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.     

Neodymium-YAG laser irradiation of stage T2 muscle-invasive bladder cancer. Long-term results

The study group consisted of 15 patients with solitary stage T2 bladder tumours treated with transurethral resection (TUR) and subsequent neodymium-YAG laser irradiation. Ten patients are alive without evidence of cancer 56 to 78 months (mean 67) after treatment; 1 died of cardiovascular disease 2 years after treatment and autopsy revealed no cancer. In 4 patients the treatment failed and cystectomy or external beam radiation was carried out. The long-term results indicate the combination of TUR and laser irradiation to be beneficial in the management of T2 tumours in selected cases.     

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.     

Recurrence of superficial bladder tumours after transurethral resection

From 1979 to January 1990, 48 patients with newly diagnosed superficial bladder tumours were treated by transurethral resection (TUR) at Toyama Medical and Pharmaceutical University Hospital. The relationship between tumour recurrence and the stage, grade, number, or size of the tumours was investigated. The 1-, 2-, 3-, 4- and 5-year non-recurrence rates were 72%, 63%, 47%, 40%, and 40%, respectively. Non-recurrence rate for pTa tumours was significantly higher than that for pT₁ tumours (p<0.05). There was no relationship between tumour grade and recurrence. The rate of recurrence of mulitple tumours was higher than that of single ones. There was no difference in non-recurrence rate between tumours smaller than 1 cm and those of 1 cm or larger. Non-recurrence rate in the instillation therapy group was significantly higher than in the non-instillation group (p<0.05). It was concluded that patients with multiple or high-stage tumours have the risk of a high rate of recurrence and that intravesical chemotherapy is effective in preventing local recurrence in some patients.     

Recent progress and problems in bladder-sparing operations in bladder tumors

Retrospective analysis of the bladder tumor patients was performed to reveal the clinical results of partial cystectomy or transurethral resection (TUR). The observed 3-, 5-, 10-year survival rates after 143 partial cystectomies indicated for the first tumors were 66.2%, 57.1% and 41.5% respectively. To obtain satisfactory results, however, the operation should be indicated for pT2 or G0-G1. Some of the G2 tumors could also be the candidates for this procedure, but the stage of the disease must be below T2. At present, all these tumors could be well controlled by TUR, and this statement was confirmed by the study of clinical results obtained by TUR. The analysis also revealed a poor outcome in 6% of the low grade or low stage tumors and it increased to 25% in high grade and pT2. The complete cure of the high stage or high grade tumor is still difficult, but to improve the survival rate, radical surgery should be employed more positively instead of partial cystectomy. The reasons for this conclusion are also discussed.     

Transurethral resection and intra-arterial chemotherapy for muscle-invasive bladder cancer

Thirty-three patients with muscle-infiltrating T2–T3a bladder carcinoma were treated by TUR through the full thickness of the bladder wall and extended into the perivesical fat. The solitary tumours were not more than 4 cm in diameter. Histology proved in every case tumour stages of pT2 (17 patients) or pT3a (16 patients), G2 or G3 transitional cell carcinoma and negative mucosal biopsies. After TUR the patients received 1 or 2 cycles of chemotherapy: 60 mg of doxorubicin, 50 mg of cisplatin, 1 g of 5-fluorouracil administered into the ipsilateral hypogastric artery. There was no perioperative mortality but one patient died of complications related to chemotherapy. During the first year of follow-up relapses of muscle-invasive cancer were observed in 3 patients (10%), two were subjected to cystectomy and one to repeated TUR. With a median follow-up of 34 months 27 patients are alive and have functional bladder. The actual 3-year and 5-year survival rates were 17/21 (81%) and 6/9 (67%), respectively. The results of this study suggest that in strictly selected patients extended TUR and intra-arterial chemotherapy may be a bladder-preserving treatment modality for muscle-invasive bladder cancer. Regular (three monthly cystoscopy, cytology, biopsy, CT) investigations and follow-up are necessary to detect recurrences.     

Clinicopathological Characteristics of Patients with Proximal Third Gastric Carcinoma

Objective : Epidemiological studies show a continuing rise in the prevalence of proximal third gastric carcinoma (PGC), and the prognosis of patients with this carcinoma is poorer than that of patients with more distally located gastric carcinomas. We compared the clinicopathological features and prognosis of PGC patients with those of patients with middle/distal gastric carcinoma (MGC/DGC).

