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Correlation Between Clinical and Pathological Staging in a Series of Radical Cystectomies for Bladder Carcinoma
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BLADDER, PENIS AND URETHRAL CANCER AND BASIC PRINCIPLES OF ONCOLOGY tumour upstaging in the cystectomy specimen. Results: LNMs were diagnosed in 33 patients (15%). After multivariate analysis modelling, the number of TURBTs and tumour upstaging in the cystectomy specimen were correlated with the prevalence of LNMs at cystectomy. The number of TURBTs increased the prevalence of LNMs from 8% in patients with one TURBT to 24% in those with two to four TURBTs. Tumour upstaging in the cystectomy specimen increased the prevalence of LNMs from 4% to 36%. Conclusion: Inappropriate delay and inadequate staging of high-grade non-muscle invasive TCC of the bladder are to be avoided. The present multivariate analysis showed that the number of TURBTs and tumour upstaging in the cystectomy specimen correlated with an increased prevalence of LNMs. Editorial Comment: There are increasing data that confirm surveillance for progression of bladder cancer is only truly effective in patients who do not have any progression. Once progression has occurred the prognosis worsens. This study suggests lymph node metastases are correlated with the number of previous transurethral resections and up staging. There is no doubt that there is some percentage of patients who die of bladder cancer because cystectomy is delayed. The impact of this delay in some cases on the overall mortality rate for bladder cancer is uncertain but individual cases are certainly devastating for the urologist and the patient. James E. Montie, M.D.
Correlation Between Clinical and Pathological Staging in a Series of Radical Cystectomies for Bladder Carcinoma V. Ficarra, O. Dalpiaz, N. Alrabi, G. Novara, A. Galfano and W. Artibani, Department of Urology, University of Verona, Verona, Italy. BJU Int, 86: 786 –790, 2006 Objective: To analyse the rate of concordance between the clinical and pathological Tumour-Nodes-Metastasis staging systems in a homogeneous series of patients who had undergone radical cystectomy for locally advanced or recurrent multifocal superficial bladder carcinoma. Patients and methods The clinical data of 156 patients who had undergone radical cystectomy and bilateral iliaco-obturator lymphadenectomy for bladder cancer in our department were analysed retrospectively. Results: The clinical stage of the primary tumour was carcinoma in situ in three patients (1.9%), cT1 in 67 (42.9%), cT2 in 70 (44.8%), cT3 in five (3.2%) and cT4 in nine (5.8%). Clinical lymph node involvement was detected in 19 patients (12.2%). The differences between clinical and pathological stages were statistically significant (P ⬍ 0.001), the concordance was moderate ( ⫽ 0.27, P ⬍ 0.001). Of the 70 patients with ⱕcT1, 40 (57%) were reconfirmed as having pathological stage ⱕT1; of the 70 with cT2, 16 (23%) had pT2 carcinoma. Of the 140 patients with clinically organ-confined (ⱕT2) neoplasms, 70 (50%) had been understaged after radical cystectomy. The clinical and pathological systems were statistically overlapping for locally advanced cases only. Pathological lymph node involvement was diagnosed in 45 patients (28.8%); this was foreseen with pelvic computed tomography in 19 (12%) only (P ⬍ 0.001). All patients designated cN⫹ were also pN⫹. Conclusion: These data confirm the high risk of clinical understaging of both local extension of the primary tumour and lymph node involvement. Editorial Comment: This retrospective analysis of 156 patients demonstrates a high degree of clinical under staging. The efficacy of neoadjuvant chemotherapy in higher stage disease creates a greater burden regarding accurately predicting pathological stage. More aggressive transurethral resection for staging purposes and improved imaging, potentially with magnetic resonance, must be evaluated prospectively. James E. Montie, M.D.
