Perivesical Fat Invasion Research Articles

Identifying the driver histology responsible for the inferior clinicopathologic features associated with plasmacytoid bladder cancer.

e16505 Background: Plasmacytoid urothelial cancer (PUC) is notorious for its spread along fascial planes which reportedly induces worse clinicopathologic. Usually, PUC is present with Conventional UC (CUC); however, the precise assessment of the PUC component in key pathological findings and its effect on clinical behavior has not been delineated. Methods: We performed a retrospective review of patients with PUC who underwent cystectomy at Moffitt Cancer Center between 2012-2022. Repeat histological review of all specimens by specialty trained genitourinary pathologists was performed (AV, ED). Positive margins and lymph nodes were examined and classified by histological subtype. We calculate the proportion of tissue sections with peri-vesical fat invasion in tumor tissue sections submitted from cystectomy specimen in pT3 cases as the microscopic surrogate for macroscopic pT3 sub staging (termed Peri-vesical Fat Invasion Ratio, PFIr). Pearson’s correlation coefficient was used to measure strength and direction of relationship between variables. Kaplan-Meier (KM) analysis was performed for overall survival (OS). Results: Population consists of 44 patients undergoing cystectomy for PUC. Median age was 70 (IQR 63-75) years old with 82% being male. Majority of patients (52.5%) had ≥cT3 disease and 55% received neoadjuvant chemotherapy (NAC). Median percent of plasmacytoid histology was 20% (IQR 5-80%) with 6 (14%), 2 (5%), 5 (11%), 16 (36%), and 15 (34%) being pT0, pT1, pT2, pT3, and pT4, respectively. Of the patients with pT3 disease, 6 were pT3a with a median 78% (IQR 39-82%) PFIr while 10 were pT3b with an associated median PFIr of 56% (42-63%). In total, 14 (32%) patients had positive soft tissue surgical margin, with 11 (79%) being of PUC histology and ten patients with a positive ureteral margin, 80% of which consisted of PUC histology. A total of 97 lymph nodes removed were positive for malignancy with 51.5% demonstrating PUC and 48.5% CUC histology. Univariate analysis confirmed an increasing percentage of PUC histology portended a worse OS (HR 3.27, 95% CI 1.22-8.73, p = 0.018). Additionally, we calculated Pearson’s correlation coefficient for percent of plasmacytoid histology with pathologic tumor stage (r = 0.468, p = < 0.001), soft tissue margin (r = 0.283, p = 0.031), and lymph node density (r = 0.264, p = 0.138). Finally, KM analysis for histologic subtype (PUC vs CUC) at positive margin or positive lymph did not affect OS (p > 0.05), likely a product of our small numbers. Conclusions: The plasmacytoid component of bladder cancer is more likely to spread through direct extension along tissue planes to the surrounding soft tissue and ureters rather than through lymphatics. Also, given the discohesive nature of PUC histology, gross peri-vesical extension may be an inadequate method of sub-stratifying stage pT3 disease.

Perivesical Fat Invasive Pattern as Prognostic Factor and Predictor of Response to Adjuvant Chemotherapy in T3 Stage Bladder Cancer

BackgroundThe prognostic value of the distinction between microscopic (pT3a) and macroscopic (pT3b) perivesical fat invasions remains a subject of debate. To explore whether the pattern of perivesical fat invasion can serve as a prognostic factor to better subgroup T3 stage bladder cancer. Materials and MethodsOne hundred and forty-nine patients diagnosed with T3 stage bladder cancer at Sun Yat-sen University Cancer Center (SYSUCC) were selected for the experimental cohort in this study. Ninety-seven T3 stage bladder cancer patients with pathological slices at the Cancer Genome Atlas (TCGA) were selected as validation cohort in this study. The perivesical fat invasive pattern was examined with hematoxylin and eosin-stained pathological slides by two pathologists independently. Two different perivesical fat invasive patterns, fibrous-surrounded (FS) pattern, and nonfibrous-surrounded (NFS) pattern were assessed. ResultsPerivesical fat invasion pattern had a significant influence on overall survival in T3 stage bladder cancer. Compared to the NFS pattern, the FS pattern was related to a better prognosis in both the SYSUCC cohort and TCGA cohort. The patients with NFS pattern tumor who underwent cisplatin-based adjuvant chemotherapy experienced an obvious improvement compared to observation after radical cystectomy in overall survival in the SYSUCC cohort. ConclusionThe perivesical fat invasion pattern could predict prognosis and clinically different chemotherapeutic survival outcomes in patients with T3 stage bladder cancer after radical cystectomy.

