Upper tract transitional cell carcinoma following treatment of superficial bladder cancer with BCG

Monitoring of the upper urinary tract in patients with bladder cancer

Upper urinary tract (UUT) transitional cell carcinoma (TCC) is relatively rare tumor. Approximately 0.7-4% of patients with primary bladder cancer develops UUT-TCC. The symptoms related to an UUT-TCC often occur with an advanced stage which leads one to emphasize a surveillance strategy to monitor the UUT to allow for an earlier diagnosis. Although the risk of UUT-TCC after bladder cancer is well established, there is a paucity of recommendations suggesting the optimal method and frequency of monitoring the UUT and there is no consensus among them. This article reviews the recommendations on monitoring the UUT in patients with bladder cancer.

Prognostic effect of urinary bladder carcinoma in situ on clinical outcome of subsequent upper tract urothelial carcinoma

OBJECTIVES

To evaluate the effect of a history of bladder carcinoma in situ (CIS) on relapse and survival after surgical management of metachronous upper tract urothelial carcinoma (UTUC). Urinary bladder CIS was previously reported to be among the independent risk factors for the development of UTUC.

METHODS

Using a multi-institutional database of patients treated with radical nephroureterectomy (RNU) for UTUC, we compared the clinicopathologic parameters and clinical outcomes of patients with and without a history of bladder CIS. Multivariate Cox regression analysis was performed to determine the independent predictors of disease recurrence and cancer-specific mortality after RNU.

RESULTS

The study included 1316 patients, 884 men and 432 women, with median follow-up of 36 months after RNU. The patients with a history of bladder CIS (n = 91) were more likely to have high-grade and sessile UTUC (P < .05). The 5 year disease-free survival and cancer-specific survival rate was 53% and 59% in those with a history of bladder CIS and 71% and 75% in those without a history of bladder CIS, respectively (P = .031 and P = .045, respectively). On multivariate Cox regression analysis, a history of bladder CIS was an independent predictor of disease recurrence and cancer-specific mortality after RNU (P = .006 and P = .045, respectively).

CONCLUSIONS

The results of our study have shown that patients with a history of bladder CIS are more likely to develop aggressive UTUC and demonstrate a greater risk of recurrence and death from cancer after RNU. Our findings suggest the need for aggressive surveillance regimens and multimodal management strategies for patients who develop UTUC in the setting of previous bladder CIS.

Intravenous urography for diagnosing synchronous upper-tract tumours in patients with newly diagnosed bladder carcinoma can be restricted to patients with high-risk superficial disease

AIM

To determine the incidence of synchronous upper-tract transitional cell carcinomas (TCCs) in patients with newly diagnosed bladder cancer and to evaluate the need for performing intravenous urography (IVU) in these patients.

MATERIALS AND METHODS

Imaging data on 330 consecutive patients who were diagnosed with TCC of the bladder over a 2-year period were retrospectively reviewed. Only 233 out of the 330 patients had IVU at presentation. The IVU results were recorded as normal, abnormal, or equivocal. The follow-up radiological or urological investigations in the patients who had an equivocal IVU were reviewed. Clinical follow-up data on all 330 patients were also recorded.

RESULTS

Only 233 out of the 330 patients had an IVU at presentation. Four of these (1.7%) patients were found to have synchronous upper-tract tumours. Twenty-two patients were reported to have equivocal findings on IVU. Nine of these patients had follow-up imaging [computed tomography (CT)=5, IVU=4], which were reported as normal. Retrograde urography was performed in two patients, which was normal. The remaining 11 patients did not have any evaluation of the upper tracts despite the equivocal findings on IVU, but routine clinical follow-up did not reveal any significant disease. Three patients with high-risk superficial disease developed upper-tract tumours that were detected on follow-up.

CONCLUSION

IVU for diagnosing synchronous upper-tract tumours in patients with newly diagnosed bladder carcinoma can be restricted to patients with high-risk superficial disease.

Risk of Cancer of the Prostate and of the Kidney Parenchyma following Bladder Cancer

Aims and Background

A registry-based cohort study of male patients with bladder cancer was conducted to determine the relative risk of second primary cancer of the prostate and kidney, the uni-/multivariate differences in relative risk according to patient characteristics, the cumulative risk by duration of the follow-up, and the prevalence:incidence ratio of prostate and kidney cancer cases detected in the first 6 months after the diagnosis of bladder cancer.

