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The Natural History of Patients Less than 40 Years Old with Bladder Tumors
O(L2'2-fii4'; /8'/ /Li/3-0395$0'2.GU/O
VoL 137. )/larch
THE Jot;RNAL OF UROLOGY
Copyright (c', 1987 by The 1Nilliams & \Vilkins Co.
Printed in U.S.A.
THE NATURAL HISTORY OF PATIENTS LESS THAN 40 YEARS OLD WITH BLADDER TUMORS KENNETH R KURZ, W. REID PITTS
AND
E. DARRACOTT VAUGHAN, JR
From the Department of Surgery (Urology), The James Buchanan Brady Foundation, The New York Hospital, Cornell University Medical Center, New York, New York
ABSTRACT
We treated 19 men and 6 women less than 40 years old with bladder tumors. The average patient age at diagnosis was 30.6 years and the mean followup was 65 months. Gross hematuria was present in 84 per cent and excretory urography showed a mass in the bladder in 44 per cent of the patients. Of 8 patients less than 30 years old 6 had papilloma and 2 had grade II to III, stage O transitional cell carcinoma. All patients with papillomas were free of disease. The pathological reports of the patients more than 30 years old revealed papilloma or grade I, stage O transitional cell carcinoma in 9, grade II to III, stage O to A papillary transitional cell carcinoma in 6 and invasive disease in 2, 1 of whom died. Of the 9 patients with papilloma or grade I, stage O disease 77 per cent are currently free of disease. Of those with grade II to III, stage O to B papillary transitional cell carcinoma only 1 is free of disease, while 6 have had resectable recurrences. One patient with grade II to HI disease was lost to followup. Accordingly, all patients, regardless of age, should be treated as aggressively as necessary on the basis of the stage and grade of the tumor. Carcinoma of the bladder is distinctly uncommon in patients less than 40 years old.u Last year we saw 4 patients with this unusual problem in 1 calling our attention to the controversies'1 ·'• surrounding the prognosis, management and followup of such patients. Therefore, we reviewed our experience from 1971 to the present in an attempt to elucidate the natural history of this disease. We found 25 patients with bladder tumors who were less than 40 years old and the charts were reviewed. MATERIALS AND METHODS
A retrospective review of 25 white patients with a pathologically proved diagnosis of a bladder tumor and age less than 40 years was undertaken. These patients were found through a computer search of our institutional records for the diagnosis of bladder tumor and age at diagnosis. There were 2 such patients whose charts could not be located. All pathological material was confirmed at our institution. Followup ranged from 3 to 288 with a mean of 65 months. RESULTS
There were 19 men and 6 women, a 3:1 male preponderance. Patient age from 14 to 39 years figure), and the average age at was 30.6 years (31.1 years for n,en and 29 years for women). The most common pn,sent1ng rn"~"rn," hematuria, which was present in 21 instances per Of the patients with gross hematuria 3 also had associated voiding symptoms. Only 3 patients had voiding symptoms (frequency, urgency and dysuria) without gross hematuria, 1 of whom had microscopic hematuria. The duration of symptoms before diagnosis ranged from l week to more than 4 years. The presence of voiding symptoms seemed to delay diagnosis. In 1 case disease was suspected during an examination for sports-related hematuria. Of our patients 46 per cent were cigarette smokers, 1 smoked a pipe, 33 per cent did not smoke and in 17 per cent the information was not recorded. The excretory urogram (IVP) proved to be the most sensitive routinely performed preoperative study, with 44 per cent (11 patients) demonstrating a mass within the bladder. Papanico0
Accepted for publication August 20, 1986. 395
