European Urology

Editorials

In the paper that is reprinted on the pages 188–193 of this issue, Laurent and Lilane Boccon-Gibod have investigated the usefulness of random biopsies of normal-looking bladder mucosa in the evaluation of bladder tumours. They concluded from this study, comprised of 75 patients, that random biopsies should be reserved for the treatment and surveillance of grade 3 tumours irrespective of their stages because 41% of these tumours had associated carcinoma in situ (CIS) and therefore a significant risk of progression to muscle invasive disease [1].

The authors raised three questions related to their findings:

• 1.Can these lesions be detected by a less invasive procedure?

• 2.What are the prognostic implications?

• 3.When should we look for them?

Although the issue of random biopsies is a key one in the daily management of superficial bladder cancer, it is interesting to note that it took an additional 12 yr after this paper was published to get some answers to these questions. Indeed, a large study by the European Organization for Research and Treatment of Cancer Genito-Urinary (EORTC-GU) Group Superficial Bladder Committee addressed these specific points and was able to guide clinicians on this issue.

The analysis by the EORTC-GU Group indicated that biopsies of normal-appearing urothelium in Ta/T1 bladder cancer showed no abnormalities in about 90% of the cases.

Noteworthy, high-risk tumours had the highest risk of abnormality found on random biopsies [2].

The EORTC trial supported that random biopsies of normal-looking mucosa were unnecessary in the evaluation of superficial bladder tumours except in the case of high-grade tumours although these random biopsies resulted very rarely (<5%) in a modification of the therapeutic approach. Indeed, the presence of CIS is the one factor that should prompt a treatment modification as compared to the treatment of the papillary tumour alone.

As early as in the 1980s, this paper supported the effectiveness of BCG endovesical immunotherapy (named chemo-immunotherapy in the paper) in the treatment of grade 3 Ta/T1 bladder tumours and CIS, the latter being successfully controlled in >90% of cases.

This paper also illustrates that many questions raised by the authors remain of prime interest and unfortunately have not yet found an answer. Among others, we are still missing a sensitive and specific enough test to replace or complement urinary cytology.

We still cannot omit cystoscopic evaluations and check-ups in bladder cancer. The management of superficial bladder tumours (although Mark Soloway from Miami and many other voices are rightly trying to “ban” the wording “superficial” from the denomination of grade 3 tumor invading the lamina propria) has not changed dramatically since the publication of this paper.

We should recognise that most changes have come from European studies, usually from the EORTC. Among others are the immediate postoperative instillation of chemotherapy agents after the endoscopic resection [3], the need to redo transurethral resection of high-grade T1 lesions, and the risk stratification of these tumors [4].

Many questions addressed by the authors have not yet found a definitive answer despite continuous investigations. Above all, the conservative versus surgical therapy of grade 3 T1 lesions associated or not with CIS still remains a question mark.

The exact management of these high-grade lesions, which often behave like “tigers,” is poorly defined and worrisome enough to prompt some to perform radical cystectomy initially, especially in the case of associated CIS.

Because of this paper [1], we have known for almost 20 yr that random biopsies should be considered in high-grade disease to diagnose CIS because it is a major prognostic factor for progression of bladder cancer.