The case for conservative management in the treatment of patients with non-muscle-invasive micropapillary bladder carcinoma without carcinoma in situ.
ABSTRACT Micropapillary carcinoma is a rare pathologic variant of urothelial cell carcinoma. Intravesical bacillus Calmette-Guérin (BCG) has been reported to be ineffective and to entail an increased risk of development of non-organ-confined, metastatic disease. We assess the treatment response and disease progression in patients with micropapillary carcinoma of the bladder.
The study comprised 18 patients with micropapillary carcinoma of the bladder who underwent transurethral resection of a bladder tumor and multiple random biopsies between 1997 and 2003. We retrospectively analyzed treatment response and clinical and pathological cancer evolution related to cancer stage and the percentage of the micropapillary component of the cancer.
Seven of the 18 patients (38.8%) had carcinoma in situ. At diagnosis, 8 of the 18 patients had non-muscle-invasive bladder cancer; 6 of these patients were treated with intravesical BCG therapy and were alive and free of disease at a median follow up of more than 5 years. Ten of the 18 patients had muscle-invasive bladder cancer; 8 of these patients underwent radical cystectomy, and 7 of the 8 patients (87.5%) had non-organ-confined disease in cystectomy specimens. Seventy percent of patients with muscle-invasive disease at diagnosis had a micropapillary carcinoma component of more than 50% in transurethral resection of the bladder specimens, compared with only 25% of patients with non-muscle-invasive disease. Patients treated successfully with intravesical BCG therapy had a low micropapillary carcinoma component. The 5-year disease-specific survival rate was significantly lower in patients with muscle-invasive disease (30%) than in patients with non-muscle-invasive disease (87.5%) after a median follow up of 52 months (p = 0.001), and it was also significantly lower in patients with a high percentage of the micropapillary component of the carcinoma.
This retrospective study of 18 patients with micropapillary carcinoma of the bladder suggests that tumor stage and patient outcome may be related to the percentage of the micropapillary component of the carcinoma. Radical surgery is mandatory in muscle-invasive disease, even though patients with lymph node involvement die from the disease. In non-muscle-invasive disease and in the absence of associated carcinoma in situ, intravesical BCG treatment may be offered when the micropapillary component of the carcinoma component is a small percentage.
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ABSTRACT: Objectives: No guidelines exist for the management of micropapillary bladder cancer (MPBC) and most reports of this variant of urothelial carcinoma are case series comprising small numbers of patients. We sought to determine current practice patterns for MPBC using a survey sent to the Society of Urologic Oncology (SUO) and to present those results in the setting of a comprehensive review of the existing literature. Materials and methods: A survey developed by the Translational Science Working Group of the Bladder Cancer Advocacy Network sponsored Think Tank meeting was distributed to members of the SUO. The results from 118 respondents were analyzed and presented with a literature review. Results: Most survey respondents were urologists, with 80% considering bladder cancer their primary area of interest. Although 78% of the respondents reported a dedicated genitourinary pathologist at their institution, there were discrepant opinions on how a pathologic diagnosis of MPBC is determined as well as variability on the proportion of MPBC that is clinically significant. Among them, 78% treat MPBC differently than conventional urothelial carcinoma, with 81% reporting that they would treat cT1 MPBC with upfront radical cystectomy. However, the respondents had split opinions regarding the sensitivity of MPBC to cisplatin-based chemotherapy, which affected utilization of neoadjuvant chemotherapy in muscle-invasive disease. Conclusions: The management of MPBC is diverse among members of the SUO. Although most favors early cystectomy for cT1 MPBC, there is no consensus on the use of neoadjuvant chemotherapy for muscle-invasive MPBC.Urologic Oncology 06/2014; 32(6). DOI:10.1016/j.urolonc.2014.01.020 · 3.36 Impact Factor
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ABSTRACT: To assess the impact of micropapillary histological variant on oncological outcome after radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinomas (UTUCs). A French multicenter retrospective study was performed on patients who underwent RNU between 1995 and 2010. Pathological reports were reviewed to identify patients with pure urothelial carcinomas (PUC) and those with micropapillary histological variant (MPC). Uni- and multivariate Cox regression analyses were performed to identify factors predictive of survival. Overall, 519 patients were included and divided into two groups: 480 PUC and 39 MPC. Median follow-up were 28 and 19 months, respectively (p = 0.63). There was no difference between the two groups for gender, age and tumor location (pelvicalyceal or ureteral). MPC was associated with high-stage and high-grade UTUC (p < 0.001 and 0.04). No difference was observed between the two groups for 5-year cancer-specific survival (76.1 vs. 88.2 %; p = 0.54). The 5-year metastasis-free survival was significantly lower in the MPC group (48.9 vs. 73.8 %; p = 0.037). In multivariate analysis, pT stage, lymphovascular invasion, margin status and adjuvant chemotherapy administration were independent predictors of specific survival (p = 0.002; 0.001; 0.02; 0.01), contrary to histological variant (p = 0.94). Micropapillary histological variant was associated with advanced UTUC and reduced metastasis-free survival after RNU. It should be considered as an aggressive tumor and thus be stated in any pathological report after radical surgery.World Journal of Urology 08/2013; 32(2). DOI:10.1007/s00345-013-1141-0 · 3.42 Impact Factor
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ABSTRACT: The clinical significance of variant histology is controversial and diagnosis is challenging. If variant architecture truly identifies high-risk patients, or those with a differential response to therapy, than treatment algorithms should be altered. This review outlines the current evidence and determines whether histologic variants should indeed alter definitive treatment. For patients with pure squamous cell, adenocarcinoma, or small cell carcinoma, there is clear evidence to alter treatment paradigms. In adenocarcinoma or squamous cell carcinoma, there is a focus on local control and multimodal therapy with radiation. In small cell carcinoma all stages should be treated with primary chemotherapy followed by surgical extirpation. For patients with other variants of urothelial differentiation (i.e., micropapillary, sarcomatoid, squamous/glandular differentiation, etc.), management guidelines are less clear and radical cystectomy remains the mainstay of treatment at this time. The management of variant histology is challenging as it not only depends on accurate diagnosis and staging, but on assumptions regarding sensitivity to multimodal therapy (i.e., chemotherapy, radiation, intravesical agents) based on a handful of retrospective case series. This will need to be the focus of future studies and collaborative efforts in order to make significant advancements in the field.Current opinion in urology 07/2013; DOI:10.1097/MOU.0b013e328363e415 · 2.12 Impact Factor