Prognostic significance of mucosal aneuploidy in stage Ta/T1 grade 3 carcinoma of the bladder.

In a prospective series of 71 patients with newly detected grade 3, stages Ta and T1 bladder carcinoma tumor characteristics, including the results of deoxyribonucleic acid (DNA) analysis as well as morphological and DNA characteristics of the grossly normal urothelium, were investigated and related to progression-free survival. The mean duration of followup was 57 months, with a minimum of 24 months. Of the 71 patients 24 underwent primary cystectomy, and 47 were conservatively treated with transurethral resection alone, or followed by instillation therapy or irradiation therapy. Of the cystectomy and conservatively treated patients 2 (8%) and 16 (34%), respectively, died of bladder carcinoma. Among the 47 conservatively treated patients tumor progression could not be predicted by the initial characteristics of tumor stage, papillary or nonpapillary growth, tumor multiplicity, tumor size, existence of 1 or multiple aneuploid cell populations, S phase value, carcinoma in situ and atypia or aneuploidy in the mucosal biopsies. Neither was progression predicted by the recurrence rate during year 1 of observation. However, a change to or persistent mucosal aneuploidy and a change to or persistent morphological abnormality of the mucosa during year 1 of observation were predictive for tumor progression (p = 0.001 and 0.045, respectively). When compared in stepwise regression analysis (Cox's proportional hazard model), DNA aneuploidy in the mucosa at 12 months after diagnosis was a highly significant predictor, whereas morphology added no further prognostic information. Therefore, progression is related to gross chromosomal abnormalities of the mucosa. High risk patients can be identified by evaluation of the grossly normal mucosa, which should be done as part of the initial diagnosis and during followup in conservatively treated patients with stages Ta and T1, grade 3 bladder carcinoma.     

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.     

Deoxyribonucleic acid profile and tumor progression in primary carcinoma in situ of the bladder: a study of 63 patients with grade 3 lesions.

In 63 patients with primary grade 3 carcinoma in situ of the bladder flow cytometric deoxyribonucleic acid (DNA) analysis was performed at diagnosis and during an average followup of 63 months. The results of DNA measurements were related to disease progression, that is invasive tumor and/or metastatic disease. The DNA histograms were classified as diploid (2 patients) or aneuploid (61). A total of 3 categories of aneuploid tumors with different prognostic significance could be defined: 1) carcinoma in situ with 1 aneuploid cell population at diagnosis and with no change to multiple aneuploid cell populations throughout observation, 2) carcinoma in situ with 1 aneuploid cell population at diagnosis but with a later change to multiple aneuploid cell populations and 3) carcinoma in situ with multiple aneuploid cell populations already at diagnosis. At 5 years the progression-free survival for the 3 categories was 94%, 43% and 20%, respectively. Over-all, of the patients with multiple aneuploid cell populations (categories 2 and 3) 76% had progression, in contrast to 19% of those in category 1 (p less than 0.0005). In category 2 development of multiple aneuploid cell populations preceded progression in 8 of 11 progressive cases by an average of 20 months. Therefore, the occurrence of multiple aneuploid cell populations must be considered as a sign of high aggressiveness. We conclude that flow cytometric DNA analysis is a potent predictor of prognosis in cases of primary carcinoma in situ of the bladder.     

DNA aberrations of bladder mucosa in patients with transitional cell carcinomas

DNA aberrations in bladder mucosa have been investigated in altogether 26 patients with aneuploid WHO grade 2 and 3 tumours (transitional cell carcinomas; TCC). In about 1/4 of the patients aneuploid cells were found only in the tumour. Hypotetraploid tumours showed the lowest frequency of involvement of the normal appearing mucosa of the trigone (43%). In hypertriploid tumours the corresponding value was 71%. In altogether 14 of the patients, the same type of aneuploid cells was found in the normal appearing mucosa as in the tumour. This indicates frequent involvement of the whole bladder mucosa in the tumour disease. In about 1/4 of the cases other types of ploidy aberrations were found in the normal appearing mucosa than in the tumour. This is indicative of preneoplastic changes in the mucosa, of which only one type of aberrations is associated with tumour growth. In some cases with multiple tumours of the bladder, all the tumours had the same aneuploid stemline, while in other cases the tumours were of different aneuploid stemlines. This is conformal with other reports of atypia in the surrounding mucosa in TCC and with the concept that recurrence of high grade tumours is the consequence of neoplastic involvement of the whole bladder.     

