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Re: Fluorescence-Guided Bladder Tumour Resection: Impact on Survival after Radical Cystectomy
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
where lesions less than 1 cm have had approximately a 50% benign rate. They suspect that this difference is due to the many small lesions that they thought were benign that were not pathologically analyzed, and, therefore, are not included in the study. This series has a higher rate of malignancy of small renal masses, likely underestimated due to selection bias. The authors conclude that benign and malignant renal masses have no specific imaging features for differentiation on magnetic resonance imaging. Cary Siegel, MD
Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Fluorescence-Guided Bladder Tumour Resection: Impact on Survival after Radical Cystectomy € fer, C. Schwentner, G. Gakis, T. Ngamsri, S. Rausch, J. Mischinger, T. Todenho M. A. Schmid, F. A. Hassan, M. Renninger and A. Stenzl Department of Urology, Eberhard-Karls University, Tuebingen, Germany World J Urol 2015; Epub ahead of print.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.028 available at http://jurology.com/ Editorial Comment: This is a single institution retrospective study of 244 consecutive patients undergoing radical cystectomy in Germany between 2002 and 2010. The authors examined the impact of transurethral resection (TUR) of bladder tumor (BT) with conventional white light (WL) cystoscopy, using 5-aminolevulinate from 2002 to 2005 and hexaminolevulinate (HAL) from 2006 to 2010. Median followup was 29 months. Patients undergoing some form of fluorescence guided resection underwent more resections than those undergoing WL cystoscopy, which resulted in a longer interval between first TURBT and radical cystectomy for these patients. Despite this “delay,” these patients also had a lower rate of postoperative chemotherapy than patients undergoing white light cystoscopy. Specifically for patients who underwent HAL TURBT there was improved recurrence-free survival, cancer specific survival and overall survival compared to patients undergoing either 5-aminolevulinate or WL TURBT. On multivariable analysis HAL TURBT, along with pathological stage, nodal status and surgical margins, was an independent predictor of recurrence-free, cancer specific and overall survival. Although improved survival analyses were reported in patients undergoing HAL TURBT, I am concerned that these patients, in fact, required and underwent more TUR procedures, which runs counter to what has been previously reported regarding fewer required procedures and decreased recurrence rates. As a result, for a small retrospective study I cannot conclude that HAL TURBT results in improved cystectomy outcomes. Sam S. Chang, MD
Suggested Reading Richards KA, Smith ND and Steinberg GD: The importance of transurethral resection of bladder tumor in the management of nonmuscle invasive bladder cancer: a systematic review of novel technologies. J Urol 2014; 191: 1655. Liu JJ, Droller MJ and Liao JC: New optical imaging technologies for bladder cancer: considerations and perspectives. J Urol 2012; 188: 361.
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BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Re: Improving Selection Criteria for Early Cystectomy in High-Grade T1 Bladder Cancer: A Meta-Analysis of 15,215 Patients W. Martin-Doyle, J. J. Leow, A. Orsola, S. L. Chang and J. Bellmunt University of Massachusetts Medical School, Worcester and Bladder Cancer Center, Dana-Farber Cancer Institute, and Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, and Institut Hospital del Mar d’Investigacions Me´diques, Barcelona, Spain J Clin Oncol 2015; 33: 643e650.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.029 available at http://jurology.com/ Editorial Comment: In a meta-analysis initially reviewing more than 15,000 abstracts the authors focused on 73 studies that included more than 15,000 patients with high grade T1 bladder cancer. The 5-year recurrence, progression and cancer specific survival rates were 42%, 21% and 87%, respectively. The highest impact factor for progression (HR 3.34, p <0.001) and cancer specific survival (HR 2.02, p ¼ 0.001) was extensive T1 depth of invasion (T1b/c vs T1a). Commonly and previously cited prognostic factors also proved to predict progression and survival outcomes. These factors included lymphovascular invasion, associated carcinoma in situ, nonuse of bacillus Calmette-Gu erin, tumor size greater than 3 cm and older age. The interplay of these factors and individual medical conditions and desires influence the decision to move to what I call “timely” cystectomy as opposed to “early” cystectomy. The cancer cure rates with cystectomy should always be considered and balanced with the need to proceed and the morbidity associated with the surgical procedure. Although the authors advocate for depth of invasion to be included in the TNM staging criteria, they do not offer specific changes in staging classification. Sam S. Chang, MD
Suggested Reading Umbreit E, Shimko M, Wilson T et al: Delayed cystectomy increases the risk of systemic progression for T1 bladder cancer. J Urol, suppl., 2012; 187: e677. abstract 1676. Sternberg I, Baldinger L, Mano R et al: Can muscle-invasive bladder cancer be predicted in patients with clinical T1 disease? J Urol, suppl., 2014; 191: e538. abstract PD18-08.
