Clinical Papers © 1991 S. Karger AG, Basel 0302-2838/91/0192-0089$2.75/0
EurUrol 1991;19:89-92
Recurrence of Superficial Bladder Tumors in Prostatic Urethra E. Solsonaa, I. Iborraa, J. V. Ricósa, J.L. Monrósa, R. Dumonta, J. Casanovaa, C. Calabuig'0 Departments of “Urology, and bPathology, Instituto Valenciano de Oncologia, Valencia, Spain 1616842
Key Words. Prostatic urethral tumor, recurrence • Bladder tumors, superficial • Chemotherapy, intravesical • Stroma, prostatic Abstract. Of our 276 patients with superficial bladder carcinoma, 242 were male, and 36 of these had recurrence in prostatic urethra, 26 with macroscopic tumors, and 10 with tumors in situ (TIS). These recurrences represent an incidence of 13.3%, with an average follow-up of 34.3 months. When the urethral tumor was limited to the mucosa, we chose conservative therapy, and the patients entered a random program with Mitomycin or Adriamycin admin istered endovesically. With this program, we could control the disease in 59.3% of the patients. However, 22.2% of them had recurrence with prostatic stromal infiltration, so that we performed a more exhaustive exploration of the prostate, taking biopsies not only at the 5 and 7 o’clock positions, but also making a wider resection in order to find the incipient infiltration of the prostatic stroma, and trying to avoid a possible understaging. When the urethral tumor had infiltrated the prostatic stroma, we performed cystoprostatourethrectomy, getting a survival rate free of disease of 40%. An association with vesical TIS was detected in 61.1 % of these patients, with terminal ureteral tumor in 8.3% and with the anterior urethra in 11.1%, showing the diffuse pattern of the disease. We conclude that when recurrence of prostatic urethra is present, it is necessary to monitor the whole urothelium during follow-up.
The presence of urothelial tumor in the prostatic ure thra has been considered as a factor of bad prognosis making radical therapy necessary [3, 8]. However, with better knowledge of this entity two different patterns of the disease have been defined; a more benign form, in which the tumor remains limited to the mucosa histolog ically, and a more aggressive form which infiltrates the prostatic stroma in spite of radical therapy [11]. As a consequence of these features, our Department has adopted a conservative approach in those cases with urethral tumors without infiltration of the basal mem brane, and a radical approach in cases with infiltration of the prostatic stroma. In the present work, we analyze the results of these approaches, in those patients with recur ring superficial bladder tumors in prostatic urethra.
Material and Methods From November 1984 to September 1987, we studied 276 patients with superficial bladder tumors (Ta, TO- Of the 242 male patients, 26 had recurrence in prostatic urethra with macroscopic tumors. From February 1986, we began the systematic practice of cold biopsy in prostatic urethra not only on the first evaluation, but also during follow-up, detecting the presence of a carcinoma in situ (TIS) in 10 cases. The patients were checked four times during the first 2 years, and thereafter half-yearly until the fifth year. Each time, we per formed cytologic and cystoscopic tests, and random biopsies (left in Freburary 1988). When, at follow-up, a cytologic test was positive in the absence of macroscopic tumors or TIS, or when a urethral TIS was detected, we performed transurethral biopsies in the prostate at the 5 and 7 o’clock positions making two deep channels. Macroscopic tumors were removed completely, and a wide vesi cal-neck resection was made. If the pathological study proved that Downloaded by: University of Exeter 144.173.6.94 - 5/8/2020 11:44:29 AM
Introduction
Solsona/Iborra/Ricós/Monrós/Dumont/Casanova/Calabuig
90
Table 1. Data of patients with prostatic urethral recurrence Recurrence average, months Vesical-neck tumor, n Vesical TIS Multifocal tumor
2.6 13(36.1) 22 (61.1) 28 (77.7)
Figures in brackets are percentages.
the tumor did not infiltrate the basal membrane, the patient entered a program of endovesical chemotherapy with randomly allocated Mitomycin C (30 mg/30 ml of saline) or Adriamycin (50 mg/50 ml of saline), weekly for 4 weeks, and monthly for 6 or 12 months thereafter. When a superficial tumor recurred, it was removed and the weekly instillations were again started. In the case of stroma infiltra tion shown by a pathological study, radical cystoprostatourethrec tomy was considered.
