- Email: [email protected]
Extravesical Tumor Relapse in Patients With Superficial Bladder Tumors
1938
PRINCIPLES OF ONCOLOGY AND IMMUNOLOGY, AND TUMORS OF BLADDER,PENIS AND URETHRA
or radiation had a decreased number of EGFR. Targeting of the EGFR thus seems potentially applicable to metastatic disease. Editorial Comment: Epidermal growth factor receptor may be over expressed in bladder cancer. Since several studies have suggested its increased expression in association with high Stage and grade, the authors examined the expression of this receptor in urothelial metastases to determine if its presence might provide a target for receptor directed therapy. Immunohistochemical staining demonstrated the receptor to be expressed as often in metastases as in the primary tumor, predominantly localized to the cell membrane and homogeneous in both. Neither radiation nor chemotherapy appeared to influence expression of the receptor. Whether such receptors on metastatic sites will permit targeting of these sites may depend on the expression of this receptor in otherwise normal tissues. Further study along these lines is needed. Michael J. Droller, M.D.
Extravesical Tumor Relapse in Patients With Superficial Bladder Tumors
H. W. HERR,Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York J. Clin. Oncol., 1 6 1099-1102, 1998 Purpose: To define the incidence of extravesical urothelial tumors among patients with high-risk superficial bladder tumors. Patients and Methods: Three hundred seven patients with multiple recurrent papillary and in situ carcinomas of the bladder were treated with transurethral resection and intravesical bacillus Calmette Guerin (BCG) therapy and monitored for a median of 12 years (range, 10 to 18). Extravesical tumors were detected during investigation of a positive urine cytology after no tumor was found in the bladder. Results: Among 307 patients, 78 (25%)developed tumors in the upper urinary tract (UTT). Of 251 men, 61 (24%) had tumors detected in the prostatic urethra or ducts (T4p). The median times to detection of an U'IT or prostatic epithelial tumor were 56 months and 11months, respectively, and 32% of the UTT and 44% of the T4p relapses were lethal. Conclusion: Patients with high-risk superficial bladder tumors who are treated successfully by a bladdersparing strategy are at increased risk for tumor relapse that involves extravesical mucosa. Reprinted with permission from American Society of Clinical Oncology. Editorial Comment: Of more than 300 patients with multiple recurrent papillary (69%stage T2, 24% stage T1) and in situ bladder cancer (80%) upper tract transitional cell cancer developed in 78 (25%). Of 251 men transitional cell cancer of the urethra or prostatic urothelium developed in 61 (24%). Median followup was 12 years. Timing of upper tract or urethral cancer appeared to be at a consistent rate throughout the study interval. In all of these cases positive urinary cytology was observed and no cancer was found in the bladder. Extravesical recurrence was an ominous event in the majority of patients. In more than three-fourths of the patients (60 of 78) upper tract recurrence was invasive and 32% (25) died of metastases. Of patients with urethral (prostatic) recurrence half (30 of 61) had stromal invasion and 44% (27) died of metastases. Since previous studies have demonstrated involvement of the distal ureters by occult carcinoma in situ in 30% of cystectomy specimens, and involvement of the prostatic urethra and ducts in 40%, progressive disease at these sites after a prolonged interval was not surprising. Indeed, one may surmise that patients in this series may have been a t particularly high risk given the large number of those with high grade cancers associated with carcinoma in situ. Thus, this report serves to underscore the potential aggressiveness of urothelial cancer in such patients, the need for continued surveillance notwithstanding initial responsiveness to transurethral resection (even with apparently effective adjunctive intravesical chemotherapy or immunotherapy) and the need for aggressive pursuit of the site of recurrent disease in all patients who present with multiple tumors, carcinoma in situ andlor recurrent positive urinary cytology at whatever interval following initial or maintenance therapy. The author underscores the value of early cystectomy in the setting of high grade disease (particularly with lamina propria invasion) and carcinoma in situ in view of the high likelihood that involvement of the distal ureters and prostatic urethra as sanctuary sites in this particular setting will permit occult progression that is difficult to detect until after metastasis. Michael J. Droller, M.D.