PD44-01 ACCURACY OF ACTUAL STAGE PREDICTION USING VESICAL IMAGING-REPORTING AND DATA SYSTEM (VI-RADS) BEFORE RADICAL CYSTECTOMY FOR UROTHELIAL CARCINOMA

You have accessJournal of UrologyCME1 Apr 2023PD44-01 ACCURACY OF ACTUAL STAGE PREDICTION USING VESICAL IMAGING-REPORTING AND DATA SYSTEM (VI-RADS) BEFORE RADICAL CYSTECTOMY FOR UROTHELIAL CARCINOMA Si Hyun Kim, Jang Hee Han, Seung-Hwan Jeong, Hyeong Dong Yuk, Chang Wook Jeong, Cheol Kwak, Hyeon Hoe Kim, and Ja Hyeon Ku Si Hyun KimSi Hyun Kim More articles by this author , Jang Hee HanJang Hee Han More articles by this author , Seung-Hwan JeongSeung-Hwan Jeong More articles by this author , Hyeong Dong YukHyeong Dong Yuk More articles by this author , Chang Wook JeongChang Wook Jeong More articles by this author , Cheol KwakCheol Kwak More articles by this author , Hyeon Hoe KimHyeon Hoe Kim More articles by this author , and Ja Hyeon KuJa Hyeon Ku More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003354.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Previous studies using the vesical imaging reporting and data system (VI-RADS) to predict muscle-invasive bladder cancer had some limitations. Most studies were performed with transurethral resection of bladder tumor specimens with few samples. This study was conducted to address these shortcomings and confirm the accuracy of VI-RADS for bladder cancer. METHODS: This study used data from the Seoul National University Prospectively Enrolled Registry for Urothelial Cancer–Radical Cystectomy (SUPER-UC-Cx). Patients who underwent multiparametric magnetic resonance imaging (mp-MRI) before radical cystectomy were included in this study between March 2020 and March 2022. All images were reported by radiologists and reviewed by two urologists. The patient characteristics and clinical information were blinded during the review. The performance of qualitative and quantitative variables in predicting muscle layer invasion or perivesical fat infiltration was verified by receiver operating characteristic (ROC) curve analysis. RESULTS: Of 208 patients, 182 (87.5%) underwent mp-MRI before radical cystectomy. Twenty-three patients with non-urothelial carcinoma, inappropriate MRI scans, and bladder filling were excluded. Cut-off for muscle invasion, VI-RADS score of 4 had the highest area under the curve (AUC) (sensitivity 0.84; specificity 0.93; accuracy 0.90; positive predictive value (PPV) 0.84; negative predictive value (NPV) 0.93, and AUC 0.88). Cut-off for perivesical fat invasion and VI-RADS score of 5 had the highest AUC (sensitivity, 0.78; specificity, 0.99; accuracy, 0.95; PPV, 0.96; NPV, 0.95; and AUC, 0.89). CONCLUSIONS: VI-RADS is a good predictor of bladder cancer staging before radical cystectomy and is especially helpful in predicting muscle invasion and perivesical fat infiltration. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1124 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Si Hyun Kim More articles by this author Jang Hee Han More articles by this author Seung-Hwan Jeong More articles by this author Hyeong Dong Yuk More articles by this author Chang Wook Jeong More articles by this author Cheol Kwak More articles by this author Hyeon Hoe Kim More articles by this author Ja Hyeon Ku More articles by this author Expand All Advertisement PDF downloadLoading ...

