Repeat Transurethral Resection Of Bladder Tumor Research Articles

The Feasibility and Diagnostic Adequacy of PD-L1 Expression Analysis Using the Cytoinclusion Technique in Bladder Cancer: A Prospective Single-Center Study.

Background: Programmed death-ligand 1 (PD-L1) expression has been recognized as a potential biomarker for various cancers, yet its diagnostic and prognostic significance in urothelial bladder cancer (BCa) requires further investigation. Methods: In this prospective single-center study, we aimed to assess the feasibility and diagnostic adequacy of PD-L1 expression analysis using cytoinclusion in BCa patients. We enrolled consecutive patients undergoing endoscopic transurethral resection of bladder tumor (TURBT), repeat TURBT, or robot-assisted radical cystectomy. Urinary and tissue specimens were collected from these patients for cytoinclusion and histopathological analysis to evaluate PD-L1 expression. Results: Out of 29 patients, PD-L1 expression was detected from cytoinclusion in 42.8% (3 out of 7), 10% (1 out of 10), and 66.8% (8 out of 12) of patients with negative/papilloma, low-grade, and high-grade tumors, respectively. Conversely, histopathological analysis identified PD-L1 expression in 57.2% (4 out of 7), 30% (3 out of 10), and 83.3% (10 out of 12) of patients with negative/papilloma, low-grade, and high-grade tumors, respectively. The diagnostic concordance between cytoinclusion and histopathology was 85.7%, 80%, and 83.3% in patients with negative/papilloma, low-grade, and high-grade tumors, respectively. Conclusions: Our study underscores the promise of cytoinclusion as a minimally invasive method for quantifying urinary PD-L1 percentages. This approach could serve as both a potential prognostic and diagnostic indicator, easily obtainable from urine samples. Standardizing this technique could facilitate its widespread use as a valuable tool.

Cell-free urinary tumor DNA to detect minimal residual disease prior to repeat-transurethral resection of bladder tumor in non-muscle invasive bladder cancer: A prospective study.

e16598 Background: Cell-free urinary tumor DNA (utDNA) generated from tumor genomic sequencing is an emerging biomarker showing tremendous potential for detecting minimal residual disease (MRD) in muscle-invasive and metastatic bladder cancer. We performed a prospective study to assess utDNA’s ability to measure MRD at the time of standard-of-care repeat transurethral resection of bladder tumor (rTURBT) in non-muscle invasive bladder cancer (NMIBC). Methods: Patients with high-risk NMIBC were enrolled prior to rTURBT. Index tumor and rTURBT mutational profile was performed via PredicineWES whole exome sequencing across 20,000 genes. Genes with non-synonymous (NS) mutations observed in index and rTURBT specimens identified in a minimum of two samples are reported. Urine samples were taken immediately prior to r-TURBT. utDNA detection was performed by ultra-deep sequencing of urinary cfDNA using a custom panel of up to 50-baseline mutations per patient together with a fixed core panel covering hotspot regions and actionable variants via PredicineBEACON Urinary tumor fraction was used to call utDNA positivity. The primary endpoint was the detection of utDNA to predict MRD at the time of repeat-TURBT. Results: Eleven patients underwent rTURBT for high risk NMIBC. Residual tumor was detected at rTURBT in 8/11 (73%) patients. Fifty genes with NS mutations found in at least two samples were identified including TP53, PIK3CA, RB1, MYC, CDKN1A and ARID1A. A median of 146 (range 39-418) and 91 NS (range 2-312) mutations were identified in the index and re-TUR specimens, respectively. Concordance rates were 83% on average between primary and rTURBT, highest for patients upstaged to T2 disease, and lowest for patients harboring CIS. Genomic alterations in urinary tumor DNA were detected in ten patients. The tumor fraction of utDNA was higher in patients with residual disease (mean 2.5% vs. 0.2%, p=0.10). Using tumor-fraction to predict MRD, the area under the receiver-operator curve (AUC) for this test was 0.85. Using an optimal threshold of ≥3.3% tumor-fraction to define utDNA positivity, the test had a sensitivity of 75% at 100% specificity. Conclusions: Urinary tumor DNA shows promise as a surrogate for minimal residual disease and may predict TURBT pathology for NMIBC. Genomic alterations between index and rTURBT tumors are highly concordant in papillary tumors even in the setting of upstaging, which may aid in targeted intravesical or systemic therapy selection. Larger cohorts and long-term follow up is needed to determine if utDNA can risk-stratify patients prior to rTURBT and predict long-term recurrence.