laou urinary cytology was positive at diagnosis in 3 cases, including 2 of carcinoma in situ with invasive carcinoma, and 1 in which 160 gm. of grade HI, stage O papillary transitional cell carcinoma subsequently was resected. Not surprisingly, a bimanually palpable mass also was present at diagnosis in these 3 cases. All of the remaining cases were of low grade and stage, and had negative urinary Papanicolaou tests. Pathological diagnosis at presentation is shown in table 1. At our institution there was a change in the terminology used during the course of this review. Whereas at the start of our series "papilloma" was a common diagnosis, the presence of any atypia would now be considered transitional cell carcinoma. Grade I papillary transitional cell carcinoma is now used in place of many papillomas. The results of the study are presented in terms of the currently used pathological definitions and the World Health Organization system of classification. The initial pathological diagnosis included papilloma in 13 patients and grade I, stage O papillary transitional cell carcinoma in 2. The more aggressive lesions consisted of grade II to HI transitional cell carcinoma in 9 patients, stage O disease in 9, stage A disease in 1 and B disease in 1. Them was 1 with cl,<·+m•s•.r:.,cw,,N~ carcinoma and muscle inva-
13 (56 per cent) have no evidence of are stable (disease present but control3 per cent) have progression (disease requiring more than endoscopic procedure) and 1 was lost to followup after initial resection. Of the 15 patients with low grade and stage O disease at presentation 12 (80 per cent) have no evidence of disease, 2 are stable with endoscopically controllable disease and 1 has upper tract disease that required nephroureterectomy. Of the patients with higher grade disease (grade II to III, stage O to A transitional cell carcinoma or poorly differentiated carcinoma) or invasive disease at presentation more frequent recurrences are evident (table 1). Only 1 of 9 (11 per cent) patients has no evidence of disease, 6 (66 per cent) are stable with endoscopically controllable disease and 2 (22 per cent) have progression. One patient has been lost to followup in this group. The data obtained when the outcome was examined as it related to the age of the patient at the time of diagnosis are listed in table 2. There were 8 patients less than 30 years old,
396
KURZ, PITTS AND VAUGHAN
26 22
17
18
Number of patients
14
10 6
2
10-19
20-29
30-39 DISCUSSION
Age in years Age at diagnosis
Analysis of outcome of patients with bladder tumors by initial pathological diagnosis (World Health Organization system)
TABLE 1.
Transitional Cell Ca 2 Inverted Papillomas 1 recurrence, now no evidence of disease No evidence of disease Intermittent resectable recurrences Disease progression
Grade I, Stage 0
Grade II-III, Stage 0-A"
Grade II- III, Stage B
1
10 2
2
1 6
1t
2
* One patient lost to followup after initial resection. t Carcinoma in situ and lamina propria invasion developed, followed 23 years later by an upper tract tumor necessitating nephroureterectomy. TABLE 2.
Outcome of patients 30 to 39 years old with bladder tumors at diagnosis (World Health Organization system)* Transitional Cell Ca Inverted Grade II-III, Stage B or Papil- Grade I, Grade II-III, Poorly Differentiated loma Stage O Stage 0-A Ca With Muscle Invasion
1 recurrence, now no evidence of disea_se No evidence of disease Intermittent resectable recurrences Disease progression
5
1
1
2
1
5
1t
(83 per cent) were stable with disease. The patient with grade II to III, stage B transitional cell carcinoma suffered progression to metastatic disease. A 32-year-old woman with poorly differentiated muscle invasive carcinoma died 5 years after partial cystectomy of distant disease but the bladder was free of tumor. Followup in this group ranged from 12 to 62 months, with a mean of 30.9 months. Intravesical therapy has been used in 3 patients, 1 of whom suffered progression to metastatic disease, at which time the bladder was pathologically negative. This patient had received bacillus Calmette-Guerin (BCG) but after failure he was treated with intravesical mitomycin. Another patient had received thiotepa with no effect. He was on a second course of BCG when an upper tract tumor developed 23 years after the initial diagnosis. The bladder was negative at that time. Diagnosis of the last patient to receive intravesical therapy had been made when she was 27 years old and, after failure with thiotepa and BCG, she currently is receiving intravesical doxorubicin.
2
* Of the patients 10 to 29 years old all 6 with papilloma currently have no evidence of disease, and 1 of the 2 patients with grade II to III, stage O transitional cell carcinoma has intermittent resectable recurrences, while the other was lost to followup after initial resection. t Carcinoma in situ and lamina propria invasion developed, followed 23 years later by an upper tract tumor necessitating nephroureterectomy.