Methods

The complete case records of all male patients (n = 2025) diagnosed with bladder cancer between 1986 and 2002 were extracted from the database of the Romagna Cancer Registry: 1539 patients were eligible for analysis of the incidence of following prostate and kidney cancers, of the relative risk and the standardized incidence ratio specific for the time interval of follow-up.

Results

A total of 108 prostate cancer cases and 23 kidney cancer cases were observed during the follow-up. The relative risk of second primary cancer of the prostate and kidney was respectively 3.52 (95% CI, 2.89-4.25) and 3.90 (95% CI, 2.475.85). The absolute excess risk was 11.8 × 1000 for prostate cancer and 2.5 × 1000 for kidney cancer. The number of prevalent cases of prostate and kidney cancer detected was approximately 10 times greater than the expected number based on incidence rates from the general population. During the follow-up, incidence of prostate cancer stabilized at a level that was 3- to 4-fold greater than that expected. Despite fluctuations, a decrease was also observed for incidence of kidney cancer.

Conclusions

In summary, our study showed the relatively constant high incidence of prostate and kidney cancers in bladder cancer patients over time. The possibility of subsequent cancer implies that an appropriate long surveillance is required. The pertinence depends on the duration of the follow- up as well as the degree of surveillance.

The Role of Imaging in the Surveillance of Urologic Malignancies

Urologic malignancies are common, accounting for approximately 25% of all new cancer cases in the United States. Patients with urologic malignancies require long-term surveillance to detect progression or recurrence as early as possible. The urologist is faced with the task of balancing patient safety and cost-effectiveness, while finding the most practical follow-up regimen. For each urologic malignancy, this article reviews the commonly used radiologic techniques for surveillance and offers recommended follow-up schedules.

Low-grade Ta (noninvasive) urothelial carcinoma of the bladder

This article discusses the development of international guidelines for the diagnosis, treatment, follow-up, and prevention of low-grade Ta urothelial carcinoma of the bladder. The authors, who are experts in this field from 3 continents and 7 countries, reviewed the English language literature through September 2004. The results of the authors' deliberations are presented here as a consensus document. The objective of this study was to determine the optimal diagnostic workup, treatment, follow-up, and prevention of low-grade, Ta urothelial carcinoma of the bladder. A consensus conference convened by the World Health Organization (WHO) and the Société Internationale d'Urologie (SIU) met to critically review the literature on the diagnosis and treatment of low-grade Ta urothelial carcinoma of the bladder. Research was conducted using Medline; this search engine also was used to identify additional works not detected at the initial search. Evidence-based recommendations for diagnosis and management of the disease were made with reference to a 4-point scale. Low-grade Ta urothelial carcinoma of the bladder is a well-studied subject with many level 1 and 2 evidence references that support clinical practice. Findings from 135 reviewed citations are summarized. Many grade A and B recommendations on the diagnostic workup and management of this disease can be given with level 1 and 2 evidence based on prospective randomized clinical trials of sufficient statistical power. This should improve the quality of the treatment of this disease.

Management of stage T1 tumors of the bladder: International Consensus Panel

The International Consensus Panel on T1 bladder tumors markers reviewed the subject from a clinical perspective. From diagnosis to treatment decisions, what are the important issues in the management of a new patient? The assessment of prognostic factors for progression requires optimal resection and documentation. The role of immediate adjuvant intravesical chemotherapy after resection remains controversial. How often should the upper tract be assessed for tumor recurrence? The decision on whether to attempt bladder conservation with intravesical therapy or to perform a cystectomy is the most difficult issue in the management of superficial bladder cancer today. Finally, what therapies exist if initial intravesical bacille Calmette-Guérin fails to eradicate the disease or prevent recurrence? The panel thoroughly explored all these subjects and has made recommendations with supporting evidence.

Risk Factors for Upper Tract Recurrence in Patients Undergoing Long-Term Surveillance for Stage Ta Bladder Cancer

PURPOSE

While the evidence is clear that patients with carcinoma in situ or high grade T1 TCC of the bladder are at higher risk for developing UUT tumors, the role of imaging the UUT in patients with Ta tumors remains controversial. We hypothesized that the number and frequency of recurrences in patients with Ta disease would allow us to identify a population who should undergo routine UUT surveillance.

