BERKELEY, CA (UroToday.com) - Bladder cancer, the most common malignancy of the urinary tract, remains an important and difficult to treat pathology in modern urology, marked by the failure to detect non-visible lesions in white light as well as well as by the incomplete resection of the primary tumors.
Although the hexaminolevulinate blue light cystoscopy (HAL-BLC) was shown to markedly improve the detection rate of bladder tumors in general and flat lesions in particular, evidence supporting the long term advantages of the method is rather remote at the present moment. Our study followed this perspective and attempted to determine the importance of HAL-BLC regarding changes in the postoperative treatment as well as recurrence rates during a follow-up period of 2 years in a prospective, randomized analysis.
A total of 362 patients suspected of bladder cancer based on positive urinary cytology and/or ultrasonographic suspicion of bladder tumors were enrolled in the trial under approved written informed consent and randomized by means of sealed envelopes. In one arm, all 181 patients underwent standard and fluorescence cystoscopy, conventional TURBT for all lesions visible in white light and blue light resection for tumors only visible in blue light, while patients in the second arm benefited from standard WLC and TURBT alone.
A single immediate postoperative mytomicin-C instillation was performed in all cases undergoing endoscopic resection. In respect of the recurrence and progression risk categories of patients (established using the EORTC electronic calculators), no additional instillations were used in low-risk patients, while adjuvant mytomicin-C chemotherapy was applied in intermediate-risk cases and BCG intravesical immunotherapy for high-risk patients. The follow-up protocol consisting of urinary cytology and WLC was performed every 3 months for a period of 2 years, during which only first time recurrences after the initial diagnostic were taken into consideration.
In the non-muscle invasive bladder cancer (NMIBC) patients of the BL group, significantly improved overall cases’ and tumors’ detection rates were determined for fluorescence cystoscopy by comparison to the standard approach (85.9% versus 95.8% and 80.3% versus 92.2%, respectively). Also, a remarkable advantage provided by HAL-BLC was emphasized concerning the CIS lesions, with detection rates per patient of 95.2% versus 71.4% and per lesion of 94.3% versus 62.9%.
Moreover, blue light found a significantly higher proportion of additional tumors by comparison to WLC (35.2% versus 14.1%), as well as pathologically confirmed fluorescent-positive margins of white light resected tumors in 8.5% of the cases. Subsequent to the additionally diagnosed lesions, HAL cystoscopy modified the recurrence and progression risk categories of patients as well as the related postoperative treatment in a significantly increased number of patients by comparison to WLC (19% versus 6.3%).
At follow-up, the 3 months’ cystoscopy revealed a significantly reduced recurrence rate in the BL arm by comparison to the WL arm (7.2% versus 15.8%), mostly due to the less frequent other site residual tumors (0.8% versus 6.1%). Throughout the entire 2 year follow-up period, the recurrence rates remained significantly lower in the BL arm. At 1 and 2 years, fewer recurrences were found due to the initial fluorescence diagnostic (21.6% versus 32.5% and 31.2% versus 45.6%, respectively).
At the end of this trial, we concluded that HAL-BLC emphasized significantly improved CIS, pTa and overall NMIBC patient and tumour detection rates by comparison to standard cystsoscopy, while additional lesions were found by blue light in a higher proportion of NMIBC cases. Consequently, fluorescence cystoscopy significantly modified the recurrence and progression risk categories of patients and improved the related postoperative intravesical instillation treatment. The 3 months’ follow-up cystoscopy revealed a significantly reduced recurrence rate in the BL arm by comparison to the WL arm, mostly due to the less frequent other site residual tumors. Throughout the entire 2 year follow-up period, the recurrence rates remained significantly lower in the BL arm.
Bogdan Geavlete, MD, PhD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Treatment changes and long-term recurrence rates after hexaminolevulinate (HAL) fluorescence cystoscopy: Does it really make a difference in patients with non-muscle-invasive bladder cancer (NMIBC)? - Abstract