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Zimmerman KA, Hain JA, Graham NSN, Rooney EJ, Lee Y, Del-Giovane M, Parker TD, Friedland D, Cross MJ, Kemp S, Wilson MG, Sylvester RJ, Sharp DJ. Prospective cohort study of long-term neurological outcomes in retired elite athletes: the Advanced BiomaRker, Advanced Imaging and Neurocognitive (BRAIN) Health Study protocol. BMJ Open 2024; 14:e082902. [PMID: 38663922 PMCID: PMC11043776 DOI: 10.1136/bmjopen-2023-082902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Although limited, recent research suggests that contact sport participation might have an adverse long-term effect on brain health. Further work is required to determine whether this includes an increased risk of neurodegenerative disease and/or subsequent changes in cognition and behaviour. The Advanced BiomaRker, Advanced Imaging and Neurocognitive Health Study will prospectively examine the neurological, psychiatric, psychological and general health of retired elite-level rugby union and association football/soccer players. METHODS AND ANALYSIS 400 retired athletes will be recruited (200 rugby union and 200 association football players, male and female). Athletes will undergo a detailed clinical assessment, advanced neuroimaging, blood testing for a range of brain health outcomes and neuropsychological assessment longitudinally. Follow-up assessments will be completed at 2 and 4 years after baseline visit. 60 healthy volunteers will be recruited and undergo an aligned assessment protocol including advanced neuroimaging, blood testing and neuropsychological assessment. We will describe the previous exposure to head injuries across the cohort and investigate relationships between biomarkers of brain injury and clinical outcomes including cognitive performance, clinical diagnoses and psychiatric symptom burden. ETHICS AND DISSEMINATION Relevant ethical approvals have been granted by the Camberwell St Giles Research Ethics Committee (Ref: 17/LO/2066). The study findings will be disseminated through manuscripts in clinical/academic journals, presentations at professional conferences and through participant and stakeholder communications.
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Affiliation(s)
- Karl A Zimmerman
- Centre for Care, Research and Technology, UK Dementia Research Institute, Imperial College London, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
- Centre for Injury Studies, Imperial College London, London, UK
| | - Jessica A Hain
- Centre for Care, Research and Technology, UK Dementia Research Institute, Imperial College London, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
| | - Neil S N Graham
- Centre for Care, Research and Technology, UK Dementia Research Institute, Imperial College London, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
- Centre for Injury Studies, Imperial College London, London, UK
| | - Erin Jane Rooney
- Centre for Care, Research and Technology, UK Dementia Research Institute, Imperial College London, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
- Institute of Sport, Exercise and Health (ISEH), University College London, London, UK
| | - Ying Lee
- Centre for Care, Research and Technology, UK Dementia Research Institute, Imperial College London, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
- Institute of Sport, Exercise and Health (ISEH), University College London, London, UK
| | - Martina Del-Giovane
- Centre for Care, Research and Technology, UK Dementia Research Institute, Imperial College London, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
| | - Thomas D Parker
- Centre for Care, Research and Technology, UK Dementia Research Institute, Imperial College London, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
- Department of Neurodegenerative Disease, The Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Daniel Friedland
- Department of Brain Sciences, Imperial College London, London, UK
- Institute of Sport, Exercise and Health (ISEH), University College London, London, UK
| | - Matthew J Cross
- Carnegie Applied Rugby Research Centre, Carnegie School of Sport, Leeds Beckett University, Leeds, UK
- Premiership Rugby, London, UK
| | - Simon Kemp
- Rugby Football Union, Twickenham, UK
- London School of Hygiene & Tropical Medicine, London, UK
| | - Mathew G Wilson
- Institute of Sport, Exercise and Health (ISEH), University College London, London, UK
- HCA Healthcare Research Institute, London, UK
| | - Richard J Sylvester
- Institute of Sport, Exercise and Health (ISEH), University College London, London, UK
- Acute Stroke and Brain Injury Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - David J Sharp
- Centre for Care, Research and Technology, UK Dementia Research Institute, Imperial College London, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
- Centre for Injury Studies, Imperial College London, London, UK
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Beijert IJ, Hentschel AE, Bründl J, Compérat EM, Plass K, Rodríguez O, Subiela Henríquez JD, Hernández V, de la Peña E, Alemany I, Turturica D, Pisano F, Soria F, Čapoun O, Bauerová L, Pešl M, Bruins HM, Runneboom W, Herdegen S, Breyer J, Brisuda A, Calatrava A, Rubio-Briones J, Seles M, Mannweiler S, Bosschieter J, Kusuma VRM, Ashabere D, Huebner N, Cotte J, Contieri R, Mertens LS, Claps F, Masson-Lecomte A, Liedberg F, Cohen D, Lunelli L, Cussenot O, El Sheikh S, Volanis D, Côté JF, Rouprêt M, Haitel A, Shariat SF, Mostafid AH, Nieuwenhuijzen JA, Zigeuner R, Dominguez-Escrig JL, Hacek J, Zlotta AR, Burger M, Evert M, Hulsbergen-van de Kaa CA, van der Heijden AG, Kiemeney LALM, Soukup V, Molinaro L, Gontero P, Llorente C, Algaba F, Palou J, N'Dow J, Ribal MJ, van der Kwast TH, Babjuk M, Sylvester RJ, van Rhijn BWG. Second TURB, restaging TURB or repeat TURB in primary T1 non-muscle invasive bladder cancer: impact on prognosis? Int Urol Nephrol 2024; 56:1323-1333. [PMID: 37980689 DOI: 10.1007/s11255-023-03867-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 10/23/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE A re-transurethral resection of the bladder (re-TURB) is a well-established approach in managing non-muscle invasive bladder cancer (NMIBC) for various reasons: repeat-TURB is recommended for a macroscopically incomplete initial resection, restaging-TURB is required if the first resection was macroscopically complete but contained no detrusor muscle (DM) and second-TURB is advised for all completely resected T1-tumors with DM in the resection specimen. This study assessed the long-term outcomes after repeat-, second-, and restaging-TURB in T1-NMIBC patients. METHODS Individual patient data with tumor characteristics of 1660 primary T1-patients (muscle-invasion at re-TURB omitted) diagnosed from 1990 to 2018 in 17 hospitals were analyzed. Time to recurrence, progression, death due to bladder cancer (BC), and all causes (OS) were visualized with cumulative incidence functions and analyzed by log-rank tests and multivariable Cox-regression models stratified by institution. RESULTS Median follow-up was 45.3 (IQR 22.7-81.1) months. There were no differences in time to recurrence, progression, or OS between patients undergoing restaging (135 patients), second (644 patients), or repeat-TURB (84 patients), nor between patients who did or who did not undergo second or restaging-TURB. However, patients who underwent repeat-TURB had a shorter time to BC death compared to those who had second- or restaging-TURB (multivariable HR 3.58, P = 0.004). CONCLUSION Prognosis did not significantly differ between patients who underwent restaging- or second-TURB. However, a worse prognosis in terms of death due to bladder cancer was found in patients who underwent repeat-TURB compared to second-TURB and restaging-TURB, highlighting the importance of separately evaluating different indications for re-TURB.
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Affiliation(s)
- Irene J Beijert
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Anouk E Hentschel
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Johannes Bründl
- Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Karin Plass
- European Association of Urology, Guidelines Office Board, Arnhem, The Netherlands
| | - Oscar Rodríguez
- Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Virginia Hernández
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Isabel Alemany
- Pathology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Diana Turturica
- Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Turin, Italy
| | - Francesca Pisano
- Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
- Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Turin, Italy
| | - Francesco Soria
- Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Turin, Italy
| | - Otakar Čapoun
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Lenka Bauerová
- Pathology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Michael Pešl
- Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - H Maxim Bruins
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Radboud University Medical Center, Nijmegen, The Netherlands
- Urology, Zuyderland Medical Center, Sittard/Heerlen, The Netherlands
| | | | - Sonja Herdegen
- Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Johannes Breyer
- Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Antonin Brisuda
- Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Ana Calatrava
- Pathology, Fundación Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - José Rubio-Briones
- Urology, Fundación Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | | | | | - Judith Bosschieter
- Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Venkata R M Kusuma
- Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - David Ashabere
- Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Nicolai Huebner
- Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Juliette Cotte
- Urology, Pitié Salpétrière Hospital, AP-HP, GRC no 5, ONCOTYPE-URO, Sorbonne University, 75013, Paris, France
| | - Roberto Contieri
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Laura S Mertens
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Francesco Claps
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Alexandra Masson-Lecomte
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Fredrik Liedberg
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Daniel Cohen
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Royal Free London-NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Luca Lunelli
- Urology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Olivier Cussenot
- Urology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Soha El Sheikh
- Pathology, Royal Free London-NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Dimitrios Volanis
- Urology, Royal Free London-NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Jean-François Côté
- Pathology, Pierre et Marie Curie Medical School, Pitié Salpétrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Morgan Rouprêt
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Pitié Salpétrière Hospital, AP-HP, GRC no 5, ONCOTYPE-URO, Sorbonne University, 75013, Paris, France
| | - Andrea Haitel
- Pathology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Shahrokh F Shariat
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
- Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - A Hugh Mostafid
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Jakko A Nieuwenhuijzen
- Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Richard Zigeuner
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Medical University of Graz, Graz, Austria
| | - Jose L Dominguez-Escrig
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Fundación Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Jaromir Hacek
- Pathology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Alexandre R Zlotta
- Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Maximilian Burger
- Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Matthias Evert
- Pathology, University of Regensburg, Regensburg, Germany
| | | | | | | | - Viktor Soukup
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Luca Molinaro
- Pathology, Città della Salute e della Scienza, University of Torino School of Medicine, Turin, Italy
| | - Paolo Gontero
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Turin, Italy
| | - Carlos Llorente
- Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Ferran Algaba
- Pathology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Palou
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - James N'Dow
- European Association of Urology, Guidelines Office Board, Arnhem, The Netherlands
| | - Maria J Ribal
- European Association of Urology, Guidelines Office Board, Arnhem, The Netherlands
| | - Theo H van der Kwast
- Laboratory Medicine Program, University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Marko Babjuk
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
- Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Richard J Sylvester
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni Van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
- Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany.
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands.
- Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada.
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Soria F, Rosazza M, Livoti S, Dutto D, Colucci F, Sylvester RJ, Shariat SF, Babjuk M, Palou J, Gontero P. Repeat Transurethral Resection (TUR) + Bacillus Calmette-Guérin (BCG) Versus Upfront Induction BCG After TUR in High-risk Non-muscle-invasive Bladder Cancer: Feasibility Phase of a Randomized Controlled Study. Eur Urol Focus 2023:S2405-4569(23)00236-5. [PMID: 37923633 DOI: 10.1016/j.euf.2023.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/10/2023] [Accepted: 10/21/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND High-level evidence supporting the role of repeat transurethral resection (reTUR) in non-muscle-invasive bladder cancer (NMIBC) is lacking. A randomized controlled trial (RCT) assessing whether immediate reTUR has an impact on patient prognosis is essential. However, since such a RCT will require enrollment of a high number of patients, a preliminary feasibility study is appropriate. OBJECTIVE To assess the feasibility of an RCT investigating the impact of immediate reTUR + adjuvant bacillus Calmette-Guérin (BCG) versus upfront induction BCG after initial TUR in NMIBC. DESIGN, SETTING, AND PARTICIPANTS Eligible patients were randomly assigned to receive either reTUR + adjuvant BCG or upfront induction BCG after TUR. Patients with macroscopically completely resected high-grade T1 NMIBC, with or without concomitant carcinoma in situ, and with detrusor muscle (DM) present in the initial TUR specimen were considered eligible for inclusion. Exclusion criteria included lymphovascular invasion (LVI), histological subtypes, hydronephrosis, concomitant upper tract urothelial carcinoma (UTUC), or urothelial carcinoma within the prostatic urethra. The aim was to enroll 30 patients in this feasibility study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The patient recruitment rate was the primary outcome. Oncological outcomes (recurrence-free and progression-free survival) were secondary endpoints. RESULTS AND LIMITATIONS Overall, 30 patients (15 per arm) were randomized over a period of 14 mo (August 2020-October 2021). Two eligible patients refused the randomization, resulting in a patient compliance rate of 93.3% for the study protocol. We excluded 49 ineligible patients before randomization because of histological subtypes (n = 16, 33%), LVI (n = 9, 18%), DM absence in the TUR specimen (n = 12, 24%), metastatic disease (n = 5, 10%), concomitant UTUC (n = 3, 6%), or hydronephrosis (n = 4, 8%). At reTUR, persistent disease was found in four patients (29%) and upstaging to muscle-invasive disease in one (7%). Over median follow-up of 17 mo, disease recurrence was detected in three patients (23%) in the reTUR arm and six patients (40%) in the upfront BCG arm. Progression to muscle-invasive disease was observed in one patient treated with upfront BCG. CONCLUSIONS The feasibility of conducting an RCT comparing upfront BCG versus reTUR + BCG in high-grade T1 NMIBC has been demonstrated. Our results underline the need to screen a large number of patients owing to characteristics meeting the exclusion criteria in a high percentage of cases. PATIENT SUMMARY We found that a clinical trial of the role of a repeat surgical procedure to remove bladder tumors through the urethra would be feasible among patients with high-grade non-muscle-invasive bladder cancer. These preliminary results may help in refining the role of this repeat procedure for patients in this category.
