Cases Of High-grade Urothelial Carcinoma Research Articles

Diagnostic value of a comprehensive, urothelial carcinoma-specific next-generation sequencing panel in urine cytology and bladder tumor specimens.

Urine cytology can reliably diagnose high-grade urothelial carcinoma (HGUC) but not low-grade urothelial carcinoma (LGUC), and a more sensitive test is needed. Previously, a pilot study highlighted the possible diagnostic utility of next-generation sequencing (NGS) in identifying both LGUC and HGUC in urine cytology specimens. Twenty-eight urine ThinPrep cytology specimens and preceding or subsequent bladder tumor biopsy/resection specimens obtained within 3 months were included in the study (LGUC, n = 15; HGUC, n = 13). A customized, bladder-specific NGS panel was performed; it covered 69 frequently mutated or altered genes in urothelial carcinoma (UC) that were reported by The Cancer Genome Atlas and the Catalogue of Somatic Mutations in Cancer. The sequencing results were compared between the urine cytology specimens and the corresponding bladder tumor biopsies/resections. TP53 was the most frequently identified mutation in HGUC cases (11 of 13 [85%]). PIK3CA and KDM6A were the most frequently identified mutations in LGUC: they occurred in 7 of 15 cases (47%) and in 6 of 15 cases (40%), respectively. Additional frequent mutations identified in the panel included ARID1A (n = 5), EP300 (n = 4), LRP1B (n = 3), ERBB2 (n = 2), STAG2 (n = 2), FGFR3 (n = 3), MLL (n = 2), MLL3 (n = 2), CREBBP1 (n = 1), RB1 (n = 1), and FAT4 (n = 1). Overall, the concordance between the cytology and surgical specimens was 75%. The sensitivity and specificity for identifying mutations in urine cytology specimens were 84% and 100%, respectively. A bladder-specific NGS panel increases the sensitivity and specificity of urine cytology's diagnostic utility in both low- and high-grade tumors and may serve as a noninvasive surveillance method in the follow-up of patients with UC harboring known mutations.

Paraneoplastic Leukemoid Reaction after Primary Tumor Resection in Patients with Urothelial Carcinoma: A Report of 2 Cases

Leukemoid reaction (LR), which is defined as leukocytosis with a white blood cell (WBC) count above 50 000/µL, can be caused by various conditions, while paraneoplastic leukemoid reaction (PLR), a rare type of paraneoplastic syndrome, occurs in cases of solid tumors. Here we report 2 cases of high-grade urothelial carcinoma (HGUC) with PLR accompanied by rapid tumor progression after complete resection of the primary tumor. We reviewed the patient’s clinical history, histopathology, and the results of laboratory tests to rule out LR induced by non-tumor causes. In both cases, PLR appeared after primary tumor resection, and the patients died of disease at the peak of PLR at 6 and 8 weeks. Immunohistochemistry for granulocyte colony-stimulating factor and its receptor was performed on tumor tissues. Patients with HGUC and PLR are rare and have an extremely poor prognosis. The mechanism by which solid tumors are associated with PLR and rapid tumor progression after surgical resection of the primary tumor is incompletely understood and will be discussed here.

Developing a Machine Learning Algorithm for Identifying Abnormal Urothelial Cells: A Feasibility Study

