Risk factors for multiple intravesical recurrences of superficial bladder cancer

Natural History of Multiple Recurrences in Intermediate-Risk Non-Muscle Invasive Bladder Cancer: Lessons From a Prospective Cohort

OBJECTIVE

To describe the risk of multiple recurrences in intermediate-risk non-muscle invasive bladder cancer (IR-NMIBC) and their impact on progression. Prognostic studies of IR-NMIBC have focused on initial recurrences, yet little is known about subsequent recurrences and their impact on progression.

MATERIALS AND METHODS

IR-NMIBC patients from the Be-Well Study, a prospective cohort study of NMIBC patients diagnosed from 2015 to 2019 at Kaiser Permanente Northern California, were identified. The frequency of first, second, and third intravesical recurrences of urothelial carcinoma were characterized using conditional Kaplan-Meier analyses and random-effects shared-frailty models. The association of multiple recurrences with progression was examined.

RESULTS

In 291 patients with IR-NMIBC (median follow-up 38 months), the 5-year risk of initial recurrence was 54.4%. After initial recurrence (n = 137), 60.1% of patients had a second recurrence by 2 years. After second recurrence (n = 70), 51.5% of patients had a third recurrence by 3 years. In multivariable analysis, female sex (Hazard Ratio 1.51, P< .01), increasing tumor size (HR 1.14, P< .01) and number of prior recurrences (HR 1.24, P< .01) were associated with multiple recurrences; whereas maintenance BCG (HR 0.66, P = .03) was associated with reduced recurrences. The 5-year risk of progression varied significantly (P< .01) by number of recurrences: 9.5%, 21.9%, and 37.9% for patients with 1, 2, and 3+ recurrences, respectively.

CONCLUSIONS

Multiple recurrences are common in IR-NMIBC and are associated with progression. Female sex, larger tumors, number of prior recurrences, and lack of maintenance BCG were associated with multiple recurrences. Multiple recurrences may prove useful as a clinical trial endpoint for IR-NMIBC.

Selection of adjuvant intravesical therapies using the European Organization for Research and Treatment of Cancer scoring system in patients at intermediate risk of non-muscle-invasive bladder cancer

PURPOSE

We investigated whether the European Organization for Research and Treatment of Cancer (EORTC) scoring system can be used for the selection of adjuvant intravesical therapies for individual patients who undergo transurethral resection (TURB) for non-muscle-invasive bladder cancer (NMIBC).

METHODS

We retrospectively analyzed the data of 469 TURB cases for NMIBC. Clinical and pathological variables were compared using univariate and multivariate Cox proportional hazards regression analyses. The recurrence-free survival (RFS) rate was estimated by the Kaplan-Meier method, and the log-rank test was used to compare groups divided according to EORTC score or type of adjuvant therapy.

RESULTS

The overall RFS rate at 1 and 3 years was 59.1 and 40.3%, respectively. Of the total, 424 TURB cases (90.4%) had an EORTC score of 1-9. Tumor number, size, and grade were significant predictors of time to recurrence. The EORTC score was a significant predictor of RFS according to multivariate analysis, and the hazard ratios increased according to each EORTC score in multivariate analysis of a combination of EORTC score and adjuvant therapies. In groups with intermediate recurrence risk as defined by the European Association of Urology guidelines, the recurrence prevention effects in patients with an EORTC score of ≥ 5 were significantly greater with intravesical Bacillus Calmette-Guérin therapy than with weekly intravesical chemotherapy.

CONCLUSION

The EORTC scoring system provides useful information for the selection of adjuvant therapies for patients at intermediate risk of NMIBC recurrence.

Expression profile of E-cadherin and N-cadherin in non-muscle-invasive bladder cancer as a novel predictor of intravesical recurrence following transurethral resection

