Prophylactic radical cystectomy for the management of keratinizing squamous metaplasia of the bladder in a man with tetraplegia

Arm crank ergometry improves cardiovascular disease risk factors and community mobility independent of body composition in high motor complete spinal cord injury

OBJECTIVE

Evaluate the effect of aerobic exercise using arm crank ergometry (ACE) in high motor complete (ISNCSCI A/B) spinal cord injury (SCI) as primarily related to cardiovascular disease (CVD) risk factors and functional mobility and secondarily to body composition and metabolic profiles.

DESIGN

Longitudinal interventional study at an academic medical center.

METHODS

Ten previously untrained participants (M8/F2, Age 36.7 y ± 10.1, BMI 24.5 ± 6.0) with high motor complete SCI (C7-T5) underwent ACE exercise training 30 minutes/day × 3 days/week for 10 weeks at 70% VO2Peak.

OUTCOME MEASURES

Primary outcome measures were pre- and post-intervention changes in markers of cardiovascular fitness (graded exercise testing (GXT): VO2, VO2Peak, respiratory quotient [RQ], GXT time, peak power, and energy expenditure [EE]) and community mobility (time to traverse a 100ft-5° ramp, and 12-minute WC propulsion test). Secondary outcome measures were changes in body composition and metabolic profiles (fasting and area under the curve for glucose and insulin, homeostasis model assessment [HOMA] for %β-cell activity [%β], %insulin sensitivity [%S], and insulin resistance [IR], and Matsuda Index [ISIMatsuda]).

RESULTS

Resting VO2, relative VO2Peak, absolute VO2Peak, peak power, RQ, 12-minute WC propulsion, fasting insulin, fasting G:I ratio, HOMA-%S, and HOMA-IR all significantly improved following intervention (P < 0.05). There were no changes in body composition (P>0.05).

CONCLUSIONS

Ten weeks of ACE at 70% VO2Peak in high motor complete SCI improves aerobic capacity, community mobility, and metabolic profiles independent of changes in body composition.

Keratinizing squamous metaplasia of the bladder: Our experience and current approaches

INTRODUCTION

Bladder mucosa is anatomically covered by urothelial epithelium. The replacement of the urothelium with stratified squamous cells is defined as squamous metaplasia which can be keratinizing or non-keratinizing. Clinically, it is also known as leukoplakia or keratinizing cystitis of the bladder. Although several etiologic factors have been proposed such as chronic inflammation, irritative stimuli and infection, its pathogenesis is not clearly understood. The natural history of squamous metaplasia and clinical treatment are controversial. Many authors consider squamous metaplasia as a premalignant lesion, so it is fundamental to find an effective treatment to reduce the risk of developing bladder squamous carcinoma.

CASE DESCRIPTION

We report our management of a 58-year-old man with histological evidence of keratinizing squamous metaplasia and severe lower urinary tract symptoms. After repeated transurethral resections, the patient was treated with intravesical instillation of hyaluronic acid showing the regression of the lesion with an improvement of macroscopic appearance followed by the resolution of clinical symptoms.

CONCLUSION

The therapeutic management of keratinizing squamous metaplasia is controversial, and currently no effective medical therapy is available for its treatment. Actually, patients undergo transurethral resections and a multidisciplinary approach is required to avoid cystectomy. Annual cystoscopy with multiple biopsies should be performed to determine the presence of dysplasia. Moreover, the therapeutic treatment with hyaluronic acid instillations could be the starting point and the gold standard in the follow-up of our patient. However, at present, further studies are required to formulate an adequate policy for therapeutic management of this unusual lesion of the bladder mucosa.

[Squamous cell lesions of the urinary bladder]

BACKGROUND

Squamous cell carcinoma (SCC) and transitional carcinoma with squamous differentiation (SCC/TCC) are rare in western countries. Chronic inflammation and irritation of the urothelium are common risk factors for the development of SCC and TCC/SCC. Tumour biology of squamous cell cancer and precancerous squamous lesions is different from transitional cell cancer (TCC). Recent advances in molecular analysis of benign and malignant squamous cell lesions indicate that they are closely associated and might lead to improved bladder cancer subclassification in the future.

AIM

At present, the clinical management and therapy of SCC remains challenging, as scientific evidence based on prospective clinical trials is not available. We performed an analysis of available literature on natural history, treatment, and prognosis of SCC, SCC/TCC and metaplastic lesions. Furthermore, recent findings in molecular cancer biology are discussed with a focus on their relevance for SCC carcinogenesis.

Squamous cell carcinogenesis and squamous cell carcinoma of the urinary bladder: a contemporary review with focus on nonbilharzial squamous cell carcinoma

Bladder squamous cell carcinoma, squamous metaplasia, and transitional cell carcinoma with squamous differentiation are infrequent findings in Western countries. A common risk factor for their development consists of chronic bladder irritation and inflammation. The prognostic and clinical relevance and natural history of squamous cell lesions has been under investigation, revealing individual premalignant characteristics. Recent developments in molecular characterization of squamous alterations of the urinary tract indicate pathogenetic similarities and interrelations and might lead to more precise tumor classification and risk stratification in the future. Nevertheless, current clinical management of patients with premalignant and malignant bladder squamous cell lesions remains challenging, as high evidence level studies are not available and prognosis of invasive squamous carcinoma is poor. Our review summarizes the available data on clinical presentation, treatment, and outcome of bladder squamous cell carcinoma, metaplastic lesions, and transitional cell carcinoma with squamous differentiation and discusses implementable current advances in the understanding of bladder cancer tumorigenesis.

Conservative management of unusual keratinising squamous metaplasia of the bladder in a 28-year-old female and overview of the literature

Keratinizing squamous metaplasia of the bladder is rare and is usually associated with urinary tract infections and chronic irritation. It is considered a precancerous condition of squamous cell carcinoma, especially when more than 50% of the bladder surface is affected. Medical treatment cannot eradicate this lesion. When it is limited to a small area of the bladder, transurethral resection is possible. Annual cystoscopy with multiple biopsies as well as annual upper tract imaging is proposed in the follow up of these patients. We present a preliminary 2-year followup report of a keratinizing squamous metaplasia of the bladder in a 28-year-old female patient with no previous risk factors.

Two adolescent girls with keratinizing squamous metaplasia of the bladder

Squamous metaplasia is a proliferative lesion characterized by the replacement of the transitional epithelium with stratified squamous cells. In the urinary system, it is mostly seen in the bladder. It can be nonkeratinized or keratinized. We report the cases of 2 adolescent girls with keratinizing metaplasia, 1 of whom presented with difficulty with indwelling catheterization and 1 with final terminal hematuria. The predisposing factors were recurrent urinary tract infection and additional catheterization in 1 of the patients. The diagnosis was confirmed by histologic examination in both patients. We report on these cases to draw attention to this rare entity in children.

Urological pathology causing free air under the diaphragm?

We report a case of long-standing, keratinising, squamous metaplasia of the bladder with undiagnosed malignant transformation to squamous cell carcinoma presenting as acute peritonitis secondary to spontaneous perforation of the bladder tumour. This presentation as an acute abdomen mimicking a perforated peptic or duodenal ulcer is the most unusual aspect of the case.