6 of whom had papillomas (2 had inverted papillomas) and 2 had grade II to III, stage O papillary carcinoma. Followup has averaged 55.2 months, ranging from 3 to 288 months. The 6 patients with papillomas have no evidence of disease and 1 with a grade II to III, stage O lesion is stable with disease after 124 months. One patient who presented with grade II to III, stage O disease has been lost to followup. Among the 30 to 39-year-old patients 7 of 9 (77 per cent) with papillomas and grade I, stage O papillary transitional cell carcinoma had no evidence of disease, 1 was stable with disease and 1 had progression. The patients with grade II to III, stage 0 to A papillary transitional cell carcinoma fared worse, with only 1 of 6 (17 per cent) having no evidence of disease and 5
Carcinoma of the bladder is increasing in frequency and the 4 young patients we saw within 1 month prompted this series. Carcinoma of the bladder in patients less than 40 years old is rare, with a reported incidence of approximately 1 per cent of all bladder tumors. 2 The first case was reported in 1872 by Smythe. 6 The IVP identified a mass within the bladder in approximately 40 per cent of our cases. This is a somewhat greater incidence than the 21.5 per cent rate reported by McCarthy and associates.' The reason for the difference is not clear. As in other series the majority of our patients presented with gross hematuria (84 per cent). There was some delay in the diagnosis in this age group because of the reluctance to study thoroughly hematuria in the younger patient and, especially, a reluctance to study voiding symptoms in a patient population in which there are a multitude of nonneoplastic diagnoses. This has been found repeatedly in other series addressing this problem, which is unfortunate because voiding symptoms can be associated with higher grade disease or carcinoma in situ. Environmental causes of bladder tumors are well known as is the relationship to tobacco use. In this series no particular environmental or occupational exposure was identified. Benton and Henderson reported on 6 young patients in whom occupational exposure to carcinogens was noted. 7 Of our patients 46 per cent smoked cigarettes. Again, no etiological cause can be evoked from our small numbers. The question of a familial occurrence of bladder tumors must be raised when faced with young patients with this disease. The father of 1 patient had just undergone cystectomy for invasive transitional cell carcinoma when an episode of total painless gross hematuria prompted further investigation and grade II papillary transitional cell carcinoma was resected. Currently, he has no evidence of disease. Lynch 8 and Purtilo 9 and their associates have each described a familial series of bladder cancer, reporting on a total of 8 families with 5 patients less than 40 years old with bladder tumors. A positive Papanicolaou cytology and a bimanually palpable mass are rare occurrences, and indicated a poor prognosis in our series (only 3 patients had a positive Papanicolaou test). There are 2 arguments presented for bladder cancer in the young patient. One group believes that bladder tumors in young patients behave less aggressively, 2• 5 while the other group indicates that there is no difference in this group of patients from the older age group. 1 • 3 • 4 In our series it appears that the pathological condition at the initial diagnosis was more important than age in determining the eventual outcome. Patients with papillomas have a good prognosis, with 77 per cent having no evidence of disease. Grade II to III papillary transitional cell carcinoma was found mainly in patients more than 30 years old, with just 2 such tumors being present in the 10 to 29-year-
PATIENTS LESS THAN 4C YEARS OLD WITH BLADDER TUMORS
old group. Of these latter 2 patients 1 has recurrent iocal disease and 1 was lost to followup. In the patients more than 30 years old 8 higher grade tumors were identified. Of these 8 patients 1 has no evidence of disease, 5 (63 per cent) have endoscopically controllable disease and 2 with high grade, muscle invasive disease suffered progression. Our numbers are too small to reach statistical significance but we believe that the pathological condition has a greater role than age in determining outcome. The 6 patients less than 30 years old with papillomas never suffered a recurrence. Thus, papillomas in general do not recur regardless of patient age. In patients less than 20 years old Javadpour and Mostofi thought that this disease was more benign than the bladder tumors usually seen. 2 This probably is because of the preponderance of papillomas and grade I, stage O papillary transitional cell carcinoma. Likewise, Benson and associates believed that the disease was more benign in this age group, possibly as a result of the more benign pathological conditions reported in their series than in other series." Meanwhile Cherrie and associates/ and Johnson and Hillis' considered this an aggressive disease, since both series contained many more patients with higher grade and stage disease. It is true that patients with papillomas do better as a group than those with higher grade lesions. What we are seeing manifested as the better prognosis in younger patients is not a result of young age per se but rather the results of a "better" pathological condition that typically is found in the younger patient. 10 After a patient is more than 30 years old the distribution of the pathological types of bladder tumors resembles more closely that of the typical patient seen with carcinoma of the bladder. It is important when following these patients that one makes therapeutic decisions based on the stage and grade of the tumor rather than on patient age. Therapy should be as aggressive as necessary to extirpate the disease. In conclusion, one cannot attribute gross hematuria to benign
397
disease without first ruling out neoplasia as a cause, regardless of patient age. Although the IVP provides a reasonable means of diagnosing bladder tumors in young patients, cystoscopy cannot be omitted. Urinary cytology is not a reasonable means of screening or following the majority of the patients. Finally, all treatment decisions should be based on the pathological condition regardless of patient age. Young age does not mitigate against the poor prognosis associated with high grade or stage lesions.
