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Re: The Role of Squamous Differentiation in Patients with Transitional Cell Carcinoma of the Bladder Treated with Radical Cystectomy
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european urology 53 (2008) 208–211
[4] Ro¨del C, Weiss W, Sauer R. Trimodality treatment and selective organ preservation for bladder cancer. J Clin Oncol 2006;24:5536–44. [5] Weiss C, Wolze C, Engehausen DG, et al. Radiochemotherapy after transurethral resection for high-risk T1 bladder cancer: an alternative to intravesical therapy or early cystectomy? J Clin Oncol 2006;24:2318–24.
Re: The Role of Squamous Differentiation in Patients with Transitional Cell Carcinoma of the Bladder Treated with Radical Cystectomy Antunes AA, Nesrallah LJ, Dall’Oglio MF, Maluf CE, Camara C, Leithe KR, Srougi M Int Braz J Urol 2007;33:339–46. Expert’s summary: The authors report a retrospective analysis of 113 patients with transitional cell cancer (TCC) of the bladder treated by radical cystectomy. Focal squamous differentiation (SD) was found in 22% of cases. It was identified when intercellular bridges or keratinisation were evident. Most patients (86.9%) had high-grade cancer. Fifteen patients presented extravesical extension or lymph node invasion and received adjuvant M-VAC therapy. Patients with pure squamous cell carcinoma, incomplete followup, or treated with neoadjuvant chemotherapy were excluded from the statistical analysis of prognostic significance. Recurrence occurred in 64% of patients with and in 34% without SD; mortality rates were, respectively, 40% and 16% (mean follow-up of 31.7 mo). At multivariate analysis only SD and tumour size were independent prognostic factors. Expert’s comments: This paper was followed by two letters to the editors [1,2]. The first letter [1] points out that the number of patients is too small and that other investigators had failed to show a prognostic difference between SD and pure TCC. The authors of the second letter report that SD, if defined by intercellular bridges and keratinisation, occurred in 21% of TCC of the bladder and in 44% of tumours of the renal pelvis. They state that the criteria for assessing SD should be better defined and that the use of immunohistochemical techniques [3] may increase its detection. Markers, such as cytokeratin 14, caveolin, uroplakin, and L1 antigen are expressed in TCC
Peter Albers Department of Urology, Klinikum Kassel, Kassel, Germany DOI: 10.1016/j.eururo.2007.10.020
but not in SD. In my own experience [4] using a monoclonal antibody selective for SD (developed by Dr. H. Kato, Japan) SD was found in 40% of patients with T2 and T3 and in 60% of those with T4 urothelial bladder cancer. The most interesting result of the present study is that SD has prognostic significance not only to reduce response rate after radiotherapy or chemotherapy, but also in patients treated only by radical surgery, being an independent prognostic factor. In the experience of the European Organization for Research and Treatment of Cancer-Urological Group [5], 71 patients with TCC of the bladder were treated with neoadjuvant chemotherapy with cisplatin and methotrexate. Tumours with SD underwent an objective response in 25% of cases versus 69% in pure TCC. Whether the unfavourable prognostic value attributed to SD is dependent on intrinsic biologic properties of the tumour and not only by a reduced response to chemotherapy and radiotherapy remains to be determined. Larger series may be necessary to confirm these data. In any case, we support the statement [2] that any further evaluation of prognostic factors for prediction of response should include an estimate of the percentage of the squamous component.
References [1] [2] [3] [4] [5]
Frydenberg M. Int Braz J Urol 2007;33:562–3. Requena MJ, et al. Int Braz J Urol 2007;33:563–4. Lopez-Baltran A, et al. Hum Pathol 2006;37:1371–88. Pavone-Macaluso M, et al. Acta Urol Ital 1995;9:299–303. Splinter TAW, et al. J Urol 1992;148:1793–6.