Accuracy of actual stage prediction using Vesical Imaging Reporting and Data System (VI-RADS) before radical cystectomy for urothelial carcinoma in SUPER-UC-Cx.

Previous studies using the Vesical Imaging Reporting and Data System (VI-RADS) to predict muscle-invasive bladder cancer (MIBC) had some limitations. Most studies were performed with transurethral resection of bladder tumor (TUR-BT) specimens with few samples. This study was conducted to address these shortcomings and confirm the accuracy of VI-RADS for bladder cancer. This study used data from the Seoul National University Prospectively Enrolled Registry for Urothelial Cancer-Radical Cystectomy (SUPER-UC-Cx). Patients who underwent multiparametric magnetic resonance imaging (mp-MRI) before radical cystectomy (RC) were included in this study between March 2020 and March 2022. All images were reported by radiologists and reviewed by two urologists. The patient characteristics and clinical information were blinded during the review. The performance of qualitative and quantitative variables in predicting muscle layer invasion or perivesical fat infiltration was verified by receiver operating characteristic (ROC) curve analysis. Of 208 patients, 182 (87.5%) underwent mp-MRI before RC. Twenty-three patients with non-urothelial carcinoma, inappropriate MRI scans, and bladder filling were excluded. Cut-off for muscle invasion, VI-RADS score of 4 had the highest area under the curve (AUC) (sensitivity 0.84; specificity 0.93; accuracy 0.90; positive predictive value (PPV) 0.84; negative predictive value (NPV) 0.93, and AUC 0.88). Cut-off for perivesical fat invasion and VI-RADS score of 5 had the highest AUC (sensitivity, 0.78; specificity, 0.99; accuracy, 0.95; PPV, 0.96; NPV, 0.95; and AUC, 0.89). VI-RADS is a good predictor of bladder cancer staging before RC and is especially helpful in predicting muscle invasion and perivesical fat infiltration.

PD03-03 HOW EFFECTIVE IS MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING VESICAL IMAGING REPORTING AND DATA SYSTEM (VI-RADS) FOR BLADDER CANCER STAGING: CAN IT REPLACE RE STAGING TRANSURETHRAL RESECTION OF BLADDER CANCER IN BLADDER CANCER?

You have accessJournal of UrologyBladder Cancer: Non-invasive I (PD03)1 Apr 2020PD03-03 HOW EFFECTIVE IS MULTIPARAMETRIC MAGNETIC RESONANCE IMAGING VESICAL IMAGING REPORTING AND DATA SYSTEM (VI-RADS) FOR BLADDER CANCER STAGING: CAN IT REPLACE RE STAGING TRANSURETHRAL RESECTION OF BLADDER CANCER IN BLADDER CANCER? Muhammad Abdus Salam*, Sharmin Akther, Faisal Islam, Pranashish Saha, Ibrahim Kaiser, Ghazi Shahinul Islam, Shahed Hossain, and SM Bakhtiar Muhammad Abdus Salam*Muhammad Abdus Salam* More articles by this author , Sharmin AktherSharmin Akther More articles by this author , Faisal IslamFaisal Islam More articles by this author , Pranashish SahaPranashish Saha More articles by this author , Ibrahim KaiserIbrahim Kaiser More articles by this author , Ghazi Shahinul IslamGhazi Shahinul Islam More articles by this author , Shahed HossainShahed Hossain More articles by this author , and SM BakhtiarSM Bakhtiar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000823.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Multiparametric MRI (mpMRI) is widely used in the imaging of other types of cancers, though its usefulness in Urothelial cancer of bladder has yet to be fully elucidated. We wanted to determine the efficacy of staging accuracy of routine use of mpMRI and VI-RADS (Vesical Imaging-Reporting And Data System) in staging Urothelial bladder cancer. METHODS: This prospective study was undertaken on 62 patients with mpMRI and VI-RADS in staging high grade Urothelial bladder cancer. Primary Transurethral resection of bladder tumor ( TURBT) mpMRI was performed routinely in all cases, from Jan 2018 to July 2019. Of them 36 patients with High grade Urothelial carcinoma of bladder, the specimen did not contain Muscularis Propria requiring a Restaging TURBT. Radical cystectomy was performed in 18 patients during this time frame. The mpMRI staging was correlated with the final pathologic staging. RESULTS: Analysis of our results revealed a highly significant (P<-0.001) mpMRI accuracy of 88% for muscle invasion, 96% accuracy for perivesical fat invasion and 74% accuracy of MRI detection of lymph node metastases. CONCLUSIONS: A larger prospective study is however, required for determining the exact role of MRI in the staging of bladder carcinoma. Source of Funding: No Sponsor © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e72-e73 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Muhammad Abdus Salam* More articles by this author Sharmin Akther More articles by this author Faisal Islam More articles by this author Pranashish Saha More articles by this author Ibrahim Kaiser More articles by this author Ghazi Shahinul Islam More articles by this author Shahed Hossain More articles by this author SM Bakhtiar More articles by this author Expand All Advertisement PDF downloadLoading ...