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Affiliation(s)
- Francesco Soria
- Division of Urology, Department of Surgical Sciences, Torino School of Medicine, Torino, Italy.
| | - Matteo Rosazza
- Division of Urology, Department of Surgical Sciences, Torino School of Medicine, Torino, Italy
| | - Simone Livoti
- Division of Urology, Department of Surgical Sciences, Torino School of Medicine, Torino, Italy
| | - Daniele Dutto
- Division of Urology, Department of Surgical Sciences, Torino School of Medicine, Torino, Italy
| | - Fulvia Colucci
- Division of Urology, Department of Surgical Sciences, Torino School of Medicine, Torino, Italy
| | - Richard J Sylvester
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Hourani Center for Applied Scientific Research, Al-Ahliyya Amman University, Amman, Jordan
| | - Marek Babjuk
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czechia
| | - Joan Palou
- Department of Urology, Fundaciò Puigvert, Barcelona, Spain
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, Torino School of Medicine, Torino, Italy
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4
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Beijert IJ, Cheng L, Liedberg F, Plass K, Williamson SR, Gontero P, Ribal MJ, Babjuk M, Black PC, Kamat AM, Algaba F, Berman DM, Hartmann A, Masson-Lecomte A, Rouprêt M, Lopez-Beltran A, Samaratunga H, Shariat SF, Mostafid AH, Varma M, Shen S, Burger M, Tsuzuki T, Palou J, Compérat EM, Sylvester RJ, van der Kwast TH, van Rhijn BW, Downes MR. International Opinions on Grading of Urothelial Carcinoma: A Survey Among European Association of Urology and International Society of Urological Pathology Members. EUR UROL SUPPL 2023; 52:154-165. [PMID: 37284047 PMCID: PMC10240524 DOI: 10.1016/j.euros.2023.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 06/08/2023] Open
Abstract
Background Grade of non-muscle-invasive bladder cancer (NMIBC) is an important prognostic factor for progression. Currently, two World Health Organization (WHO) classification systems (WHO1973, categories: grade 1-3, and WHO2004 categories: papillary urothelial neoplasm of low malignant potential [PUNLMP], low-grade [LG], high-grade [HG] carcinoma) are used. Objective To ask the European Association of Urology (EAU) and International Society of Urological Pathology (ISUP) members regarding their current practice and preferences of grading systems. Design setting and participants A web-based, anonymous questionnaire with ten questions on grading of NMIBC was created. The members of EAU and ISUP were invited to complete an online survey by the end of 2021. Thirteen experts had previously answered the same questions. Outcome measurements and statistical analysis The submitted answers from 214 ISUP members, 191 EAU members, and 13 experts were analyzed. Results and limitations Currently, 53% use only the WHO2004 system and 40% use both systems. According to most respondents, PUNLMP is a rare diagnosis with management similar to Ta-LG carcinoma. The majority (72%) would consider reverting back to WHO1973 if grading criteria were more detailed. Separate reporting of WHO1973-G3 within WHO2004-HG would influence clinical decisions for Ta and/or T1 tumors according the majority (55%). Most respondents preferred a two-tier (41%) or a three-tier (41%) grading system. The current WHO2004 grading system is supported by a minority (20%), whereas nearly half (48%) supported a hybrid three- or four-tier grading system composed of both WHO1973 and WHO2004. The survey results of the experts were comparable with ISUP and EAU respondents. Conclusions Both the WHO1973 and the WHO2004 grading system are still widely used. Even though opinions on the future of bladder cancer grading were strongly divided, there was limited support for WHO1973 and WHO2004 in their current formats, while the hybrid (three-tier) grading system with LG, HG-G2, and HG-G3 as categories could be considered the most promising alternative. Patient summary Grading of non-muscle-invasive bladder cancer (NMIBC) is a matter of ongoing debate and lacks international consensus. We surveyed urologists and pathologists of European Association of Urology and International Society of Urological Pathology on their preferences regarding NMIBC grading to generate a multidisciplinary dialogue. Both the "old" World Health Organization (WHO) 1973 and the "new" WHO2004 grading schemes are still used widely. However, continuation of both the WHO1973 and the WHO2004 system showed limited support, while a hybrid grading system composed of both the WHO1973 and the WHO2004 classification system may be considered a promising alternative.
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Affiliation(s)
- Irene J. Beijert
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, Brown University Warren Alpert Medical School, Lifespan Academic Medical Center and Legorreta Cancer Center at Brown University, Providence, RI, USA
| | - Fredrik Liedberg
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Urology, Skåne University Hospital, Malmö, Sweden
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Karin Plass
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- European Association of Urology, Guidelines Office Board, Arnhem, The Netherlands
| | | | - Paolo Gontero
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Maria J. Ribal
- European Association of Urology, Guidelines Office Board, Arnhem, The Netherlands
- Department of Urology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Marko Babjuk
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
- Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Peter C. Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Ashish M. Kamat
- Department of Urology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Ferran Algaba
- Department of Pathology, Fundació Puigvert, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - David M. Berman
- Kingston Health Sciences Centre, Queen’s University, Kingston, ON, Canada
- Department of Pathology and Molecular Medicine, Queen’s University, Kingston, ON, Canada
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Alexandra Masson-Lecomte
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Urology, Université de Paris, APHP, Saint Louis Hospital, Paris, France
| | - Morgan Rouprêt
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Urology, Pitié Salpétrière Hospital, AP-HP, GRC n°5, ONCOTYPE-URO, Sorbonne University, Paris, France
| | - Antonio Lopez-Beltran
- Department of Morphological Sciences, University of Cordoba Medical School, Cordoba, Spain
- Anatomic Pathology, Champalimaud Clinical Center, Lisbon, Portugal
| | - Hemamali Samaratunga
- Department of Pathology, Aquesta Uropathology and University of Queensland, Brisbane, Australia
| | - Shahrokh F. Shariat
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
- Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - A. Hugh Mostafid
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Murali Varma
- Department of Cellular Pathology, University Hospital of Wales, Cardiff, UK
| | - Steven Shen
- Department of Pathology Genomic Medicine, Houston Methodist Hospital and Weill Cornell Medical College, Houston, TX, USA
| | - Maximilian Burger
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Toyonori Tsuzuki
- Department of Surgical Pathology, Aichi Medical University Hospital, Nagakute, Japan
| | - Joan Palou
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eva M. Compérat
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Pathology, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Richard J. Sylvester
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Theo H. van der Kwast
- Laboratory Medicine Program, University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Bas W.G. van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute – Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- European Association of Urology, Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Michelle R. Downes
- Division of Anatomic Pathology, Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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5
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Sylvester RJ, Rodríguez O, Hernández V, Turturica D, Bauerová L, Max Bruins H, Bründl J, van der Kwast TH, Brisuda A, Rubio-Briones J, Seles M, Hentschel AE, Kusuma VRM, Huebner N, Cotte J, Mertens LS, Volanis D, Cussenot O, Subiela Henríquez JD, de la Peña E, Pisano F, Pešl M, van der Heijden AG, Herdegen S, Zlotta AR, Hacek J, Calatrava A, Mannweiler S, Bosschieter J, Ashabere D, Haitel A, Côté JF, El Sheikh S, Lunelli L, Algaba F, Alemany I, Soria F, Runneboom W, Breyer J, Nieuwenhuijzen JA, Llorente C, Molinaro L, Hulsbergen-van de Kaa CA, Evert M, Kiemeney LALM, N'Dow J, Plass K, Čapoun O, Soukup V, Dominguez-Escrig JL, Cohen D, Palou J, Gontero P, Burger M, Zigeuner R, Mostafid AH, Shariat SF, Rouprêt M, Compérat EM, Babjuk M, van Rhijn BWG. Erratum to "European Association of Urology (EAU) Prognostic Factor Risk Groups for Non-muscle-invasive Bladder Cancer (NMIBC) Incorporating the WHO 2004/2016 and WHO 1973 Classification Systems for Grade: An Update from the EAU NMIBC Guidelines Panel" [Eur. Urol. 79(4) (2021) 480-488]. Eur Urol 2023; 83:e140-e141. [PMID: 36841687 DOI: 10.1016/j.eururo.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Affiliation(s)
- Richard J Sylvester
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands.
| | - Oscar Rodríguez
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Virginia Hernández
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Diana Turturica
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Lenka Bauerová
- Department of Pathology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Harman Max Bruins
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes Bründl
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Theo H van der Kwast
- Laboratory Medicine Program, University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Antonin Brisuda
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - José Rubio-Briones
- Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Maximilian Seles
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Anouk E Hentschel
- Department of Urology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands; Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Venkata R M Kusuma
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Nicolai Huebner
- Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Juliette Cotte
- Department of Urology, Pitié Salpétrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Laura S Mertens
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Dimitrios Volanis
- Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Olivier Cussenot
- Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | | | - Enrique de la Peña
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Francesca Pisano
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Michael Pešl
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | | | - Sonja Herdegen
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Alexandre R Zlotta
- Department of Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Jaromir Hacek
- Department of Pathology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Ana Calatrava
- Department of Pathology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | | | - Judith Bosschieter
- Department of Urology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - David Ashabere
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Andrea Haitel
- Department of Pathology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Jean-François Côté
- Department of Pathology, Pitié Salpétrière Hospital, AP-HP, Pierre et Marie Curie Medical School, Sorbonne University, Paris, France
| | - Soha El Sheikh
- Department of Pathology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Luca Lunelli
- Department of Urology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Ferran Algaba
- Department of Pathology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Isabel Alemany
- Department of Pathology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Francesco Soria
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Willemien Runneboom
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes Breyer
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Jakko A Nieuwenhuijzen
- Department of Urology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Carlos Llorente
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Luca Molinaro
- Department of Pathology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | | | - Matthias Evert
- Department of Pathology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | | | - James N'Dow
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Karin Plass
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Otakar Čapoun
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Viktor Soukup
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Jose L Dominguez-Escrig
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Daniel Cohen
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Joan Palou
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Paolo Gontero
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Maximilian Burger
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Richard Zigeuner
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Medical University of Graz, Graz, Austria
| | - Amir Hugh Mostafid
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Shahrokh F Shariat
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Morgan Rouprêt
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Pitié Salpétrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Eva M Compérat
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Marko Babjuk
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Bas W G van Rhijn
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
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6
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Boormans J, Sylvester RJ, Anson-Cartwright L, Glicksman R, Hamilton RJ, Daugaard G, Lauritsen J, Wagner T, Avuzzi B, Nicolai N, Aparicio J, Garcia del Muro X, Laguna P. European Association of Urology (EAU) Testicular Cancer Guidelines Panel: A new prognostic factor risk group classification for patients with clinical stage 1 seminoma in active surveillance. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
410 Background: Between 4%- 30% of patients with clinical stage 1 (CS I) seminoma testis (ST) in active surveillance (AS) relapse depending on pathological risk factors tumor size (TS) and rete testis invasion (RTI). The level of evidence supporting these pathological risk factors in clinical decision-making is low due to heterogeneous study design and reporting and the difficulty to analyze patient subgroups according to combination of these factors. The objectives of the present study were to identify the most important pathological prognostic factors predicting relapse in CS I seminoma patients with normal post-orchidectomy serum tumor marker (STM) levels in AS and to construct risk-groups for guiding treatment decision-making and follow-up. Methods: Individual patient data from 1016 CS I-ST patients diagnosed between February 1994 and January 2019 in AS were collected from 9 institutions. Central pathology review was not routinely performed in all institutions; therefore, pagetoid and stromal RTI were not differentiated explicitly in most cases. Assessing patient age, pre-orchidectomy STM b-human chorionic gonadotropin and lactate dehydrogenase, pathological TS, RTI, lympho-vascular invasion (LVI), multi-focality, and GCNIS, multivariable Cox proportional hazards regression models were fit to identify the most important prognostic factors for the time to first relapse by imaging and/or markers (primary endpoint). Probabilities of relapse were estimated using Kaplan-Meier curves. Results: After median follow-up of 7.7 years, 149 (14.7%) patients relapsed, 104 identified by imaging alone, 44 by imaging with elevated STMs and 1 by elevated STMs alone. Excluding 18 patients with unknown LVI from the multivariable analyses, TS (≤ 2 cm, between 2 and 5 cm, > 5 cm), presence of RTI and presence of LVI were used to form three risk groups: very low, low and high-risk (Table). Five-years probability of relapse varied from 8% in the very low risk-group to 44% in the high risk-group. The new model outperformed the current model with TS < 4cm vs ≥ 4 and RTI (Harrell's C index 0.65 vs 0.61) and identifies a subgroup of patients with a higher risk of relapse. Conclusions: The new risk-group stratification for CS I -ST patients in AS outperforms the histopathological model based on TS and RTI. It will serve to better inform patients on the risk of relapse during follow-up after orchidectomy but requires an independent validation. [Table: see text]
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Affiliation(s)
| | | | | | | | | | - Gedske Daugaard
- University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | | | - Thomas Wagner
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Barbara Avuzzi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Nicola Nicolai
- Urology Unit - Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Jorge Aparicio
- Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | | | - Pilar Laguna
- Istanbul Medipol University, Dept urology, Istanbul, Turkey
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7
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Beijert IJ, Hentschel AE, Bründl J, Compérat EM, Plass K, Rodríguez O, Subiela Henríquez JD, Hernández V, de la Peña E, Alemany I, Turturica D, Pisano F, Soria F, Čapoun O, Bauerová L, Pešl M, Bruins HM, Runneboom W, Herdegen S, Breyer J, Brisuda A, Calatrava A, Rubio-Briones J, Seles M, Mannweiler S, Bosschieter J, Kusuma VRM, Ashabere D, Huebner N, Cotte J, Mertens LS, Claps F, Masson-Lecomte A, Liedberg F, Cohen D, Lunelli L, Cussenot O, El Sheikh S, Volanis D, Côté JF, Rouprêt M, Haitel A, Shariat SF, Mostafid AH, Nieuwenhuijzen JA, Zigeuner R, Dominguez-Escrig JL, Hacek J, Zlotta AR, Burger M, Evert M, Hulsbergen-van de Kaa CA, van der Heijden AG, Kiemeney LALM, Soukup V, Molinaro L, Gontero P, Llorente C, Algaba F, Palou J, N'Dow J, Ribal MJ, van der Kwast TH, Babjuk M, Sylvester RJ, van Rhijn BWG. Prognosis of Primary Papillary Ta Grade 3 Bladder Cancer in the Non-muscle-invasive Spectrum. Eur Urol Oncol 2023; 6:214-221. [PMID: 36670042 DOI: 10.1016/j.euo.2023.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/05/2022] [Accepted: 01/02/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Ta grade 3 (G3) non-muscle-invasive bladder cancer (NMIBC) is a relatively rare diagnosis with an ambiguous character owing to the presence of an aggressive G3 component together with the lower malignant potential of the Ta component. The European Association of Urology (EAU) NMIBC guidelines recently changed the risk stratification for Ta G3 from high risk to intermediate, high, or very high risk. However, prognostic studies on Ta G3 carcinomas are limited and inconclusive. OBJECTIVE To evaluate the prognostic value of categorizing Ta G3 compared to Ta G2 and T1 G3 carcinomas. DESIGN, SETTING, AND PARTICIPANTS Individual patient data for 5170 primary Ta-T1 bladder tumors from 17 hospitals were analyzed. Transurethral resection of the tumor was performed between 1990 and 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Time to recurrence and time to progression were analyzed using cumulative incidence functions, log-rank tests, and multivariable Cox-regression models with interaction terms stratified by institution. RESULTS AND LIMITATIONS Ta G3 represented 7.5% (387/5170) of Ta-T1 carcinomas of which 42% were classified as intermediate risk. Time to recurrence did not differ between Ta G3 and Ta G2 (p = 0.9) or T1 G3 (p = 0.4). Progression at 5 yr occurred for 3.6% (95% confidence interval [CI] 2.7-4.8%) of Ta G2, 13% (95% CI 9.3-17%) of Ta G3, and 20% (95% CI 17-23%) of T1 G3 carcinomas. Time to progression for Ta G3 was shorter than for Ta G2 (p < 0.001) and longer than for T1 G3 (p = 0.002). Patients with Ta G3 NMIBC with concomitant carcinoma in situ (CIS) had worse prognosis and a similar time to progression as for patients with T1 G3 NMIBC with CIS (p = 0.5). Multivariable analyses for recurrence and progression showed similar results. CONCLUSIONS The prognosis of Ta G3 tumors in terms of progression appears to be in between that of Ta G2 and T1 G3. However, patients with Ta G3 NMIBC with concomitant CIS have worse prognosis that is comparable to that of T1 G3 with CIS. Our results support the recent EAU NMIBC guideline changes for more refined risk stratification of Ta G3 tumors because many of these patients have better prognosis than previously thought. PATIENT SUMMARY We used data from 17 centers in Europe and Canada to assess the prognosis for patients with stage Ta grade 3 (G3) non-muscle-invasive bladder cancer (NMIBC). Time to cancer progression for Ta G3 cancer differed from both Ta G2 and T1 G3 tumors. Our results support the recent change in the European Association of Urology guidelines for more refined risk stratification of Ta G3 NMIBC because many patients with this tumor have better prognosis than previously thought.
