A model to predict the outcome of the bilharzial bladder cancer patient after radical cystectomy

Vascular endothelial growth factor, p53, and the H-ras oncogene in Egyptian patients with bladder cancer

AIM: To evaluate the relationship between vascular endothelial growth factor (VEGF), p53, and the H-ras oncogene and different clinicopathological parameters in Egyptian patients with Schistosoma-associated transitional cell carcinoma of the bladder.

METHODS: The study included 50 patients with transitional cell carcinoma for whom radical cystectomy and urinary diversions were carried out. VEGF and p53 protein expressions were evaluated with an immunohistochemical staining method, and H-ras oncogene mutations were analyzed with a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique.

RESULTS: High grade tumors revealed higher p53 immunostaining than low grade tumors (P = 0.016). p53 and VEGF protein expressions, as well as H-ras oncogene mutations, had an insignificant impact on patient outcomes (P = 0.962, P = 0.791, and P = 967, respectively). Cancer extension to regional lymph nodes was associated with poor outcomes (P = 0.008).

CONCLUSION: VEGF, p53 and the H-ras oncogene have no relation to patient survival and outcome in Schistosoma-associated transitional cell carcinoma.

Distant metastasis from bilharzial bladder cancer

BACKGROUND

Distant metastasis is rarely described among bilharzial bladder cancer patients. However, with improved 5-year survival rates following adjuvant local therapy, distant metastasis is now reported with increasing frequency.

METHODS

Three-hundred-fifty-seven bilharzial bladder cancer patients were treated at the National Cancer Institute in Cairo, Egypt, during the period 1981-1990. They were treated with either cystectomy alone, cystectomy preceded by a short course of preoperative radiotherapy (2000 cGy/5 fractions/1 week), or cystectomy followed by postoperative irradiation (5000 cGy/25 fractions/5 weeks or 3750 cGy/30 fractions/2 weeks). These patients were retrospectively analyzed.

RESULTS

The overall 5-year actuarial rate of distant metastasis was 23% (95% confidence interval, 21-25%), which was essentially the same in the 3 therapeutic groups. Both univariate and multivariate analyses revealed that the independent risk factors for distant metastasis were pelvic lymph node involvement (P = 0.005), pathologic stage (P = 0.004), and histopathologic grade (P = 0.05). Histologic type and local pelvic recurrence appeared in the univariate analysis as working risk factors; however, they were proven by multivariate analysis to be dependent on other risk factors. Patients who had none of the independent risk factors had a lower rate of distant metastasis (II%) and a high local control rate (88%). Those who had more than one risk factor had high distant metastasis rate (51%) and low local control rate (41%), regardless of the therapeutic modality used. The identified independent risk factors determined both the distant metastasis and the local control rates.

CONCLUSIONS

Unlike previous reports, this rigorous study of distant metastasis in bilharzial bladder cancer revealed an occurrence rate of 23%. This high rate was associated with pelvic lymph node involvement, pathologic stage, and histopathologic grade. Histologic type, local pelvic recurrence, or the addition of pre- or post-operative radiotherapy proved not to be independent risk factors.

A classification after radical cystectomy of patients with bladder cancer associated with schistosomiasis

The aim of this study was to classify the bilharzial bladder cancer patients after radical cystectomy into several prognostic strata with increasing risk of recurrence. 310 patients through the period 1977-1983 at the National Cancer Institute of Cairo were systematically analysed for 12 variables evaluated after radical cystectomy. Eight factors were shown to have a significant influence on the recurrence-free survival curve after radical cystectomy namely: tumour stage, size, grade and location in the bladder, lymph node involvement, metastasis, renal insufficiency and urinary diversion. Using the proportional hazard model, five factors were significantly related to a lower recurrence-free survival, one major prognostic factor, tumour grade (G2 or G3) (relative risk estimate of 5.5), and four minor prognostic factors (relative risk estimates around 2), namely tumour diameter greater than 5 cm, anterior or trigonal location of the tumour, tumour stage (T3 or T4) and presence of renal insufficiency before surgery. Four prognostic strata have been defined in relation to the presence of these prognostic factors. This classification was validated on a second sample of 122 patients by comparing for each prognostic stratum, the recurrence-free survival curve observed on this sample and the corresponding predicted curve by Cox model. No statistically significant difference could be detected. This classification of bladder cancer patients appears to be adequate for bilharzial bladder cancer patients after radical cystectomy, at least in the conditions they presented and were treated for at the NIC in Cairo.

Postoperative radiotherapy of carcinoma in bilharzial bladder: improved disease free survival through improving local control

Two hundred thirty-six patients with T3 bladder cancer who survived radical surgery and proved to have P3a, P3b, or P4a tumors were randomized in two phases into three groups: (a) no further treatment (83 patients); (b) postoperative radiotherapy multiple daily fractionation (MDF), using 3 daily fractions of 1.25 Gy each, with 3 hr between fractions, up to a total dose of 37.5 Gy in 12 days (75 patients); and (c) postoperative radiotherapy conventional fractionation (CF), for a total dose of 50 Gy/5 weeks (78 patients). The tolerance of the patients to postoperative radiotherapy was quite acceptable, with equal acute reactions in MDF and CF groups. The 5-year disease-free survival (DFS) rates amounted to 49 and 44% in MDF and CF postoperative radiotherapy groups, respectively, compared to 25% in the cystectomy-alone group. The 5-year local control rates were 87% and 93% for those treated with multiple daily fractionation and conventional fractionation while it was 50% in the surgery-alone group. The therapeutic benefit of postoperative irradiation was consistent for all tumor types, histological grades, and pathological stages for both the disease-free survival and local control. Patients with nodal metastases demonstrated lower recurrence rates in the postoperative radiotherapy groups, but this was not associated with improved disease-free survival. Multivariate analysis using the Cox Model confirmed these results. The independent prognostic factors affecting both disease-free survival and local control were the addition of postoperative radiotherapy, the nodal status, the pathological stage, and the tumor grade. Late complications of radiotherapy in the skin, small intestine, rectum, and the anastomotic site of the urinary division were lower with MDF than with conventional fractionation.