinary bladder neoplasms differ considerably in biological potential, and tumor morphology alone cannot predict their clinical behaviors. Polymorphisms in xenobiotic metabolic genes reportedly modulate susceptibility to bladder neoplasms and may affect the clinical course and outcomes of the disease. This study was conducted to determine the effect of polymorphisms in the xenobiotic metabolic genes on the disease course and clinical outcomes of urinary bladder neoplasms.

MATERIAL AND METHODS

Patients with urinary bladder neoplasms who had been followed up for a 5-year period were genotyped for NQO1 (R139W, P187S), NAT (rapid/slow), GSTP1 (I105V), GSTT1 and GSTM1 (non-null/null) and MTHFR (A222V, E429A) polymorphisms.

RESULTS

Variant allele carriers of the NQO1 (P187S) polymorphism showed a higher risk for high-stage disease than non-carriers at diagnosis [relative risk (RR)=1.4; 95% CI 1.0-1.8). A higher risk for highly malignant disease (T2+) was also observed in variant allele carriers than non-carriers of the GSTP1 (I105V) polymorphism (RR=1.6; 95% CI 1.1-2.5). NQO1 (R139W) variant allele carrier patients with intermediate malignant disease (TaG3+T1) had shorter disease-free survival than non-carriers (p=0.05). In contrast, carriers of the variant allele for the MTHFR (A222V) polymorphism had significantly longer disease-free survival than non-carriers (p=0.02).

CONCLUSIONS

Our data are consistent with the notion that NQO1 polymorphisms influence the course and clinical outcomes of urinary bladder neoplasms. However, our results need to be confirmed in a large study as most of the associations detected were only of marginal statistical significance, and would be lost on correction for multiple comparisons.

Hsp27 knockdown using nucleotide-based therapies inhibit tumor growth and enhance chemotherapy in human bladder cancer cells

Heat shock protein 27 (Hsp27) is a cytoprotective chaperone that is phosphoactivated during cell stress that prevents aggregation and/or regulate activity and degradation of certain client proteins. Recent evidence suggests that Hsp27 may be involved in tumor progression and the development of treatment resistance in various tumors, including bladder cancer. The purpose of this study was to examine, both in vitro and in vivo, the effects of overexpression of Hsp27 and, correspondingly, the down-regulation of Hsp27 using small interfering (si) RNA and OGX-427, a second-generation antisense oligonucleotide targeting Hsp27. Hsp27 overexpression increased UMUC-3 cell growth and resistance to paclitaxel. Both OGX-427 and Hsp27 siRNA decreased Hsp27 protein and mRNA levels by >90% in a dose- and sequence-specific manner in human bladder cancer UMUC-3 cells. OGX-427 or Hsp27 siRNA treatment induced apoptosis and enhanced sensitivity to paclitaxel in UMUC-3 cells. In vivo, OGX-427 significantly inhibited tumor growth in mice, enhanced sensitivity to paclitaxel, and induced significantly higher levels of apoptosis compared with xenografts treated with control oligonucleotides. Collectively, these findings suggest that Hsp27 knockdown with OGX-427 and combined therapy with paclitaxel could be a novel strategy to inhibit the progression of bladder cancer.

The pathology of bladder cancer: an update on selected issues

OBJECTIVE

To achieve a closer relationship between urologists and pathologists and to use a common language and identical objectives in the pathology of bladder cancer.

METHODS AND RESULTS

Special emphasis was given to an analysis of the new World Health Organization (WHO) grading system, to the interpretation of the last Tumour-Nodes-Metastasis staging rules, and to identifying new markers of prognostic significance in clinical practice. A consensus was achieved on the main points.

CONCLUSIONS

The 2004 WHO grading system must become acceptable to clinicians, perhaps by a minimal modification of the present terminology. Simple transurethral resection-biopsy should be expressed in terms of clinical rather than pathological staging. Although there are substantial improvements, no new markers can be recommended for routine use in histopathology at present.

Cytokeratin-20 and seminal vesicle secretory protein VI as possible marker proteins in urinary bladder preneoplastic lesions induced by N-butyl-N-(4-hydroxybutyl) nitrosamine

BACKGROUND

A simple and non-invasive methods for the diagnosis of transitional cell carcinoma of the bladder are needed for the prevention of invasive tumor. A proteomic technology has recently been developed to facilitate protein profiling of biological mixtures. We tried to detect the marker proteins by proteomic approach during the initiation stages on N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN)-induced bladder carcinogenesis in rats.

METHODS

Ten rats in group A were given 0.05% BBN in drinking water for 12 weeks. Other 10 rats in group B with 10 rats were designated as a control group and were not given BBN. Whole urinary bladders of all rats were excised at 12 weeks from the beginning of the experiment. Conventional proteomics was performed with high resolution 2-dimension gel electrophoresis followed by computational image analysis and protein identification using mass spectrometry.

RESULTS

A comparison of urinary bladder hyperplasia tissue with control tissue showed that five proteins; actin gamma2 propeptide, cytokeratin-20 (CK-20), proapolipoprotein, alpha2 actin (alpha-cardiac actin) and heat shock 27 kDa protein-1 were over-expressed in hyperplastic tissues. Three proteins; transcription factor myocardin, seminal vesicle secretory protein VI (SVS-VI) precursor and hypothetical protein RMT-7 were under-expressed in hyperplastic tissues.

CONCLUSION

In our animal mode, BBN-induced urinary bladder mucosal hyperplasia resulted in an increase in the expression of five proteins and a decrease in the expression of three proteins. Of these, CK-20 and SVS-VI seem to be of particular interest. However other method such as Western blotting seems to be needed for confirmation of these proteins and more information on human bladder tissue is needed for clinical application.