Cell-free urinary tumor DNA to detect minimal residual disease prior to repeat-transurethral resection of bladder tumor in non–muscle-invasive bladder cancer: A prospective study.

LBA445 Background: Cell-free urinary tumor DNA (utDNA) generated from tumor genomic sequencing is an emerging biomarker showing tremendous potential for detecting minimal residual disease (MRD) in muscle-invasive and metastatic bladder cancer. We performed a prospective study to assess utDNA’s ability to measure MRD at the time of standard-of-care repeat transurethral resection of bladder tumor (rTURBT) in non-muscle invasive bladder cancer (NMIBC). Methods: Patients with high-risk NMIBC were enrolled prior to rTURBT. Index tumor and rTURBT mutational profile was performed via PredicineWES whole exome sequencing across 20,000 genes. Genes with non-synonymous (NS) mutations observed in index and rTURBT specimens identified in a minimum of two samples are reported. Urine samples were taken immediately prior to r-TURBT. utDNA detection was performed by ultra-deep sequencing of urinary cfDNA using a custom panel of up to 50-baseline mutations per patient together with a fixed core panel covering hotspot regions and actionable variants via PredicineBEACON. Urinary tumor fraction was used to call utDNA positivity. The primary endpoint was the detection of utDNA to predict MRD at the time of repeat-TURBT. Results: Eleven patients underwent rTURBT for high-risk NMIBC. Residual tumor was detected at rTURBT in 8/11 (73%) patients. Fifty genes with NS mutations found in at least two samples were identified including TP53, PIK3CA, RB1, MYC, CDKN1A and ARID1A. A median of 146 (range 39-418) and 91 NS (range 2-312) mutations were identified in the index and re-TUR specimens, respectively. Concordance rates were 83% on average between index and rTURBT, highest for patients upstaged to T2 disease, and lowest for patients harboring CIS. New somatic variants not observed in the index tissue were detected in rTURBT for 4/6 patients and 7/14 were also detected in the pre-operative urine. Overall, 50% of utDNA mutations were concordant with index tumor tissue, 39% were concordant with rTURBT tissue, and 33% were concordant with both. The tumor fraction of utDNA was higher in patients with residual disease (mean 2.5% vs. 0.2%, p=0.10). Using tumor-fraction to predict MRD, the area under the receiver-operator curve was 0.85. Using an optimal threshold of ≥3.3% tumor-fraction to define utDNA positivity, the test had a sensitivity of 75% at 100% specificity. Conclusions: Urinary tumor DNA shows promise as a surrogate for minimal residual disease and may predict TURBT pathology for NMIBC. Genomic alterations between index and rTURBT tumors are highly concordant in papillary tumors even in the setting of upstaging, which may aid in targeted intravesical or systemic therapy selection. Larger cohorts and long-term follow up is needed to determine if utDNA can risk-stratify patients prior to rTURBT and predict long-term recurrence.

Atezolizumab (atezo) with or without Bacille Calmette-Guérin (BCG) in patients (pts) with high-risk nonmuscle-invasive bladder cancer (NMIBC): Results from a phase Ib/II study.

493 Background: Standard treatment (tx) for high-risk NMIBC is transurethral resection of bladder tumor (TURBT) followed by BCG induction and maintenance. However, ≈50% of pts experience recurrence and/or progression after tx and may be ineligible for or refuse cystectomy. The PD-L1/PD-1 pathway may be involved with immune escape in NMIBC following BCG exposure. Here, we report results of atezo (anti–PD-L1) ± BCG in BCG-unresponsive, high-risk NMIBC. Methods: This multicenter study (NCT02792192) enrolled pts with BCG-unresponsive NMIBC with carcinoma in situ who had repeat TURBT. Cohort 1A and 1B pts received atezo 1200 mg IV q3w for ≤96 wk. Cohort 1B pts also received standard BCG induction (qw × 6 doses) and maintenance (qw × 3 doses at 3 mo), with optional maintenance courses at 6, 12, 18, 24, and 30 mo. For cohort 1B only, de-escalation was allowed for ≤3 BCG dose levels (full dose 50 mg, 66% and 33% of full dose). Co-primary outcomes were safety and complete response (CR) rate at 6 mo (6-mo bladder biopsy required). Duration of CR and 3-mo CR rate (key secondary outcomes) and 12-mo CR rate (exploratory) were also shown. Results: Cohorts 1A and 1B enrolled 12 pts each. Median age was 74 y; most pts had ECOG PS 0 (n = 7 [58%] in each cohort). At data cutoff (Sep 29, 2020), median atezo tx duration was 22.7 wk in cohort 1A and 31.6 wk in 1B. Following dose de-escalation in cohort 1B, the recommended BCG dose was 50 mg. BCG dose modification/interruption occurred in 4 pts (33%) due to an AE. The most common reason for tx discontinuation was disease recurrence or progression in both cohorts. Three pts (25%) in cohort 1A had atezo-related Gr 3 AEs (most common: maculopapular rash, n = 2); no atezo- or BCG-related Gr ≥3 AEs were seen in cohort 1B. Three dose-limiting toxicities occurred (1 [8%] in cohort 1A and 2 [17%] in cohort 1B), all reported as AEs of special interest. No Gr 4/5 AEs were reported. CRs, which appeared durable, were seen in both cohorts (Table). Conclusions: In this first report of atezo + BCG in NMIBC, atezo as mono- and combination therapy was well tolerated, with no new safety signals or tx-related deaths. Preliminary data suggested clinically meaningful activity, especially with atezo + BCG, requiring confirmation in a larger setting. Clinical trial information: NCT02792192. [Table: see text]