REFERENCES
Johnson, D. E. and Hillis, S. S.: Carcinoma of the bladder m patients less than 40 years old. J. Urol., 120: 172, 1978. 2. Javadpour, N. and Mostofi, F. K.: Primary epithelial tumors of the bladder in the first two decades of life. J. Urol., 101: 706, 1969. 3. Cherrie, R. J., Lindner, A. and deKernion, J. B.: Transitional cell carcinoma of bladder in first four decades of life. Urology, 20: 1.
582, 1982.
4. McCarthy, J. P., Gavrell, G. J. and LeBlanc, G. A.: Transitional cell carcinoma of bladder in patients under thirty years of age. Urology, 13: 487, 1979. 5. Benson, R. C., Jr., Tomera, K. M. and Kelalis, P. P.: Transitional cell carcinoma of the bladder in children and adolescents. J. Urol., 130: 54, 1983. 6. Smythe, S. T.: Cited by Deming, C. L.: Primary bladder tumors in the first decade of life. Surg., Gynec. & Obst., 39: 432, 1924. 7. Benton, B. and Henderson, B. E.: Environmental exposure and bladder cancer in young males. J. Natl. Cancer Inst., 51: 269, 1973.
8. Lynch, H. T., Walzak, M. P., Fried, R., Domina, A.H. and Lynch, J. F.: Familial factors in bladder carcinoma. J. Urol., 122: 458, 1979.
9. Purtilo, D. T., McCarthy, B., Yang, J. P. and Friedel!, G. H.: Familial urinary bladder cancer. Sem. Oncol., 6: 254, 1979. 10. Fitzpatrick, ,J.M. and Reda, M.: Bladder carcinoma in patients 40 years old or less. J. Urol., 135: 53, 1986.
VoL 137. )/larch
THE Jot;RNAL OF UROLOGY
Copyright (c', 1987 by The 1Nilliams & \Vilkins Co.
Printed in U.S.A.
THE NATURAL HISTORY OF PATIENTS LESS THAN 40 YEARS OLD WITH BLADDER TUMORS KENNETH R KURZ, W. REID PITTS
AND
E. DARRACOTT VAUGHAN, JR
From the Department of Surgery (Urology), The James Buchanan Brady Foundation, The New York Hospital, Cornell University Medical Center, New York, New York
ABSTRACT
We treated 19 men and 6 women less than 40 years old with bladder tumors. The average patient age at diagnosis was 30.6 years and the mean followup was 65 months. Gross hematuria was present in 84 per cent and excretory urography showed a mass in the bladder in 44 per cent of the patients. Of 8 patients less than 30 years old 6 had papilloma and 2 had grade II to III, stage O transitional cell carcinoma. All patients with papillomas were free of disease. The pathological reports of the patients more than 30 years old revealed papilloma or grade I, stage O transitional cell carcinoma in 9, grade II to III, stage O to A papillary transitional cell carcinoma in 6 and invasive disease in 2, 1 of whom died. Of the 9 patients with papilloma or grade I, stage O disease 77 per cent are currently free of disease. Of those with grade II to III, stage O to B papillary transitional cell carcinoma only 1 is free of disease, while 6 have had resectable recurrences. One patient with grade II to HI disease was lost to followup. Accordingly, all patients, regardless of age, should be treated as aggressively as necessary on the basis of the stage and grade of the tumor. Carcinoma of the bladder is distinctly uncommon in patients less than 40 years old.u Last year we saw 4 patients with this unusual problem in 1 calling our attention to the controversies'1 ·'• surrounding the prognosis, management and followup of such patients. Therefore, we reviewed our experience from 1971 to the present in an attempt to elucidate the natural history of this disease. We found 25 patients with bladder tumors who were less than 40 years old and the charts were reviewed. MATERIALS AND METHODS
A retrospective review of 25 white patients with a pathologically proved diagnosis of a bladder tumor and age less than 40 years was undertaken. These patients were found through a computer search of our institutional records for the diagnosis of bladder tumor and age at diagnosis. There were 2 such patients whose charts could not be located. All pathological material was confirmed at our institution. Followup ranged from 3 to 288 with a mean of 65 months. RESULTS