Results Of the 276 patients, 242 were men (aged 31-81 years, with an average of 66.3 years), 26 (10.7%) of them had recurrence in prostatic urethra with macroscopic tu mors. When the TIS cases from February 1986 on are included, the incidence is even higher: 13.3%. The initial bladder tumors could be staged as follows: Ta_i 7 times, Ti.n 26 times, and Tun 3 times. All these patients had previously received endovesical chemother apy on several occasions.
61.1 % of these patients had a history of vesical TIS (table 1); when considering only the recurrence of ure thral TIS, the incidence of vesical TIS was 70%, i.e. with out a significant difference (p > 0.1). In 32 cases, no infiltration of the prostatic stroma could be detected. Therefore the patients entered the chemotherapy program. Twelve (37.4%) of them had no recurrence with an average follow-up of 27.3 months; 20 (62.5%) patients had recurrences, 7 of them with super ficial tumors returning to the chemotherapy program, and thereafter all were free of tumor, with an average follow-up of 25.2 months. The other 13 went into pro gression: in 3 cases due to vesical recurrence (T>2); in 5 cases due to urethral recurrence (with infiltration of the stroma in 4, and of the anterior urethra in 1 case); in 3 cases due to simultaneous progression in the bladder (T>2) and in the prostatic urethra (stromal infiltration); in 1 case due to simultaneous progression in the prostatic stroma and métastasés, and finally, 1 patient had pulmo nary métastasés, while the bladder and urethra were free of tumor (table 2). Due to progression of the disease, 8 patients under went radical cystoprostatourethrectomy, 1 radical radio therapy, and 4 patients systemic chemotherapy (2 cases), because the tumors were disseminated, or palliative ther apy (2 cases), because their bad condition or advanced age made other forms of therapy impossible (table 3). In 4 patients, there was an infiltration of the prostatic stroma at the initial diagnosis of urethral tumor; in all
Table 2. Outcome of patients with tumor limited to the mucosa
12 (37.5%): No recurrence 7 (4 Ti, 3 TIS urethra) 20 (62.5%): Recurrence
3 T>2 13 Progression
4 Stroma 5 Urethra 1 Anterior urethra 3 (T>2 + stroma)
1 Stroma + métastasés (M+)
1 Métastasés (M+) Downloaded by: University of Exeter 144.173.6.94 - 5/8/2020 11:44:29 AM
32
Recurrence of Superficial Bladder Tumors in Prostatic Urethra
Discussion In the present work, we studied the aggressive behav ior of superficial bladder tumors associated with recur rence in prostatic urethra. With a progression rate of 47.2% it is significantly superior to the underlying dis ease, i.e. 9.1 % (p < 0.01). In the same way, we checked the different behaviors of urethral tumors without infil tration of the basal membrane, of those that had already infiltrated the prostatic stroma. The survival rate free of disease was 86.9% and 33.3% (p < 0.01) respectively. With conservative therapy, we were able to save 59.3% of the patients with a tumor initially limited to the basal membrane. Therefore, we consider endovesical chemotherapy the treatment of choice for this group of patients. However, of the patients treated in a conserva tive way, 22.2% had recurrence with infiltration in a period of time between 3-18 months (average 10.2 months). This shows that the first evaluation has to be more exhaustive, performing not only biopsies at the 5 and 7 o’clock positions, but also wider resections of the prostate so that the pathologic study will be more exten sive. In this way, it is possible to find the incipient infil tration of the stroma, avoiding possible understaging. Radical cystoprostatourethrectomy, on the other hand, is the treatment of choice when infiltration of the stroma is present, although the results have not been good so far [11, 12]. However, our results are better with a survival rate free of tumor of 40%, than those of
Fig. l. Overall survival. NED = No evidence of disease.
Table 3. Treatment and survival of progression patients
RCTU XRT Chemotherapy Palliative therapy
Alive NED
Alive tumor
Dead NED
Dead tumor
Total
4
2
1 l
1
8
1
2
2
2
1
l
NED = No evidence of disease; RCTU = radical cystoprostato urethrectomy; XRT = radical radiotherapy.
