Value of repeated transurethral resection combined with random biopsy in middle and high risk non-muscle-invasive bladder cancer: a prospective randomized trial
-
摘要: 目的 探讨中高危非肌层浸润性膀胱癌二次电切术中行膀胱黏膜随机活检的价值。方法 采用前瞻性随机对照研究方法。选取2020年1月-2021年10月复旦大学医学院附属中山医院闵行分院收治的100例中高危非肌层浸润膀胱癌患者, 按照随机数字表法分为2组。实验组为随机活检(50例), 在二次电切术中, 进行随机黏膜活检, 包括膀胱前壁、后壁、左侧壁、右侧壁、顶壁、三角区、颈部的黏膜。对照组为靶向活检(50例), 在二次电切术中根据镜下表现对可疑黏膜进行靶向活检, 而肉眼正常黏膜不进行活检。比较实验组及对照组尿路上皮癌检出率。结果 实验组活检阳性9例(18%), 高于对照组的2例(4%), 差异有统计学意义(P < 0.05)。分层分析, 在高级别尿路上皮癌中, 实验组活检阳性8例(16%), 高于对照组的2例(4%), 差异有统计学意义(P < 0.05)。Logistic回归分析结果显示原发肿瘤最大直径≥3 cm及原发肿瘤合并原位癌将增加活检阳性的风险, 差异均有统计学意义(P < 0.05)。结论 在中高危非肌层浸润性膀胱癌二次电切术中行膀胱黏膜随机活检, 可及时发现伴发的肿瘤, 尤其是对于高危和极高危组患者。同时可重新评估肿瘤分级分期及阶段性治疗效果, 并为术后改变治疗方案提供依据。
-
关键词:
- 二次经尿道膀胱肿瘤电切术 /
- 非肌层浸润性膀胱癌 /
- 随机黏膜活检
Abstract: Objective To evaluate the value of random biopsy during repeated transurethral resection in middle and high risk non-muscle-invasive bladder cancer.Methods A prospective randomized trial was performed between random biopsy group and targeted biopsy group. From January 2020 to October 2021, 100 patients of middle and high risk non-muscle-invasive bladder cancer were selected and randomly divided into two groups by means of random number table. Fifty patients were treated with random biopsy including suspicious lesion of 7 sites of bladder. Other 50 patients were treated with targeted biopsy. Whether to make targeted biopsy or not depended on the cystoscopic findings during repeated transurethral resection. The positive detection rate of the two groups were compared and analyzed.Results Nine cases (18%) of random biopsy group and 2 cases (4%) of targeted biopsy group were found positive. The difference was statistically significant (P < 0.05). Stratified analysis showed that in high grade bladder cancer, 8 cases (16%) of random biopsy group and 2 cases (4%) of targeted biopsy group were found positive. The difference was statistically significant (P < 0.05). Logistic regression analysis showed that primary tumors over 3 cm and primary tumor combined with carcinoma in situ would increase the positive detection rate. The differences were statistically significant (P < 0.05).Conclusion More concomitant tumors can be found by random biopsy during repeated transurethral resection in middle and high risk non-muscle-invasive bladder cancer, especially for high risk and very high risk patients. At the same time, by this means, the tumor grade, stage and the therapeutic effect can be reevaluated. More evidence can be provided for changing postoperative treatment. -
-
表 1 患者一般资料
例，X±S 项目 实验组(50例) 对照组(50例) t χ2 P值 男/女 38/12 36/14 0.208 0.648 年龄/岁 68.2±10.1 66.0±11.1 1.184 0.240 肿瘤最大直径/cm 2.71±0.49 2.53±0.43 2.051 0.136 初发肿瘤 42 42 < 0.001 1.000 复发肿瘤 8 8 单发肿瘤 29 26 0.364 0.546 多发肿瘤 21 24 肿瘤病理分期 0.386 0.534 Ta 20 17 T1 30 33 肿瘤病理分级 0.047 0.829 LG 16 15 HG 34 35 既往存在上尿路肿瘤 2 0 2.041 0.153 合并CIS 4 2 0.709 0.400 EORTC评分a) 复发风险评分 4.42±2.24 4.46±2.14 1.194 0.319 进展风险评分 8.54±4.19 8.68±3.67 2.466 0.096 危险度分组b) 1.113 0.573 中危NMIBC 8 9 高危NMIBC 36 38 极高危NMIBC 6 3 注：a)本研究中将LG尿路上皮癌归入G2，HG尿路上皮癌归入G3；b)根据2019版中国泌尿外科及男科疾病诊疗指南。 
下载: 导出CSV
表 2 结果分析
例 项目 实验组
(阳性/阴性)对照组
(阳性/阴性)χ2 P值 活检 9/41 2/48 5.005 0.025 危险度分层 中危 1/7 0/9 0.905 0.341 高危 4/32 1/37 2.550 0.110 极高危 4/2 1/2 0.900 0.343 病理分期分层 Ta 3/17 0/17 2.775 0.096 T1 6/24 2/31 2.754 0.097 病理分级分层 LG 1/15 0/15 0.969 0.325 HG 8/26 2/33 4.417 0.036 单发 4/29 0/26 3.381 0.066 多发 5/16 2/22 2.042 0.153
下载: 导出CSV
表 3 活检阳性患者logistic回归分析
