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Re: Urinary Cytology has a Poor Performance for Predicting Invasive or High-Grade Upper-Tract Urothelial Carcinoma
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
Poisson regression. Results: As of July 2010, 15 bladder tumours were detected in 14 participants. GH was found in four out of nine high-grade tumours and associated with a rate ratio of 3.82, 95% confidence interval (CI) 0.50 –29.15 for the development of bladder lesions. The PPV of GH was 11.4%, but only 1.2% for H. H occurred in 18.8% of urine samples and was not associated with bladder cancer [rate ratio (RR) 0.72, 95% CI 0.11– 4.78]. Abundant urinary leukocytes were associated with H [odds ratio (OR) 8.34, 95% CI 2.26 –30.69] and even stronger with GH (OR 22.25, 95% CI 6.42–77.06). Haematuria and leukocytes influenced NMP22 positivity (H: OR 1.63, 95% CI 1.06 –2.51, abundant leukocytes: OR 8.90, 95% CI 1.58 –50.16), but not test results for urine cytology and UroVysion™ Conclusion: While the PPV of H for bladder cancer was low, there was a strong influence of haematuria and leukocytes on the protein-based tumour test NMP22®. Erythrocytes and leukocytes should be determined at least semi-quantitatively for the interpretation of positive NMP22 test results. In addition, a panel of tumour tests that includes methods not affected by the presence of erythrocytes or leukocytes such as cytology and UroVysion™ would improve bladder cancer screening. Editorial Comment: The positive predictive value of microhematuria for bladder cancer in individuals at high risk for bladder cancer (aromatic amine exposure) was only 1.2%, compared to 11.4% for gross hematuria. Contaminating leukocytes decreased the predictive value of NMP22. The cost of evaluating every patient with microhematuria for a low detection rate needs to be considered. David P. Wood, M.D.
Re: Urinary Cytology has a Poor Performance for Predicting Invasive or High-Grade Upper-Tract Urothelial Carcinoma J. Messer, S. F. Shariat, J. C. Brien, M. P. Herman, C. K. Ng, D. S. Scherr, B. Scoll, R. G. Uzzo, M. Wille, S. E. Eggener, G. Steinberg, J. D. Terrell, S. M. Lucas, Y. Lotan, S. A. Boorjian and J. D. Raman Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania BJU Int 2011; 108: 701–705.
Objective: To evaluate the diagnostic accuracy of urine cytology for detecting aggressive disease in a multi-institutional cohort of patients undergoing extirpative surgery for upper-tract urothelial carcinoma (UTUC). Methods: We reviewed the records of 326 patients with urinary cytology data who underwent a radical nephroureterectomy or distal ureterectomy without concurrent or previous bladder cancer. We assessed the association of cytology (positive, negative and atypical) with final pathology. Sensitivity and positive predictive value (PPV) of a positive (⫾ atypical) cytology for high-grade and muscle-invasive UTUC was calculated. Results: On final pathology, 53% of patients had nonmuscle invasive disease (pTa, pTis, pT1) and 47% had invasive disease (ⱖ pT2). Low-grade and high-grade cancers were present in 33% and 67% of patients, respectively. Positive, atypical and negative urine cytology was noted in 40%, 40% and 20% of cases. Positive urinary cytology had sensitivity and PPV of 56% and 54% for high-grade and 62% and 44% for muscle-invasive UTUC. Inclusion of atypical cytology with positive cytology improved the sensitivity and PPV for highgrade (74% and 63%) and muscle-invasive (77% and 45%) UTUC. Restricting analysis to patients with selective ureteral cytologies further improved the diagnostic accuracy when compared with bladder specimens (PPV ⬎ 85% for high-grade and muscle-invasive UTUC). Conclusions: In this cohort of patients with UTUC treated with radical surgery, urine cytology in isolation lacked performance characteristics to accurately predict muscle-invasive or high-grade disease. Improved surrogate markers for pathological grade and stage are necessary, particularly when considering endoscopic modalities for UTUC. Editorial Comments: Diagnosing upper tract urothelial cancer is a challenge, especially with the trend away from computerized tomographic urograms, which are associated with
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BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
a relatively high rate of radiation exposure. It appears that selective ureteral cytologies are necessary to evaluate patients with upper tract filling defects and to monitor those at high risk for upper tract tumors. David P. Wood, M.D.
This is a large multi-institutional study that attempted to assess the accuracy of urinary cytology to detect aggressive urothelial cancers in the upper tracts. Records of 326 patients who had undergone radical nephroureterectomy or distal ureterectomy without history of bladder cancer were reviewed, and urinary cytology was not predictive of either muscle invasive disease or high grade urothelial lesions. The authors conclude that markers other than cytology are needed to correlate better with grade and stage of upper tract lesions. Richard K. Babayan, M.D.