Introduction: Urine cytology plays an important role in diagnosing urothelial carcinoma (UC). However, urine cytology interpretation is subjective and difficult. Morphogo (ALAB, Boston, MA, USA), equipped with automatic acquisition and scanning, optical focusing, and automatic classification with convolutional neural network has been developed for bone marrow aspirate smear analysis of hematopoietic diseases. The goal of this preliminary study was to determine the feasibility of developing a machine learning algorithm on Morphogo for identifying abnormal urothelial cells in urine cytology slides. Methods: Thirty-seven achieved abnormal urine cytology slides from cases with the diagnosis of atypical urothelial cells and above (suspicions or positive for UC) were obtained from 1 hospital. A pathologist (J.R.) reviewed the slides and manually selected and annotated representative cells to feed into Morphogo with following categories: benign (urothelial cells, squamous cells, degenerated cells, and inflammatory cells), atypical cells, and suspicious cells. Initial validation of the algorithm was performed on a subset of the original 37 cases. Urine samples from additional 12 unknown cases with various histological diagnoses (6 cases of high-grade urothelial carcinoma (HGUC), 1 case of low-grade urothelial carcinoma (LGUC), 1 case of prostate adenocarcinoma, 1 case of renal cell carcinoma, and 4 cases of non-neoplastic conditions) were collected from another hospital for initial blind testing. Results: A total of 1,910 benign and 1,978 abnormal (atypical and suspicious) cells from 37 slides were annotated for developing and training of the algorithm. This algorithm was validated on 27 slides that resulted in identification of at least 1 abnormal cell per slide, with a total of 200 abnormal cells, and an average of 7.4 cells per slide. Of the 12 unknown cases tested, the original cytology was positive for tumor cells in 2 HGUC samples. Morphogo was abnormal (atypical or suspicious) for 6 samples from patients with UC, including one with LGUC and one with prostate adenocarcinoma. Conclusion: Morphogo machine learning algorithm is capable of identifying abnormal urothelial cells. Further validation studies with a larger number of urine samples will be needed to determine if it can be used to assist the cytological diagnosis of UC.

Impact of Implementing the Paris System for Reporting Urinary Cytology: A Single-institutional Experience With Emphasis on Diagnostic Yield of High-grade Urothelial Carcinoma and Low-grade Urothelial Neoplasm.

The Paris System (TPS) has recently been proposed as a method to standardize urinary cytology reporting. In this study, we evaluated the impact of implementing TPS compared to the traditional reporting system. In total, 299 urine samples were reclassified according to TPS. We examined correlations between cytological and histological diagnoses, and calculated probabilities for detecting high-grade urothelial carcinoma (HGUC). TPS resulted in a decrease in the proportion of cases diagnosed as atypical urothelial cell (AUC) (43% to 31%). Among the AUC cases, the proportion of histologically confirmed HGUC cases rose (75% to 80%), as did the proportion of low-grade urothelial neoplasms (57% to 71%). All probabilities for detecting HGUC significantly increased using TPS. TPS improved the diagnostic yield of urinary cytology. The implementation of TPS is expected to be a major step towards standardizing urinary cytology reporting and providing clear information to clinicians.

An institutional experience evaluating hTERT immunostaining in 100 consecutive ThinPrep urine specimens

Studies have shown that expression of human telomerase reverse transcriptase (hTERT) in mature urothelial cells indicates an increased risk of urothelial carcinoma. We evaluated the utility of immunocytochemistry with a commercially available anti-hTERT antibody (SCD-A7) in 100 consecutive urine cytology specimens using ThinPrep processing. ThinPrep slides prepared from 100 consecutive urine specimens were stained using anti-hTERT antibody (SCD-A7) after staining optimization had been successfully completed. Patient demographics, cytology diagnoses, histologic follow-up data, and anti-hTERT staining results were recorded. The cytology diagnoses included 7 cases of high-grade urothelial carcinoma (HGUC), 2 cases suspicious for HGUC (SHGUC), 24 cases of atypical urothelial cells (AUCs), and 67 cases negative for HGUC (NHGUC). Of 92 samples, 68 (74%) were positive and 24 (26%) were negative for anti-hTERT staining. Although 31 of 32 specimens (97%) with a diagnosis of AUCs and greater showed positive staining, 37 of 60 NHGUC cases (62%) were also positive for anti-hTERT. Although the HGUC and suspicious for HGUC cases were more likely to show strong staining (6 of 9; 67%), 7 AUC (32%) and 8 NHGUC (22%) cases also demonstrated strong staining. Eight samples (8%) were unsatisfactory for interpretation. Anti-hTERT staining of nonurothelial cells was seen in 77 of 92 samples (84%). Interpretation of anti-hTERT immunocytochemical staining of ThinPrep material is challenging owing to obscuring of nonurothelial cell staining and difficulty discerning individual urothelial cell cytomorphology when the cells are stained. The significance of the large number of anti-hTERT-positive but cytology-negative cases in our study is uncertain.

