Value of Immunohistochemistry in StagingT1 Urothelial Bladder Carcinoma

Size: px

Start display at page:

Download "Value of Immunohistochemistry in StagingT1 Urothelial Bladder Carcinoma"

Coleen Booth
5 years ago
Views:

European Urology European Urology 42 (2002) 459±463 Value of Immunohistochemistry in StagingT1 Urothelial Bladder Carcinoma Paulette Mhawech a,*, Christophe Iselin b, Marie-FrancËoise Pelte a a

1 European Urology European Urology 42 (2002) 459±463 Value of Immunohistochemistry in StagingT1 Urothelial Bladder Carcinoma Paulette Mhawech a,*, Christophe Iselin b, Marie-FrancËoise Pelte a a Pathologie Clinique, Geneva University Hospital CMU, Michel-Servet, 1, 1211 Geneva, 4, Switzerland b Urology Clinic, Department of Surgery, Geneva University Hospital, Geneva, Switzerland Accepted 7 August 2002 Abstract Purpose: The subclassi cation of T1 bladder tumors into T1A and T1B has an important prognostic signi cance and a great impact on patient management. Unfortunately, staging T1 tumors is highly subject to interpathologist variation that can be critical for patients included in randomized clinical trials. To determine the value of immunohistochemistry (IHC), such as desmin and keratin, in comparison to hematoxylin-eosin (H&E) in classifying T1 stage disease, we retrospectively examined 93 consecutive cases diagnosed at our department. Materials and Methods: The study was conducted in two phases (H&E then IHC), each in two time periods. First H&E, and then IHC slides were reviewed independently by two experienced pathologists and discrepant cases from each phase were discussed between the two pathologists to reach a nal decision. Results: The two methodologies (H&E and IHC) showed total agreement in 76 out of 93 cases. IHC downstaged seven cases, that is from T1B to T1A, upstaged four cases, that is from T1A to T1B, lowered the rate of imprecision and eliminated the disagreement between the two pathologists. However, IHC failed to subclassify T1 tumors in three cases. Finally, the discussion supported by the IHC was very useful in reaching the diagnosis in some cases. Conclusions: IHC appears to be a useful tool in staging T1 bladder cancer, especially in dif cult cases where specimen orientation and artifact could create a major hindrance in reaching an accurate diagnosis. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Urothelial bladder cancer; T1A; T1B; Hematoxylin-eosin; Immunohistochemistry 1. Introduction Besides the pattern of tumor growth and the histological grade, tumor stage is considered one of the most important prognostic factors of urothelial carcinoma of the bladder. Management of these tumors depends greatly on depth of tumor invasion [1]. Tumors con- ned to the epithelium (pta) are treated with surveillance, intravesical chemotherapy and eventually repeated transurethral resections, while those invading the muscularis propria (pt2) require radical cystectomy with urinary diversion. Moreover, tumors with in ltration of the lamina propria (pt1) remain a therapeutic dilemma. While some authors have advocated * Corresponding author. Tel ; Fax: address: paulette.mhawech-fauceglia@hcuge.ch (P. Mhawech). an aggressive surgical management similar to pt2 tumors, others recommended a conservative attitude as in pta tumors [2]. The identi cation of a muscularis mucosae (MM) in the lamina propria, a scattered muscular ber running along large blood vessels, has had a great impact on staging T1 bladder tumors and subsequently led to their classi cation into three subgroups [3±5]: T1a, tumors extending into the lamina propria but above the level of the MM; T1b, tumors reaching the level of the MM; and T1c, those invading beyond the MM. Furthermore, this subclassi cation has proven to be of prognostic value. Since it has been shown that the prognostic signi cance of T1c is worse when compared to T1a and T1b put together, the two latter stages were grouped and renamed as T1A (or minimally invasive tumors), and T1c was renamed as T1B (or invasive tumors) in this study and elsewhere [5±8]. For the clinicians, this subclassi cation seemed /02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S (02)