Diagnostic performance and predictive capacity of early urine cytology after transurethral resection of nonmuscle invasive bladder cancer: A prospective study

ObjectivesTo prospectively evaluate the value of early urine cytology (EUC) after the primary transurethral resection of bladder tumor (TURBT) of nonmuscle invasive bladder cancer (NMIBC) for the prediction of positive biopsy findings on repeat TURBT. MethodsAfter approval of institutional review board, patients who underwent TURBT for NMIBC between February 2014 and July 2018 were included in the study. Patients with concomitant Carcinoma in Situ (CIS), upper tract urothelial tumors, biopsy proven muscle invasion, or low-risk NMIBC (single, primary, Ta, and G1 tumor) were excluded. Forty-eight hours after primary TURBT, EUC was retrieved and patients were scheduled for repeat TURBT 2 to 6 weeks later according to the predetermined protocol. The primary outcome was to determine the role of positive EUC to predict positive biopsy findings on repeat TURBT. ResultsDuring the study period, 198 patients fulfilled the study inclusion criteria of which 49 (25%) had recurrent NMIBC. Primary TURBT pathology results showed T1 stage in 195 (98.5%) patients and high-grade malignancy in 158 (79.8%). Intermediate- and high-risk NMIBC were defined in 49 (25%) and 149 (75%) patients, respectively. EUC was positive in 114 patients; of whom 78 (68.4%) showed positive biopsy findings on repeat TURBT (P = 0.001). The sensitivity, specificity, negative, and positive predictive values of EUC for biopsy findings at repeat TURBT were 90% (95%CI: 87–94), 75% (95%CI: 71–79), 89% (95%CI: 85–94), and 68% (95%CI: 62–74), respectively. On mean (±SD) follow-up of 42(±13) months, tumor recurrence was encountered in 101 (53%) patients. On multivariate Cox regression analysis, EUC was significantly associated with tumor recurrence (HR = 4.6, 95%CI: 2.37–8.9, P < 0.001). ConclusionsPositive EUC after primary TURBT for NMIBC is significantly associated with positive repeat TURBT for malignancy. EUC is an independent predictor of tumor recurrence. EUC might be implemented after primary TURBT to help refining indications of repeat biopsy and planning of further intervention.

Utility and Safety of Repeat Transurethral Resection of Bladder Tumor Performed at a Tertiary Center.

Introduction Repeat transurethral resection of bladder tumor (ReTURBT) has become an integral part of the management of superficial bladder cancers at various urological centers around the world. Early detection of residual disease, leading to upstaging in some cases, leads to decrease in recurrence rates. Our study aimed to analyze the impact of ReTURBT in detecting residual tumor and tumor recurrences, hence validating the benefits of procedure as a routine. Materials and Methods A total of 152 patients with superficial bladder cancer who were treated at Cancer Institute (WIA) between January 2005 and December 2013 were analyzed and followed up for 3 years. Results Of the 152 cases who underwent ReTURBT, 47 patients had residue in the final histopathology of the resected specimen (31%). The overall rate of upstaging to muscle-invasive disease following ReTURBT was 3.3%. The mean follow-up period was 47.13 months, during which 25 (17%) out of 147 patients who underwent ReTURBT had disease recurrence. There was no additional morbidity due to ReTURBT as compared with the primary procedure. Conclusion ReTURBT is an effective procedure in treating recurrent tumors also as long as they remain superficial. The procedure when performed with utmost care in experienced hands remains a very safe procedure to be followed as a routine and standard.