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Affiliation(s)
- Irene J Beijert
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Anouk E Hentschel
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Johannes Bründl
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Karin Plass
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Oscar Rodríguez
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Virginia Hernández
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Enrique de la Peña
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Isabel Alemany
- Department of Pathology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Diana Turturica
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Francesca Pisano
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Francesco Soria
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Otakar Čapoun
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czechia
| | - Lenka Bauerová
- Department of Pathology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czechia
| | - Michael Pešl
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czechia
| | - H Maxim Bruins
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willemien Runneboom
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sonja Herdegen
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Johannes Breyer
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Antonin Brisuda
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czechia
| | - Ana Calatrava
- Department of Pathology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - José Rubio-Briones
- Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Maximilian Seles
- Department of Urology, Medical University of Graz, Graz, Austria
| | | | - Judith Bosschieter
- Department of Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Venkata R M Kusuma
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - David Ashabere
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Nicolai Huebner
- Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Juliette Cotte
- Department of Urology, Pitié Salpétrière Hospital, AP-HP, GRC n°5, ONCOTYPE-URO, Sorbonne University, Paris, France
| | - Laura S Mertens
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Francesco Claps
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Alexandra Masson-Lecomte
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Fredrik Liedberg
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Daniel Cohen
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Luca Lunelli
- Department of Urology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Olivier Cussenot
- Department of Urology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Soha El Sheikh
- Department of Pathology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Dimitrios Volanis
- Department of Urology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Jean-François Côté
- Department of Pathology, Pitié Salpétrière Hospital, AP-HP, Pierre et Marie Curie Medical School, Sorbonne University, Paris, France
| | - Morgan Rouprêt
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Pitié Salpétrière Hospital, AP-HP, GRC n°5, ONCOTYPE-URO, Sorbonne University, Paris, France
| | - Andrea Haitel
- Department of Pathology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Shahrokh F Shariat
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czechia; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - A Hugh Mostafid
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Jakko A Nieuwenhuijzen
- Department of Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Richard Zigeuner
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Medical University of Graz, Graz, Austria
| | - Jose L Dominguez-Escrig
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Pathology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Jaromir Hacek
- Department of Pathology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czechia
| | - Alexandre R Zlotta
- Department of Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Matthias Evert
- Department of Pathology, University of Regensburg, Regensburg, Germany
| | | | | | - Lambertus A L M Kiemeney
- Department of Health Evidence and Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Viktor Soukup
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czechia
| | - Luca Molinaro
- Department of Pathology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Paolo Gontero
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Carlos Llorente
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Ferran Algaba
- Deaprtment of Pathology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Palou
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - James N'Dow
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Maria J Ribal
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Theo H van der Kwast
- Laboratory Medicine Program, University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Marko Babjuk
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czechia; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Richard J Sylvester
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada.
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Rouprêt M, Gontero P, McCracken SRC, Dudderidge T, Stockley J, Kennedy A, Rodriguez O, Sieverink C, Vanié F, Allasia M, Witjes JA, Colombel M, Longo F, Montanari E, Palou J, Sylvester RJ. Reducing the Frequency of Follow-up Cystoscopy in Low-grade pTa Non-muscle-invasive Bladder Cancer Using the ADXBLADDER Biomarker. Eur Urol Focus 2022; 8:1643-1649. [PMID: 35300937 DOI: 10.1016/j.euf.2022.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/26/2022] [Accepted: 02/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Non-muscle-invasive bladder cancer (NMIBC) is one of the most expensive cancers owing to frequent follow-up cystoscopies for detection of recurrence. OBJECTIVE To assess if the noninvasive ADXBLADDER urine test could permit a less intensive surveillance schedule for patients with low-grade (LG) pTa tumor without carcinoma in situ (CIS) at the previous diagnosis. DESIGN, SETTING, AND PARTICIPANTS In a prospective, double-blind, multicenter study, 629 patients underwent follow-up cystoscopy, transurethral resection of bladder tumor/biopsy of suspect lesions, and ADXBLADDER testing. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Diagnostic test accuracy and decision curve analysis were used to evaluate the impact of ADXBLADDER on decision-making on whether to perform follow-up cystoscopy. The primary endpoint was the negative predictive value (NPV) of ADXBLADDER for detection of high-grade and/or CIS (HG/CIS) recurrence and its impact on reducing unnecessary cystoscopies. RESULTS AND LIMITATIONS ADXBLADDER had sensitivity of 66.7% (95% confidence interval [CI] 34.9-90.1%) and an NPV of 99.15% (95% CI 97.8-99.8%) for detection of HG/CIS recurrence. The probability of HG/CIS recurrence was 5.0% for ADXBLADDER-positive patients and 0.85% for ADXBLADDER-negative patients. For HG/CIS recurrence threshold probabilities between 0.85% and 5.0%, ADXBLADDER yields a net benefit with omission of cystoscopy for ADXBLADDER-negative patients. The corresponding net reduction in unnecessary cystoscopies ranges from 11 to 62 per 100 patients. CONCLUSIONS Patients with LG pTa tumor at the previous diagnosis, for which the risk of HG/CIS recurrence is low and the ADXBLADDER NPV for ruling out HG/CIS recurrence is 99.15%, are ideally suited for a less intensive, personalized follow-up surveillance strategy using ADXBLADDER, with omission of cystoscopy for ADXBLADDER-negative patients. PATIENT SUMMARY ADXBLADDER is a urine test that can predict the probability of recurrence of bladder cancer. Patients diagnosed with low-grade cancer confined to the bladder mucosa are ideally suited for less intensive follow-up using this test, which could reduce unnecessary cystoscopy procedures for those with a negative result, potentially improve quality of life, and reduce overall health care costs.
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Affiliation(s)
- Morgan Rouprêt
- Sorbonne Université GRC 5 Predictive Onco-Uro, Urology Department, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Paolo Gontero
- Department of Urology, Ospedale Molinette, Turin, Italy
| | | | - Tim Dudderidge
- Department of Urology, University Hospital Southampton, Southampton, UK
| | | | | | | | - Caroline Sieverink
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Felicien Vanié
- Sorbonne Université GRC 5 Predictive Onco-Uro, Urology Department, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Marco Allasia
- Department of Urology, Ospedale Molinette, Turin, Italy
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marc Colombel
- Department of Urology, Hôpital Edouard Herriot, Lyon, France
| | - Fabrizio Longo
- Department of Urology, Università Policlinico Milano, Milan, Italy
| | | | - Joan Palou
- Department of Urology, Fundacio Puigvert, Barcelona, Spain
| | - Richard J Sylvester
- European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel, Brussels, Belgium.
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9
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Beijert IJ, Hentschel AE, Bründl J, Compérat EM, Plass K, Rodríguez O, Subiela Henríquez JD, Hernández V, de la Peña E, Alemany I, Turturica D, Pisano F, Soria F, Čapoun O, Bauerová L, Pešl M, Maxim Bruins H, Runneboom W, Herdegen S, Breyer J, Brisuda A, Calatrava A, Rubio-Briones J, Seles M, Mannweiler S, Bosschieter J, Kusuma VRM, Ashabere D, Huebner N, Cotte J, Mertens LS, Masson-Lecomte A, Liedberg F, Cohen D, Lunelli L, Cussenot O, El Sheikh S, Volanis D, Côté JF, Rouprêt M, Haitel A, Shariat SF, Mostafid AH, Nieuwenhuijzen JA, Zigeuner R, Dominguez-Escrig JL, Hacek J, Zlotta AR, Burger M, Evert M, Hulsbergen-van de Kaa CA, van der Heijden AG, A L M Kiemeney L, Soukup V, Molinaro L, Gontero P, Llorente C, Algaba F, Palou J, N'Dow J, Ribal MJ, van der Kwast TH, Babjuk M, Sylvester RJ, van Rhijn BWG. T1G1 Bladder Cancer: Prognosis for this Rare Pathological Diagnosis Within the Non-muscle-invasive Bladder Cancer Spectrum. Eur Urol Focus 2022; 8:1627-1634. [PMID: 35577750 DOI: 10.1016/j.euf.2022.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/13/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The pathological existence and clinical consequence of stage T1 grade 1 (T1G1) bladder cancer are the subject of debate. Even though the diagnosis of T1G1 is controversial, several reports have consistently found a prevalence of 2-6% G1 in their T1 series. However, it remains unclear if T1G1 carcinomas have added value as a separate category to predict prognosis within the non-muscle-invasive bladder cancer (NMIBC) spectrum. OBJECTIVE To evaluate the prognostic value of T1G1 carcinomas compared to TaG1 and T1G2 carcinomas within the NMIBC spectrum. DESIGN, SETTING, AND PARTICIPANTS Individual patient data for 5170 primary Ta and T1 bladder tumors from 17 hospitals in Europe and Canada were analyzed. Transurethral resection (TUR) was performed between 1990 and 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Time to recurrence and progression were analyzed using cumulative incidence functions, log-rank tests, and multivariable Cox regression models stratified by institution. RESULTS AND LIMITATIONS T1G1 represented 1.9% (99/5170) of all carcinomas and 5.3% (99/1859) of T1 carcinomas. According to primary TUR dates, the proportion of T1G1 varied between 0.9% and 3.5% per year, with similar percentages in the early and later calendar years. We found no difference in time to recurrence between T1G1 and TaG1 (p = 0.91) or between T1G1 and T1G2 (p = 0.30). Time to progression significantly differed between TaG1 and T1G1 (p < 0.001) but not between T1G1 and T1G2 (p = 0.30). Multivariable analyses for recurrence and progression showed similar results. CONCLUSIONS The relative prevalence of T1G1 diagnosis was low and remained constant over the past three decades. Time to recurrence of T1G1 NMIBC was comparable to that for other stage/grade NMIBC combinations. Time to progression of T1G1 NMIBC was comparable to that for T1G2 but not for TaG1, suggesting that treatment and surveillance of T1G1 carcinomas should be more like the approaches for T1G2 NMIBC in accordance with the intermediate and/or high risk categories of the European Association of Urology NMIBC guidelines. PATIENT SUMMARY Although rare, stage T1 grade 1 (T1G1) bladder cancer is still diagnosed in daily clinical practice. Using individual patient data from 17 centers in Europe and Canada, we found that time to progression of T1G1 cancer was comparable to that for T1G2 but not TaG1 cancer. Therefore, our results suggest that primary T1G1 bladder cancers should be managed with more aggressive treatment and more frequent follow-up than for low-risk bladder cancer.