MATERIALS AND METHODS

We reviewed our database of 375 patients who underwent resection of a stage Ta TCC between 1975 and 1995. Median followup was 6 years. Patients were stratified according to the presence of an UUT occurrence, rate and timing of superficial recurrences, and grade of the initial bladder tumor.

RESULTS

Among the 375 patients 50% had no bladder recurrence, 25% had 1 tumor, 15% had 2 tumors, and 10% had 3 or more tumors. Average time between tumors was 17 months. UUT tumor developed in 13 patients (3.4%) at an average of 22 months after their initial bladder tumor. A high risk group consisting of patients who had 2 or more bladder recurrences recurring within 12 months of each other were at 4.5-fold the risk of UUT tumor.

CONCLUSIONS

Stage Ta bladder cancer patients with 2 or more recurrences of bladder tumors with a median of less than 12 months between recurrences are at higher risk for developing an UUT tumor and should be considered for more frequent UUT surveillance.

Upper tract surveillance in primary bladder cancer follow-up

OBJECTIVE

To determine if there is national variation in regimens of upper urinary tract surveillance in patients with primary bladder cancer.

METHODS

A questionnaire was sent to 470 consultant urologists from a British Association of Urological Surgeons list in the UK; 301 anonymous replies were received. Two replies were incomplete and therefore the results of 299 questionnaires (64%) were analysed.

RESULTS

Of the 299 surgeons, 19 (6%) use no form of upper urinary tract surveillance; 162 (54%) use surveillance in selected patients, i.e. those with carcinoma in situ (47%), multiple bladder tumours at first presentation (39%) and after cystectomy (70%), and 118 (39%) use upper tract surveillance on all patients with a history of bladder cancer. The median (range) screening interval was 24 (12-60) months and surveillance continued for a median of 10 (2 to indefinite) years, continuing for an indefinite period in 33%.

CONCLUSIONS

Most urologists use upper tract surveillance in patients with bladder cancer but there is wide variation in the duration and interval for which it continues, and in the type of patient selected for surveillance. Some patients at high risk of upper tract tumour are not being screened. Asymptomatic upper tract tumours may not be diagnosed because the intervals between surveillance are too long, and the duration for which it continues inadequate. There is a need for multidisciplinary national guidelines to reduce variation in practice.

Evaluation and follow-up strategies for superficial bladder cancer

Superficial bladder cancer comprises the majority of bladder tumors presenting today. Although the word "superficial" connotes a benign behaving curable disease, it is clear from long-term observations of the natural history of the disease that there are two discrete entities of superficial bladder cancer, one a low-grade innocuous tumor and the other a high-grade potentially lethal tumor. These two entities vary in their histologic appearance, risk of tumor recurrence, pattern of recurrence, and risk of tumor progression. Although work on prognostic markers is promising, currently none are sufficiently reliable; therefore, clinical factors are used to identify patients with a higher risk of tumor recurrence or progression. These include the tumor stage, tumor grade, number of tumors (multifocality), presence of associated carcinoma in situ, and initial response to therapy. Surveillance schedules are individualized based on the risks for recurrence and progression. High-risk patients who undergo successful treatment of their bladder tumor initially recur more commonly in the bladder, but have a progressive risk over time of extravesical recurrences necessitating lifelong surveillance of the bladder, urethra, prostate, and upper tracts. Patients who are refractory to conservative management with intravesical therapy and TUR should be apprised of the risks for further conservative treatment and consider early radical cystectomy in an attempt to improve long-term survival. The advent and long-term success of orthotopic continent diversions has made the decision for early radical cystectomy more palatable to both the patient and physician.

Value of selective upper tract cytology for recognition of upper tract tumors after treatment of superficial bladder cancer

BACKGROUND

The value of selective upper urinary tract (UT) cytology in patients who are asymptomatic and tumor free at control cystoscopy after being treated for superficial bladder carcinoma has not been studied. The present study was performed to evaluate the value of selective UT cytology in patients who are tumor free at control cystoscopy after being treated for superficial bladder cancer.