Usefulness of narrow-band imaging in transurethral resection of bladder tumor: Early experience from a tertiary center in India.

Background:The current standard for diagnosis and treatment of urinary bladder cancer is transurethral resection of bladder tumor (TURBT) using white light guidance. Narrow band imaging (NBI) has emerged as a promising method for identifying additional bladder lesions. Various studies have been published to evaluate its sensitivity in identifying new lesions and its impact on decreasing recurrences. In this study, we evaluated our early experience using NBI in TURBTs.Aims and Objective:The aim of the study is to determine the accuracy of NBI in identifying additional malignant lesions during TURBT.Materials and Methods:We retrospectively collected data for all patients who underwent either TURBT or repeat TURBT with white light and NBI from November 2016 to July 2017 at Cancer Institute (WIA). The number of additional lesions identified using NBI was evaluated along with its correlation with the final histopathology.Results:Forty patients were analysed of which 20 underwent TURBT and 20 underwent repeat TURBT. Of these, 36 patients had complete resection of tumour. Additional lesions were detected in 6 patients (14%) by NBI of which 2 (33%) were malignant histology. The additional lesions detected were carcinoma in situ and no patient was upstaged.Conclusion:The inclusion of NBI to conventional white light TURBT increases the sensitivity for identifying additional lesions. The limitation of NBI is high false positivity and its availability. Long term follow up studies with larger subset of patients are required to evaluate its role in decreasing recurrences and justification in routine clinical practice.

Clinical significance of urothelial carcinoma ambiguous for muscularis propria invasion on initial transurethral resection of bladder tumor.

To evaluate the clinical significance of invasive urothelial carcinoma that is ambiguous for muscularis propria invasion on initial transurethral resection of bladder tumor (TURBT). All consecutive in-house TURBTs with invasive urothelial carcinoma from 1999 to 2017 that underwent radical cystectomy (RC) were grouped as follows: invasion of the lamina propria (INLP; n = 102; 24%), invasion of muscularis propria (INMP; n = 296; 69%) and ambiguous for muscularis propria invasion (AMP; n = 30; 7%). AMP was defined as extensive invasive carcinoma displaying thin muscle bundles where it is difficult to determine with certainty if those muscle bundles represent muscularis mucosae or muscularis propria (detrusor). Cases with any amount of small cell carcinoma or prior therapy were excluded. The average age was 66years in INLP, 67years in INMP, and 65years in AMP. RC showed invasive carcinoma stage pT2 or above in 50/102 (49%) of INLP vs. 255/296 (86%) of INMP (P ≤ 001) vs. 25/30 (83.33%) of AMP (P = 0.002). Lymph nodes showed metastatic carcinoma in 18/98 (18.36%) of INLP vs. 96/272 (35.29%) of INMP (P = 0.002), and 6/25 (24%) in AMP (P = 0.729). The average follow-up was 48months (range 0-192). Survival of AMP patients was similar to INLP and both were significantly better than INMP (P = 0.002 and P = 0.016). The great majority of patients with AMP on initial TURBT have advanced disease on RC and emphasizes the need for early repeat TURBT or even consideration of early cystectomy to lower the risk of worse pathological findings and to prolong survival.

Differences in Pathologic Results of Repeat Transurethral Resection of Bladder Tumor (TURBT) according to Institution Performing the Initial TURBT: Comparative Analyses between Referred and Nonreferred Group.

Objective Although transurethral resection of bladder tumor (TURBT) is a standard treatment and determines staging for nonmuscle invasive bladder cancer, many deficiencies persist. There is a risk of upstaging and residual cancer when repeat TURBT is performed. Authors compared the results of repeat TURBT by institution performing the initial TURBT. Methods We retrospectively reviewed the medical records of 289 patients who underwent repeat TURBT within 2-6 weeks after initial TURBT between 1998 and 2013. The patients were divided into the referred group and the nonreferred group by institution performing the initial TURBT. And we analyzed the intergroup differences in residual tumor and upstaging rate and the factors significantly correlated with residual tumor. Results The mean age was 69.6 ± 11.1 years and the mean follow-up was 49.7 (range: 0–191) months. The referred group included 69 patients, while the nonreferred group included 220 patients. The referred group included 57 (82.6%) patients with residual tumor after repeat TURBT. Overall upstaging occurred in 15 (21.7%), and upstaging to T2 occurred in 11 (15.9%) of the initial Ta and T1 patients. In the nonreferred group, there were 123 (55.9%) patients with residual tumor. Overall upstaging occurred in 10 (4.5%) and upstaging to T2 occurred in 7 (3.2%) patients. Conclusions Gross hematuria, grade, and tumor quantity and size were significantly associated with residual cancer on multivariate analysis. In the referred group, repeat TURBT and restaging are necessary.

