UROLOGICAL ONCOLOGY

Concomitant carcinoma in situ is a feature of aggressive disease in patients with organ-confined TCC at radical cystectomy.
Shariat SF, Palapattu GS, Karakiewicz PI, Rogers CG, Vazina A, Bastian PJ, Schoenberg MP, Lerner SP, Sagalowsky AI, Lotan Y
Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
Eur Urol. 2007; 51: 152-60

• Objectives: Carcinoma in situ (CIS) is a nonpapillary, high-grade, potentially aggressive, and unpredictable manifestation of transitional cell carcinoma (TCC) of the bladder. The aim of this study was to assess whether presence of concomitant CIS has a detrimental effect on cancer control after radical cystectomy.
• Methods: The records of 812 consecutive patients who underwent radical cystectomy and pelvic lymphadenectomy for bladder TCC at three US academic centres were reviewed. Ninety-nine of 812 (12%) patients had CIS only at radical cystectomy and were excluded from the analyses.
• Results: Three hundred thirty of the 713 (46.3%) patients had concomitant CIS at radical cystectomy. Patients with TCC involvement of the urethra were more likely to have concomitant CIS than not (61% vs. 40%, p=0.018). Concomitant CIS was significantly more common in patients with lower cystectomy stages and higher tumour grades. In univariate, but not multivariate, analysis, patients with concomitant CIS versus those without were at increased risk of disease recurrence (p=0.0371). In patients with organ-confined disease, concomitant CIS was an independent predictor of disease recurrence (p=0.048 and p=0.012, respectively) but not bladder cancer-specific mortality (p=0.160 and p=0.408, respectively) after adjusting for the effects of standard postoperative features.
• Conclusions: Concomitant CIS in the cystectomy specimen is common, and patients with concomitant CIS are at increased risk of urethral TCC involvement. The presence of concomitant CIS appears to confer a worse prognosis in patients with non-muscle-invasive TCC treated with radical cystectomy.
  
  
• Editorial Comment
  The outcome of patients with bladder cancer of any stage and concomitant CIS was analyzed in this retrospective study on 713 patients undergoing radical cystectomy. Several issues deserve comments: The percentage of CIS present increased over the years from 33% in the eighties to 52% in period from 2001 to 2003. The majority of patients had grade 3 tumors (82.5%) and/or pT2 and pT3 disease (60.8%). Roughly, half of the patients had lymphovascular invasion, one-fourth (24.9%) had lymph node metastases. Accordingly, after 5 years, half of the patients with concomitant CIS had recurrences and half of the patients with concomitant CIS had died from bladder cancer. Patients without concomitant CIS fared better than those with concomitant CIS (7-year recurrence-free survival 58.1% and 41.5%, respectively). Interestingly, the incidence of concomitant CIS was highest in patients with organ-confined disease (pTa excluded) and higher in lower-stage and higher grade disease. Involvement of the urethra was more common in CIS patients.
  The authors state correctly, that presence of concomitant CIS worsens the outcome significantly. In practical terms, early radical treatment should be considered if CIS is present.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany