Positive urinary cytology after tumor resection: an indicator for concomitant carcinoma in situ

Concomitant urothelial atypia (grade II atypia or carcinoma in situ) is predictive of new tumor growth after transurethral tumor resection. Concomitant urothelial atypia can be demonstrated by pre-selected site mucosal biopsies. However, a number of patients have new tumors despite normal pre-selected site biopsies. To investigate whether urinary cytology is a better indicator for concomitant urothelial atypia than pre-selected site biopsies, we studied in bladder tumor patients the correlation between the findings of pre-selected site biopsies (8 per patient) at tumor resection and urinary cytology (2 per patient) after successful resection. Concomitant urothelial atypia was demonstrated by biopsies in 52 per cent of the patients, of whom 60 per cent had grade II atypia and 40 per cent had carcinoma in situ. All patients with concomitant carcinoma in situ in biopsies had positive cytology findings. Of the patients with concomitant grade II atypia in biopsies 15 per cent had negative cytology studies. In 48 per cent of the patients no urothelial atypia in pre-selected site biopsies was demonstrable. However, cytology was positive, that is neoplastic cells were present, in 64 per cent of these specimens (19 patients). Of the 19 patients 16 currently have had demonstrable urothelial atypia in pre-selected site mucosal biopsies at a later occasion. We conclude that urinary cytology seems to be a better indicator for the presence of concomitant urothelial atypia than pre-selected site mucosal biopsies and, therefore, it can be used as a screening procedure for patients without demonstrable concomitant carcinoma in situ at tumor resection.     

The significance of urine cytology three consecutive days after transurethral resection as a predictor of superficial bladder cancer recurrence

To determine whether there was any correlation between recurrence of superficial bladder cancer and the results of urinary cytology examined for 3 consecutive days after transurethral resection of the bladder cancer (TURBT), we retrospectively studied 64 patients with newly diagnosed Ta/T1 transitional cell carcinoma (TCC) of the bladder who had previously undergone TURBT. Urine cytology samples were reported as negative (class I, II) or positive (class III, IV, V). We used the Kaplan-Meier method to calculate the non-recurrence rate, and Cox-proportional hazard models to determine the prognostic significance of clinical and pathological findings. If any sample among the three consecutive cytology examinations was positive, we defined the case as positive. After a mean follow up of 19.5 months, 22 cases (34.4%) demonstrated recurrence probabilities of 24.1% and 42.3%, at 12 and 24 months, respectively. Of the positive cytology group (n = 33), 15 patients (45.5%) had recurrent tumor, while in the negative group (n = 31), only 7 cases (22.6%) developed recurrence. Multivarite analysis demonstrated that tumor size (p = 0.0022, Hazard ratio 8.9316), result of urine cytology for three consecutive days after TUR (p = 0.0051, Hazard ratio 4.5728), and age (p = 0.0124, Hazard ratio 3.7652) were associated with tumor recurrence. We suggest that positive results on urinary cytology for three consecutive days after TUR are indicative for tumor recurrence.     

Limited significance of routine excretory urography in the follow-up of patients with superficial bladder cancer after transurethral resection

OBJECTIVES: To evaluate the utility of routine excretory intravenous urography (IVU) for detecting subsequent upper urinary tract cancer (UUTC) during the follow-up of patients with superficial bladder cancer. PATIENTS AND METHODS: The study included 413 patients who had transurethral resection (TUR) of superficial bladder cancer between January 1986 and December 2003, and were followed for at least 1 year. After TUR, patients were followed by periodic cystoscopy, urinary cytology and IVU. The risk factors for UUT recurrence after TUR were analysed, and based on this outcome, we then determined whether routine IVU should be used for patients with superficial bladder cancer. RESULTS: During the observation period, UUTCs developed in 20 of the 413 patients (4.8%) within a median of 33 months from the initial TUR to the detection of UUTCs. Among several factors examined, only multiplicity was significantly associated with UUT recurrence after TUR. Of the 20 patients with secondary UUTCs, only two, who had multiple superficial bladder cancers at initial presentation, were diagnosed as having UUTCs by routine IVU, while the remaining 18 presented with symptoms suggesting possible UUT recurrence before IVU, including macrohaematuria (10 patients), intravesical recurrence (five), positive urinary cytology (five), abdominal pain (three) and high fever (two). CONCLUSIONS: Most patients with recurrent UUTCs presented with some subjective and/or objective symptoms, and routine IVU failed to detect recurrent diseases in such patients. Therefore, routine IVU may not be required for all patients who have TUR of superficial bladder cancer.     

