Recurrent Bladder Carcinoma Research Articles

The value of exfoliative urine cytology in combination with flexible cystoscopy in the diagnosis of recurrent transitional cell carcinoma of the urinary bladder.

To study the value of exfoliative urine cytology in predicting recurrent tumour in patients undergoing surveillance for transitional cell carcinoma (TCC) and to assess the suitability of these patients for flexible cystoscopy. Specimens of early-morning and freshly voided urine were submitted 2 weeks before surveillance cystoscopy by 111 consecutive patients with known TCC. All patients then underwent cystoscopy under general anaesthesia. The urine specimens were analysed by two pathologists with no knowledge of the patients' history. Cytological findings were correlated with the findings of cystoscopy. Urine cytology predicted 82% of all recurrent tumours found subsequently at cystoscopy; 60% of patients with non-neoplastic pathology had normal cystoscopy. Only 51% of patients with positive urine cytology were shown to have recurrent TCC, but 87% of patients with negative cytology had no recurrent tumours. Urine cytology is a good adjunct to assessing the suitability of flexible cystoscopy in the follow-up of patients with transitional cell tumours.

Nuclear morphometry for improved prediction of the prognosis of human bladder carcinoma.

Histologic grade and clinical stage generally are used for estimating the prognosis of bladder carcinoma. However, both methods have been reported to have a rather low reproducibility and to be unsatisfactory for predicting the recurrence and progression of superficial bladder carcinoma. Recently, nuclear morphometry was used to quantitate the malignant potential of cancer cells in a more objective and reproducible manner. The authors quantitatively analyzed the malignant potential of bladder carcinoma at initial presentation using a combination of several nuclear morphometric variables. The subjects were 156 patients with previously untreated bladder carcinoma. Three morphometric variables were measured in each subject: the mean nuclear volume (MNV), the nuclear roundness factor (NRF), and the variation of nuclear area (VNA). Univariate analysis showed that MNV and NRF were significant prognostic indicators for survival (MNV, P < 0.0001; NRF, P = 0.008). In addition, MNV was a prognostic indicator for tumor recurrence (P = 0.001), whereas MNV and NRF were prognostic indicators for invasive progression (MNV, P = 0.02; NRF, P = 0.009). For accurate prediction of the prognosis of patients with bladder carcinoma, a prognostic score, a recurrence score, and a progression score were designed using the coefficients of MNV and NRF in a proportional hazards model. The prognostic score clearly divided the patients into two different groups with 5-year survival rates of 88% and 64% (P = 0.0002). In addition, patients with superficial bladder carcinoma and a low recurrence score had a significantly higher 5-year recurrence free rate than those with a high recurrence score (40% vs. 23%, P = 0.0004), and the 5-year progression free rate of patients with a low progression score was significantly higher than that of those with a high progression score (98% vs. 73%, P = 0.0006). These findings suggest that nuclear morphometry is a reliable technique with which to identify prognostic indicators for human bladder carcinoma. A combination of several nuclear morphometric variables provides a more accurate indication of prognosis than any single parameter.

Cytokine-mediated antitumor effect of bacillus Calmette-Guérin on tumor cells in vitro.

Intravesical instillation therapy of bacillus Calmette-Guérin (BCG) is a useful modality for recurrent superficial transitional-cell carcinoma (TCC) of the urinary bladder. The mechanism of BCG effect has not yet been well characterized. BCG was tested in vitro for cytokine-mediated antiproliferative activity against T24 and KK47 cells (cell lines established from human TCC of the urinary bladder), and ACHN cells (cell line established from human renal cell carcinoma) using a modified human tumor clonogenic assay. Continuous exposure of cells to BCG at concentrations of more than 5 micrograms/ml in the presence of peripheral blood mononuclear cells (PBMC) consisting of a mixture of 5 x 10(4) monocytes/dish and 5 x 10(5) lymphocytes/dish, obtained from healthy donors, significantly inhibited colony formation of T24 and ACHN cells in comparison with growth inhibition in the absence of PBMC (P < 0.05). Slightly inhibited colony formation was observed with KK47 cells under the same conditions. At the same time various cytokines were measured in supernatants when BCG and the same conditioned PBMC were co-cultured. Tumor necrosis factor alpha (TNF alpha) and interleukin-1 beta (IL-1 beta) were detected at markedly high levels at 24 h, and interferon gamma (IFN gamma) was detected at 120 h. IL-2 and macrophage-colony-stimulating factor were not detected. Neutralizing anti-TNF alpha monoclonal antibody significantly reduced the anti-proliferative activity of ACHN cells, and anti-IFN gamma antibody reduced that of T24 cells. The results obtained suggest that cytokines mediated by BCG play an important role in the antitumor activity of BCG and that the sensitivity of bladder cancer cells to the cytokines induced by BCG may differ considerably.