2 460 P. Mhawech et al. / European Urology 42 (2002) 459±463 to be useful in patient management, as it can orient the treatment either in a minimally invasive perspective or towards a more aggressive treatment such as a radical cystectomy. However, the interpretation of the depth of tumor invasion within the T1 stage is a complicated task for pathologists. Misorientation, cautery artifact and necrosis are the leading causes of interpretation subjectivity and consequent to intrapathologist variation and disagreement [9±12]. In an attempt to reduce this variability, we decided to perform an immunohistochemistry (IHC) study employing two widely used antibodies, total keratin to highlight tumor in ltrates and desmin to highlight muscle bers of the MM and muscularis propria. Our aim was to de ne the value of a simple IHC in comparison to hematoxylin-eosin (H&E) in reaching a nal diagnosis. 2. Materials and methods A retrospective study during 5-year period (1996±2001) was conducted. A series of 93 consecutive transurethral resection bladder tumors from 93 patients bearing the diagnosis of T1 urothelial bladder cancer were identi ed from the archives of the Department of Pathology at Geneva University Hospital. Paraf n-embedded tissues and hematoxylin-eosin (H&E) stained surgical slides were available for all patients. The number of H&E slides for review ranged from 1 to 10 per patient with the majority of the patients having in average four slides examined. Additional sections were cut from the paraf n blocks and processed for immunohistochemistry (IHC). Slides for total keratin (monoclonal: pool, 1:100, Dako, Copenhagen, Denmark and 1:25, Biogenex, Basel, Switzerland) and desmin (monoclonal, 1:10, Dako) were pre-treated by an antigen retrieval method and IHC performed using the avidin±biotin complex (ABC) technique. One representative paraf n block and when necessary, two or three blocks per case were chosen for IHC. The study was done in two phases, H&E then IHC, and each of the two phases was conducted in two time periods. For the rst phase, H&E slides were examined for histology independently by two pathologists (P.M. and M.-F.P.). On routine H&E sections, the muscularis mucosa was recognized as scattered and discontinuous muscle bers, closely associated with large blood vessels in the lamina propria. In those cases where muscle bers were absent, large blood vessels were considered as indirect indication of the level of the muscularis mucosa. Based on this morphological criterion, the tumor stage was classi ed in two groups, T1A and T1B as already de ned in the introduction. A third group, T1 not otherwise speci ed (T1NOS), was added for those cases in which the pathologists were unable to categorize the tumors in T1A or T1B. In a second time, the H&E results were compared and the discrepant as well as the T1NOS cases were discussed between the two pathologists to reach a nal decision. Then, the IHC (total keratin and desmin) stained slides were reviewed and tumor stage was registered independently by the same two pathologists. In a second time, the results were compared and the discrepant as well as the T1NOS cases were discussed between the two pathologists to reach a nal diagnosis. H&E slides were at all times available to the pathologists for review. 3. Results Ninety-three cases were con rmed by the two pathologists as stage T1 bladder cancer by H&E and recon rmed by IHC review. On H&E examination, the rst reviewer classi ed T1A in 66/93 cases (71%), T1B in 20/93 cases (21%), and T1NOS in 7/93 cases (7.5%). The second reviewer classi ed T1A in 58/93 cases (62%), T1B in 16/93 cases (17%), and T1NOS in 19/93 cases (20%). After discussion between the two pathologists a classi cation of T1A was retained in 65/93 cases (70%), T1B in 18/93 cases (19%) and T1NOS in 7/93 cases (7.5%). No consensus was reached in three cases (3%), and all these three cases were classi ed as T1A by the rst reviewer and T1NOS by the second. These numbers have already been included in the initial count of T1A and T1NOS (Table 1). On IHC, Table 1 Comparison between the two reviewers using the H&E staining First reviewer Second reviewer Discussion T1A 66 (71) 58 (62) 65 (70) T1B 20 (21.5) 16 (17) 18 (19) T1NOS 7 (7.5) 19 (20) 7 (7.5) No consensus 3 (3) a a Three cases were T1A and three cases T1NOS stage for the first and second reviewer, respectively. These numbers are already included in the initial counting of T1A and T1NOS. Table 2 Comparison between the two reviewers using the IHC staining First reviewer Second reviewer Discussion T1A 65 (70) 75 (81) 74 (79.5) T1B 25 (27) 15 (16) 16 (17) T1NOS 3 (3) 3 (3) 3 (3) Table 3 Comparison between the H&E and the IHC stainings H&E IHC T1A T1B T1NOS T1A 63 (68) 4 (4) T1B 7 (7.5) 11 (12) T1NOS 5 (5) 2 (2) No consensus 1 (1) 1 (1) 1 (1)

P. Mhawech et al. / European Urology 42 (2002) 459±463 461 Fig. 1. (A) Bladder biopsy showing tumor in ltrates super cial to the prominent vessels. However, the muscularis mucosa is not seen.

(C) IHC for desmin (10) highlights the muscularis mucosa which appears to be in a discontinuous and scattered fashion. In this case, the IHC helped to illustrate a better topography.

