A novel algorithm to improve pathologic stage prediction of clinically organ-confined muscle-invasive bladder cancer

CA125 for the Diagnosis of Advanced Urothelial Carcinoma of the Bladder: A Systematic Review and Meta-Analysis

BACKGROUND

Urothelial carcinoma of the bladder (UCB) is the second most common genitourinary cancer. This study aims to assess the diagnostic accuracy of CA125 in advanced UCB.

METHODS

We searched prevalent studies in PubMed, the Cochrane Library, Scopus, Embase, the Web of Science China National Knowledge Infrastructure database, and Wanfang data before October 2022. Pooled sensitivity, specificity, and summary receiver operating characteristics were used to assess the diagnostic value of CA125.

RESULTS

One thousand six hundred forty-one patients from 14 studies were analyzed. UCB stage T3-4N1 was defined as advanced UCB in ten studies; T2-4 was used in three studies; and N1M1 in one study. Patients' age was between 21 to 92, and 21% to 48.6% of patients were female. The pooled sensitivity was 0.695 (95% confidence interval (CI): 0.426-0.875). The pooled specificity was 0.846 (95% CI: 0.713-0.924). The diagnostic odds ratio was 8.138 (95% CI: 4.559-14.526). The AUC was 0.797.

CONCLUSION

CA125 may provide significant diagnostic accuracy in identifying muscle-invasive, lymph node-involved, and distant metastatic tumors in patients with urothelial carcinoma of the bladder. Limited studies have been conducted on the prognostic role of CA125. More studies are needed for a meta-analysis on the prognostic role of CA125 in UCB.

Association between precystectomy epithelial tumor marker response to neoadjuvant chemotherapy and oncological outcomes in urothelial bladder cancer

INTRODUCTION AND OBJECTIVES

We previously reported that elevated precystectomy serum levels of epithelial tumor markers predict worse oncological outcome in patients with invasive bladder cancer (BC). Herein, we evaluated the effect of neoadjuvant chemotherapy (NAC) on elevated tumor marker levels and their association with oncological outcomes.

METHODS

Under IRB approval, serum levels of Carbohydrate Antigen 125 (CA-125), Carbohydrate Antigen 19-9 (CA 19-9) and Carcinoembryonic Antigen (CEA) were prospectively measured in 480 patients with invasive BC from August 2011 through December 2016. In the subgroup undergoing NAC, markers were measured prior to the first and after the last cycle of chemotherapy (prior to cystectomy).

RESULTS

Three hundred and thirty-seven patients were eligible for the study, with a median age was 71 years (range 34-93) and 81% (272) male. Elevated precystectomy level of any tumor markers (31% of patients) was independently associated with worse recurrence-free survival (hazard ratio [HR] = 2.81; P < 0.001) and overall survival (HR = 3.97; P < 0.001). One hundred and twenty-five (37%) patients underwent NAC, of whom 59 had a complete tumor marker profile and 30 (51%) had an elevated pre-NAC tumor marker. Following completion of chemotherapy, 10/30 (33%) patients normalized their tumor markers, while 20/30 (67%) had one or more persistently elevated markers. There was no difference in clinical or pathological stage between groups (P = 0.54 and P = 0.09, respectively). Further analysis showed a significantly lower rate and longer median time to recurrence/progression in the responder group (50% in responders vs. 90% in nonresponders at a median time of 22 vs. 4.8 months, respectively; P = 0.015). There was also significant difference in mortality rates and median overall survival between the study groups (30% in responders vs. 70% in nonresponders at a median time of 27.3 vs. 11.6 months respectively; P = 0.037). Two of the three patients that died in the normalized tumor marker group had tumor marker relapse at recurrence prior to their death.

CONCLUSIONS

To our knowledge, this is the first study showing tumor marker response to NAC. Patients with persistently elevated markers following NAC have a very poor prognosis following cystectomy, which may help identifying chemotherapy-resistant tumors. A larger, controlled study with longer follow up is needed to determine their role in predicting survival.