Re: Randomized Trial of Narrow-Band versus White-Light Cystoscopy for Restaging (Second-Look) Transurethral Resection of Bladder Tumors H. W. Herr Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York Eur Urol 2015; 67: 605e608.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.030 available at http://jurology.com/ Editorial Comment: Patients were randomized 1 to 1 to undergo repeat transurethral resection of bladder tumor using either narrow band imaging (NBI) or standard white light (WL) cystoscopy. Main outcomes were number of patients who were tumor-free at 2 years and 2-year recurrence-free survival rate. Interestingly patients underwent NBI resection after NBI and WL cystoscopy. Within 2 years 22% of the NBI group vs 33% of the WL group had recurrence (p ¼ 0.05). Mean recurrencefree survival was 22 months for the NBI group and 19 months for the WL group (p ¼ 0.02). Having used the NBI technique as well as others (eg CysviewÒ), I believe that I see better, I am less likely to miss a small tumor and I resect more completely. In addition, I have diagnosed and obtained tissue verification of urothelial carcinoma in patients who were described as having a normal bladder at cystoscopy. I agree wholeheartedly with Herr that continued study is necessary for this technique and others. Do patients not deserve the best visualization possible for the surgeon performing transurethral resection? Sam S. Chang, MD
where lesions less than 1 cm have had approximately a 50% benign rate. They suspect that this difference is due to the many small lesions that they thought were benign that were not pathologically analyzed, and, therefore, are not included in the study. This series has a higher rate of malignancy of small renal masses, likely underestimated due to selection bias. The authors conclude that benign and malignant renal masses have no specific imaging features for differentiation on magnetic resonance imaging. Cary Siegel, MD
Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Fluorescence-Guided Bladder Tumour Resection: Impact on Survival after Radical Cystectomy € fer, C. Schwentner, G. Gakis, T. Ngamsri, S. Rausch, J. Mischinger, T. Todenho M. A. Schmid, F. A. Hassan, M. Renninger and A. Stenzl Department of Urology, Eberhard-Karls University, Tuebingen, Germany World J Urol 2015; Epub ahead of print.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.028 available at http://jurology.com/ Editorial Comment: This is a single institution retrospective study of 244 consecutive patients undergoing radical cystectomy in Germany between 2002 and 2010. The authors examined the impact of transurethral resection (TUR) of bladder tumor (BT) with conventional white light (WL) cystoscopy, using 5-aminolevulinate from 2002 to 2005 and hexaminolevulinate (HAL) from 2006 to 2010. Median followup was 29 months. Patients undergoing some form of fluorescence guided resection underwent more resections than those undergoing WL cystoscopy, which resulted in a longer interval between first TURBT and radical cystectomy for these patients. Despite this “delay,” these patients also had a lower rate of postoperative chemotherapy than patients undergoing white light cystoscopy. Specifically for patients who underwent HAL TURBT there was improved recurrence-free survival, cancer specific survival and overall survival compared to patients undergoing either 5-aminolevulinate or WL TURBT. On multivariable analysis HAL TURBT, along with pathological stage, nodal status and surgical margins, was an independent predictor of recurrence-free, cancer specific and overall survival. Although improved survival analyses were reported in patients undergoing HAL TURBT, I am concerned that these patients, in fact, required and underwent more TUR procedures, which runs counter to what has been previously reported regarding fewer required procedures and decreased recurrence rates. As a result, for a small retrospective study I cannot conclude that HAL TURBT results in improved cystectomy outcomes. Sam S. Chang, MD
Suggested Reading Richards KA, Smith ND and Steinberg GD: The importance of transurethral resection of bladder tumor in the management of nonmuscle invasive bladder cancer: a systematic review of novel technologies. J Urol 2014; 191: 1655. Liu JJ, Droller MJ and Liao JC: New optical imaging technologies for bladder cancer: considerations and perspectives. J Urol 2012; 188: 361.
