908
E D I T O R I A L
Counterpoint
See reply to counterpoint on pages 910-2 and
referenced original article on pages 1035– 43, this
issue.
Address for reprints: Harry W. Herr, M.D., Depart-
ment of Urology, Memorial Sloan-Kettering Cancer
Center, 1275 York Avenue, New York, NY 10021.
Received April 9, 1999; accepted June 9, 1999.
© 1999 American Cancer Society
Progression of T1 Bladder
Tumors
Better Staging or Better Biology?
Harry W. Herr, M.D.1
Victor E. Reuter, M.D.2
1
Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York.
2
Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York.
T 1 bladder tumors represent a significant cancer threat. Although
initially patients are treated with aggressive transurethral resec-
tion (TUR) and many receive intravesical therapy, .50% of patients
develop a muscle-invasive tumor if followed for 15 years and 33% die
of metastatic bladder carcinoma.1 Identifying the subset of patients
with T1 bladder tumors who are at risk of disease progression is a
major goal. The authors propose to accomplish this by substaging T1
bladder carcinoma based on the depth of submucosal invasion as
measured by micrometer.2 Using a depth of 1.5 mm, tumor invasion
below this level in TUR specimens appears to indicate a more ad-
vanced pathologic stage. The authors are on the right track by at-
tempting to refine histologic analysis of TUR specimens and to derive
from them maximum prognostic information. Unfortunately, their
study and methods fail to address the seminal question of which
patients with T1 tumors that appear to be histologically identical will
develop disease progression and which patients will not. The reasons
are threefold.
First, the patient population in the current study did not have
T1 tumors because 78% were understaged and had in fact higher
stage tumors ($T2). Understaging of T1 tumors should be no
higher than 20% and in fact an experienced urologist working with
an experienced pathologist can stage true T1 tumors correctly in .
90% of cases.3 Second, the authors do not indicate how many of the
outside TUR specimens reviewed had muscularis propria present.
Without such information, a clinical diagnosis of a T1 tumor can-
not be made with reasonable certainty. For example, a recent
prospective analysis of 58 patients who presented with T1 tumors
showed that 48% (11 of 23) with no muscle present in their TUR
specimen were understaged (.T1) compared with 14% (5 of 35)
who had deep muscle present and uninvolved with tumor.4 Third,
all 55 patients studied by the authors underwent immediate cys-
tectomy, but we are not told how these patients were selected for
aggressive rather than conservative therapy. Using retrospective
pathologic data from cystectomy specimens to make prospective

treatment decisions in individual patients who are
staged clinically must be done cautiously. To the
authors’ credit, they acknowledge these deficiencies
in their analysis.
Last, the authors propose that their findings indi-
cate a need for more accurate preoperative staging
and repeat biopsy in patients with T1 bladder carci-
noma. We agree, and in fact have lobbied in recent
years that a second TUR be performed in all cases of
T1 tumor before a decision is made in favor of cystec-
tomy over conservative therapy.3,4
Counterpoint/Herr and Reuter 909
REFERENCES
1. Cookson MS, Herr HW, Zhang Z-F, Soloway S, Sogani PC,
Fair WR. The treated natural history of high risk superfi-
cial bladder cancer: 15-year outcome. J Urol 1997;158:
62–7.
2. Cheng L, Weaver AL, Neumann RM, Scherer BG, Bostwick
DG. Substaging of T1 bladder carcinoma based on the depth
of invasion as measured by micrometer: a new proposal.
Cancer 1999;86:1035– 43.
3. Herr HW. Uncertainty and outcome of invasive bladder
tumors. Urol Oncol 1996;2:92–5.
4. Herr HW. The value of a repeat transurethral resection (re-
TUR) in evaluating bladder tumors. J Urol 1999; in press.