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Affiliation(s)
- Irene J Beijert
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Anouk E Hentschel
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Johannes Bründl
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Karin Plass
- European Association of Urology, Guidelines Office Board, Arnhem, The Netherlands
| | - Oscar Rodríguez
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Virginia Hernández
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Enrique de la Peña
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Isabel Alemany
- Department of Pathology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Diana Turturica
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Francesca Pisano
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Francesco Soria
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Otakar Čapoun
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Lenka Bauerová
- Department of Pathology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Michael Pešl
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - H Maxim Bruins
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Willemien Runneboom
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sonja Herdegen
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Johannes Breyer
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Antonin Brisuda
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Ana Calatrava
- Department of Pathology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - José Rubio-Briones
- Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Maximilian Seles
- Department of Urology, Medical University of Graz, Graz, Austria
| | | | - Judith Bosschieter
- Department of Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Venkata R M Kusuma
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - David Ashabere
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Nicolai Huebner
- Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Juliette Cotte
- Department of Urology, Pitié Salpétrière Hospital, AP-HP, GRC no. 5, Oncotype-Uro, Sorbonne University, Paris, France
| | - Laura S Mertens
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Alexandra Masson-Lecomte
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Fredrik Liedberg
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Daniel Cohen
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Luca Lunelli
- Department of Urology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Olivier Cussenot
- Department of Urology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Soha El Sheikh
- Department of Pathology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Dimitrios Volanis
- Department of Urology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Jean-François Côté
- Department of Pathology, Pitié Salpétrière Hospital, AP-HP, Pierre et Marie Curie Medical School, Sorbonne University, Paris, France
| | - Morgan Rouprêt
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Pitié Salpétrière Hospital, AP-HP, GRC no. 5, Oncotype-Uro, Sorbonne University, Paris, France
| | - Andrea Haitel
- Department of Pathology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Shahrokh F Shariat
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - A Hugh Mostafid
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Jakko A Nieuwenhuijzen
- Department of Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Richard Zigeuner
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Medical University of Graz, Graz, Austria
| | - Jose L Dominguez-Escrig
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Jaromir Hacek
- Department of Pathology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Alexandre R Zlotta
- Department of Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Matthias Evert
- Department of Pathology, University of Regensburg, Regensburg, Germany
| | | | | | - Lambertus A L M Kiemeney
- Department of Health Evidence and Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Viktor Soukup
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Luca Molinaro
- Department of Pathology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Paolo Gontero
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Carlos Llorente
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Ferran Algaba
- Department of Pathology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Palou
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - James N'Dow
- European Association of Urology, Guidelines Office Board, Arnhem, The Netherlands
| | - Maria J Ribal
- European Association of Urology, Guidelines Office Board, Arnhem, The Netherlands
| | - Theo H van der Kwast
- Laboratory Medicine Program, University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Marko Babjuk
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Richard J Sylvester
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada.
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10
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Lobo N, Hensley PJ, Bree KK, Nogueras-Gonzalez GM, Navai N, Dinney CP, Sylvester RJ, Kamat AM. Updated European Association of Urology (EAU) Prognostic Factor Risk Groups Overestimate the Risk of Progression in Patients with Non-muscle-invasive Bladder Cancer Treated with Bacillus Calmette-Guérin. Eur Urol Oncol 2021; 5:84-91. [PMID: 34920986 DOI: 10.1016/j.euo.2021.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/07/2021] [Accepted: 11/17/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The 2021 European Association of Urology (EAU) guidelines contain updated prognostic factor risk groups for non-muscle-invasive bladder cancer (NMIBC). These groups are based on the following predictors of progression: tumour stage, grade, number, and size; concomitant carcinoma in situ; and age. However, the groups were derived from datasets excluding patients treated with bacillus Calmette-Guérin (BCG). OBJECTIVE To determine the validity of the updated EAU prognostic factor risk groups in patients with NMIBC treated with BCG. DESIGN, SETTING, AND PARTICIPANTS We reviewed patients treated with BCG at our institution between 2000 and 2018. Patients were analysed according to the receipt of "at least induction" and "adequate" BCG (as defined by the US Food and Drug Administration). Risk groups were assigned according to the 2021 EAU NMIBC risk calculator (https://nmibc.net/). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The Kaplan-Meier method was used to estimate the risks of progression at 1 and 5 yr. Probabilities of progression obtained with the updated prognostic factor risk groups in our series were compared with those reported by the EAU. Discrimination was assessed using the concordance index (c-index). RESULTS AND LIMITATIONS A total of 529 patients received at least induction BCG with a median follow-up of 47.3 mo (interquartile range 25.3-86.9). Of these patients, 494 received adequate BCG. We found lower progression rates at 1 yr in the very-high-risk group patients receiving at least induction (6.9%) and adequate BCG (4.0%) versus 16.0% for the EAU predicted rates. Additionally, progression rates were also lower at 5 yr in the high-risk group-7.4% for at least induction and 5.3% for adequate BCG versus 9.6% for EAU predicted rates; the rates in the very-high-risk group were as follows: 16.7% for at least induction and 14.9% for adequate BCG versus 40.0% for EAU predicted rates. The c-index in our series was lower than that reported by the EAU (0.63 vs 0.80). Of interest, our multivariable analysis identified grade, stage, and age (p < 0.02) to be the predictors of progression after BCG therapy. CONCLUSIONS While the 2021 EAU prognostic factor risk groups successfully stratified progression risks in our cohort, treatment with BCG reduced their discriminative ability. Furthermore, the groups overestimate progression risks in BCG-treated patients. These findings should be used in conjunction with the updated risk groups to counsel patients with higher-risk NMIBC about their risk of progression with and without BCG. PATIENT SUMMARY Although the updated European Association of Urology prognostic factor risk groups are able to stratify patients with non-muscle-invasive bladder cancer according to their risk of progression to muscle-invasive bladder cancer, this risk is overestimated in patients treated with bacillus Calmette-Guérin (BCG).
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Affiliation(s)
- Niyati Lobo
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick J Hensley
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Bree
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Neema Navai
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Colin P Dinney
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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11
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Babjuk M, Burger M, Capoun O, Cohen D, Compérat EM, Dominguez Escrig JL, Gontero P, Liedberg F, Masson-Lecomte A, Mostafid AH, Palou J, van Rhijn BWG, Rouprêt M, Shariat SF, Seisen T, Soukup V, Sylvester RJ. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (Ta, T1, and Carcinoma in Situ). Eur Urol 2021; 81:75-94. [PMID: 34511303 DOI: 10.1016/j.eururo.2021.08.010] [Citation(s) in RCA: 475] [Impact Index Per Article: 158.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/15/2021] [Indexed: 02/08/2023]
Abstract
CONTEXT The European Association of Urology (EAU) has released an updated version of the guidelines on non-muscle-invasive bladder cancer (NMIBC). OBJECTIVE To present the 2021 EAU guidelines on NMIBC. EVIDENCE ACQUISITION A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines since the 2020 version was performed. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS Tumours staged as Ta, T1 and carcinoma in situ (CIS) are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of tissue obtained via transurethral resection of the bladder (TURB) for papillary tumours or via multiple bladder biopsies for CIS. For papillary lesions, a complete TURB is essential for the patient's prognosis and correct diagnosis. In cases for which the initial resection is incomplete, there is no muscle in the specimen, or a T1 tumour is detected, a second TURB should be performed within 2-6 wk. The risk of progression may be estimated for individual patients using the 2021 EAU scoring model. On the basis of their individual risk of progression, patients are stratified as having low, intermediate, high, or very high risk, which is pivotal to recommending adjuvant treatment. For patients with tumours presumed to be at low risk and for small papillary recurrences detected more than 1 yr after a previous TURB, one immediate chemotherapy instillation is recommended. Patients with an intermediate-risk tumour should receive 1 yr of full-dose intravesical bacillus Calmette-Guérin (BCG) immunotherapy or instillations of chemotherapy for a maximum of 1 yr. For patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. For patients at very high risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is also recommended for BCG-unresponsive tumours. The extended version of the guidelines is available on the EAU website at https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/. CONCLUSIONS These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. PATIENT SUMMARY The European Association of Urology has released updated guidelines on the classification, risk factors, diagnosis, prognostic factors, and treatment of non-muscle-invasive bladder cancer. The recommendations are based on the literature up to 2020, with emphasis on the highest level of evidence. Classification of patients as having low, intermediate, or and high risk is essential in deciding on suitable treatment. Surgical removal of the bladder should be considered for tumours that do not respond to bacillus Calmette-Guérin (BCG) treatment and tumours with the highest risk of progression.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria.
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Otakar Capoun
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Daniel Cohen
- Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Eva M Compérat
- Department of Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | | | - Paolo Gontero
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Fredrik Liedberg
- Department of Translational Medicine, Lund University, Malmö, Sweden; Department of Urology, Skåne University Hospital, Malmö, Sweden
| | | | - A Hugh Mostafid
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Joan Palou
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; Department of Surgical Oncology (Urology), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Morgan Rouprêt
- GRC 5 Predictive Onco-Uro, Department of Urology, Sorbonne University, AP-HP, Pitié Salpétrière Hospital, Paris, France
| | - Shahrokh F Shariat
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Thomas Seisen
- GRC 5 Predictive Onco-Uro, Department of Urology, Sorbonne University, AP-HP, Pitié Salpétrière Hospital, Paris, France
| | - Viktor Soukup
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
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Sylvester RJ, Rodríguez O, Hernández V, Turturica D, Bauerová L, Bruins HM, Bründl J, van der Kwast TH, Brisuda A, Rubio-Briones J, Seles M, Hentschel AE, Kusuma VRM, Huebner N, Cotte J, Mertens LS, Volanis D, Cussenot O, Subiela Henríquez JD, de la Peña E, Pisano F, Pešl M, van der Heijden AG, Herdegen S, Zlotta AR, Hacek J, Calatrava A, Mannweiler S, Bosschieter J, Ashabere D, Haitel A, Côté JF, El Sheikh S, Lunelli L, Algaba F, Alemany I, Soria F, Runneboom W, Breyer J, Nieuwenhuijzen JA, Llorente C, Molinaro L, Hulsbergen-van de Kaa CA, Evert M, Kiemeney LALM, N'Dow J, Plass K, Čapoun O, Soukup V, Dominguez-Escrig JL, Cohen D, Palou J, Gontero P, Burger M, Zigeuner R, Mostafid AH, Shariat SF, Rouprêt M, Compérat EM, Babjuk M, van Rhijn BWG. European Association of Urology (EAU) Prognostic Factor Risk Groups for Non-muscle-invasive Bladder Cancer (NMIBC) Incorporating the WHO 2004/2016 and WHO 1973 Classification Systems for Grade: An Update from the EAU NMIBC Guidelines Panel. Eur Urol 2021; 79:480-488. [PMID: 33419683 DOI: 10.1016/j.eururo.2020.12.033] [Citation(s) in RCA: 174] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/17/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The European Association of Urology (EAU) prognostic factor risk groups for non-muscle-invasive bladder cancer (NMIBC) are used to provide recommendations for patient treatment after transurethral resection of bladder tumor (TURBT). They do not, however, take into account the widely used World Health Organization (WHO) 2004/2016 grading classification and are based on patients treated in the 1980s. OBJECTIVE To update EAU prognostic factor risk groups using the WHO 1973 and 2004/2016 grading classifications and identify patients with the lowest and highest probabilities of progression. DESIGN, SETTING, AND PARTICIPANTS Individual patient data for primary NMIBC patients were collected from the institutions of the members of the EAU NMIBC guidelines panel. INTERVENTION Patients underwent TURBT followed by intravesical instillations at the physician's discretion. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable Cox proportional-hazards regression models were fitted to the primary endpoint, the time to progression to muscle-invasive disease or distant metastases. Patients were divided into four risk groups: low-, intermediate-, high-, and a new, very high-risk group. The probabilities of progression were estimated using Kaplan-Meier curves. RESULTS AND LIMITATIONS A total of 3401 patients treated with TURBT ± intravesical chemotherapy were included. From the multivariable analyses, tumor stage, WHO 1973/2004-2016 grade, concomitant carcinoma in situ, number of tumors, tumor size, and age were used to form four risk groups for which the probability of progression at 5 yr varied from <1% to >40%. Limitations include the retrospective collection of data and the lack of central pathology review. CONCLUSIONS This study provides updated EAU prognostic factor risk groups that can be used to inform patient treatment and follow-up. Incorporating the WHO 2004/2016 and 1973 grading classifications, a new, very high-risk group has been identified for which urologists should be prompt to assess and adapt their therapeutic strategy when necessary. PATIENT SUMMARY The newly updated European Association of Urology prognostic factor risk groups for non-muscle-invasive bladder cancer provide an improved basis for recommending a patient's treatment and follow-up schedule.
