Change in Management Based on Pathologic Second Opinion among Bladder Cancer Patients Presenting to a Comprehensive Cancer Center: Implications for Clinical Practice

INTRODUCTION - To evaluate the incidence and degree of change from a pathologic second opinion of bladder biopsies at a Comprehensive Cancer Center that were initially performed at referring community hospitals. The secondary objective was to determine the impact the potential changes would have on a patient's treatment.

MATERIALS AND METHODS - Dedicated genito-urinary pathologists reviewed 1,191 transurethral biopsies of the bladder and/or prostatic urethra from 2008-2013. Major and minor treatment changes were defined as altering recommendations for cystectomy, systemic chemotherapy, or primary cancer diagnosis and alterations in intravesical regimens, respectively.

RESULTS - There were 326/1191 patients (27.4%) with a pathologic change on second opinion: grade (62/1191, 5.2%), stage (115/1191, 9.7%), muscle in the specimen (29/1191, 2.4%), presence or absence of Carcinoma-in-Situ (34/1191, 2.9%). Outside pathology did not address the presence or absence of lymphovascular invasion (LVI) in 620/759(81.7%) of invasive cases (>cT1), of which, 35/620(5.6%) had LVI. There were 212 mixed, variant, or nonurothelial histologies detected in 199/1191(16.7%) patients with 114/212(53.7%) resulting in reclassification by our pathologists. Potential treatment alterations accounted for 182/1191(15.3%) of cases with 141/1191(11.8%) imparting major changes. There were 82/1191(6.8%) changes in recommendation for a radical cystectomy, 38/1191(3.2%) had a complete change in primary tumor type and 21/1191(1.8%) for change in chemotherapy regimen.

CONCLUSIONS - The amount and degree of pathologic changes and its potential impact on treatment emphasizes the importance of bladder cancer patients having their histology reviewed by genito-urinary dedicated pathologists. In our cohort, 15.3% of patients could see a treatment alteration, with 11.8% being a major change.

Urology. 2016 Mar 31 [Epub ahead of print]

Adam M Luchey, Neil J Manimala, Shohreh Dickinson, Jasreman Dhillon, Gautum Agarwal, Jorge L Lockhart, Philippe E Spiess, Wade J Sexton, Julio M Pow-Sang, Scott M Gilbert, Michael A Poch