Clinicopathologic analysis of upper urinary tract carcinoma with variant histology.

We report on the clinicopathologic features of 115 cases of high-grade urothelial carcinoma of the upper urinary tract with variant histology present in 39 (34%). Variant histology was typically seen in high pathological stage (pT2-pT4) (82%, 32 cases) patients with lower survival rate (70%, 27 cases, median survival 31months) and consisted in urothelial with one (23%), two (3%), and three or more variants (3%); 4% of cases presented with pure variant histology. Squamous divergent differentiation was the most common variant (7%) followed by sarcomatoid (6%) and glandular (4%), followed by 3% each of micropapillary, diffuse-plasmacytoid, inverted growth, clear cell glycogenic, or lipid-rich. The pseudo-angiosarcomatous variant is seen in 2%, and 1% each of nested, giant-cell, lymphoepithelioma-like, small-cell, trophoblastic, rhabdoid, microcystic, lymphoid-rich stroma, or myxoid stroma/chordoid completed the study series. Loss of mismatch repair protein expression was identified in one case of upper urinary tract carcinoma with inverted growth variant (3.6%). Variant histology was associated to pathological stage (p = 0.007) and survival status (p = 0.039). The univariate survival analysis identified variant histology as a feature of lower recurrence-free survival (p = 0.046). Our findings suggest that variant histology is a feature of aggressiveness in urothelial carcinoma of the upper urinary tract worth it to be reported.

Evaluation of cancer testis antigen (CT10, PRAME) and MHC I expression in high-grade urothelial carcinoma of the bladder.

Immunotherapeutic strategies are increasingly used in the treatment of a number of malignancies including high grade urothelial carcinoma (HGUC) of the bladder. Because of this, detailed and accurate assessment of the tumour immune microenvironment is paramount. In this study, we aimed to correlate the composition of the tumour immune microenvironment with oncologic outcome and the expression of two cancer testis antigens (CTAs), CT10 and PRAME, potential cancer vaccine targets, as well as major histocompatibility complex I (MHC I), a molecule associated with tumour immune escape and resistance to immunotherapy.Triplicate tissue microarrays (TMAs) were constructed using 207 cases of HGUC of the bladder. Oncologic outcome data was gathered for each case. Consecutive sections from the TMA blocks were stained with CD3, CD4, CD8, FOXP3, PD1, PD-L1, CT10, PRAME, and MHC I. 21% and 15% of cases expressed CT10 and PRAME, respectively. 88% of cases showed absent or decreased MHC I expression. CT10-expressing tumours showed a significantly worse disease specific survival (p = 0.007, hazard ratio 2.245, confidence interval 1.223–4.122). CT10, PRAME, and MHC I expression significantly correlated with other some immune parameters. CT10 and PRAME are expressed in a subset of HGUC and CTA and MHC I expression correlate with a number of important immune parameters. Together, these findings highlight the potential for exploring novel immune therapeutic strategies in HGUC. Additional studies evaluating the clinical relevance of these findings are warranted.

Utility of The Paris System for Reporting Urinary Cytology in upper urinary tract specimens

