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Cancer
Published in Jahangir Moini, Matthew Adams, Anthony LoGalbo, Complications of Diabetes Mellitus, 2022
Jahangir Moini, Matthew Adams, Anthony LoGalbo
The transitional cell carcinomas of the bladder are superficial and well differentiated, growing outward. They are subclassified as papillary carcinomas. They invade early and then metastasize. Approximately 40% of transitional cell carcinomas recur at the same site in the bladder, or in another site – especially if they are large. Bladder cancer often metastasizes to the lungs, liver, intestines, bones, and lymph nodes. Some of these tumors may be linked to faster progression and resistance to chemotherapeutic agents. Squamous cell carcinoma has cells that similar to the flat cells of the skin. The squamous cells have intracellular bridges, keratohyalin granules, and pearls. They must be distinguished from urothelial cancer that has squamous differentiation.
Bladder Cancer
Published in Pat Price, Karol Sikora, Treatment of Cancer, 2020
The development of multi-drug combinations increased response rates and survival. MVAC and CMV regimes102 incorporate methotrexate, vinblastine, and cisplatin (with or without doxorubicin), described in Table 13.5. Both attain high response rates, including a significant complete response rate. Typically in an average patient population response rates of 40–50% with a 10% complete response rate were more common.103 These schedules improve median survival of patients with metastatic urothelial cancer from around 3–6 months, to around 9–12 months with treatment.102,104,105 Though not tested against best supportive care, there is improved survival compared to single-agent or less intensive schedules.104,105 Toxicities include significant rates of mucositis (40%), renal toxicity (31%), and neutropenic sepsis (20%), with a toxic death rate of 4%.102 An accelerated MVAC schedule administered on a 2-week cycle supported by granulocyte colony-stimulating factor (GCSF) was shown to achieve more complete responses (21% versus 12%) with some borderline evidence of benefit in long-term survival (24.6% versus 13.2%, borderline statistical significance) in EORTC randomized trial.106 As there were similar or lower levels of toxicity and treatment is completed more quickly this would be the preferred way to administer MVAC.
Bladder cancer
Published in Anju Sahdev, Sarah J. Vinnicombe, Husband & Reznek's Imaging in Oncology, 2020
The urothelium is the lining epithelium of the urinary collecting system, including the renal pelvis, ureters, bladder, and part of the urethra. Depending on the state of distension of the bladder, its thickness varies from three to seven cell layers. Under normal circumstances, these cells have a slow turnover rate, in the region of 3–6 months and will desquamate, but very few cells are seen in normal urine cytology specimens. When malignant transformation takes place, shedding of cells and haematuria will occur. Urothelial cancer can be classified according to its biological behavioural or morphological features. Behavioural features divide bladder cancer into non–muscle-invasive low-grade lesions or high-grade muscle-invasive lesions with risk of metastasis, and carcinoma in situ with propensity for muscle invasion. Non-invasive tumours can be divided into two morphological categories: papillary or flat. Carcinoma devoid of papillary structures is called carcinoma in situ (CIS) and is, by definition, high grade. Papillary lesions have delicate frond-like projections into the bladder lumen, non-papillary, or mixed papillary and infiltrative tumours. Papillary tumours are usually solitary intraluminal masses; non-papillary tumours may be infiltrative, ulcerative, or polypoid. These patterns of tumour growth are well demonstrated on imaging with CT and MR (Figure 16.1).
Recent advances in the understanding of urothelial tumorigenesis
Published in Expert Review of Anticancer Therapy, 2023
Masato Yasui, Liam Cui, Hiroshi Miyamoto
Disease recurrence in patients with superficial tumor after transurethral surgery, which is seen in roughly half of them, may represent urothelial tumorigenesis, while no further ‘treatment’ is often offered prior to the development of recurrent tumor. Compared with those involving tumor progression, the therapeutic application of new findings related to the pathogenesis of urothelial cancer may thus be limited. Nonetheless, potential clinical intervention includes the prevention of recurrent disease following initial tumor resection, as intravesical pharmacotherapy has been being used. Meanwhile, changes in the expression of target molecules, as well as alterations and variations in driver genes, can be useful for postoperative risk stratification in patients with urothelial cancer.
Robot-assisted nephroureterectomy for upper tract urothelial carcinoma—feasibility and complications: a single center experience
Published in Scandinavian Journal of Urology, 2022
F. Liedberg, J. Abrahamsson, J. Bobjer, S. Gudjonsson, A. Löfgren, M. Nyberg, A. Sörenby
Ten patients were subjected to hybrid surgery with an open bladder cuff, mainly in the early study period in patients with advanced tumours in the lower ureter. In 14 patients (10%), excision of the bladder cuff was not performed (Figure 3). This was due to a palliative intent in one patient and to shorten the procedure in four patients with severe co-morbidity and extensive adhesions after previous pelvic surgery. In eight patients, the reason for refraining from bladder cuff excision was not stated in the medical records. Moreover, one patient had residual carcinoma in situ of the bladder, although repeated BCG induction therapy, but was considered unfit for simultaneous cystectomy. Therefore, to avoid introducing tumour cells from the bladder into the abdomen a bladder cuff was not excised. During the last three years of the study, bladder cuff excision was performed in 99 of 100 patients, all robotically. The aim of keeping the upper urinary tract intact throughout the procedure was not achieved in eight patients (5.5%) as perforation occurred during distal dissection of the ureter in five patients, perforation of the renal pelvis occurred in two patients and the specimen bag ruptured during extraction in one patient (Figure 3). Of these eight patients, three have died of urothelial cancer, of which all had tumour up-staging from ≤ T1 to > T1 in the pathological report. One of the patients had positive margins where the ureter was fixed to the iliac artery. The other two patients relapsed with retroperitoneal lymph node metastasis, with one also having liver metastasis and ascites.
The cost effectiveness of pembrolizumab versus chemotherapy or atezolizumab as second-line therapy for advanced urothelial carcinoma in the United States
Published in Journal of Medical Economics, 2020
Rachael Louise Slater, Yizhen Lai, Yichen Zhong, Haojie Li, Yang Meng, Blanca Homet Moreno, James Luke Godwin, Tara Frenkl, Guru P. Sonpavde, Ronac Mamtani
Immunotherapy has revolutionized cancer care, particularly among patients with urothelial cancer. One concern about the adoption of novel therapeutics is that they are usually associated with high treatment costs. This US-based economic analysis suggests that pembrolizumab improves both survival and QALYs and is a cost-effective treatment compared with chemotherapy at a WTP threshold of $100,000 or $180,000 per QALY gained and dominates atezolizumab with cost savings. The use of individual patient longer follow-up data from the Phase III KEYNOTE-045 trial further mitigate the uncertainty of the projected survival of pembrolizumab and chemotherapy. To our knowledge, this is the first analysis which evaluates the cost-effectiveness of pembrolizumab vs. atezolizumab in the 2L mUC setting using the best available evidence from ITC. This analysis contributes to the value assessment for these important oncology drugs.