Adjuvant therapy in different risk-groups of patients with superficial bladder cancer.

OBJECTIVES: We assessed and compared the outcomes of two different courses of adjuvant therapy to patients with superficial bladder TCC. METHODS: The study included 142 patients (28 women and 114 men with a median age of 58.5 years) with newly diagnosed bladder transitional cell carcinoma (TCC), who underwent transurethral resection of bladder tumor (TURBT) between October 2002 and October 2003. Before surgery patients underwent routine examination, including measurement of tPSA level and transrectal ultrasound sonography (TRUS). In 26 (18.3%) patients with considerably enlarged prostate and LUTS we simultaneously performed TURBT and transurethral resection of the prostate (TURP). Pathological findings showed pTa stage in 20 (14.1%), pT1G1-2 in 99 (69.7%), pT1G3 in 15 (10.6%) and pTis in 3 (2.1%) cases; we additionally examined prostate specimens after TURP. The main criteria for adjuvant treatment were: grade, number and location of the tumor in the bladder The group of patients (group A) with G3 and multicentric lesions, localized at the lower third of the bladder, underwent BCG-therapy according the conventional schedule (60 patients, 42.3%). In group B (82 patients, 57.7%) patients underwent local chemotherapy (Thiotepa 80 mg p/week or Doxorubicin 50 mg p/week), started within 24 hours after operation. A second-look TURBT was performed within 6 weeks of treatment course in both groups. The morphological records of surgery were reviewed, compared with the initial findings and analysed statistically. RESULTS: Recurrence rate in groups A and B was 18.3% (11 patients) and 25.6% (21 patients), respectively (with common level 22.5%) (p=0.04). Three (5.0%) patients of group A and five (6.1%) of group B withdrew consent. We observed recurrent low-grade pTa tumours in 4 patients (36.4%) and 8 patients (38.1%) respectively in group A and B (p<0.03) and pT1 G1-2 tumours in 5 patients (45.5%) and 8 patients (38.1%) respectively in group A and B (p<0.005). We observed pT1G3 in two (18.2%) cases of group A, and in two (9.5%) cases of group B. In addition, two (9.5%) patients of B group had T2G2 lesions. Adjuvant therapy was continued in all patients, except four patients with G3 and two patients with T2 stage who underwent more aggressive treatment (4 cystectomies and 2 external beam radiotherapy). We switched 16 patients in group B with recurrent cancer to BCG treatment. Nobody of TURP-operated patients had recurrence in the distal part of urethra, and toxicity level of TURP-operated patients was not worse than in the whole patients cohort (not more than grade II). CONCLUSION: BCG adjuvant therapy demonstrated good results in the treatment of the recurrence of superficial TCC. However, in patients with low recurrence risk we used chemotherapy successfully. A second-look TURBT within 6 weeks after the initial surgery provided important prognostic information. Patients with T1G3 tumors, being at high risk of residual, or even invasive, cancer, could be offered definitive therapy within a 1-year period. Patients who underwent simultaneous TURP for relief of LUTS did not show cancer recurrences in the operated area or an higher toxicity of adjuvant treatment.

Could the sextant prostate biopsy be replaced by transurethral resection?

AIM OF THE STUDY: We studied patients with elevated serum levels of prostate specific antigen (PSA) and low urinary tract symptoms (LUTS) aiming to determine whether histological examination after transurethral resection of the prostate (TURP) could detect prostate cancer (PC) missed by previous routine transrectal ultrasound (TRUS) guided sextant prostate biopsies. MATERIALS AND METHODS: We considered 98 consecutive men with serum tPSA level from 4 to 12 ng/mL who were submitted to TRUS-guided sextant biopsies. RESULTS: PC was detected in 28 (28.6%) cases at first biopsy. Of the 70 patients who were not proven to have PC, 49 underwent TURP for severe LUTS. The median volume of resected tissue was 14.2 g (11.0-19.4 g). PC was detected in 12 (24.5%) specimens of resected tissue after TURPF PC lesions diagnosed after TURP were located mainly in the TZ, with cancer volume not more than 0.108 cm3. In 21 patients with negative first biopsy who did not underwent TURP was prescribed a conservative treatment and follow-up. In 7 of those patients elevated serum PSA levels were revealed during the follow-up. A second sextant TRUS-guided biopsy demonstrated PC in 4 patients. The remaining patients showed no significant increase in their serum PSA level and are still observed in present days. CONCLUSIONS: The sensitivity of routine sextant TRUS-guided biopsy of the prostate is not high enough and the detection of cancer is not warranted using this standard procedure. TURP can detect cancers in TZ of the prostate, when performed for treating LUTS in patients with negative prostate biopsy. In patients who did not need TURP: only in 4 out of 21 patients with a negative first biopsy a repeat biopsy demonstrated PC. In conclusion TURP is recommended for all the patients with enlarged prostate, negative prostate biopsy and severe LUTS after unsuccessful conservative treatment.