1229
1230
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Re: Improving Selection Criteria for Early Cystectomy in High-Grade T1 Bladder Cancer: A Meta-Analysis of 15,215 Patients W. Martin-Doyle, J. J. Leow, A. Orsola, S. L. Chang and J. Bellmunt University of Massachusetts Medical School, Worcester and Bladder Cancer Center, Dana-Farber Cancer Institute, and Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, and Institut Hospital del Mar d’Investigacions Me´diques, Barcelona, Spain J Clin Oncol 2015; 33: 643e650.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.029 available at http://jurology.com/ Editorial Comment: In a meta-analysis initially reviewing more than 15,000 abstracts the authors focused on 73 studies that included more than 15,000 patients with high grade T1 bladder cancer. The 5-year recurrence, progression and cancer specific survival rates were 42%, 21% and 87%, respectively. The highest impact factor for progression (HR 3.34, p <0.001) and cancer specific survival (HR 2.02, p ¼ 0.001) was extensive T1 depth of invasion (T1b/c vs T1a). Commonly and previously cited prognostic factors also proved to predict progression and survival outcomes. These factors included lymphovascular invasion, associated carcinoma in situ, nonuse of bacillus Calmette-Gu erin, tumor size greater than 3 cm and older age. The interplay of these factors and individual medical conditions and desires influence the decision to move to what I call “timely” cystectomy as opposed to “early” cystectomy. The cancer cure rates with cystectomy should always be considered and balanced with the need to proceed and the morbidity associated with the surgical procedure. Although the authors advocate for depth of invasion to be included in the TNM staging criteria, they do not offer specific changes in staging classification. Sam S. Chang, MD
Suggested Reading Umbreit E, Shimko M, Wilson T et al: Delayed cystectomy increases the risk of systemic progression for T1 bladder cancer. J Urol, suppl., 2012; 187: e677. abstract 1676. Sternberg I, Baldinger L, Mano R et al: Can muscle-invasive bladder cancer be predicted in patients with clinical T1 disease? J Urol, suppl., 2014; 191: e538. abstract PD18-08.
Re: Randomized Trial of Narrow-Band versus White-Light Cystoscopy for Restaging (Second-Look) Transurethral Resection of Bladder Tumors H. W. Herr Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York Eur Urol 2015; 67: 605e608.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.030 available at http://jurology.com/ Editorial Comment: Patients were randomized 1 to 1 to undergo repeat transurethral resection of bladder tumor using either narrow band imaging (NBI) or standard white light (WL) cystoscopy. Main outcomes were number of patients who were tumor-free at 2 years and 2-year recurrence-free survival rate. Interestingly patients underwent NBI resection after NBI and WL cystoscopy. Within 2 years 22% of the NBI group vs 33% of the WL group had recurrence (p ¼ 0.05). Mean recurrencefree survival was 22 months for the NBI group and 19 months for the WL group (p ¼ 0.02). Having used the NBI technique as well as others (eg CysviewÒ), I believe that I see better, I am less likely to miss a small tumor and I resect more completely. In addition, I have diagnosed and obtained tissue verification of urothelial carcinoma in patients who were described as having a normal bladder at cystoscopy. I agree wholeheartedly with Herr that continued study is necessary for this technique and others. Do patients not deserve the best visualization possible for the surgeon performing transurethral resection? Sam S. Chang, MD