Predictive role of neutrophil-to-lymphocyte ratio on upstaging of organ-confined invasive urothelial bladder cancer to non-organ-confined disease

Objective

The aim of this study is to examine the usefulness of preoperative neutrophile-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and lymphocyte-to-monocyte ratios to predict pathological upstaging of invasive bladder cancer who underwent radical cystectomy.

Material and methods

A total of 126 patients who underwent radical cystectomy at our clinic between January 2006 and March 2015 were retrospectively analysed. One hundred and twelve patients with organ-confined invasive bladder tumors (T2) detected at histopathological examination of transuretral resection material were included in the study. Upstaging was seen at histopathological examination of radical cystectomy specimens of 42 patients. We compared preoperative neutrophile-to-lymphocyte ratio, platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio between upstaged and not-upstaged groups.

Results

There were no statistically significant correlation between age, time to radical cystectomy, gender, lymphocyte-to-monocyte ratio, platelet-to-lymphocyte ratio ratios and carcinoma in situ in upstaged and non-upstaged groups. Statistical analyses showed that preoperative neutrophile-to-lymphocyte ratio was higher in upstaged patients (p=0.009). In multivariate analysis preoperative neutrophile-to-lymphocyte ratio and positive surgical margin were significantly higher in upstaged group.

Conclusion

In organ-confined muscle invasive bladder cancer neutrophile-to-lymphocyte ratio seems to be an acceptable parameter to predict locally advanced disease.

A combined prognostic factor for improved risk stratification of patients with oral cancer

PURPOSE

We aimed to identify a combined prognostic factor for predicting better performance in risk stratification.

MATERIALS AND METHODS

We reviewed the clinical and pathological variables of 316 patients with oral squamous cell carcinoma (OSCC) who underwent surgery. To identify a combined predictor, principal component analysis (PCA) was performed.

RESULTS

Univariate analysis showed that the independent prognostic variables for overall survival (OS) were pathologic T stage (T1 vs T4, HR = 1.99, 95% CI: = 1.083-3.675, P = 0.026) and pathologic N stage (N0 vs N2, HR=1.90, 95% CI: = 1.17-3.08, P = 0.008). In the multivariate analysis, only pathologic T stage was significant (P = 0.006 and P = 0.007); however, the multivariate model was not significant (P = 0.191). The multivariate model became significant by including lymph node ratio (LNR) instead of pathologic N stage (P = 0.0025 in numeric LNR, P = 0.0007 in categorized LNR). Also, the performance of prediction model was improved by a combined prognostic factor (P = 0.0002).

CONCLUSIONS

The newly identified combined prognostic factor included resection margin, differentiation, and LNR, and they were insignificant factors independently except for LNR. This combined prognostic factor showed a good performance although it did not include molecular markers; therefore, it may be used conveniently for risk stratification of patients with OSCC by combining only clinical information.

Ulceration in bladder cancer associates with extravesical disease, independent of cell cycle, or hypoxia pathways status: Integrating gross morphology and expression profiles in cystectomies

OBJECTIVE

Ulceration is common in bladder tumors, but its prognostic role, although intuitive, is not established. We aim to explore the presence of gross ulceration and its relationship with other morphological and biological features classically associated with extravesical disease, in patients submitted to radical cystectomy.

METHODS

Tumor size and morphology were noted on 101 cystectomy patients (2000-2010). Papillary, exophytic, and vegetant tumors were grouped as "papillary" and solid/nodular, ulcerated and infiltrative as "nonpapillary." Ulceration was noted grossly in every case as a binary parameter, regardless of morphology. Immunohistochemistry was performed for hypoxia (hypoxia-inducible factor-1α and vascular endothelial growth factor), and cell cycle proteins (pRb, p53, and cyclin D1).