Urothelial atypia concomitant with primary bladder tumour. Incidence in a consecutive series of 500 unselected patients

A consecutive series of 500 primary bladder tumours from a single clinic is presented, with distribution of the tumours according to T category and histologic type and grade. Mucosal biopsies were obtained from pre-selected sites at initial cystoscopy or initial transurethral resection of the tumour in 396 cases. In 54% of the patients with grade III tumour there was concomitant urothelial atypia, either carcinoma in situ (urothelial atypia grade III, 30%) or urothelial atypia grade II (24%). In 30% of the patients with invasive grade II bladder tumour and in 14% of those with noninvasive grade II tumour there was concomitant urothelial atypia, mostly grade II. Since concomitant urothelial atypia predicts new tumour growth after successful transurethral surgery or radiotherapy, mucosal biopsies should be performed at preselected sites during initial cystoscopy or transurethral tumour resection in order to identify high-risk patients.     

Long term follow-up of superficial invasive bladder carcinoma with or without concomitant epithelial atypia--recurrence and progression

OBJECTIVE: To examine the significance of concomitant epithelial atypia on late recurrence and progression by long-term follow-up of superficial invasive bladder tumours (stage T1). MATERIAL AND METHODS: Seventy consecutive, unselected patients with newly diagnosed transurethral resection (TURB)-treated stage T1 bladder tumour, and at least 1 year progression-free survival. Preselected site biopsies (PSB) were obtained prospectively to evaluate the significance of concomitant urothelial atypia. Followed for up to 17.6 years. RESULTS: The cumulative probability of recurrence (overall) was 85%, and for new stage T1 tumour 70% after 10 years. Forty per cent of those who survived 5 years without recurrence, were readmitted with often invasive recurrence later. Positive PSB significantly (p < 0.0001) predicted new T1 tumour. Progression (T2+ or metastases) occurred in 27 cases (39%) after the first year. The cumulative probability was 60% (15 years), with a mean progression-free interval of 64 months. Positive PSB, size >3 cm and early recurrence were significant predictive factors in multivariate analysis. CONCLUSION: T1-tumours are at high risk for late invasive recurrence and progression, especially if associated with urothelial atypia elsewhere in the bladder.     

The value of a second transurethral resection for T1 bladder cancer

OBJECTIVE: To evaluate a series of repeat transurethral resections (TURs) of tumour in patients with T1 bladder cancer, usually used to ensure a complete resection and to exclude the possibility muscle-invasive disease. PATIENTS AND METHODS: In all, 136 consecutive patients had a second TUR because of a histopathological diagnosis of T1 transitional cell carcinoma (TCC) after their initial TUR. Of the 136 patients, 101 were first presentations and 35 had recurrent tumours. The second TUR was done 4-6 weeks later. The evaluation included the presence of previously undetected residual tumour, changes to histopathological staging/grading, and tumour location. RESULTS: In all, 71 patients (52%) had residual disease according to findings from specimens obtained during the second TUR. The staging was: no tumour, 65 (48%); Ta, 11 (8%); T1, 32 (24%); Tis, 15 (11%); and > or = T2, 13 (10%). Histopathological changes that worsened the prognosis (>T1 and or concomitant Tis) were found in 21% of patients. Residual malignant tissue was found in the same location as the first TUR in 86% of the patients, and at different locations in 14%. Overall, 28 patients (21% of the original 136) had a radical cystectomy as a consequence of the second TUR findings. CONCLUSIONS: A routine second TUR should be advised in patients with T1 TCC of the bladder, to achieve a more complete tumour resection and to identify patients who should have a prompt cystectomy.     