Diagnosing upper urinary tract (UUT) lesions using cytology has been historically difficult because of a lack of standardized terminology, cytomorphologic criteria, and the presence of instrumentation artifact. The goal of The Paris System for Reporting Urinary Cytology (TPSRUC) was to provide standardized terminology and cytomorphologic criteria. The aim of this study was to evaluate the utility of TPSRUC in UUT cytology specimens at our institution. Single ThinPrep archival slides from 30 UUT cytology cases with corresponding histological follow-up were reviewed using TPSRUC. Those results were compared with the original cytology diagnoses. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for high-grade urothelial carcinoma (HGUC) using TPSRUC were 71%, 100%, 100%, and 71%. The TPSRUC was reliable at identifying HGUC. These data showed that this system had a lower sensitivity (71% versus 100%) and NPV (71% versus 100%) for UUT specimens compared with original cytology diagnoses. TPSRUC had a sensitivity and specificity that were comparable to reported overall sensitivity and specificity of UUT cytology for detection of HGUC. A major cause of discrepancy with TPSRUC was the classification of urine samples (n = 8) from histologically proven HGUC cases as only atypical (n = 6) or negative (n = 2), mainly owing to nuclear hypochromasia rather than hyperchromasia. Thus, hyperchromasia, a criteria used in TPSRUC, may not be as relevant in UUT specimens.

CT texture analysis in bladder carcinoma: histologic grade characterization

Objective: To explore the value of CT texture analysis (CTTA) in differentiating the pathological grade of urothelial carcinoma of the bladder (UCB). Methods: A total of 53 lesions from 43 patients with bladder cancer confirmed by postoperative pathology were retrospectively analyzed, including 27 cases of high-grade urothelial carcinoma (HGUC) and 26 cases of low-grade urothelial carcinoma (LGUC). All the patients took pelvic CT and enhanced scanning in the same CT scanner with same scanning parameters. Lesions on both plain and enhanced CT images were delineated on software by two radiologists to extract the corresponding volumes of interest (VOI) and then 92 parameters based on feature classes were generated. The average values of two radiologists were obtained. The difference parameters between HGUC group and LGUC group were screened by nonparametric test, and the receiver operating characteristic (ROC) was drawn. The corresponding optimal thresholds were determined and diagnostic effect was assessed. Results: Nine difference texture parameters between HGUC group and LGUC group were selected, including 5 parameters on unenhanced images, namely, skewness, root mean squared, cluster shade, zone percentage and large area high gray level emphasis. There were 4 parameters on enhanced images, namely, skewness, kurtosis, cluster shade and zone percentage. The largest area under curve of 0.840±0.058 (95% CI 0.726-0.955) was obtained from skewness generated by VOI of unenhanced images. The cut-off value of skewness was 0.186 5, which permitted the diagnosis of HGUC with sensitivity of 92.59%, specificity of 73.08%, positive predictive value of 78.13%, negative predictive value of 90.48% and accuracy of 83.02%. Conclusion: CTTA can effectively distinguish between LGUC and HGUC. Skewness from unenhanced CT images had the optimal diagnostic performance.

P53 immunohistochemistry in high-grade urothelial carcinoma of the bladder is prognostically significant.

TP53 mutations are characteristic of the high-grade pathway in the dual pathway of urothelial carcinogenesis. These mutations have been correlated with aberrant accumulation of p53 protein; however the definition and significance of this vary in the literature. The aim of this study was to assess p53 immunostaining in a cohort of high-grade urothelial carcinomas by using standard published cut-offs and a novel binarized method that included assessment of the null phenotype. Each scoring method was correlated with oncological outcome. A triplicate core tissue microarray was constructed from 207 cases of high-grade urothelial carcinoma treated by cystectomy, and was stained with p53. The percentage nuclear staining was recorded for each core and averaged for every case (206 cases were evaluable). Cases were categorized as positive/negative according to published cut-offs (10%, 40%) or by binarizing them as abnormal (null phenotype or >50% positivity) and wild type (1-49% positivity). Correlation with disease-specific survival was not significant according to standard definitions of p53 positivity. When a 40% cut-off was used, a correlation with relapse-free survival was significant on univariate analysis (P = 0.038) but not on multivariate analysis (P = 0.079). Abnormal p53 expression showed a near-significant trend for association with disease-specific survival (P = 0.052) and was a significant predictor for relapse-free survival on both univariate analysis (P = 0.047) and multivariate analysis (P = 0.035). Prior to this study, the p53 null phenotype was not well described in urothelial carcinoma of the bladder. Abnormal p53 immunoexpression (null staining pattern or staining in >50% of cells) is prognostic in terms of oncological outcome.