3 P. Mhawech et al. / European Urology 42 (2002) 459± Fig. 1. (A) Bladder biopsy showing tumor in ltrates super cial to the prominent vessels. However, the muscularis mucosa is not seen. Hematoxylin and eosin (H&E) staining (10). (B) Immunohistochemistry (IHC) for keratin (KALL) (10) demonstrates the depth of invasiveness of the tumor cells. (C) IHC for desmin (10) highlights the muscularis mucosa which appears to be in a discontinuous and scattered fashion. In this case, the IHC helped to illustrate a better topography. This is a case of urothelial bladder cancer classi ed as T1A, both on H&E and IHC. the rst reviewer classi ed these cases as follows; T1A in 65/93 cases (70%), T1B in 25/93 cases (27%), and T1NOS in 3/93 cases (3%). The second reviewer classi ed these tumors as T1A in 75/93 cases (81%), T1B in 15/93 cases (16%), and T1NOS in 3/93 cases (3%). IHC without discussion between pathologists changed the reviewers' classi cation in comparison to H&E in 11 cases for the rst and 20 cases for the second. Of those cases, ve constituted a major problem for each of the two reviewers. After discussion, 74/93 cases (79.5%), 16/93 cases (17%), and 3/93 cases (3.0%) were classi ed as T1A, T1B and T1NOS, respectively (Table 2). The discussion supported by the IHC was helpful to reclassify 15 cases. IHC without discussion was of no help in seven cases, that is neither of the two pathologists has changed his/ Fig. 2. (A) A case of invasive tumor, but the depth of invasiveness is limited by the specimen orientation as neither prominent vessels nor the muscularis mucosa could be identi ed (H&E 10). (B) IHC for desmin (10) demonstrates sheets of tumor surrounded by the muscularis mucosa (thin smooth muscle bers). This is a case of T1B urothelial carcinoma which was classi ed as T1NOS on H&E.

4 462 P. Mhawech et al. / European Urology 42 (2002) 459±463 Fig. 3. (A) A case of tumor cells in ltrates admixed with massive in ammatory cells. Tumor cells appear to be in contact with the muscularis propria and we classi ed it as T1B (H&E 10). However, IHC for KALL (10) (B) and desmin (10) (C) shows that tumoral cells are far from the muscularis propria and what we saw on H&E in contact with the muscularis propria were in ammatory cells. This case was reclassi ed as T1A urothelial carcinoma. her diagnosis in comparison to H&E. In those cases, the discussion between the two pathologists supported by the IHC played a major role in reaching a diagnosis. In comparison to H&E result, IHC upstaged four cases, meaning from T1A to T1B, downstaged seven cases meaning from T1B to T1A and classi ed ve T1NOS cases into T1A. On the other hand, IHC left three cases (3.2%) as T1NOS due to extensive tissue necrosis (two cases) and loss of the area of interest in deeper level (one case) (Table 3). The two methodologies (H&E and IHC) had a total agreement in 76 of all cases (82%); with 63 cases (68%), 11 cases (12%), and 2 cases (2%) as T1A, T1B and T1NOS, respectively. Remarkably, IHC lowered the rate of imprecision in T1 staging from 7 (7.5%) to 3 (3%) for the rst reviewer and from 19 (20%) to 3 (3%) for the second reviewer. Finally, IHC eliminated the disagreement between the two pathologists in reaching a nal diagnosis. 4. Discussion Urinary bladder cancer is the fourth leading cause of cancer in men and the eighth in women [13]. Thevast majority of cases (70%) are super cial bladder tumors (Tis, Ta and T1) with high rate of recurrence and/or progression. While Ta tumors show a high recurrence rate but rare progression, T1 tumors have a progression rate of 30% and reaching 50% in poorly differentiated cases [14]. Classi cation of these tumors in term of invasion with respect to the MM has been shown to be of considerable prognostic signi cance. However, the identi cation of the MM is quite impossible in all cases, especially in transurethral resection material, where misorientation of the specimen and artifactual changes are important causes of intrapathologist variation and disagreement. Despite the explicit identi cation of these limitations in many previous works, no study

