UF experts say little-used procedure could help identify male bladder cancer patients at risk of recurrence

Published: February 18 2004

Category:Health, Research

GAINESVILLE, Fla. — A diagnostic procedure sometimes used to monitor male bladder cancer patients after radical surgery may not be any more accurate than doctors’ observations in identifying those who would benefit from an additional operation. But a University of Florida study found the procedure may help doctors answer a more basic question: After surgery, which patients are most likely to suffer further disease progression?

Patients monitored after bladder and prostate removal with a cancer-detecting procedure known as urethral wash cytopathology often undergo a second operation to remove the urethra – the tube through which urine is eliminated from the body – if the procedure indicates some cancer cells remain, said Dr. William Murphy, a professor of pathology at UF’s College of Medicine and the senior author of the study, published in the current issue of Cancer/Cancer Cytopathology.

The additional surgery is believed to reduce the risk of disease progression in the urethra or elsewhere in the body, he said. But Murphy and co-author Dr. Jacquelyn Knapik, a UF assistant professor of pathology, found no difference in the long-term outcomes for patients who had their urethras removed after a positive result from the urethral wash compared with patients who did not receive the procedure but had their urethras removed.

“You would think in those situations where a urethral wash was done that we would pick up the neoplasms faster than if we waited, which would help the patients because then we could do a urethrectomy sooner – but according to our data that is not the case,” said Murphy, an internationally known expert on pathology of the kidney, bladder and urinary system. “What the study says … is that the risk for the patient has been determined pretty much by the time that the (bladder and prostate removal) is done.”

Consequently, a positive result from a urethral wash should perhaps be viewed as a warning sign that tumors may develop elsewhere in the body, rather than being considered an indicator that the urethra should be removed, he said.

Bladder cancer is the fourth most common form of cancer among U.S. men, diagnosed in 38,000 individuals each year, according to the National Cancer Institute. It is the eighth most common form of cancer in U.S. women, with 15,000 diagnoses annually.

In the United States, surgery known as cystoprostatectomy, which removes the bladder, prostate and seminal vesicles, is used to treat men with bladder tumors that do not respond to other therapies or have spread beyond the bladder, Murphy said. He estimated about one-fourth of U.S. men who develop abnormal bladder tissue growths – which often develop into cancer – eventually have this operation.

Usually, a portion of the urethra is left intact to simplify surgery and reduce blood loss, he said. If a new tumor is suspected or detected in the urethra, the only treatment option is surgical removal of the urethra.

UF researchers reviewed 176 cases, involving every patient who received a cystoprostatectomy at Shands at UF medical center from 1990 to 2001. The patients were, on average, 67 years old. Urethral wash cytopathology was used on 48 patients – 27 percent – as part of their follow-up, which lasted an average of 3 years.

The study showed no statistical difference in the rate of disease progression between patients monitored with the urethral wash and those who were not. But UF researchers found an unexpected distinction within the group of patients who received the procedure: Only 14 percent of those with a negative result had cancer recurrence during follow-up, compared with recurrence in 54 percent of patients who had a positive result, he said.

“That’s something that ought to be emphasized,” Murphy said. “You should do urethral wash cytopathology not only to find out who’s at higher risk … but also to find out who is at lower risk because that’s good news for them – at the very least they may not need to have (the urethra removed).”

Urethral wash cytopathology is a simple, inexpensive procedure, Knapik said. Specimens are collected by passing a straight catheter into the remaining urethra as far as possible, then injecting a small amount of saline solution into the catheter to wash the urethra. Cancer cells dislodge fairly easily from the lining of the urethra into the saline. The fluid is collected as it drains from the urethra, run through a centrifuge to separate cells from the saline, then cells are placed on slides and stained to make them easier to examine. Finally, a pathologist evaluates the cells under a microscope.

The biggest hurdle to using urethral wash cytopathology to assess patients’ risk for cancer recurrence is that many pathologists are not sufficiently familiar with the technique, said Dr. Zev Wajsman, a UF professor and chief of urological surgery.

“This methodology requires a high level of expertise,” Wajsman said. “Not every pathologist in the country is trained to use cytopathology, especially for urethral washing for diagnosis follow-up of bladder cancer…But it’s a very, very, very useful technique.”

Few research studies have been conducted on urethral wash cytopathology, Murphy said. The UF study cites a handful of papers on the subject.

Urologic surgeon Dr. Guido Dalbagni, of New York’s Memorial Sloan-Kettering Cancer Center, said he was not surprised the UF study showed men with negative results had the lowest rates of disease recurrence.

“(In our study), the patients who presented with symptoms did not do any differently than patients that were picked up by having a wash,” said Dalbagni, the senior author of a 2003 article on urethral wash cytopathology. “However, the number of patients that we had was very limited, and we have to interpret that with caution.”

Credits

Writer
Tom Nordlie, tnordlie@ifas.ufl.edu, (352) 392-0400, ext. 276

Category:Health, Research