Selective embolization of internal iliac artery for massive haemorrhage from bladder secondary to carcinoma

Uncontrolled haemorrhage from the urinary bladder secondary to carcinoma can at times be a life-threatening complication. We report a case of recurrent carcinoma of bladder where all the conservative measures for controlling hematuria had failed. Selective embolization of both internal iliac arteries was undertaken which controlled haematuria within 12 hours of the procedure. The procedure had not caused any complication up until the patient was last seen 5 months after the procedure.

Intravesical Epirubicin with and Without Verapamil for the Prophylaxis of Superficial Bladder Tumours

Seventy-five patients with recurrent bladder carcinoma were randomized after electroresection to receive either epirubicin (E) or epirubicin + verapamil (E + V) instillation of the bladder at regular intervals for 2 years. Samples of the bladder wall, tumour tissue and peripheral blood were taken from 20 patients. The average follow-up period was 21 months. Fifty per cent of the patients in the E group and 37% in the E + V group developed recurrent tumours. Recurrence rates (RR) were 6.3 and 4.7, respectively. Before the instillation therapy the RR was 16.0. There was a highly significant reduction of RR during the instillation therapies; in group E p less than 0.005 and in group E + V p less than 0.001. The difference between the treatment groups was not statistically significant. Verapamil increased epirubicin concentrations in both the bladder wall and the tumour tissue, but did not affect concentrations in the peripheral blood. Side effects were few and did not lead to discontinuation of treatment.

MR imaging of bladder neoplasms: Correlation with pathologic staging

This retrospective study describes the accuracy of magnetic resonance (MR) imaging in determination of local disease extent in 34 examinations performed for evaluation of primary or recurrent bladder carcinoma. The 34 examinations were carried out in 29 patients (17 men, 12 women, aged 34-89 years). All studies were followed within 30 days by surgical and pathologic evaluation. Images were interpreted by two radiologists unaware of clinical or pathologic findings. MR imaging staging conformed to the TNM system of the International Union Against Cancer (IUAC). Pathologic evaluation showed bladder neoplasms in all cases; three patients' pathologic specimens contained two or more histologic types of tumors. MR imaging staging of the depth of tumor invasion was correct in 85% of examinations. Sensitivity of MR imaging for detection of deep muscle invasion was 97%, specificity 83%, and accuracy 94%. Sensitivity of MR imaging for detection of extravesical tumor extension was 95%, specificity 100%, and accuracy 97%. Sensitivity for detection of pelvic lymph node metastases was 50%, specificity 100%, and accuracy 82%. Our population included many patients with locally advanced disease. This pattern reflects standards of clinical practice by which superficial lesions are staged and resected endoscopically, and deeply invasive tumors are imaged prior to radical surgery.

One-stage Repair of the Anterior Abdominal Wall Using Bilateral Rectus Femoris Myocutaneous Flaps

Total lower abdominal wall resection was required to remove a recurrent exophytic bladder carcinoma in a 36-year-old woman. The resulting 25 x 30-cm fascial defect was repaired with Marlex mesh. Bilateral rectus femoris myocutaneous flaps were rotated to close the 25 x 18-cm area of skin deficiency. These provided the advantages of robust cover of the lower abdominal wall in a single-stage procedure and primary closure of the donor sites.

Computed Tomography and Magnetic Resonance Imaging before Salvage Cystectomy

Nine patients who developed recurrence of bladder carcinoma following radical radiotherapy were assessed for salvage cystectomy by computed tomography (CT) and magnetic resonance imaging (MRI) to predict extravesical spread. Both tests correctly identified a patient with such advanced local disease that surgery was deemed inappropriate at examination under anaesthesia and both tests indicated that surgery might be difficult in a further patient with inoperable disease. Both tests demonstrated abnormalities in the perivesical and pelvic fat planes in all patients but they had difficulty in distinguishing between malignant infiltration and the effects of radiotherapy. Nevertheless, each test is useful in excluding gross pelvic disease and predicting involvement of adjacent organs. The advantages of the multiplanar images provided by MRI must be balanced against the high cost. CT readily demonstrates the upper abdomen, the kidneys and para-aortic nodes as well as the pelvis and is more widely available.