Dynamic magnetic-resonance cystography in diagnosis of perivesical fat invasion in bladder cancer

Objective: to evaluate the diagnostic capabilities of the dynamic magnetic-resonance cystography technique in detecting invasion of perivesical fat in case of bladder cancer.Materials and methods. The study included 125 patients (105 male and 20 females, mean 62.6 Ѓ} 11.0 years) with transitional cell carcinoma of the bladder. To assess the accuracy of the dynamic cystography method, cases with a tumor size of more than 20 mm, affecting the wall outside the bladder triangle, were selected with suspicion of perivesical fat invasion on magnetic-resonance scans. A furacilin solution was fractional injected into the catheterized bladder to obtain repeated series of T2‑haste-FS images until the bladder was completely expanded.Results. In postprocessing, the selection of areas of interest (ROI) was performed along the contour of the affected wall in the cross section through the center of the tumor. Comparison of the displacement of the affected and intact walls by a diagram of the values of the intensity of the magnetic-resonance signal in the dynamics of bladder dilatation was evaluated. The verification method was the morphological study of the surgical material after the operative treatment. The limit of values with a more likely lesion of perivesical fat was found, which is less than 11 % of the intensity change of the magnetic-resonance signal in selected ROIs during bladder wall expansion.Conclusion. The effectiveness of dynamic magnetic-resonance cystography in the differential diagnosis of perivesical fat infiltration in bladder cancer is characterized by a sensitivity of 90.0 %, a specificity of 93.3 %, and an accuracy of 92.0 %. The proposed technique improves the accuracy of the magnetic resonance imaging method with suspected infiltration of perivesical fat and is well tolerated by patients.

Reassessment of the predictive role of perivesical fat invasion in invasive bladder cancer prognosis in 151 Chinese patients.

Perivesical fat invasion is considered as an important prognostic factor for bladder cancer. However, the predictive role of perivesical fat invasion in invasive bladder cancer prognosis has never been reported in Chinese patients. The aim of the study was to assess the predictive value of perivesical fat invasion for prognoses of T2 and T3 bladder cancer in Chinese patients. One hundred and fifty-one patients who underwent radical cystectomy for pT2-3N0M0 invasive bladder cancer from 2001 to 2007 were studied. Cancer-specific survival rate (CSS) and recurrence-free survival rate (RFS) were compared between the pT2 and pT3 patient groups. Other clinicopathological parameters were also retrospectively analyzed by univariate and multivariate analyses to identify the independent predictor for the prognoses of this cohort. Average patient age at surgery was 58 years. Ninety (60.3%) patients had grade I and II disease. During follow-up (median 66 months), 27 patients (17.9%) had tumor recurrence and 18 (11.9%) died of bladder cancer. In the univariate analysis, the CSS and RFS curves between T2 and T3 patients showed no significant difference (P = 0.756 and 0.354, respectively). Multivariate Cox regression showed that histological classification and grade were independent predictors for CSS, while grade was the sole independent predictor for RFS. For this group of Chinese patients, perivesical fat invasion did not demonstrate a statistically significant difference in prognosis between T2 and T3 patients. Nontransitional cell carcinoma (non-TCC) and high-grade patients had short CSS, and patients with high-grade tumor had higher recurrent risk.

