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EVERYTHING OLD IS NEW AGAIN
0022-5347/04/1723-0826/0 THE JOURNAL OF UROLOGY® Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 172, 826, September 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000136486.65243.7a
EVERYTHING OLD IS NEW AGAIN Suppose you were starting your career in urology and decided that you wanted to learn something about the etiology, incidence and management of bladder cancer. After a thorough review of the scientific literature from the last century you might draw the following conclusions. Bladder cancer is caused by exposure to carcinogens (indeed, this was first noticed in the 1870s and first described by Rehn in 18951) affecting men more often than women, presumably because of smoking patterns that differ between the sexes. You would no doubt also come to understand that certain tumors have expressed biological potential to do harm long before definitive surgical intervention can be affected (look up any cystectomy series you wish, although Jewett and Strong’s contribution to this Journal from 1946 has genuine historical verisimilitude2). Finally, you would also probably come to believe that not all patients with invasive (ie biologically aggressive) cancers need to have the bladder removed to be cured. If you needed additional fuel for your fire, 3 articles in this issue of The Journal provide it and some additional observations worth pondering. Hayne et al (page 1051) bring us up-to-date on the epidemiology of bladder cancer in England and Wales. The incidence of disease is increasing (approximately 60% during the last 3 decades), and inexplicably it is rising more rapidly among young female cohorts in a fashion not clearly related to tobacco use. These apparently simple observations carry profound clinical weight. Why have women not enjoyed the improvement in cancer survival seen in men with bladder cancer? We live in a chemical world and exposure to carcinogens occurs along many avenues. How can we study susceptibility to the impact of carcinogens on different populations? What does genotypic gender have to do with this? This interesting report invites research into an area under explored by urologists and their colleagues in epidemiology, basic research and environmental medicine. Hassan et al (page 882) describe a select experience at Vanderbilt University, evaluating the fate of patients with carcinoma in situ only (pTis) in the final pathology specimen after radical cystectomy. They found that patients with a pre-cystectomy diagnosis of muscle invasion (greater than T2) were 7 times more likely to have metastatic disease postoperatively (5 of 22 or 22.7%) than were patients whose highest disease stage preoperatively was Tis/T1 (1 of 28 or 3.6%). This approximately 20% failure rate is precisely what one would expect in a group of patients undergoing cystectomy for T2 disease in whom residual invasion is identified in the final specimen. Although it is interesting that transurethral resection down staging made no difference in survival for this subset, the intriguing question remains, how do we
identify patients in whom early systemic dissemination of cancer occurs. We collectively hope that the answer will come from the molecular biology laboratory. Attempts to use marker data (ie p53 gene mutation status to identify patients most likely to benefit from systemic therapies after cystectomy) may soon shed light on this issue. Holzbeierlein et al (page 878) at Memorial Sloan-Kettering Cancer Center reviewed their use of partial cystectomy in patients with bladder cancer. They concluded that, even in the era of modern polychemotherapy and improved preoperative and postoperative care, factors that determine the fate of patients in this group are the presence of carcinoma in situ or multifocal disease, nodal disease or persistently positive surgical margins at the time of resection. In other words, if you could not remove the cancer, the patients were at high risk for clinical recurrence. Interestingly, patients in whom the cancer was completely resectable enjoyed a high likelihood of disease-free survival. This is not a new observation, and it is sobering to note that our forbearers were good enough technical surgeons to achieve similar results in the absence of many modern conveniences such as systemic antibiotics, laminar flow operating rooms, disposable everything and a greater general wakefulness that is no doubt a function of the 80-hour work week. What is of perhaps greater interest is the residual novelty of partial cystectomy. Few patients with focal, invasive lesions come to my office having had random biopsies. Without these, it is impossible to determine if partial cystectomy is an option. Thus, the patient is subjected to another examination under anesthesia which could perhaps have been avoided. This is an excellent reference for those with busy practices including patients who might be candidates for partial excision of the bladder for cure. Not only do the authors clearly outline the criteria for identifying a patient appropriate for partial cystectomy, but reading the article will refocus one’s attention on the value of this elegant and simple therapeutic option.
826
Mark Schoenberg Department of Urology James Buchanan Brady Urological Institute The Johns Hopkins Hospital Baltimore, Maryland 1. Rehn, L.: Blasengeschwulste bei Anilinarbeitern. Arch Klin Chir, 50: 588, 1895 2. Jewett, H. J. and Strong, G. H.: Infiltrating carcinoma of the bladder: relation of depth of penetration of the bladder wall to incidence of local extension and metastases. J Urol, 55: 366, 1946
Vol. 172, 826, September 2004 Printed in U.S.A.