Recurrence of Superficial Bladder Carcinoma after Intravesical Instillation of Mitomycin‐Comparison of Exposure Times

A total of 70 patients were treated with intravesical instillations of Mitomycin-C (MMC) following transurethral resection for superficial bladder carcinoma. In this randomised prospective study the influence of 2 exposure times (0.5 and 1 h) was studied in relation to tumour recurrence, recurrence interval, tumour progression and toxicity. The number of patients with recurrent tumours was significantly lower in the 1-h group. Tumour progression was seen in only 2 patients in each group and all had primary or secondary carcinoma in situ of the bladder or prostatic urethra. Fourteen patients were excluded from further evaluation because of side effects. A longer instillation time over a longer period and a lower dose of MMC are recommended.

T-zone histiocytes and recurrence of papillary urothelial bladder carcinoma.

We have studied the histologic distribution and prognostic significance of T-zone histiocytes (TZH) in 89 papillary urothelial bladder carcinomas (PUC), 3 cases of nonspecific cystitis (NC) and 4 cases of follicular cystitis (FC) by immunohistochemical determination of S-100 protein. Nineteen (21.37%) of the PUC cases have been found to have TZH S-100-positive with a variable density intratumor, along the papillary axis, or in the lymphoid aggregates of the vesical wall. All four FC cases were also TZH-positive, with a distribution and density similar to those of follicular dendritic cells of lymph nodes, although none of the 3 NC cases presented TZH. The recurrence-free period was significantly (p less than 0.05) longer in TZH-positive patients.

ABH isoantigens in bladder carcinoma patients grouped according to DNA changes over time.

Eighteen patients with transitional cell bladder carcinoma and increasingly abnormal ploidy were assembled to evaluate the relation over time between ploidy and ABH isoantigen deletion. Fifteen patients with diploid recurrent tumors and 16 with aneuploid tumors over time were used as controls. ABH isoantigen deletion at diagnosis was closely related to cancer death, while isoantigen assessments on recurrences gave less prognostic information. Aneuploidy at diagnosis also indicated an adverse prognosis, as did recurrent bladder carcinoma with deteriorating ploidy. Patients with tumors deleted of isoantigen expression at diagnosis but with normal ploidy had as bad a prognosis as patients with deleted tumors and aneuploidy, indicating that isoantigen deletion may occur earlier than ploidy changes.

Bladder carcinoma arising from regenerated urothelium over lyophilized dura patch

Lyophilized human dura was used for augmentation cystoplasty in a women who had a scarred bladder because of multiple resections and fulgurations of superficial bladder tumors. Thirty months later, two sessile tumors developed from the urothelium regenerated over the dura patch, together with infiltrating recurrences elsewhere in the bladder, and a radical cystectomy was performed. This case supports the concept that implantation of tumor cells is a factor in the recurrence of superficial bladder carcinoma.

Urethral recurrence of bladder carcinoma following cystectomy

1978年より1983年までの6年間に施行した男子膀胱腫瘍における膀胱全摘術症例は74例で, 予防的尿道摘出術を施行しなかった65例中7例 (10.8%) に, 膀胱全摘後9ヵ月より61ヵ月 (平均22.1ヵ月) にて尿道再発が認められた. 7例中5例が癌死したが, 5例中4例は他の遠隔転移を伴っており, 尿道再発が死因と考えられたのは1例のみであった. 男子膀胱腫瘍における尿道の取り扱いについて定まった見解はないが, 予防的全摘術としての尿道全摘術を全例に対して適応させることには疑問が残ると考えた. また, 同時予防的あるいは膀胱全摘後の尿道全摘術の適応について文献的考察を行った.

Adjuvant Doxorubicin Hydrochloride and Radiation in Stage D Bladder Cancer: A Preliminary Report

The prognosis of patients with stage D bladder cancer is dismal. This report expands the results of our efforts to modify the clinical course of such patients by administration of doxorubicin hydrochloride sandwiched around pelvic radiation. Pathologic stage D bladder cancer was recognized in 19 patients by evaluation of tissue obtained by radical cystectomy and pelvic lymphadenectomy (8), pelvic lymph node dissection (5) or biopsies (3), ileal conduit and pelvic lymph node biopsy (1), or transurethral biopsy of the bladder and prostate (2). Treatment of these patients with doxorubicin hydrochloride before and after radiation was initiated 3 to 4 weeks postoperatively. The treatment regimen consisted of 1) 60mg. per M.2 doxorubicin intravenously every 3 weeks for 3 cycles, 2) 5,000 rad external radiation to the entire pelvis in 5 to 6 weeks and 3) doxorubicin for 5 cycles. The observed survival rates were 37 per cent at 3 years and 28 per cent at 5 years. The median survival time was 16 months. Five patients had no evidence of disease 13 to 63 months postoperatively. One patient underwent salvage cystectomy for recurrent bladder carcinoma at 33 months and had no evidence of disease at 74 months. One patient was alive with recurrent disease at 13 months. Three patients who died did not complete the protocol owing to metastatic disease, 8 lived 6 to 52 months without recognized disease and died of metastases, and 1 died of a second primary. The extent of surgical excision was not associated significantly with survival. Of 8 patients treated with radical cystectomy 7 suffered a significant obstruction of the small bowel that required decompression or bypass surgery and all 7 recovered completely. These preliminary observations indicate encouraging results with a high but manageable morbidity for this regimen.