Nested Variant of Urothelial Carcinoma: A Clinicopathologic and Immunohistochemical Study of 12 Cases O. Lin, M. Cardillo, G. Dalbagni, I. Linkov, B. Hutchinson and V. E. Reuter, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York Mod Pathol, 16: 1289 –1298, 2003 Nested variant of urothelial carcinoma is characterized by confluent small nests and abortive tubules of mildly atypical neoplastic cells infiltrating the lamina propria and/or muscularis propria of the bladder. Despite its deceptively bland histomorphologic appearance, the lesion is reported to have an aggressive
BLADDER, PENIS AND URETHRAL CANCER AND BASIC PRINCIPLES OF ONCOLOGY tumour upstaging in the cystectomy specimen. Results: LNMs were diagnosed in 33 patients (15%). After multivariate analysis modelling, the number of TURBTs and tumour upstaging in the cystectomy specimen were correlated with the prevalence of LNMs at cystectomy. The number of TURBTs increased the prevalence of LNMs from 8% in patients with one TURBT to 24% in those with two to four TURBTs. Tumour upstaging in the cystectomy specimen increased the prevalence of LNMs from 4% to 36%. Conclusion: Inappropriate delay and inadequate staging of high-grade non-muscle invasive TCC of the bladder are to be avoided. The present multivariate analysis showed that the number of TURBTs and tumour upstaging in the cystectomy specimen correlated with an increased prevalence of LNMs. Editorial Comment: There are increasing data that confirm surveillance for progression of bladder cancer is only truly effective in patients who do not have any progression. Once progression has occurred the prognosis worsens. This study suggests lymph node metastases are correlated with the number of previous transurethral resections and up staging. There is no doubt that there is some percentage of patients who die of bladder cancer because cystectomy is delayed. The impact of this delay in some cases on the overall mortality rate for bladder cancer is uncertain but individual cases are certainly devastating for the urologist and the patient. James E. Montie, M.D.
Correlation Between Clinical and Pathological Staging in a Series of Radical Cystectomies for Bladder Carcinoma V. Ficarra, O. Dalpiaz, N. Alrabi, G. Novara, A. Galfano and W. Artibani, Department of Urology, University of Verona, Verona, Italy. BJU Int, 86: 786 –790, 2006 Objective: To analyse the rate of concordance between the clinical and pathological Tumour-Nodes-Metastasis staging systems in a homogeneous series of patients who had undergone radical cystectomy for locally advanced or recurrent multifocal superficial bladder carcinoma. Patients and methods The clinical data of 156 patients who had undergone radical cystectomy and bilateral iliaco-obturator lymphadenectomy for bladder cancer in our department were analysed retrospectively. Results: The clinical stage of the primary tumour was carcinoma in situ in three patients (1.9%), cT1 in 67 (42.9%), cT2 in 70 (44.8%), cT3 in five (3.2%) and cT4 in nine (5.8%). Clinical lymph node involvement was detected in 19 patients (12.2%). The differences between clinical and pathological stages were statistically significant (P ⬍ 0.001), the concordance was moderate ( ⫽ 0.27, P ⬍ 0.001). Of the 70 patients with ⱕcT1, 40 (57%) were reconfirmed as having pathological stage ⱕT1; of the 70 with cT2, 16 (23%) had pT2 carcinoma. Of the 140 patients with clinically organ-confined (ⱕT2) neoplasms, 70 (50%) had been understaged after radical cystectomy. The clinical and pathological systems were statistically overlapping for locally advanced cases only. Pathological lymph node involvement was diagnosed in 45 patients (28.8%); this was foreseen with pelvic computed tomography in 19 (12%) only (P ⬍ 0.001). All patients designated cN⫹ were also pN⫹. Conclusion: These data confirm the high risk of clinical understaging of both local extension of the primary tumour and lymph node involvement. Editorial Comment: This retrospective analysis of 156 patients demonstrates a high degree of clinical under staging. The efficacy of neoadjuvant chemotherapy in higher stage disease creates a greater burden regarding accurately predicting pathological stage. More aggressive transurethral resection for staging purposes and improved imaging, potentially with magnetic resonance, must be evaluated prospectively. James E. Montie, M.D.
Nested Variant of Urothelial Carcinoma: A Clinicopathologic and Immunohistochemical Study of 12 Cases O. Lin, M. Cardillo, G. Dalbagni, I. Linkov, B. Hutchinson and V. E. Reuter, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York Mod Pathol, 16: 1289 –1298, 2003 Nested variant of urothelial carcinoma is characterized by confluent small nests and abortive tubules of mildly atypical neoplastic cells infiltrating the lamina propria and/or muscularis propria of the bladder. Despite its deceptively bland histomorphologic appearance, the lesion is reported to have an aggressive