Table 4. Treatment and survival of patients with prostatic stroma infiltration
RCTU Chemotherapy Palliative therapy
Alive NED
Alive tumor
Dead NED
Dead tumor
Total
4
1
2
2
9 2 1
1
1
1
NED = No evidence of disease; RCTU = radical cystoprostato urethrectomy.
Hardeman et al. [4] and Lockhart et al. [9], But as these results are still not satisfactory, neoadjuvant chemother apy may be indicated in this entity, as suggested by Wishnow and Ro [12]. It is important to note that the recurrence of prostatic urethra is usually associated with vesical TIS [2, 10, 13, 14], In our study, this was true in 61.1 % of the patients. Downloaded by: University of Exeter 144.173.6.94 - 5/8/2020 11:44:29 AM
cases, radical cystoprostatourethrectomy was performed. 8 patients in the recurrence group had a history of stro mal infiltration. Overall, 12 patients were examined for infiltration of the stroma. They were treated as shown in table 4. Four of them are alive and free of tumor. As to those patients with tumor limited to the mucosa only, 20 of 23 are alive and free of disease (p < 0.01). As a whole group 25 (69.4%) patients with recurrence in prostatic urethra are alive and free of tumor, 3 (8.3%) are alive with recurrence, 3 (8.3%) died free of disease, and 5 (13.8%) died of tumor (fig. 1). In 3 cases, we diagnosed a superficial tumor in the terminal ureter. All these patients underwent cystopros tatourethrectomy. One of them showed recurrence in both pyeloureteral systems. In 4 patients we found recur rence in the anterior urethra: 3 of them underwent cys toprostatourethrectomy, and the other only palliative treatment because of his bad condition. Three patients died of tumor, and the 4th is alive with métastasés.
91
Solsona/Iborra/Ricós/Monrós/Dumont/Casanova/Calabuig
Usually the presence of tumor in the terminal ureter is associated with both prostatic urethra and vesical TIS [4, 5, 13]. This was our experience in 13.6% of our patients. We also found 4 recurrences in the anterior urethra asso ciated with vesical or urethral TIS, which shows the dif fuse behavior of the urothelial carcinoma when recurring in the posterior urethra. This shows the importance of monitoring the whole urothelium. Therefore, our diag noses were in the first place based on cytologic findings, followed by endoscopic evaluation and biopsy of the bladder, ureter (ureterorenoscopy) and urethra. The recurrence of prostatic growth should not be underestimated because of its frequency and aggressive behavior. As evaluated by Hardeman et al. [4], the fre quency is 16%, but in our study it was 13.3%. Recur rence appeared in patients previously treated with endovesical chemotherapy and immunotherapy [4, 7, 9], and in some cases after positive response to the treat ment of vesical TIS [1, 6]. Therefore, the prostatic ure thra is an area which should be controlled carefully in patients with superficial bladder tumors, particularly those of the multifocal type and those associated with TIS.
References 1 Catalona, W.J.; Hudson, M.L.; Gillen, D.P.; Andriole, G.L.; Ratlifft, L.: Risks and benefits of repeated courses of intravesical bacillus Calmette-Guérin therapy for superficial bladder cancer. J. Urol. 137: 220 (1987). 2 Chibber, P.J.; McIntyre, M.A.; Hindmarsh, J.R.; Newsam, J.E.; Chisholm, G.D.: Transitional cell carcinoma involving the pros tate. Br. J. Urol. 53: 605 (1981). 3 Grabstald, H.: Prostatic biopsy in selected patients with carci noma in situ of the bladder: Preliminary report. J. Urol. 132: 1117 (1984). 4 Hardeman, S.W.; Perry, A.; Soloway, M.S.: Transitional cell car cinoma of the prostate following intravesical therapy for transi tional cell carcinoma of the bladder. J. Urol. 140: 289 (1988).