METHODS

Forty-seven consecutive patients who had undergone definitive surgical treatment for superficial bladder cancer at least 24 months prior and were tumor free at control cystoscopy were evaluated with bladder wash for cytology as well as selective UT urine cytology by catheterization of both ureteral orifices. Of the 47 patients, disease was stage Ta in 30 (63.8%), T1 in 15 (31.9%) and Ta/Tcis in 2 (4.3%). Primary tumor was unifocal in 24 (51.1%) and multifocal in 23 (48.9%) patients. The time elapsed from the initial diagnosis to the last evaluation ranged from 2 to 21 years (mean 5.39).

RESULTS

UT cytology was positive in 2 cases. Although, excretory urography (IVP) revealed mild pelvicalicectasis in 1 of these 2 patients, ureterorenoscopy (URS) revealed no abnormality. In the other patient with normal IVP and retrograde pyelography (RGP), URS revealed a ureteral tumor 5 mm in diameter. Although the UT cytology was normal in the remaining 45 patients, IVP revealed right hydronephrosis in 1 patient and URS revealed multiple ureteral tumors.

CONCLUSION

Given the normal appearance of the UT, it is highly unlikely that these patients have tumor in the UT. Thus, during the follow-up of patients with superficial bladder cancer, it is not useful to perform UT select cytology in the absence of any identifiable filling defects in the upper urinary tract.

Upper-tract tumors after an initial diagnosis of bladder cancer: argument for long-term surveillance

PURPOSE

To determine the relative risk (RR) of upper-tract tumors (UTT) after bladder cancer, stratified by bladder tumor characteristics, demographic factors, and follow-up duration, in order to develop an improved risk-based surveillance strategy.

PATIENTS AND METHODS

The 1973 to 1996 Surveillance, Epidemiology, and End Results (SEER) database was used to determine the observed and expected number of UTT after bladder cancer. The RR with 95% confidence intervals (CI) were calculated, stratifying by race, sex, stage, grade, histology, and follow-up duration. The tumor characteristics and clinical outcome were compared in patients with UTT after bladder cancer and those with de novo UTT.

RESULTS

A total of 94,591 patients had a first diagnosis of bladder cancer, of whom 91,245 had follow-up (median, 4.1 years), with no antecedent or synchronous UTT. UTT developed subsequently in 657 of 91,245 (0.7%), with 12.80 expected cases (RR = 51.3; 95% CI, 47.5 to 55.4). The respective RRs for UTT for white men and women were 64.2 (95% CI, 55.1 to 74.3) and 75.4 (95% CI, 57.7 to 96.9) at less than 2 years, 44.3 (95% CI, 36.7 to 53.0) and 40.5 (95% CI, 27.9 to 56.8) at 2 to 5 years, 50.8 (95% CI, 42.2 to 60.7) and 42.1 (95% CI, 28.8 to 59.4) at 5 to 10 years, and 43.2 (95% CI, 32.6 to 56.1) and 22.2 (95% CI, 10.1 to 42.2) at >or= 10 years. Similar RRs were seen among different strata of race, stage, grade, and histology. Patients with UTT after bladder cancer had lower stage and improved disease-specific survival compared with those with de novo UTT.

CONCLUSION

The incidence of UTT is stable on long-term follow-up, with no significant risk factors identified. These findings suggest that upper-tract surveillance remain rigorous on extended follow-up of bladder cancer patients.

Upper urinary tract tumors developing after treatment of superficial bladder cancer: 7-year follow-up of 591 consecutive patients

OBJECTIVES

To evaluate upper urinary tract tumor (UUTT) incidence and characteristics in 591 consecutive patients with low-, intermediate-, or high-risk superficial bladder cancer, who were followed up for at least 5 years or until death.

METHODS

From 1986 to 1992, 591 patients were treated for superficial bladder cancer: 216 patients with primary, solitary, low-grade (G1-G2), and low-stage (Ta-T1) superficial bladder cancer were considered at low risk of disease recurrence and treated with transurethral resection (TUR) alone; 182 patients with recurrent or multifocal superficial bladder cancer were considered at intermediate risk of disease recurrence or progression and treated with intravesical chemotherapy after TUR; 193 patients with carcinoma in situ, high-grade (G3) superficial bladder tumor, or intravesical chemotherapy failure were considered at high risk of disease recurrence or progression and treated with bacille Calmette-Guérin (BCG).