PRINCIPLES OF ONCOLOGY AND IMMUNOLOGY, AND TUMORS OF BLADDER,PENIS AND URETHRA
or radiation had a decreased number of EGFR. Targeting of the EGFR thus seems potentially applicable to metastatic disease. Editorial Comment: Epidermal growth factor receptor may be over expressed in bladder cancer. Since several studies have suggested its increased expression in association with high Stage and grade, the authors examined the expression of this receptor in urothelial metastases to determine if its presence might provide a target for receptor directed therapy. Immunohistochemical staining demonstrated the receptor to be expressed as often in metastases as in the primary tumor, predominantly localized to the cell membrane and homogeneous in both. Neither radiation nor chemotherapy appeared to influence expression of the receptor. Whether such receptors on metastatic sites will permit targeting of these sites may depend on the expression of this receptor in otherwise normal tissues. Further study along these lines is needed. Michael J. Droller, M.D.
Extravesical Tumor Relapse in Patients With Superficial Bladder Tumors
H. W. HERR,Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York J. Clin. Oncol., 1 6 1099-1102, 1998 Purpose: To define the incidence of extravesical urothelial tumors among patients with high-risk superficial bladder tumors. Patients and Methods: Three hundred seven patients with multiple recurrent papillary and in situ carcinomas of the bladder were treated with transurethral resection and intravesical bacillus Calmette Guerin (BCG) therapy and monitored for a median of 12 years (range, 10 to 18). Extravesical tumors were detected during investigation of a positive urine cytology after no tumor was found in the bladder. Results: Among 307 patients, 78 (25%)developed tumors in the upper urinary tract (UTT). Of 251 men, 61 (24%) had tumors detected in the prostatic urethra or ducts (T4p). The median times to detection of an U'IT or prostatic epithelial tumor were 56 months and 11months, respectively, and 32% of the UTT and 44% of the T4p relapses were lethal. Conclusion: Patients with high-risk superficial bladder tumors who are treated successfully by a bladdersparing strategy are at increased risk for tumor relapse that involves extravesical mucosa. Reprinted with permission from American Society of Clinical Oncology. Editorial Comment: Of more than 300 patients with multiple recurrent papillary (69%stage T2, 24% stage T1) and in situ bladder cancer (80%) upper tract transitional cell cancer developed in 78 (25%). Of 251 men transitional cell cancer of the urethra or prostatic urothelium developed in 61 (24%). Median followup was 12 years. Timing of upper tract or urethral cancer appeared to be at a consistent rate throughout the study interval. In all of these cases positive urinary cytology was observed and no cancer was found in the bladder. Extravesical recurrence was an ominous event in the majority of patients. In more than three-fourths of the patients (60 of 78) upper tract recurrence was invasive and 32% (25) died of metastases. Of patients with urethral (prostatic) recurrence half (30 of 61) had stromal invasion and 44% (27) died of metastases. Since previous studies have demonstrated involvement of the distal ureters by occult carcinoma in situ in 30% of cystectomy specimens, and involvement of the prostatic urethra and ducts in 40%, progressive disease at these sites after a prolonged interval was not surprising. Indeed, one may surmise that patients in this series may have been a t particularly high risk given the large number of those with high grade cancers associated with carcinoma in situ. Thus, this report serves to underscore the potential aggressiveness of urothelial cancer in such patients, the need for continued surveillance notwithstanding initial responsiveness to transurethral resection (even with apparently effective adjunctive intravesical chemotherapy or immunotherapy) and the need for aggressive pursuit of the site of recurrent disease in all patients who present with multiple tumors, carcinoma in situ andlor recurrent positive urinary cytology at whatever interval following initial or maintenance therapy. The author underscores the value of early cystectomy in the setting of high grade disease (particularly with lamina propria invasion) and carcinoma in situ in view of the high likelihood that involvement of the distal ureters and prostatic urethra as sanctuary sites in this particular setting will permit occult progression that is difficult to detect until after metastasis. Michael J. Droller, M.D.