RESULTS

Mean age was 66.7 year, male:female ratio was 2:1, 20 patients received bacillus Calmette-Guerin and 10 neoadjuvant chemotherapy. Upstaging rate was 56.4%. Ulcerated lesions presented mostly as nonpapillary and nonorgan confined (nOC), whereas nonulcerated tumors were often papillary and organ confined (OC). Tumor size was smaller in nonpapillary tumors (P = 0.002), but did not associate with altered hypoxia or cell cycle expressions. pRb and cyclin D1 loss and p53 overexpression were more frequent in ulcerated and non-OC tumors as did the phenotype vascular endothelial growth factor-negative/hypoxia-inducible factor-1α-low (P<0.001). On a multivariate model, ulceration was an independent predictor of non-OC and extravesical disease.

CONCLUSION

Patients with ulcerated tumors were often staged with extravesical disease, independent of other morphologic and biological features known to affect prognosis. Prospective studies are needed to confirm the predictive value of tumor ulceration at cystoscopy, which could improve patient stratification for neoadjuvant chemotherapy.

Predictive value of pretreatment inflammation-based prognostic scores (neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio) for invasive bladder carcinoma

Purpose

Inflammation-based prognostic scores including neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) are associated with oncologic outcomes in diverse malignancies. We evaluated the predictive value of pretreatment prognostic scores in differentiating nonmuscle invasive (NMIBC) and muscle invasive bladder cancer (MIBC).

Materials and Methods

Consecutive transurethral resection of bladder tumour (TURBT) cases from January 2011 to December 2013 were analysed retrospectively. Patient demographics, tumour characteristics and prognostic scores results were recorded. Receiver operating characteristics curves were used to determine prognostic score cutoffs. Univariate and multivariate binomial logistic regression analysis was performed to evaluate the association between variables and MIBC.

Results

A total of 226 patients were included, with 175 and 51 having NMIBC (stages Ta and T1) and MIBC (stage T2+) groups, respectively. Median age was 75 years and 174 patients were male. The NLR cutoff was 3.89 and had the greatest area under the curve (AUC) of 0.710, followed by LMR (cutoff<1.7; AUC, 0.650) and PLR (cutoff>218; AUC, 0.642). Full blood count samples were taken a median of 12 days prior to TURBT surgery. Multivariate logistic regression analysis identified tumour grade G3 (odds ration [OR], 32.848; 95% confidence interval [CI], 9.818-109.902; p=0.000), tumour size≥3 cm (OR, 3.353; 95% CI, 1.347-8.345; p=0.009) and NLR≥3.89 (OR, 8.244; 95% CI, 2.488-27.316; p=0.001) as independent predictors of MIBC.

Conclusions

NLR may provide a simple, cost-effective and easily measured marker for MIBC. It can be performed at the time of diagnostic flexible cystoscopy, thereby assisting in the planning of further treatment.

Prognostic and Prediction Tools in Bladder Cancer: A Comprehensive Review of the Literature

CONTEXT

This review focuses on risk assessment and prediction tools for bladder cancer (BCa).

OBJECTIVE

To review the current knowledge on risk assessment and prediction tools to enhance clinical decision making and counseling of patients with BCa.

EVIDENCE ACQUISITION

A literature search in English was performed using PubMed in July 2013. Relevant risk assessment and prediction tools for BCa were selected. More than 1600 publications were retrieved. Special attention was given to studies that investigated the clinical benefit of a prediction tool.

EVIDENCE SYNTHESIS

Most prediction tools for BCa focus on the prediction of disease recurrence and progression in non-muscle-invasive bladder cancer or disease recurrence and survival after radical cystectomy. Although these tools are helpful, recent prediction tools aim to address a specific clinical problem, such as the prediction of organ-confined disease and lymph node metastasis to help identify patients who might benefit from neoadjuvant chemotherapy. Although a large number of prediction tools have been reported in recent years, many of them lack external validation. Few studies have investigated the clinical utility of any given model as measured by its ability to improve clinical decision making. There is a need for novel biomarkers to improve the accuracy and utility of prediction tools for BCa.