A Second-Look at the Repeat Resections of Bladder Tumors

Background: Research looking at the effects of repeat transurethral resection of bladder tumor (TURBT) on long-term survival and recurrence of bladder cancer has mixed results, with some studies showing improvement and others showing unclear benefit. The purpose of this current study is to evaluate the differences in recurrence rates, progression, and survival for patients with non-muscle invasive bladder cancer (NMIBC) who underwent a second TURBT 2 - 6 weeks after an initial TURBT, as compared to patients who only had an initial TURBT. Methods: We performed a retrospective analysis of patients who received a TURBT at our institution over a 12-year period (2005 - 2017). Patients 18 years or older with high-grade pT1 or pTis pathology on initial TURBT were included. Patients with low-grade, pTa, or stage pT2 or greater on initial TURBT and patients with variant histology other than urothelial carcinoma were excluded from the study. Differences in overall survival, recurrence rates, and cancer progression were analyzed using Cox regression to event and Poisson regression to number of occurrences in patients who had repeat TURBT vs. those who did not. Cancer progression was measured as time to cystectomy. Results: One hundred fifty-three patients with a diagnosis of high-grade NMIBC were included in the study. Forty-six patients (30.1%) had a repeat TURBT. There was no significant difference in baseline characteristics including age, stage, or gender between the two groups. After a median follow-up of 67.5 months (range 7.5 - 200 months), there was no significant difference in overall survival (OS) (P = 0.63), cancer progression (P = 0.51) or recurrence rates (P = 0.60) for patients who underwent second-look TURBT compared to those who did not. Of those patients who underwent repeat TURBT, 32 (69.6%) had residual tumor and 13 (28.2%) had a change in stage. Of the patients that had a change in stage, five were upstaged to muscle invasive (pT2) disease. Conclusions: Our analysis did not show an association between second-look TURBT with overall survival, progression, or recurrence rate of bladder cancer as compared to no second-look TURBT. However, there was a small rate of upstaging to pT2 disease on repeat TURBT. Even though there was no change in OS, repeat TURBT has an important role in finding T2 disease, and this is so critical that continuing with this conservative approach of a second TURBT is still recommended. World J Nephrol Urol. 2018;7(3-4):63-66 doi: https://doi.org/10.14740/wjnu361w

Pathology in repeated transurethral resection of a bladder tumor as a risk factor for prognosis of high-risk non-muscle-invasive bladder cancer.

The prognostic value of repeat transurethral resection of bladder tumor (TURBT) in patients with diagnosed high-risk, non-muscle-invasive bladder cancer (NMIBC) was investigated. We retrospectively reviewed the medical records of patients treated from October 2004 to December 2013 at Seoul National University who underwent repeated TURBT within 2–6 weeks after an initial resection. The study enrolled patients who had been diagnosed with NMIBC at both the initial and repeat TURBT; patients with muscle-invasive tumors on repeat TURBT were excluded. We used stepwise multivariate Cox regression models stratified by study to assess the independent effects of the predictive factors and estimated hazard ratios (HRs) from the Cox models. We investigated a total of 198 patients who were diagnosed with high-risk NMIBC. In logistic regression analyses, number of bladder tumors (2–7: OR, 2.319; 8≤: OR, 3.353; p<0.05), initially high tumor grade (OR, 2.435; p = 0.040), and presence of carcinoma in situ lesion (OR, 3.639; p = 0.017) correlated with residual tumor in the repeated-TURBT specimen. T1 stage in repeated-TURBT significantly correlated with recurrence (HR, 1.837; p = 0.010) and progression (HR, 2.806; p = 0.029) in multivariate analysis. The high grades of tumors in repeated-TURBT also significantly correlated with progression but not recurrence in the multivariate analysis (HR 2.152; p = 0.008). In this study, the pathologic findings in repeated-TURBT correlated with recurrence and progression in high-risk NMIBC. Repeated-TURBT is valuable because it can predict the recurrence and progression of high-risk NMIBC in addition to obtaining accurate pathologic findings.