Importance of cellular DNA content in pre-malignant breast disease and pre-invasive carcinoma of the female breast

The risk of malignant change in pre-invasive breast disease such as proliferative atypia (PA) or the risk of invasive carcinoma arising from ductal carcinoma in situ (DCIS) remains uncertain in individual women because of the absence of any prognostic criteria. In order to clarify this, the cellular DNA content (ploidy) of 51 screen-detected lesions has been investigated. Cellular DNA measurements were made by static cytometry following Feulgen staining of disaggregated tissue sections and the resulting histograms classified as either diploid or aneuploid. Thirteen cases of PA and twelve of DCIS were compared with twenty-six biopsies showing DCIS with adjacent invasive carcinoma (DCIS + Ca). In the latter group, ploidy of the invasive carcinoma was compared with the associated DCIS in 16 cases. Aneuploid cells were found in approximately 30 per cent of PA and DCIS lesions but in 23 of 26 cases of DCIS + Ca. Of 16 assessable cases of co-existing DCIS and micro-invasive carcinoma both were aneuploid in 11, both diploid in 1, and in 4 cases the DCIS was aneuploid whereas the invasive carcinoma was diploid. These results suggest that aneuploidy may be of value in predicting the most biologically aggressive of these pre-invasive lesions.     

Characterization of bladder carcinomas by flow DNA analysis

Three-hundred and three consecutive newly detected bladder tumours were studied by DNA flow cytometry. The tumours were classified as diploid or aneuploid. The degree of aneuploidy was determined and the existence of more than one aneuploid cell peak was considered. Proliferative properties of the tumours were assessed from the proportion of S-phase cells. The majority of grade 1 tumours were diploid and grade 3 tumours aneuploid with few exceptions, while half of the grade 2 tumours were diploid or aneuploid. Ta tumours differed from T1 tumours in that they had a lower frequency of aneuploid cases, a lower proliferation rate and fewer cases with more than one aneuploid cell line. The proportion of S-phase cells increased with grade and stage. More than one aneuploid cell line was most frequently found for muscle-invasive tumours and in carcinoma in situ. A subdivision of bladder tumours based on the DNA pattern is presented.     

Comparative flow cytometric deoxyribonucleic acid studies on exophytic tumor and random mucosal biopsies in untreated carcinoma of the bladder

In 290 patients with untreated carcinoma of the bladder the deoxyribonucleic acid properties, as measured by flow cytometry, of 3 random mucosal biopsies were studied and compared to those of the exophytic tumors. Mucosal aneuploidy was found with few exceptions in aneuploid tumors only, and in a significantly lower frequency in aneuploid tumors of grade 2 than grade 3. The individual specificity of bladder tumors is emphasized by the observation that the level of ploidy was mostly the same in aneuploid mucosal biopsies as in the exophytic tumor. This is underlined further by the occurrence of cell populations of the same ploidy in different parts of the bladder mucosa. However, S-phase values of the concomitant intraurothelial lesions were significantly lower than those of the exophytic tumors. Therefore, we concluded that the process of evolution from malignantly transformed lesions, confined to the urothelium, to an exophytic or invasive tumor is dependent on a further elevated proliferation of the urothelial lesions.     

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.     