Re: Defecation Disturbances After Cystectomy for Urinary Bladder Cancer H. Thulin, U. Kreicbergs, E. Onelöv, C. Ahlstrand, M. Carringer, S. Holmäng, B. Ljungberg, P. U. Malmström, D. Robinsson, H. Wijkström, N. P. Wiklund, G. Steineck and L. Henningsohn Division of Clinical Cancer Epidemiology, Department of Oncology and Pathology, Karolinska Institutet, Karolinska University Hospital-Huddinge, Stockholm, Sweden BJU Int 2011; 108: 196 –203.
Objective: To describe and compare long-term defecation disturbances in patients who had undergone a cystectomy due to urinary bladder cancer with non-continent urostomies, continent reservoirs and orthotopic neobladder urinary diversions. Patients and Methods: During their follow-up we attempted to contact all men and women aged 30 – 80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals. During a qualitative phase we identified defecation disturbances as a distressful symptom and included this item in a study-specific questionnaire together with free-hand comments. The patients completed the questionnaire at home. Outcome variables were dichotomized and the results are presented as relative risks with 95% confidence interval. Results: The questionnaire was returned from 452 (92%) of 491 identified patients. Up to 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability). A sense of decreased straining capacity was reported by 20% of the men and women with non-continent urostomy and 14% and 8% of those with continent reservoirs and orthotopic neobladders, respectively. Conclusions: Of the cystectomized individuals 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability). Those wanting to improve the situation for bladder cancer survivors may consider communicating before surgery the possibility of stool-emptying problems, and asking about them after surgery. Editorial Comment: This multi-institutional study from Sweden retrospectively reviewed long-term defecation disturbances in patients who had undergone cystectomy for bladder cancer. The authors contacted patients and sent out a specific bowel emptying questionnaire, which was filled out by 92% of patients identified to have undergone cystectomy. The results demonstrated 30% reporting disturbances of bowel emptying following cystectomy. This report raises awareness of potential nonurological issues following cystectomy and urinary diversion that may affect patient satisfaction. The authors suggest that potential bowel issues be discussed with patients before cystectomy and urinary diversion. Richard K. Babayan, M.D.
Poisson regression. Results: As of July 2010, 15 bladder tumours were detected in 14 participants. GH was found in four out of nine high-grade tumours and associated with a rate ratio of 3.82, 95% confidence interval (CI) 0.50 –29.15 for the development of bladder lesions. The PPV of GH was 11.4%, but only 1.2% for H. H occurred in 18.8% of urine samples and was not associated with bladder cancer [rate ratio (RR) 0.72, 95% CI 0.11– 4.78]. Abundant urinary leukocytes were associated with H [odds ratio (OR) 8.34, 95% CI 2.26 –30.69] and even stronger with GH (OR 22.25, 95% CI 6.42–77.06). Haematuria and leukocytes influenced NMP22 positivity (H: OR 1.63, 95% CI 1.06 –2.51, abundant leukocytes: OR 8.90, 95% CI 1.58 –50.16), but not test results for urine cytology and UroVysion™ Conclusion: While the PPV of H for bladder cancer was low, there was a strong influence of haematuria and leukocytes on the protein-based tumour test NMP22®. Erythrocytes and leukocytes should be determined at least semi-quantitatively for the interpretation of positive NMP22 test results. In addition, a panel of tumour tests that includes methods not affected by the presence of erythrocytes or leukocytes such as cytology and UroVysion™ would improve bladder cancer screening. Editorial Comment: The positive predictive value of microhematuria for bladder cancer in individuals at high risk for bladder cancer (aromatic amine exposure) was only 1.2%, compared to 11.4% for gross hematuria. Contaminating leukocytes decreased the predictive value of NMP22. The cost of evaluating every patient with microhematuria for a low detection rate needs to be considered. David P. Wood, M.D.
Re: Urinary Cytology has a Poor Performance for Predicting Invasive or High-Grade Upper-Tract Urothelial Carcinoma J. Messer, S. F. Shariat, J. C. Brien, M. P. Herman, C. K. Ng, D. S. Scherr, B. Scoll, R. G. Uzzo, M. Wille, S. E. Eggener, G. Steinberg, J. D. Terrell, S. M. Lucas, Y. Lotan, S. A. Boorjian and J. D. Raman Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania BJU Int 2011; 108: 701–705.