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Affiliation(s)
- Richard J Sylvester
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands.
| | - Oscar Rodríguez
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Virginia Hernández
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Diana Turturica
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Lenka Bauerová
- Department of Pathology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Harman Max Bruins
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes Bründl
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Theo H van der Kwast
- Laboratory Medicine Program, University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Antonin Brisuda
- Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - José Rubio-Briones
- Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Maximilian Seles
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Anouk E Hentschel
- Department of Urology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands; Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Venkata R M Kusuma
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Nicolai Huebner
- Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Juliette Cotte
- Department of Urology, Pitié Salpétrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Laura S Mertens
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Dimitrios Volanis
- Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Olivier Cussenot
- Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | | | - Enrique de la Peña
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Francesca Pisano
- Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Michael Pešl
- Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | | | - Sonja Herdegen
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Alexandre R Zlotta
- Department of Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Jaromir Hacek
- Department of Pathology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Ana Calatrava
- Department of Pathology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | | | - Judith Bosschieter
- Department of Urology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - David Ashabere
- Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Andrea Haitel
- Department of Pathology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Jean-François Côté
- Department of Pathology, Pitié Salpétrière Hospital, AP-HP, Pierre et Marie Curie Medical School, Sorbonne University, Paris, France
| | - Soha El Sheikh
- Department of Pathology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Luca Lunelli
- Department of Urology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Ferran Algaba
- Department of Pathology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Isabel Alemany
- Department of Pathology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Francesco Soria
- Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Willemien Runneboom
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes Breyer
- Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Jakko A Nieuwenhuijzen
- Department of Urology, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Carlos Llorente
- Department of Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Luca Molinaro
- Department of Pathology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | | | - Matthias Evert
- Department of Pathology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | | | - James N'Dow
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Karin Plass
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Otakar Čapoun
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Viktor Soukup
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Jose L Dominguez-Escrig
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Daniel Cohen
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Royal Free London NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Joan Palou
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Paolo Gontero
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Maximilian Burger
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Richard Zigeuner
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Medical University of Graz, Graz, Austria
| | - Amir Hugh Mostafid
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Shahrokh F Shariat
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Morgan Rouprêt
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Pitié Salpétrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Eva M Compérat
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Marko Babjuk
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Department of Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Bas W G van Rhijn
- European Association of Urology Non-Muscle-Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Department of Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
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van Rhijn BWG, Hentschel AE, Bründl J, Compérat EM, Hernández V, Čapoun O, Bruins HM, Cohen D, Rouprêt M, Shariat SF, Mostafid AH, Zigeuner R, Dominguez-Escrig JL, Burger M, Soukup V, Gontero P, Palou J, van der Kwast TH, Babjuk M, Sylvester RJ. Prognostic Value of the WHO1973 and WHO2004/2016 Classification Systems for Grade in Primary Ta/T1 Non-muscle-invasive Bladder Cancer: A Multicenter European Association of Urology Non-muscle-invasive Bladder Cancer Guidelines Panel Study. Eur Urol Oncol 2021; 4:182-191. [PMID: 33423944 DOI: 10.1016/j.euo.2020.12.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/23/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In the current European Association of Urology (EAU) non-muscle-invasive bladder cancer (NMIBC) guideline, two classification systems for grade are advocated: WHO1973 and WHO2004/2016. OBJECTIVE To compare the prognostic value of these WHO systems. DESIGN, SETTING, AND PARTICIPANTS Individual patient data for 5145 primary Ta/T1 NMIBC patients from 17 centers were collected between 1990 and 2019. The median follow-up was 3.9 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Univariate and multivariable analyses of WHO1973 and WHO2004/2016 stratified by center were performed for time to recurrence, progression (primary endpoint), cystectomy, and duration of survival, taking into account age, concomitant carcinoma in situ, gender, multiplicity, tumor size, initial treatment, and tumor stage. Harrell's concordance (C-index) was used for prognostic accuracy of classification systems. RESULTS AND LIMITATIONS The median age was 68 yr; 3292 (64%) patients had Ta tumors. Neither classification system was prognostic for recurrence. For a four-tier combination of both WHO systems, progression at 5-yr follow-up was 1.4% in low-grade (LG)/G1, 3.8% in LG/G2, 7.7% in high grade (HG)/G2, and 18.8% in HG/G3 (log-rank, p < 0.001). In multivariable analyses with WHO1973 and WHO2004/2016 as independent variables, WHO1973 was a significant prognosticator of progression (p < 0.001), whereas WHO2004/2016 was not anymore (p = 0.067). C-indices for WHO1973, WHO2004, and the WHO systems combined for progression were 0.71, 0.67, and 0.73, respectively. Prognostic analyses for cystectomy and survival showed results similar to those for progression. CONCLUSIONS In this large prognostic factor study, both classification systems were prognostic for progression but not for recurrence. For progression, the prognostic value of WHO1973 was higher than that of WHO 2004/2016. The four-tier combination (LG/G1, LG/G2, HG/G2, and HG/G3) of both WHO systems proved to be superior, as it divides G2 patients into two subgroups (LG and HG) with different prognoses. Hence, the current EAU-NMIBC guideline recommendation to use both WHO classification systems remains correct. PATIENT SUMMARY At present, two classification systems are used in parallel to grade non-muscle-invasive bladder tumors. Our data on a large number of patients showed that the older classification system (WHO1973) performed better in terms of assessing progression than the more recent (WHO2004/2016) one. Nevertheless, we conclude that the current guideline recommendation for the use of both classification systems remains correct, since this has the advantage of dividing the large group of WHO1973 G2 patients into two subgroups (low and high grade) with different prognoses.
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Affiliation(s)
- Bas W G van Rhijn
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Surgical Oncology (Urology), Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany; Surgical Oncology (Urology), University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada.
| | - Anouk E Hentschel
- Surgical Oncology (Urology), Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands; Urology, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Johannes Bründl
- Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Pathology, Tenon Hospital, AP-HP, Sorbonne University, Paris, France
| | - Virginia Hernández
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Otakar Čapoun
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - H Maxim Bruins
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Daniel Cohen
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Royal Free London - NHS Foundation Trust, Royal Free Hospital, London, UK
| | - Morgan Rouprêt
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Pitié Salpétrière Hospital, AP-HP, GRC n°5, ONCOTYPE-URO, Sorbonne University, Paris, France
| | - Shahrokh F Shariat
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - A Hugh Mostafid
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, The Stokes Centre for Urology, Royal Surrey Hospital, Guildford, UK
| | - Richard Zigeuner
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Medical University of Graz, Graz, Austria
| | - Jose L Dominguez-Escrig
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Fundación Instituto Valenciano de Oncología (I.V.O.), Valencia, Spain
| | - Maximilian Burger
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Caritas St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Viktor Soukup
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, General Teaching Hospital and 1st Faculty of Medicine, Charles University Praha, Prague, Czech Republic
| | - Paolo Gontero
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Città della Salute e della Scienza, University of Torino School of Medicine, Torino, Italy
| | - Joan Palou
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Fundacio Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Theo H van der Kwast
- Laboratory Medicine Program, University Health Network, Princess Margaret Cancer Center, University of Toronto, Toronto, Canada
| | - Marko Babjuk
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands; Urology, Teaching Hospital Motol and 2nd Faculty of Medicine, Charles University Praha, Prague, Czech Republic; Urology, Comprehensive Cancer Center, Medical University Vienna, Vienna General Hospital, Vienna, Austria
| | - Richard J Sylvester
- European Association of Urology Non-Muscle Invasive Bladder Cancer Guidelines Panel, Arnhem, The Netherlands
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Hentschel AE, van Rhijn BW, Bründl J, Compérat EM, Plass K, Rodríguez O, Henríquez JDS, Hernández V, de la Peña E, Alemany I, Turturica D, Pisano F, Soria F, Čapoun O, Bauerová L, Pešl M, Bruins HM, Runneboom W, Herdegen S, Breyer J, Brisuda A, Scavarda-Lamberti A, Calatrava A, Rubio-Briones J, Seles M, Mannweiler S, Bosschieter J, Kusuma VR, Ashabere D, Huebner N, Cotte J, Mertens LS, Cohen D, Lunelli L, Cussenot O, Sheikh SE, Volanis D, Coté JF, Rouprêt M, Haitel A, Shariat SF, Mostafid AH, Nieuwenhuijzen JA, Zigeuner R, Dominguez-Escrig JL, Hacek J, Zlotta AR, Burger M, Evert M, Hulsbergen-van de Kaa CA, van der Heijden AG, Kiemeney LA, Soukup V, Molinaro L, Gontero P, Llorente C, Algaba F, Palou J, N'Dow J, Babjuk M, van der Kwast TH, Sylvester RJ. Papillary urothelial neoplasm of low malignant potential (PUN-LMP): Still a meaningful histo-pathological grade category for Ta, noninvasive bladder tumors in 2019? Urol Oncol 2020; 38:440-448. [DOI: 10.1016/j.urolonc.2019.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/23/2019] [Accepted: 10/02/2019] [Indexed: 12/21/2022]
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Li R, Sundi D, Zhang J, Kim Y, Sylvester RJ, Spiess PE, Poch MA, Sexton WJ, Black PC, McKiernan JM, Steinberg GD, Kamat AM, Gilbert SM. Systematic Review of the Therapeutic Efficacy of Bladder-preserving Treatments for Non-muscle-invasive Bladder Cancer Following Intravesical Bacillus Calmette-Guérin. Eur Urol 2020; 78:387-399. [PMID: 32143924 DOI: 10.1016/j.eururo.2020.02.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/14/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT There is a critical need for effective bladder-sparing therapies for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC). Owing to the current lack of effective agents that can be used as a control, the US Food and Drug Administration began to accept single-arm trials for patients with carcinoma in situ (CIS), using complete response rate (CRR) and duration of response as the primary endpoints to support marketing applications. Despite the ensuing growth of clinical trials in this space, no consensus exists on a clinically relevant benchmark for CRR. OBJECTIVE To elucidate the CRR and recurrence-free rate (RFR) using bladder-sparing agents after BCG failure in order to provide a frame of reference for future clinical trial results. EVIDENCE ACQUISITION We performed a systematic review of clinical trials utilizing bladder-sparing therapeutics for NMIBC recurring after intravesical BCG (PROSPERO CRD42019130553). The search was performed in MEDLINE, EMBASE, and Cochrane Library. Relevant studies identified from bibliography search and conference abstracts were searched to complement the systematic review. A total of 42 studies utilizing 24 treatment options and consisting of 2254 patients were included for final analysis. EVIDENCE SYNTHESIS Median CRRs in the treatment of CIS-containing tumors were 26% at 6 mo, 17% at 12 mo, and 8% at 24 mo after treatment. In comparison, median RFRs in the papillary-only studies were 67% at 6 mo, 44% at 12 mo, and 10% at 24 mo. Specifically in the BCG-unresponsive population, 6- and 12-mo CRRs in CIS-containing patients treated with Mycobacterium phlei cell wall-nucleic acid complex were 45% and 27%, respectively, and the median 6-, 12-, and 24-mo disease-free rates in the other studies were 43%, 35%, and 18%, respectively. The median progression-free rate was 91%: 95% in the CIS-containing studies and 89% in studies restricted to papillary-only recurrences. Toxicities of intravesical agents were generally mild, with very few dose limiting toxicities. CONCLUSIONS We demonstrate that, to date, bladder-sparing therapies achieved modest efficacy in patients with NMIBC after BCG. Results from the current study will serve as a frame of reference for emerging trial results in the BCG-unresponsive space. PATIENT SUMMARY In this study, we found that bladder-sparing therapies achieved modest efficacy in patients with non-muscle-invasive bladder cancer after bacillus Calmette-Guérin (BCG). These results will serve to inform future clinical trial results for salvage agents used to treat BCG-unresponsive bladder cancer.
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| | - Debasish Sundi
- Department of Urology, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Peter C Black
- Vancouver Prostate Center, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
| | | | | | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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Chen C, Huang H, Zhao Y, Liu H, Luo Y, Sylvester RJ, Li JP, Lam TB, Lin T, Huang J. Diagnostic accuracy of photodynamic diagnosis with 5-aminolevulinic acid, hexaminolevulinate and narrow band imaging for non-muscle invasive bladder cancer. J Cancer 2020; 11:1082-1093. [PMID: 31956355 PMCID: PMC6959070 DOI: 10.7150/jca.34527] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/27/2019] [Indexed: 11/05/2022] Open
Abstract
Objective: To assess the diagnostic test accuracy (DTA) of photodynamic diagnosis with 5-aminolaevulinic acid (5-ALA), hexylaminolevulinate (HAL) and narrow band imaging (NBI) for non-muscle-invasive bladder cancer (NMIBC), with white light-guided cystoscopy (WLC) as reference standard. Materials and Methods: A systematic review and narrative synthesis was performed in accordance with PRISMA. Major electronic databases were searched until 20th May 2019. All studies assessing the DTA of 5-ALA, HAL and NBI compared with WLC at patient and lesion-level were included. Relevant sensitivity analyses and risk of bias (RoB) assessment were undertaken. Results: 26 studies recruiting 3979 patients were eligible for inclusion. For patient-level analysis, NBI appeared to be the best (median sensitivity (SSY) 100%, median specificity (SPY) 68.45%, median positive predictive value (PPV) 90.75%, median negative predictive value (NPV) 100% and median false positive rate (FPR) 31.55%), showing better DTA outcomes than either HAL or 5-ALA. For lesion-level analysis, median SSY across NBI, HAL and 5-ALA were 93.08% (IQR 87.04-98.81%), 93.16% (IQR 91.48-97.04%) and 94.42% (IQR 82.37-95.73%) respectively. As for FPR, median values for NBI, HAL and 5-ALA were 20.40% (IQR 13.68-27.36%), 17.43% (IQR 12.79-22.40%) and 28.12% (IQR 22.08-42.39%), respectively. Sensitivity analyses based on studies with low to moderate RoB and studies with n>100 patients show similar findings. Conclusions: NBI appears to outperform 5-ALA and HAL in terms of diagnostic accuracy. All three modalities present high FPR, hence indicating the ability to detect additional cases and lesions beyond WLC.
