A total of 135 patients, 22 (16,3%) female and 113 (83,7%) male, aged varying from 22 to 107 (mean: 65,1 ± 12,7), were enrolled in the study. The majority of cases (n = 120, 88,9%) were high-grade. Tumor diameters varied from 0,5 to 10 (median: 3) cm and the most common locations were the lateral walls, base, ureteral orifices, and posterior wall, respectively.
At the last follow-up, 37 (27,4%) cases had recurrence (median RFS time: 15 months) at least once and 34 (25.2%) of them were exitus (median OS time: 27 months). Intravesical treatment (BCG, Epirubicin, Mitomycin C) was applied to 61 (45,2%) patients, and 4 cases received systemic chemotherapy. BCG was applied to a total of 50 cases, 42 of them were after the initial surgery and 8 of them were in cases where recurrence was detected during follow-up. The characteristics of the cases are summarized in Table 1.
Table 1
The characteristics of the patients
Characteristics | n | % |
Age (year) | 22–107 (mean: 65,1 ± 12,7) |
Gender | Female | 22 | 16,3 |
Male | 113 | 83,7 |
Grade | Low | 15 | 11,1 |
High | 120 | 88,9 |
Size (cm), median: 3 (0,5–10) | > 3,5 | 48 | 35,6 |
≤ 3,5 | 79 | 58,5 |
NK | 8 | 5,9 |
Multiplicity | Unifocal | 73 | 54,1 |
Multifocal | 57 | 42,2 |
NK | 5 | 3,7 |
Number of tumor focuses | Single | 73 | 54,1 |
2–3 | 37 | 27,4 |
≥ 4 | 20 | 14,8 |
NK | 5 | 3,7 |
Primary site | Lateral wall | 68 | 50,4 |
Base | 17 | 12,6 |
Ureteric orifice | 15 | 11,1 |
Posterior | 12 | 8,9 |
Dome | 8 | 5,9 |
Bladder neck | 6 | 4,4 |
Anterior wall | 1 | 0,7 |
Diffuse | 2 | 1,5 |
NK | 6 | 4,4 |
Stage | pTa | 76 | 56,3 |
pT1 | 49 | 36,3 |
pT2 | 10 | 7,4 |
In situ | Present | 50 | 37,0 |
Absent | 85 | 63,0 |
Necrosis | Present | 19 | 14,1 |
Absent | 116 | 85,9 |
TLS | 0 | 32 | 23,7 |
1–2 | 35 | 25,9 |
3–4 | 27 | 20,0 |
≥ 5 | 41 | 30,4 |
Local treatment | Present | 61 | 45,2 |
BCG | 50 | 37,1 |
Epirubicin | 10 | 7,4 |
Mitomycin C | 1 | 0,7 |
Absent | 71 | 52,6 |
NK | 3 | 2,2 |
Recurrens | Present | 37 | 27,4 |
Absent | 98 | 72,6 |
Survival | Alive | 101 | 74,8 |
Exitus | 34 | 25,2 |
Total | | 135 | 100.0 |
TLS: Tertiary lymphoid structure, RFS: Recurrence-free survival, OS: Overall survival |
TLS was detected in 103 (76,3%) cases and its numbers varied between 1 and 19 (median: 3). TLSs were more frequently found in high-grade tumors (p = 0,008) and showed a strong association with stage progression (p < 0,001). Moreover, a significant relationship was found between high TLS and tumor diameter (TLS ≥ 2, p = 0,026), multifocality (TLS ≥ 3, p = 0,003), number of tumor foci (TLS ≥ 3, p = 0,020), presence of urothelial carcinoma in situ (TLS ≥ 3, p = 0,024), and necrosis (TLS ≥ 3, p = 0,003). In line with these findings, it was found that cases with high TLS (≥ 2) showed shorter OS (p = 0,025, Fig. 3F).
Alternatively, when analyzing the prognostic effect of TLS for each stage, patients with TLS ≥ 3 showed longer overall survival in the pTa and pT2 stages. However, the results were not statistically significant (p = 0,204 and p = 0,201, respectively).
High TLS (≥ 1, ≥ 2, and ≥ 3) appeared to be associated with fewer recurrences (p = 0,032, p = 0,001, and p = 0,018, respectively), and cases with higher TLS showed longer recurrence-free survival (p = 0,089, p = 0,023, p = 0,037, respectively) (Fig. 3C, 3E, 3G). Table 2 summarizes the TLS and clinicopathological characteristics relationship for thresholds ≥ 1, ≥2, and ≥ 3.