Prediction of survival and recurrence in bladder carcinoma

We have followed a large population of patients receiving radiation treatment for bladder carcinoma with respect to survival and recurrence-free survival. Bivariate and multivariate life table analyses have been performed using a set of independent variables. The most important were T class, grade (G), urinary carcinoembryonic antigen (U-CEA) taken before treatment and cytological analysis 4 months after treatment. We compared the usual way of classifying a patient (T + G) with the combination of U-CEA and cytology since the latter two variables seemed to have great prognostic importance. The analyses show that T + G gives the best significance for survival (p = 0.0003) while U-CEA and cytology is better for recurrence-free survival (rho = 0.0002). 0.0002).

Current status of transcatheter management of neoplasms.

Transcatheter arterial infusion and arterial embolization are employed in the treatment of various neoplasms. In patients with carcinoma of the colon metastatic to the liver, the hepatic arterial infusion (HAI) of floxuridine and Mitomycin produced a 55% partial response and a 12% complete response, as well as an improved median survival of 18 months. In metastatic breast carcinoma, a 30% response was achieved. In some cases, proximal embolization of aberrant hepatic arteries was performed to redistribute the hepatic flow to a single vessel to assist infusion of the entire liver using a single catheter. Devascularization by hepatic artery embolization has also been used to treat hepatic neoplasms. Arterial occlusion of renal carcinoma, followed after four to seven days by nephrectomy and hormonal therapy, produced a 36% response rate in 49 patients with distant metastases. In 14 patients with osteosarcoma treated with cis-diaminedichloroplatinum (CDDP) arterial infusion, a 57% response rate was achieved. Benign bone tumors were treated with arterial occlusion with a 60% response rate. Tumors of the pelvis were managed by bilateral internal iliac artery infusion using CDDP. In 21 patients with recurrent bladder carcinoma, control of pain and hematuria and prolonged survival were achieved.

Peripheral neuropathy associated with cis-dichlorodiammineplatinum (II) treatment

Peripheral neuropathy developed in two cases of recurrent bladder carcinoma treated with Cis-dichlorodiammineplatinum (II) (DDP) at a dose of 75 mg/m2 IV every 3 weeks. The neuropathy appeared in both patients while they were achieving a subjective and objective response to DDP. The neuropathy was reversible in one patient. In the other patient, a disabling sensory neuropathy progressed despite cessation of therapy. The temporal relationship between the neurological symptoms and the administration of DDP implicate this drug as the possible causative agent in the peripheral neuropathy.

Transfer of adoptive immunity by intra-arterial injection of tumor-immune pig lymph node cells: Treatment of recurrent urinary bladder carcinoma after radical radiotherapy

Twenty four patients with invasive transitional cell carcinoma of the urinary bladder, recurrent after radical radiotherapy, were treated by intra-arterial infusion of tumor-immune pig lymph node cells. In 11 patients there was a remission of the disease process, and 3 patients remain alive and free of disease in excess of one year after treatment.

Chemotherapy in bladder carcinoma.

In a series of patients with recurrent bladder carcinoma, treatment with various cytostatic drugs was generally unsatisfactory in cases of infiltrating carcinoma. Better results were achieved using instillation of Thiotepa for bladder papillomatosis and by instillation of Adriamycin for carcinoma in situ.

BONE FORMATION IN METASTASIS FROM CARCINOMA OF URINARY BLADDER: REPORT OF A CASE WITH REVIEW OF THE LITERATURE

SUMMARY A male aged 54 developed recurrent carcinoma of urinary bladder. No bone formed in the stroma of the bladder growths at any time, but well-formed bone was present in the stroma of a metastasis in the abdominal wall. The literature of osseous metaplasia in such tumours is reviewed and its pathogenesis discussed.