Material and methods : Of the 2696 patients diagnosed with gastric carcinoma who underwent surgery in our hospital in a 15-year period, 271 patients (10.1%) were diagnosed with PGC and retrospectively reviewed. Results : T1-category tumours were less common in patients with PGC than in patients with MGC/DGC (p < 0.001). Lymph node invasion was more common in patients with PGC than in patients with MGC/DGC (p < 0.05). Tumour stage (stage I) and T category (T1) significantly influenced the 5-year survival rates of patients whose tumours were resected with curative intent. The 5-year survival rate of patients whose PGC were resected with curative intent was higher than that of patients whose PGC were resected with palliative intent (57.4 vs. 12.6%, p < 0.001). The 5-year survival rate was 49.3% for patients with PGC and 57.3% for patients with MGC/DGC (p = 0.0273). Multivariate analysis showed that tumour size, lymph node status, and resection with curative intent were significant prognostic factors for survival in patients with PGC.

Conclusion : The poor prognosis of PGC is mainly due to its more advanced stage at diagnosis compared with that of more distally located gastric carcinoma. Early detection is important for improving the prognosis of patients with proximal third gastric carcinoma.     

Treatment of 255 patients with bladder tumors

During about 10 years from November, 1977 to March, 1987, two hundreds and fifty-five patients with bladder tumors were treated at the Department of Urology, Hamamatsu University School of Medicine and the affiliated hospitals. There were 198 males and 57 females with the highest age incidence in the seventies. Histologically, 242, 11 and 2 tumors were of transitional cell, squamous cell and adenocarcinoma, respectively. Of the 242 transitional cell carcinomas, 7 were Tis; 43 Ta, 111 T1, 33 T2, 19 T3, 5 T4, 14 M+ (with metastatic lesion), and 10 TX. As to grading, 6 was G0; 66 G1, 100 G2, 64 G3, and 6 GX. Staging was correlated with grading. The 5-year survival rates (Kaplan-Meier's method) were 64% in patients with transitional cell carcinoma; 58% in those with squamous cell carcinoma. In patients with transitional cell carcinoma, the 5-year survival rates were 100% for G0, 73% for G1, 73% for G2 and 40% for G3. As to staging, the 5-year survival rates were 67%, 81%, 81%, 35%, 41%, 40% and 12% in patients with stage of Tis, Ta, T1, T2, T3, T4 and M+, respectively. As to the initial treatment, the 5-year survival rates after TUR (137 cases), partial cystectomy (4 cases) and total cystectomy (56 cases) were 81%, 36% and 61%, respectively. The rate of intravesical recurrence after TUR was evaluated with the cumulative non-recurrence rate calculated by Kaplan-Meier's method.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bladder preservation for locally advanced bladder cancer by transurethral resection, systemic chemotherapy and radiation

Twenty-three out of 31 patients with clinical T2-4a N0 M0 bladder cancer and given a trial of trimodality therapy including transurethral resection (TUR), systemic chemotherapy and radiation between 1991 and 2002 completed this therapy. The other 8 dropped out because of insufficient clinical effect. Local bladder recurrence was seen in 3 patients and the bladder preservation rate was 64.5%. Nineteen of the 23 patients showed a complete histological response on a subsequent TUR specimen, the other 4 were not examined for histological response. Thirteen of the 19 patients showed a complete histological response after maximal TUR and systemic chemotherapy, while 6 did after TUR, chemotherapy and radiotherapy. Bladder cancer was T2 in, 15, T3 in 1, and T4a in 3 patients. The CR rate for T2 cancer was significantly higher than that for T3-4a cancer. The 5-year disease-specific survival of the 23 patients treated with preservation therapy was 67.1%. Some of the patients with locally advanced bladder cancer may benefit from this preservation therapy.     

