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Re: Transurethral Resection Specimens of the Bladder: Outcome of Invasive Urothelial Cancer Involving Muscle Bundles Indeterminate Between Muscularis Mucosae and Muscularis Propria
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BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Mechanisms of Recurrence of Ta/T1 Bladder Cancer R. T. Bryan, S. I. Collins, M. C. Daykin, M. P. Zeegers, K. K. Cheng, D. M. Wallace and G. M. Sole Department of Public Health, Epidemiology and Biostatistics, School of Population Sciences, University of Birmingham, Birmingham, United Kingdom Ann R Coll Surg Engl 2010; 92: 519 –524.
Introduction: Bladder cancer recurrence occurs via four mechanisms – incomplete resection, tumour cell re–implantation, growth of microscopic tumours, and new tumour formation. The first two mechanisms are influenced by clinicians before and immediately after resection; the remaining mechanisms have the potential to be influenced by chemopreventive agents. However, the relative importance and timing of these mechanisms is currently unknown. Our objective was to postulate the incidence and timing of these mechanisms by investigating the location of bladder cancer recurrences over time. Patients and Methods: The topographical locations of tumours and their recurrences were analysed retrospectively for 169 patients newly-diagnosed with Ta/T1 bladder cancer, with median follow-up of 33.8 months. Tumours were assigned to one or more of six bladder sectors, and time to recurrence and location of recurrences were recorded. Results: Median time to first tumour recurrence was 40 months. Median times between subsequent recurrences were 6.6, 7.9, 8.0 and 6.6 months for recurrences 1 to 2, 2 to 3, 3 to 4, and 4 to 5, respectively. The risk of first tumour recurrence in any given bladder sector increased by nearly 4-fold if the primary tumour was resected from that sector (P ⬍ 0.001); this association was not significant for subsequent recurrences. The proportion of tumour recurrences in multiple bladder sectors increased from 13% for the first recurrence to 100% for recurrence seven onwards. Conclusions: First tumour recurrence appears different to subsequent recurrences; incomplete resection and tumour cell reimplantation may dominate at this time-point. Only later does genuine new tumour formation appear to increase in importance. This has important implications for clinical trials, especially those involving chemopreventive agents. Editorial Comment: Management of nonmuscle invasive bladder cancer is expensive due to multiple tumor recurrences and invasive diagnostic procedures.1 This article suggests that the first tumor recurrence is delayed and biologically different than subsequent recurrences. Modification of bladder surveillance schedules should be considered. David P. Wood, M.D. 1. Hollenbeck BK, Ye Z, Dunn RL et al: Provider treatment intensity and outcomes for patients with early-stage bladder cancer. J Natl Cancer Inst 2009; 101: 571.
Re: Transurethral Resection Specimens of the Bladder: Outcome of Invasive Urothelial Cancer Involving Muscle Bundles Indeterminate Between Muscularis Mucosae and Muscularis Propria H. Miyamoto and J. I. Epstein Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland Urology 2010; 76: 600 – 602.
Objectives: Thin muscle fibers on transurethral resection of the bladder (TURB) can represent either muscularis propria destroyed or splayed by urothelial carcinoma or muscularis mucosae, which can be hyperplastic. Methods: The data from 94 patients with invasive bladder cancer seen at our institution (1986 –2008) with a mean of 25.4 months of follow-up, who had had an uncertain patho-
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
logic diagnosis, were analyzed (72 men and 22 women, mean age 69.4 years). Results: Subsequent restaging TURB or a definitive therapeutic procedure performed ⱕ3 months after the original TURB in 57 patients revealed that 22 patients (38.6%) had nonmuscle-invasive disease and 32 (56.1%) had Stage pT2 or greater disease. The staging for 3 patients remained ambiguous. Of the 94 patients, 37 did not undergo a restaging/therapeutic procedure within 3 months of their original TURB. Conclusions: Restaging TURB is critical when the initial TURB findings are equivocal for muscularis propria invasion. Although this might seem intuitive, 37 of 94 patients did not undergo repeat staging/ therapeutic procedures within 3 months of their initial TURB. Editorial Comment: Once again, restaging TURB is shown to be critical for accurately staging bladder cancer and should be performed in all cases with lamina propria invasion, even if muscle is present in the specimen. David P. Wood, M.D.
