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Introduction
Squamous carcinoma of the bladder has a poor prognosis. Low overall 5 year survival 7-50% is cited due to advanced stage at presentation, grade and vascular density. We show in our series that there are many unusual features of this tumour. This includes a worse all cause mortality that, we propose, is probably due to worse co-morbidities than in the TCC population.
Methods
Study population was 258 patients who underwent radical cystectomy who were followed over 18 years. 230 had transitional cell cancer and 16 had squamous cell cancer on final histology. Kaplan Meier curves are generated. Patient and tumour characteristics are compared.
Results
16 Squamous cell
230 Transition cell
P value Fishers and t
Private
3
32
0.7
Male/female
5/11
185/45
0.03
Age
67
68
0.58
Neobladder
2
51
0.37
Grade High
8
213
0.0001
Intermediate
6
17
0.0021
Low
0
0.0045
Tumour volume cc
101
14
0.019
Positive surgical margins
6/16 (38%)
21/230 (9%)
0.0052
Localised/locally advanced
3/13 (19%)
140/90 (61%)
0.0006
CIS
105
0.45
Node positive patients
4
1.0
Number of nodes positive (total number of nodes)
13
128
Node harvest
214
2299
Node density
0.06
0.055
0.75
Extracapsular extension
22
Proportion of ECE
2/13 = 0.15
22/128 = 0.17
Prostate cancer
2/5 =0.4
83/185 = 0.45
0.69
Complications
59
Additional treatment
44
0.76
Progression free survival at 5 years
0.63
0.046
Disease specific survival at 5 years
0.5
0.71
0.0037
All cause survival at 5 years
0.13
0.61
Number of disease specific deaths
8 (50%)
80 (35%)
0.31
Number of all cause deaths
14 (88%)
113 (49%)
0.010
Discussion
SCC is quoted as accounting for only 1% of bladder cancer in UK. Our series has 6%. We note a number of differences between the two categories of SCC and TCC. Our series showed a predominance of women 69% with SCC which is contrary to most bladder cancer series with of 19% TCC being women. Both cohorts are of a similar age. The grade of squamous cell tumours are significantly lower than TCC yet have a far worse prognosis. 50% were low (2) or intermediate (6) grade SCC compared to only 7% with TCC. This may be partly related to the far larger tumour volume. Overall mean tumour volume of 106cc for SCC and 14cc for TCC. There was no significant difference between tumour volume of high grade SCC (101cc) compared to medium and low grade SCC (111cc). Only 19% of SCC were localised compared to 61% for TCC. 81% of SCC were locally advanced. 38% of SCC had positive surgical margins compared to only 9% of TCC. Interestingly, we do not see any greater lymph node involvement. We see an earlier tendency to progression ( 40% at 5 years local recurrence or metastasis) for SCC compared to only 24% for TCC. There is a higher disease specific mortality of 50% for SCC compared to only 29% for TCC at 5 years. However there is a far higher all cause mortality of 81% at 5 years with SCC compared to 39% for TCC.
Conclusions
The study population have very large tumours that are locally advanced with positive surgical margins. The tumour volumes are of a similar size amongst the range of grades in SCC. There is a greater disease specific mortality for SCC. However, half of SCC are low and intermediate grades. Both long term SCC survivors had high grade tumours. A high grade SCC may not be as severe as a high grade TCC? Low and medium grade SCC does not confer a survival advantage, the effect of stage being a more powerful determinant of prognosis. There is a worse prognosis for SCC. This is probably due to a higher incidence of severe comorbidities accounting for the worse all cause mortality. Features specific to SCC account for the higher disease specific mortality.