V12-01 MULTIMODAL ENHANCED CYSTOSCOPY FOR IMPROVED BLADDER TUMOR RESECTIONS

You have accessJournal of UrologyBladder Oncology and Diversion1 Apr 2017V12-01 MULTIMODAL ENHANCED CYSTOSCOPY FOR IMPROVED BLADDER TUMOR RESECTIONS Timothy Chang, Dharati Trivedi, Mario Sofer, and Joseph Liao Timothy ChangTimothy Chang More articles by this author , Dharati TrivediDharati Trivedi More articles by this author , Mario SoferMario Sofer More articles by this author , and Joseph LiaoJoseph Liao More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3207AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Conventional transurethral resection of bladder tumor (TURBT) with white light cystoscopy (WLC) has recognized shortcomings including missed small tumors, inadequate assessment of resection margins and depth, and difficulty in differentiating cancerous from benign lesions. These limitations contribute to cancer recurrences and compel the need for repeat TURBT to ensure adequate cancer staging. Adjunctive optical imaging technologies including photodynamic diagnosis (PDD), narrow band imaging (NBI), and confocal laser endomicroscopy (CLE) improve tumor identification and characterization. Given their respective strengths and complementary characteristics, we postulate that combining wide-field (PDD and NBI) with microscopic (CLE) imaging technologies will further enhance TURBT. Towards that goal, we report our preliminary experience with multimodal enhanced cystoscopy. METHODS The study received IRB approval. PDD was performed using hexaminolevulinate (Photocure) in combination with blue light cystoscope (Storz). NBI (Olympus) was performed with an NBI-enabled camera head attached to the standard resectoscope. Probe-based CLE was performed with fluorescein as the contrast agent along with 2.6 or 0.85 mm endomicroscopes (Cellvizio, Mauna Kea Technologies). Following TURBT with PDD or NBI, the resection bed was imaged with CLE. Imaging features of the resection bed were characterized by 3 urologists and achieved consensus. RESULTS To date, 10 subjects have undergone multimodal imaging. No adverse events were noted due to the combination of instruments or imaging agents used. Confocal imaging features of the resection bed including elastin fibers (network of thin, interwoven strands), muscle fibers (sheets of straight, connected columns) and perivesical fat (collection of dark, round globules) were observed. Muscularis propria was present in the resected tissue on pathology assessment, confirming adequate resection. Patients are currently undergoing follow-up for cancer recurrence. CONCLUSIONS We report real-time microscopic inspection of the resection bed to assess for adequate depth of resection with CLE in combination with the macroscopic imaging technologies PDD and NBI. Further studies are needed to determine if multimodal enhanced cystoscopy results in improved TURBT with adequate depth and margins of resection and decreased recurrence rate, which may eventually translate to a decreased need for repeat TURBT. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1371-e1372 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Timothy Chang More articles by this author Dharati Trivedi More articles by this author Mario Sofer More articles by this author Joseph Liao More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP13-11 HIGH SPECIFICITY OF DIFFUSION-WEIGHTED MRI IN DIFFERENTIATING RESIDUAL BLADDER CANCER FROM POSTOPERATIVE CHANGES