Michele Pavone-Macaluso Department of Urology, University of Palermo, Palermo, Italy DOI: 10.1016/j.eururo.2007.10.021
european urology 53 (2008) 208–211
[4] Ro¨del C, Weiss W, Sauer R. Trimodality treatment and selective organ preservation for bladder cancer. J Clin Oncol 2006;24:5536–44. [5] Weiss C, Wolze C, Engehausen DG, et al. Radiochemotherapy after transurethral resection for high-risk T1 bladder cancer: an alternative to intravesical therapy or early cystectomy? J Clin Oncol 2006;24:2318–24.
Re: The Role of Squamous Differentiation in Patients with Transitional Cell Carcinoma of the Bladder Treated with Radical Cystectomy Antunes AA, Nesrallah LJ, Dall’Oglio MF, Maluf CE, Camara C, Leithe KR, Srougi M Int Braz J Urol 2007;33:339–46. Expert’s summary: The authors report a retrospective analysis of 113 patients with transitional cell cancer (TCC) of the bladder treated by radical cystectomy. Focal squamous differentiation (SD) was found in 22% of cases. It was identified when intercellular bridges or keratinisation were evident. Most patients (86.9%) had high-grade cancer. Fifteen patients presented extravesical extension or lymph node invasion and received adjuvant M-VAC therapy. Patients with pure squamous cell carcinoma, incomplete followup, or treated with neoadjuvant chemotherapy were excluded from the statistical analysis of prognostic significance. Recurrence occurred in 64% of patients with and in 34% without SD; mortality rates were, respectively, 40% and 16% (mean follow-up of 31.7 mo). At multivariate analysis only SD and tumour size were independent prognostic factors. Expert’s comments: This paper was followed by two letters to the editors [1,2]. The first letter [1] points out that the number of patients is too small and that other investigators had failed to show a prognostic difference between SD and pure TCC. The authors of the second letter report that SD, if defined by intercellular bridges and keratinisation, occurred in 21% of TCC of the bladder and in 44% of tumours of the renal pelvis. They state that the criteria for assessing SD should be better defined and that the use of immunohistochemical techniques [3] may increase its detection. Markers, such as cytokeratin 14, caveolin, uroplakin, and L1 antigen are expressed in TCC
Peter Albers Department of Urology, Klinikum Kassel, Kassel, Germany DOI: 10.1016/j.eururo.2007.10.020
but not in SD. In my own experience [4] using a monoclonal antibody selective for SD (developed by Dr. H. Kato, Japan) SD was found in 40% of patients with T2 and T3 and in 60% of those with T4 urothelial bladder cancer. The most interesting result of the present study is that SD has prognostic significance not only to reduce response rate after radiotherapy or chemotherapy, but also in patients treated only by radical surgery, being an independent prognostic factor. In the experience of the European Organization for Research and Treatment of Cancer-Urological Group [5], 71 patients with TCC of the bladder were treated with neoadjuvant chemotherapy with cisplatin and methotrexate. Tumours with SD underwent an objective response in 25% of cases versus 69% in pure TCC. Whether the unfavourable prognostic value attributed to SD is dependent on intrinsic biologic properties of the tumour and not only by a reduced response to chemotherapy and radiotherapy remains to be determined. Larger series may be necessary to confirm these data. In any case, we support the statement [2] that any further evaluation of prognostic factors for prediction of response should include an estimate of the percentage of the squamous component.
References [1] [2] [3] [4] [5]
Frydenberg M. Int Braz J Urol 2007;33:562–3. Requena MJ, et al. Int Braz J Urol 2007;33:563–4. Lopez-Baltran A, et al. Hum Pathol 2006;37:1371–88. Pavone-Macaluso M, et al. Acta Urol Ital 1995;9:299–303. Splinter TAW, et al. J Urol 1992;148:1793–6.
Michele Pavone-Macaluso Department of Urology, University of Palermo, Palermo, Italy DOI: 10.1016/j.eururo.2007.10.021