- Email: [email protected]
Prognostic Value of Serum Cholinesterase in Non–muscle-invasive Bladder Cancer
Accepted Manuscript Prognostic value of serum cholinesterase in non-muscle invasive bladder cancer Shoji Kimura, Francesco Soria, David D’Andrea, Beat Foerster, Mohammad Abufaraj, Mihai D. Vartolomei, Pierre I. Karakiewicz, Romain Mathieu, Marco Moschini, Michael Rink, Shin Egawa, Shahrokh F. Shariat, Kilian M. Gust PII:
S1558-7673(18)30415-4
DOI:
10.1016/j.clgc.2018.07.002
Reference:
CLGC 1081
To appear in:
Clinical Genitourinary Cancer
Received Date: 18 May 2018 Revised Date:
2 July 2018
Accepted Date: 3 July 2018
Please cite this article as: Kimura S, Soria F, D’Andrea D, Foerster B, Abufaraj M, Vartolomei MD, Karakiewicz PI, Mathieu R, Moschini M, Rink M, Egawa S, Shariat SF, Gust KM, Prognostic value of serum cholinesterase in non-muscle invasive bladder cancer, Clinical Genitourinary Cancer (2018), doi: 10.1016/j.clgc.2018.07.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Prognostic value of serum cholinesterase in non-muscle invasive bladder cancer
Pierre I. Karakiewicz7 [email protected] Romain Mathieu8 [email protected] Marco Moschini9,10 [email protected] Michael Rink11 [email protected]
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Shin Egawa2 [email protected] Shahrokh F. Shariat1,12,13,14 [email protected] Kilian M. Gust1,14 [email protected]
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David D’Andrea1 [email protected] Beat Foerster1,4 [email protected] Mohammad Abufaraj1,5 [email protected] Mihai D. Vartolomei1,6 [email protected]
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Shoji Kimura1,2 [email protected] Francesco Soria1,3 [email protected]
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Department of Urology, Medical University of Vienna, Vienna, Austria Department of Urology, Jikei University School of Medicine, Tokyo, Japan 3 Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of 2
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Studies of Torino, Turin, Italy 4 Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland 5 Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan 6
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Division of Urology, University of Montreal Health Center, Montreal, QC, Canada Department of Urology, Rennes University Hospital, Rennes, France Klinik für Urologie, Luzerner Kantonsspital, Lucerne, Switzerland Urological Research Institute, San Raffaele Scientific Institute, Vita-Salute San Raffaele University,
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Department of Cell and Molecular Biology, University of Medicine and Pharmacy, Tirgu Mures, Romania
Milan, Italy 11 Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany 12 Department of Urology, Weill Cornell Medical College, New York, NY, USA 13 Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA 14 Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria Corresponding author: Kilian M. Gust; Department of Urology and Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria. Tel: +4314040026150 Fax: +4314040023320. Email: [email protected] 1
ACCEPTED MANUSCRIPT Disclosures and funding sources We confirm that there are no known conflicts of interest associated with this study.
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We confirm that the manuscript has been read and approved by all authors.
We confirm that the contents of this manuscript have not been copyrighted or published previously.
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We confirm that the contents of this manuscript are not now under consideration for publication
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elsewhere.
This research did not receive any specific grant from funding agencies in the public, commercia, or
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not-for-profit sectors.
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ACCEPTED MANUSCRIPT Abbreviation BC=bladder cancer BCG=bacillus Calmette-Guérin ChE=cholinesterase
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95%CI=95% confidence interval EAU=European Association of Urology
EORTC=European Organization for Research and Treatment of Cancer
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HR=hazard ratio IQR=interquartile range
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MIBC=muscle invasive bladder cancer NMIBC=non-muscle invasive bladder cancer PFS=progression-free survival RFS=recurrence-free survival ROC= Receiver Operating Characteristics
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TURB= transurethral resection of the bladder
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ACCEPTED MANUSCRIPT Micro Abstract
Serum Cholinesterase (ChE) is associated with poor oncologic outcome in patients with advanced
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cancer such as muscle invasive bladder cancer. In this retrospective study, we found that ChE is significantly associated with disease recurrence in patients with non-muscle invasive bladder cancer
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(NMIBC).
Abstract
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Background: Serum Cholinesterase (ChE) has been reported to be a prognostic factor in several cancers, but its relationship with oncologic outcomes of non-muscle invasive bladder cancer (NMIBC) has not been well studied yet.
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Material and Methods: We retrospectively assessed 1,117 patients with NMIBC undergoing transurethral resection of the bladder (TURB). Cox regression analyses were performed to elucidate
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the association between preoperative ChE and oncologic outcomes such as recurrence-free survival
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(RFS) and progression-free survival (PFS).
Results: The median (IQR) preoperative ChE level was 5.51kU/L [IQR:4.95-7.01], and the optimal cut-off value of ChE obtained from ROC analysis was 5.55kU/L. Five-year RFS in patients with low and normal ChE levels were 41.1% and 70.0%, respectively (p<0.001). Five-year PFS in patients with low and normal ChE levels were 93.2% and 91.4%(p=0.053), respectively. On multivariable analysis, ChE was significantly associated with shorter RFS (p<0.001). ChE as a continuous variable and low 4
ACCEPTED MANUSCRIPT ChE levels improved the C-Index for prediction of disease recurrence by 4.0% and 2.7% to 72.4% and 71.1%, respectively. In patients stratified into the EAU high risk, serum ChE was also strong
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predictor of disease recurrence (HR 4.14; 95%CI: 2.90-5.89). Moreover, in the EAU high risk patients treated with BCG, serum ChE was still strongly correlated with worse RFS (HR 5.46; 95%CI: 2.91-10.2).
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Conclusions: Decreased ChE is associated with shorter RFS in patients with NMIBC undergoing TURB.
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Preoperative ChE could improve patients’ risk stratification and selection for adjuvant therapy. The mechanisms underlying this association needs further elucidation to design potential targets for intervention.
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Key words
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Bladder cancer, cholinesterase, recurrence, non-muscle invasive, biomarker
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Introduction In 2018, it is estimated that, only in US, 81,190 patients will receive a diagnosis of bladder cancer
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(BC) and 17,240 will succumb to the disease1. Approximately 75% of BC patients in industrialized countries present with non-muscle invasive bladder cancer (NMIBC) at initial diagnosis2 3. Up to 70% of NMIBC patients will experience disease recurrence within the first year and 10-20% will
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experience disease progression to muscle invasive bladder cancer (MIBC) despite adequate therapy . Standard therapy of NMIBC includes transurethral resection of the bladder (TURB), eventually
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followed by adjuvant intravesical chemotherapy or immunotherapy based on patients’ risk 5 6. Those who experience disease progression to MIBC are recommended for radical cystectomy (RC), eventually with perioperative chemotherapy 7. The patients have a worse survival compared to patients who are diagnosed with primary MIBC 8. Despite progress, unfortunately, the accuracy for
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predicting disease recurrence and progression remains suboptimal9 10. Several additional biomarkers have been investigated as predictors of oncologic outcomes, but none
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of them have reached sufficient accuracy to be integrated into daily clinical practice11-14. Biomarkers may help improve patients’ risk stratification by personalizing follow up scheduling, selecting for
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specific adjuvant intravesical instillation therapy or for early RC, especially for the patients with high risk compared to low and intermediate risk patients who are already well treated and needed no further risk stratification15-17.