CONCLUSIONS

Decision tools hold the promise of facilitating the shared decision process, potentially improving clinical outcomes for BCa patients. Prediction models need external validation and assessment of clinical utility before they can be incorporated into routine clinical care.

PATIENT SUMMARY

We looked at models that aim to predict outcomes for patients with bladder cancer (BCa). We found a large number of prediction models that hold the promise of facilitating treatment decisions for patients with BCa. However, many models are missing confirmation in a different patient cohort, and only a few studies have tested the clinical utility of any given model as measured by its ability to improve clinical decision making.

Serum CA 19-9 as a good prognostic biomarker in patients with bladder cancer

BACKGROUND

Bladder cancer (BC) is the second leading malignant tumors of the genitourinary system. CA 19-9 has served as a diagnostic and prognostic marker for pancreatic carcinoma for years. In recent year, although a few studies have evaluated the roles of CA 19-9 in BC, the results are conflicting and the number of the patients studied is very small.

AIM

To investigate the potential of serum CA 19-9 to serve as a diagnostic and prognostic marker of BC in a larger number of patients.

METHODS

A total of 272 (144 BC patients and 128 healthy subjects) were enrolled. Patients were followed-up routinely at 3-month intervals for 5 years. Serum CA 19-9 level was detected by ELISA.

RESULTS

CA 19-9 level was much higher than that in healthy subjects (43.69 ± 6.92 U/ml vs. 12.31 ± 4.39 U/ml, p < 0.001). However, when the value of 37 U/ml of serum CA 19-9 was used as the cut-off value for BC the sensitivity of CA 19-9 for BC was dropped to 38.8%. CA 19-9 was much higher in muscle invasive tumor subgroup than that in superficial tumor subgroup (38.09 ± 7.14 U/ml vs. 20.71 ± 4.15 U/ml, p < 0.027). CA 19-9 level was comparable in both subgroups (29.78 ± 5.07 U/ml vs. 26.13 ± 5.97 U/ml, p = 0.565). BC patients with more than 5 years survival time had lower serum CA 19-9 level than the rest (15.86 U/ml vs 46.68 U/ml, p < 0.001). Survival rate (>5 years) of patients with lower CA 19-9 levels (<29 U/ml) was significantly increased in comparison to those with elevated serum CA 19-9 levels (>29 U/ml) (p < 0.001).

CONCLUSIONS

serum CA 19-9 is not a good diagnostic maker, but a very powerful prognostic marker for BC. Such a study might be helpful for urologists to manage patients with BC.

Can composite performance measures predict survival of patients with colorectal cancer?

AIM: To assess the relationship between long-term colorectal patient survival and methods of calculating composite performance scores.

METHODS: The Taiwan Cancer Database was used to identify patients who underwent bowel resection for colorectal adenocarcinoma between 2003 and 2004. Patients were assigned to one of three cohorts based on tumor staging: cohort 1, colon cancer stage < III; cohort 2, colon cancer stage III; cohort 3, rectal cancer. A composite performance score (CPS) was calculated for each patient using five different aggregating methods, including all-or-none, 70% standard, equal weight, analytic hierarchy process (AHP), and principal component analysis (PCA) algorithms. The relationships between CPS and five-year overall, disease-free, and disease-specific survivals were evaluated by a Cox proportional hazards model. A goodness-of-fit analysis for all five methods was performed using Akaike’s information criterion.

RESULTS: A total of 3272 colorectal cancer patients (cohort 1, 1164; cohort 2, 790; cohort 3, 1318 patients) with a mean age of 65 years were enrolled in the study. Bivariate correlation analysis showed that CPS values from the equal weight method were highly correlated with those from the AHP method in all cohorts (all P < 0.05). Multivariate Cox hazards analysis showed that CPS values derived from equal weight and AHP methods were significantly associated with five-year survivals of patients in cohorts 1 and 2 (all P < 0.05). In these cohorts, higher CPS values suggested a higher probability of five-year survival. However, CPS values derived from the all-or-none method did not show any significant process-outcome relationship in any cohort. Goodness-of-fit analyses showed that CPS values derived from the PCA method were the best fit to the Cox proportional hazards model, whereas the values from the all-or-none model showed the poorest fit.