A case of polypoid and papillary cystitis mimicking an advanced bladder carcinoma with invasion of perivesical fat

A rare case of polypoid and papillary cystitis without a history of catheterization is reported. A 69-year-old man was admitted to our hospital because of pain during urination and gross hematuria. The cystscopic and imaging findings including ultrasound, CT, and MR image showed an irregular wall thickening and stranding in the perivesical fat, which indicated an advanced bladder carcinoma, but histopathological findings obtained by transurethral resection revealed polypoid and papillary cystitis. Such benign lesions need to be discussed in the differential diagnosis of patients with bladder tumor to avoid excessive resection.

The usefulness of diffusion-weighted magnetic resonance imaging in bladder cancer staging and functional analysis.

We assessed the effect of adding diffusion-weighted magnetic resonance imaging (DW-MRI) to conventional MRI for T staging and the correlation between apparent diffusion coefficient (ADC) values and clinicopathological parameters for patients with bladder cancer. We retrospectively reviewed the records of 160 patients with bladder cancer who underwent MRI at our institute. All patients were routinely assessed with conventional MR imaging. Since January 2008, we added DW-MRI. In these 160 patients, 127 (79.4%) tumors were detectable by MRI. In all patients with detectable tumors, on a stage-by-stage basis, 96 (75.6%) of 127 patients received the correct diagnosis. With DW-MRI, accurate diagnosis was obtained in 80 (80.0%) of 100 cases; without DWI in only 16 (59.3%) of 27 cases (P=0.026). For T staging, the accuracy for distinguishing muscle invasion (T≦1 vs T≧2) with DW-MRI (83.0%) was superior to that without DW-MRI (66.7%). The accuracy for distinguishing perivesical fat invasion (T≦2 vs T≧3) with DW-MRI (98.0%) was also superior to that without DW-MRI (92.6%). The ADC values were significantly related with tumor diameter (<3 cm vs ≧3 cm, P<0.001), histopathological grade (low grade vs high grade, P<0.001), T stage (≦T1 vs ≧T2, P<0.001), and operative method (transurethral resection vs total cystectomy, P<0.001). We demonstrated that DW-MRI is not only useful for bladder cancer T staging, but also a prognostic factor for patients with bladder cancer.

Neuroendocrine carcinoma of the urinary bladder: a retrospective study of CT findings

The purpose of this study was to evaluate the radiographic features of neuroendocrine carcinoma of the urinary bladder (NECB) on CT and to review the literature regarding carcinogenesis, treatment, and prognosis. The presenting CT of patients with pathology-proven NECB were retrospectively reviewed for features including size and appearance of the bladder mass, the presence of hydronephrosis, bladder wall thickening, invasion of perivesical fat, lymph nodes, and distant metastasis. Follow-up imaging and the medical record were reviewed to determine patient treatment and overall survival. Sixteen patients (13 males, 3 females) were diagnosed with NECB with a mean age of 75.5 years (range 48-90). The characteristic CT appearance was a large polypoid bladder mass (average size 4.9 cm). Extension into the perivesical fat, adjacent organ involvement, and distant metastases were common. NECB is an aggressive primary neoplasm of the bladder that presents on CT as a large bladder mass with local extension into the perivesical fat, involvement of adjacent organs, and metastasis.

Perivesical fat invasion in bladder cancer: implications for prognosis comparing pT2b, pT3a and pT3b stages and consequences for adjuvant chemotherapy indications