Practice Patterns and Recurrence After Partial Cystectomy for Bladder Cancer N. Fahmy, A. Aprikian, S. Tanguay, S. M. Mahmud, M. Al-Otaibi, S. Jeyaganth, M. Amin and W. Kassouf Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada World J Urol 2010; 28: 419 – 423.
Purpose: Partial cystectomy (PC) remains a viable alternative to radical cystectomy (RC) for management of invasive bladder cancer in approximately 5% of patients. We used a population-based database to examine practice patterns and recurrence after partial cystectomy. Materials and Methods: We obtained billing records of all partial and radical cystectomies performed for bladder cancer in Quebec from 1983 until 2005. Analysis included age, gender, year of surgery, surgeon’s age, hospital type, preoperative and postoperative visits with accompanying diagnoses and dates of recurrences salvage RC, and death. Results: A total of 714 (30.4%) patients with invasive bladder cancer underwent PC. Majority of PC (65%) were performed in non-academic institutions. Pelvic lymphadenectomy was performed in only 163 patients (23%) and concomitant ureteral reimplantation was performed in 89 patients (13%). Of 714 patients, 52 (23.7%) required a salvage RC. Median time from PC to salvage RC was 17.6 months (range 1–240 months), respectively. Patients who underwent PC had similar 5-year overall survival compared with patients who underwent upfront RC (49.8% vs. 51%, p ⫽ 0.21). Conclusions: Rate of PC for invasive bladder cancer is significantly higher than expected. Pelvic lymphadenectomy is underutilized in bladder cancer patients treated with PC. Whether prevalent use of PC is due to less stringent selection criteria remains unknown. Since late recurrence is not uncommon, lifelong follow-up is recommended. Editorial Comment: The finding that 30% of patients with invasive bladder cancer underwent partial cystectomy is surprising, as well as the infrequent use of pelvic lymph node dissection. Use of partial cystectomy should be rare due to the field change effect in urothelial cancer. Survival rates in patients undergoing partial cystectomy vs up-front radical cystectomy were similar, suggesting that salvage radical cystectomy (23.7% of patients in partial cystectomy group) was effective. David P. Wood, M.D.
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BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Mechanisms of Recurrence of Ta/T1 Bladder Cancer R. T. Bryan, S. I. Collins, M. C. Daykin, M. P. Zeegers, K. K. Cheng, D. M. Wallace and G. M. Sole Department of Public Health, Epidemiology and Biostatistics, School of Population Sciences, University of Birmingham, Birmingham, United Kingdom Ann R Coll Surg Engl 2010; 92: 519 –524.
Introduction: Bladder cancer recurrence occurs via four mechanisms – incomplete resection, tumour cell re–implantation, growth of microscopic tumours, and new tumour formation. The first two mechanisms are influenced by clinicians before and immediately after resection; the remaining mechanisms have the potential to be influenced by chemopreventive agents. However, the relative importance and timing of these mechanisms is currently unknown. Our objective was to postulate the incidence and timing of these mechanisms by investigating the location of bladder cancer recurrences over time. Patients and Methods: The topographical locations of tumours and their recurrences were analysed retrospectively for 169 patients newly-diagnosed with Ta/T1 bladder cancer, with median follow-up of 33.8 months. Tumours were assigned to one or more of six bladder sectors, and time to recurrence and location of recurrences were recorded. Results: Median time to first tumour recurrence was 40 months. Median times between subsequent recurrences were 6.6, 7.9, 8.0 and 6.6 months for recurrences 1 to 2, 2 to 3, 3 to 4, and 4 to 5, respectively. The risk of first tumour recurrence in any given bladder sector increased by nearly 4-fold if the primary tumour was resected from that sector (P ⬍ 0.001); this association was not significant for subsequent recurrences. The proportion of tumour recurrences in multiple bladder sectors increased from 13% for the first recurrence to 100% for recurrence seven onwards. Conclusions: First tumour recurrence appears different to subsequent recurrences; incomplete resection and tumour cell reimplantation may dominate at this time-point. Only later does genuine new tumour formation appear to increase in importance. This has important implications for clinical trials, especially those involving chemopreventive agents. Editorial Comment: Management of nonmuscle invasive bladder cancer is expensive due to multiple tumor recurrences and invasive diagnostic procedures.1 This article suggests that the first tumor recurrence is delayed and biologically different than subsequent recurrences. Modification of bladder surveillance schedules should be considered. David P. Wood, M.D. 1. Hollenbeck BK, Ye Z, Dunn RL et al: Provider treatment intensity and outcomes for patients with early-stage bladder cancer. J Natl Cancer Inst 2009; 101: 571.
