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Elbæk SK, Andreasen TG, Taber A, Young-Halvorsen K, Neijber A, Jensen JB, Dyrskjøt L. Immune Contexture Changes Following Blue Light Cystoscopy with Hexaminolevulinate in Bladder Cancer. EUR UROL SUPPL 2023; 58:37-46. [PMID: 38152487 PMCID: PMC10751544 DOI: 10.1016/j.euros.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/29/2023] Open
Abstract
Background Transurethral resection of bladder tumor (TURBT) is a central component in the diagnosis of non-muscle-invasive bladder cancer (NMIBC) and can be guided by several optical imaging techniques for better visualization of lesions. Objective To investigate if a change in tumor microenvironment (TME) composition could be observed as an effect of hexaminolevulinate (HAL)-assisted blue light cystoscopy (BLC) in TURBT samples from patients with bladder cancer. Design setting and participants This was a retrospective study of 40 patients with bladder cancer who underwent either BLC-guided TURBT (n = 20) or white light cystoscopy (WLC)-guided TURBT (n = 20) before radical cystectomy (RC). Tissue samples (n = 80) were collected from paired TURBT and RC specimens for all 40 patients. Tumor tissue was stained using multiplex immunofluorescence and immunohistochemistry. Outcome measurements and statistical analysis Immune cell infiltration was assessed according to the proportions of each immune cell or immune evasion marker and the relative change from TURBT as baseline was calculated. Statistical comparisons between groups were performed using the Wilcoxon rank-sum test or the paired-sample Wilcoxon test. Results and limitations Comparison of relative changes in the TME revealed a significant decrease in stromal infiltration of cytotoxic T cells (p = 0.024), B cells (p = 0.041), and stromal cells expressing PD-1 (p = 0.011) in patients treated with BLC-guided TURBT compared to WLC-guided TURBT. Conclusions Our pilot study showed that HAL-BLC during TURBT in bladder cancer may influence the immune cell composition and TME. Patient summary We investigated the potential therapeutic effect of blue light versus white light for guidance in removing bladder tumors via the urethra in patients with bladder cancer. For blue light guidance, a compound called hexaminolevulinate is used to visualize tumor tissue. We found changes in immune cell composition that may have been influenced by the blue light guidance.
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Affiliation(s)
| | | | - Ann Taber
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Anders Neijber
- Global Medical Affairs and Clinical Development, Photocure ASA, Oslo, Norway
| | - Jørgen Bjerggaard Jensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Dyrskjøt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
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Pohar KS, Patel S, Lotan Y, Trabulsi E, Woods M, Downs T, Huang WC, Jones J, Taylor J, O'Donnell M, Bivalacqua TJ, DeCastro J, Steinberg G, Kamat AM, Resnick MJ, Konety B, Schoenberg M, Jones JS, Daneshmand S. Safety of repeat blue light cystoscopy with hexaminolevulinate (HAL) in the management of bladder cancer: Results from a phase III, comparative, multi-center study. Urol Oncol 2022; 40:382.e1-382.e6. [PMID: 35750559 DOI: 10.1016/j.urolonc.2022.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 04/03/2022] [Accepted: 04/25/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE The therapeutic benefit of intravesical instillation of hexaminolevulinate (HAL) at the time of transurethral resection of bladder tumor (TURBT) has been demonstrated in multiple studies. The purpose of this study was to prospectively assess the safety of repeated administration of HAL from a phase III pre-trial planned analysis. MATERIALS AND METHODS All patients evaluated in the study received at least 1 dose of HAL at the time of office cystoscopy, and a subset of these patients (n = 103, 33.2%) received a second dose a few weeks later at the time of TURBT. Adverse events (AEs) were recorded, and the safety of repeat use of HAL was determined by comparing the proportion of patients with AEs considered causally related to HAL in the surveillance examination compared to the OR examination. Association between categorical variables was tested using Fisher's Exact Test, and a P < 0.05 was considered statistically significant. RESULTS HAL-related AEs were experienced by 6 patients (2.2%) during surveillance cystoscopy and 3 patients (3.4%) following TURBT (P = 0.76); 181 patients (59.5%) had prior exposure to HAL before enrolling in the study with no difference in the number of AEs when comparing prior exposure to HAL to no prior exposure (P = 0.76). Of the patients who previously received intravesical therapy, 8 (2.9%) had at least 1 AE during surveillance compared to 3 (9.7%) who had no prior intravesical therapy (P = 0.09). CONCLUSIONS Repeat use of HAL is safe even when administered within a few weeks of receiving a dose of intravesical therapy.