Neuro-Fuzzy Modeling: An Accurate and Interpretable Method for Predicting Bladder Cancer Progression

PURPOSE

New methods are required to improve the prediction of cancer progression as traditional statistical tests have limited accuracy. Accurate predictions would allow physicians to offer specific treatment according to individual patient risk. While predictive improvements are obtained using ANN, the hidden nature of these networks prevents insight and has hindered their widespread implementation. NFM is an alternate form of artificial intelligence using fuzzy logic (which is a multivalued logic which provides reasoning under uncertainty). By defuzzification the NFM rule base becomes transparent to overcome the black box nature of ANN.

MATERIALS AND METHODS

Combinations of clinicopathological (tumor stage and grade, patient age, gender, and smoking status) and molecular (immunohistochemical expression of p53 and methylation status of 11 loci) data from 117 patients were used to develop and compare predictive models of tumor progression using NFM, ANN and LR.

RESULTS

NFM (88% to 100% sensitivity, 97% to 100% specificity and 94% to 100% accuracy) predicted the presence and timing of cancer progression more accurately than ANN (81% to 87%, 95% to 100% and 89% to 90%, p = 0.002) and LR 3%, 61% to 72% and 47% to 53%, p = 0.00005). NFM was able to interrogate the clinicopathological and molecular data, and select the most important parameters (age, grade, stage, smoking, methylation) for progression prediction.

CONCLUSIONS

Intelligent systems and molecular biomarkers improved the accuracy of cancer progression predictions. NFM appeared superior to ANN in terms of accuracy, sensitivity, specificity and transparency. The use of NFM in routine clinical practice warrants further validation.

Antisense oligonucleotide therapy in the management of bladder cancer

PURPOSE OF REVIEW

In this paper, we will review the recent advances in antisense oligonucleotide therapy in the treatment of superficial bladder cancer. Bladder cancer has an exciting potential as a model to study antisense oligonucleotide therapy because of the ease of accessibility of treatment, ease of diagnosis through biopsy and urine cytology, and direct observation of treatment efficacy through cystoscopy and posttreatment biopsy.

RECENT FINDINGS

We will elaborate on the recent developments in the delivery of antisense oligonucleotide and the implications of these results on the use of antisense oligonucleotide intravesically. We will also discuss recent preclinical in-vitro results of antisense oligonucleotide therapy in different bladder cancer cell lines.

SUMMARY

Recent developments of the in-vitro and animal in-vivo effectiveness of antisense treatment in bladder cancer provide the foundation to pursue future phase I clinical trials. Antisense oligonucleotide technology is a promising tool that may become an effective method of treating bladder cancer.

Micropapillary carcinoma of the urothelial tract

Micropapillary carcinoma (MPC) of the bladder is a rare and aggressive variant of bladder carcinoma. The goals of this study are to investigate whether this variant of bladder carcinoma represents a more aggressive disease than conventional urothelial carcinoma (CUC) and to determine the incidence of MPC in our country. A total of 630 urothelial carcinomas diagnosed from 1997 to 2003 at the Department of Pathology, Oncology Hospital, in Mexico City were analyzed to identify MPC. Thirty-eight patients were found to have this diagnosis and along with a group of 76 patients diagnosed with CUC serve as the basis for this study. In 37 patients with MPC, the lesions were located in the bladder, and in 1 patient in the ureter. The mean patients' age at diagnosis was 68 years, and the male-female ratio was 37:1. The initial stage at presentation was high in most of the patients: Three patients had stage T1, 8 had stage T2, 18 had stage T3, and 9 had stage T4. The disease-specific survival rate for patients with MPC at 3.1 years was 39.5% (95% confidence interval [CI], 2.7%-3.4%) whereas for patient with CUC was 55.3% (95% CI, 3.9%-4.4%). Patients with a micropapillary component of more than 50% had a relative mortality risk of 2.4 (1.3-4.2), whereas patients with less than 50% of MPC did not have a significantly increased mortality risk (RR, 1.8; 0.5-6.0). In summary, in this study, MPC was far more aggressive clinically than CUC. In Mexico, the incidence of 6% of MPC in relation to CUC and the male-female ratio of 37.1 for MPC are much higher than reported in the literature.

ImmunoCyt/uCyt+ improves the sensitivity of urine cytology in patients followed for urothelial carcinoma

ImmunoCyt/uCyt is a fluorescent test combining three monoclonal antibodies. In this study, it has been tested as a complement to cytology in the detection of urothelial carcinoma in urine. It has been performed simultaneously with standard cytology and cystoscopy on 870 urine analyses from one hospital. In 136 cases, one or more bladder tumors were found. Overall sensitivity of cytology, ImmunoCyt/uCyt and combined analyses reached 29, 74 and 84%, respectively, and overall specificity was 98, 62 and 61%. The negative predictive value of cytology, ImmunoCyt/uCyt and both analyses was 88, 93 and 95%, respectively, and the positive predictive value was 70, 26 and 29%. The sensitivity of cytology for low malignant potential neoplasms, low- and high-grade papillary carcinomas was 6, 18 and 53%, while it reached 71, 79 and 93% when combined with ImmunoCyt/uCyt. The sensitivity of cytology for stages Ta, T1, T2 and over and Tis tumors was 12, 67, 47 and 50%, while it reached 78, 83, 79 and 100% when combined with ImmunoCyt/uCyt. In the absence of tumor on cystoscopy but with positive ImmunoCyt/uCyt, 18% of patients developed a tumor, 2-6 months later. Of the 109 cases diagnosed as suspicious for malignancy by cytology, a tumor was present in 30 cases and ImmunoCyt/uCyt was positive in 22 (73%) of them. In conclusion, ImmunoCyt/uCyt may be used to postpone cystoscopies in patients followed for bladder cancer and may help to save cytologist and pathologist screening time.