Application of The Paris System to atypical urine cytology samples: correlation with histology and UroVysion® FISH.

To evaluate whether atypical urine cytology cases may be stratified more objectively using The Paris System (TPS) and whether reclassified cases correlate with histology and UroVysion® results. Atypical urine cytology cases subjected to UroVysion® testing over a period of 6 years were reviewed. Each case was reclassified according to TPS and correlated with histology and UroVysion® results. A total of 91 cases were identified; 70.3% were reclassified as 'negative for high-grade urothelial carcinoma (HGUC)' and 14.3% as 'atypical urothelial cells (AUC)'. The histological correlation was available in 45 cases. In the 'negative for HGUC' category, 67.9% had no histological evidence of malignancy, but 17.9% were diagnosed as HGUC. In the 'AUC' category, histology revealed urothelial carcinoma in 70% of the cases (of these, 71.4% were high grade). There was no histological evidence of malignancy in 30% of cases; notably, all of which were from patients under surveillance. The sensitivity and specificity of UroVysion® were 85.7% and 33.3% in the 'AUC' group and 62.5% and 100% in the 'negative for HGUC' group. The Paris System is an objective template for reporting urine cytology specimens, and is particularly useful in identifying HGUC cases and refining the category of 'AUC'.

A diagnostic immunohistochemical panel for challenging cases of high-grade urothelial carcinoma versus high-grade prostatic adenocarcinoma

A diagnostic immunohistochemical panel for challenging cases of high-grade urothelial carcinoma versus high-grade prostatic adenocarcinoma

High apoptotic index in urine cytology is associated with high-grade urothelial carcinoma.

The significance of apoptosis and its association with high-grade urothelial carcinoma (HGUC) in urine cytology has yet to be determined. A computerized search of the study laboratory information system was performed over a 3-year period for all urine cytology specimens processed using the SurePath liquid-based preparation technique. Only those cases with correlating surgical pathology obtained within 6 months after the urine cytologic samples were included in the current study. Cases from ileal conduit samples were excluded. A semiquantitative numerical scoring system (apoptotic index) was used to assess the amount of pyknosis or karyorrhexis, with 0 indicating none, 1 indicating < 10 per 10 high-power fields, 2 indicating 10 to 30 per 10 high-power fields, and 3 indicating > 30 per 10 high-power fields. Statistical analysis using the Pearson chi-square test was performed. A total of 228 cases including 105 benign cases, 79 cases of HGUC, and 44 cases of low-grade urothelial carcinoma (LGUC) diagnosed on follow-up surgical pathology were selected. A score of 0 was observed in 70 benign, 11 HGUC, and 8 LGUC cases; a score of 1 was observed in 31 benign, 21 HGUC, and 23 LGUC cases; a score of 2 was observed in 3 benign, 27 HGUC, and 9 LGUC cases; and a score of 3 was observed in 1 benign, 20 HGUC, and 4 LGUC cases. Excluding ileal conduit urine specimens, the finding of a high apoptotic index (score ≥ 2) with the presence of pyknosis or karyorrhexis in ≥10 per 10 high-power fields in the urine cytology appears to be significantly associated with HGUC (P<.05). Cancer Cytopathol 2016;124:546-51. © 2016 American Cancer Society.

The utility of p63, p40, and GATA-binding protein 3 immunohistochemistry in diagnosing micropapillary urothelial carcinoma.

