Abstract
BackgroundTo evaluate fluorescence cystoscopy with hexaminolevulinate (HAL) in the early detection of dysplasia (DYS) and carcinoma in situ (CIS) in select high risk patients.MethodsWe selected 30 consecutive bladder cancer patients at high risk for progression. After endoscopic resection, all patients received (a) induction BCG schedule when needed, and (b) white light and fluorescence cystoscopy after 3 months. HAL at doses of 85 mg (GE Healthcare, Buckinghamshire, United Kingdom) dissolved in 50 ml of solvent to obtain an 8 mmol/L solution was instilled intravesically with a 12 Fr catheter into an empty bladder and left for 90 minutes. The solution was freshly prepared immediately before instillation. Cystoscopy was performed within 120 minutes of bladder emptying. Standard and fluorescence cystoscopy was performed using a double light system (Combilight PDD light source 5133, Wolf, Germany) which allowed an inspection under both white and blue light.ResultsThe overall incidence was 43.3% dysplasia, 23.3% CIS, and 13.3% superficial transitional cell cancer. In 21 patients, HAL cystoscopy was positive with one or more fluorescent flat lesions. Of the positive cases, there were 4 CIS, 10 DYS, 2 association of CIS and DYS, 4 well-differentiated non-infiltrating bladder cancers, and 1 chronic cystitis. In 9 patients with negative HAL results, random biopsies showed 1 CIS and 1 DYS. HAL cystoscopy showed 90.1% sensitivity and 87.5% specificity with 95.2% positive predictive value and 77.8% negative predictive value.ConclusionPhotodynamic diagnosis should be considered a very important tool in the diagnosis of potentially evolving flat lesions on the bladder mucosa such as DYS and CIS. Moreover, detection of dysplasic lesions that are considered precursors of CIS may play an important role in preventing disease progression. In our opinion, HAL cystoscopy should be recommended in the early follow-up of high risk patients.
Highlights
Bladder cancer is costly in both human and societal terms, yet the level of awareness of the disease and its early symptoms is low among the public and health care professionals
The positive cases consisted of 4 carcinoma in situ (CIS), 10 DYS, and 2 associations of CIS and DYS, well-differentiated superficial bladder cancer non-infiltrating to the lamina propria in 4 cases, and chronic cystitis in 1 case
CIS is considered an important risk factor for disease progression because specific survival is heavily affected by the presence of CIS alone or associated with papillary superficial bladder cancer and non papillary T1 tumours [18]
Summary
Bladder cancer is costly in both human and societal terms, yet the level of awareness of the disease and its early symptoms is low among the public and health care professionals. Transitional cells cancer is the most common bladder neoplasm and his infiltrating form may heavily affect the patient survival. In this regard the main challenge is to early diagnose aggressive cancer yet in a limited stage or might be done by identification of a known precursor of CIS called severe dysplasia (DYS) [4,5]. Dysplasia is often located in normal-appearing bladder mucosa and can be missed under standard white-light (WL) cystoscopy [6]. To evaluate fluorescence cystoscopy with hexaminolevulinate (HAL) in the early detection of dysplasia (DYS) and carcinoma in situ (CIS) in select high risk patients
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