Telomerase activity in urine after transurethral resection of superficial bladder cancer and early recurrence

BACKGROUND: To explore the relationship between telomerase activity in urine after transurethral resection (TUR) of superficial bladder cancer and early intravesical recurrence. METHODS: Urine samples were obtained from 42 patients with superficial bladder cancers prior to TUR and on the postoperative day 1 and day 6. These patients were followed-up prospectively by cystoscopy at 3 and 6 months after TUR in combination with urinary cytology and telomerase activity. Telomerase activity in the urine was assessed by the telomeric repeat amplification protocol assay. RESULTS: Urinary telomerase activity prior to TUR was positive in 24 (57%) of the 42 patients. On the postoperative day 1 and day 6, positive urinary telomerase activity was seen in 13 (31%) and nine (21%) patients, respectively. Postoperative urinary telomerase activity on either day 1 or day 6 was significantly associated with pre-operative urinary telomerase activity status (P = 0.0024). Fifteen patients showed intravesical tumor recurrence at 3 months cystoscopic check-up and an additional nine had recurred at the 6 months check-up. Recurrence rate within 6 months in patients with pre-operative positive urinary telomerase activity was similar to that in those with negative activity (58.3 vs 58.8%). However, recurrence rate at 3 months for patients with positive activity was higher than that of those with negative activity (50 vs 17.7%), in 23 patients treated only by TUR. CONCLUSIONS: Presence of cells positive for telomerase activity in urine after TUR of superficial bladder cancer indicates persistently existing cancer cells in the urine. It is, however, not a sole predictor of the early intravesical recurrence.     

The role of exfoliative cytology in the management of bladder carcinoma

Summary Cytological analyses of bladder washings from 974 patients with disorders of the urinary tract are reported. The cytological findings were compared with the clinical and histological diagnoses. The histological grading of bladder tumours was based on the classification proposed by Bergkvist et al. No false positive diagnosis of malignancy was made in the 320 patients without tumour growth. The five cases with positive cytology had histologically verified carcinoma in situ. The frequency of cytological diagnosis of cancer increased with the histological grade of malignancy in the 428 patients with bladder neoplasm. Carcinoma was graded in smears according mainly to the degree of epithelial atypia. A comparison with the histological grading was attempted. Of 226 cases of bladder carcinoma treated with supervoltage irradiation, 108 had persistence or recurrence of carcinoma. The clinical diagnosis was cytologically confirmed in 92 per cent of these cases.     

Histopathological and immunohistochemical study of papillary urothelial neoplasms of low malignant potential and grade associated with extensive invasive low-grade urothelial carcinoma

OBJECTIVE: To report five cases of papillary urothelial neoplasm of low malignant potential (UNLMP) and papillary urothelial carcinoma of low grade (UCLG) associated with extensive muscle invasion, and to investigate the clinical and histopathological presentation and their immunohistochemical properties. MATERIALS AND METHODS: Consecutive cystectomy and correlating transurethral resection (TUR) of urinary bladder tumour specimens were reviewed to identify cases of UCLG having extensive invasion into the urinary bladder wall. All specimens were stained immunohistochemically, as were those from 10 control cases having reactive urothelium or superficial UNLMP. The clinical charts were reviewed. RESULTS: Of a total of 95 cystectomy cases there were four of UNLMP or UCLG with extensive invasion. An additional case was added from our consultation file. All five cases had biopsies misdiagnosed as benign lesions or prostatic adenocarcinoma. The superficial invasive components consisted of UCLG conforming to the previously described entities of nested transitional cell carcinoma (TCC), microcystic or deceptively benign-appearing TCC. Immunostaining for cytokeratin 20, MIB-1 and p53 was similar to reactive epithelia, whereas E-cadherin immunoreactivity was slightly different, with focal negativity compared with extensive immunoreactivity in invasive vs noninvasive UCLG. Four patients developed distant metastases; three died within a follow-up of 3 years. CONCLUSIONS: UNLMP and UCLG that widely and deeply invade the bladder accounted for 4% of urothelial carcinoma (UC) in cystectomy specimens and commonly pose diagnostic problems in superficial TUR specimens. From this study with few cases the diagnosis of this entity in superficial biopsies is aided by an awareness of it and by identifying 'benign appearing' nests of urothelial cells which are deeply seated in the stroma. Immunostaining is unlikely to be very useful.     