Table 2
The relationship of TLS thresholds and clinicopathological characteristics.
| | TLS |
Characteristics | n (%) | < 1 | ≥ 1 | p | < 2 | ≥ 2 | p | < 3 | ≥ 3 | p |
n (%) | 135 (100,0) | 32 (23,7) | 103 (76,3) | | 46 (34,1) | 89 (65,9) | | 67 (49,6) | 68 (50,4) | |
Age (year) | (mean: 65,1 ± 12,7) | 63,8 ± 12,3 | 65,5 ± 12,8 | 0,506 | 62,3 ± 12,6 | 66,6 ± 12,5 | 0,042 | 63,3 ± 13,3 | 66,9 ± 11,9 | 0,106 |
> 67 | 57 (42,2) | 13 (22,8) | 44 (77,2) | 0,996 | 16 (28,1) | 41 (71,9) | 0,283 | 26 (45,6) | 31 (54,4) | 0,425 |
≤ 67 | 78 (57,8) | 19 (24,4) | 59 (75,6 | 30 (38,5) | 48 (61,5) | 41 (52,6) | 37 (47,4) |
Gender | Female | 22 (16,3) | 6 (27,3) | 16 (72,7) | 0,876 | 8 (36,4) | 14 (63,6) | 0,999 | 11 (50,0) | 11 (50,0) | 1,000 |
Male | 113 (83,7) | 26 (23,0) | 87 (77,0) | 38 (33,6) | 75 (66,4) | 56 (49,6) | 57 (50,4) |
Grade | Low | 15 (11,1) | 8 (53,3) | 7 (46,7) | 0,008 | 9 (60,0) | 6 (40,0) | 0,050 | 11 (73,3) | 4 (26,7) | 0,094 |
High | 120 (88,9) | 24 (20,0) | 96 (80,0) | 37 (30,8) | 83 (69,2) | 56 (46,7) | 64 (53,3) |
Size (cm) | > 3,5 | 48 (37,8) | 7 (14,6) | 41 (85,4) | 0,098 | 10 (20,8) | 38 (79,2) | 0,026 | 18 (37,5) | 30 (62,5) | 0,037 |
≤ 3,5 | 79 (62,2) | 23 (29,1) | 56 (70,9) | 33 (41,8) | 46 (58,2) | 46 (58,2) | 33 (41,8) |
NK | 8 | | | | | | |
Multiplicity | Unifocal | 73 (56,2) | 22 (30,1) | 51 (69,9) | 0,090 | 32 (43,8) | 41 (56,2) | 0,011 | 44 (60,3) | 29 (39,7) | 0,008 |
Multifocal | 57 (43,8) | 9 (15,8) | 48 (84,2) | 12 (21,1) | 45 (78,9) | 21 (36,8) | 36 (63,2) |
NK | 5 | | | | | | |
Focus number | 1 | 73 (56,2) | 22 (30,1) | 51 (69,9) | 0,140 | 32 (43,8) | 41 (56,2) | 0,022 | 44 (60,3) | 29 (39,7) | 0,020 |
2–3 | 37 (28,5) | 5 (13,5) | 32 (86,5) | 7 (18,9) | 30 (81,1) | 12 (32,4) | 25 (67,6) |
≥ 4 | 20 (15,4) | 4 (20,0) | 16 (80,0) | 5 (25,0) | 15 (75,0) | 9 (45,0) | 11 (55,0) |
NK | 5 | | | | | | |
Stage | pTa | 76 (56,3) | 29 (38,2) | 47 (61,8) | < 0,001 | 39 (51,3) | 37 (48,7) | < 0,001 | 51 (67,1) | 25 (32,9) | < 0,001 |
pT1 | 49 (36,3) | 3 (6,1) | 46 (93,9) | 7 (14,3) | 42 (85,7) | 13 (26,5) | 36 (73,5) |
pT2 | 10 (7,4) | 0 (0,0) | 10 (100,0) | 0 (0,0) | 10 (100,0) | 3 (30,0) | 7 (70,0) |
In situ | Present | 50 (37,0) | 10 (20,0) | 40 (80,0) | 0,571 | 14 (28,0) | 36 (72,0) | 0,340 | 18 (36,0) | 32 (64,0) | 0,024 |
Absent | 85 (63,0) | 22 (25,9) | 63 (74,1) | 32 (37,6) | 53 (62,4) | 49 (57,6) | 36 (42,4) |
Necrosis | Present | 19 (14,1) | 1 (5,3) | 18 (94,7) | 0,044 | 2 (10,5) | 17 (89,5) | 0,038 | 3 (15,8) | 16 (84,2) | 0,003 |
Absent | 116 (85,9) | 31 (26,7) | 85 (73,3) | 44 (37,9) | 72 (62,1) | 64 (55,2) | 52 (44,8) |
Recurrens | Present | 37 (27,4) | 14 (37,8) | 23 (62,2) | 0,032 | 21 (56,8) | 16 (43,2) | 0,001 | 25 (67,6) | 12 (32,4) | 0,018 |
Absent | 98 (72,6) | 18 (18,4) | 80 (81,6) | 25 (25,5) | 73 (74,5) | 42 (42,9) | 56 (57,1) |
Survival | Alive | 101 (74,8) | 27 (26,7) | 74 (73,3) | 0,233 | 38 (37,6) | 63 (62,4) | 0,197 | 50 (49,5) | 51 (50,5) | 1,000 |
Exitus | 34 (25,2) | 5 (14,7) | 29 (85,3) | 8 (23,5) | 26 (76,5) | 17 (50,0) | 17 (50,0) |
TLS: Tertiary lymphoid structure |
The amount of TLS in patients who received BCG after the initial surgery (n = 42) was lower (median: 3, minimum-maximum: 0–7) in patients who had recurrence (n = 11) than in those who did not (median: 4, minimum-maximum: 0–15) (Fig. 4). However, this finding did not reach statistical significance (p = 0,267).