项目 单因素分析 多因素分析 OR(95%CI) P值 OR(95%CI) P值 性别(女vs男) 0.890(0.241~3.281) 0.861 年龄(<70岁 vs ≥70岁) 0.396(0.081~1.945) 0.254 病理分期(Ta vs T1) 1.648(0.409~6.646) 0.482 病理分级(LG vs HG) 5.085(0.621~41.610) 0.129 肿瘤最大直径(< 3 cm vs ≥3 cm) 5.347(1.409~20.291) 0.014 5.195(1.107~24.389) 0.037 是否合并CIS(无vs有) 24.857(3.855~160.296) 0.001 14.332(1.032~199.105) 0.047 单发vs多发 3.748(0.931~15.081) 0.063 初发vs复发 2.192(0.514~9.360) 0.289 危险度分组(中危vs高危vs极高危) 8.845(2.154~36.325) 0.002 1.695(0.337~8.524) 0.522
下载: 导出CSV
-
[1] Burger M, Catto JW, Dalbagni G, et al. Epidemiology and risk factors of urothelial bladder cancer[J]. Eur Urol, 2013, 63(2): 234-241. doi: 10.1016/j.eururo.2012.07.033
[2] Babjuk M, Burger M, Compérat EM, et al. European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer(Ta T1 and Carcinoma In Situ)-2019 Update[J]. Eur Urol, 2019, 76(5): 639-657. doi: 10.1016/j.eururo.2019.08.016
[3] Fujimoto N, Harada S, Terado M, et al. Multiple biopsies of normal-looking urothelium in patients with superficial bladder cancer: Are they necessary?[J]. Int J Urol, 2003, 10(12): 631-635. doi: 10.1046/j.1442-2042.2003.00724.x
[4] Takamatsu K, Matsumoto K, Kikuchi E, et al. Can random bladder biopsies be eliminated after bacillus Calmette-Guérin therapy against carcinoma in situ?[J]. Int Urol Nephrol, 2021, 53(3): 465-469. doi: 10.1007/s11255-020-02667-9
[5] Thorstenson A, Schumacher MC, Wiklund NP, et al. Diagnostic random bladder biopsies: reflections from a population-based cohort of 538 patients[J]. Scand J Urol Nephrol, 2010, 44(1): 11-19. doi: 10.3109/00365590903419020
[6] Kumano M, Miyake H, Nakano Y, et al. Significance of random bladder biopsies in non-muscle invasive bladder cancer[J]. Curr Urol, 2013, 7(2): 57-61. doi: 10.1159/000356249
[7] 李阿兴, 吴开杰, 贺大林, 等. 非肌层浸润性膀胱癌经尿道切除术中随机黏膜活检的临床病理特征[J]. 现代泌尿外科杂志, 2017, 22(5): 361-364. doi: 10.3969/j.issn.1009-8291.2017.05.012
[8] Calò B, Falagario U, Sanguedolce F, et al. Impact of time to second transurethral resection on oncological outcomes of patients with high-grade T1 bladder cancer treated with intravesical Bacillus Calmette-Guerin[J]. World J Urol, 2020, 38(12): 3161-3167. doi: 10.1007/s00345-020-03108-z
[9] Bishr M, Lattouf JB, Latour M, et al. Tumour stage on re-staging transurethral resection predicts recurrence and progression-free survival of patients with high-risk non-muscle invasive bladder cancer[J]. Can Urol Assoc J, 2014, 8(5-6): E306-E310. doi: 10.5489/cuaj.1514
[10] Witjes JA, Bruins HM, Cathomas R, et al. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines[J]. Eur Urol, 2021, 79(1): 82-104. doi: 10.1016/j.eururo.2020.03.055
[11] Fernandez-Gomez J, Madero R, Solsona E, et al. Predicting nonmuscle invasive bladder cancer recurrence and progression in patients treated with bacillus Calmette-Guerin: the CUETO scoring model[J]. J Urol, 2009, 182(5): 2195-2203. doi: 10.1016/j.juro.2009.07.016
[12] Palou J, Sylvester RJ, Faba OR, et al. Female gender and carcinoma in situ in the prostatic urethra are prognostic factors for recurrence, progression, and disease-specific mortality in T1 G3 bladder cancer patients treated with bacillus Calmette-Guérin[J]. Eur Urol, 2012, 62(1): 118-125. doi: 10.1016/j.eururo.2011.10.029
[13] Ploussard G, Shariat SF, Dragomir A, et al. Conditional survival after radical cystectomy for bladder cancer: evidence for a patient changing risk profile over time[J]. Eur Urol, 2014, 66(2): 361-370. doi: 10.1016/j.eururo.2013.09.050
[14] 吴树军, 苏文涛, 张军民. 卡介苗不同治疗方案对高危非肌层浸润性膀胱癌远期生存率的影响效果观察[J]. 临床泌尿外科杂志, 2020, 35(10): 823-826. https://lcmw.chinajournal.net.cn/WKC/WebPublication/paperDigest.aspx?paperID=371e543d-1e0c-4e54-8ed0-7fc495b1bedb
-