Serum cholinesterase (ChE), also named butyrylcholinesterase or pseudocholinesterase, is an alpha-glycoprotein synthesized in the liver and released into plasma immediately after synthesis 18. Decreased ChE levels have been closely related to liver damage, inflammation and malnutrition 19. Moreover, decreased levels of ChE have been recently shown to be associated with poor prognosis 6
ACCEPTED MANUSCRIPT in several cancers with or without hepatic involvement
18, 20, 21
. While ChE have already been
reported to be of prognostic value in MIBC patients treated with RC 22, its role in patients with NMIBC remains unknown. We hypothesized that lower pre-TURB ChE would be associated with worse prognosis in patients with NMIBC. To test this, we, retrospectively, investigated the
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relationship of preoperative serum ChE with disease recurrence and progression in a cohort of patients treated with TURB with or without intravesical therapy for NMIBC.
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Material and Methods
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Patient population and treatment
We retrospectively reviewed clinical records in four tertiary referral centers in US and Europe after acquisition of ethical approval of each center. Overall, 1,117 patients with primary or recurrent NMIBC undergoing TURB with or without adjuvant intravesical instillation therapy were identified
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for the purpose of this study. None of patients had metastatic disease, concurrent upper tract urothelial cancer or prostatic invasion at the time of TURB. Exclusion criteria includes patients with severe liver impairment/chronic liver disease. According to guidelines, 493 patients were
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postoperatively treated with adjuvant intravesical instillation therapy consisting of either immediate single-dose intravesical instillation (40mg mitomycin C, 80mg epirubicin, or 50mg doxorubicin),
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adjuvant intravesical mitomycin C chemotherapy, or bacillus Calmette-Guerin (BCG) immunotherapy. All BCG patients received maintenance therapy. A second TUR was not routinely performed. Patient evaluation
The following clinicopathological features were obtained for each patient: age, gender, smoking status, tumor status (primary or recurrent), pathological T stage, tumor grade, concomitant carcinoma in situ, tumor size, number of tumor and type of intravesical therapy. Patients were 7
ACCEPTED MANUSCRIPT stratified into low, intermediate and high group in accordance to European Association of Urology guidelines 5. All TURB specimens were assessed according to standard pathological procedure and staged based on the 2009 TNM classification. Tumor grade was based on the 1973 World Health Organization system. Preoperative laboratory test including ChE was performed within 30 days
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before TURB. Patients were stratified according to cut-off value of ChE into low (< 5.55kU/L) and normal (≥ 5.55kU/L) levels. This cut-off was calculated in preliminary analyses (see results).
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Follow up
All included patients were generally followed postoperatively, according to the guidelines at that
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time, with urine cytology, abdominal ultrasound, flexible/rigid cystoscopy and/or cold biopsy/TURB of suspicious lesions according to international guidelines and individual risk evaluation. Evaluation of upper urinary tract using imaging were performed at diagnosis and yearly, when indicated, after
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TURB. End points
The end points of this retrospective study were disease recurrence defined as any evidence of
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disease and disease progression defined as muscle invasion or metastasis during follow up.
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Recurrence free survival (RFS) time was calculated as interval between TURB and the date of tumor recurrence. Progression free survival (PFS) time was calculated as interval between TURB and the date of disease progression. ChE measurement
Serum samples from 1,117 subjects were analyzed using Ortho VITROS 5.1 FS and 5600 Integrated System (Ortho Clinical Diagnostics, Raritan, NJ, USA) assays for ChE. Analytical methods were controlled according to the manufacturer’s instructions using preventative maintenance, function 8
ACCEPTED MANUSCRIPT checks, calibration, and quality control which passed specifications prior to testing samples. The rate of color loss is monitored by reflectance spectrophotometry (400nm). The rate of change in reflection density is proportional to the ChE activity in the sample. Statistical analysis
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The optimal ChE cut-off point was determined through Receiver Operating Characteristics (ROC) curve analysis using Youden index [maximum(sensitivity+specificity-1)]
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. Chi-square and
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Mann-Whitney U tests were performed for categorical and continuous variables to compare with the population in each group. RFS and PFS rates were calculated using Kaplan-Meier curves among
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two groups and compared using the log-lank test. The Log-rank test was used to provide differential estimation between low and normal ChE levels. Univariable and multivariable analysis using Cox regression model were performed to elucidate the association between preoperative ChE (as a continuous and categorical variable divided by the cut-off value) and RFS as well as PFS.
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Discrimination between the models was assessed with Harrell’s C-index. Data were analyzed using JMP 13 (SAS Institute, Cary, CA, USA) and STATA 13 (Stata Corp., College Station, TX). All tests were
Results
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two-sided and P<0.05 was considered as statistically significant.
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Patient characteristics
The median preoperative ChE of all patients was 5.51 [IQR:4.95-7.01] kU/L. The optimal ChE cut-off value defined according to ROC curve analysis was 5.55kU/L (Supplementary Figure A1). The clinicopathologic characteristics of the 1,117 patients stratified according to ChE levels are shown in Table1. Overall, 51% of patients had low ChE levels. Low ChE levels were correlated with female (p<0.05), large tumor size (p<0.05), and more common use of intravesical BCG treatment (p<0.05). Association of ChE with disease recurrence 9
ACCEPTED MANUSCRIPT Within a median follow up of 64 months (IQR:26.2-110.4), 469 patients (42.0%) developed disease recurrence. Among them, 317 (67.6%) and 387 (82.5%)patients experienced disease recurrence within one and two years after TURB, respectively. Five-year RFS rate for all patients was 54.4%. Five-year RFS rate in patients with low and normal ChE levels were 41.1% and 70.0%, respectively
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(p<0.001) (Figure1A). On Cox regression analysis, low ChE levels was significantly associated with shorter RFS in both univariable (HR 2.28; 95%CI: 1.88-2.76, p<0.001) and multivariable (HR 2.24;
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95%CI: 1.85-2.72, p<0.001) analyses (Table 2). Additionally, as a continuous variable, low ChE was also significantly associated with shorter RFS in both univariable (HR 0.74; 95%CI: 0.69-0.78,
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p<0.001) and multivariable (HR 0.75; 95%CI: 0.71-0.80, p<0.001) analyses (Table2). ChE analyzed either as a continuous or categorical variable improved the C-Index of a base model that included established clinicopathologic features for prediction of disease recurrence by 4.0% and 2.7%, respectively (to 72.4% and 71.1%).
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Association of ChE with disease progression
Overall, 103 patients (9.2%) developed disease progression within the follow up period. Among
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them, 34 (33%) and 51 (49.5%) patients experienced disease progression within one and two years after TURB, respectively. Five-year PFS rate was 96.8%. Five-year PFS rates in patients with low and
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normal ChE levels were 93.2% and 91.4%, respectively (p=0.053) (Figure1B). On univariable analysis, ChE as a continuous or categorical variable were not associated with PFS (HR 0.94; 95%CI: 0.83-1.05 p=0.25 and HR 0.68; 95%CI: 0.46-1.005, p=0.053, respectively) (Table2). Subgroup analysis in patients within the EAU high risk group Taken together, 522 (47%) patients were found to harbor tumors stratified to be within the EAU high risk group. Median follow up in these patients was 50.5 months (IQR:20.6-91.1). During follow up, 195 (37%) and 64 (12%) patients experienced disease recurrence and progression, respectively. 10
ACCEPTED MANUSCRIPT Five-year RFS rate of patients with low and normal ChE levels were 42.4% and 82.1%, respectively (p<0.001) (Figure2A). Meanwhile, five-year PFS rate of patients with low and normal ChE levels were 88.3% and 86.4%, respectively (p=0.47) (Figure2B). In patients with EAU high risk group, low ChE levels was a stronger predictor for disease recurrence (HR 4.14; 95%CI: 2.90-5.89, p<0.001)
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compared to patients in the EAU low (HR 0.92; 95%CI: 0.52-1.63, p=0.77, on univariable analysis) or intermediate risk groups (HR1.63; 95%CI: 1.25-2.13, p<0.001, on multivariable analysis). This was
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also true when ChE was analyzed as a continuous variable (HR 0.58; 95%CI: 0.52-0.66, p<0.001) (Table3) (Table4). However, in the EAU high risk group, ChE was not correlated with disease
Correlation with intravesical BCG therapy
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progression on univariable analysis (Table4).