Conservative management of advanced bladder cancer

Between January 1991 and October 1993, 32 consecutive patients with documented primary bladder tumours invading muscle received 3 cycles of methotrexate, vinblastin, doxorubicin and cisplatin (MVAC). The disease was re-staged by bimanual examination with the patient under anaesthesia, CT scanning and transurethral biopsy or resection. Of the 32 patients 2 underwent total or partial cystectomy and 30 did not, because re-staging showed no residual tumour in 8 (25%), stage T1–2 in 12 (37.5%) and far-advanced tumour in 10 (31.2%). The median follow-up was 2.8 years. Twelve patients with stage T1–2 tumour have required TUR, and cystectomy has not been necessary. Two patients who underwent total/partial cystectomy were all downstaged pathologically. Of the 10 failures 5 patients died of disease and 5 are alive with metastatic disease. The overall survival rate was 84.3% (27 of 32) and was 96.8% for patients with a functioning bladder. The data suggested that this active regimen can clinically induce down-staging in a significant number of patients with primary muscle-infiltrating bladder tumours. Transurethral resection plus MVAC chemotherapy is important for increased curability in patients with advanced bladder cancer.     

Retrospective analysis of transurethral resection, second-look resection, and long-term chemo-metaphylaxis for superficial bladder cancer: indications and efficacy of a differentiated approach

BACKGROUND AND PURPOSE: Because of controversy concerning risk factors for progression, recurrence, and persistence of bladder cancer, we reviewed the data of our patients with superficial bladder tumors. Based on a differentiated approach with second-look transurethral resection (TUR) and/or intravesical metaphylaxis, we wanted to answer the following questions: Was this approach efficient? What risk factors demand a second-look TUR? Is surveillance appropriate for patients at low risk? MATERIALS AND METHODS: Retrospectively we analyzed the data of 251 patients with superficial bladder cancer with a mean follow-up time of 69 (range 20 to 107) months. We focused on recurrence rates, tumor-persistence and progression, and types of adjuvant treatment. An early reintervention within 6 to 8 weeks after primary resection was defined as a second-look TUR. To judge the necessity of early reintervention and metaphylaxis, we performed a matched-pair analysis for the low-risk group. RESULTS: Tumor stages included T(a) (170 patients, 68%); T(1) (72 patients, 29%); carcinoma in situ (CIS) (9 patients, 4%). Grades included grade 1 (58 patients, 23%); grade 2 (117 patients, 47%); and grade 3 (76 patients, 30%). Thirty-eight (15%) tumors were already classified as recurrent. A second-look TUR was performed on 222 (88%) patients, indicating a persistence rate of 25%. Persistence rates for low-risk tumors (T(a) grade 1/2) were 9%; rates for T(a) grade 3 tumors were significantly higher. Risk factors for persistence were multilocularity and higher grade and stage. Matched-pair analysis for the low-risk group did not show any significant advantage for second-look TUR. After complete resection of T(1) grade 3 tumors, the risk of progression is similar to that for tumors of lower grade and stage. The overall recurrence rate was 25%, with a higher risk of upstaging in cases of higher stage or grade and multilocular and persisting tumors. CONCLUSION: The overall tumor recurrence rate of 25% reflects the efficacy of our differentiated approach with selective use of second-look TUR and intravesical metaphylaxis (intravesical chemotherapy). Second-look TUR is indicated for multifocal and recurrent tumors or in patients whose tumors put them at high risk. Patients with grade 2/3 tumors, multifocal grade 1 tumors, and all T(1) tumors received metaphylaxis; intravesical bacillus Calmette-Guerin was instilled in patients with CIS. With this regimen, even in T(1) grade 3 stages, organ preservation can be achieved.     

T1G3 transitional cell carcinoma of the bladder: recurrence, progression and survival

OBJECTIVES: To report our experience with T1G3 bladder tumours over the last 10 years. PATIENTS AND METHODS: We analysed the outcome of 74 consecutive patients treated for a T1G3 bladder cancer between 1991 and 2001. Fifty-seven patients (77%) were treated with transurethral resection (TUR) plus six weekly instillations of bacillus Calmette-Guérin (BCG) therapy. Ten patients (13.5%) with contraindications to BCG or with a small T1a tumour were treated with TUR plus mitomycin-C, and seven (9.5%) were treated with TUR alone because of their age. Patients treated with BCG had systematic biopsies taken at the end of the first course. Patients with residual tumour received a second course of six weekly instillations. Patients with negative biopsies received maintenance BCG therapy consisting of intravesical instillations each week for 3 weeks given 3, 6, 12, 18, 24, 30 and 36 months after the first course. RESULTS: The median follow-up was 53 months. The overall recurrence rate was 46% and the overall progression rate 19%. The rate of delayed cystectomy was 8% and that of disease-specific survival 91%. In patients who received BCG therapy, the recurrence and progression rates were 42% and 23%, respectively. In this group the rate of disease-specific survival was 88%. CONCLUSION: This study confirms that maintenance BCG therapy is an effective treatment for T1G3 bladder tumours, with an acceptable rate of bladder preservation.     

