Pathological stage review is indicated in primary pT1 bladder cancer

BJU Int 2010; 106: 206–211. Objective: To evaluate the effect of a pathology review on the clinical outcome of patients with primary pT1 bladder cancer (BC), as the clinical course of such patients is variable. Patients and Methods: The slides of 164 primary (first diagnosis) pT1 bladder tumours from two university hospitals were reviewed by one pathologist for stage and grade (World Health Organization 1973 and 2004). Patients were initially managed conservatively with bacille Calmette-Guerin (BCG). Uni- and multivariate analyses compared the predictive value of age, gender, hospital, carcinoma in situ (CIS), tumour-size, reviewed grade and reviewed stage. Results: With a mean follow-up of 6.4 years, there was disease progression in 48 (29%) patients and 26 (16%) died from BC. Associated CIS was found in 55 (34%) patients. After reviewing the slides, 24 (15%) tumours were downstaged to pTa, 134 (82%) remained pT1 and six (4%) were upstaged to or pT2. The grade review resulted in 74 G2, 90 G3, 37 low-grade and 127 high-grade lesions for the two systems used. In multivariate analyses, reviewed stage (both P 0.001) and CIS (P 0.017 and 0.023) had independent significance for progression and disease-specific survival, respectively. Conclusion: A stage review is indicated in pT1 BC, as almost 20% of pT1 tumours were up- or downstaged, and the reviewed stage predicted the patient’s prognosis. Hence, pathology review identified patients with different prognoses who might benefit from other treatment strategies than BCG. We confirmed that CIS is an unfavourable sign in pT1 bladder cancer. Editorial Comment: This article is unique in that instead of evaluating whether review of cases from a community hospital is beneficial, the authors reviewed cases from 2 major universities with expertise in urological pathology. Of T1 tumors 20% were either upstaged or down-staged, and the reviewed stage was an independent predictor of disease specific survival. It appears that even if an expert pathologist reads a case, review of all T1 tumors by more than 1 pathologist is important.