CAN URINE BOUND DIAGNOSTIC TESTS REPLACE CYSTOSCOPY IN THE MANAGEMENT OF BLADDER CANCER?

Purpose

We compare the diagnostic value of NMP22 [dagger] and BTA stat [double dagger] testing, and QUANTICYT [section] computer assisted dual parameter image analysis to cytology and cystoscopy in patients who had symptoms suggestive of transitional cell cancer or were being followed after treatment for that disease.[dagger] Matritech, Inc., Newton, Massachusetts.[double dagger] Bard Diagnostics, Redmond, Washington.[section] Gentian Scientific Software, Niawier, The Netherlands.

Materials and Methods

We prospectively evaluated voided urine and/or barbotage specimens from 291 patients a mean of 65.2 years old. All voided urine samples were evaluated by quick staining and standard cytology, the BTA stat 1-step qualitative assay (which detects a bladder tumor associated antigen) and the NMP22 test (which detects a nuclear mitotic apparatus protein). In addition, barbotage specimens were evaluated by QUANTICYT computer assisted dual parameter image analysis. All patients underwent subsequent cystoscopy and biopsy evaluation of any suspicious lesion. Sensitivity, specificity, and the predictive value of positive and negative results were determined in correlation with endoscopic and histological findings.

Results

In 91 patients with histologically proved transitional cell carcinoma overall sensitivity was 48, 57, 58, 59 and 59% for the NMP22 test, the BTA stat test, rapid staining cytology of barbotage samples, rapid staining cytology of voided urine specimens and image analysis, respectively. For histological grades 1 to 3 underlying transitional cell carcinoma sensitivity was 17, 61 and 90% for urinary cytology, 48, 58 and 63% for the BTA stat test, and 52, 45 and 50% for the NMP22 test, respectively. Specificity was 100% for cytology, 93% for image analysis, 70% for the NMP22 test and 68% for the BTA stat test.

Conclusions

Immunological markers are superior to cytological evaluation and image analysis for detecting low grade transitional cell carcinoma but they have low specificity and sensitivity in grade 3 transitional cell carcinoma. Urine bound diagnostic tools cannot replace cystoscopy.     

DOES PROSTATE TRANSITIONAL CELL CARCINOMA PRECLUDE ORTHOTOPIC BLADDER RECONSTRUCTION AFTER RADICAL CYSTOPROSTATECTOMY FOR BLADDER CANCER?

Purpose

We determined if urethral preservation and orthotopic bladder replacement in patients with transitional cell carcinoma within the prostatic urethra or prostate placed these patients at risk for urethral recurrence or death.

Materials and Methods

The clinical course of all patients undergoing urethral preservation and orthotopic bladder replacement was reviewed. The urethra was sacrificed only if the distal prostatic urethral margin was positive for transitional cell carcinoma. The pathological T stage and the grade of the primary malignancy, local recurrence, site of recurrence (urethral, pelvic, distant) and death were documented.

Results

Of 81 patients, 70 were evaluated (June 1996) with a mean followup of 35 months. Of the 70 patients 48 were alive without evidence of disease for a mean of 38 months (range 8 to 107) and 5 died without evidence of disease. Eight of these 53 patients (15%) had prostatic involvement (carcinoma in situ in 6, intraductal carcinoma in 1 and stromal invasive transitional cell carcinoma in 1). Of the 70 patients 17 had disease recurrence (13 died of disease and 4 are alive, 1 of whom had urethral recurrence without initial prostatic transitional cell carcinoma). Of the 17 patients (35%) 6 had transitional cell carcinoma prostatic involvement (carcinoma in situ in 4 and stromal invasion in 2), and 5 of these 6 died, none with or of urethral recurrence but of the primary bladder pathology. Of these 5 patients 1 had stromal invasive transitional cell carcinoma of the prostate and experienced a bulbar urethra recurrence at 1 month and a pelvic recurrence at 3 months, and died at 5 months. Death was not secondary to the urethral recurrence. Thus, of the 14 patients who had prostatic transitional cell carcinoma, only 1 had urethral recurrence (7%), and this recurrence did not present as the cause of death.

Conclusions

The guidelines for urethral resection can be relaxed, increasing the opportunities for orthotopic reconstruction, without placing the patients at increased risk for death of transitional cell carcinoma.     