There were 19 men and 6 women, a 3:1 male preponderance. Patient age from 14 to 39 years figure), and the average age at was 30.6 years (31.1 years for n,en and 29 years for women). The most common pn,sent1ng rn"~"rn," hematuria, which was present in 21 instances per Of the patients with gross hematuria 3 also had associated voiding symptoms. Only 3 patients had voiding symptoms (frequency, urgency and dysuria) without gross hematuria, 1 of whom had microscopic hematuria. The duration of symptoms before diagnosis ranged from l week to more than 4 years. The presence of voiding symptoms seemed to delay diagnosis. In 1 case disease was suspected during an examination for sports-related hematuria. Of our patients 46 per cent were cigarette smokers, 1 smoked a pipe, 33 per cent did not smoke and in 17 per cent the information was not recorded. The excretory urogram (IVP) proved to be the most sensitive routinely performed preoperative study, with 44 per cent (11 patients) demonstrating a mass within the bladder. Papanico0
Accepted for publication August 20, 1986. 395
laou urinary cytology was positive at diagnosis in 3 cases, including 2 of carcinoma in situ with invasive carcinoma, and 1 in which 160 gm. of grade HI, stage O papillary transitional cell carcinoma subsequently was resected. Not surprisingly, a bimanually palpable mass also was present at diagnosis in these 3 cases. All of the remaining cases were of low grade and stage, and had negative urinary Papanicolaou tests. Pathological diagnosis at presentation is shown in table 1. At our institution there was a change in the terminology used during the course of this review. Whereas at the start of our series "papilloma" was a common diagnosis, the presence of any atypia would now be considered transitional cell carcinoma. Grade I papillary transitional cell carcinoma is now used in place of many papillomas. The results of the study are presented in terms of the currently used pathological definitions and the World Health Organization system of classification. The initial pathological diagnosis included papilloma in 13 patients and grade I, stage O papillary transitional cell carcinoma in 2. The more aggressive lesions consisted of grade II to HI transitional cell carcinoma in 9 patients, stage O disease in 9, stage A disease in 1 and B disease in 1. Them was 1 with cl,<·+m•s•.r:.,cw,,N~ carcinoma and muscle inva-
13 (56 per cent) have no evidence of are stable (disease present but control3 per cent) have progression (disease requiring more than endoscopic procedure) and 1 was lost to followup after initial resection. Of the 15 patients with low grade and stage O disease at presentation 12 (80 per cent) have no evidence of disease, 2 are stable with endoscopically controllable disease and 1 has upper tract disease that required nephroureterectomy. Of the patients with higher grade disease (grade II to III, stage O to A transitional cell carcinoma or poorly differentiated carcinoma) or invasive disease at presentation more frequent recurrences are evident (table 1). Only 1 of 9 (11 per cent) patients has no evidence of disease, 6 (66 per cent) are stable with endoscopically controllable disease and 2 (22 per cent) have progression. One patient has been lost to followup in this group. The data obtained when the outcome was examined as it related to the age of the patient at the time of diagnosis are listed in table 2. There were 8 patients less than 30 years old,
396
KURZ, PITTS AND VAUGHAN
26 22
17
18
Number of patients
14
10 6
2
10-19
20-29
30-39 DISCUSSION
Age in years Age at diagnosis
Analysis of outcome of patients with bladder tumors by initial pathological diagnosis (World Health Organization system)
TABLE 1.
Transitional Cell Ca 2 Inverted Papillomas 1 recurrence, now no evidence of disease No evidence of disease Intermittent resectable recurrences Disease progression
Grade I, Stage 0
Grade II-III, Stage 0-A"
Grade II- III, Stage B
1
10 2
2
1 6
1t
2
* One patient lost to followup after initial resection. t Carcinoma in situ and lamina propria invasion developed, followed 23 years later by an upper tract tumor necessitating nephroureterectomy. TABLE 2.