二次电切治疗单发广基型T1G3期膀胱尿路上皮癌临床分析

目的探讨经尿道膀胱肿瘤二次电切术（二次电切）治疗单发广基型T1G3期膀胱尿路上皮癌的临床疗效。方法分析我院收集并随机分组的46例T1G3期膀胱尿路上皮癌患者资料。其中21例作为实验组于首次电切后4～6周行二次电切,明确有无肿瘤残留及确切的临床分期。与未接受二次电切患者（对照组）进行复发率、疾病进展率及无复发生存率的比较。结果两组患者性别、年龄、随访时间、肿瘤体积等的差异均无统计学意义（均为P〉0．05）．21例行二次电切的患者中,术后病理证实有肿瘤残余8例（38．1％）,3例（14．3％）临床分期升高。术后平均随访时间（34±6．2）个月,对照组1年、3年、总复发率分别是：54．55％（12／17）、88．89％（16／18）、68％（17／25）;疾病进展率：70．59％（12／17）;实验组1年、3年、总复发率分别是：15．79％（3／19）、42．86％（6／14）、38．10％（8／21）;疾病进展率：37．5％（3／8）。二组相比,1年、3年、总复发率（Х^2=6．60,P〈O．05;P〈0．01;Х^2=4．11,P〈0．05）;疾病进展率（P=0．026）、无复发生存率（Х^2=7．28,P〈0．05）比较,差异均有统计学意义。结论二次电切可以降低T1G3期膀胱尿路上皮癌肿瘤残留率,并可以减少肿瘤的复发率、疾病进展率及改善无复发生存率。     

Restaging transurethral resection of high risk superficial bladder cancer improves the initial response to bacillus Calmette-Guerin therapy

PURPOSE: This study was an evaluation of whether restaging transurethral resection (TUR) of superficial bladder cancer improves the early response to bacillus Calmette-Guerin (BCG) therapy. MATERIALS AND METHODS: A total of 347 patients with high risk superficial bladder cancer (high grade Ta and T1 tumors associated with carcinoma in situ) underwent a single transurethral resection (TUR, 132 patients) or restaging TUR (215 patients) before receiving 6 weekly intravesical BCG treatments. The patients were evaluated for response (presence or absence of tumor) at first followup cystoscopy, at 6 and 12 months after treatment, and evaluated for disease stage progression within 3 years of followup. RESULTS: Of the 132 patients who underwent a single TUR before BCG therapy, 75 (57%) had residual or recurrent tumor at the first cystoscopy and 45 (34%) later had progression, compared with 62 of 215 patients (29%) who had residual or recurrent tumors and 16 (7%) who had progression after undergoing restaging TUR (p = 0.001). CONCLUSIONS: Restaging TUR of high risk superficial bladder cancer improves the initial response rate to BCG therapy, reduces the frequency of subsequent tumor recurrence and appears to delay early tumor progression.     

Urothelial atypia and survival rate of 500 unselected patients with primary transitional-cell tumour of the urinary bladder

In a consecutive series of 500 unselected patients with primary urinary bladder tumours the influence of urothelial atypia on the 5 years survival-rate was examined. All tumours were transitional-cell tumours categorized according to the T-classification. Mucosal biopsies from 7 pre-selected sites were taken at the initial cystoscopy in 391 patients (78%) to identify urothelial atypia. The over-all cumulative 5 years survival-rate was 48%. Submucosal and muscle invasion had major influence on survival, whereas tumour grade was less important. Patients with urothelial atypia fared significantly worse than those with normal bladder mucosa (5 years survival 42% versus 62%). This difference in survival-rate became apparent first after two years of observation. Grade II atypia in the bladder mucosa and grade III (carcinoma in situ) had equal significance assessed by the survival-rates.     