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Affiliation(s)
- Changhao Chen
- Department of Urology
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, P. R. China
| | - Hao Huang
- Department of Urology
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, P. R. China
| | - Yue Zhao
- Department of Interventional Oncology, Sun Yat-Sen University First Affiliated Hospital, Guangzhou, China
| | - Hao Liu
- Department of Urology, Chengdu Fifth People's Hospital, Chengdu, P. R. China
| | - Yuming Luo
- Department of Pancreatobiliary Surgery, Sun Yat-Sen Memorial Hospital, Guangzhou, Guangdong P. R. China
| | | | - Jia ping Li
- Department of Interventional Oncology, Sun Yat-Sen University First Affiliated Hospital, Guangzhou, China
| | - Thomas B. Lam
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Tianxin Lin
- Department of Urology
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, P. R. China
| | - Jian Huang
- Department of Urology
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangdong, P. R. China
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Peyronnet B, Seisen T, Dominguez-Escrig JL, Bruins HM, Yuan CY, Lam T, Maclennan S, N’dow J, Babjuk M, Comperat E, Zigeuner R, Sylvester RJ, Burger M, Mostafid H, van Rhijn BW, Gontero P, Palou J, Shariat SF, Roupret M. Oncological Outcomes of Laparoscopic Nephroureterectomy Versus Open Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: An European Association of Urology Guidelines Systematic Review. Eur Urol Focus 2019; 5:205-223. [DOI: 10.1016/j.euf.2017.10.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 08/10/2017] [Accepted: 10/10/2017] [Indexed: 01/16/2023]
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Cumberbatch MGK, Foerster B, Catto JWF, Kamat AM, Kassouf W, Jubber I, Shariat SF, Sylvester RJ, Gontero P. Repeat Transurethral Resection in Non-muscle-invasive Bladder Cancer: A Systematic Review. Eur Urol 2018. [PMID: 29523366 DOI: 10.1016/j.eururo.2018.02.014] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
CONTEXT Initial treatment for most bladder cancers (BCs) involves transurethral resection (TUR) or tumours. Often more cancer is found after the initial treatment in around half of patients, requiring a second resection. Repeat transurethral resection (reTUR) is recommended for high-risk, non-muscle-invasive bladder cancer (NMIBC) to remove any residual disease and improve cancer outcomes. OBJECTIVE To systematically review the practice and therapeutic benefit of an early reTUR for high-risk NMIBC. EVIDENCE ACQUISITION A systematic review of original articles was performed using PubMed/Medline and Web of Science databases in December 2016 (initial) and October 2017 (final). We searched the references of included papers. EVIDENCE SYNTHESIS We screened 15 209 manuscripts and selected 31 detailing 8409 persons with high-grade Ta and T1BC for inclusion. Detrusor muscle was found at initial TUR histology in 30-100% of cases. Residual tumour at reTUR was found in 17-67% of patients following Ta and in 20-71% following T1 cancer. Most residual tumours (36-86%) were found at the original resection site. Upstaging occurred in 0-8% (Ta to ≥T1) and 0-32% (T1 to ≥T2) of cases. Conflicting data report the impact of reTUR on subsequent recurrence and cancer-specific mortality. Recurrence for Ta was 16% in the reTUR group versus 58% in the non-reTUR group. For T1, recurrence ranged from 18% to 56%, but no clear trend was identified between reTUR and control. No clear relationship between reTUR and progression was found for Ta, although for T1 rates were higher in the non-reTUR group in series with control populations (5/6 studies). Overall mortality was slightly reduced in the reTUR group in two studies with controls (22-30% vs 26-36% [no reTUR]). CONCLUSIONS Residual tumour is common after TUR for high-risk NMIBC. The reTUR helps in the diagnosis of this residual cancer and may improve outcomes for cancers initially staged as T1. PATIENT SUMMARY Some bladder cancers (BCs) are aggressive but confined to the bladder surface. Initial treatment includes endoscopic resection. More cancer is found after the initial treatment in approximately half of patients. In the aggressive but confined group of BC, a second resection, a few weeks after the first, may help find this residual cancer and improve outcomes, although the evidence quality for this is weak.
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Affiliation(s)
| | - Beat Foerster
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wassim Kassouf
- Division of Urology, McGill University Health Center, Montreal, Canada
| | - Ibrahim Jubber
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
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19
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Rouprêt M, Babjuk M, Compérat E, Zigeuner R, Sylvester RJ, Burger M, Cowan NC, Gontero P, Van Rhijn BWG, Mostafid AH, Palou J, Shariat SF. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2017 Update. Eur Urol 2017; 73:111-122. [PMID: 28867446 DOI: 10.1016/j.eururo.2017.07.036] [Citation(s) in RCA: 547] [Impact Index Per Article: 78.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/26/2017] [Indexed: 02/06/2023]
Abstract
CONTEXT The European Association of Urology (EAU) Guidelines Panel on Upper Urinary Tract Urothelial Carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. OBJECTIVE To provide an overview of the EAU guidelines on UTUC as an aid to clinicians. EVIDENCE ACQUISITION The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using the following keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; ureteroscopy; nephroureterectomy; adjuvant treatment; instillation; recurrence; risk factors; and survival. References were weighted by a panel of experts. EVIDENCE SYNTHESIS Owing to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing number of retrospective articles in UTUC. The 2017 tumour, node, metastasis (TNM) classification is recommended. Recommendations are given for diagnosis and risk stratification, as well as for radical and conservative treatment; prognostic factors are also discussed. A single postoperative dose of intravesical mitomycin after radical nephroureterectomy reduces the risk of bladder tumour recurrence. Kidney-sparing management should be offered as a primary treatment option to patients with low-risk tumours and two functional kidneys. CONCLUSIONS These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. PATIENT SUMMARY Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis; appropriate diagnosis and management is most important. We present recommendations based on current evidence for optimal management.
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Affiliation(s)
- Morgan Rouprêt
- AP-HP, Hôpital La Pitié-Salpétrière, Service d'Urologie, Paris, France; UPMC University Paris 06, GRC5, ONCOTYPE-Uro, Institut Universitaire de Cancérologie, Paris, France.
| | - Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Praha, Czech Republic
| | - Eva Compérat
- Department of Pathology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, UPMC Paris VI, Paris, France
| | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | | | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Nigel C Cowan
- Department of Radiology, Queen Alexandra Hospital, Portsmouth, UK
| | - Paolo Gontero
- Division of Urology, Department of Surgical Sciences, Molinette Hospital, University of Studies of Torino, Turin, Italy
| | - Bas W G Van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A Hugh Mostafid
- Department of Urology, Royal Surrey County Hospital, Guildford, UK
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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Sylvester RJ, Canfield SE, Lam TB, Marconi L, MacLennan S, Yuan Y, MacLennan G, Norrie J, Omar MI, Bruins HM, Hernández V, Plass K, Van Poppel H, N’Dow J. Conflict of Evidence: Resolving Discrepancies When Findings from Randomized Controlled Trials and Meta-analyses Disagree. Eur Urol 2017; 71:811-819. [DOI: 10.1016/j.eururo.2016.11.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/16/2016] [Indexed: 01/08/2023]
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21
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Babjuk M, Böhle A, Burger M, Capoun O, Cohen D, Compérat EM, Hernández V, Kaasinen E, Palou J, Rouprêt M, van Rhijn BW, Shariat SF, Soukup V, Sylvester RJ, Zigeuner R. EAU Guidelines on Non–Muscle-invasive Urothelial Carcinoma of the Bladder: Update 2016. Eur Urol 2017; 71:447-461. [DOI: 10.1016/j.eururo.2016.05.041] [Citation(s) in RCA: 1330] [Impact Index Per Article: 190.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 05/30/2016] [Indexed: 12/15/2022]
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22
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Sylvester RJ. A "CONSORT'd" Effort to Improve the Reporting of Urological Randomized Controlled Trials. Eur Urol 2016; 70:1050-1051. [PMID: 27522163 DOI: 10.1016/j.eururo.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/02/2016] [Indexed: 11/16/2022]
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23
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Seisen T, Peyronnet B, Dominguez-Escrig JL, Bruins HM, Yuan CY, Babjuk M, Böhle A, Burger M, Compérat EM, Cowan NC, Kaasinen E, Palou J, van Rhijn BWG, Sylvester RJ, Zigeuner R, Shariat SF, Rouprêt M. Oncologic Outcomes of Kidney-sparing Surgery Versus Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Systematic Review by the EAU Non-muscle Invasive Bladder Cancer Guidelines Panel. Eur Urol 2016; 70:1052-1068. [PMID: 27477528 DOI: 10.1016/j.eururo.2016.07.014] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 07/11/2016] [Indexed: 12/21/2022]
Abstract
CONTEXT There is uncertainty regarding the oncologic effectiveness of kidney-sparing surgery (KSS) compared with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). OBJECTIVE To systematically review the current literature comparing oncologic outcomes of KSS versus RNU for UTUC. EVIDENCE ACQUISITION A computerised bibliographic search of the Medline, Embase, and Cochrane databases was performed for all studies reporting comparative oncologic outcomes of KSS versus RNU. Approaches considered for KSS were segmental ureterectomy (SU) and ureteroscopic (URS) or percutaneous (PC) management. Using the methodology recommended by the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, we identified 22 nonrandomised comparative retrospective studies published between 1999 and 2015 that were eligible for inclusion in this systematic review. A narrative review and risk-of-bias (RoB) assessment were performed using cancer-specific survival (CSS) as the primary end point. EVIDENCE SYNTHESIS Seven studies compared KSS overall (n=547) versus RNU (n=1376). Information on the comparison of SU (n=586) versus RNU (n=3692), URS (n=162) versus RNU (n=367), and PC (n=66) versus RNU (n=114) was available in 10, 5, and 2 studies, respectively. No significant difference was found between SU and RNU in terms of CSS or any other oncologic outcomes. Only patients with low-grade and noninvasive tumours experienced similar CSS after URS or PC when compared with RNU, despite an increased risk of local recurrence following endoscopic management of UTUC. The RoB assessment revealed, however, that the analyses were subject to a selection bias favouring KSS. CONCLUSIONS Our systematic review suggests similar survival after KSS versus RNU only for low-grade and noninvasive UTUC when using URS or PC. However, selected patients with high-grade and invasive UTUC could safely benefit from SU when feasible. These results should be interpreted with caution due to the risk of selection bias. PATIENT SUMMARY We reviewed the studies that compared kidney-sparing surgery versus radical nephroureterectomy for upper tract urothelial carcinoma. We found similar oncologic outcomes for favourable tumours when using ureteroscopic or percutaneous management, whereas indications for segmental ureterectomy could be extended to selected cases of aggressive tumours.
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Affiliation(s)
- Thomas Seisen
- Academic Department of Urology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris; Pierre et Marie Curie Medical School, University Paris 6, Paris, France.
| | | | | | - Harman M Bruins
- Department of Urology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Cathy Yuhong Yuan
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, ON, Canada
| | - Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Praha, Czech Republic
| | - Andreas Böhle
- Department of Urology, HELIOS Agnes-Karll-Krankenhaus, Bad Schwartau, Germany
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Eva M Compérat
- Department of Pathology, Hôpital La Pitié-Salpétrière, UPMC, Paris, France
| | - Nigel C Cowan
- Radiology Department, Queen Alexandra Hospital, Portsmouth, UK
| | - Eero Kaasinen
- Department of Urology, Hyvinkää Hospital, Hyvinkää, Finland
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Bas W G van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Morgan Rouprêt
- Academic Department of Urology, Pitié-Salpétrière Hospital, Assistance-Publique Hôpitaux de Paris; Pierre et Marie Curie Medical School, University Paris 6, Paris, France
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Oddens JR, Sylvester RJ, Brausi MA, Kirkels WJ, van de Beek C, van Andel G, de Reijke TM, Prescott S, Alfred Witjes J, Oosterlinck W. Increasing age is not associated with toxicity leading to discontinuation of treatment in patients with urothelial non-muscle-invasive bladder cancer randomised to receive 3 years of maintenance bacille Calmette-Guérin: results from European Organisation for Research and Treatment of Cancer Genito-Urinary Group study 30911. BJU Int 2016; 118:423-8. [PMID: 26945890 DOI: 10.1111/bju.13474] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine the relationship of age to side-effects leading to discontinuation of treatment in patients with stage Ta-T1 non-muscle-invasive bladder cancer (NMIBC) treated with maintenance bacille Calmette-Guérin (BCG). PATIENTS AND METHODS We evaluated toxicity for 487 eligible patients with intermediate- or high-risk Ta-T1 (without carcinoma in situ) NMIBC randomised to receive 3 years of maintenance BCG therapy (247 BCG alone and 240 BCG + isoniazid) in European Organisation for Research and Treatment of Cancer Genito-Urinary Group trial 30911. The percentage of patients who stopped for toxicity and the number of treatment cycles that they received were compared in four age groups, ≤60, 61-70, 71-75 and >75 years, using the Mantel-Haenszel chi-square test for trend. RESULTS The percentage of patients stopping BCG for toxicity was 17.9% in patients aged ≤60 years, 21.9% in patients aged 61-70 years, 22.9% in patients aged 71-75 years, and 16.4% in patients aged >75 years (P = 0.90). For both systemic and local side-effects, there was likewise no significant difference. CONCLUSION In patients with intermediate- and high-risk Ta-T1 NMIBC treated with BCG, no differences in toxicity as a reason for stopping treatment were detected based on patient age.
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Affiliation(s)
- Jorg R Oddens
- Department of Urology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Richard J Sylvester
- Department of Biostatistics, European Organization for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | | | - Wim J Kirkels
- Department of Urology, Erasmus MC, Rotterdam, The Netherlands
| | - Cees van de Beek
- Department of Urology, Maastricht UMC+, Maastricht, The Netherlands
| | | | - Theo M de Reijke
- Department of Urology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Stephen Prescott
- Department of Urology, St James's University Hospital, Leeds, UK
| | - J Alfred Witjes
- Department of Urology, Radboud UMC, Nijmegen, The Netherlands
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Oddens JR, Sylvester RJ. Chemohyperthermia with Mitomycin-C Compared with Bacillus Calmette-Guérin: A "Hot" Topic. Eur Urol 2016; 69:1053-4. [PMID: 26873840 DOI: 10.1016/j.eururo.2016.01.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 01/24/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Jorg R Oddens
- Department of Urology, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, The Netherlands.
| | - Richard J Sylvester
- Senior Statistical Scientist Emeritus, European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium
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Kamat AM, Sylvester RJ, Böhle A, Palou J, Lamm DL, Brausi M, Soloway M, Persad R, Buckley R, Colombel M, Witjes JA. Definitions, End Points, and Clinical Trial Designs for Non-Muscle-Invasive Bladder Cancer: Recommendations From the International Bladder Cancer Group. J Clin Oncol 2016; 34:1935-44. [PMID: 26811532 DOI: 10.1200/jco.2015.64.4070] [Citation(s) in RCA: 250] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide recommendations on appropriate clinical trial designs in non-muscle-invasive bladder cancer (NMIBC) based on current literature and expert consensus of the International Bladder Cancer Group. METHODS We reviewed published trials, guidelines, meta-analyses, and reviews and provided recommendations on eligibility criteria, baseline evaluations, end points, study designs, comparators, clinically meaningful magnitude of effect, and sample size. RESULTS NMIBC trials must be designed to provide the most clinically relevant data for the specific risk category of interest (low, intermediate, or high). Specific eligibility criteria and baseline evaluations depend on the risk category being studied. For the population of patients for whom bacillus Calmette-Guérin (BCG) has failed, the type of failure (BCG unresponsive, refractory, relapsing, or intolerant) should be clearly defined to make comparisons across trials feasible. Single-arm designs may be relevant for the BCG-unresponsive population. Here, a clinically meaningful initial complete response rate (for carcinoma in situ) or recurrence-free rate (for papillary tumors) of at least 50% at 6 months, 30% at 12 months, and 25% at 18 months is recommended. For other risk levels, randomized superiority trial designs are recommended; noninferiority trials are to be used sparingly given the large sample size required. Placebo control is considered unethical for all intermediate- and high-risk strata; therefore, control arms should comprise the current guideline-recommended standard of care for the respective risk level. In general, trials should use time to recurrence or recurrence-free survival as the primary end point and time to progression, toxicity, disease-specific survival, and overall survival as potential secondary end points. Realistic efficacy thresholds should be set to ensure that novel therapies receive due review by regulatory bodies. CONCLUSION The International Bladder Cancer Group has developed formal recommendations regarding definitions, end points, and clinical trial designs for NMIBC to encourage uniformity among studies in this disease.