CONCLUSION: CPS values may highlight process-outcome relationships for patients with colorectal cancer in addition to evaluating quality of care performance.

External validation of existing nomograms predicting lymph node metastases in cystectomized patients

OBJECTIVES

Karakiewicz et al. and Green et al. created pre-cystectomy nomograms to predict lymph node involvement. The aim of the study was to externally validate these two nomograms in intermediate-volume institutions in Europe.

PATIENTS AND METHODS

Data from a Serbian single-centre cystectomy series comprising 183 patients with bladder cancer were used for the validation of two US nomograms, which were originally based on data from 726 and 201 patients, respectively. A multivariate regression model assessed the value of the clinical parameters integrated in the two nomograms. The expected predictive accuracy, calibration and clinical utility according to the nomograms were calculated.

RESULTS

Comparison of our dataset with the previously published data shows differences in nearly all underlying risk variables. Overall, 109 (59.6 %) patients had lymph node metastases. The analysis demonstrated that hydronephrosis and status of lymph nodes on computed tomography have independent prognostic value. The performance of the nomograms deteriorated from the development set, and the predictive accuracies for the two models showed moderate discriminatory ability (61.2-69.1 %). In the decision curve analysis, only the Green et al. model predicting lymph node positivity provided net benefit.

CONCLUSIONS

The Green et al. nomogram seems applicable to patients from Europe, despite varying risk factors in the validation dataset. Acceptance of such a tool into daily clinical management may lead to more appropriate decision-making. Nevertheless, further improvement and implementation of novel statistical models with enhanced predictive accuracy is needed.

NLR is predictive of upstaging at the time of radical cystectomy for patients with urothelial carcinoma of the bladder

OBJECTIVE

To evaluate the ability of preoperative neutrophil-lymphocyte ratio (NLR) to predict pathologic upstaging and nonorgan-confined (NOC) (≥pT3) disease.

METHODS AND MATERIALS

After institutional review board approval, the records of consecutive patients undergoing radical cystectomy (RC) for urothelial carcinoma from 2002 to 2012 at the University of Wisconsin Hospital were reviewed. A total of 102 patients with NLR within 100 days of surgery were eligible for analysis. The primary outcome was difference in stage from preoperative assessment to time of RC. Differences in preoperative NLR between groups were evaluated with an unequal variance t test. A univariate analysis assessed whether NLR, preoperative stage, grade, associated lymphovascular invasion, preoperative hydronephrosis, gender, previous pelvic radiotherapy, previous intravesical bladder cancer treatments, or nodal stage were related to upstaging. Multivariate analyses were performed to evaluate the relationship of NLR to upstaging and relative organ-confined (≤pT2) and NOC disease.

RESULTS

Of 390 consecutive patients undergoing RC, 102 patients met study criteria. Overall, 55 (53.9%) patients were upstaged, 25 (25.5%) were unchanged, and 21 (20.6%) were downstaged. Fifty-one patients (50%) were upstaged to more advanced disease (≥pT3). NLR and preoperative hydronephrosis were significantly related to pathologic tumor staging. NLR, preoperative hydronephrosis, and preoperative tumor stage were significantly related to upstaging to NOC disease. Patients who were upstaged to≥pT3 demonstrated statistically significant greater NLRs (4.33±0.87) compared with patients who remained at≤pT2 stage (2.66±0.29) (P<0.001).

CONCLUSIONS

Preoperative NLR is a simple measurement that can be used to identify high-risk patients who may be upstaged at the time of RC and may benefit from neoadjuvant chemotherapy.