Is radical cystectomy mandatory in every patient with variant histology of bladder cancer

Abstract

Urothelial carcinomas have an established propensity for divergent differentiation. Most of these variant tumors are muscle invasive but not all. The response of non muscle invasive variant tumors to intravesical immunotherapy with BCG is not established in the literature, and is reported here. Between June 1995 and December 2007, 760 patients (mean age of 67.5 years) underwent transurethral resection of first time bladder tumors in our institution. Histologically variant tumors were found in 79 patients (10.4%). Of these 57 patients (72%) of them had muscle-invasive disease or extensive non-muscle invasive tumors and remaining 22 patients (28%) were treated with BCG immunotherapy. These included 7 patients with squamous differentiation, 4 with glandular, 6 with nested, 4 with micropapillary and 1 patient with sarcomatoid variant. The response of these patients to immunotherapy was compared with that of 144 patients having high-grade conventional urothelial carcinomas. Median follow-up was 46 months. The 2 and 5-year progression (muscle-invasion) free survival rates were 92% and 84.24% for patients with conventional carcinoma compared to 81.06% and 63.16% for patients with variant disease (P=0.02). The 2 and 5-year disease specific survival rates were 97% and 91.43% for patients with conventional carcinoma compared to 94.74 % and 82% for patients with variant disease (P=0.33). 5 patients (22.7%) of variant group and 13 patients (9.03%) of conventional group underwent cystectomy during follow-up (P=0.068).Patients with non-muscle invasive variants of bladder cancers can be managed with intravesical immunotherapy if tumor is not bulky (>4 cm). Although progression to muscle invasive disease is more common than in conventional group and occurs in about 40% of the patients, life expectancy is similar to patients with conventional high-grade urothelial carcinomas provided that follow-up is meticulous.

Impact of divergent differentiation in urothelial carcinoma on oncological outcome in patients with T1 high-grade bladder cancer

“…Few reports to date have described the association of divergent differentiation with oncological outcomes in patients with T1-HG bladder cancer. In a study by Shapur et al [16], 22 patients with divergent differentiation treated with BCG therapy had significantly worse 5-year PFS with a shorter median time to progression than did patients with a pure UC counterpart, although RFS and CSS were not significantly different. Their data partially support our results that divergent differentiation was associated with a worse PFS.…”

The association between variant urothelial histologies, pathological stage and disease specific survival in patients with bladder cancer

“…Meanwhile, the rate of MIBC was 52.5% in patients with PUH; whereas this rate was over 70% in all other non-urothelial VHs. Similarly, Shapur et al [11] found that 57 (72%) of 79 patients with VH were found to have MIBC; whereas patients with VH were only 10.4% of the study cohort. Moreover, 5-year muscle invasion free survival rates were 84.4% and 63.1% (p=0.02) for patients with PUH vs. VH.…”

Yüksek Riskli Kasa İnvaze Olmayan Mesane Kanserinde Erken Sistektomi mi yoksa Mesane Koruyucu Tedavi mi Tercih edelim?

“…Bu açıdan rezeksiyonun ve patolojik değerlendirmenin standardizasyonu şarttır. Bu konu üzerinde yapılmış çalışmalarda ilk TUR materyali muskularis propria içerse dahi re-TUR veya ilk TUR sonrası radikal sistektomide evre yükselmesi oranları %20-%30 arasında bulunmuştur (6,7). Patoloji uzmanları arasındaki değişkenliği inceleyen Avrupa Onkolojik Araştırmalar Birliği'nin (EORTC) 1400 hastanın verilerini inceledikleri çalışmalarında ise ilk TUR patolojisi T1G3 transizyonel hücreli karsinom (TCC) olan hastaların sadece %50'sinin tanısı üzerinde uzlaşılmış ve kalan yarısının ise düşük veya yüksek evreli olduğu tespit edilmiştir (8).…”

“…Bunun nedeni tanı kısmında da bahsedildiği üzere re-TUR'un ilk TUR patoloji sonucunun çoğunlukla da evresini yükseltmesi ve böylece daha doğru bir tanı sağlamasının yanında rezidü tümörü belirleme ve tedavi etme olanağı vermesi ve böylece sağ kalıma katkı sağlamasıdır (6,7,8). Bununla ilgili yapılan önemli bir çalışmada TUR+MMC ile TUR+MMC+re-TUR hastalarının randomize edildiği Divrik ve ark.…”