207 (39.7%) patients with EAU high risk group received adjuvant intravesical BCG therapy. Median follow up in these patients was 48.7 months (IQR:21.8-81.1). Five-year RFS rate of patients with low
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and normal ChE levels were 45.3% and 84.4%, respectively (p<0.001) (Figure3A). Meanwhile, five-year PFS rate of patients with low and normal ChE levels were 93.6% and 87.3%, respectively
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(p=0.09) (Figure3B). On multivariable analysis, low ChE levels was a strong predictor of disease recurrence (HR 5.46; 95%CI: 2.91-10.2, p<0.001). This was also true when ChE was analyzed as a
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continuous variable (HR 0.57; 95%CI: 0.47-0.68, p<0.001) (Table4). Conversely, ChE was not correlated with disease progression on univariable analysis (Table4). Discussion
ChE is an α-glycoprotein found in the liver, central and peripheral nervous system, which is synthesized in the liver 21. While increased ChE level is observed in fatty liver, obesity and metabolic syndrome 24, 25, decreased ChE level is observed in several conditions such as acute and chronic liver damage, cirrhosis, and liver metastasis as well as protein energy malnutrition, stress and 11
ACCEPTED MANUSCRIPT inflammation 19. ChE correlates significantly inversely with inflammatory cytokines such as IL-6 and tumor necrosis factor alfa (TNF-α) 26. In addition, the decreased ChE has been reported in advanced and metastatic cancer21. Patients with advanced or metastatic cancer have secondary body inflammation and often anorexia reflected in the ChE levels. Several studies investigated this
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phenomenon and demonstrated the relationship between decreased ChE and worse oncologic outcomes in various non-urologic cancers20, 27, 28. Recently, ChE was investigated in urologic cancers. In prostate cancer, Battisti et al. demonstrated in 66 patients that decreased ChE was associated
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with higher Gleason score and bone metastasis 29. In MIBC, Koie et al. demonstrated that decreased
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ChE was significantly associated with worse overall survival and disease specific free survival in patients treated with RC for MIBC22. Additionally, Noro et al. reported, in upper urinary tract urothelial carcinoma patients treated with radical nephroureterectomy, that decreased ChE was associated with worse overall survival and disease specific free survival30.
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In this retrospective study, we investigated the association between ChE and RFS and PFS in patients with NMIBC undergoing TURB with or without adjuvant intravesical instillation therapy. As far as we know, this study is the first study to elucidate the association between ChE and oncologic outcomes
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in NMIBC patients. We found that decreased pre-TURB serum ChE significantly predicted shorter
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RFS on multivariable analysis. In patients stratified into the EAU high risk, decreased ChE was a strong predictor for disease recurrence. Additionally, in the EAU high risk patients after controlling for the effect of intravesical BCG treatment, ChE was sill strongly correlated with worse RFS. This result highlights decreased ChE might identify the patients who are at increased risk of BCG failure, because recurrent tumors in high risk patients after BCG treatment are likely to be high grade disease, which also lead to very high risk. However, we failed to find an association with PFS on univariable analysis.
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ACCEPTED MANUSCRIPT Two of the most used predictive risk stratification models are the EAU5 and the EORTC
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risk
stratification models, which are partially associated. Although these predictive models, based on several clinicopathologic features could help clinicians in decision making, some inaccuracy and inconsistences between models were reported. Rieken et al. demonstrated, in their large cohort
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study, that the application of the EAU categories on patients stratified by EORTC categories lead to a reclassification of 45.7% EORTC recurrence intermediate risk patients to EAU high risk category 10. Similarly, Xylinas et al. showed that the EORTC model overestimated the risk of disease recurrence
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. In our retrospective study, we
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should be improved with readily available markers
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and progression in high risk group 32. To better assess with more accuracy, these predicting models
demonstrated that patients with decreased ChE are more likely to experience disease recurrence, also in high risk patients after controlling for the effect of intravesical BCG treatment. Therefore, closer follow up could be advocated for patients in this category. Finally, some of these patients may
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benefit from adjuvant treatment such as intravesical chemotherapy and BCG immunotherapy independently from tumor characteristics, and additionally, some may benefit from early RC if they are reclassified to very high risk for disease progression.
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This study has several limitations mainly related to its retrospective nature. Second, due to its
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multicentric nature, we cannot control for TURB quality, experience and skill of each surgeon and differences between intravesical therapeutic agents of each center. Third, TURB specimens were not assessed by central pathologic review. Additionally, we used the 1973 WHO classification and 398 of the cohort were G2. This could affect the results of the study if we assign them to the 2004 WHO classification. Moreover, the presence of carcinoma in situ could have been underestimated as cold biopsies were performed only when CIS was suspected, which also might affect result of this study. Fourth, the number of patients with disease progression was relatively small in this study, which
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ACCEPTED MANUSCRIPT might influence the results of our study. Fifth, clear definition in the cut-off of ChE does not exist. However, to overcome this limitation, we performed analyses using ChE as a continuous variable as well as a categorical variable. Finally, in this study, serum ChE had low sensitivity and specificity for predicting disease recurrence. However, these are higher than those of commonly used urine
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cytology. ChE might be more useful for predicting disease recurrence when combined with urine cytology. Taking advantage of its easy accessibility and noninvasiveness, this biomarker could be 36
. Prospective well-designed trials are needed to elucidate the
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easily interpreted in clinical care
relationship between ChE and NMIBC as well as BC in general. The underlying biological
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phenomenon needs to be elucidated to uncover potential therapeutic strategies.
Conclusions
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ChE is significantly associated with RFS in patients with NMIBC undergoing TURB with or without adjuvant intravesical therapy. Preoperative serum ChE might help identify the patients likely to experience disease recurrence and could give additional information for clinical decision making
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regarding adjuvant therapy after TURB.
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Clinical practice points
Decreased ChE have been recently shown to be associated with poor prognosis in several cancers with or without hepatic involvement
18, 20, 21
. While ChE have already been reported to be of
prognostic value in MIBC patients treated with RC
22
, its role in patients with NMIBC remains
unknown. We retrospectively assessed 1,117 patients with NMIBC undergoing TURB. We found that ChE is significantly correlated with worse RFS in NMIBC patients treated with TURB. Additionally, in 14
ACCEPTED MANUSCRIPT patients within the EAU high risk group even with BCG treatment, serum ChE was also strong predictor of disease recurrence. This inexpensive and easily accessible biomarker could help identify the patients who are likely to
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benefit from severe follow up scheduling and adjuvant therapy. Prospective well-designed trials are needed to elucidate the relationship between ChE and NMIBC
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Author Contributions:
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in the future.