Residual tumour in the marginal resection after a complete transurethral resection is associated with local recurrence in Ta/T1 urinary bladder cancer

Abstract Objective. This study investigated the presence of residual tumour in the marginal resection (MR) after a complete transurethral resection (TURB) of Ta/T1 transitional urinary bladder cancer. The association between positive MR and recurrence was analysed. Material and methods. After macroscopically complete TURB, a marginal resection of 7 mm (corresponding to the diameter of the resection loop) was removed around the entire resection area. Univariate and multivariate Cox regression analyses were performed to assess the influence of residual disease on recurrence. Results. In all, 94 patients with a median follow-up time of 36 months were included, and residual tumour in the MR was present in 24 (26%). The recurrence rates for all cases, for those with a tumour-positive and a tumour-free MR were 60 (64%), 20 (83%) and 40 (57%), respectively. Local recurrence was found in 14 (58%) of the patients with tumour presence in the MR compared to 13 (19%) of those with a tumour-free margin. A positive MR was significantly associated with overall recurrence (p < 0.001) and local recurrence (p = 0.001). Conclusion. Incomplete transurethral resection of bladder cancer is common, as demonstrated in 26% patients with positive MR. The presence of tumour in the MR may be a risk factor for recurrence, and particularly local recurrence.     

Quantitative molecular urinary cytology by fluorescence in situ hybridization: a tool for tailoring surveillance of patients with superficial bladder cancer?

OBJECTIVE: To determine whether it is possible to stratify patients with superficial bladder cancer into low- and high-risk groups for tumour recurrence/progression based on the chromosomal pattern detected by fluorescence in situ hybridization (FISH) in one urine cytology specimen used for follow-up testing. PATIENTS AND METHODS: Voided urine samples from 47 consecutive patients with urinary tract neoplasms (13 with no history of urothelial malignancy and 34 under follow-up after complete transurethral resection of superficial urothelial carcinoma of the bladder) were evaluated by liquid-based cytology (ThinPrep(R), CYTYC Corp., Boxborough, MA, USA) and UroVysion FISH (Vysis-Abbott, Downers Grove, IL). RESULTS: Of the 34 patients under surveillance, the UroVysion test was negative in four, 17 had loss of 9p21 sequences either alone or combined with low-frequency trisomy/ies or tetrasomy/ies of chromosomes 3, 7 and 17 in single cells (low-risk FISH), and 13 also had complex aneusomies of the remaining chromosomes (high-risk FISH). One of the four FISH-negative neoplasms, four of the 17 low-risk FISH cases and five of the 11 informative high-risk FISH-positive patients developed recurrence. Progression occurred only in patients with high-risk FISH results, showing high-frequency complex chromosomal polysomies (four of 11). CONCLUSION: The results from this pilot study indicate that the UroVysion FISH test may help to individually assess the clinical behaviour of superficial bladder cancer, based on the chromosomal pattern of exfoliated tumour cells in follow-up urinary cytology. It might be of use to identify those patients likely to progress at earlier and curable stages of disease, and lengthen the surveillance period in those with persistent or recurrent low-risk disease.     

5-aminolaevulinic acid-induced fluorescence cystoscopy during transurethral resection reduces the risk of recurrence in stage Ta/T1 bladder cancer

OBJECTIVE: To assess the influence of 5-aminolaevulinic acid-induced fluorescence cystoscopy (FC) during transurethral resection (TUR) on the recurrence rate and the length of tumour-free interval in stage Ta/T1 transitional cell carcinoma (TCC) of the urinary bladder. PATIENTS AND METHODS: In all, 122 patients with primary or recurrent stage Ta/T1 bladder TCC treated with TUR were enrolled in a prospective randomized study. In group A the TUR was performed with standard white-light endoscopy, and in group B with FC. The patients were followed using standard cystoscopy and urinary cytology. The recurrence-free interval was evaluated in whole groups, for single and multiple, and for primary and recurrent tumours separately. RESULTS: At the time of the first cystoscopy (10-15 weeks after TUR) tumour recurrence was detected in 23 of 62 patients (37%) in group A, but only in five of 60 patients (8%) in group B. The recurrence-free survival rates in group A were 39% and 28% after 12 and 24 months, compared to 66% and 40% respectively in group B (P = 0.008, log-rank test). In separate analyses, the recurrence-free survival rates were significantly higher using FC in multiple (P = 0.001) and in recurrent (P = 0.02) tumours. In solitary and primary tumours the median time to recurrence was also longer in group B, but the difference was not statistically significant. CONCLUSION: 5-aminolaevulinic acid-induced FC during TUR reduces the recurrence rate in stage Ta/T1 bladder TCC. The most significant benefit is in patients with multiple and recurrent tumours.     

