BERKELEY, CA (UroToday.com) - In the United States this year there will be approximately 70,000 new cases of bladder cancer and 15,000 deaths attributable to this cancer.
Bladder cancer is more prevalent in males and is the fourth and seventh most common cause of new cancer cases and cancer deaths in men, respectively. Classically, bladder cancer is sub-divided into muscle-invasive disease and superficial bladder cancer. Superficial or, as it’s now known, non-muscle-invasive bladder cancer (NMIBC), accounts for 75% of new bladder cancer diagnoses. Within the rubric of NMIBC lies a unique form of bladder cancer—high-grade T1 disease (HGT1). Approximately 25% of patients with NMIBC present with HGT1 disease, representing over 13,000 patients annually. This group of patients poses a vexing clinical problem in that as a group, they follow a heterogeneous clinical course with the majority exhibiting a very aggressive phenotype. However, as a rule, these patients are treated in a manner similar to other patients with NMIBC.
Presently, an optimal treatment strategy for HGT1 bladder cancer remains elusive. The lamina propria, the layer to which T1 bladder cancer extends, is the principal site of lymphatic and vascular channels responsible for possible metastases. Nevertheless, the current treatment recommendation for patients with HGT1 disease is complete transurethral resection followed by a re-resection four to six weeks later. If the re-resection does not upgrade clinical staging, the patient would then receive induction intravesical BCG for six weeks. However, there have been a number of prior reports from single institutions showing that an immediate or early radical cystectomy for patients with HGT1 disease improves recurrence-free and bladder cancer-specific survivals. Yet, this approach comes with the potential morbidity, mortality, and quality of life issues accompanying cystectomy. The need for better risk stratification of patients for early aggressive therapy in the form of cystectomy is paramount so that we avoid both over-treatment and under-treatment of this complex patient cohort.
In our article, we present a case of a patient with clinical HGT1 bladder cancer having features consistent with a micropapillary variant that presented with metastatic disease to the pancreas. Although rare and unique, this case highlights the potential lethality of HGT1 bladder cancer and argues for the need for better clinical, pathologic, and potentially molecular predictors of a more aggressive form of HGT1 bladder cancer that would improve the decision-making process for those medically fit patients for whom early radical cystectomy is offered. Indeed, the micropapillary variant of bladder cancer may be such a marker. Kamat et al. reviewed M.D. Anderson’s extensive experience with bladder cancer patients harboring micropapillary features and found that of the 27 patients with NMIBC who opted for initial bladder-sparing therapy, 67% progressed to muscle-invasive disease and 22% developed metastatic disease. In this subset of patients, BCG offered no clinical benefit. The authors concluded that immediate cystectomy in patients with micropapillary T1 bladder cancer offered the best chance for cure. Further risk stratification for all patients with bladder cancer is needed to identify which patients require early aggressive surgery in the form of cystectomy and which patients can be safely managed with bladder-sparing approaches.
Written by:
Daniel Canter, Robert G. Uzzo, and Alexander Kutikov 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.
Clinical Stage T1 micropapillary urothelial carcinoma presenting with metastasis to the pancreas - Abstract
UroToday.com Bladder Cancer Section