Multivariable analyses revealed that multifocality was found to be an independent risk factor predicting RFS (p = 0,023, HR = 2,302). Alternatively, TLS ≥ 3 was found to be an independent parameter that was negatively associated with RFS (p = 0,019, HR = 0,401) (Table 3). Age (p < 0,001, HR: 0,153), stage (p = 0,022, HR: 0,312), tumor size (p = 0,008, HR: 0,335), presence of necrosis (p = 0,035, HR: 3,096), TLS ≥ 2 (p = 0,036, HR: 0,304) and TLS ≥ 3 (p = 0,004, HR: 3,523) were found to be independent risk factors predicting OS (Table 4).
Table 3
Factors affecting RFS by Cox regression analysis.
| Univariable | Multivariable (Backward: Wald) |
| B | Sig. | Exp(B) | 95,0% CI for Exp(B) | B | Sig. | Exp(B) | 95,0% CI for Exp(B) |
Lower | Upper | Lower | Upper |
Age (≤ 67/>67) | -0,421 | 0,210 | 0,657 | 0,340 | 1,268 | | | | | |
In situ (+/-) | 0,319 | 0,344 | 1,375 | 0,711 | 2,661 | | | | | |
Grade (Low/High) | -0,523 | 0,332 | 0,593 | 0,206 | 1,704 | | | | | |
Stage (pTa/pT1 | 0,049 | 0,887 | 1,050 | 0,537 | 2,053 | | | | | |
Size (≤ 3,5/>3,5) | -0,285 | 0,451 | 0,752 | 0,359 | 1,576 | | | | | |
Multiplicity (Unifocal/Multifocal) | 0,486 | 0,160 | 1,625 | 0,826 | 3,199 | 0,834 | 0,023 | 2,302 | 1,120 | 4,731 |
Necrosis (+/-) | 0,168 | 0,728 | 1,183 | 0,460 | 3,044 | | | | | |
TLS (< 1/≥1) | -0,569 | 0,096 | 0,566 | 0,290 | 1,107 | | | | | |
TLS (< 2/≥2) | -0,747 | 0,027 | 0,474 | 0,244 | 0,920 | | | | | |
TLS (< 3/≥3) | -0,731 | 0,043 | 0,481 | 0,237 | 0,979 | -0,913 | 0,019 | 0,401 | 0,187 | 0,860 |
TLS: Tertiary lymphoid structure, RFS: Recurrence-free survival |
Table 4
Factors affecting OS by Cox regression analysis.
| Univariable | Multivariable (Backward: Wald) |
| B | Sig. | Exp(B) | 95,0% CI for Exp(B) | B | Sig. | Exp(B) | 95,0% CI for Exp(B) |
Lower | Upper | Lower | Upper |
Age (≤ 67/>67) | -1,588 | < 0,001 | 0,204 | 0,095 | 0,438 | -1,880 | < 0,001 | 0,153 | 0,064 | 0,362 |
In situ (+/-) | 0,148 | 0,675 | 1,160 | 0,580 | 2,317 | | | | | |
Grade (Low/High) | -0,114 | 0,877 | 0,893 | 0,211 | 3,771 | 1,603 | 0,059 | 4,969 | 0,940 | 26,262 |
Stage (pTa/pT1-pT2 | -1,285 | < 0,001 | 0,277 | 0,132 | 0,580 | -1,165 | 0,022 | 0,312 | 0,116 | 0,843 |
Size (≤ 3,5/>3,5) | -1,172 | 0,001 | 0,310 | 0,151 | 0,635 | -1,093 | 0,008 | 0,335 | 0,148 | 0,756 |
Multiplicity (Unifocal/Multifocal) | -0,228 | 0,513 | 0,796 | 0,402 | 1,577 | | | | | |
Necrosis (+/-) | -0,594 | 0,142 | 0,552 | 0,250 | 1,221 | 1,130 | 0,035 | 3,096 | 1,084 | 8,840 |
TLS (< 1/≥1) | -0,828 | 0,088 | 0,437 | 0,169 | 1,130 | | | | | |
TLS (< 2/≥2) | -0,882 | 0,030 | 0,414 | 0,187 | 0,918 | -1,190 | 0,036 | 0,304 | 0,100 | 0,928 |
TLS (< 3/≥3) | -0,143 | 0,678 | 0,867 | 0,442 | 1,701 | 1,259 | 0,004 | 3,523 | 1,488 | 8,338 |
TLS: Tertiary lymphoid structure, OS: Overall survival |