Editorial note: Bladder cancer & other cancers of the lining of the urinary system are usually transitional cell cancers - tumors that have the potential to grow & spread to other areas of the body but arise from the "transitional cells" that protect the body from reabsorption of urine in the bladder and associated structures.

Evaluation and prognostic factors

Survivin, a protein inhibitor of apoptosis, was measured in the urine of patients with transitional cell carcinoma of the bladder in a 2001 study reported in JAMA (Smith et al., 2001.) Urinary survivin levels were highly specific and sensitive in predicting the presence of tumors in this small study of 46 patients. Prior studies have shown that detection of human complement factor H related protein [BTA test] (Raitanen et al., 2001) has a role in patients at risk for recurrent bladder cancer. Sanchez-Carbayo et al. (2001) also reported on the urinary tests CYFRA 21-1 and NMP22 for patients at risk for bladder cancer recurrence. Although all of these tests are more sensitive for detection of recurrent bladder tumors than cytology, the clinical value of such urinary screening tests appears limited as they cannot remove cystoscopic evaluation in the follow-up of patients with bladder cancer. Other tumor markers evaluated on histologic study of transitional cell carcinoma of the bladder included E-cadherin (Byrne et al, 2001), bcl-2, p53 and Ki-67 index (Wu et al., 2000), p53 and muscularis mucosae invasion (Bernardini et al. 2001) and p21, p53, Ki67 and pRb as well as mitotic frequency (Holmang et al., 2001.) In most studies, p53 overexpression and depth of invasion have correlated with tumor progression. The Ki-67 labeling index appears to be an independent predictor of tumor recurrence, as has loss of E-cadherin immunoreactivity.

Superficial disease

Recurrent TA, T1 and CIS treatment with maintenance BCG was reported in a large randomized multi-institutional study by SWOG (Lamm et al., 2000.) This study showed an improvement in recurrence-free survival in the 3-week maintenance arm compared to no maintenance. Maintenance appeared to be beneficial for select patients with Ta and T1 disease as well as those with CIS. No difference in 5-year survival was detected.

Invasive bladder cancer

The mechanisms of prostatic stromal invasion in patients with bladder cancer was investigated at Memorial Hospital (Donat et al., 2001.) They found that tumors at the bladder neck may directly invade prostatic stroma without extravesical or intraurethral spread. Such patterns of spread are not easily detected with standard clinical biopsies.

A contemporary series of 300 patients treated with cystectomy for bladder cancer was also reported from Memorial (Dalbagni et al., 2001.) The authors proposed categorizing lesions into organ-confined and nonorgan-confined lesions, with no observed differences in survival among patients with pT3 to pT4a tumors, nor among histological subtypes. Herr & Donat (2001) reported on 84 patients with grossly node positive disease who had pelvic lymph node dissection and radical cystectomy with a 24% overall survival rate. Survival was better for T2 tumors (32%) than for patients with stage T3 disease. The effect of perioperative MVAC on relapse after cystectomy for patients with muscle-invasive bladder cancer was reported from Columbia (Ennis et al., 2000.) They showed that low risk patients had excellent disease control with cystectomy alone, and perioperative chemotherapy affected pelvic failure but not metastatic disease. The preservation of urethral sensitivity distal to the membranous urethra after cystectomy and ileal bladder substitution was common and appeared to be an important factor in achieving continence after these procedures (Hugonnet et al., 2001.)

Upper tract TCC

Ureteroscopic management of 23 patients with upper tract tumors was reported by Chen & Bagley (2000.) With 35 month mean follow-up, all patients were alive withough evidence of disease progression. However, the patients treated were mostly low- and intermediate-grade lesions who were followed very aggressively by an expert endourologist. It is not clear if this is the optimal management for all patients with upper tract transitional cell tumors.