S. Kimura: manuscript writing, data analysis
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F. Soria: manuscript editing, data analysis D. D’Andrea: manuscript editing, data collection B. Foerster: manuscript editing M Abufaraj: manuscript editing M.D. Vartolomei: manuscript editing, data analysis P.I. Karakiewicz: manuscript editing, data collection R. Mathieu: manuscript editing, data collection 15
ACCEPTED MANUSCRIPT M. Moschini: manuscript editing, data collection S. Egawa: manuscript editing S.F Shariat: project development, manuscript editing
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K.M Gust: project development, manuscript editing
Acknowledgement
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with cardiometabolic risk factors among apparently healthy adults. Journal of cardiovascular medicine (Hagerstown, Md.). 2014;15:377-383. Camarero Gonzalez E, Munoz Leira V, Iglesias Guerrero M, Fernandez Alvarez JA, Cabezas-Cerrato J. [Protein-energy malnutrition: its effects on 4 metabolic parameters]. Nutricion hospitalaria. 1995;10:158-160. Coulter DW, Boettner AD, Kortylewicz ZP, et al. Butyrylcholinesterase as a Blood Biomarker in Neuroblastoma. Journal of pediatric hematology/oncology. 2017;39:272-281. Prabhu K, Naik D, Ray S, Vadiraj, Rao A, Kamath A. Significance of serum butyrylcholinesterase levels in oral cancer. The Australasian medical journal. 2011;4:374-378. Battisti V, Bagatini MD, Maders LD, et al. Cholinesterase activities and biochemical determinations in patients with prostate cancer: influence of Gleason score, treatment and bone metastasis. Biomedicine & pharmacotherapy = Biomedecine & pharmacotherapie. 2012;66:249-255. Noro D, Koie T, Hashimoto Y, et al. Significance of preoperative butyrylcholinesterase level as an independent predictor of survival in patients with upper urinary tract urothelial carcinoma treated with nephroureterectomy. Japanese journal of clinical oncology. 2017:1-6. Sylvester RJ, van der Meijden AP, Oosterlinck W, et al. Predicting recurrence and progression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a combined analysis of 2596 patients from seven EORTC trials. European urology. 2006;49:466-465; discussion 475-467. Xylinas E, Kent M, Kluth L, et al. Accuracy of the EORTC risk tables and of the CUETO scoring model to predict outcomes in non-muscle-invasive urothelial carcinoma of the bladder. British journal of cancer. 2013;109:1460-1466. Fritsche HM, Burger M, Svatek RS, et al. Characteristics and outcomes of patients with clinical T1 grade 3 urothelial carcinoma treated with radical cystectomy: results from an international cohort. European urology. 2010;57:300-309. Shariat SF, Ashfaq R, Sagalowsky AI, Lotan Y. Correlation of cyclin D1 and E1 expression with bladder cancer presence, invasion, progression, and metastasis. Human pathology. 2006;37:1568-1576. Shariat SF, Kim J, Raptidis G, Ayala GE, Lerner SP. Association of p53 and p21 expression with clinical outcome in patients with carcinoma in situ of the urinary bladder. Urology. 2003;61:1140-1145. Bensalah K, Montorsi F, Shariat SF. Challenges of cancer biomarker profiling. European urology. 2007;52:1601-1609.
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Table1.Patient characteristics according to ChE level (cut-off 5.55kU/L) Variables Total Preoperative ChE Low Normal Number of patients 1,117 564 (51) 553 (49) Median age(IQR) 67 (58-74) 67 (59-74) 66 (58-74) Gender, n (%) female 262 (23) 147 (56) 115 (44) male 855 (77) 418 (49) 437 (51) Smoking status, n (%) never 272 (24) 136 (50) 136 (50) former 331(30) 168 (51) 163 (49) current 514(46) 261 (51) 253 (49) Prior recurrence, n (%) Primary tumor 931(83) 472(84) 459(83) Recurrent tumor 186(17) 92 (16) 94 (17) Pathological T stage, n (%) pTa 653(58) 314 (48) 339 (52) pTis 21(2) 10 (48) 12 (52) pT1 443(40) 241 (54) 202 (46) Pathological tumor grade, n (%) Grade1 231(21) 106 (46) 125 (54) Grade2 398(35) 198 (49) 200 (51) Grade3 488(44) 261 (53) 227 (47) Concomitant CIS, n (%) 66(6) 35 (6) 31 (6) Tumor size, n (%) <1cm 368(33) 179 (49) 189 (51) 1-3cm 448(40) 214 (48) 234 (52) >3cm 301(27) 172 (57) 129 (43) Number of tumor, n (%) 1 718(64) 363 (51) 355 (49) 1-7 297(27) 150 (51) 147(49) 102(9) 52 (51) 50 (49) ≧8 Intravesical therapy, n (%) 493(44) 241 (43) 252 (46) Type of Intravesical therapy, n (%) 19
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0.74
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0.15
0.68 <0.05
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Early single installation 145(13) 51 (9) 94 (17) ACCEPTED MANUSCRIPT Adjuvant chemotherapy 48(4) 21(4) 27 (5) Adjuvant BCG 300(27) 169 (30) 131 (24) EAU risk stratification, n (%) Low risk 130(12) 65(50) 65(50) Intermediate risk 465(41) 242(52) 223(48) High risk 522(47) 245(47) 277(53) BCG=bacillus Calmette-Guérin; CIS= carcinoma in situ; EAU= European Association of Urology; IQR=interquartile range
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Table2.Univariable and Multivariable Cox regression analyses for the prediction of disease recurrence and progression in 1,117 patients treated with TURB with or without adjuvant intravesical therapy for bladder cancer. Variable
Recurrence free survival Univariable
Multivariable
Univariable
Multivariable
95%CI 1.02-1.03 0.84-1.29
p <0.001 0.72
HR 1.02 -
95%CI 1.01-1.03 -
p <0.001 -
HR 1.04 1.15
95%CI 1.02-1.06 0.74-1.79
p <0.001 0.53
HR 1.04 -
95%CI 1.02-1.06 -
p <0.001 -
1.12 1.15 0.72
0.87-1.44 0.91-1.45 0.55-0.94
0.36 0.24 0.015
0.96
0.72-1.27
0.76
2.78 1.68 2.04
1.52-5.06 0.92-3.07 1.30-3.18
0.001 0.09 0.002
2.94 1.68 2.17
1.60-5.39 0.92-3.07 1.37-3.44
0.001 0.09 0.001
0.79 0.71
0.39-1.59 0.59-0.86
0.51 0.001
0.93 0.38
1.77 1.57
0.43-7.28 1.06-2.31
0.43 0.025
0.45 0.36
0.10-2.03 0.18-0.72
0.30 0.004
1.97 1.51-2.57 <0.001 1.58 1.20-2.08 0.001 2.52 1.17-5.44 0.018 1.26 0.96-1.66 0.09 2.59 1.64-4.09 <0.001 4.00 1.91-8.37 <0.001 0.95 0.64-1.42 0.81 1.43 0.66-3.08 0.36 2.39 1.98-2.87 <0.001 2.11 1.73-2.56 <0.001 1.39 0.93-2.08 0.11 1.36 1.13-1.64 0.001 1.47 1.21-1.80 <0.001 1.68 1.14-2.49 0.009 0.59 0.48-.071 <0.001 0.63 0.51-0.78 <0.001 1.14 0.77-1.69 0.51 0.74 0.69-0.78 <0.001 0.75 0.71-0.80 <0.001 0.94 0.83-1.05 0.25 2.28 1.88-2.76 <0.001 2.24 1.85-2.72 <0.001 0.68 0.46-1.005 0.053 ChE= cholinesterase; 95%CI=95% confidence interval; CIS= carcinoma in situ; HR=hazard ratio
2.81 9.43 1.25 -
1.29-6.11 3.65-24.3 0.84-1.87 -
0.009 <0.001 0.27 -
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HR 1.02 1.04
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0.45-1.92 0.25-0.57
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Age(continuous) Female gender Smoking status (ref: never smoker) Former smoker Current smoker Recurrent vs Primary tumor Pathological T stage (ref: pTa) pTis pT1 Pathological tumor grade (ref: grade1) Grade2 Grade3 Concomitant CIS Tumor size Number of tumor Intravesical therapy ChE (continuous) ChE (low vs normal) cut-off 5.55
Progression free survival
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0.84 <0.001
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Table3. Univariable and multivariable Cox regression analyses for the prediction of disease recurrence adjusted for clinicopathological features in 130 patients with EAU low risk and 465 patients with EAU intermediate risk 130 patients with EAU low risk Recurrence free survival Univariable Multivariable HR 95%CI p HR 95%CI p 1.07 0.91-1.25 0.44 ChE (continuous) 0.92 0.52-1.63 0.77 ChE (low vs normal) cut-off 5.55 465 patients with EAU intermediate risk Recurrence free survival Univariable Multivariable HR 95%CI p HR 95%CI p 0.78 0.72-0.85 <0.001 0.81 0.75-0.88 <0.001 ChE (continuous) 1.76 1.35-2.30 <0.001 1.63 1.25-2.13 <0.001 ChE (low vs normal) cut-off 5.55 ChE=cholinesterase; 95%CI=95% confidence interval; EAU=European Association of Urology; HR=hazard ratio