Re: Transurethral Resection Specimens of the Bladder: Outcome of Invasive Urothelial Cancer Involving Muscle Bundles Indeterminate Between Muscularis Mucosae and Muscularis Propria H. Miyamoto and J. I. Epstein Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland Urology 2010; 76: 600 – 602.
Objectives: Thin muscle fibers on transurethral resection of the bladder (TURB) can represent either muscularis propria destroyed or splayed by urothelial carcinoma or muscularis mucosae, which can be hyperplastic. Methods: The data from 94 patients with invasive bladder cancer seen at our institution (1986 –2008) with a mean of 25.4 months of follow-up, who had had an uncertain patho-
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
logic diagnosis, were analyzed (72 men and 22 women, mean age 69.4 years). Results: Subsequent restaging TURB or a definitive therapeutic procedure performed ⱕ3 months after the original TURB in 57 patients revealed that 22 patients (38.6%) had nonmuscle-invasive disease and 32 (56.1%) had Stage pT2 or greater disease. The staging for 3 patients remained ambiguous. Of the 94 patients, 37 did not undergo a restaging/therapeutic procedure within 3 months of their original TURB. Conclusions: Restaging TURB is critical when the initial TURB findings are equivocal for muscularis propria invasion. Although this might seem intuitive, 37 of 94 patients did not undergo repeat staging/ therapeutic procedures within 3 months of their initial TURB. Editorial Comment: Once again, restaging TURB is shown to be critical for accurately staging bladder cancer and should be performed in all cases with lamina propria invasion, even if muscle is present in the specimen. David P. Wood, M.D.
Practice Patterns and Recurrence After Partial Cystectomy for Bladder Cancer N. Fahmy, A. Aprikian, S. Tanguay, S. M. Mahmud, M. Al-Otaibi, S. Jeyaganth, M. Amin and W. Kassouf Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada World J Urol 2010; 28: 419 – 423.
Purpose: Partial cystectomy (PC) remains a viable alternative to radical cystectomy (RC) for management of invasive bladder cancer in approximately 5% of patients. We used a population-based database to examine practice patterns and recurrence after partial cystectomy. Materials and Methods: We obtained billing records of all partial and radical cystectomies performed for bladder cancer in Quebec from 1983 until 2005. Analysis included age, gender, year of surgery, surgeon’s age, hospital type, preoperative and postoperative visits with accompanying diagnoses and dates of recurrences salvage RC, and death. Results: A total of 714 (30.4%) patients with invasive bladder cancer underwent PC. Majority of PC (65%) were performed in non-academic institutions. Pelvic lymphadenectomy was performed in only 163 patients (23%) and concomitant ureteral reimplantation was performed in 89 patients (13%). Of 714 patients, 52 (23.7%) required a salvage RC. Median time from PC to salvage RC was 17.6 months (range 1–240 months), respectively. Patients who underwent PC had similar 5-year overall survival compared with patients who underwent upfront RC (49.8% vs. 51%, p ⫽ 0.21). Conclusions: Rate of PC for invasive bladder cancer is significantly higher than expected. Pelvic lymphadenectomy is underutilized in bladder cancer patients treated with PC. Whether prevalent use of PC is due to less stringent selection criteria remains unknown. Since late recurrence is not uncommon, lifelong follow-up is recommended. Editorial Comment: The finding that 30% of patients with invasive bladder cancer underwent partial cystectomy is surprising, as well as the infrequent use of pelvic lymph node dissection. Use of partial cystectomy should be rare due to the field change effect in urothelial cancer. Survival rates in patients undergoing partial cystectomy vs up-front radical cystectomy were similar, suggesting that salvage radical cystectomy (23.7% of patients in partial cystectomy group) was effective. David P. Wood, M.D.
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