Is Tumor Budding a New Predictor for Early Cystectomy in pT1 High-Grade Bladder Cancer?

Background & Objectives: We aimed to evaluate the risk of progression in high-grade T1 (HGT1) tumors using tumor budding (TB) and other standard clinical and histological features. TB is defined as an isolated cancer cell or a cluster composed of fewer than 5 cells scattered in the stroma and is usually used as a strong predictor of lymph node metastasis in T1 colorectal cancer. METHODS: This is an observational longitudinal cohort study involving 168 consecutive patients with HGT1 between 2013 and 2016. Cox regression was performed to analyze the relationship between the clinical and histological features and progression. All slides were blindly assessed by 2 genitourinary pathologists. Budding was determined to be positive when the number of buds was equal to or greater than 6. RESULTS: The median age was 75 years; 152 (90.5%) patients were men, and 49 (29.2%) were positive for TB. At a median follow-up time of 35 months, 33 patients (19.6%) showed progression. Progression was observed in 32.7% of the patients positive for TB and in only 14.3% of those who were negative (p = 0.006). TB was significantly associated with the endoscopic tumor pattern (TP) (papillary/solid) and lymphovascular invasion (LVI). Univariate analysis showed that TB, carcinoma in situ (CIS), TP, LVI, sub-staging, and BCG induction predict progression. The multivariate analysis showed that TB (p = 0.032, hazard ratio 2.1), CIS, TP, and lack of BCG induction were significant for progression. CONCLUSIONS: TB is a new and significant pathological variable for predicting progression in HGT1 tumors and can be easily introduced in clinical practice. Its inclusion in the TNM system should be carefully considered, as it may aid early cystectomy decisions.

Predictive factors of the absence of residual disease at repeated transurethral resection of the bladder. Is there a possibility to avoid it in well-selected patients?

PURPOSE: To evaluate the predictive factors of pT0 at repeated transurethral resection of the bladder (re-TURB) in pT1 high-grade (HG) nonmuscle invasive bladder cancer in order to explore the possibility to avoid it in well-selected patients. METHODS: This multicenter retrospective study included patients with pT1HG nonmuscle invasive bladder cancer from 4 different centers who underwent a complete TURB. Re-TURB was defined as a second resection which involved the site of the first TURB performed within 2-6 weeks from the previous resection. A multivariable logistic-regression model was performed to evaluate the predictors of pT0 at re-TURB. A nomogram was built to calculate the probability of obtaining a negative histology at re-TURB. The performance of the nomogram and its net benefit were tested with the decision curve analysis. RESULTS: Overall, 321 patients were included in the study. On multivariable logistic regression, detrusor muscle in the specimen (HR 1.99, P = 0.02), concomitant carcinoma in situ (HR 0.29, P = 0.005) and resection performed with en-bloc technique (HR 7.71, P = 0.01) were independent predictors of pT0 at re-TURB. Decision curve analysis showed a net benefit for the nomogram for each probability over 0.35 compared to the strategy to perform a re-TURB in all pT1HG tumors. CONCLUSIONS: The presence of detrusor muscle in TURB specimen, the absence of concomitant carcinoma in situ and the en-bloc resection were able to predict a negative histology at re-TURB, opening the door to the possibility to avoid it in an extremely well-selected cohort of patients. External validations and prospective studies are urgently needed.