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Table4. Univariable and multivariable Cox regression analyses for the prediction of disease recurrence and progression adjusted for clinicopathological features in 522 patients with EAU high risk and 207 patients with EAU high risk received BCG treatment 522 patients with EAU high risk Recurrence free survival Progression free survival Univariable Multivariable Univariable Multivariable HR 95%CI p HR 95%CI p HR 95%CI p HR 95%CI p 0.87 0.74-1.01 0.08 ChE (continuous) 0.56 0.49-0.62 <0.001 0.58 0.52-0.66 <0.001 0.84 0.51-1.37 0.47 ChE (low vs normal) cut-off 5.55 4.37 3.09-6.20 <0.001 4.14 2.90-5.89 <0.001 207 patients with EAU high risk received BCG treatment Recurrence free survival Progression free survival Univariable Multivariable Univariable Multivariable HR 95%CI p HR 95%CI p HR 95%CI p HR 95%CI p 0.58 0.49-0.69 <0.001 0.57 0.47-0.68 <0.001 0.99 0.76-1.31 0.99 ChE (continuous) 0.44 0.17-1.17 0.10 ChE (low vs normal) cut-off 5.55 4.75 2.55-8.83 <0.001 5.46 2.91-10.2 <0.001 ChE=cholinesterase; 95%CI=95% confidence interval; EAU=European Association of Urology; HR=hazard ratio
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S1558-7673(18)30415-4
DOI:
10.1016/j.clgc.2018.07.002
Reference:
CLGC 1081
To appear in:
Clinical Genitourinary Cancer
Received Date: 18 May 2018 Revised Date:
2 July 2018
Accepted Date: 3 July 2018
Please cite this article as: Kimura S, Soria F, D’Andrea D, Foerster B, Abufaraj M, Vartolomei MD, Karakiewicz PI, Mathieu R, Moschini M, Rink M, Egawa S, Shariat SF, Gust KM, Prognostic value of serum cholinesterase in non-muscle invasive bladder cancer, Clinical Genitourinary Cancer (2018), doi: 10.1016/j.clgc.2018.07.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Prognostic value of serum cholinesterase in non-muscle invasive bladder cancer
Pierre I. Karakiewicz7 [email protected] Romain Mathieu8 [email protected] Marco Moschini9,10 [email protected] Michael Rink11 [email protected]
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Shin Egawa2 [email protected] Shahrokh F. Shariat1,12,13,14 [email protected] Kilian M. Gust1,14 [email protected]
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David D’Andrea1 [email protected] Beat Foerster1,4 [email protected] Mohammad Abufaraj1,5 [email protected] Mihai D. Vartolomei1,6 [email protected]
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Shoji Kimura1,2 [email protected] Francesco Soria1,3 [email protected]
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Department of Urology, Medical University of Vienna, Vienna, Austria Department of Urology, Jikei University School of Medicine, Tokyo, Japan 3 Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of 2
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Studies of Torino, Turin, Italy 4 Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland 5 Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan 6
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Division of Urology, University of Montreal Health Center, Montreal, QC, Canada Department of Urology, Rennes University Hospital, Rennes, France Klinik für Urologie, Luzerner Kantonsspital, Lucerne, Switzerland Urological Research Institute, San Raffaele Scientific Institute, Vita-Salute San Raffaele University,
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Department of Cell and Molecular Biology, University of Medicine and Pharmacy, Tirgu Mures, Romania
Milan, Italy 11 Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany 12 Department of Urology, Weill Cornell Medical College, New York, NY, USA 13 Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA 14 Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria Corresponding author: Kilian M. Gust; Department of Urology and Comprehensive Cancer Center, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria. Tel: +4314040026150 Fax: +4314040023320. Email: [email protected] 1
ACCEPTED MANUSCRIPT Disclosures and funding sources We confirm that there are no known conflicts of interest associated with this study.
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We confirm that the manuscript has been read and approved by all authors.
We confirm that the contents of this manuscript have not been copyrighted or published previously.
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We confirm that the contents of this manuscript are not now under consideration for publication
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elsewhere.
This research did not receive any specific grant from funding agencies in the public, commercia, or
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not-for-profit sectors.
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ACCEPTED MANUSCRIPT Abbreviation BC=bladder cancer BCG=bacillus Calmette-Guérin ChE=cholinesterase
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95%CI=95% confidence interval EAU=European Association of Urology
EORTC=European Organization for Research and Treatment of Cancer
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HR=hazard ratio IQR=interquartile range
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MIBC=muscle invasive bladder cancer NMIBC=non-muscle invasive bladder cancer PFS=progression-free survival RFS=recurrence-free survival ROC= Receiver Operating Characteristics
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TURB= transurethral resection of the bladder
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ACCEPTED MANUSCRIPT Micro Abstract
Serum Cholinesterase (ChE) is associated with poor oncologic outcome in patients with advanced
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cancer such as muscle invasive bladder cancer. In this retrospective study, we found that ChE is significantly associated with disease recurrence in patients with non-muscle invasive bladder cancer
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(NMIBC).
Abstract
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Background: Serum Cholinesterase (ChE) has been reported to be a prognostic factor in several cancers, but its relationship with oncologic outcomes of non-muscle invasive bladder cancer (NMIBC) has not been well studied yet.
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Material and Methods: We retrospectively assessed 1,117 patients with NMIBC undergoing transurethral resection of the bladder (TURB). Cox regression analyses were performed to elucidate
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the association between preoperative ChE and oncologic outcomes such as recurrence-free survival
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(RFS) and progression-free survival (PFS).
Results: The median (IQR) preoperative ChE level was 5.51kU/L [IQR:4.95-7.01], and the optimal cut-off value of ChE obtained from ROC analysis was 5.55kU/L. Five-year RFS in patients with low and normal ChE levels were 41.1% and 70.0%, respectively (p<0.001). Five-year PFS in patients with low and normal ChE levels were 93.2% and 91.4%(p=0.053), respectively. On multivariable analysis, ChE was significantly associated with shorter RFS (p<0.001). ChE as a continuous variable and low 4
ACCEPTED MANUSCRIPT ChE levels improved the C-Index for prediction of disease recurrence by 4.0% and 2.7% to 72.4% and 71.1%, respectively. In patients stratified into the EAU high risk, serum ChE was also strong
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predictor of disease recurrence (HR 4.14; 95%CI: 2.90-5.89). Moreover, in the EAU high risk patients treated with BCG, serum ChE was still strongly correlated with worse RFS (HR 5.46; 95%CI: 2.91-10.2).
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Conclusions: Decreased ChE is associated with shorter RFS in patients with NMIBC undergoing TURB.
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Preoperative ChE could improve patients’ risk stratification and selection for adjuvant therapy. The mechanisms underlying this association needs further elucidation to design potential targets for intervention.