5 Herr, H.W.; Whitmore, W.F.: Ureteral carcinoma in situ after successful intravesical therapy for superficial bladder tumours: Incidence, possible pathogenesis and management. J. Urol. 138: 292 (1987). 6 Herr, H.W.; Pinnsky, C.M.; Whitmore, W.F.; Sogani, P.C.; Oettgen, H.F.; Melamed, M.R.: Long-term effect of intravesical bacillus Calmette-Guérin on flat carcinoma in situ of the blad der. J. Urol. 135: 265 (1986). 7 Hylliard, R.D.; Ladaga, L.; Schellhammer, P.F.: Superficial tran sitional cell carcinoma of the bladder associated with mucosal involvement of the prostatic urethra: Results of treatment with intravesical bacillus Calmette-Guérin. J. Urol. 139: 290 (1988). 8 Johnson, D.E.; Hogan, J.M.; Ayala, A.C.: Transitional cell carci noma of the prostate: A clinical and morphologic study. Cancer 29: 287 (1972). 9 Lockhart, J.L.; Chaikin, L.; Bondhus, M.J.; Politano, V.A.: Pros tatic recurrences in the management of superficial bladder tu mors. J. Urol. 130: 256 (1983). 10 Schellhammer, P.F.; Bean, M.A.; Whitmore, W.F.: Prostatic involvement by transitional cell carcinoma: Pathogenesis, pat terns and prognosis. J. Urol. 118: 399 (1977). 11 Seemayer, T.A.; Knaack, J.; Thelmo, W.L.; Nai-Shan, W.; Ahmed, N.: Further observations on carcinoma in situ of the urinary bladder: Silent but extensive intraprostatic involvement. Cancer 36: 514 (1975). 12 Wishnow, K.I.; Ro, J.Y.: Importance of early treatment of tran sitional cell carcinoma of prostatic ducts. Urology 32: 11 (1988). 13 Wood, D.P.; Montie, J.E.; Pontes, J.E.; Medendorf, S.V.; Levin, H.S.: Transitional cell carcinoma of prostate in cystoprostatectomy specimens removed for bladder cancer. J. Urol. 141: 349 (1989). 14 Zincke, H.; Utz, D.C.; Farrow, G.M.: Review of Mayo Clinic experience with carcinoma in situ. Urology 26: 39 (1985).
Dr. E. Solsona Narbón Service of Urology Instituto Valenciano de Oncologia C/Prof. Beltran Baguena, 19 E-46009 Valencia (Spain)
Downloaded by: University of Exeter 144.173.6.94 - 5/8/2020 11:44:29 AM
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EurUrol 1991;19:89-92
Recurrence of Superficial Bladder Tumors in Prostatic Urethra E. Solsonaa, I. Iborraa, J. V. Ricósa, J.L. Monrósa, R. Dumonta, J. Casanovaa, C. Calabuig'0 Departments of “Urology, and bPathology, Instituto Valenciano de Oncologia, Valencia, Spain 1616842
Key Words. Prostatic urethral tumor, recurrence • Bladder tumors, superficial • Chemotherapy, intravesical • Stroma, prostatic Abstract. Of our 276 patients with superficial bladder carcinoma, 242 were male, and 36 of these had recurrence in prostatic urethra, 26 with macroscopic tumors, and 10 with tumors in situ (TIS). These recurrences represent an incidence of 13.3%, with an average follow-up of 34.3 months. When the urethral tumor was limited to the mucosa, we chose conservative therapy, and the patients entered a random program with Mitomycin or Adriamycin admin istered endovesically. With this program, we could control the disease in 59.3% of the patients. However, 22.2% of them had recurrence with prostatic stromal infiltration, so that we performed a more exhaustive exploration of the prostate, taking biopsies not only at the 5 and 7 o’clock positions, but also making a wider resection in order to find the incipient infiltration of the prostatic stroma, and trying to avoid a possible understaging. When the urethral tumor had infiltrated the prostatic stroma, we performed cystoprostatourethrectomy, getting a survival rate free of disease of 40%. An association with vesical TIS was detected in 61.1 % of these patients, with terminal ureteral tumor in 8.3% and with the anterior urethra in 11.1%, showing the diffuse pattern of the disease. We conclude that when recurrence of prostatic urethra is present, it is necessary to monitor the whole urothelium during follow-up.