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Affiliation(s)
- Kamal S Pohar
- Department of Urology, The Ohio State University, Columbus, OH.
| | - Sanjay Patel
- Department of Urology, University of Oklahoma, Oklahoma City, OK
| | - Yair Lotan
- Department of Urology, UT Southwestern Medical Center, Dallas, TX
| | - Edouard Trabulsi
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | | | - Tracy Downs
- Department of Urology, University of Virginia, Charlottesville, VA
| | - William C Huang
- Department of Urology, New York University School of Medicine, New York, NY
| | | | | | | | | | - Joel DeCastro
- Department of Urology, Columbia University Medical Center, New York, NY
| | - Gary Steinberg
- Department of Urology, New York University Langone Health, New York, NY
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Siamak Daneshmand
- Department of Urology, University of Southern California, Los Angeles, CA
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Lewicki P, Arenas-Gallo C, Qiu Y, Venkat S, Basourakos SP, Scherr D, Shoag JE. Underutilization of Blue Light Cystoscopy for Bladder Cancer in the United States. Eur Urol Focus 2021; 8:968-971. [PMID: 34711530 DOI: 10.1016/j.euf.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/21/2021] [Accepted: 09/30/2021] [Indexed: 11/30/2022]
Abstract
Blue light cystoscopy (BLC) during transurethral resection of bladder tumor (TURBT) is guideline-recommended as it improves cancer detection and decreases recurrence of the disease. However, the extent to which BLC is used has not been established. We studied BLC use in the Premier Healthcare Database, a large, national sample that captured 158 870 index TURBT procedures between January 2011 and March 2020. Billing data were queried for the administration of hexaminolevulinate at TURBT as a proxy for BLC, and logistic regression models were constructed to identify variables associated with BLC use. BLC was used in 1.2% of index TURBT procedures over the study period. Its use increased following the American Urological Association non-muscle-invasive bladder cancer guideline publication in October 2016 but plateaued in late 2018. After adjusting for patient characteristics, higher odds for BLC use were found for academic hospitals and hospitals with higher TURBT volumes and higher radical cystectomy volumes. Within hospitals with BLC capability, predictors of a surgeon never using BLC included low surgeon TURBT volumes, low surgeon radical cystectomy volumes, and lack of mitomycin C use. Our findings highlight a concerning underutilization and stagnation in the adoption of evidence and guideline-supported intervention. PATIENT SUMMARY: Use of blue light visualization of the bladder improves the detection of cancer during removal of bladder tumors via the urethra. We reviewed records in a large US database for use of this technique and found that it is being underutilized. Since this technique improves detection of cancer in the bladder so that it can be removed to reduce recurrence, blue light visualization should be more widely used.
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Affiliation(s)
- Patrick Lewicki
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Camilo Arenas-Gallo
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Yuqing Qiu
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Siv Venkat
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Spyridon P Basourakos
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Douglas Scherr
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Jonathan E Shoag
- Department of Urology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA; Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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Abstract
PURPOSE OF REVIEW It has been firmly established that hexaminolevulinate-assisted blue light cystoscopy (HAL-BLC) reduces cancer recurrence rates. This review explores the impact of HAL-BLC on other meaningful outcomes in patients with bladder cancer, including disease progression, and earlier detection of disease at the time of surveillance cystoscopy. RECENT FINDINGS A randomized clinical trial confirmed earlier implementation of HAL-BLC at the time of surveillance cystoscopy increased identification of cancerous lesions, including those of high grade, when compared with white light cystoscopy. In addition, the evidence is evolving that the use of HAL-BLC at the time of endoscopic treatment of high-risk tumors may lead to lower rates of progression to muscle invasion, and this in part may be due to better risk stratification leading to changes in treatment plan. The clinical contexts for the use of HAL-BLC are broader than prior knowledge. It is also becoming more clear that the positive impact of HAL-BLC is likely more than just reducing cancer recurrence rates, and patients would benefit from the technology at many time points in the management and follow-up of their disease.