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Key words
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Bladder cancer, cholinesterase, recurrence, non-muscle invasive, biomarker
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Introduction In 2018, it is estimated that, only in US, 81,190 patients will receive a diagnosis of bladder cancer
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(BC) and 17,240 will succumb to the disease1. Approximately 75% of BC patients in industrialized countries present with non-muscle invasive bladder cancer (NMIBC) at initial diagnosis2 3. Up to 70% of NMIBC patients will experience disease recurrence within the first year and 10-20% will
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experience disease progression to muscle invasive bladder cancer (MIBC) despite adequate therapy . Standard therapy of NMIBC includes transurethral resection of the bladder (TURB), eventually
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followed by adjuvant intravesical chemotherapy or immunotherapy based on patients’ risk 5 6. Those who experience disease progression to MIBC are recommended for radical cystectomy (RC), eventually with perioperative chemotherapy 7. The patients have a worse survival compared to patients who are diagnosed with primary MIBC 8. Despite progress, unfortunately, the accuracy for
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predicting disease recurrence and progression remains suboptimal9 10. Several additional biomarkers have been investigated as predictors of oncologic outcomes, but none
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of them have reached sufficient accuracy to be integrated into daily clinical practice11-14. Biomarkers may help improve patients’ risk stratification by personalizing follow up scheduling, selecting for
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specific adjuvant intravesical instillation therapy or for early RC, especially for the patients with high risk compared to low and intermediate risk patients who are already well treated and needed no further risk stratification15-17.
Serum cholinesterase (ChE), also named butyrylcholinesterase or pseudocholinesterase, is an alpha-glycoprotein synthesized in the liver and released into plasma immediately after synthesis 18. Decreased ChE levels have been closely related to liver damage, inflammation and malnutrition 19. Moreover, decreased levels of ChE have been recently shown to be associated with poor prognosis 6
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18, 20, 21
. While ChE have already been
reported to be of prognostic value in MIBC patients treated with RC 22, its role in patients with NMIBC remains unknown. We hypothesized that lower pre-TURB ChE would be associated with worse prognosis in patients with NMIBC. To test this, we, retrospectively, investigated the
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relationship of preoperative serum ChE with disease recurrence and progression in a cohort of patients treated with TURB with or without intravesical therapy for NMIBC.
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Material and Methods
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Patient population and treatment
We retrospectively reviewed clinical records in four tertiary referral centers in US and Europe after acquisition of ethical approval of each center. Overall, 1,117 patients with primary or recurrent NMIBC undergoing TURB with or without adjuvant intravesical instillation therapy were identified
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for the purpose of this study. None of patients had metastatic disease, concurrent upper tract urothelial cancer or prostatic invasion at the time of TURB. Exclusion criteria includes patients with severe liver impairment/chronic liver disease. According to guidelines, 493 patients were
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postoperatively treated with adjuvant intravesical instillation therapy consisting of either immediate single-dose intravesical instillation (40mg mitomycin C, 80mg epirubicin, or 50mg doxorubicin),
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adjuvant intravesical mitomycin C chemotherapy, or bacillus Calmette-Guerin (BCG) immunotherapy. All BCG patients received maintenance therapy. A second TUR was not routinely performed. Patient evaluation
The following clinicopathological features were obtained for each patient: age, gender, smoking status, tumor status (primary or recurrent), pathological T stage, tumor grade, concomitant carcinoma in situ, tumor size, number of tumor and type of intravesical therapy. Patients were 7
ACCEPTED MANUSCRIPT stratified into low, intermediate and high group in accordance to European Association of Urology guidelines 5. All TURB specimens were assessed according to standard pathological procedure and staged based on the 2009 TNM classification. Tumor grade was based on the 1973 World Health Organization system. Preoperative laboratory test including ChE was performed within 30 days
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before TURB. Patients were stratified according to cut-off value of ChE into low (< 5.55kU/L) and normal (≥ 5.55kU/L) levels. This cut-off was calculated in preliminary analyses (see results).
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Follow up
All included patients were generally followed postoperatively, according to the guidelines at that
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time, with urine cytology, abdominal ultrasound, flexible/rigid cystoscopy and/or cold biopsy/TURB of suspicious lesions according to international guidelines and individual risk evaluation. Evaluation of upper urinary tract using imaging were performed at diagnosis and yearly, when indicated, after
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TURB. End points
The end points of this retrospective study were disease recurrence defined as any evidence of
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disease and disease progression defined as muscle invasion or metastasis during follow up.
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Recurrence free survival (RFS) time was calculated as interval between TURB and the date of tumor recurrence. Progression free survival (PFS) time was calculated as interval between TURB and the date of disease progression. ChE measurement
Serum samples from 1,117 subjects were analyzed using Ortho VITROS 5.1 FS and 5600 Integrated System (Ortho Clinical Diagnostics, Raritan, NJ, USA) assays for ChE. Analytical methods were controlled according to the manufacturer’s instructions using preventative maintenance, function 8
ACCEPTED MANUSCRIPT checks, calibration, and quality control which passed specifications prior to testing samples. The rate of color loss is monitored by reflectance spectrophotometry (400nm). The rate of change in reflection density is proportional to the ChE activity in the sample. Statistical analysis
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The optimal ChE cut-off point was determined through Receiver Operating Characteristics (ROC) curve analysis using Youden index [maximum(sensitivity+specificity-1)]
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. Chi-square and
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Mann-Whitney U tests were performed for categorical and continuous variables to compare with the population in each group. RFS and PFS rates were calculated using Kaplan-Meier curves among
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two groups and compared using the log-lank test. The Log-rank test was used to provide differential estimation between low and normal ChE levels. Univariable and multivariable analysis using Cox regression model were performed to elucidate the association between preoperative ChE (as a continuous and categorical variable divided by the cut-off value) and RFS as well as PFS.
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Discrimination between the models was assessed with Harrell’s C-index. Data were analyzed using JMP 13 (SAS Institute, Cary, CA, USA) and STATA 13 (Stata Corp., College Station, TX). All tests were
Results
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two-sided and P<0.05 was considered as statistically significant.
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Patient characteristics
The median preoperative ChE of all patients was 5.51 [IQR:4.95-7.01] kU/L. The optimal ChE cut-off value defined according to ROC curve analysis was 5.55kU/L (Supplementary Figure A1). The clinicopathologic characteristics of the 1,117 patients stratified according to ChE levels are shown in Table1. Overall, 51% of patients had low ChE levels. Low ChE levels were correlated with female (p<0.05), large tumor size (p<0.05), and more common use of intravesical BCG treatment (p<0.05). Association of ChE with disease recurrence 9
ACCEPTED MANUSCRIPT Within a median follow up of 64 months (IQR:26.2-110.4), 469 patients (42.0%) developed disease recurrence. Among them, 317 (67.6%) and 387 (82.5%)patients experienced disease recurrence within one and two years after TURB, respectively. Five-year RFS rate for all patients was 54.4%. Five-year RFS rate in patients with low and normal ChE levels were 41.1% and 70.0%, respectively
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(p<0.001) (Figure1A). On Cox regression analysis, low ChE levels was significantly associated with shorter RFS in both univariable (HR 2.28; 95%CI: 1.88-2.76, p<0.001) and multivariable (HR 2.24;
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95%CI: 1.85-2.72, p<0.001) analyses (Table 2). Additionally, as a continuous variable, low ChE was also significantly associated with shorter RFS in both univariable (HR 0.74; 95%CI: 0.69-0.78,
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p<0.001) and multivariable (HR 0.75; 95%CI: 0.71-0.80, p<0.001) analyses (Table2). ChE analyzed either as a continuous or categorical variable improved the C-Index of a base model that included established clinicopathologic features for prediction of disease recurrence by 4.0% and 2.7%, respectively (to 72.4% and 71.1%).