Inverted papilloma of the bladder with mild atypia

A case of inverted papilloma of the bladder with mild atypia in a 31-year-old male is reported. The patient was admitted complaining of macroscopic hematuria. An excretory urogram revealed a small filling defect in the center of the bladder. A 15 x 11 mm. exophytic lesion was noted at the center of the trigone by cystoscopy and ultrasonography. The patient underwent transurethral resection of the bladder tumor and selected-site mucosal biopsies. The result of a histopathological examination of the tumor was an inverted configuration with nuclear atypia, corresponding to transitional cell carcinoma, grade 1. No histopathological abnormalities in the normal-appearing bladder mucosa were observed. The patient has been subsequently followed up for 43 months and there was no evidence of recurrence.     

Studies on multiple mucosal biopsy in patients with bladder cancer. 4. Evaluation of Thomsen-Friedenreich antigen in multiple mucosal biopsy and transitional cell carcinoma of the bladder

The significance of Thomsen-Friedenreich antigen (T-Ag) in bladder carcinomas and multiple mucosal biopsies was studied. The T-antigen, a precursor of MN blood group antigen, is not found in normal cells, in which T-antigen is cryptic (cryptic T-Ag) but can be unmasked with neuraminidase digestion. Specimens of 27 main tumors and 201 mucosal biopsies from 28 patients with carcinoma in situ or microinvasion of carcinoma in situ were examined for the expression of T-antigen by Avidin-Biotin-Peroxidase Complex (ABC) method with peanut agglutinin (PNA). The T-Ag-positive rate was 22% for G2 tumors, 56% for G3 tumors, while cryptic T-Ag-positive rate was 86% for G2 tumors and 50% for G3 tumors. The correlation between T-antigen, cryptic T-antigen and histologic grade was not statistically significant. The T-Ag-positive rate in mucosal biopsies was 43% in microinvasion of carcinoma in situ, 11% in carcinoma in situ, 17% in transitional cell carcinoma, 8% in dysplasia, 33% in squamous metaplasia, 33% in proliferative cystitis and 13% in normal epithelium. Of histological findings, microinvasion of carcinoma in situ showed a significantly higher T-Ag-positive rate than carcinoma in situ and normal epithelium (P less than 0.005, P less than 0.001). The cryptic T-Ag-positive rate in mucosal biopsies was 38% in microinvasion of carcinoma in situ, 74% in carcinoma in situ, 100% in transitional cell carcinoma, 82% in dysplasia, 100% in squamous metaplasia, 100% in proliferative cystitis and 96% in normal epithelium. Of the histological findings, carcinoma in situ, proliferactive cystitis and normal epithelium showed a significantly higher cryptic T-Ag-positive rate than microinvasion of carcinoma in situ (P less than 0.025, P less than 0.05, P less than 0.001). Microinvasion of carcinoma in situ expressed the T-Ag (43%), the cryptic T-Ag (21%) and lacked the cryptic T-Ag (36%). Microinvasion of carcinoma in situ showed statistically significant difference in the mode of T-Ag and cryptic T-Ag expression than other histological types in mucosal biopsies, including carcinoma in situ (P less than 0.001).(ABSTRACT TRUNCATED AT 400 WORDS)     

Chromosomal gains and losses detected by comparative genomic hybridization and proliferation activity in renal cell carcinoma