Study Type--Therapy (retrospective cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? The more that bladder cancer progresses from the urothelium to the outside of the bladder the worse the prognosis. To date, the use of adjuvant chemotherapy has not been completely defined. The present study clarifies the prognosis and benefits of adjuvant chemotherapy for different stages of bladder cancer that invade perivesical fat. • To assess the prognosis of pT2b, pT3a and pT3b bladder cancers after radical cystectomy (RC) in order to define potential situations where chemotherapy may be of benefit. • Between 1985 and 2009, 903 patients underwent a RC and pelvic bilateral lymphadenectomy in an Institutional Referral Centre. • In all, 87 patients (9.6%) had a pT2b tumour, 111 patients (12.3%) a pT3a tumour, and 129 patients (14.3%) a pT3b tumour. • The median (range) overall follow-up was 23 (1-350) months. • Overall (OS), disease-specific (DSS), metastases-free (MFS) and local recurrence-free survival (LRFS) was estimated and compared using Kaplan-Meier plots and log-rank test. • The 5-year survivals pT2b and pT3a were similar for LRFS (86% vs 84%), MFS (69% vs 63%), DSS (72% vs 70%) and OS (66% vs 61%), and the prognosis was better than for pT3b stage tumours (69%, 44%, 40%, and 31% respectively). • In pN0 disease, MFS differences between pT2b-pT3a and pT3b tumours were not significant in patients who had received adjuvant chemotherapy (MSF of 87%, 69% and 56%, respectively) while they were significant in patients without adjuvant chemotherapy (MFS of 70%, 68% and 42%, respectively). • Bladder cancers invading perivesical tissue macroscopically have a greater propensity to produce lymph node metastases, local recurrence, and have lower MFS, DSS, and OS. In pN0 disease, pT3b tumours may receive more benefit from adjuvant chemotherapy. • Our results could be a useful for selecting patients for adjuvant chemotherapy.

External Validation of a Risk Model to Predict Recurrence-Free Survival After Radical Cystectomy in Patients With Pathological Tumor Stage T3N0 Urothelial Carcinoma of the Bladder

Patients with stage pT3N0 urothelial bladder cancer vary in outcome after radical cystectomy. To improve prognosis estimation a model was recently developed that defines 3 risk groups for recurrence-free survival based on pT substaging, lymphovascular invasion and positive surgical margin. We present what is to our knowledge the first external validation of this risk model. Analogous to the risk model derivation cohort our study group comprised 472 patients with stage pT3, pN0, cM0 disease without perioperative chemotherapy and with a median followup of 42 months (IQR 20-75). The primary end point was recurrence-free survival. The effect of variables was determined by univariate and multivariate Cox regression analysis, and predictive accuracy was determined by ROC analysis. Stage pT3aN0 and pT3bN0 cases showed significantly different recurrence-free survival after 5 years (51% vs 29%, p<0.001). In the multivariate Cox model pT3 substage (HR 1.86, p<0.001), lymphovascular invasion (HR 1.48, p=0.002), positive surgical margins (HR 1.90, p=0.030) and patient age with a dichotomy at 70 years (HR 1.51, p=0.001) had an independent effect on recurrence-free survival. In the low (221 patients or 47%), intermediate (184 or 39%) and high (67 or 14%) risk groups the 5-year recurrence-free survival rate was 55%, 45% and 13%, respectively (p<0.001). The concordance index of the risk model to predict recurrence-free survival was 0.64 (95% CI 0.59-0.69). This user friendly risk model can be recommended to estimate prognosis in patients with stage pT3N0 after radical cystectomy. Patients at high risk showed clearly compromised recurrence-free survival and should be included in adjuvant therapy studies.

Prognostic Risk Stratification of Pathological Stage T3N0 Bladder Cancer After Radical Cystectomy