The objective of this study was to investigate the impact of the expression profile of E-cadherin and N-cadherin in newly diagnosed non-muscle-invasive bladder cancer (NMIBC) on the probability of intravesical recurrence in patients undergoing transurethral resection (TUR). This study included 115 consecutive patients diagnosed as having NMIBC following TUR. Expression levels of E-cadherin and N-cadherin in TUR specimens from these patients were measured by immunohistochemical staining. In this series, intravesical recurrence occurred in 35 of 115 patients (30.4%). Immunohistochemical study showed that positive expression of E-cadherin and N-cadherin were noted in 62 (53.9%) and 48 (41.7%) specimens, respectively. Intravesical recurrence was detected in only 7 of 62 patients (11.3%) with positive E-cadherin expression, while 33 of 48 patients (68.8%) with positive N-cadherin expression developed intravesical recurrence. When patients were divided into 4 groups according to the positivities of E-cadherin and N-cadherin expression, intravesical recurrence was detected in 27 of 30 patients (90.0%) with negative E-cadherin as well as positive N-cadherin expression, and the intravesical recurrence-free survival of this group was significantly poorer than those of the remaining 3 groups. Furthermore, negative E-cadherin as well as positive N-cadherin expression was identified as the most powerful independent predictor for intravesical recurrence following TUR on multivariate analysis. These findings suggest that the loss of E-cadherin and gain of N-cadherin expression in on NMIBC appeared to be significantly associated with postoperative recurrence; therefore, the switch from E-cadherin to N-cadherin expression might be involved in the mechanism underlying intravesical recurrence of on NMIBC.

Bioluminescence imaging to monitor bladder cancer cell adhesion in vivo: a new approach to optimize a syngeneic, orthotopic, murine bladder cancer model

OBJECTIVE

To improve the orthotopic murine bladder cancer model by using bioluminescent (BL) MB49 tumour cells for noninvasive in vivo monitoring of tumour growth and to examine the efficacy of integrin receptor-blocking oligopeptides on preventing tumour cell adhesion in this improved bladder cancer model.

MATERIALS AND METHODS

The capacity of oligopeptide combinations to interfere with tumour cell adhesion was assessed in vivo in a syngeneic, orthotopic, murine bladder cancer model. Tumour outgrowth was monitored noninvasively by bioluminescence imaging (BLI) after administration of luciferase-expressing MB49(LUC) bladder cancer cells. The presence of tumour cells was verified histologically and immunohistochemically on paraffin wax-embedded sections of excised bladders.

RESULTS

Anti-adhesive oligopeptides effectively inhibited tumour outgrowth. BLI detected tumour cells at an early stage when there were no clinical signs of cancer in any of the mice. The technique has high sensitivity in detecting tumour cell implantation, but is less reliable in assessing tumour volume in advanced-stage disease due to light attenuation in large tumours.

CONCLUSIONS

Peptides targeting adhesion molecules prevent attachment of bladder cancer cells to the injured bladder wall. BLI is a sensitive method for detecting luminescent bladder cancer cells in an orthotopic mouse model.

The frequency of hydronephrosis at initial diagnosis and its effect on recurrence and progression in patients with superficial bladder cancer

PURPOSE

We determined the frequency of hydronephrosis at initial diagnosis, and its effect on recurrence and progression in patients with superficial bladder cancer.

MATERIALS AND METHODS

Between January 1993 and April 2006 we retrospectively reviewed the records of 931 patients with superficial transitional cell carcinoma of the bladder at our institute. Hydronephrosis status was determined by excretory urogram, ultrasound or computerized tomography of the abdomen and pelvis at initial evaluation. The number of tumors, tumor size, tumor location, T category (pTa vs pT1) and histological grade were assessed at study entry. The absence or presence of unilateral or bilateral upper tract obstruction/hydronephrosis was recorded for all cohorts. We examined the frequency of hydronephrosis in patients with superficial bladder carcinoma according to T status and investigated the relationship between hydronephrosis, and recurrence-free and progression-free survival for pTa and pT1 stage. The end points assessed were recurrence and progression.

RESULTS

Histopathological results showed that 63.8% of all superficial bladder cancer cases were pT1 stage. Preoperative radiological evaluation revealed unilateral and bilateral hydronephrosis in 70 (7.5%) and 19 (2.1%) patients in all cohorts, respectively. Of patients with pTa tumors 304 (90.2%) had low grade lesions and 207 (61.4%) had a single tumor. Unilateral and bilateral hydronephrosis was detected in 16 (4.7%) and 4 (1.2%) patients with pTa, respectively. Of patients with pT1 tumors 196 (33.0%) had low grade lesions and 283 (47.6%) had a single tumor. Unilateral and bilateral hydronephrosis was detected in 54 (9.1%) and 15 (2.5%) patients with pT1 disease, respectively. The increased probability of hydronephrosis was detected in higher stage, higher grade multiple tumors and in tumors larger than 3 cm. Of 931 patients 37.9% had at least 1 recurrence with an incidence of 27.3% for Ta and 43.9% for T1 disease. The recurrence rate was 52.8% for patients with hydronephrosis, that is 35.0% for Ta and 58.0% for T1 disease. Median time to first recurrence was 22 months. Multivariate Cox analysis confirmed that T category, grade, tumor size and hydronephrosis were significant prognostic variables of recurrence. Of the cases 11% progressed to muscle invasive bladder cancer. Multivariate analysis revealed that progression was statistically significant for T category, disease grade, multiplicity, tumor size and the presence or absence of hydronephrosis.