Objective: To evaluate the diagnostic accuracy of urine cytology for detecting aggressive disease in a multi-institutional cohort of patients undergoing extirpative surgery for upper-tract urothelial carcinoma (UTUC). Methods: We reviewed the records of 326 patients with urinary cytology data who underwent a radical nephroureterectomy or distal ureterectomy without concurrent or previous bladder cancer. We assessed the association of cytology (positive, negative and atypical) with final pathology. Sensitivity and positive predictive value (PPV) of a positive (⫾ atypical) cytology for high-grade and muscle-invasive UTUC was calculated. Results: On final pathology, 53% of patients had nonmuscle invasive disease (pTa, pTis, pT1) and 47% had invasive disease (ⱖ pT2). Low-grade and high-grade cancers were present in 33% and 67% of patients, respectively. Positive, atypical and negative urine cytology was noted in 40%, 40% and 20% of cases. Positive urinary cytology had sensitivity and PPV of 56% and 54% for high-grade and 62% and 44% for muscle-invasive UTUC. Inclusion of atypical cytology with positive cytology improved the sensitivity and PPV for highgrade (74% and 63%) and muscle-invasive (77% and 45%) UTUC. Restricting analysis to patients with selective ureteral cytologies further improved the diagnostic accuracy when compared with bladder specimens (PPV ⬎ 85% for high-grade and muscle-invasive UTUC). Conclusions: In this cohort of patients with UTUC treated with radical surgery, urine cytology in isolation lacked performance characteristics to accurately predict muscle-invasive or high-grade disease. Improved surrogate markers for pathological grade and stage are necessary, particularly when considering endoscopic modalities for UTUC. Editorial Comments: Diagnosing upper tract urothelial cancer is a challenge, especially with the trend away from computerized tomographic urograms, which are associated with
1587
1588
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
a relatively high rate of radiation exposure. It appears that selective ureteral cytologies are necessary to evaluate patients with upper tract filling defects and to monitor those at high risk for upper tract tumors. David P. Wood, M.D.
This is a large multi-institutional study that attempted to assess the accuracy of urinary cytology to detect aggressive urothelial cancers in the upper tracts. Records of 326 patients who had undergone radical nephroureterectomy or distal ureterectomy without history of bladder cancer were reviewed, and urinary cytology was not predictive of either muscle invasive disease or high grade urothelial lesions. The authors conclude that markers other than cytology are needed to correlate better with grade and stage of upper tract lesions. Richard K. Babayan, M.D.
Re: Defecation Disturbances After Cystectomy for Urinary Bladder Cancer H. Thulin, U. Kreicbergs, E. Onelöv, C. Ahlstrand, M. Carringer, S. Holmäng, B. Ljungberg, P. U. Malmström, D. Robinsson, H. Wijkström, N. P. Wiklund, G. Steineck and L. Henningsohn Division of Clinical Cancer Epidemiology, Department of Oncology and Pathology, Karolinska Institutet, Karolinska University Hospital-Huddinge, Stockholm, Sweden BJU Int 2011; 108: 196 –203.
Objective: To describe and compare long-term defecation disturbances in patients who had undergone a cystectomy due to urinary bladder cancer with non-continent urostomies, continent reservoirs and orthotopic neobladder urinary diversions. Patients and Methods: During their follow-up we attempted to contact all men and women aged 30 – 80 years who had undergone cystectomy and urinary diversion at seven Swedish hospitals. During a qualitative phase we identified defecation disturbances as a distressful symptom and included this item in a study-specific questionnaire together with free-hand comments. The patients completed the questionnaire at home. Outcome variables were dichotomized and the results are presented as relative risks with 95% confidence interval. Results: The questionnaire was returned from 452 (92%) of 491 identified patients. Up to 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability). A sense of decreased straining capacity was reported by 20% of the men and women with non-continent urostomy and 14% and 8% of those with continent reservoirs and orthotopic neobladders, respectively. Conclusions: Of the cystectomized individuals 30% reported problems with the physiological emptying process of stool (bowel movement, sensory rectal function, awareness of need for defecation, motoric rectal and anal function, straining ability). Those wanting to improve the situation for bladder cancer survivors may consider communicating before surgery the possibility of stool-emptying problems, and asking about them after surgery. Editorial Comment: This multi-institutional study from Sweden retrospectively reviewed long-term defecation disturbances in patients who had undergone cystectomy for bladder cancer. The authors contacted patients and sent out a specific bowel emptying questionnaire, which was filled out by 92% of patients identified to have undergone cystectomy. The results demonstrated 30% reporting disturbances of bowel emptying following cystectomy. This report raises awareness of potential nonurological issues following cystectomy and urinary diversion that may affect patient satisfaction. The authors suggest that potential bowel issues be discussed with patients before cystectomy and urinary diversion. Richard K. Babayan, M.D.