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JU INSIGHT Grade Heterogeneity in High-Grade Urothelial Carcinomas: Does It Have an Impact on the Survival?

By: Murat Can Karaburun, MD, FEBU, Acıpayam State Hospital, Denizli, Turkey, Ankara University, Turkey; Ezgi Dicle Kuz, MD, Ankara University, Turkey; Çağrı Akpınar, MD, FEBU, Ankara University, Turkey, Ankara Etlik City Hospital, Turkey; Khaled Obaid, MD, Ankara University, Turkey; Cagatay Göğüş, MD, Ankara University, Turkey; Saba Kiremitci, MD, Ankara University, Turkey; Duygu Enneli, MD, Ankara University, Turkey; Sümer Baltacı, MD, Ankara University, Turkey; Evren Süer, MD, FEBU, Ankara University, Turkey | Posted on: 17 Jul 2024

Karaburun MC, Kuz ED, Akpınar Ç, et al. Grade heterogeneity in high-grade urothelial carcinomas: does it have an impact on the survival of patients with intermediate/high-risk nonmuscle-invasive bladder cancer who received adequate adjuvant bacillus Calmette-Guérin therapy?. J Urol. 2024;212(1):104-113. doi:10.1097/JU.0000000000003990

Study Need and Importance

Tumor histological grade is an important prognostic parameter for nonmuscle-invasive bladder cancer (NMIBC). Although the majority of NMIBCs are classified as pure low-grade or pure high-grade (HG), a considerable amount of grade heterogeneity can also be seen. However, there is still debate and a lack of consensus on the prognostic and therapeutic implications of this issue in NMIBCs. Because there is a gap in the literature in this field, we aimed to compare the recurrence-free survival and progression-free survival (PFS) of the patients with pure HG vs mixed-grade (MG) NMIBC who received adequate bacillus-Calmette-Guérin therapy.

What We Found

We performed a single-institution retrospective review to determine the impact of MG vs pure HG histology on oncologic outcomes for NMIBC. The study included 203 patients, with a median follow-up of 36 months. The 36-month recurrence-free survival rates were similar between the groups (69% vs 72%, Kaplan-Meier curves; log-rank P = .58). We found that the HG–urothelial carcinoma (UC) group had a worse 36-month PFS rate than the MG-UC group (84% and 94%, respectively, Kaplan-Meier curves; log-rank P = .042; Figure). Age and tumor grade were significant risk factors for the development of progression on multivariate analysis.

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Figure. Kaplan-Meier curves for progression-free survival. TURBT indicates transurethral resection of bladder tumor.

Limitations

The retrospective nature and relatively small number of patients were the main limitations of the study.

Interpretation for Patient Care

Our findings show that patients reported as HG according to the recommended reporting system actually differ from each other in terms of PFS. The indication of MG UC category separate from pure HG carcinomas in the pathology report seems to be an important issue that can guide patient management. Therefore, it is highly important to identify and report these patients with MG tumors during histological examination. In this way, we think that both more accurate risk classification and more accurate patient counseling can be performed. More importantly, the treatment plan can be made more accurately on a patient-specific basis.

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