OBJECTIVE: The number of DNA losses found using comparative genomic hybridization (CGH) and the proliferation index MIB-1 have been shown to be prognostic factors in renal cell carcinoma (RCC). We evaluated the associations of these two factors with each other and with histopathology and clinical outcome. MATERIAL AND METHODS: In this prospective study, specimens from 20 primary RCCs were investigated using CGH and MIB-1 assay. The associations of the commonest chromosomal aberrations with histopathology, stage and the clinical outcome of the disease were evaluated. RESULTS: CGH detected genetic aberrations in all tumours. Losses of genetic material (85%) were more common than gains (65%). Most common was loss in the short arm of chromosome 3, which was found in 70% of the tumours. Other frequent changes (20%) were losses of 4q, 13q, 18 and Xp, as well as gains of 5q, 7p, 7q (25%) and chromosome 12. The number of deleted chromosomal areas varied from none to six. The MIB-1 index varied from 0 to 39 (median 4.0). The total number of chromosomal aberrations or deletions showed no association with MIB-1 index or nuclear grade. Most grade 1 and 2 tumours showed a low MIB-1 index. All nuclear grade 4 tumours progressed and were associated with short survival. CONCLUSION: CGH gives an overview of DNA changes in RCC and helps to locate targets for more precise genetic evaluation. CGH findings are also helpful for classifying tumours. In this study, genetic aberrations in primary RCCs were not associated with histopathology, proliferation or clinical outcome, which suggests that CGH does not necessarily give any additional information on the prognosis of the disease. MIB-1 index and TNM stage were associated with survival.     

Studies on multiple mucosal biopsy in patients with bladder cancer. 3. Evaluation of ABH antigenicity in specimens of multiple mucosal biopsy and transitional cell carcinoma of the bladder

Eighty-nine patients with bladder cancer underwent multiple mucosal biopsies of the bladder mucosa 129 times between April 1980 and June 1983. In total there were 126 tumor specimens and 723 mucosal biopsies. Blood group antigens (BGA) were detected by means of the specific red cell adherence (SRCA) test in blood group A, AB, and B patients and direct immunoperoxidase method in blood group O patients. Histological abnormalities in this paper indicate transitional cell carcinoma, microinvasion of carcinoma in situ, carcinoma in situ, dysplasia and hyperplasia. The Kaplan-Meier's method was used for the estimation of recurrence-free rate and logrank test for testing the significance of difference in recurrence-free rate. The BGA-positive rate in mucosal biopsies was 17% for microinvasion of carcinoma in situ, 29% for carcinoma in situ, 47% for transitional cell carcinoma, 35% for dysplasia, 71% for hyperplasia, 100% for squamous metaplasia, 87% for proliferative cystitis and 77% for normal epithelium. Of histological findings, microinvasion of carcinoma in situ, carcinoma in situ, transitional cell carcinoma and dysplasia showed a significantly lower BGA-positive rate than proliferative cystitis and normal epithelium (P less than 0.001). The BGA-positive rate of main tumor was 61% in G1 tumors, 23% in G2 tumors and 21% in G3 tumors. The BGA-positive rate was shown to be decreasing with the increase in the histological grade of main tumor, and this reciprocal relationship was statistically significant (P less than 0.005). No statistical correlation between BGA in tumors and histological stage was found. The frequency of histological abnormalities in mucosal biopsy was 5.2% in patients with BGA-positive tumors, 21.2% in those with BGA-negative tumors, the difference being statistically significant (P less than 0.001). The 5-year recurrence-free rate after transurethral resection (TUR) was 57.3% in patients with BGA-positive tumors, 18.2% in those with BGA-negative tumors, the difference between the 2 groups being significant (P less than 0.001).     

Characterization of squamous cell bladder tumors by flow cytometric deoxyribonucleic acid analysis: a report of 100 cases

We studied 100 cases of squamous cell carcinoma of the bladder by flow cytometry after cystectomy. Tumors were classified according to the deoxyribonucleic acid profile into diploid or aneuploid. Proliferation of the tumors was assessed from the proportions of S-phase cells. The flow cytometric data were correlated to the histopathological stage and grade. Grade 1 tumors could be subdivided into diploid and aneuploid in 60 and 40% of the cases, respectively, while 95% of the grade 2 and all grade 3 tumors were aneuploid. Diploid tumors had low proliferation rates, while aneuploid tumors had significantly higher values. A high frequency of muscle invasive diploid squamous cell tumors was noted. Tumor heterogeneity was studied by comparing cell material from superficial and deep tumor areas, which were in agreement in 77% of the cases. By comparing biopsy material with that obtained by bladder washings, biopsy material yielded better information regarding deoxyribonucleic acid ploidy in half of the aneuploid tumors. These results indicate that flow cytometry offers an additional objective method to characterize squamous cell carcinoma.     