You have accessJournal of UrologyBladder Cancer: Non-Invasive I1 Apr 2016MP13-11 HIGH SPECIFICITY OF DIFFUSION-WEIGHTED MRI IN DIFFERENTIATING RESIDUAL BLADDER CANCER FROM POSTOPERATIVE CHANGES Yuki Nakamura, Soichiro Yoshida, Hiroshi Tanaka, Masaharu Inoue, Masaya Ito, Minato Yokoyama, Junichiro Ishioka, Yoh Matsuoka, Noboru Numao, Kazutaka Saito, Yasuhisa Fujii, and Kazunori Kihara Yuki NakamuraYuki Nakamura More articles by this author , Soichiro YoshidaSoichiro Yoshida More articles by this author , Hiroshi TanakaHiroshi Tanaka More articles by this author , Masaharu InoueMasaharu Inoue More articles by this author , Masaya ItoMasaya Ito More articles by this author , Minato YokoyamaMinato Yokoyama More articles by this author , Junichiro IshiokaJunichiro Ishioka More articles by this author , Yoh MatsuokaYoh Matsuoka More articles by this author , Noboru NumaoNoboru Numao More articles by this author , Kazutaka SaitoKazutaka Saito More articles by this author , Yasuhisa FujiiYasuhisa Fujii More articles by this author , and Kazunori KiharaKazunori Kihara More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2492AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In managing bladder cancer, the significant risk of residual cancer after initial transurethral resection of bladder tumor (TURBT) is a big concern, and repeat TURBT is recommended in selected patients. The ability of magnetic resonance imaging (MRI) to detect bladder cancer at diagnosis is excellent. However, differentiating residual cancer from changes after the initial TURBT remains challenging. Growing evidence has emerged showing the usefulness of Diffusion-weighted MRI (DW-MRI) as an imaging biomarker for characterizing the pathophysiology of bladder cancer. In this study, we evaluated the diagnostic ability of DW-MRI in parallel with T2-weighted MRI (T2W-MRI) and dynamic contrast-enhanced MRI (DCE-MRI) in differentiating residual cancer from postoperative changes after initial TURBT. METHODS Between January 2013 and August 2015, a total of 67 patients underwent repeat TURBT at our institute. Of these 67 patients, 25 who underwent high-quality multi-sequence MRI including DCE-MRI and DW-MRI after initial TURBT and prior to repeat TURBT were retrospectively evaluated in the current study. Two urologists independently interpreted the images. Bladder wall thickening on T2W-MRI, early enhancement on DCE-MRI, and high signal intensity on DW-MRI with a b-value of 1000 s/mm2 were assigned to positive findings. Discrepancies were resolved by consensus. In the 25 eligible patients, 32 lesions were histologically evaluated in repeat TURBT. We analyzed the diagnostic abilities of each imaging sequence. RESULTS The interobserver agreement was excellent for T2W-MRI (κ = 0.840) and DW-MRI (κ = 0.936), and good for DCE-MRI (κ = 0.784). Of the 32 lesions, 16 were confirmed histologically to be a residual cancer (pTa/T1/T2 = 2/6/8). The sensitivity/specificity/accuracy of T2W, DCE, and DW-MRI were 94/13/52%, 100/13/58% and 100/81/91%, respectively. The specificity/accuracy of DW-MRI were significantly higher than that of T2W-MRI (p < 0.01/p < 0.01) and DCE-MRI (p < 0.01/p < 0.01). CONCLUSIONS The feasibility of DW-MRI in differentiating bladder cancer from postoperative change after initial TURBT was shown. The findings of DW-MRI showing high specificity can be a useful adjunct for selecting patients who can avoid repeat TURBT. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e138 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Yuki Nakamura More articles by this author Soichiro Yoshida More articles by this author Hiroshi Tanaka More articles by this author Masaharu Inoue More articles by this author Masaya Ito More articles by this author Minato Yokoyama More articles by this author Junichiro Ishioka More articles by this author Yoh Matsuoka More articles by this author Noboru Numao More articles by this author Kazutaka Saito More articles by this author Yasuhisa Fujii More articles by this author Kazunori Kihara More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP13-14 WHAT BENCHMARKS CAN WE EXPECT IN DETERMINING MARKERS OF QUALITY IN THE TREATMENT OF NON-MUSCLE INVASIVE BLADDER CANCER?

INTRODUCTION AND OBJECTIVES: Specific practices in the management of non-muscle invasive bladder cancer (NMIBC) have strong evidence supporting their benefit in reducing rates of recurrence and progression. These key practices include the utilization of intravesical chemotherapy following transurethral resection of bladder tumor (TURBT) for low grade (LG) disease, as well as re-staging TURBT and intravesical BCG therapy for high grade (HG) or T1 disease. However, recent studies, including the featured best poster at the AUA meeting in 2015, report alarmingly low adoption of such practices at a population level.(1) We report institutional rates of utilization of such practices following the implementation of quality improvement initiatives to determine reasonable expected benchmarks for implementation of these practices. METHODS: As part of a quality assessment and improvement initiative within our institution, data was prospectively collected for all patients with a new diagnosis of NMIBC undergoing TURBT over a 2 year period spanning 2014 and 2015. Summary data at the institution level was reported back to all providers to increase awareness and provide feedback. Data was collected on patient medical history, clinical and pathologic staging, and treatments performed. Reasons for failure to utilize specific practices in otherwise eligible patients were also assessed. RESULTS: A total of 153 patients were enrolled over a 2 year period across all stages of bladder cancer. Among incident cases of LG NMIBC, 77% received immediate intravesical chemotherapy following TURBT. Among patients with HG or T1 NMIBC, 76% underwent repeat TURBT within 3 months. When considering patients scheduled for restaging TURBT but unable to complete their surgery, rates increased to 92%. For patients with either HG or T1 disease, 91% underwent either induction intravesical therapy or radical cystectomy. The remaining 9% of patients who did not receive appropriate therapy either refused recommended treatment or were unable to receive due to the BCG shortage. CONCLUSIONS: In contrast to a wealth of data demonstrating shortcomings at the population level in the utilization of evidence based practices in NMIBC, we present encouraging results from a local quality initiative with a focus on maximizing such practices. We also report expected achievable rates of utilization with minimal intervention in the current practice environment. (1) Nabbout P, Slaton J. BCG and re-staging transurethral bladder tumor resection underused for T1 bladder cancer. AUA News. 20(10): 11-12, October 2015.