DOES BODY MASS INDEX AFFECT SURVIVAL OF PATIENTS UNDERGOING RADICAL OR PARTIAL CYSTECTOMY FOR BLADDER CANCER?

PURPOSE: Obesity is estimated to account for up to 20% of all cancer deaths. We evaluated the effect of body mass index (BMI) on survival in patients undergoing radical or partial cystectomy for bladder cancer. MATERIALS AND METHODS: Pathological and medical records on 300 consecutive patients undergoing radical or partial cystectomy for invasive bladder cancer between January 1990 and December 1993 were reviewed. The standard WHO definition of BMI was used, that is normal weight-less than 25 kg/m, overweight-25 to 29.9 kg/m and obesity-30 kg/m or greater. Sufficient data were available on 288 of 300 patients (96%) with cystectomy (radical in 264 and partial in 24) for analysis. RESULTS: The BMI distribution was normal weight in 34% of patients, overweight in 41% and obesity in 25%. Mean followup was 53.4 months (median 39, range 1 to 168). Median overall survival was 43.0 months (95% CI 37.1 to 58.4), while median disease specific survival was 82.5 months (95% CI 50.0 to 127.5). Multivariate analysis revealed that age greater than 65 years, pathological stage, smoking history and soft tissue margin status as significant factors impacting overall survival (p <0.05). Pathological stage was organ confined (less than pT3a) in 51% of cases. BMI was not associated with disease specific survival as a continuous (p = 0.17) or categorical (p = 0.51) variable. Although it was insignificant, unadjusted analysis showed lower disease specific mortality in patients with a BMI of less than 25 mg/kg and organ confined disease (p = 0.08). CONCLUSIONS: There was no significant association between BMI and overall or disease specific survival, although there may be a trend toward better disease specific survival in normal weight (BMI less than 25 kg/m) patients with organ confined disease (p = 0.08).     

BLADDER TUMOURS: TIME FOR A PARADIGM SHIFT?

The results for many types of cancers have improved during later decades but not so for bladder cancer. Most patients with muscle-invasive tumors will still succumb to the disease and a high recurrence rate characterises non-muscle invasive tumors.The objective is to critically review the present model of bladder cancer based on newly acquired biological data. The definition of bladder cancer has extended with the introduction of the WHO classification. The corresponding loss of distinction between benign tumor and cancer has not been rewarding and should be reintroduced to facilitate exploration of new molecular findings. The common endpoints recurrence and progression should be redefined or replaced by more appropriate endpoints. The concept of surgery only for locally advanced cancers has proven unsuccessful and has to be complemented with early administered systemic treatment.     

IS SURVEILLANCE NECESSARY FOR INVERTED PAPILLOMA IN THE URINARY BLADDER AND URETHRA?

BACKGROUND: A case series of inverted papilloma of the urinary bladder and urethra is presented, together with a review of the literature with respect to multiplicity, recurrence rate and association with transitional cell carcinoma, and a discussion on surveillance of the lesion. METHODS: Cases of inverted papilloma of the lower urinary tract in a single centre were reviewed. Patient and tumour characteristics, recurrence and associated transitional cell carcinoma are reported. RESULTS: Twenty patients were included (18 male, two female). The mean age was 60.8 years (range 35-78 years). All had solitary tumours ranging from 3 mm to 30 mm in size. Median cystoscopic follow up was 30 months (range 2-140 months). There was no recurrence. One patient was associated with subsequent transitional cell carcinoma 44 and 76 months later. Together with the present 20 cases, review of the English literature with respect to inverted papilloma of the lower urinary tract identified a total of 322 cases reported, with a recurrence rate of 3.85%. Moreover, 1.55%, 5.90% and 1.54% were associated with previous, simultaneous and subsequent transitional cell carcinoma, respectively. CONCLUSIONS: Recurrence is not uncommon and risk of subsequent transitional cell carcinoma is not rare, such that non-invasive surveillance with flexible cystoscopy is recommended for inverted papilloma of the lower urinary tract.     

GALL BLADDER POLYPS IN SCLEROSING CHOLANGITIS: DOES THE 1‐CM RULE APPLY?

