Discrepancies between cytology, cystoscopy and biopsy in bladder cancer detection after Bacille Calmette‐Guerin intravesical therapy

Abstract

Objectives: To evaluate discrepancies in the detection of Bacille Calmette-Guerin (BCG)-resistant bladder cancer by cystoscopy, bladder biopsy and urinary cytology. Methods: Between January 1992 and August 2006, 127 bladder cancer patients underwent a cycle of eight weekly BCG instillations. Four weeks after the last BCG instillation, urinary cytological analysis and cystoscopy with targeted biopsy in addition to eight-nine selected-site biopsies were performed. Results: Biopsy-proven cancer was found in 11/27 (40.7%), 5/42 (11.9%), and 11/58 (19.0%) of positive, suspicious, and negative cytology cases, respectively. Abnormal and normal cystoscopic findings correlated with a biopsy-proven cancer in 13/53 (24.5%) and 14/74 (18.9%) cases, respectively. The combination of a macroscopic cystoscopic suspicion and a positive cytology missed malignant cases in 15.9% of the cases. In 100 cases without biopsy-proven cancer, the rates of denuded urothelium at biopsy in the cases with positive and non-positive cytology were 7/16 (43.8%) and 16/84 (19.0%), respectively Conclusions: According to our study, routine biopsy is recommended in the evaluation of BCG treatment, even if the timing, limitations and disadvantages of the procedure should be taken into account.

Significance of Random Bladder Biopsies in Non-Muscle Invasive Bladder Cancer

“…To identify powerful predictive factors for the findings of the random biopsies, we further evaluated the values of preoperatively available parameters using logistic regression analyses, and preoperative findings of urinary cytology were shown to be independently associated with the probability of positive findings of the random biopsies. Hara et al [10] previously reported a finding similar to that of this study; that is, dominant positive cytology was independently associated with the presence of concomitant CIS in patients with NMIBC. Although these findings suggest the usefulness of preoperative urinary cytology for predicting the findings of random biopsies, it remains unknown whether urinary cytology could be an alternative to random biopsies, even in a limited cohort of NMIBC with special characteristics.…”

“…For example, May et al [5] reported that 12.4% of patients with high- or intermediate-risk NMIBC had urothelial cancer in random biopsies, while in a study conducted by the European Organization for Research and Treatment of Cancer (EORTC), there were no abnormal findings of the random biopsies in 95.6% of patients with low-risk NMIBC and 88.4% of patients with high- and intermediate-risk NMIBC [4]. In addition, Hara et al [10] reported that the incidence of positive findings of random biopsies for high- and intermediate-risk NMIBC was approximately 4 times as high as that in the EORTC study. These inconsistent detection rates could be explained by several factors, such as different indications of the random biopsies and variation in the number of biopsy cores among these studies.…”

“…Of the 100 patients who were diagnosed as low risk NMIBC, including low grade, small size and solitary tumors, concomitant urothelial cancer was detected in 10 (10%) patients by the random biopsies. To date, various proportions of patients showing positive findings of random bladder biopsies have been reported [4,5,6,7,8,9,10]. For example, May et al [5] reported that 12.4% of patients with high- or intermediate-risk NMIBC had urothelial cancer in random biopsies, while in a study conducted by the European Organization for Research and Treatment of Cancer (EORTC), there were no abnormal findings of the random biopsies in 95.6% of patients with low-risk NMIBC and 88.4% of patients with high- and intermediate-risk NMIBC [4].…”

“…It has been well recognized that the execution of bladder biopsies is associated with some risks, including bleeding, perforation, infection and cancer dissemination [10]; therefore, it is necessary to develop novel strategies to avoid this procedure. One strategy is to accumulate a much larger number of patients with NMIBC undergoing random bladder biopsies prospectively and to identify predictive parameters with acceptable sensitivity as well as specificity in each group classified according to the EORTC risk tables [13].…”

“…To date, there have been few studies investigating the significance of random bladder biopsies for patients with NMIBC, and their findings on the indication of this procedure were controversial [4,5,6,7,8,9,10]. For example, van der Meijden et al [4] reported that random bladder biopsies contributed to neither the staging nor the selection of adjuvant therapy following TUR of NMIBC, while May et al [5] showed the strong impact of random biopsies on the decision to undertake post-TUR therapy for patients with NMIBC.…”