5 P. Mhawech et al. / European Urology 42 (2002) 459± to this date has attempted to solve some of these problems [5,6,11,15]. Due to the urgent demand from the clinicians for more speci city in staging T1 tumors and the need for more objectivity in pathology reports, we conducted a retrospective study to evaluate the use of total keratin and desmin, two widely used antibodies, in comparison to H&E. By highlighting the tumor in ltrates (total keratin) and the muscular bers (desmin), we can obtain better topography and consequently reach a nal diagnosis with more objectivity (Fig. 1). In this review of 93 cases, IHC reduced dramatically many of the dif culties related to specimen misorientation and bad topography facing each of the two pathologists and that are critical in T1 stage assessment (Figs. 2 and 3). IHC technique was superior compared with H&E in lowering the rate of imprecision in staging T1 tumors critical in patient management for both reviewers. Also, IHC especially after discussion was superior in eliminating the disagreement between pathologists. IHC changed the staging in 11 cases, avoiding overtreatment or leading to closer patient's follow-up and possibly different treatment strategy. In addition, it appeared that the discussion between pathologists supported by IHC gives an additional bene t in reaching a nal diagnosis. By giving better topography, thus adding more objectivity to the histologic interpretation, IHC improved the agreement between pathologists. Therefore, we highly advice the review of the slides (H&E and IHC for desmin and KALL) by more than one pathologist to obtain a better consensus before starting treatment. Despite the great value of the IHC, it still has limitations such as extensive tumor necrosis and loss of material in deeper level. In a similar situation, we recommend a rebiopsy to reach an accurate and precise diagnosis. Hence, the patients might bene t from a better treatment and follow-up and especially in those patients who are included in randomized clinical trials. The question to be asked is why these two classi cations have different behavior. Are they biologically different or the same tumor but with different stage of invasion? We are currently investigating some of the biological parameters in these two classi cations and the result will be the subject of a separate paper. Staging T1 tumors are subject to inter and intrapathologist variation. Despite the identi cation of this problem in many scienti c works, no study has been conducted so far to discuss this issue. Our study is the rst to do so, and we clearly showed that (1) by using IHC, a better distinction between minimally invasive (T1A) and invasive (T1B) bladder tumors is possible in vast majority of cases; (2) discussing H&E and IHC sections between pathologists can add a great bene t in reaching a precise diagnosis. Acknowledgements The authors like to thank Madame Monique Coassin and the immunohistochemistry laboratory at Geneva University Hospital for the technical assistance. We are grateful to Ludovic Metral for his help in searching the archives and to Dr. Thom McKee for his critical review of the manuscript. References [1] Cheng L, Weaver AL, Neumann RM, Scherer BG, Bostwick DG. Substaging of T1 bladder carcinoma on the depth of invasion as measured by micrometer: a new proposal. Cancer 1999;86:1035±43. [2] Soloway MS, Sofer M, Vaidya A. Contemporary management of stage T1 transitional cell carcinoma of the bladder. J Urol 2002;167:1573±83. [3] Dixon JS, Gosling JA. Histology and ne structure of the muscularis mucosae of the human urinary bladder. J Anat 1983;13:265±71. [4] Ro JY, Ayala AG, El-Naggar A. Muscularis mucosa of urinary bladder. Importance for staging and treatment. Am J Surg Pathol 1987;11:668±73. [5] Younes M, Sussman J, True LD. The usefulness of the level of the muscularis mucosae in the staging of invasive transitional cell carcinoma of the urinary bladder. Cancer 1990;66:543±8. [6] Angulo JC, Lopez JI, Grignon DJ, Sanchez-Chapado M. Muscularis mucosa differentiates two populations with different prognosis in stage T1 bladder cancer. Urology 1995;45:47±53. [7] Hasui Y, Osada Y, Kitada S, Nishi S. Signi cance of invasion to the muscularis mucosa on the progression of super cial bladder cancer. Urology 1994;43:782±6. [8] Holmang S, Hedelin H, Anderstrom C, Holmberg E, Johansson SL. The importance of the depth of invasion in stage T1 bladder carcinoma: A retrospective cohort study. J Urol 1997;157:800±4. [9] Witjes JA, Kiemeney LALM, Schaafsma HE, Debruyne FMJ. The in uence of review pathology on study outcome of a randomized multicentre super cial bladder cancer trial. Br J Urol 1994;73: 172±6. [10] Angulo JC, Lopez JI. The importance of the depth of invasion in stage T1 bladder carcinoma: A retrospective cohort study (letter to the editor). J Urol 1997;158:1922±3. [11] van der Meijden A, Sylvester R, Collette L, Bono A, ten Kate F. The role and impact of pathology review on stage and grade assessment of stages TA and T1 bladder tumors: A combined analysis of 5 European organization for research and treatment of cancer trials. J Urol 2000;164:1533±7. [12] Dutta SC, Smith JA, Shappell SB, Coffey CS, Chang SS, Cookson MS. Clinical under staging of high risk nonmuscle invasive urothelial carcinoma treated with radical cystectomy. J Urol 2001;166: 490±3. [13] Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer statistics CA Cancer J Clin 2001;51:15±36. [14] Heney NM, Ahmed S, Flanadan MJ, Frable W, Corder MP, Hafermann MD, et al. Super cial bladder cancer: progression and recurrence. J Urol 1983;130:142±7. [15] Amling CL. Diagnosis and management of super cial bladder cancer. Curr Probl Cancer 2001;25:217±80.

Radical Cystectomy Often Too Late? Yes, But...

european urology 50 (2006) 1129 1138 available at www.sciencedirect.com journal homepage: www.europeanurology.com Editorial 50th Anniversary Radical Cystectomy Often Too Late? Yes, But... Urs E. Studer