Actas Urológicas Españolas

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Actas Urol Esp. 2011;35(8):446---447
Actas Urológicas Españolas
www.elsevier.es/actasuro
COMMENTARY
Comment to ‘‘Photodynamic Diagnosis With Hexaminolevulinaate
in Non-Muscle-Invasive Bladder Cancer. Experience of the BLUE
GROUP’’夽
Comentario a «Diagnóstico fotodinámico con hexaminolevulinato en el
cáncer vesical no músculo invasivo: experiencia del grupo B.L.U.E.»
M. Burger
Department of Urology, Caritas St. Josef Medical Center, University of Regensburg, Germany
In the present analysis, Burgués and the B.L.U.E. Group
present data on the Hexvix® fluorescence guided TUR.1 The
authors must be congratulated on their outstanding report,
which transmits new and wonderful concepts about this
technique. Recently, there have been many data on Hexvix
supporting the value of this complement to white light.
The current guideline of the European Association of Urology supports its use,2 as well as the recommendations of
an international commission.3 In fact, many factors suggest
the extensive use of Hexvix. All the documents on Hexvix
are unanimous about the best detection and reduced relapse
rates; the simple bladder cancer epidemiology justifies the
use of techniques that can mitigate the enormous impact of
this disease on overall health, especially since the associated costs appear to reduce the global financial burden.3,4
However, there are, of course, many aspects to clarify.4,5 To
what extent is the advantage of the detection the basis of
the Hexvix feasibility? The B.L.U.E. Group presents a very
detailed and rigorous analysis on the diagnostic accuracy of
Hexvix. Certainly, I am aware of a comparable single series
by the group Munich de Dirk Zaak et al.6 They presented data
on about 4500 samples of 1700 TURs in 800 patients over
7 years of age at their center, and they conducted a photodynamic diagnosis to overcome the sensitivity of white light
夽 Please cite this article as: Burger M. Comentario a ‘‘Diagnóstico
fotodinámico con hexaminolevulinato en el cáncer vesical no
músculo invasivo: experiencia del grupo’’. Actas Urol Esp. 2011;35:
446---7.
E-mail address: maximilian.burger@klinik.uni-regensburg.de
decisively (92% vs. 76%); 24% of the lesions were identified
exclusively by photodynamic diagnosis.
However, the present contribution of the B.L.U.E. Group
is unique in two aspects. On the one hand, we compare
three different approaches, i.e., white light versus Hexvixassisted TUR versus random biopsies, whereas Zaak et al.
compared visually identified lesions only with white light
versus blue light. I have no knowledge of any comparative
assessment of random sampling versus the photodynamic
diagnosis in the diagnosis of CIS. Secondly, this series uses
Hexvix, this is, hexaminolevulinic acid as a fluorescent dye
instead of 5-aminolevulinic acid. This latter substance has
never been approved for its use in the TUR and, as Burgués
and the B.L.U.E. Group state in their manuscript, it has been
suggested as disadvantageous compared with Hexvix due to
its reduced bioavailability and its less stable pharmacodynamics. Therefore, the present series reflects the current
state of the technique.
What is interesting of these findings? Hexvix overall sensitivity was 94% versus 78%; as Hexvix complements white
light, almost all malignant lesions are detected by photodynamic diagnosis. But they would have avoided 22 of
the 600 total lesions, which were only detected by random biopsy; 20 of these lesions were CIS. While it has not
been revealed how many of the lesions detected by random biopsy were concomitant to CIS in other areas of the
bladder diagnosed by white light and Hexvix, it would mean
that none of the patients with high-grade bladder cancer
and/or CIS would have remained without such a diagnosis
after Hexvix-TUR, even with the omission of the random
biopsies.
2173-5786/$ – see front matter © 2011 AEU. Published by Elsevier España, S.L. All rights reserved.
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Comment to ‘‘Photodynamic Diagnosis With Hexaminolevulinaate in Non-Muscle-Invasive Bladder Cancer
But what is the price of the sensitivity achieved by
Hexvix? Obviously, the specificity is reduced. The B.L.U.E.
Group clearly indicates that although the photodynamics is less specific than white light, the difference is not
more than 9%. This finding is consistent with the broadest
and potentially most representative multicenter randomized trial carried out in accordance with the FDA standards.
Stenzl et al. reveal that the rate of false positives of white
and blue lights does not vary significantly.7 We like it or not,
our evaluation of white light is not perfectly specific either.
Thus, the price of the sensitivity achieved by Hexvix seems
right, as shown by Burgués and the B.L.U.E. group.
Nevertheless, we still have some questions. Does that
advantage have any relevant impact on the evolution of
all bladder cancers? Which patients benefit decisively and
should be considered for this methodology? What is the place
of Hexvix in the management of long-term bladder cancer?
I’m sure we’ll find out and I am even more confident that
the B.L.U.E. Group will find more answers.
References
1. Burgués JP, Conde G, Oliva J, Abascal JM, Iborra I, Puertas M,
et al. Diagnóstico fotodinámico con hexaminolevulinato en
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7.
447
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Babjuk M, Oosterlinck W, Sylvester R, Kaasinen E, Böhle A,
Palou-Redorta J, et al. EAU Guidelines on Non-Muscle-Invasive
Urothelial Carcinoma of the Bladder, the 2011 Update. Actas
Urol Esp. 2011;35:373---88.
Witjes JA, Redorta JP, Jacqmin D, Sofras F, Malmström PU,
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Oliva Encina J, Rioja Sanz C. Photodynamic diagnosis (PDD) in
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Oliva Encina J, Marco Valdenebro A, Pelegrí Gabarró J,
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Hungerhuber E, Stepp H, Kriegmair M, Stief C, Hofstetter A,
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