Significance of carcinoma in situ and dysplasia in association with bladder cancer

Cystectomy specimens of 118 transitional cell carcinomas of the bladder were analyzed by step-sectioning. The carcinoma in situ and dysplasia adjacent to and remote from the visible bladder cancer were correlated with the tumor configuration on cystoscopy, and grade and stage of the disease. Results showed that a combination of papillary and nodular carcinomas in a single bladder was associated with a high incidence of mucosal involvement. Moreover, more than 50 per cent of all grade 3 carcinomas were associated with carcinoma in situ and dysplasia adjacent to and remote from the visible tumors. Carcinoma in situ and dysplasia were not related to the stage of disease. For management of bladder cancer, it appears important to assess the gross configuration of tumors by cystophotography and to determine the grade of tumors by biopsy, because mucosal involvement was found to be correlated closely with the tumor configuration and grade 3 disease.     

Analysis of the malignant potentiality in superficial esophageal carcinoma by cytofluorometry of nuclear DNA and cellular protein contents--in relation to histopathologic findings and prognosis]

Recently patients with superficial esophageal carcinoma have increased due to progress in endoscopy, but the results of surgical treatment are still not satisfactory. Cytofluorometric analysis of nuclear DNA and cellular protein contents, measurements of malignant potentiality, in superficial esophageal carcinoma were performed, and DNA ploidy patterns were compared statistically with histological findings and prognosis. Nuclear DNA and cellular protein contents were measured by the multiparametric cytofluorometry in 72 patients with squamous cell carcinoma (mucosal ca.: 14 cases, submucosal ca.: 58 cases). DNA ploidy patterns were classified into diploid (without polyploid), polyploid, and aneuploid according to the peaks of the DNA content histogram. In the current study, there were 22 cases (30%) of diploid, 17 cases (24%) of polyploid, and 33 cases (46%) of aneuploid. In patients with polyploid and aneuploid, there was high frequency of lymph vessel invasion, as compared with diploid (p less than 0.01). The overall five-year survival rates of patients with diploid, polyploid, aneuploid were 91%, 71%, 55%. The prognosis in patients with aneuploid was poorer than diploid (p less than 0.05). The recurrent cases of early esophageal carcinoma were aneuploid only. DNA ploidy patterns proved to be one of the major prognostic factors by multivariate analysis. The patients with higher DNA content had a high frequency of lymph node metastasis. In the patients with poor prognosis, cellular protein content showed higher. These results suggest that the analysis of nuclear DNA and cellular protein contents are useful for assessing the prognosis and planning postoperative combined therapy in patients with superficial esophageal carcinoma.     

Studies on multiple mucosal biopsy in patients with bladder cancer. 1. Evaluation of the results of multiple mucosal biopsy in patients with bladder cancer and in vivo methylene blue staining