Outcome of patients 30 to 39 years old with bladder tumors at diagnosis (World Health Organization system)* Transitional Cell Ca Inverted Grade II-III, Stage B or Papil- Grade I, Grade II-III, Poorly Differentiated loma Stage O Stage 0-A Ca With Muscle Invasion
1 recurrence, now no evidence of disea_se No evidence of disease Intermittent resectable recurrences Disease progression
5
1
1
2
1
5
1t
(83 per cent) were stable with disease. The patient with grade II to III, stage B transitional cell carcinoma suffered progression to metastatic disease. A 32-year-old woman with poorly differentiated muscle invasive carcinoma died 5 years after partial cystectomy of distant disease but the bladder was free of tumor. Followup in this group ranged from 12 to 62 months, with a mean of 30.9 months. Intravesical therapy has been used in 3 patients, 1 of whom suffered progression to metastatic disease, at which time the bladder was pathologically negative. This patient had received bacillus Calmette-Guerin (BCG) but after failure he was treated with intravesical mitomycin. Another patient had received thiotepa with no effect. He was on a second course of BCG when an upper tract tumor developed 23 years after the initial diagnosis. The bladder was negative at that time. Diagnosis of the last patient to receive intravesical therapy had been made when she was 27 years old and, after failure with thiotepa and BCG, she currently is receiving intravesical doxorubicin.
2
* Of the patients 10 to 29 years old all 6 with papilloma currently have no evidence of disease, and 1 of the 2 patients with grade II to III, stage O transitional cell carcinoma has intermittent resectable recurrences, while the other was lost to followup after initial resection. t Carcinoma in situ and lamina propria invasion developed, followed 23 years later by an upper tract tumor necessitating nephroureterectomy.
6 of whom had papillomas (2 had inverted papillomas) and 2 had grade II to III, stage O papillary carcinoma. Followup has averaged 55.2 months, ranging from 3 to 288 months. The 6 patients with papillomas have no evidence of disease and 1 with a grade II to III, stage O lesion is stable with disease after 124 months. One patient who presented with grade II to III, stage O disease has been lost to followup. Among the 30 to 39-year-old patients 7 of 9 (77 per cent) with papillomas and grade I, stage O papillary transitional cell carcinoma had no evidence of disease, 1 was stable with disease and 1 had progression. The patients with grade II to III, stage 0 to A papillary transitional cell carcinoma fared worse, with only 1 of 6 (17 per cent) having no evidence of disease and 5
Carcinoma of the bladder is increasing in frequency and the 4 young patients we saw within 1 month prompted this series. Carcinoma of the bladder in patients less than 40 years old is rare, with a reported incidence of approximately 1 per cent of all bladder tumors. 2 The first case was reported in 1872 by Smythe. 6 The IVP identified a mass within the bladder in approximately 40 per cent of our cases. This is a somewhat greater incidence than the 21.5 per cent rate reported by McCarthy and associates.' The reason for the difference is not clear. As in other series the majority of our patients presented with gross hematuria (84 per cent). There was some delay in the diagnosis in this age group because of the reluctance to study thoroughly hematuria in the younger patient and, especially, a reluctance to study voiding symptoms in a patient population in which there are a multitude of nonneoplastic diagnoses. This has been found repeatedly in other series addressing this problem, which is unfortunate because voiding symptoms can be associated with higher grade disease or carcinoma in situ. Environmental causes of bladder tumors are well known as is the relationship to tobacco use. In this series no particular environmental or occupational exposure was identified. Benton and Henderson reported on 6 young patients in whom occupational exposure to carcinogens was noted. 7 Of our patients 46 per cent smoked cigarettes. Again, no etiological cause can be evoked from our small numbers. The question of a familial occurrence of bladder tumors must be raised when faced with young patients with this disease. The father of 1 patient had just undergone cystectomy for invasive transitional cell carcinoma when an episode of total painless gross hematuria prompted further investigation and grade II papillary transitional cell carcinoma was resected. Currently, he has no evidence of disease. Lynch 8 and Purtilo 9 and their associates have each described a familial series of bladder cancer, reporting on a total of 8 families with 5 patients less than 40 years old with bladder tumors. A positive Papanicolaou cytology and a bimanually palpable mass are rare occurrences, and indicated a poor prognosis in our series (only 3 patients had a positive Papanicolaou test). There are 2 arguments presented for bladder cancer in the young patient. One group believes that bladder tumors in young patients behave less aggressively, 2• 5 while the other group indicates that there is no difference in this group of patients from the older age group. 