The presence of urothelial tumor in the prostatic ure thra has been considered as a factor of bad prognosis making radical therapy necessary [3, 8]. However, with better knowledge of this entity two different patterns of the disease have been defined; a more benign form, in which the tumor remains limited to the mucosa histolog ically, and a more aggressive form which infiltrates the prostatic stroma in spite of radical therapy [11]. As a consequence of these features, our Department has adopted a conservative approach in those cases with urethral tumors without infiltration of the basal mem brane, and a radical approach in cases with infiltration of the prostatic stroma. In the present work, we analyze the results of these approaches, in those patients with recur ring superficial bladder tumors in prostatic urethra.
Material and Methods From November 1984 to September 1987, we studied 276 patients with superficial bladder tumors (Ta, TO- Of the 242 male patients, 26 had recurrence in prostatic urethra with macroscopic tumors. From February 1986, we began the systematic practice of cold biopsy in prostatic urethra not only on the first evaluation, but also during follow-up, detecting the presence of a carcinoma in situ (TIS) in 10 cases. The patients were checked four times during the first 2 years, and thereafter half-yearly until the fifth year. Each time, we per formed cytologic and cystoscopic tests, and random biopsies (left in Freburary 1988). When, at follow-up, a cytologic test was positive in the absence of macroscopic tumors or TIS, or when a urethral TIS was detected, we performed transurethral biopsies in the prostate at the 5 and 7 o’clock positions making two deep channels. Macroscopic tumors were removed completely, and a wide vesi cal-neck resection was made. If the pathological study proved that Downloaded by: University of Exeter 144.173.6.94 - 5/8/2020 11:44:29 AM
Introduction
Solsona/Iborra/Ricós/Monrós/Dumont/Casanova/Calabuig
90
Table 1. Data of patients with prostatic urethral recurrence Recurrence average, months Vesical-neck tumor, n Vesical TIS Multifocal tumor
2.6 13(36.1) 22 (61.1) 28 (77.7)
Figures in brackets are percentages.
the tumor did not infiltrate the basal membrane, the patient entered a program of endovesical chemotherapy with randomly allocated Mitomycin C (30 mg/30 ml of saline) or Adriamycin (50 mg/50 ml of saline), weekly for 4 weeks, and monthly for 6 or 12 months thereafter. When a superficial tumor recurred, it was removed and the weekly instillations were again started. In the case of stroma infiltra tion shown by a pathological study, radical cystoprostatourethrec tomy was considered.
Results Of the 276 patients, 242 were men (aged 31-81 years, with an average of 66.3 years), 26 (10.7%) of them had recurrence in prostatic urethra with macroscopic tu mors. When the TIS cases from February 1986 on are included, the incidence is even higher: 13.3%. The initial bladder tumors could be staged as follows: Ta_i 7 times, Ti.n 26 times, and Tun 3 times. All these patients had previously received endovesical chemother apy on several occasions.
61.1 % of these patients had a history of vesical TIS (table 1); when considering only the recurrence of ure thral TIS, the incidence of vesical TIS was 70%, i.e. with out a significant difference (p > 0.1). In 32 cases, no infiltration of the prostatic stroma could be detected. Therefore the patients entered the chemotherapy program. Twelve (37.4%) of them had no recurrence with an average follow-up of 27.3 months; 20 (62.5%) patients had recurrences, 7 of them with super ficial tumors returning to the chemotherapy program, and thereafter all were free of tumor, with an average follow-up of 25.2 months. The other 13 went into pro gression: in 3 cases due to vesical recurrence (T>2); in 5 cases due to urethral recurrence (with infiltration of the stroma in 4, and of the anterior urethra in 1 case); in 3 cases due to simultaneous progression in the bladder (T>2) and in the prostatic urethra (stromal infiltration); in 1 case due to simultaneous progression in the prostatic stroma and métastasés, and finally, 1 patient had pulmo nary métastasés, while the bladder and urethra were free of tumor (table 2). Due to progression of the disease, 8 patients under went radical cystoprostatourethrectomy, 1 radical radio therapy, and 4 patients systemic chemotherapy (2 cases), because the tumors were disseminated, or palliative ther apy (2 cases), because their bad condition or advanced age made other forms of therapy impossible (table 3). In 4 patients, there was an infiltration of the prostatic stroma at the initial diagnosis of urethral tumor; in all