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.     

Clinical analysis of high grade bladder cancer

The prognosis and other clinical manifestation of 128 patients with high grade bladder tumor were analyzed. Thirty two percent of the total cases of bladder cancer were high grade bladder cancer and 83% of their tumors were invasive tumor at stage T2 and worse. Urinary cytologies were positive in 88% of these patients. The 5-year survival rate in these patients was 32% and those in T1, T2 T3 and T4 cases were 64.2%, 55.6%, 22.7% and 8.0% respectively. The patients treated with radical (total) cystectomy showed a much better survival rate than the cases treated with TUR or partial cystectomy. These results suggest that high grade bladder cancers tend to be invasive and the patients with high grade bladder cancer would have a poorer prognosis than the patients with other histological grade tumors. Thus, these patients should be treated more aggressively including radical cystectomy than the other cases of bladder cancers.     

Survival of breast-cancer patients with previous or subsequent neoplasms.

The authors reviewed retrospectively 1510 patients with breast cancer operated on between 1960 and 1980. They compared 1353 patients who had an isolated breast cancer (group 1) with 157 patients who also had breast cancer but had other cancers either previously or subsequently (group 2). The mean age of patients in group 2 was 2 years more than that of patients in group 1. Group 2 patients had fewer T3 tumours, more T1 tumours (TNM classification), a lower incidence of lymph-node involvement and clinically less advanced tumours than group 1 patients. Hormonal status, histologic type of tumour and surgical and adjuvant treatment were identical in both groups. The 10-year survival rate (considering death from breast cancer) was 54.6% in group 1 versus 78.1% in group 2. The overall survival rate (considering death from breast cancer or from the other cancer) was 54.1% in group 1 versus 64.5% in group 2. Survival was also better in group 2 for each clinical stage. The authors conclude that patients who have another cancer before or after the development of their breast cancer have a better survival rate than those who have isolated breast cancer with no previous or subsequent neoplasms.     

影响膀胱肿瘤术后复发的COX回归模型多因素分析

采用ＣＯＸ回归模型对２０１例次保留膀胱手术的患者进行多因素分析，其中ＴＵＲＢｔ（经尿道膀胱肿瘤电切术）１６３例次；膀胱部分切除术３８例次，７２例次复发，总复发率３８５％。结果显示肿瘤的综合分级分期、分级、分期、既往复发史依次为影响术后肿瘤复发的主要危险因素，而术后膀胱灌注药物为主要保护性因素。同时Ｌｏｇｒａｎｋ检验计算及比较两种术式术后的复发率。结果显示Ｔ１或（和）Ｇ１患者ＴＵＲＢｔ术后的复发率低于膀胱部分切除术，Ｔ３，４或（和）Ｇ３患者膀胱部分切除术后的复发率低于ＴＵＲＢｔ，Ｔ２Ｇ２患者两种术式术后复发率无差别。     

The management of early stage non-seminomatous germ cell tumours of the testis: Edinburgh 1970-1981

This study describes the management of early stage non-seminomatous germ cell tumours of the testis in Edinburgh between 1970 and 1981. There were 69 patients in clinical Stage I and 22 patients in clinical Stage IIA. All were treated by orchiectomy and radiotherapy to the para-aortic nodes. Some of the patients with Stage IIA disease received additional therapy. The overall 5-year actuarial survival rate was 83%. In a group of 52 patients with Stage I disease who had had lymphography as part of their initial staging the 5-year actuarial survival rate was 94.2%. The overall relapse rate was 27/91 (29.7%). The relapse rate in State IIA disease was 11/22 (50%) and the 5-year actuarial survival rate was 64%. Patients with primary tumours beyond T1 had a significantly higher relapse rate than patients with T1 primary tumours: 10/20 (50%) and 13/52 (25%) respectively. The histology of the primary tumour did not have a statistically significant influence upon relapse rate.     