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Affiliation(s)
- Ashish M Kamat
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
| | - Richard J Sylvester
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Andreas Böhle
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Joan Palou
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Donald L Lamm
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Maurizio Brausi
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Mark Soloway
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Raj Persad
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Roger Buckley
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Marc Colombel
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - J Alfred Witjes
- Ashish M. Kamat, University of Texas MD Anderson Cancer Center, Houston, TX; Richard J. Sylvester, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Andreas Böhle, HELIOS Agnes Karll Hospital, Bad Schwartau, Germany; Joan Palou, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain; Donald L. Lamm, University of Arizona and BCG Oncology, Phoenix, AZ; Maurizio Brausi, Azienda Unità Sanitaria Locale di Modena, Modena, Italy; Mark Soloway, University of Miami School of Medicine, Miami, FL; Raj Persad, Bristol Royal Infirmary and Bristol Urological Institute, Bristol, United Kingdom; Roger Buckley, North York General Hospital, Toronto, Ontario, Canada; Marc Colombel, Claude Bernard University, Hôpital Edouard Herriot, Lyon, France; and J. Alfred Witjes, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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Sylvester RJ. Maintenance Bacillus Calmette-Guérin Therapy: The Search for the Optimum Treatment Schedule Continues. Eur Urol 2015; 68:263-4; discussion 265-6. [DOI: 10.1016/j.eururo.2015.03.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/11/2015] [Indexed: 10/23/2022]
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Cambier S, Sylvester RJ, Collette L, Gontero P, Brausi MA, van Andel G, Kirkels WJ, Silva FCD, Oosterlinck W, Prescott S, Kirkali Z, Powell PH, de Reijke TM, Turkeri L, Collette S, Oddens J. EORTC Nomograms and Risk Groups for Predicting Recurrence, Progression, and Disease-specific and Overall Survival in Non-Muscle-invasive Stage Ta-T1 Urothelial Bladder Cancer Patients Treated with 1-3 Years of Maintenance Bacillus Calmette-Guérin. Eur Urol 2015. [PMID: 26210894 DOI: 10.1016/j.eururo.2015.06.045] [Citation(s) in RCA: 402] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND There are no prognostic factor publications on stage Ta-T1 non-muscle-invasive bladder cancer (NMIBC) treated with 1-3 yr of maintenance bacillus Calmette-Guérin (BCG). OBJECTIVE To determine prognostic factors in NMIBC patients treated with 1-3 yr of BCG after transurethral resection of the bladder (TURB), to derive nomograms and risk groups, and to identify high-risk patients who should be considered for early cystectomy. DESIGN, SETTING, AND PARTICIPANTS Data for 1812 patients were merged from two European Organization for Research and Treatment of Cancer randomized phase 3 trials in intermediate- and high-risk NMIBC. INTERVENTION Patients received 1-3 yr of maintenance BCG after TURB and induction BCG. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Prognostic factors for risk of early recurrence and times to late recurrence, progression, and death were identified in a training data set using multivariable models and applied to a validation data set. RESULTS AND LIMITATIONS With a median follow-up of 7.4 yr, 762 patients recurred; 173 progressed; and 520 died, 83 due to bladder cancer (BCa). Statistically significant prognostic factors identified by multivariable analyses were prior recurrence rate and number of tumors for recurrence, and tumor stage and grade for progression and death due to BCa. T1G3 patients do poorly, with 1- and 5-yr disease-progression rates of 11.4% and 19.8%, respectively, and 1- and 5-yr disease-specific death rates of 4.8% and 11.3%. Limitations include lack of repeat transurethral resection in high-risk patients and exclusion of patients with carcinoma in situ. CONCLUSIONS NMIBC patients treated with 1-3 yr of maintenance BCG have a heterogeneous prognosis. Patients at high risk of recurrence and/or progression do poorly on currently recommended maintenance schedules. Alternative treatments are urgently required. PATIENT SUMMARY Non-muscle-invasive bladder cancer patients at high risk of recurrence and/or progression do poorly on currently recommended bacillus Calmette-Guérin maintenance schedules, and alternative treatments are urgently required. TRIAL REGISTRATION Study 30911 was registered with the US National Cancer Institute clinical trials database (protocol ID: EORTC 30911). Study 30962 was registered at ClinicalTrials.gov, number NCT00002990; http://clinicaltrials.gov/ct2/show/record/NCT00002990.
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Affiliation(s)
| | | | | | - Paolo Gontero
- Department of Surgical Sciences, Molinette Hospital, Torino, Italy
| | | | | | - Wim J Kirkels
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Stephen Prescott
- Department of Urology, St. James's University Hospital, Leeds, UK
| | - Ziya Kirkali
- Department of Urology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Philip H Powell
- Department of Urology, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Theo M de Reijke
- Department of Urology, Academic Medical Center, Amsterdam, The Netherlands
| | - Levent Turkeri
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
| | | | - Jorg Oddens
- Department of Urology, Jeroen Bosch Ziekenhuis, s'-Hertogenbosch, The Netherlands
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Rouprêt M, Babjuk M, Compérat E, Zigeuner R, Sylvester RJ, Burger M, Cowan NC, Böhle A, Van Rhijn BWG, Kaasinen E, Palou J, Shariat SF. European Association of Urology Guidelines on Upper Urinary Tract Urothelial Cell Carcinoma: 2015 Update. Eur Urol 2015; 68:868-79. [PMID: 26188393 DOI: 10.1016/j.eururo.2015.06.044] [Citation(s) in RCA: 392] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 06/23/2015] [Indexed: 01/03/2023]
Abstract
CONTEXT The European Association of Urology (EAU) guidelines panel on upper urinary tract urothelial cell carcinoma (UTUC) has prepared updated guidelines to aid clinicians in the current evidence-based management of UTUC and to incorporate recommendations into clinical practice. OBJECTIVE To provide a brief overview of the EAU guidelines on UTUC as an aid to clinicians. EVIDENCE ACQUISITION The recommendations provided in the current guidelines are based on a thorough review of available UTUC guidelines and articles identified following a systematic search of Medline. Data on urothelial malignancies and UTUC were searched using these keywords: urinary tract cancer; urothelial carcinomas; upper urinary tract, carcinoma; renal pelvis; ureter; bladder cancer; chemotherapy; nephroureterectomy; adjuvant treatment; instillation; neoadjuvant treatment; recurrence; risk factors; and survival. References were weighted by a panel of experts. EVIDENCE SYNTHESIS Due to the rarity of UTUC, there are insufficient data to provide strong recommendations (ie, grade A). However, the results of recent multicentre studies are now available, and there is a growing interest in UTUC. The 2009 TNM classification is recommended. Recommendations are given for diagnosis and risk stratification as well as radical and conservative treatment, and prognostic factors are discussed. A single postoperative dose of intravesical mitomycin after nephroureterectomy reduces the risk of bladder tumour recurrence. Recommendations are also provided for patient follow-up after different therapeutic strategies. CONCLUSIONS These guidelines contain information on the management of individual patients according to a current standardised approach. Urologists should take into account the specific clinical characteristics of each patient when determining the optimal treatment regimen, based on the proposed risk stratification of these tumours. PATIENT SUMMARY Urothelial carcinoma of the upper urinary tract is rare, but because 60% of these tumours are invasive at diagnosis, an appropriate diagnosis is most important. A number of known risk factors exist.
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Affiliation(s)
- Morgan Rouprêt
- Department of Urology, Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie, Institut Universitaire de Cancérologie, Paris, France.
| | - Marko Babjuk
- Department of Urology, Hospital Motol and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Eva Compérat
- Department of Pathology, Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie, Institut Universitaire de Cancérologie, Paris, France
| | - Richard Zigeuner
- Department of Urology, Medizinische Universität Graz, Graz, Austria
| | - Richard J Sylvester
- EAU Guidelines Office Board, European Association of Urology, The Netherlands
| | - Maximilian Burger
- Department of Urology, Caritas St. Josef Medical Centre, University of Regensburg, Regensburg, Germany
| | - Nigel C Cowan
- Department of Radiology, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Bas W G Van Rhijn
- Department of Urology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Eero Kaasinen
- Department of Surgery, Hyvinkää Hospital, Hyvinkää, Finland
| | - Joan Palou
- Department of Urology, Universitat Autònoma de Barcelona-Fundació Puigvert, Barcelona, Spain
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Centre, Medical University of Vienna, Vienna General Hospital, Vienna, Austria; Department of Urology, Weill Medical College of Cornell University, New York, NY, USA; Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Oddens JR, Sylvester RJ, Brausi MA, Kirkels WJ, van de Beek C, van Andel G, de Reijke TM, Prescott S, Witjes JA, Oosterlinck W. The Effect of Age on the Efficacy of Maintenance Bacillus Calmette-Guérin Relative to Maintenance Epirubicin in Patients with Stage Ta T1 Urothelial Bladder Cancer: Results from EORTC Genito-Urinary Group Study 30911. Eur Urol 2014; 66:694-701. [DOI: 10.1016/j.eururo.2014.05.033] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 05/23/2014] [Indexed: 11/26/2022]
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Goebell PJ, Kamat AM, Sylvester RJ, Black P, Droller M, Godoy G, Hudson MA, Junker K, Kassouf W, Knowles MA, Schulz WA, Seiler R, Schmitz-Dräger BJ. Assessing the quality of studies on the diagnostic accuracy of tumor markers. Urol Oncol 2014; 32:1051-60. [PMID: 25159014 DOI: 10.1016/j.urolonc.2013.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 10/03/2013] [Accepted: 10/05/2013] [Indexed: 01/11/2023]
Abstract
OBJECTIVES With rapidly increasing numbers of publications, assessments of study quality, reporting quality, and classification of studies according to their level of evidence or developmental stage have become key issues in weighing the relevance of new information reported. Diagnostic marker studies are often criticized for yielding highly discrepant and even controversial results. Much of this discrepancy has been attributed to differences in study quality. So far, numerous tools for measuring study quality have been developed, but few of them have been used for systematic reviews and meta-analysis. This is owing to the fact that most tools are complicated and time consuming, suffer from poor reproducibility, and do not permit quantitative scoring. METHODS The International Bladder Cancer Network (IBCN) has adopted this problem and has systematically identified the more commonly used tools developed since 2000. RESULTS In this review, those tools addressing study quality (Quality Assessment of Studies of Diagnostic Accuracy and Newcastle-Ottawa Scale), reporting quality (Standards for Reporting of Diagnostic Accuracy), and developmental stage (IBCN phases) of studies on diagnostic markers in bladder cancer are introduced and critically analyzed. Based upon this, the IBCN has launched an initiative to assess and validate existing tools with emphasis on diagnostic bladder cancer studies. CONCLUSIONS The development of simple and reproducible tools for quality assessment of diagnostic marker studies permitting quantitative scoring is suggested.
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Affiliation(s)
- Peter J Goebell
- Urologische Klinik, Friedrich-Alexander-Universität, Erlangen, Germany
| | - Ashish M Kamat
- Department of Urology, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Peter Black
- Department of Urology, Division of Surgery, University of British Columbia, Vancouver, Canada
| | | | - Guilherme Godoy
- Scott Department of Urology, Baylor College of Medicine, Houston, TX
| | - M'Liss A Hudson
- Ochsner Clinic Foundation, Tom and Gayle Benson Cancer Center, New Orleans, LA
| | - Kerstin Junker
- Urologische Klinik und Poliklinik, Universität des Saarlandes, Saarland, Germany
| | - Wassim Kassouf
- Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada
| | - Margaret A Knowles
- Section of Experimental Oncology, Leeds Institute of Cancer and Pathology, St James's University Hospital, Leeds, UK
| | - Wolfgang A Schulz
- Urologische Klinik und Poliklinik, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Roland Seiler
- Department of Urology, University of Berne, Berne, Switzerland
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Babjuk M, Burger M, Zigeuner R, Shariat SF, van Rhijn BWG, Compérat E, Sylvester RJ, Kaasinen E, Böhle A, Palou Redorta J, Rouprêt M. EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder: update 2013. Eur Urol 2013; 64:639-53. [PMID: 23827737 DOI: 10.1016/j.eururo.2013.06.003] [Citation(s) in RCA: 912] [Impact Index Per Article: 82.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT The first European Association of Urology (EAU) guidelines on bladder cancer were published in 2002 [1]. Since then, the guidelines have been continuously updated. OBJECTIVE To present the 2013 EAU guidelines on non-muscle-invasive bladder cancer (NMIBC). EVIDENCE ACQUISITION Literature published between 2010 and 2012 on the diagnosis and treatment of NMIBC was systematically reviewed. Previous guidelines were updated, and the levels of evidence and grades of recommendation were assigned. EVIDENCE SYNTHESIS Tumours staged as Ta, T1, or carcinoma in situ (CIS) are grouped as NMIBC. Diagnosis depends on cystoscopy and histologic evaluation of the tissue obtained by transurethral resection (TUR) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TUR is essential for the patient's prognosis. Where the initial resection is incomplete, where there is no muscle in the specimen, or where a high-grade or T1 tumour is detected, a second TUR should be performed within 2-6 wk. The risks of both recurrence and progression may be estimated for individual patients using the EORTC scoring system and risk tables. The stratification of patients into low-, intermediate-, and high-risk groups is pivotal to recommending adjuvant treatment. For patients with a low-risk tumour, one immediate instillation of chemotherapy is recommended. Patients with an intermediate-risk tumour should receive one immediate instillation of chemotherapy followed by 1 yr of full-dose bacillus Calmette-Guérin (BCG) intravesical immunotherapy or by further instillations of chemotherapy for a maximum of 1 yr. In patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. In patients at highest risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is recommended in BCG-refractory tumours. The long version of the guidelines is available from the EAU Web site: http://www.uroweb.org/guidelines/. CONCLUSIONS These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. PATIENT SUMMARY The EAU Panel on Non-muscle Invasive Bladder Cancer released an updated version of their guidelines. Current clinical studies support patient selection into different risk groups; low, intermediate and high risk. These risk groups indicate the likelihood of the development of a new (recurrent) cancer after initial treatment (endoscopic resection) or progression to more aggressive (muscle-invasive) bladder cancer and are most important for the decision to provide chemo- or immunotherapy (bladder installations). Surgical removal of the bladder (radical cystectomy) should only be considered in patients who have failed chemo- or immunotherapy, or who are in the highest risk group for progression.