Table 2. Outcome of patients with tumor limited to the mucosa
12 (37.5%): No recurrence 7 (4 Ti, 3 TIS urethra) 20 (62.5%): Recurrence
3 T>2 13 Progression
4 Stroma 5 Urethra 1 Anterior urethra 3 (T>2 + stroma)
1 Stroma + métastasés (M+)
1 Métastasés (M+) Downloaded by: University of Exeter 144.173.6.94 - 5/8/2020 11:44:29 AM
32
Recurrence of Superficial Bladder Tumors in Prostatic Urethra
Discussion In the present work, we studied the aggressive behav ior of superficial bladder tumors associated with recur rence in prostatic urethra. With a progression rate of 47.2% it is significantly superior to the underlying dis ease, i.e. 9.1 % (p < 0.01). In the same way, we checked the different behaviors of urethral tumors without infil tration of the basal membrane, of those that had already infiltrated the prostatic stroma. The survival rate free of disease was 86.9% and 33.3% (p < 0.01) respectively. With conservative therapy, we were able to save 59.3% of the patients with a tumor initially limited to the basal membrane. Therefore, we consider endovesical chemotherapy the treatment of choice for this group of patients. However, of the patients treated in a conserva tive way, 22.2% had recurrence with infiltration in a period of time between 3-18 months (average 10.2 months). This shows that the first evaluation has to be more exhaustive, performing not only biopsies at the 5 and 7 o’clock positions, but also wider resections of the prostate so that the pathologic study will be more exten sive. In this way, it is possible to find the incipient infil tration of the stroma, avoiding possible understaging. Radical cystoprostatourethrectomy, on the other hand, is the treatment of choice when infiltration of the stroma is present, although the results have not been good so far [11, 12]. However, our results are better with a survival rate free of tumor of 40%, than those of
Fig. l. Overall survival. NED = No evidence of disease.
Table 3. Treatment and survival of progression patients
RCTU XRT Chemotherapy Palliative therapy
Alive NED
Alive tumor
Dead NED
Dead tumor
Total
4
2
1 l
1
8
1
2
2
2
1
l
NED = No evidence of disease; RCTU = radical cystoprostato urethrectomy; XRT = radical radiotherapy.
Table 4. Treatment and survival of patients with prostatic stroma infiltration
RCTU Chemotherapy Palliative therapy
Alive NED
Alive tumor
Dead NED
Dead tumor
Total
4
1
2
2
9 2 1
1
1
1
NED = No evidence of disease; RCTU = radical cystoprostato urethrectomy.
Hardeman et al. [4] and Lockhart et al. [9], But as these results are still not satisfactory, neoadjuvant chemother apy may be indicated in this entity, as suggested by Wishnow and Ro [12]. It is important to note that the recurrence of prostatic urethra is usually associated with vesical TIS [2, 10, 13, 14], In our study, this was true in 61.1 % of the patients. Downloaded by: University of Exeter 144.173.6.94 - 5/8/2020 11:44:29 AM
cases, radical cystoprostatourethrectomy was performed. 8 patients in the recurrence group had a history of stro mal infiltration. Overall, 12 patients were examined for infiltration of the stroma. They were treated as shown in table 4. Four of them are alive and free of tumor. As to those patients with tumor limited to the mucosa only, 20 of 23 are alive and free of disease (p < 0.01). As a whole group 25 (69.4%) patients with recurrence in prostatic urethra are alive and free of tumor, 3 (8.3%) are alive with recurrence, 3 (8.3%) died free of disease, and 5 (13.8%) died of tumor (fig. 1). In 3 cases, we diagnosed a superficial tumor in the terminal ureter. All these patients underwent cystopros tatourethrectomy. One of them showed recurrence in both pyeloureteral systems. In 4 patients we found recur rence in the anterior urethra: 3 of them underwent cys toprostatourethrectomy, and the other only palliative treatment because of his bad condition. Three patients died of tumor, and the 4th is alive with métastasés.