DOI: 10.1097/01.ju.0000136486.65243.7a
EVERYTHING OLD IS NEW AGAIN Suppose you were starting your career in urology and decided that you wanted to learn something about the etiology, incidence and management of bladder cancer. After a thorough review of the scientific literature from the last century you might draw the following conclusions. Bladder cancer is caused by exposure to carcinogens (indeed, this was first noticed in the 1870s and first described by Rehn in 18951) affecting men more often than women, presumably because of smoking patterns that differ between the sexes. You would no doubt also come to understand that certain tumors have expressed biological potential to do harm long before definitive surgical intervention can be affected (look up any cystectomy series you wish, although Jewett and Strong’s contribution to this Journal from 1946 has genuine historical verisimilitude2). Finally, you would also probably come to believe that not all patients with invasive (ie biologically aggressive) cancers need to have the bladder removed to be cured. If you needed additional fuel for your fire, 3 articles in this issue of The Journal provide it and some additional observations worth pondering. Hayne et al (page 1051) bring us up-to-date on the epidemiology of bladder cancer in England and Wales. The incidence of disease is increasing (approximately 60% during the last 3 decades), and inexplicably it is rising more rapidly among young female cohorts in a fashion not clearly related to tobacco use. These apparently simple observations carry profound clinical weight. Why have women not enjoyed the improvement in cancer survival seen in men with bladder cancer? We live in a chemical world and exposure to carcinogens occurs along many avenues. How can we study susceptibility to the impact of carcinogens on different populations? What does genotypic gender have to do with this? This interesting report invites research into an area under explored by urologists and their colleagues in epidemiology, basic research and environmental medicine. Hassan et al (page 882) describe a select experience at Vanderbilt University, evaluating the fate of patients with carcinoma in situ only (pTis) in the final pathology specimen after radical cystectomy. They found that patients with a pre-cystectomy diagnosis of muscle invasion (greater than T2) were 7 times more likely to have metastatic disease postoperatively (5 of 22 or 22.7%) than were patients whose highest disease stage preoperatively was Tis/T1 (1 of 28 or 3.6%). This approximately 20% failure rate is precisely what one would expect in a group of patients undergoing cystectomy for T2 disease in whom residual invasion is identified in the final specimen. Although it is interesting that transurethral resection down staging made no difference in survival for this subset, the intriguing question remains, how do we
identify patients in whom early systemic dissemination of cancer occurs. We collectively hope that the answer will come from the molecular biology laboratory. Attempts to use marker data (ie p53 gene mutation status to identify patients most likely to benefit from systemic therapies after cystectomy) may soon shed light on this issue. Holzbeierlein et al (page 878) at Memorial Sloan-Kettering Cancer Center reviewed their use of partial cystectomy in patients with bladder cancer. They concluded that, even in the era of modern polychemotherapy and improved preoperative and postoperative care, factors that determine the fate of patients in this group are the presence of carcinoma in situ or multifocal disease, nodal disease or persistently positive surgical margins at the time of resection. In other words, if you could not remove the cancer, the patients were at high risk for clinical recurrence. Interestingly, patients in whom the cancer was completely resectable enjoyed a high likelihood of disease-free survival. This is not a new observation, and it is sobering to note that our forbearers were good enough technical surgeons to achieve similar results in the absence of many modern conveniences such as systemic antibiotics, laminar flow operating rooms, disposable everything and a greater general wakefulness that is no doubt a function of the 80-hour work week. What is of perhaps greater interest is the residual novelty of partial cystectomy. Few patients with focal, invasive lesions come to my office having had random biopsies. Without these, it is impossible to determine if partial cystectomy is an option. Thus, the patient is subjected to another examination under anesthesia which could perhaps have been avoided. This is an excellent reference for those with busy practices including patients who might be candidates for partial excision of the bladder for cure. Not only do the authors clearly outline the criteria for identifying a patient appropriate for partial cystectomy, but reading the article will refocus one’s attention on the value of this elegant and simple therapeutic option.
826
Mark Schoenberg Department of Urology James Buchanan Brady Urological Institute The Johns Hopkins Hospital Baltimore, Maryland 1. Rehn, L.: Blasengeschwulste bei Anilinarbeitern. Arch Klin Chir, 50: 588, 1895 2. Jewett, H. J. and Strong, G. H.: Infiltrating carcinoma of the bladder: relation of depth of penetration of the bladder wall to incidence of local extension and metastases. J Urol, 55: 366, 1946