Patients with pathological T3N0 stage urothelial carcinoma of the bladder show a range of outcomes after radical cystectomy. Given that nomograms have included heterogeneous groups of patients, we focused on and stratified patients with pT3N0 urothelial carcinoma of the bladder after radical cystectomy into prognostically different risk groups to facilitate the development of adjuvant therapy trials for those at high risk. The study comprised a total of 578 patients from 9 centers worldwide with pT3N0 urothelial carcinoma of the bladder who underwent radical cystectomy without perioperative chemotherapy. We evaluated the effect of pT3 substage at radical cystectomy, age, grade, lymphovascular invasion, margin status and number of lymph nodes removed on recurrence-free survival using Cox regression analysis. A weighted prognostic model was devised. Median followup was 39.4 months (IQR 64). On multivariate analysis pT3 substage at radical cystectomy (pT3b vs pT3a HR 2.056, p <0.0001), lymphovascular invasion (positive vs negative HR 2.004, p <0.0001) and margin status (positive vs negative HR 2.503, p = 0.002) were associated with recurrence-free survival (concordance index 0.66) in the context of generally adequate lymph node dissection, that is with a median of 17 removed. Three risk groups were devised based on weighted variables with a 5-year recurrence-free survival rate of 79% (95% CI 70-84), 57% (95% CI 50-64) and 37% (95% CI 26-48) in the low, intermediate and high risk groups, respectively. We constructed a user friendly prognostic risk model for patients with pT3N0 urothelial carcinoma of the bladder treated with radical cystectomy based on pT3 substage at radical cystectomy, lymphovascular invasion and margin status. These data warrant validation and may enable tailored monitoring and selection of appropriate patients for adjuvant therapy trials.

Microscopic Invasion of Perivesical Fat by Urothelial Carcinoma: Implications for Prognosis and Pathology Practice

To determine whether microscopic invasion of perivesical fat by urothelial carcinoma (stage pT3a) confers a different prognosis relative to deep muscle invasion (pT2b) and/or gross extravesical extension (pT3b) among patients with a given nodal status treated by cystectomy. Cancer records for patients diagnosed with stage pT2b-pT3b bladder cancer from 1998-2006 were obtained from the SEER database (n = 2388). Pathologic substage (pT3a vs pT2b vs pT3b) was the primary covariate of interest. Other covariates included age, sex, race, grade, number of nodes examined, number of positive nodes, nodal stages, and radiotherapy. Cox regression model was used to estimate the covariate-adjusted effect of tumor substages on all-cause mortality. The risk of nodal metastases increased with increasing substage (pT2b = 20%, pT3a = 36%, pT3b = 48%, trend P <.001). Among patients with node-negative tumors, the adjusted hazard ratios for all-cause mortality were 1.68 (P <.001) for pT3a vs pT2b and 1.03 (P = .78) for pT3b vs pT3a tumors, whereas for node-positive disease, they were 1.42 (P = .009) for pT3a vs pT2b and 1.44 (P = .001) for pT3b vs pT3a tumors. Microscopic invasion of perivesical fat was associated with significantly inferior survival relative to pT2b disease of the same nodal status. For node-positive pT3 tumors, more advanced pathologic substage (pT3b vs pT3a) was also associated with decreased survival. Our findings support the current practice of pathologic distinction between pT2b and pT3a disease and substaging of extravesical tumors based on microscopic versus gross extravesical extension.

Laparoscopic Cystoprostatectomy in a Heart Transplant Recipient

A 72-year-old orthotopic cardiac transplant recipient with multiple, previously resected, cutaneous squamous cell carcinoma (SCC) presented with invasive SCC of the urinary bladder. At surgery, clot retention was managed with clot evacuation and continuous bladder irrigation to facilitate dissection. Laparoscopic cystoprostatectomy and bilateral pelvic lymph node dissection with extracorporeal ileal conduit urinary diversion were performed in 6 hours without complication. This approach minimized blood loss and allowed sufficient time out of steep Trendelenberg to reequilibrate the patient's cardiovascular system. Final pathology revealed SCC with perivesical fat invasion. This immunocompromised patient remains disease free 2 months after resection.

Radical Cystectomy for Carcinoma of the Bladder: 2,720 Consecutive Cases 5 Years Later

We performed a critical analysis of the results of radical cystectomy for invasive bladder carcinoma treated at 1 center. Between 1970 and 2000, 2,090 men and 630 women with invasive bladder cancer were treated with 1-stage radical cystectomy and urinary diversion. Followup ranged from 0 to 34.2 years with a mean of 5.5 +/- 5.7. Survival data were correlated to patient and tumor characteristics using univariate and multivariate analysis. Postoperative mortality was 2.6%. Squamous tumors accounted for 49.4% of cases, transitional cell carcinoma for 36.4% and adenocarcinoma for 9.6%. Regional lymph nodes were involved in 20.4% of cases. The 5 and 10-year disease-free survival rates were 55.5% and 50.03%, respectively. Evidence was provided that tumor stage, histological grade and lymph node status are the only independent variables which affect survival probability. Contemporary cystectomy can be performed with minimal mortality. Radical cystectomy for organ confined disease is followed by good therapeutic results and enhances the possibilities for functional restoration. With stage progression there is a stepwise reduction in survival probability. The radical operation can provide disease-free survival for an important subgroup of node positive cases (27.3%). Additional therapy is needed to improve the oncological outcome for advanced locoregional disease.