Between March, 1980 and July, 1984, 165 multiple mucosal biopsies were performed in 111 patients with bladder cancer. Of these 165 multiple mucosal biopsies, 87 were performed in new cases and 78 in recurrent cases: 147 were performed under in vivo staining with intravesical methylene blue. Before endoscopic tumor resection, biopsies were taken with a flexible cup biopsy forceps from non-tumorous urothelium lateral to the ureteral orifices, in the midline posteriorly, from both lateral wall and bladder neck, adjacent to the tumor and from the tumor itself. Histological abnormalities in this paper indicate transitional cell carcinoma, microinvasion of carcinoma in situ, carcinoma in situ, dysplasia and hyperplasia. In the total 955 biopsy specimens, transitional cell carcinoma was found in 45 (4.7%), microinvasion of carcinoma in situ in 30 (3.1%), carcinoma in situ in 55 (5.8%), dysplasia in 27 (2.8%), hyperplasia in 141 (1.5%), squamous metaplasia in 4 (0.4%), proliferative cystitis in 58 (6.1%), inflammation in 230 (24.1%) and normal epithelium in 492 (51.5%). The frequency of histological abnormalities in biopsied specimens was 14.8% in new cases, 21.1% in recurrent cases, the difference being statistically significant (P less than 0.01). Transitional cell carcinoma and dysplasia were more common in mucosal biopsies of recurrent cases than those of new cases (P less than 0.001, P less than 0.05). The frequency of histological abnormalities was 11.5% in 836 biopsy specimens from cystoscopically normal-looking mucosa, while 65.5% in 119 biopsy specimens from grossly abnormal mucosa, the difference being statistically significant (P less than 0.001). Of histological abnormalities, transitional cell carcinoma, microinvasion of carcinoma in situ and carcinoma in situ were more common in biopsy specimens from grossly abnormal mucosa than those from normal-looking mucosa (P less than 0.001). The frequency of histological abnormalities in mucosal biopsy was 11.4% in patients who exhibited a single tumor, and 26.7% in those with multiple tumors, the difference being significant (P less than 0.005). Biopsies of mucosa adjacent to a visible tumor were abnormal most frequently (26.9%), while those taken lateral to the ureteral orifices, from the midline posteriorly and from both lateral wall revealed a slightly lower rate of abnormal findings. The frequency of histological abnormalities in mucosal biopsy was 7.7% in patients with G1 tumor, 15.8% in those with G2 tumor and 36.0% in those with G3 tumor. The histological abnormalities increased with the increase in the grade of main tumor; this correlation was statistically significant (P less than 0.001).(ABSTRACT TRUNCATED AT 400 WORDS)     

Selection toward diploid cells in prostatic carcinoma derived cell cultures

For elucidation of the growth-regulatory mechanisms in prostatic carcinoma, in vitro investigations on prostatic cell cultures are required. However, one major problem of cell culturing is the selection of particular cell types such that the cell lines representing only some of the features as compared with the tumor of origin. We studied the chromosomal composition of 20 prostatic tissue-derived cell cultures and 12 original (fresh) tissue specimens that were obtained from 13 patients with prostatic adenocarcinoma. Using fluorescence in situ DNA hybridization (FISH), evident clonal abnormalities were detected in 78% of the fresh cancer samples and in 47% of the cultured cancer samples. Of the seven cases revealing clonal abnormalities in the fresh cancer specimen, aneuploidy was detected in only two samples after cell culturing at the earliest passage studied. The aneuploid cell populations in the cultured samples were all lost during progressive subcultivation (after passage 4). Interestingly, by performing FISH on cytogenetic preparations aneuploidy was confined to the interphases, with the metaphases being found to be diploid. This finding indicates that the aneuploid cells have a proliferation disadvantage in cell culture resulting in an overgrowth of diploid cells. © 1996 Wiley-Liss, Inc.     

Flow cytometric analysis of DNA content in bladder cancer: prognostic value of the DNA-index with respect to early tumour recurrence in G2 tumours

Summary Flow cytometric DNA analysis was performed on 167 biopsies from 131 patients with transitional cell carcinoma of the bladder, all histologically confirmed. The degree of aneuploidy increased with tumour grade: G1 tumours were generally diploid (71%); G2, G3 tumours and carcinoma in situ were aneuploid (61%, 79% and 100%, respectively). There were 33 cases of newly diagnosed G2 tumours, all treated by transurethral resection; 11 tumours were diploid, whereas the aneuploid cases could be divided into two distinct populations on the basis of the DNA-index (DI): I) 1.01.5. In group I a significantly lower number of cases (9%) showed tumour recurrence within 1 year, compared to group II (77%) (P=0.001; Fisher's test). This could not be explained solely by differences in tumour stage. G2 tumours of a higher stage (at least P1b) showed more early recurrences compared to lower stage tumours (P=0.02). In cases of discrepancies, however, the degree of aneuploidy, was found highly predictive for early tumour recurrence. Flow cytometric analysis of DNA content offers additional information for the recognition of rapidly recurring G2 bladder tumours allowing early installation of appropriate therapy.     