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Association of ChE with disease progression
Overall, 103 patients (9.2%) developed disease progression within the follow up period. Among
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them, 34 (33%) and 51 (49.5%) patients experienced disease progression within one and two years after TURB, respectively. Five-year PFS rate was 96.8%. Five-year PFS rates in patients with low and
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normal ChE levels were 93.2% and 91.4%, respectively (p=0.053) (Figure1B). On univariable analysis, ChE as a continuous or categorical variable were not associated with PFS (HR 0.94; 95%CI: 0.83-1.05 p=0.25 and HR 0.68; 95%CI: 0.46-1.005, p=0.053, respectively) (Table2). Subgroup analysis in patients within the EAU high risk group Taken together, 522 (47%) patients were found to harbor tumors stratified to be within the EAU high risk group. Median follow up in these patients was 50.5 months (IQR:20.6-91.1). During follow up, 195 (37%) and 64 (12%) patients experienced disease recurrence and progression, respectively. 10
ACCEPTED MANUSCRIPT Five-year RFS rate of patients with low and normal ChE levels were 42.4% and 82.1%, respectively (p<0.001) (Figure2A). Meanwhile, five-year PFS rate of patients with low and normal ChE levels were 88.3% and 86.4%, respectively (p=0.47) (Figure2B). In patients with EAU high risk group, low ChE levels was a stronger predictor for disease recurrence (HR 4.14; 95%CI: 2.90-5.89, p<0.001)
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compared to patients in the EAU low (HR 0.92; 95%CI: 0.52-1.63, p=0.77, on univariable analysis) or intermediate risk groups (HR1.63; 95%CI: 1.25-2.13, p<0.001, on multivariable analysis). This was
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also true when ChE was analyzed as a continuous variable (HR 0.58; 95%CI: 0.52-0.66, p<0.001) (Table3) (Table4). However, in the EAU high risk group, ChE was not correlated with disease
Correlation with intravesical BCG therapy
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progression on univariable analysis (Table4).
207 (39.7%) patients with EAU high risk group received adjuvant intravesical BCG therapy. Median follow up in these patients was 48.7 months (IQR:21.8-81.1). Five-year RFS rate of patients with low
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and normal ChE levels were 45.3% and 84.4%, respectively (p<0.001) (Figure3A). Meanwhile, five-year PFS rate of patients with low and normal ChE levels were 93.6% and 87.3%, respectively
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(p=0.09) (Figure3B). On multivariable analysis, low ChE levels was a strong predictor of disease recurrence (HR 5.46; 95%CI: 2.91-10.2, p<0.001). This was also true when ChE was analyzed as a
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continuous variable (HR 0.57; 95%CI: 0.47-0.68, p<0.001) (Table4). Conversely, ChE was not correlated with disease progression on univariable analysis (Table4). Discussion
ChE is an α-glycoprotein found in the liver, central and peripheral nervous system, which is synthesized in the liver 21. While increased ChE level is observed in fatty liver, obesity and metabolic syndrome 24, 25, decreased ChE level is observed in several conditions such as acute and chronic liver damage, cirrhosis, and liver metastasis as well as protein energy malnutrition, stress and 11
ACCEPTED MANUSCRIPT inflammation 19. ChE correlates significantly inversely with inflammatory cytokines such as IL-6 and tumor necrosis factor alfa (TNF-α) 26. In addition, the decreased ChE has been reported in advanced and metastatic cancer21. Patients with advanced or metastatic cancer have secondary body inflammation and often anorexia reflected in the ChE levels. Several studies investigated this
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phenomenon and demonstrated the relationship between decreased ChE and worse oncologic outcomes in various non-urologic cancers20, 27, 28. Recently, ChE was investigated in urologic cancers. In prostate cancer, Battisti et al. demonstrated in 66 patients that decreased ChE was associated
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with higher Gleason score and bone metastasis 29. In MIBC, Koie et al. demonstrated that decreased
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ChE was significantly associated with worse overall survival and disease specific free survival in patients treated with RC for MIBC22. Additionally, Noro et al. reported, in upper urinary tract urothelial carcinoma patients treated with radical nephroureterectomy, that decreased ChE was associated with worse overall survival and disease specific free survival30.
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In this retrospective study, we investigated the association between ChE and RFS and PFS in patients with NMIBC undergoing TURB with or without adjuvant intravesical instillation therapy. As far as we know, this study is the first study to elucidate the association between ChE and oncologic outcomes
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in NMIBC patients. We found that decreased pre-TURB serum ChE significantly predicted shorter
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RFS on multivariable analysis. In patients stratified into the EAU high risk, decreased ChE was a strong predictor for disease recurrence. Additionally, in the EAU high risk patients after controlling for the effect of intravesical BCG treatment, ChE was sill strongly correlated with worse RFS. This result highlights decreased ChE might identify the patients who are at increased risk of BCG failure, because recurrent tumors in high risk patients after BCG treatment are likely to be high grade disease, which also lead to very high risk. However, we failed to find an association with PFS on univariable analysis.
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risk
stratification models, which are partially associated. Although these predictive models, based on several clinicopathologic features could help clinicians in decision making, some inaccuracy and inconsistences between models were reported. Rieken et al. demonstrated, in their large cohort
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study, that the application of the EAU categories on patients stratified by EORTC categories lead to a reclassification of 45.7% EORTC recurrence intermediate risk patients to EAU high risk category 10. Similarly, Xylinas et al. showed that the EORTC model overestimated the risk of disease recurrence
33-35
. In our retrospective study, we
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should be improved with readily available markers
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and progression in high risk group 32. To better assess with more accuracy, these predicting models
demonstrated that patients with decreased ChE are more likely to experience disease recurrence, also in high risk patients after controlling for the effect of intravesical BCG treatment. Therefore, closer follow up could be advocated for patients in this category. Finally, some of these patients may
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benefit from adjuvant treatment such as intravesical chemotherapy and BCG immunotherapy independently from tumor characteristics, and additionally, some may benefit from early RC if they are reclassified to very high risk for disease progression.
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This study has several limitations mainly related to its retrospective nature. Second, due to its
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multicentric nature, we cannot control for TURB quality, experience and skill of each surgeon and differences between intravesical therapeutic agents of each center. Third, TURB specimens were not assessed by central pathologic review. Additionally, we used the 1973 WHO classification and 398 of the cohort were G2. This could affect the results of the study if we assign them to the 2004 WHO classification. Moreover, the presence of carcinoma in situ could have been underestimated as cold biopsies were performed only when CIS was suspected, which also might affect result of this study. Fourth, the number of patients with disease progression was relatively small in this study, which
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cytology. ChE might be more useful for predicting disease recurrence when combined with urine cytology. Taking advantage of its easy accessibility and noninvasiveness, this biomarker could be 36
. Prospective well-designed trials are needed to elucidate the
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easily interpreted in clinical care
relationship between ChE and NMIBC as well as BC in general. The underlying biological
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Conclusions
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ChE is significantly associated with RFS in patients with NMIBC undergoing TURB with or without adjuvant intravesical therapy. Preoperative serum ChE might help identify the patients likely to experience disease recurrence and could give additional information for clinical decision making
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regarding adjuvant therapy after TURB.
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Clinical practice points
Decreased ChE have been recently shown to be associated with poor prognosis in several cancers with or without hepatic involvement
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. While ChE have already been reported to be of
prognostic value in MIBC patients treated with RC
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, its role in patients with NMIBC remains
unknown. We retrospectively assessed 1,117 patients with NMIBC undergoing TURB. We found that ChE is significantly correlated with worse RFS in NMIBC patients treated with TURB. Additionally, in 14
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benefit from severe follow up scheduling and adjuvant therapy. Prospective well-designed trials are needed to elucidate the relationship between ChE and NMIBC
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Author Contributions:
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in the future.