Recurrence, progression and survival in bladder cancer. A retrospective analysis of 232 patients with greater than or equal to 5-year follow-up

A retrospective study of 232 bladder tumours with minimum follow-up 5 years is presented. The carcinoma was superficial in 66%, muscle-invasive in 31% and could not be staged in 3%. Primary treatment was mainly transurethral resection for superficial tumour, but was cystectomy or radiotherapy in 22 of 29 T1 G3. Of the superficial tumours, 71% recurred. Progression to higher T stage occurred in 15% of Ta and 29% of T1 tumours, and half of these patients died of bladder cancer. The corrected 5-year survival rates in grades 1, 2A, 2B and 3-4 were 96, 84, 64 and 43%, and in stages Ta, T1, T2 and T3 they were 94, 69, 40 and 31%. All patients with T4 tumour died within 4 years. Among the 45 patients with 40 Gy irradiation + cystectomy, the corrected 5-year survival rate was 83% in superficial and 64% in muscle-invasive tumours, and among the 38 with radical radiotherapy the rates in T1-3 were 46, 36 and 13%. Transurethral resection was successful in most Ta cases. Most T1 tumours were, like T2-4, of higher grade than Ta. Prognosis was worse in T1 than in Ta. After progression to muscle-invasive disease, even during close follow-up the outlook was poor, as poor as for patients with primary muscle-invasive disease.     

Staging error in the Bladder tumor: The correlation between stage of tur and cystectomy

Objectives:Because tumor stage is very important in determining therapy, accurate sraging of bladder cancer must be estimated. For this aim, we examined the stage of TUR and compared it with the stage of cystectomy.Materials and methods:From 1992 to 1999, operations were performed on 127 patients with local invasive bladder cancer. Eight cases (74 male, 6 femle) underwent complete TUR of the tumor and then radical cystectomy. There was no residual macroscopic tumor after TUR in the bladder. The pathological staging of TUR and cystectomy were estimated and compared in these 80 cases. All pathologies were evaluated by the same pathology center.Results:There was correlation in only 20 patients (25%; 15 were T1, 5 were T2) while there was global error and discordance in 60 patients (75%). All of these 60 cases were overstaging in cystectomy specimens and downstaging was not found in any case. Fifty per cent of 10 T1 tumors were T1, while 50% were T3a;21.4% of T2 tumors were T2, 35.7% were T3a and 42.8% were T3b.Conclusions:The staging error of TUR in the bladder tumor may cause severe mistakes on deciding about radical surgery. However, although there was no understaging, which is more risky for false cystectomy indication, urologists must be careful about overstage/understage in the staging of TUR.     

Analysis of factors predicting intravesical recurrence of superficial transitional cell carcinoma of the bladder without concomitant carcinoma in situ

BACKGROUND: The objective of this study was to investigate risk factors for intravesical recurrence in patients with superficial bladder cancer without concomitant carcinoma in situ (CIS). METHODS: In this series, we analyzed data from patients with newly diagnosed superficial Ta or T1 transitional cell carcinoma (TCC) of the bladder without concomitant CIS who underwent complete transurethral resection (TUR) without any adjuvant intravesical instillation therapies. Multivariate analysis was used to determine significant risk factors affecting intravesical recurrence after TUR. Differences in clinicopathological features between primary and recurrent tumors were also characterized. RESULTS: Among 341 patients undergoing TUR of Ta or T1 bladder cancer, 187 diagnosed as having concomitant CIS and/or treated with adjuvant intravesical therapy were excluded, and the remaining 154 were evaluated. Intravesical recurrence was detected in 64 of the 154 patients, showing a 5-year recurrence-free survival rate of 58.3%. Among several factors examined, only tumor size was significantly associated with intravesical recurrence. Multivariate analysis identified tumor size as an independent predictor for intravesical recurrence irrespective of other parameters including age, gender, multiplicity, growth pattern, grade and stage. Recurrent tumors were significantly smaller and of a lower grade and lower stage than primary tumors, despite the absence of differences in growth pattern and the multiplicity between them. CONCLUSIONS: These findings suggest that primary tumor size could be used as a potential risk factor for predicting intravesical recurrence following TUR of superficial TCC of the bladder without concomitant CIS, and that the pathological characteristics of recurrent tumors are more favorable than those of primary tumors.