title: Early detection of urothelial premalignant lesions using hexaminolevulinate fluorescence cystoscopy in high risk patients.
abstract: BACKGROUND
  To evaluate fluorescence cystoscopy with hexaminolevulinate (HAL) in the early detection of dysplasia (DYS) and carcinoma in situ (CIS) in select high risk patients.
  
  
  METHODS
  We selected 30 consecutive bladder cancer patients at high risk for progression. After endoscopic resection, all patients received (a) induction BCG schedule when needed, and (b) white light and fluorescence cystoscopy after 3 months. HAL at doses of 85 mg (GE Healthcare, Buckinghamshire, United Kingdom) dissolved in 50 ml of solvent to obtain an 8 mmol/L solution was instilled intravesically with a 12 Fr catheter into an empty bladder and left for 90 minutes. The solution was freshly prepared immediately before instillation. Cystoscopy was performed within 120 minutes of bladder emptying. Standard and fluorescence cystoscopy was performed using a double light system (Combilight PDD light source 5133, Wolf, Germany) which allowed an inspection under both white and blue light.
  
  
  RESULTS
  The overall incidence was 43.3% dysplasia, 23.3% CIS, and 13.3% superficial transitional cell cancer. In 21 patients, HAL cystoscopy was positive with one or more fluorescent flat lesions. Of the positive cases, there were 4 CIS, 10 DYS, 2 association of CIS and DYS, 4 well-differentiated non-infiltrating bladder cancers, and 1 chronic cystitis. In 9 patients with negative HAL results, random biopsies showed 1 CIS and 1 DYS. HAL cystoscopy showed 90.1% sensitivity and 87.5% specificity with 95.2% positive predictive value and 77.8% negative predictive value.
  
  
  CONCLUSIONS
  Photodynamic diagnosis should be considered a very important tool in the diagnosis of potentially evolving flat lesions on the bladder mucosa such as DYS and CIS. Moreover, detection of dysplasic lesions that are considered precursors of CIS may play an important role in preventing disease progression. In our opinion, HAL cystoscopy should be recommended in the early follow-up of high risk patients.
authors.affiliation: Department of Urology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy. sblanco_74@yahoo.it
authors.forename: Salvatore
authors.initials: S
authors.lastname: Blanco
authors.forename: Marco
authors.initials: M
authors.lastname: Raber
authors.forename: Biagio Eugenio
authors.initials: BE
authors.lastname: Leone
authors.forename: Luca
authors.initials: L
authors.lastname: Nespoli
authors.forename: Marco
authors.initials: M
authors.lastname: Grasso
mesh_terms: D003558:Cystoscopy / Q000379:methods*; D005453:Fluorescence; D006801:Humans; D011230:Precancerous Conditions / Q000175:diagnosis*; D001749:Urinary Bladder Neoplasms / Q000175:diagnosis*