RESULTS

After a median follow-up of 86 months (range 20 to 143), 2 (0.9%) of 216 patients at low risk, 4 (2.2%) of 182 patients at intermediate risk, and 19 (9.8%) of 193 patients at high risk developed UUTTs. The incidence of UUTTs is significantly higher in patients at high risk than in those at low risk (P = 0.0004, odds ratio = 11.6, 95% confidence interval [CI] 2.5 to 40.7) or at intermediate risk (P = 0.004, odds ratio = 4.8, 95% CI 1.5 to 17.2), or both (P = 0.000006, odds ratio = 7.3, 95% CI 2.6 to 20.3). The difference between patients at low risk and those at intermediate risk was not statistically significant (P = 0.5, odds ratio = 0.4, 95% CI 0.02 to 2.6). After a median time of 36 months (range 9 to 119) from UUTT diagnosis, 5 (20%) of 25 patients have died of the disease.

CONCLUSIONS

The incidence of metachronous UUTTs is low in patients with superficial bladder cancer at low or intermediate risk of disease recurrence or progression and significantly higher for patients at high risk. Because UUTT is often asymptomatic, and mortality is high, frequent and lifelong examination of the upper urinary tract is suggested, with an annual intravenous urogram and urinary cytologic analysis every 4 months in patients with superficial bladder cancer at high risk of disease recurrence or progression.

Results of transurethral resection plus adjuvant intravesical chemotherapy for superficial bladder cancer

BACKGROUND

We analyzed the results of conservative therapy for superficial bladder cancer to determine the risk factors for recurrence and progression.

METHODS

Between May 1984 and February 1997, 111 patients with primary superficial bladder cancer were treated by a transurethral resection with or without intravesical instillation of chemotherapy, or for patients with concomitant carcinoma in situ (CIS), bacillus Calmette-Guérin. We examined the relationship between tumor stage, grade, incidence of concomitant CIS and recurrence-free survival according to pathologic findings and the drugs instilled.

RESULTS

The incidence of concomitant CIS in pT1, grade 3 tumors was significantly higher than that in pTa, grade 1 tumors (42% vs. 3%, P= 0.006). The 5-year recurrence-free survival rate of all patients was 73%. There was no significant difference in recurrence-free survival and pathologic stage, tumor grade, presence of concomitant CIS, or drugs used for instillation. However, the recurrence-free survival in patients with > or = 5 tumors was significantly lower than in patients with less than 5 tumors. Of the 111 patients, only 3 patients demonstrated disease progression and underwent a radical cystectomy, while 1 patient with a pT1b, grade 3 tumor developed a tumor in the ureter. No patient died of bladder cancer.

CONCLUSION

Our results indicate that the prognosis of superficial bladder cancer patients with a high-stage, high-grade (pT1, grade 3) tumor is favorable when treated by a transurethral resection and intravesical instillation. Bacillus Calmette-Guérin therapy is useful to prevent the recurrence of tumors with concomitant CIS.

Intravesical bacillus Calmette-Guérin treatment for Stage T1 grade 3 transitional cell carcinoma of the bladder

OBJECTIVES

To retrospectively analyze intravesical bacillus Calmette-Guerin (BCG) treatment for Stage T1 grade 3 (T1G3) transitional cell carcinoma (TCC) of the bladder.

METHODS

Between 1984 and 1995, 78 patients with Stage T1 grade 3 tumor were treated by transurethral resection of all visible tumors and adjuvant BCG intravesical instillations. Median follow-up was 56 months (range 12 to 141).

RESULTS

After an initial induction course, 52 patients (67%) were tumor-free. Twenty-two patients (28%) had recurrent tumor after a median of 7 months (range 5 to 62). Progression occurred in 6 patients (7.7%) after a median of 18 months (range 5 to 56).

CONCLUSIONS

Intravesical BCG appears to be an effective treatment for patients with Stage T1 grade 3 TCC. Patients whose tumors recur after an initial induction course may benefit from a second course of BCG. Intravesical BCG treatment may lower the tumor progression rate. Late recurrence, beyond 2 years, warrants long-term follow-up.