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Affiliation(s)
- Kamal S Pohar
- Department of Urology, The Ohio State University, Suite 3000, 915 Olentangy River Rd, Columbus, OH, 43212, USA.
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Doisy L, Walz J, Fakhfakh S, Rybikowski S, Koskas Y, Gravis G, Pignot G. [Is a routine second transurethral resection of the bladder still necessary after hexaminolévulinate photodynamic diagnosis-assisted TURBT?]. Prog Urol 2019; 29:332-339. [PMID: 31104952 DOI: 10.1016/j.purol.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 01/13/2019] [Accepted: 04/18/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The aim of our study was to assess the impact of blue light cystoscopy with hexaminolevulinate on residual tumor rates at second-look transurethral resection of the bladder (TURB). MATERIAL AND METHODS Among all patients undergoing TURB in our center between 2012 and 2017, 52 patients had a second-look after a first complete TURB with a delay<3months. We compare patients with standard white light cystoscopy/TURB then second-look blue light cystoscopy/re-TURB (group A, n=30) and patients with blue light cystoscopy/TURB at the initial procedure then white light cystoscopy/re-TURB (group B, n=22). The residual tumor rates at second-look, restaging and changing in therapeutic strategy, as well as recurrence free survival and progression rate were compared. RESULTS Residual tumor at the time of second-look cystoscopy was detected in 42.3% of cases in our cohort, with a significant difference between the two groups (63.3% in group A versus 0% in group B, <0.001). In group A, 16.7% (5/30) of patients had upstaging and/or upgrading at second-look cystoscopy, resulting in a change in therapeutic strategy in most cases (4/5) while none upstaging was observed in group B. In multivariate analysis, the use of luminofluorescence at the first TURB was the only independent predictive factor of residual tumor (P=0.0031). CONCLUSION The quality of the initial TURB, when performed by using blue light cystoscopy, had a significant impact on the rate of residual tumor at the second-look resection and could modify therapeutic strategy of NMIBC. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- L Doisy
- Service de chirurgie oncologique 2, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France.
| | - J Walz
- Service de chirurgie oncologique 2, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France.
| | - S Fakhfakh
- Service de chirurgie oncologique 2, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France.
| | - S Rybikowski
- Service de chirurgie oncologique 2, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France.
| | - Y Koskas
- Service de chirurgie oncologique 2, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France.
| | - G Gravis
- Service de chirurgie oncologique 2, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France.
| | - G Pignot
- Service de chirurgie oncologique 2, institut Paoli-Calmettes, 232, boulevard de Sainte-Marguerite, 13009 Marseille, France.
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Pederzoli F, Murati Amador B, Samarska I, Lombardo KA, Kates M, Bivalacqua TJ, Matoso A. Diagnosis of urothelial carcinoma in situ using blue light cystoscopy and the utility of immunohistochemistry in blue light-positive lesions diagnosed as atypical. Hum Pathol 2019; 90:1-7. [PMID: 31071342 DOI: 10.1016/j.humpath.2019.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/22/2019] [Accepted: 04/28/2019] [Indexed: 11/28/2022]
Abstract
Carcinoma in situ (CIS) is difficult to visualize with white light cystoscopy (WLC), whereas blue light cystoscopy (BLC) using photosensitizing agents improves detection rates. We retrospectively reviewed transurethral biopsies of bladder tumors in which both WLC and BLC evaluations were performed (n = 135 samples from 79 patients). Biopsies were classified based on the presence/absence of fluorescence under BLC and the final pathological report (CIS/benign/atypical). Forty-one (30%) cases were diagnosed as CIS; of those, 38 (93%) were BLC(+), including 23 that were WLC(-). Conversely, 51 (38%) lesions were BLC(+) but classified as non-CIS. Eleven BLC(+) cases were diagnosed as "atypical." These cases were anonymized and reviewed by 7 pathologists for concordance and then immunostained for CK20, p53, and Ki-67. Immunohistochemistry results were interpreted as consistent with CIS if there was full-thickness staining of CK20, more than 50% p53-positive cells, and more than 50% Ki-67-positive cells. Review of BLC(+)/atypical cases showed a mean agreement of 79%, and none of the cases showed staining pattern consistent with CIS. Therefore, all 11 cases of BLC(+)/atypical were considered non-CIS for the final analysis. All patients with BLC(+)/atypical lesions had a history of intravesical Bacillus Calmette-Guerin and/or mitomycin. Using final pathology as the reference, sensitivity, specificity, and negative predictive value of BLC were 93% (confidence interval [CI], 80.1%-98.5%), 46% (CI, 35.4%-56.3%), and 94% (CI, 82.5%-97.8%), respectively. The low specificity of BLC leads to BLC(+) lesions with atypical diagnosis. Morphological classification of these lesions is fairly consistent among different pathologists. Immunohistochemistry for p53/CK20/Ki-67 in this setting is only helpful to potentially avoid overcalling CIS.