S. Kimura: manuscript writing, data analysis
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F. Soria: manuscript editing, data analysis D. D’Andrea: manuscript editing, data collection B. Foerster: manuscript editing M Abufaraj: manuscript editing M.D. Vartolomei: manuscript editing, data analysis P.I. Karakiewicz: manuscript editing, data collection R. Mathieu: manuscript editing, data collection 15
ACCEPTED MANUSCRIPT M. Moschini: manuscript editing, data collection S. Egawa: manuscript editing S.F Shariat: project development, manuscript editing
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K.M Gust: project development, manuscript editing
Acknowledgement
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Table1.Patient characteristics according to ChE level (cut-off 5.55kU/L) Variables Total Preoperative ChE Low Normal Number of patients 1,117 564 (51) 553 (49) Median age(IQR) 67 (58-74) 67 (59-74) 66 (58-74) Gender, n (%) female 262 (23) 147 (56) 115 (44) male 855 (77) 418 (49) 437 (51) Smoking status, n (%) never 272 (24) 136 (50) 136 (50) former 331(30) 168 (51) 163 (49) current 514(46) 261 (51) 253 (49) Prior recurrence, n (%) Primary tumor 931(83) 472(84) 459(83) Recurrent tumor 186(17) 92 (16) 94 (17) Pathological T stage, n (%) pTa 653(58) 314 (48) 339 (52) pTis 21(2) 10 (48) 12 (52) pT1 443(40) 241 (54) 202 (46) Pathological tumor grade, n (%) Grade1 231(21) 106 (46) 125 (54) Grade2 398(35) 198 (49) 200 (51) Grade3 488(44) 261 (53) 227 (47) Concomitant CIS, n (%) 66(6) 35 (6) 31 (6) Tumor size, n (%) <1cm 368(33) 179 (49) 189 (51) 1-3cm 448(40) 214 (48) 234 (52) >3cm 301(27) 172 (57) 129 (43) Number of tumor, n (%) 1 718(64) 363 (51) 355 (49) 1-7 297(27) 150 (51) 147(49) 102(9) 52 (51) 50 (49) ≧8 Intravesical therapy, n (%) 493(44) 241 (43) 252 (46) Type of Intravesical therapy, n (%) 19
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0.98
0.74
0.12
0.15
0.68 <0.05
0.99
0.31 <0.05
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Early single installation 145(13) 51 (9) 94 (17) ACCEPTED MANUSCRIPT Adjuvant chemotherapy 48(4) 21(4) 27 (5) Adjuvant BCG 300(27) 169 (30) 131 (24) EAU risk stratification, n (%) Low risk 130(12) 65(50) 65(50) Intermediate risk 465(41) 242(52) 223(48) High risk 522(47) 245(47) 277(53) BCG=bacillus Calmette-Guérin; CIS= carcinoma in situ; EAU= European Association of Urology; IQR=interquartile range
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Table2.Univariable and Multivariable Cox regression analyses for the prediction of disease recurrence and progression in 1,117 patients treated with TURB with or without adjuvant intravesical therapy for bladder cancer. Variable
Recurrence free survival Univariable
Multivariable
Univariable
Multivariable
95%CI 1.02-1.03 0.84-1.29
p <0.001 0.72
HR 1.02 -
95%CI 1.01-1.03 -
p <0.001 -
HR 1.04 1.15
95%CI 1.02-1.06 0.74-1.79
p <0.001 0.53
HR 1.04 -
95%CI 1.02-1.06 -
p <0.001 -
1.12 1.15 0.72
0.87-1.44 0.91-1.45 0.55-0.94
0.36 0.24 0.015
0.96
0.72-1.27
0.76
2.78 1.68 2.04
1.52-5.06 0.92-3.07 1.30-3.18
0.001 0.09 0.002
2.94 1.68 2.17
1.60-5.39 0.92-3.07 1.37-3.44
0.001 0.09 0.001
0.79 0.71
0.39-1.59 0.59-0.86
0.51 0.001
0.93 0.38
1.77 1.57
0.43-7.28 1.06-2.31
0.43 0.025
0.45 0.36
0.10-2.03 0.18-0.72
0.30 0.004
1.97 1.51-2.57 <0.001 1.58 1.20-2.08 0.001 2.52 1.17-5.44 0.018 1.26 0.96-1.66 0.09 2.59 1.64-4.09 <0.001 4.00 1.91-8.37 <0.001 0.95 0.64-1.42 0.81 1.43 0.66-3.08 0.36 2.39 1.98-2.87 <0.001 2.11 1.73-2.56 <0.001 1.39 0.93-2.08 0.11 1.36 1.13-1.64 0.001 1.47 1.21-1.80 <0.001 1.68 1.14-2.49 0.009 0.59 0.48-.071 <0.001 0.63 0.51-0.78 <0.001 1.14 0.77-1.69 0.51 0.74 0.69-0.78 <0.001 0.75 0.71-0.80 <0.001 0.94 0.83-1.05 0.25 2.28 1.88-2.76 <0.001 2.24 1.85-2.72 <0.001 0.68 0.46-1.005 0.053 ChE= cholinesterase; 95%CI=95% confidence interval; CIS= carcinoma in situ; HR=hazard ratio
2.81 9.43 1.25 -
1.29-6.11 3.65-24.3 0.84-1.87 -
0.009 <0.001 0.27 -
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Age(continuous) Female gender Smoking status (ref: never smoker) Former smoker Current smoker Recurrent vs Primary tumor Pathological T stage (ref: pTa) pTis pT1 Pathological tumor grade (ref: grade1) Grade2 Grade3 Concomitant CIS Tumor size Number of tumor Intravesical therapy ChE (continuous) ChE (low vs normal) cut-off 5.55
Progression free survival
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Table3. Univariable and multivariable Cox regression analyses for the prediction of disease recurrence adjusted for clinicopathological features in 130 patients with EAU low risk and 465 patients with EAU intermediate risk 130 patients with EAU low risk Recurrence free survival Univariable Multivariable HR 95%CI p HR 95%CI p 1.07 0.91-1.25 0.44 ChE (continuous) 0.92 0.52-1.63 0.77 ChE (low vs normal) cut-off 5.55 465 patients with EAU intermediate risk Recurrence free survival Univariable Multivariable HR 95%CI p HR 95%CI p 0.78 0.72-0.85 <0.001 0.81 0.75-0.88 <0.001 ChE (continuous) 1.76 1.35-2.30 <0.001 1.63 1.25-2.13 <0.001 ChE (low vs normal) cut-off 5.55 ChE=cholinesterase; 95%CI=95% confidence interval; EAU=European Association of Urology; HR=hazard ratio
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Table4. Univariable and multivariable Cox regression analyses for the prediction of disease recurrence and progression adjusted for clinicopathological features in 522 patients with EAU high risk and 207 patients with EAU high risk received BCG treatment 522 patients with EAU high risk Recurrence free survival Progression free survival Univariable Multivariable Univariable Multivariable HR 95%CI p HR 95%CI p HR 95%CI p HR 95%CI p 0.87 0.74-1.01 0.08 ChE (continuous) 0.56 0.49-0.62 <0.001 0.58 0.52-0.66 <0.001 0.84 0.51-1.37 0.47 ChE (low vs normal) cut-off 5.55 4.37 3.09-6.20 <0.001 4.14 2.90-5.89 <0.001 207 patients with EAU high risk received BCG treatment Recurrence free survival Progression free survival Univariable Multivariable Univariable Multivariable HR 95%CI p HR 95%CI p HR 95%CI p HR 95%CI p 0.58 0.49-0.69 <0.001 0.57 0.47-0.68 <0.001 0.99 0.76-1.31 0.99 ChE (continuous) 0.44 0.17-1.17 0.10 ChE (low vs normal) cut-off 5.55 4.75 2.55-8.83 <0.001 5.46 2.91-10.2 <0.001 ChE=cholinesterase; 95%CI=95% confidence interval; EAU=European Association of Urology; HR=hazard ratio
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