Separated pyelocolocutaneous diversion after bilateral ureterectomy and radical cystectomy for transitional cell carcinoma

OBJECTIVES

To report a technique for excision of bilateral ureteral transitional cell carcinoma which preserves renal function and provides ready access for endoscopic follow-up and therapy of the renal pelvis.

METHODS

The operative procedure of bilateral ureterectomy with construction of a separated pyelocolocutaneous diversion utilizing transverse colon is described and the clinical course of 4 patients is reported.

RESULTS

All 4 patients maintained excellent renal function and normal electrolytes. Conduit urine cytologic studies and renal pelvis endoscopic examinations have remained normal. Parastomal herniation was the most frequently observed postoperative complication.

CONCLUSIONS

This approach is well suited for the treatment of bilateral ureteral transitional cell carcinoma. Long-term complications are minimal and renal function is preserved. Periodic endoscopic visualization of each renal pelvis with resection and fulguration and/or instillation of immunotherapeutic or chemotherapeutic agents for recurrent renal pelvic lesions is readily accomplished.

The treated natural history of high risk superficial bladder cancer: 15-year outcome

PURPOSE

The long-term outcome of patients with high risk superficial bladder cancer is unknown. We report the results of 15 years of followup of high risk patients treated initially with aggressive local therapy, including transurethral resection alone or combined with intravesical bacillus Calmette-Guerin.

MATERIALS AND METHODS

Between 1978 and 1981, 86 high risk patients enrolled in a randomized study of transurethral resection alone or with intravesical bacillus Calmette-Guerin for superficial bladder cancer. Of these patients 81% had diffuse carcinoma in situ and 44% had stage T1 tumors before entry into the study. Patients were followed until death (61%) or until the present time (median followup 184 months).

RESULTS

Disease stage progressed in 46 patients (53%) and 31 (36%) eventually underwent cystectomy for progression (28) or refractory carcinoma in situ (3), while 18 (21%) had upper tract tumors at a median of 7.3 years. The 10 and 15-year disease specific survival rates were 70 and 63%, respectively. At 15 years 34% of patients overall were dead of bladder cancer, 27% were dead of other causes and 37% were alive, including 27% with an intact functioning bladder.

CONCLUSIONS

Despite aggressive local therapy patients with high risk superficial bladder cancer are at lifelong risk for development of stage progression and upper tract tumors. A third of patients are at risk for death from bladder cancer, justifying careful and vigilant long-term followup. These results support the use of initial aggressive local therapy in patients with high risk superficial bladder cancer.

Upper urinary tract involvement in patients with bladder carcinoma in situ (Tis): its impact on management

OBJECTIVES

To analyze the biologic behavior and etiologic mechanism of upper-tract involvement in patients with bladder cancer in situ (Tis) and its impact on management of these patients.

METHODS

One hundred thirty-eight patients with bladder Tis, 786 with superficial bladder cancer, and 179 patients with invasive bladder cancer treated by cystectomy were studied: 34 (24.6%), 18 (2.3%), and 7 (3.9%) developed upper-tract involvement in each group, respectively. Sixty-three patients with primary urothelial upper-tract tumors were also studied. Taking progression-free survival as an end point, univariate and multivariate analyses were performed.

RESULTS

The upper-tract recurrence rate was significantly higher in patients with bladder Tis than in patients with superficial bladder tumors (P <0.001); it was also significantly higher in patients treated with cystectomy because of bladder Tis compared with those treated because of invasive tumors (P <0.01). Patients with bladder Tis and upper-tract involvement showed high rates of upper-tract bilaterality (32.3%) and prostate involvement (67.4%). On pathologic examination, the upper tract showed predominantly superficial (Ta-T1-Tis) tumors (67.4%) and distal ureter location as the only finding (47%). In patients with bladder Tis, upper-tract involvement alone does not have a negative impact on the survival rate according to univariate and multivariate analysis (P = NS).

CONCLUSIONS

In patients with bladder Tis, upper-tract involvement represents a diffuse process; therefore, a close evaluation of both the prostate and the upper tract is recommended. Upper-tract involvement has no impact on bladder-preservation strategy. Many of these patients could also be offered a conservative management for the involved upper tract.