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Affiliation(s)
- Filippo Pederzoli
- Vita-Salute San Raffaele University, Milan 20132, Italy; Urology, The Johns Hopkins Medical Institutions, , Baltimore, MD 21231, USA
| | - Belkiss Murati Amador
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231, USA
| | - Iryna Samarska
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231, USA; Pathology, Maastricht University Medical Center, Maastricht, Netherlands, 6229 HX
| | - Kara A Lombardo
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231, USA; Johns Hopkins Greenberg Bladder Cancer Institute, Baltimore, MD 21231, USA
| | - Max Kates
- Urology, The Johns Hopkins Medical Institutions, , Baltimore, MD 21231, USA; Johns Hopkins Greenberg Bladder Cancer Institute, Baltimore, MD 21231, USA; Oncology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231, USA
| | - Trinity J Bivalacqua
- Urology, The Johns Hopkins Medical Institutions, , Baltimore, MD 21231, USA; Johns Hopkins Greenberg Bladder Cancer Institute, Baltimore, MD 21231, USA; Oncology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231, USA
| | - Andres Matoso
- Urology, The Johns Hopkins Medical Institutions, , Baltimore, MD 21231, USA; Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231, USA; Johns Hopkins Greenberg Bladder Cancer Institute, Baltimore, MD 21231, USA; Oncology, The Johns Hopkins Medical Institutions, Baltimore, MD 21231, USA.
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Daneshmand S, Bazargani ST, Bivalacqua TJ, Holzbeierlein JM, Willard B, Taylor JM, Liao JC, Pohar K, Tierney J, Konety B. Blue light cystoscopy for the diagnosis of bladder cancer: Results from the US prospective multicenter registry. Urol Oncol 2018; 36:361.e1-361.e6. [PMID: 29859728 DOI: 10.1016/j.urolonc.2018.04.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 04/16/2018] [Accepted: 04/23/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Blue light cystoscopy (BLC) using hexaminolevulinate (HAL/Cysview/Hexvix) has been previously shown to improve detection of non-muscle-invasive bladder cancer (NMIBC). Herein, we evaluated the detection of malignant lesions in a heterogenous group of patients in the real world setting and documented the change in risk category due to upstaging or upgrading. METHODS Prospective enrollment during April 2014 to December 2016 of consecutive adult patients with suspected or known non-muscle-invasive bladder cancer based on prior cystoscopy or imaging, undergoing transurethral resection of bladder tumor at 9 different referral medical centers. HAL was instilled in the bladder for 1 to 3 hours before evacuation and inspection. Sensitivity and specificity of BLC, white light cystoscopy (WLC), and the combination of both BLC and WLC for detection of any malignancy was reported on final pathology. Number of patients with a change in American Urological Association (AUA) risk category based on BLC findings leading to a possible change in management and adverse events were recorded. RESULTS Overall, 1,632 separate samples from bladder resection or biopsy were identified from 641 BLC procedures on 533 patients: 85 (16%) underwent repeat BLC (range: 2-5). Sensitivity of WLC, BLC, and the combination for diagnosis of any malignant lesion was 76%, 91%, and 98.5%, respectively. Addition of BLC to standard WLC increased detection rate by 12% for any papillary lesion and 43% for carcinoma in-situ. Within the WLC negative group, an additional 206 lesions in 133 (25%) patients were detected exclusively with BLC. In multifocal disease, BLC resulted in AUA risk-group migration occurred in 33 (6%) patients and a change in recommended management in 74 (14%). False-positive rate was 25% for WLC and 30% for BLC. One mild dermatologic hypersensitivity reaction (0.2%). CONCLUSIONS BLC increases detection rates of carcinoma in-situ and papillary lesions over WLC alone and can change management in 14% of cases. Repeat use of HAL for BLC is safe.