CONCLUSIONS

Unilateral/bilateral hydronephrosis detected at the first evaluation at diagnosis of superficial bladder tumors is an independent prognostic factor for recurrence and progression.

Analysis of factors predicting intravesical recurrence of superficial transitional cell carcinoma of the bladder without concomitant carcinoma in situ

BACKGROUND

The objective of this study was to investigate risk factors for intravesical recurrence in patients with superficial bladder cancer without concomitant carcinoma in situ (CIS).

METHODS

In this series, we analyzed data from patients with newly diagnosed superficial Ta or T1 transitional cell carcinoma (TCC) of the bladder without concomitant CIS who underwent complete transurethral resection (TUR) without any adjuvant intravesical instillation therapies. Multivariate analysis was used to determine significant risk factors affecting intravesical recurrence after TUR. Differences in clinicopathological features between primary and recurrent tumors were also characterized.

RESULTS

Among 341 patients undergoing TUR of Ta or T1 bladder cancer, 187 diagnosed as having concomitant CIS and/or treated with adjuvant intravesical therapy were excluded, and the remaining 154 were evaluated. Intravesical recurrence was detected in 64 of the 154 patients, showing a 5-year recurrence-free survival rate of 58.3%. Among several factors examined, only tumor size was significantly associated with intravesical recurrence. Multivariate analysis identified tumor size as an independent predictor for intravesical recurrence irrespective of other parameters including age, gender, multiplicity, growth pattern, grade and stage. Recurrent tumors were significantly smaller and of a lower grade and lower stage than primary tumors, despite the absence of differences in growth pattern and the multiplicity between them.

CONCLUSIONS

These findings suggest that primary tumor size could be used as a potential risk factor for predicting intravesical recurrence following TUR of superficial TCC of the bladder without concomitant CIS, and that the pathological characteristics of recurrent tumors are more favorable than those of primary tumors.

Clinical study of bladder cancer: Proteinuria as a predictor of recurrence and efficacy of intravesical bacille Calmette-Guerin therapy

AIM

We studied the clinical characteristics of bladder cancer, with special attention to the clinical and pathological variables that affect tumor stage, relapse and efficacy of intravesical therapy.

METHODS

We reviewed the medical records of 152 patients of the Saiseikai Central Hospital who had been diagnosed as having bladder cancer between 1981 and 2001.

RESULTS

The age of the patients ranged from 24 to 88 years, with a median of 63.5 years. The median follow up was 52.4 months (range, 0.5-259.5 months). There was no difference in the incidence of gross hematuria as a presenting symptom among the patients with invasive cancer, superficial cancer and carcinoma in situ (CIS). However, the incidence of urinary frequency and painful urination did differ significantly between patients. Although patients with invasive cancer had a longer time to hospital visit than those with superficial cancer, this time difference was not statistically significant. Presence of proteinuria, multifocality and intravesical bacille Calmette-Guerin (BCG) therapy were the significant predictors of relapse after transurethral resection (TUR). Presence of proteinuria was shown to adversely affect the efficacy of intravesical BCG therapy. In the BCG-treated group, 3-year relapse-free survival was 78.4% for patients without proteinuria and 40.0% for those with proteinuria; this difference was statistically significant (P = 0.0277).

CONCLUSIONS

Time to hospital visit did not influence the pathological stage of cancer in patients included in the present study. Presence of proteinuria, multifocality and BCG therapy were the significant predictors of relapse after TUR. Presence of proteinuria was shown to adversely affect the efficacy of intravesical BCG therapy. Proteinuria might be helpful in predicting tumor relapse and efficacy of intravesical BCG therapy in clinical settings, along with other markers.