Macroscopic, but not microscopic, perivesical fat invasion at radical cystectomy is an adverse predictor of recurrence and survival

To examine whether the presence of microscopic (pT3a) or macroscopic (pT3b) disease worsens the prognosis relative to pT2 disease at radical cystectomy, as the prognostic significance of pT3a vs pT3b perivesical fat invasion (pT3) is controversial. In all, 242 patients with pT3 disease (pT3a in 88, pT3b in 121) had radical cystectomy and bilateral pelvic lymphadenectomy for transitional cell carcinoma of the urinary bladder; they were compared with 172 who had organ-confined muscle-invasive disease (pT2). For the analyses we used univariable and multivariable Cox regression models of recurrence and cancer-specific survival, adjusted for age, tumour grade, lymphovascular invasion and the presence of lymph node metastases. In multivariable analyses, microscopic perivesical fat extension (pT3a) was not associated with higher recurrence (P = 0.3) or the mortality rate (P = 0.06) vs pT2 disease. Conversely, the presence of deep perivesical fat extension (pT3b) was associated with 1.8 times the rate of recurrence (P = 0.002) and with twice the rate of death (P = 0.001) vs pT2 disease. These findings imply that a detailed assessment of the cystectomy specimen for the presence of microscopic perivesical fat invasion might not be necessary, as the presence of pT3a disease has no strong effect on recurrence or mortality. Moreover, patients with pT3a disease might not require more aggressive therapy than their counterparts with pT2 disease. However, further validation of our data is required.

Primary Invasive versus Progressive Invasive Transitional Cell Bladder Cancer: Multicentric Study of Overall Survival Rate

Introduction and Objective: When feasible, the treatment for all-invasive bladder cancer is radical cystectomy. The aim of the present study was to analyze the prognostic difference, disease-specific survival rate, of muscle-invasive transitional cell cancer of the bladder (TCCB) for progressive invasive TCCB. Patients and Methods: A retrospective multicentric analysis was performed studying a total of 242 patients who underwent radical cystectomy for invasive TCCB from 1993 to 2005. The patients were divided into two groups: group 1 included 57 patients with progressive invasive TCCB, and group 2 included 185 patients with primary invasive TCCB. Both groups were further divided according to the pathological findings in pT2/3 (muscle and/or perivesical fat invasion), pT4 (adjacent organs/structure invasion), N+ (positive lymphatic nodes) and M+ (distant organ metastasis). Several tests were employed for statistical analysis: χ², Mann-Whitney, Kaplan-Meier method and Wilcoxon (Breslow) method were used to compare the possible survival curve differences of groups 1 and 2. Multivariated analysis determined by proportional risk regression excluded sex, age and disease stage interferences in the final results. Results: The average time for a superficial TCCB to become muscle-invasive was 37.4 months, and the average number of transurethral resections performed in each patient was 3. The average and median global survival rates were, respectively, 96 and 88 months in group 1 and 98 and 90 months in group 2, without a statistically significant difference (p = 0.0734). The 1-year survival rate was 84.32% in group 1 and 76.54% in group 2. After 3 years of follow-up the survival rate fell to 74.50% in group 1 and to 59.05% in group 2. Finally, the 5-year survival rate was 57.94% in group 1 and 52.24% in group 2. Conclusion: In the present study, patients with primary invasive and progressive invasive TCCB showed a similar 5-year disease-specific survival rate. Pathological stage (pTN, N and M) and patient demography did not interfere with the results.