91
Solsona/Iborra/Ricós/Monrós/Dumont/Casanova/Calabuig
Usually the presence of tumor in the terminal ureter is associated with both prostatic urethra and vesical TIS [4, 5, 13]. This was our experience in 13.6% of our patients. We also found 4 recurrences in the anterior urethra asso ciated with vesical or urethral TIS, which shows the dif fuse behavior of the urothelial carcinoma when recurring in the posterior urethra. This shows the importance of monitoring the whole urothelium. Therefore, our diag noses were in the first place based on cytologic findings, followed by endoscopic evaluation and biopsy of the bladder, ureter (ureterorenoscopy) and urethra. The recurrence of prostatic growth should not be underestimated because of its frequency and aggressive behavior. As evaluated by Hardeman et al. [4], the fre quency is 16%, but in our study it was 13.3%. Recur rence appeared in patients previously treated with endovesical chemotherapy and immunotherapy [4, 7, 9], and in some cases after positive response to the treat ment of vesical TIS [1, 6]. Therefore, the prostatic ure thra is an area which should be controlled carefully in patients with superficial bladder tumors, particularly those of the multifocal type and those associated with TIS.
References 1 Catalona, W.J.; Hudson, M.L.; Gillen, D.P.; Andriole, G.L.; Ratlifft, L.: Risks and benefits of repeated courses of intravesical bacillus Calmette-Guérin therapy for superficial bladder cancer. J. Urol. 137: 220 (1987). 2 Chibber, P.J.; McIntyre, M.A.; Hindmarsh, J.R.; Newsam, J.E.; Chisholm, G.D.: Transitional cell carcinoma involving the pros tate. Br. J. Urol. 53: 605 (1981). 3 Grabstald, H.: Prostatic biopsy in selected patients with carci noma in situ of the bladder: Preliminary report. J. Urol. 132: 1117 (1984). 4 Hardeman, S.W.; Perry, A.; Soloway, M.S.: Transitional cell car cinoma of the prostate following intravesical therapy for transi tional cell carcinoma of the bladder. J. Urol. 140: 289 (1988).
5 Herr, H.W.; Whitmore, W.F.: Ureteral carcinoma in situ after successful intravesical therapy for superficial bladder tumours: Incidence, possible pathogenesis and management. J. Urol. 138: 292 (1987). 6 Herr, H.W.; Pinnsky, C.M.; Whitmore, W.F.; Sogani, P.C.; Oettgen, H.F.; Melamed, M.R.: Long-term effect of intravesical bacillus Calmette-Guérin on flat carcinoma in situ of the blad der. J. Urol. 135: 265 (1986). 7 Hylliard, R.D.; Ladaga, L.; Schellhammer, P.F.: Superficial tran sitional cell carcinoma of the bladder associated with mucosal involvement of the prostatic urethra: Results of treatment with intravesical bacillus Calmette-Guérin. J. Urol. 139: 290 (1988). 8 Johnson, D.E.; Hogan, J.M.; Ayala, A.C.: Transitional cell carci noma of the prostate: A clinical and morphologic study. Cancer 29: 287 (1972). 9 Lockhart, J.L.; Chaikin, L.; Bondhus, M.J.; Politano, V.A.: Pros tatic recurrences in the management of superficial bladder tu mors. J. Urol. 130: 256 (1983). 10 Schellhammer, P.F.; Bean, M.A.; Whitmore, W.F.: Prostatic involvement by transitional cell carcinoma: Pathogenesis, pat terns and prognosis. J. Urol. 118: 399 (1977). 11 Seemayer, T.A.; Knaack, J.; Thelmo, W.L.; Nai-Shan, W.; Ahmed, N.: Further observations on carcinoma in situ of the urinary bladder: Silent but extensive intraprostatic involvement. Cancer 36: 514 (1975). 12 Wishnow, K.I.; Ro, J.Y.: Importance of early treatment of tran sitional cell carcinoma of prostatic ducts. Urology 32: 11 (1988). 13 Wood, D.P.; Montie, J.E.; Pontes, J.E.; Medendorf, S.V.; Levin, H.S.: Transitional cell carcinoma of prostate in cystoprostatectomy specimens removed for bladder cancer. J. Urol. 141: 349 (1989). 14 Zincke, H.; Utz, D.C.; Farrow, G.M.: Review of Mayo Clinic experience with carcinoma in situ. Urology 26: 39 (1985).
Dr. E. Solsona Narbón Service of Urology Instituto Valenciano de Oncologia C/Prof. Beltran Baguena, 19 E-46009 Valencia (Spain)
Downloaded by: University of Exeter 144.173.6.94 - 5/8/2020 11:44:29 AM
92