PD25-10 RESIDENT INVOLVEMENT IN ENDOSCOPIC BLADDER CANCER SURGERY IS ASSOCIATED WITH INADEQUATE PATHOLOGY SPECIMENS AND PROLONGED TIME TO CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Detection and Screening II1 Apr 2015PD25-10 RESIDENT INVOLVEMENT IN ENDOSCOPIC BLADDER CANCER SURGERY IS ASSOCIATED WITH INADEQUATE PATHOLOGY SPECIMENS AND PROLONGED TIME TO CYSTECTOMY Derek Bos, Christopher Allard, Shawn Dason, Vladimir Ruzhynsky, Anil Kapoor, and Bobby Shayegan Derek BosDerek Bos More articles by this author , Christopher AllardChristopher Allard More articles by this author , Shawn DasonShawn Dason More articles by this author , Vladimir RuzhynskyVladimir Ruzhynsky More articles by this author , Anil KapoorAnil Kapoor More articles by this author , and Bobby ShayeganBobby Shayegan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1659AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Transurethral resection of bladder tumor (TURBT) specimens lacking detrusor muscle are associated with clinical upstaging and the need for additional procedures which may delay curative treatment. We evaluated whether resident involvement in TURBTs is associated with adequacy of pathology specimens and time to cystectomy at a single academic centre in Ontario, Canada. METHODS We identified all TURBTs performed at St. Joseph's Healthcare Hamilton from November 2011 to June 2014. Charts were reviewed to determine baseline characteristics, resident involvement, and pathologic findings including presence of detrusor muscle. Logistic regression was used to assess associations between resident involvement and adequacy of tumor specimens. Among patients who underwent cystectomy, we assessed the time to cystectomy from initial high risk TURBT (high grade, ≥T1, or CIS), excluding patients with subsequent low risk TURBTs, BCG, or neoadjuvant chemotherapy. Associations between resident involvement with pathologic outcomes and time to cystectomy were determined with Chi−square and log rank tests, respectively. RESULTS A total 664 TURBTs were performed on 471 patients during the study period. Patient and tumor characteristics were comparable for TURBTs performed by attendings and residents. Attendings were more likely to obtain muscle in specimens for all TURBTs (OR1.68 [95%CI 1.09, 2.59], p=0.018) and for the subset of 275 high risk TURBTs (OR1.99 [95%CI 1.11, 3.55], p=0.019). Senior residents (PGY3−5) had higher odds of muscle in all (OR1.91 [95%CI 1.12, 3.25], p=0.017) and high risk (OR2.9 [95%CI 1.43, 5.9], p=0.003) specimens compared with juniors. In multivariate analysis adjusting for covariates patient age, sex, and tumor size, resident involvement was associated with inadequate tumor specimens among all patients (p=0.032) and only high risk tumors (p=0.049). Resident involvement was associated with a non-significant increased need for repeat TURBT. The median time from initial high risk TURBT to cystectomy was 73.3 (IQR 51.8, 131.4) and 49.4 (IQR 31.4, 65.7) days for residents and attendings, respectively (p=0.024). CONCLUSIONS Resident involvement during TURBTs is associated with inconclusive pathology and delayed time to cystectomy. Future studies should assess educational tools to improve endoscopic surgical training techniques minimizing effects of resident learning on patient outcomes. Further studies are needed to clarify the impact of resident involvement on long-term patient outcomes. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e564 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Derek Bos More articles by this author Christopher Allard More articles by this author Shawn Dason More articles by this author Vladimir Ruzhynsky More articles by this author Anil Kapoor More articles by this author Bobby Shayegan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...