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Affiliation(s)
- Siamak Daneshmand
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
| | - Soroush T Bazargani
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD
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Abstract
Photodynamic diagnostic technique with blue light cystoscopy (BLC) takes advantage of the preferential uptake and accumulation of protoporphyrins in neoplastic tissue which emit a red fluorescence when illuminated with blue light (360-450 nm wavelengths). This allows enhanced visualization of small papillary tumors and flat carcinoma in situ lesions that might have been missed on white light cystoscopy (WLC). There is compelling evidence that the ability of BLC to detect these additional tumors translates into improved recurrence rates compared to WLC. However, the impact of BLC with regard to progression rates and in patients who are managed with intravesical therapy is not yet known. Further work is required to optimize the integration of BLC into clinical practice, but the future for BLC appears promising.
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Krishna SR, Konety BR. Current Concepts in the Management of Muscle Invasive Bladder Cancer. Indian J Surg Oncol 2017; 8:74-81. [PMID: 28127187 PMCID: PMC5236024 DOI: 10.1007/s13193-016-0586-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022] Open
Abstract
Bladder cancer is the ninth most common cancer in the world. Twenty to twenty-five percent of all newly diagnosed bladder cancers are muscle invasive in nature, and further, 20-25% of patients who are diagnosed with high-risk non-muscle invasive disease will eventually progress to muscle invasive disease in due course of time irrespective of adjuvant intravesical therapies. Availability of newer imaging modalities improves appropriate identification of patients with muscle invasive disease. Radical cystectomy remains the mainstay of treatment for management of muscle invasive disease. Availability of neoadjuvant chemotherapy has improved overall survival. Risk stratification systems are now in consideration to identify patients who benefit maximally from neoadjuvant chemotherapy. Urinary diversion is a major cause of morbidity in these patients, and several strategies are being employed to reduce morbidity. In this article, we review available literature on various aspects of management of muscle invasive disease.
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Affiliation(s)
- Suprita R. Krishna
- Department of Urology, University of Minnesota, Minneapolis, MN 55455 USA
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Bach T, Bastian PJ, Blana A, Kaminsky A, Keller S, Knoll T, Lang C, Promnitz S, Ubrig B, Keller T, Qvick B, Burger M; OPTIC III Study Group. Optimised photodynamic diagnosis for transurethral resection of the bladder (TURB) in German clinical practice: results of the noninterventional study OPTIC III. World J Urol 2017; 35:737-44. [PMID: 27578233 DOI: 10.1007/s00345-016-1925-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/13/2016] [Indexed: 11/04/2022] Open
Abstract
Purpose White light cystoscopy (WLC) is the standard procedure for visualising non-muscle invasive bladder cancer (NMIBC). However, WLC can fail to detect all cancerous lesions, and outcomes with transurethral resection of the bladder differ between institutions, controlled trials, and possibly between trials and routine application. This noninterventional study assessed the benefit of hexaminolevulinate blue light cystoscopy (HALC; Hexvix®, Ipsen Pharma GmbH, Germany) plus WLC versus WLC alone in routine use. Methods From May 2013 to April 2014, 403 patients with suspected NMIBC were screened from 30 German centres to perform an unprecedented detailed assessment of the additional detection of cancer lesions with HALC versus WLC alone. Results Among the histological results for 929 biopsy samples, 94.3 % were obtained from suspected cancerous lesions under either WLC or HALC: 59.5 % were carcinoma tissue and 40.5 % were non-cancerous tissue. Of all cancer lesions, 62.2 % were staged as Ta, 20.1 % as T1, 9.3 % as T2, 7.3 % as carcinoma in situ (CIS), and 1.2 % were unknown. Additional cancer lesions (+6.8 %) and CIS lesions (+25 %, p < 0.0001) were detected by HALC plus WLC versus WLC alone. In 10.0 % of patients, ≥1 additional positive lesion was detected with HALC, and 2.2 % of NMIBC patients would have been missed with WLC alone. No adverse events were observed. Conclusions The results of this study demonstrate that HALC significantly improves the detection of NMIBC versus WLC alone in routine clinical practice in Germany. While this benefit is statistically significant across all types of NMIBC, it seems most relevant in CIS.
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