Giulianelli Roberto, Gentile Barbara Cristina, Mirabile Gabriella, Albanesi Luca, Tariciotti Paola, Rizzo Giorgio, Buscarini Maurizio, Vermiglio Mauro
CUrA, Nuova Villa Claudia Clinic, Rome.
Arch Ital Urol Androl. 2017 Dec 31;89(4):272-276. doi: 10.4081/aiua.2017.4.272.
Understaging after initial transurethral resection is common in patients with high-risk non muscle infiltrating bladder cancer (NMIBC) and can delay accurate diagnosis and definitive treatment. The rate of upstaging from T1 to T2 disease after repeated transurethral resection ranges from 0 to 28%, although the rate of upstaging may be even higher up to 49% when muscularis propria is absent in the first specimen. A restaging classic transurethral resection of bladder tumour (re-cTURBT) is the better predictor of early stage progression. According to some reports, the rate of positivity for tumor in re-cTURBT performed within eight weeks after initial cTURBT was as high as 18-77%, and in about 40% of the patients a change in tumor stage was reported. We aimed to investigate, in high risk group, the presence of residual tumor following white light classical transurethral resection of bladder tumor (WLre-cTURBT) and the different recurrence and progression rate between patients with persistent or negative (pT0) oncological disease after WLre-cTURBT.
A cohort of 285 patients presenting with primitive bladder cancer underwent to WLcTURBT from January 2011 to December 2015; out of them 92 (32.28%) were T1HG. In according to EAU guidelines 2011, after 4-6 weeks all HG bladder cancer patients underwent a WL recTURBT . All patients were submitted to a subsequent followup including cystoscopy every 3 months with multiple biopsies, randomly and in the previous zone of resection; urinary citology on 3 specimens and kidney/bladder ultrasound every 6 months. The average follow-up was 48 months.
Following WLre-cTURBT we observed a persistent disease in 18 (15.2%) patients: 14 (77.7%) with a HG-NMIBC and 4 (22.2%) with a high grade (HG) muscle invasive bladder cancer (pT2HG). After follow up of all 92 patients according to the guidelines EAU, we observed recurrence in 36/92 (39.1%) and progression in 14/92 (15.2%). Of 14 NMIBC with persistent disease, 10 patients (71.4%) showed recurrence: 4 patients (40%) were pT1HG with concomitant carcinoma in situ (CIS), 3 patients (30%) multifocal pTaHG, 2 (20%) patients CIS and one patient (10%) a muscle invasive neoplasm (pT2HG). Instead of the group of 48 patients pT0 following WL recTURBT, we observed recurrence in 26 patients (54.1%) and in two patients (4.1%) progressions, who presented after 3 months in association with CIS. The remaining 22 patients (45.9%) with initial pT1HG are still progression free. Multivariate analysis showed that the most important variable of early progression were persistent neoplasm and histopathological findings at WLre-cTURBt (p = 0.01), followed by the Summary No conflict of interest declared. INTRODUCTION Bladder cancer is a common genito-urinary malignancy, with transitional cell carcinoma comprising nearly 90% of all primary bladder tumours. At the first diagnosis 70% to 80% of urothelial tumours are confined to the epithelium, the remainder is characterized by muscle invasion. A significant number of patients with high risk non-muscle invasive bladder tumours (HG-NMIBT) treated with white light classic transurethral resection of bladder tumours (WLcTURBT) and intravesical BCG will progress to invasive disease (1-3). Progression to muscle invasion (pT2) mandates immediate radical cystectomy (4). WLcTURBT is the standard initial therapy for NMIBT, but the high percentage of recurrence after surgery is still an unresolved problem (5). High grade pT1 bladder neoplasm (pT1HG) really represents a therapeutic challenge due to the high risk of progression (about 15-30%) to muscle-invasive disease, usually within 5 years (6). However, no consensus exists regarding the treatment of patients with recurrent bladder tumours that invade the lamina propria (pT1) (7-9). Recent studies suggested that the first cTURBT may be incomplete in a significant number of cases (10). Understaging at the time of the initial transurethral resection is common for patients with high-risk NMIBC and can delay accurate diagnosis and definitive treatment. It is therefore recommended for patients with high-risk disease and in those with large or multiple tumors or when the initial transurethral resection is incomplete, to repeat WLre-cTURBT within 2-6 DOI: 10.4081/aiua.2017.4.272 result of the first cystoscopy (p = 0.002) and presence of CIS (p = 0.02).
Following WLre-cTURBt in HG-NMIBC patients we identified in 15% of cases a persistent disease with a 4.3% of MIBC. In the high risk persistent bladder neoplasms group we observed recurrent and progression rate higher than in T0 bladder tumours group (Δ = + 17.3% and = Δ + 62.5%, p < 0.05.
在高危非肌层浸润性膀胱癌（NMIBC）患者中，初次经尿道切除术后分期过低很常见，这可能会延迟准确诊断和确定性治疗。重复经尿道切除术后从T1期进展至T2期疾病的比例为0%至28%，不过，若首次标本中无固有肌层，进展比例可能更高，达49%。再次分期的经典膀胱肿瘤经尿道切除术（re-cTURBT）是早期进展的更好预测指标。根据一些报告，在初次cTURBT后八周内进行的re-cTURBT中，肿瘤阳性率高达18%-77%，约40%的患者报告肿瘤分期有变化。我们旨在研究高危组患者在白光下经典膀胱肿瘤经尿道切除术（WLre-cTURBT）后残留肿瘤的情况，以及WLre-cTURBT后持续性或阴性（pT0）肿瘤疾病患者之间不同的复发和进展率。
2011年1月至2015年12月期间，一组285例原发性膀胱癌患者接受了WLcTURBT；其中92例（32.28%）为T1HG。根据2011年欧洲泌尿外科学会（EAU）指南，4-6周后，所有HG膀胱癌患者均接受了WL reTURBT。所有患者均接受后续随访，包括每3个月进行一次膀胱镜检查并多次随机活检，活检部位为先前的切除区域；对3份标本进行尿液细胞学检查，每六个月进行一次肾脏/膀胱超声检查。平均随访时间为48个月。
WLre-cTURBT后，我们观察到18例（15.2%）患者存在持续性疾病：14例（77.7%）为HG-NMIBC，4例（22.2%）为高级别（HG）肌层浸润性膀胱癌（pT2HG）。根据EAU指南对所有92例患者进行随访后，我们观察到36/92例（39.1%）复发，14/92例（15.2%）进展。在14例有持续性疾病的NMIBC患者中（10例（71.4%）出现复发：4例（40%）为pT1HG伴原位癌（CIS），3例（30%）为多灶性pTaHG，2例（20%）为CIS，1例（10%）为肌层浸润性肿瘤（pT2HG））。在WL reTURBT后pT0的48例患者组中，我们观察到26例（54.1%）复发，2例（4.1%）进展，这2例患者在3个月后出现并伴有CIS。其余22例初始pT1HG患者（45.9%）仍无进展。多变量分析显示，早期进展的最重要变量是WLre-cTURBt时的持续性肿瘤和组织病理学结果（p = 0.01），其次是首次膀胱镜检查结果（p = 0.002）和CIS的存在（p = 0.02）。
在HG-NMIBC患者的WLre-cTURBt后，我们在15%的病例中发现了持续性疾病，其中4.3%为MIBC。在高危持续性膀胱肿瘤组中，我们观察到复发率和进展率高于T0膀胱肿瘤组（差异= + 17.3%，进展差异= + 62.5%，p < 0.05）。