Transitional cell carcinoma of the renal pelvis and ureter: prognostic relevance of nuclear deoxyribonucleic acid ploidy studied by slide cytometry: an 8-year survival time study.

In 72 patients with urothelial carcinoma of the renal pelvis or ureter the ploidy, deoxyribonucleic acid (DNA) heterogeneity and counts of cell cycle phases in the tumor were analyzed by means of single cell DNA cytophotometry with the intention of finding new prognostic factors in addition to those already known (stage and grade). Followup ranged from 1 to 8 years. The results of the DNA analyses were related to the tumor categories, histopathological grading of the tumors and clinical course. Malignancy grade 1 tumors showed DNA frequency peaks in the diploid range, while tumors assessed as malignancy grade 2 showed heterogeneous DNA distribution patterns. Malignancy grade 3 tumors exhibited 71% aneuploid and 29% tetraploid DNA values. The proliferation rate of the tumor cells was statistically significantly higher in malignancy grades 2 and 3 than in malignancy grade 1. The prognosis for grade 1 tumors is good, whereas it is unfavorable in the case of grade 3 tumors. For these 2 groups (patients with grades 1 and 3 tumors) DNA ploidy affords no additional prognostic information. Grade 2 tumors, on the other hand, are heterogeneous in respect to DNA ploidy although they exhibit the same histomorphological degree of differentiation. These tumors can be subclassified as aneuploid (biologically aggressive) and diploid or tetraploid (biologically less aggressive) tumors. There was also a positive correlation between T category and DNA ploidy. The cell lines were aneuploid in 38% of the patients with stage T1 tumors, 56% with stage T2 tumors and almost 85% with stage T3, N+ tumors. A significant correlation was found between the results of DNA cytophotometry and the clinical course of the disease. Patients with diploid tumor cell nuclei had no metastases and no local tumor progression for up to 8 years, whereas patients with aneuploid tumor cell nuclei suffered metastasis and local tumor progression within 24 to 36 months. The patients died of the tumor 36 months after primary diagnosis on the average. The determination of DNA ploidy, tumor heterogeneity and tumor cell proliferation by means of DNA cytophotometry affords valuable clues as to prognosis.     

DNA analysis in predicting survival of irradiated patients with transitional cell carcinoma of bladder.

A total of 115 patients with invasive transitional cell carcinoma of the bladder underwent radical radiotherapy between 1975 and 1986 and were followed up until the end of 1990. Apart from routine clinical observations, flow cytometric DNA measurements made on fresh tumour material were available for analysis. Actuarial cancer-free survival controlling for response to treatment was analysed with the log-rank test, bivariate and multivariate analyses using Cox's stepwise regression model on probable prognostic factors. The overall actuarial 5-year cancer-free survival rate was 30%. Survival was significantly correlated with response to treatment: 59% for patients with complete regression and 5% for those with residual tumour. Prognostic factors that significantly correlated with death from cancer were advanced stage, large size, incomplete resection, ureteric obstruction, anaemia, carcinoma in situ grade 3 and occurrence of more than one aneuploid cell population. However, only 3 of these factors were of independent power in the multivariate analysis: stage, size and carcinoma in situ. Of 21 patients with a history of primary or secondary carcinoma in situ, 19 died from cancer during follow-up: 18 of the 21 patients had tumours that were aneuploid with more than one aneuploid cell population. It is concluded that curative radiotherapy can be successful only in patients with less advanced tumours assessed according to clinical stage and size, aneuploid tumours with not more than one aneuploid cell line, no carcinoma in situ, no ureteric obstruction, and in whom a complete transurethral resection of the exophytic tumour is possible.