INTRODUCTION: Polyps of the gall bladder (PLG) are common findings in radiological investigations of the gall bladder and most are benign although carcinoma of the gall bladder can arise in PLG. In the general population PLG less than 1 cm in diameter are thought to have a low risk of malignancy and can be cautiously observed. METHODS: All patients undergoing surgical resection for gall bladder cancer were entered into a prospective database. Four patients with primary sclerosing cholangitis (PSC) presenting with gall bladder cancer in a PLG are studied. RESULTS: Four patients (two men; median age 46.5 years, range 37-71 years) presented with PLG and known histories of PSC. All patients were shown to have PLG of size between 7 mm x 8 mm and 25 mm x 14 mm on imaging with no radiological evidence of carcinoma. Tumour markers carcinoembryonic antigen and CA19-9 were within the normal range in all patients. All patients were managed with cholecystectomy. Two patients with T1 tumours remain alive and well at 2 and 4 years post-cholecystectomy. Of the remaining two patients with T2 tumours, one underwent re-resection of the liver bed and portal lymph nodes and remains alive and well at 12 months. The remaining patient developed an abdominal wall recurrence 12 months after cholecystectomy. She has also undergone resection with postoperative radiation therapy and remains well after 12 months of clinical follow up. CONCLUSION: Gall bladder polyps, which are common and are usually benign in the general population, are often malignant in PSC. Regardless of size, any PLG in a patient with PSC should be considered for cholecystectomy.     

MANAGEMENT OF RUPTURES OF THE ANTERIOR CRUCIATE LIGAMENT

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LIST OF CONTRIBUTORS

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REAPPRAISAL OF SERUM β2-MICROGLOBULIN AS MARKER OF GFR

Introduction. Beta 2 microglobulin(β2M) is filtered by the glomeruli and reabsorbed by the proximal tubularcells where it is metabolized. Its plasma concentration increases with decreasingrenal function. Aim. To compare serum creatinine(Cr) and serum β2M as markers of GFR. Patientsand Methods. In 160 adult patients, with various kidney diseasesand different GFR, serum Cr (autoanalyzer), serum β2M (RIA) and GFR (bladdercumulative method using ^99mTc-DTPA as glomerulartracer) were measured in the same day. Results.A linear relationship was observed between ln GFR and both ln serum Cr (lnCr= 3.112–0.716lnGFR; r = 0.92) and ln serum β2M (lnβ2M = 4.274–0.814lnGFR; r = 0.90). With decreasing GFR the increase in serum β2M was higherthan that of serum Cr (see regression coefficients that are significantlydifferent). The normal upper limit of serum Cr corresponds to a GFR 48.1 mL/minwhile that of serum β2M to a GFR 65.0. With decreasing GFR the increaseof serum β2M occurs before than that of serum Cr. Conclusions.With declining renal function, serum β2M increases more and before thanserum Cr. Serum β2M is a good endogenous marker of GFR, better than serumCr.     

EXPERIMENTAL STUDY OF CHEMICAL CHOLECYSTECTOMY ：OBSERVATION OF PATHOLOGICAL CHANGES

Objective:To verifY through animal experimant the validity of chemical cholecystectomy. Methods: The experimental objects seven healthy juvenile piss, herdener was infused into the gallbladder, after infusion the samples were collected by pathological examination, according to the different duration under anesthestize. Results:The mucous destructive and digestive process remained with one week,the inflarmmatory reacton in two weeks, the chronic inflammatory reaction compained a great deal of granulation tissue and scar formation occurred in 4th-8th week, 10 weeks latter,the inflamma-tory reaction reduced,and scar tissue formed. Conelusion: Chemical cholecystectomy is safe and reliable in clinical.     

PLASMA CONCENTRATIONS OF THE STEREOISOMERS OF PRILOCAINE AFTER ADMINISTRATION OF THE RACEMATE: IMPLICATIONS FOR TOXICITY?

A chiral high pressure liquid chromatography method was developedto measure the separate isomers of prilocaine in plasma afteradministration of the racemate. The concentrations of the isomersin six patients were similar (S(+)/R(–) = 1.06 (SD 0.06))after brachial plexus block with 1.5% (RS)-prilocaine hydrochloride35 ml, suggesting that a higher systemic safety margin may notbe achieved by substituting racemic prilocaine by one of itsisomers. Much higher plasma concentrations of the S(+)- thanthe R(–)-form after oral administration of 300 mg of theracemate (n = 4) indicated a large difference in intrinsic metabolicclearance of the isomers on first pass through gut, liver orboth organs. This work was presented at the British Pharmacological SocietyMeeting in Leeds, July 1989, and published in abstract formin the British Journal of Clinical Pharmacology 1989; 28: 742P.