A re-staging transurethral resection predicts early progression of superficial bladder cancer

OBJECTIVE: To determine whether pathology on a re-staging transurethral resection (TUR) predicts the early progression of superficial bladder cancer. PATIENTS AND METHODS: In all, 710 patients presenting with multiple superficial bladder cancers were evaluated by re-staging TUR and followed for 5 years. Tumours were classified by stage as confined to mucosa (Ta) or invading submucosa (T1), and by grade (low- or high-grade). Pathology on re-staging TUR was correlated with the endpoints of tumour recurrence and stage progression. RESULTS: Of the 710 patients, 490 (69%) had a recurrence and 149 (21%) progressed over 5 years. Eighty patients had high-grade invasive (T1G3) cancer on re-staging TUR and 61 (76%) progressed to muscle invasion (median time to progression 15 months), compared with 88 of 630 (14%) who had no evidence of tumour (T0) or other than T1 tumours detected on re-staging TUR. CONCLUSION: A re-staging TUR identifies patients with superficial bladder cancer who are at high risk of early tumour progression.     

Is a second transurethral resection necessary for newly diagnosed pT1 bladder cancer?

PURPOSE: We evaluated the potential benefit of a second transurethral resection in patients with newly diagnosed pT1 transitional cell carcinoma of the bladder. MATERIALS AND METHODS: Between January 2001 and May 2003, 80 patients with stage T1 bladder cancer were included in this protocol in which all patients prospectively received second TUR within 2 to 6 weeks following the initial resection. Patients with incomplete resections were excluded from study. The pathological findings of the second TUR were reviewed. RESULTS: Of the 80 patients who underwent second resection, 18 (22.5%) had macroscopic tumors before resection. However, with the addition of microscopic tumors, overall residual disease was determined in 27 (33.8%) patients. Of the 27 patients 7 had pTa, 14 had pT1, 3 had pT1+pTis and 3 had pT2 disease. Residual cancers were detected in 5.8%, 38.2% and 62.5% in G1, G2 and G3 tumors, respectively. The risk of residual tumor directly correlated with the grade of the initial tumor (p = 0.009). CONCLUSIONS: Although second TUR dramatically changed the treatment strategy in a small percentage of cases, we strongly recommend performing second TUR in all cases of primary pT1 disease, especially in high grade cases.     

Bladder preservation by chemoradiotherapy in combination with radical TUR-Bt in muscle invasive bladder cancer

PURPOSE: To evaluate bladder preservation protocol by radical TUR-Bt and subsequent concurrent chemoradiotherapy in muscle invasive bladder cancer. PATIENTS AND METHODS: Twenty-six patients with muscle invasive bladder cancer (T2-T4NOM0) were treated with concurrent chemoradiotherapy after transurethral resection of the tumor as much as possible beyond muscle layers. Chemotherapy was consisted of systemic administration of methoterexete (30 mg/m2 day 1 and day 22) and intraarterial infusion of cisplatin (70 mg/m2, day 2 and day 23). The response was evaluated by TUR, urine cytology, CT and/or MRI 4 to 6 weeks after the treatment. RESULTS: Among 24 evaluable cases, pathological complete response was achieved in 13 cases (50%) and residual tumors were noted in 11 cases (pT1 in 9 and pT2 in 2). During follow-up period up to 69.8 months, invasive recurrence was observed in 2 cases, superficial recurrence was noted in 5 patients and distant metastasis without evidence of local recurrence was noted in 4 cases. Overall bladder preservation rate was 92%. CONCLUSIONS: The bladder preservation by radical TUR-Bt and chemoradiotherapy is a safe and effective treatment option for muscle invasive bladder cancer.     