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Affiliation(s)
- Marko Babjuk
- Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
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Yates DR, Brausi MA, Catto JW, Dalbagni G, Rouprêt M, Shariat SF, Sylvester RJ, Witjes JA, Zlotta AR, Palou-Redorta J. Treatment Options Available for Bacillus Calmette-Guérin Failure in Non–muscle-invasive Bladder Cancer. Eur Urol 2012; 62:1088-96. [DOI: 10.1016/j.eururo.2012.08.055] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 08/27/2012] [Indexed: 11/17/2022]
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Palou J, Sylvester RJ, Faba OR, Parada R, Peña JA, Algaba F, Villavicencio H. Female Gender and Carcinoma In Situ in the Prostatic Urethra Are Prognostic Factors for Recurrence, Progression, and Disease-Specific Mortality in T1G3 Bladder Cancer Patients Treated With Bacillus Calmette-Guérin. Eur Urol 2012; 62:118-25. [DOI: 10.1016/j.eururo.2011.10.029] [Citation(s) in RCA: 179] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 10/18/2011] [Indexed: 11/30/2022]
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Sylvester RJ. How Well Can You Actually Predict Which Non–Muscle-Invasive Bladder Cancer Patients Will Progress? Eur Urol 2011; 60:431-3; discussion 433-4. [DOI: 10.1016/j.eururo.2011.06.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Accepted: 06/01/2011] [Indexed: 11/16/2022]
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Abstract
Bacillus Calmette-Guérin (BCG) has been used in the intravesical treatment of non-muscle invasive bladder cancer (NMIBC) for nearly 35 years; however, its use is still subject to controversy. The objective of this paper is to review the role of BCG in the treatment of patients with NMIBC. Clinical trials, meta-analyses and guidelines related to the administration, safety and efficacy of intravesical BCG were reviewed. Intravesical BCG is more effective than intravesical chemotherapy in decreasing the risk of recurrence and progression to muscle invasive disease; however, it is associated with more local and systemic side-effects. It is the gold standard in patients at high risk of progression. Maintenance BCG is required in order to achieve the best therapeutic results; however, the optimal dose, induction and maintenance schedules, and duration of treatment are unknown and might be different for each patient. Patients failing BCG treatment have a poor prognosis, and cystectomy is then the recommended treatment. Patients at low risk of recurrence and progression should not receive BCG, because of its side effects. Intermediate-risk patients might be treated with either intravesical chemotherapy or BCG; however, for patients at high risk of progression, BCG is recognized as the treatment of choice. Further research is urgently needed to identify markers associated with BCG failure and to develop effective alternatives to cystectomy in patients failing BCG.
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Affiliation(s)
- Richard J Sylvester
- Department of Biostatistics, European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium.
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Sylvester RJ, Brausi MA, Kirkali Z, de Reijke TM. Reply from Authors re: Marko Babjuk. New Insights in Intravesical Treatment for Intermediate- and High-Risk Non–Muscle-Invasive Urothelial Bladder Carcinoma. Eur Urol 2010;57:774–6. Eur Urol 2010. [DOI: 10.1016/j.eururo.2010.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Malmström PU, Sylvester RJ. Reply to Donald Lamm, Andreas Böhle, Joan Palou, et al.’s Letter to the Editor re: Per-Uno Malmström, Richard J. Sylvester, David E. Crawford, et al. An Individual Patient Data Meta-Analysis of the Long-Term Outcome of Randomised Studies Comparing Intravesical Mitomycin C versus Bacillus Calmette-Guérin for Non–Muscle-Invasive Bladder Cancer. Eur Urol 2009;56:247–56. Eur Urol 2010. [DOI: 10.1016/j.eururo.2009.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sylvester RJ, Brausi MA, Kirkels WJ, Hoeltl W, Calais Da Silva F, Powell PH, Prescott S, Kirkali Z, van de Beek C, Gorlia T, de Reijke TM. Long-term efficacy results of EORTC genito-urinary group randomized phase 3 study 30911 comparing intravesical instillations of epirubicin, bacillus Calmette-Guérin, and bacillus Calmette-Guérin plus isoniazid in patients with intermediate- and high-risk stage Ta T1 urothelial carcinoma of the bladder. Eur Urol 2009; 57:766-73. [PMID: 20034729 DOI: 10.1016/j.eururo.2009.12.024] [Citation(s) in RCA: 279] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Accepted: 12/10/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intravesical chemotherapy and bacillus Calmette-Guérin (BCG) reduce the recurrence rate in patients with stage Ta T1 urothelial bladder cancer; however, the benefit of BCG relative to chemotherapy for long-term end points is controversial, especially in intermediate-risk patients. OBJECTIVE The aim of the study was to compare the long-term efficacy of BCG and epirubicin. DESIGN, SETTING, AND PARTICIPANTS From January 1992 to February 1997, 957 patients with intermediate- or high-risk stage Ta T1 urothelial bladder cancer were randomized after transurethral resection to one of three treatment groups in the European Organization for Research and Treatment of Cancer Genito-Urinary Group phase 3 trial 30911. INTERVENTION Patients received six weekly instillations of epirubicin, BCG, or BCG plus isoniazid (INH) followed by three weekly maintenance instillations at months 3, 6, 12, 18, 24, 30, and 36. MEASUREMENTS End points were time to recurrence, progression, distant metastases, overall survival, and disease-specific survival. RESULTS AND LIMITATIONS With 837 eligible patients and a median follow-up of 9.2 yr, time to first recurrence (p<0.001), distant metastases (p=0.046), overall survival (p=0.023), and disease-specific survival (p=0.026) were significantly longer in the two BCG arms combined as compared with epirubicin; however, there was no difference for progression. Three hundred twenty-three patients with stage T1 or grade 3 tumors were high risk, and the remaining 497 patients were intermediate risk. The observed treatment benefit was at least as large, if not larger, in the intermediate-risk patients compared with the high-risk patients. CONCLUSIONS In patients with intermediate- and high-risk stage Ta and T1 urothelial bladder cancer, intravesical BCG with or without INH is superior to intravesical epirubicin not only for time to first recurrence but also for time to distant metastases, overall survival, and disease-specific survival. The benefit of BCG is not limited to just high-risk patients; intermediate-risk patients also benefit from BCG. TRIAL REGISTRATION This study was registered with the US National Cancer Institute clinical trials database [protocol ID: EORTC-30911]. http://www.cancer.gov/search/ViewClinicalTrials.aspx?cdrid=77075&version=HealthProfessional&protocolsearchid=6540260.
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Malmström PU, Sylvester RJ. Rebuttal from Authors re: Guido Dalbagni. Is Intravesical Bacillus Calmette-Guérin Better than Mitomycin for Intermediate-Risk Bladder Cancer? Eur Urol 2009;56:257–8. Eur Urol 2009. [DOI: 10.1016/j.eururo.2009.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sylvester RJ, Oosterlinck W. An Immediate Instillation after Transurethral Resection of Bladder Tumor in Non–Muscle-Invasive Bladder Cancer: Has the Evidence Changed? Eur Urol 2009; 56:43-5. [DOI: 10.1016/j.eururo.2009.03.074] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 03/24/2009] [Indexed: 11/25/2022]
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Malmström PU, Sylvester RJ, Crawford DE, Friedrich M, Krege S, Rintala E, Solsona E, Di Stasi SM, Witjes JA. An individual patient data meta-analysis of the long-term outcome of randomised studies comparing intravesical mitomycin C versus bacillus Calmette-Guérin for non-muscle-invasive bladder cancer. Eur Urol 2009; 56:247-56. [PMID: 19409692 DOI: 10.1016/j.eururo.2009.04.038] [Citation(s) in RCA: 427] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 04/16/2009] [Indexed: 01/18/2023]
Abstract
BACKGROUND Patients with non-muscle-invasive bladder cancer with an intermediate or high risk need adjuvant intravesical therapy after surgery. Based largely on meta-analyses of previously published results, guidelines recommend using either bacillus Calmette-Guérin (BCG) or mitomycin C (MMC) in these patients. Individual patient data (IPD) meta-analyses, however, are the gold standard. OBJECTIVE To compare the efficacy of BCG and MMC based on an IPD meta-analysis of randomised trials. DESIGN, SETTING, AND PARTICIPANTS Trials were searched through Medline and review articles. The relevant trial investigators were contacted to provide IPD. MEASUREMENTS The drugs were compared with respect to time to recurrence, progression, and overall and cancer-specific death. RESULTS AND LIMITATIONS Nine trials that included 2820 patients were identified, and IPD were obtained from all of them. Patient characteristics were 71% primary, 54% Ta, 43% T1, 25% G1, 58% G2, and 16% G3, and 7% had prior intravesical chemotherapy. Based on a median follow-up of 4.4 yr, 43% recurred. Overall, there was no difference in the time to first recurrence (p=0.09) between BCG and MMC. In the trials with BCG maintenance, a 32% reduction in risk of recurrence on BCG compared to MMC was found (p<0.0001), while there was a 28% risk increase (p=0.006) for BCG in the trials without maintenance. BCG with maintenance was more effective than MMC in both patients previously treated and those not previously treated with chemotherapy. In the subset of 1880 patients for whom data on progression, survival, and cause of death were available, 12% progressed and 24% died, and, of those, 30% of the deaths were due to bladder cancer. No statistically significant differences were found for these long-term end points. CONCLUSIONS For prophylaxis of recurrence, maintenance BCG is required to demonstrate superiority to MMC. Prior intravesical chemotherapy was not a confounder. There were no statistically significant differences regarding progression, overall survival, and cancer-specific survival between the two treatments.
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Affiliation(s)
- Per-Uno Malmström
- Uppsala University Hospital, Department of Urology, Uppsala, Sweden.
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Abstract
The use of molecular markers and gene expression profiling provides a promising approach for improving the predictive accuracy of current prognostic indices for predicting which patients with non-muscle-invasive bladder cancer will progress to muscle-invasive disease. There are many statistical pitfalls in establishing the benefit of a multigene expression classifier during its development. First, there are issues related to the identification of the individual genes and the false discovery rate, the instability of the genes identified and their combination into a classifier. Secondly, the classifier should be validated, preferably on an independent data set, to show its reproducibility. Next, it is necessary to show that adding the classifier to an existing model based on the most important clinical and pathological factors improves the predictive accuracy of the model. This cannot be determined based on the classifier's hazard ratio or p-value in a multivariate model, but should be assessed based on an improvement in statistics such as the area under the curve and the concordance index. Finally, nomograms are superior to stage and risk group classifications for predicting outcome, but the model predicting the outcome must be well calibrated. It is important for investigators to be aware of these pitfalls in order to develop statistically valid classifiers that will truly improve our ability to predict a patient's risk of progression.
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Sylvester RJ. Editorial comment on: prognostic factors in patients with non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin: multivariate analysis of data from four randomized CUETO trials. Eur Urol 2007; 53:1002. [PMID: 17950990 DOI: 10.1016/j.eururo.2007.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Sylvester RJ. Intravesical Chemotherapy in Non–Muscle-Invasive Bladder Cancer: What Schedule and Duration of Treatment? Eur Urol 2007; 52:951-3; discussion 953-4. [PMID: 17374437 DOI: 10.1016/j.eururo.2007.03.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2007] [Accepted: 03/09/2007] [Indexed: 11/30/2022]
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Sylvester RJ. The use of intravesical chemotherapy and possibilities for improving its efficacy. Eur Urol 2006; 50:233. [PMID: 18219714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Abstract
Superficial bladder cancer encompasses patients with stage Ta T1 tumors and patients with carcinoma in situ (CIS). The natural history or treatment-related prognosis of these patients varies considerably from one patient to the next based on the patients clinical and the tumor's pathological characteristics. Based on a review of the literature, the most important prognostic factors for recurrence are the prior recurrence rate, number of tumors, and tumor size; whereas for progression, the most important prognostic factors are the T category, grade, and presence of CIS. Treatment with intravesical bacillus Calmette-Guerin reduces both the risk of recurrence and the risk of progression, and is the treatment of choice in high-risk papillary tumors and in patients with CIS. Assessment of a patient's prognostic factors and his or her risk of recurrence and progression is a prerequisite for determining the most appropriate treatment and frequency of follow-up for a given patient.
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Affiliation(s)
- Richard J Sylvester
- European Organisation for Research and Treatment of Cancer Data Center, Brussels, Belgium.
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