1 • 3 • 4 In our series it appears that the pathological condition at the initial diagnosis was more important than age in determining the eventual outcome. Patients with papillomas have a good prognosis, with 77 per cent having no evidence of disease. Grade II to III papillary transitional cell carcinoma was found mainly in patients more than 30 years old, with just 2 such tumors being present in the 10 to 29-year-
PATIENTS LESS THAN 4C YEARS OLD WITH BLADDER TUMORS
old group. Of these latter 2 patients 1 has recurrent iocal disease and 1 was lost to followup. In the patients more than 30 years old 8 higher grade tumors were identified. Of these 8 patients 1 has no evidence of disease, 5 (63 per cent) have endoscopically controllable disease and 2 with high grade, muscle invasive disease suffered progression. Our numbers are too small to reach statistical significance but we believe that the pathological condition has a greater role than age in determining outcome. The 6 patients less than 30 years old with papillomas never suffered a recurrence. Thus, papillomas in general do not recur regardless of patient age. In patients less than 20 years old Javadpour and Mostofi thought that this disease was more benign than the bladder tumors usually seen. 2 This probably is because of the preponderance of papillomas and grade I, stage O papillary transitional cell carcinoma. Likewise, Benson and associates believed that the disease was more benign in this age group, possibly as a result of the more benign pathological conditions reported in their series than in other series." Meanwhile Cherrie and associates/ and Johnson and Hillis' considered this an aggressive disease, since both series contained many more patients with higher grade and stage disease. It is true that patients with papillomas do better as a group than those with higher grade lesions. What we are seeing manifested as the better prognosis in younger patients is not a result of young age per se but rather the results of a "better" pathological condition that typically is found in the younger patient. 10 After a patient is more than 30 years old the distribution of the pathological types of bladder tumors resembles more closely that of the typical patient seen with carcinoma of the bladder. It is important when following these patients that one makes therapeutic decisions based on the stage and grade of the tumor rather than on patient age. Therapy should be as aggressive as necessary to extirpate the disease. In conclusion, one cannot attribute gross hematuria to benign
397
disease without first ruling out neoplasia as a cause, regardless of patient age. Although the IVP provides a reasonable means of diagnosing bladder tumors in young patients, cystoscopy cannot be omitted. Urinary cytology is not a reasonable means of screening or following the majority of the patients. Finally, all treatment decisions should be based on the pathological condition regardless of patient age. Young age does not mitigate against the poor prognosis associated with high grade or stage lesions.
REFERENCES
Johnson, D. E. and Hillis, S. S.: Carcinoma of the bladder m patients less than 40 years old. J. Urol., 120: 172, 1978. 2. Javadpour, N. and Mostofi, F. K.: Primary epithelial tumors of the bladder in the first two decades of life. J. Urol., 101: 706, 1969. 3. Cherrie, R. J., Lindner, A. and deKernion, J. B.: Transitional cell carcinoma of bladder in first four decades of life. Urology, 20: 1.
582, 1982.
4. McCarthy, J. P., Gavrell, G. J. and LeBlanc, G. A.: Transitional cell carcinoma of bladder in patients under thirty years of age. Urology, 13: 487, 1979. 5. Benson, R. C., Jr., Tomera, K. M. and Kelalis, P. P.: Transitional cell carcinoma of the bladder in children and adolescents. J. Urol., 130: 54, 1983. 6. Smythe, S. T.: Cited by Deming, C. L.: Primary bladder tumors in the first decade of life. Surg., Gynec. & Obst., 39: 432, 1924. 7. Benton, B. and Henderson, B. E.: Environmental exposure and bladder cancer in young males. J. Natl. Cancer Inst., 51: 269, 1973.
8. Lynch, H. T., Walzak, M. P., Fried, R., Domina, A.H. and Lynch, J. F.: Familial factors in bladder carcinoma. J. Urol., 122: 458, 1979.
9. Purtilo, D. T., McCarthy, B., Yang, J. P. and Friedel!, G. H.: Familial urinary bladder cancer. Sem. Oncol., 6: 254, 1979. 10. Fitzpatrick, ,J.M. and Reda, M.: Bladder carcinoma in patients 40 years old or less. J. Urol., 135: 53, 1986.