Narrow band imaging for detecting residual/recurrent cancerous tissue during second transurethral resection of newly diagnosed non‐muscle‐invasive high‐grade bladder cancer

Study Type – Diagnostic (case series)
Level of Evidence 4

OBJECTIVE

To determine if narrow‐band imaging (NBI) can be used to detect high‐grade cancerous lesions missed with the white light at the time of a second transurethral resection (TUR) of high‐grade non‐muscle‐invasive bladder cancer (NMIBC).

PATIENTS AND METHODS

Consecutive patients with newly diagnosed high‐grade NMIBC were enrolled in a prospective observational study. Patients with incomplete resection or absence of muscle tissue in the specimen were excluded. About 1 month after the first TUR, NBI cold‐cup biopsies were taken from areas suspicious for urothelial cancer at the end of an extensive white‐light second TUR protocol including: (i) resection of the scar of the primary tumour; (ii) resection of any overt or suspected urothelial lesions; and (iii) six random cold‐cup biopsies of healthy mucosa.

RESULTS

In 2008, 47 consecutive patients were recruited after giving written consent (median age 62 years, range 49–83, 39 men and eight women). Nine patients (19%) had macroscopic or microscopic high‐grade NMI urothelial cancer, whereas one was reassessed as having muscle‐invasive disease at the white‐light second TUR plus the six random biopsies. NBI biopsies were taken in 40 of the 47 patients and detected six more patients with high‐grade cancerous tissue (13%). In all 16 of the 47 patients (34%) were found to have residual/recurrent cancer using our extensive protocol of second TUR followed by NBI biopsies.

CONCLUSIONS

Adding NBI biopsies at the end of an extensive second TUR protocol in patients with newly diagnosed high‐grade NMIBC can lead to the identification of patients with otherwise missed high‐grade residual/recurrent urothelial carcinoma.     

Urinary fibronectin as a predictor of a residual tumour load after transurethral resection of bladder transitional cell carcinoma

OBJECTIVE

To determine whether the level of urinary fibronectin predicts the residual tumour load after transurethral resection (TUR) of bladder transitional cell carcinoma (TCC).

PATIENTS AND METHODS

Urine samples were collected from 167 consecutive patients with suspected bladder cancer admitted for TUR. Samples were taken both before and after surgery. Bladder tumour fibronectin (BTF) was analysed using a solid‐phase chemiluminescent immunometric test. Creatinine in urine was also determined and the BTF/creatinine ratio calculated.

RESULTS

Patients were divided into a control group of 41 whose previous diagnosis was negative for BT and another of 126 with a positive diagnosis for BT, which was further subdivided into those with and without residual tumour, according to findings from specimens obtained during the second procedure (repeat TUR or cystectomy). After the second procedure, 68 patients (56%) had no residual tumour, whereas 54 (44%) did. Four patients with BT who did not have the second procedure were excluded from the study. The median BTF and BTF/creatinine value in the control group was 33.2 µg/L and 51.4 µg/g, respectively, before the first TUR, and 29.6 µg/L and 46.7 µg/g, respectively, after the first TUR. There were no statistically significant changes in BTF and BTF/creatinine ratio (P = 0.61 and 0.79, respectively). In the group with TCC, the BTF decreased from 211.9 to 97.3 µg/L (P = 0.02) and the BTF/creatinine ratio from 281.6 to 146.5 µg/g (P = 0.009) for those with residual tumour, while it decreased from 195.1 to 34.0 µg/L (P = 0.007) and the BTF/creatinine ratio decreased from 249.1 to 53.7 µg/g (P = 0.003) for those with no residual tumour. After initial TUR, the patients with residual tumour had significantly greater levels of BTF and BTF/creatinine than did those with no residual tumour (P = 0.004 and 0.006, respectively). The receiver operating characteristic curves showed an optimum threshold of 67.8 µg/L and 81.3 µg/g for BTF and the BTF/creatinine in detecting residual tumour, respectively, with a sensitivity of 91.4% and 89.0%, respectively, and a specificity of 87.8% and 85.6%, respectively.

CONCLUSION

Urinary fibronectin, in addition to being one of the best markers for diagnosing bladder carcinoma, can be used to determine the presence of residual tumour load after TUR of bladder TCC.