Micropapillary urothelial carcinoma (MPUC) is an uncommon variant of urothelial carcinoma (UC) with an aggressive clinical course. There have been limited studies on the UC markers GATA-binding protein 3 (GATA3), p63, and p40 in MPUC. Our study investigated the immunoreactivity of these 3 markers in MPUC compared with conventional UC of different grades and stages. Immunohistochemistry was performed on 62 cases of high-grade urothelial carcinoma (HGUC), 16 low-grade urothelial carcinoma (LGUC), and 20 MPUC. p63 expression was strong and diffuse in all LGUC, significantly decreased in high stage and HGUC, and virtually absent in MPUC. p40 expression was decreased in HGUC and markedly decreased in MPUC relative to LGUC. These results suggest that loss of p63 expression in a UC appears to be associated with adverse features--including cases with micropapillary differentiation. Decreased GATA3 expression was seen frequently in high-grade and high-pathologic stage (≥pT2) tumors but was retained in MPUC cases. The findings of retained GATA3 expression in MPUC, which often shows a loss of expression of other urothelial markers such as p63, may be helpful for determining the origin of micropapillary carcinoma of unknown primary. Compared with the traditional markers p63 and p40, GATA3 is the most sensitive marker of conventional UC and MPUC.

The value of serum CYFRA21-1 examination in the detection of urothelial carcinoma

Objective To evaluate the value of CYFRA21-1 examination in the detection of urothelial carcinoma (UC).Methods Serum concentrations of CYFRA21-1 were examined by electrochemiluminescence technique in 65 cases with UC,61 cases of non-UC patients (including 21 cases of renal carcinoma,20 cases of benign prostatic hyperplasia,10 cases of prostatic carcinoma,10 cases of urolithiasis) and 43 hea]thy individuals.Sixty-five UC cases including 9 renal pelvis UC cases,4 ureter UC cases,52 bladder UC cases,61 non-UC cases including 21 renal carcinoma cases,20 benign prostatic hyperplasia cases,10 prostatic carcinoma cases,10 urolithasis cases.Results The serum CYFRA21-1 concentration in UC patients (7.57± 12.76) μg/L was significantly higher than the healthy controls (2.58±0.97) μg/L and also the non-UC patients (2.75± 1.34) μg/L (P＜0.01).The difference between the healthy individuals and the nonUC patients was not significant (P＞0.05).According to the manual in the reagent kit,the positive value of serum CYFRA21-1 was defined as greater than 3.3 μg/L.The false positive rate in healthy controls and the non-UC patients was 10％-30％.The positive percentage of serum CYFRA21-1 of the 65 UC patients was 67.7％ (44/65).In low,middle and high grade UC cases,the positive rates were 50.0％ (10/20),62.5％ (5/8) and 78.3％ (29/37) respectively.The difference of the positive rates between the high grade group and middle,low grade groups was significant (x2 =4.55,P＜0.05).The positive rates in non-muscle invasive (Ta-Ti) UC and in healthy controls were 40.9％ (9/22) and 23.2％ (10/43) respectively,and the difference between the two groups was not significant (x2=2.19,P＞0.05).The positive rate in muscle invasive (T2-T3) UC was 78.6％ (22/28) and the difference compared with healthy controls was significant (x2=20.96,P＜0.01).The positive rate in local advanced and metastatic UC (＞T3) was 86.7％ (13/15).The positive rates were not significantly deferent between the T2-T3 group and the ＞ T3 group (x2 =1.97,P＞0.05).Conclusions The serum CYFRA21-1 positive rate is 67.7％ in UC patients,which was higher than non-UC patients and healthy controls,and associated positively with the pathologic grade and the clinical stage of UC.Monitoring the serum CYFRA21-1 is effective in assessing the outcomes and prognosis of UC,if the serum CYFRA21-1 was positive.The serum CYFRA21-1 test has some significance in distinguishing UC from renal carcinoma and prostatic carcinoma. Key words: Urothelium; Carcinoma; Tumor markers; Keratins

Cytological Findings of the Micropapillary Variant of Urothelial Carcinoma: A Comparison with Typical High-Grade Urothelial Carcinoma

BackgroundMicropapillary variant of urothelial carcinoma (MPUC) showed distinct pathologic features and aggressive behavior. The cytologic findings of MPUC are still indistinct. In this study, we evaluated the cytological findings of MPUC compared with those of high-grade urothelial carcinoma (HGUC).MethodsThe voided urine cytology of 8 cases of MPUC and 8 cases of HGUC was reviewed. Following cytological parameters were evaluated: cellularity, background, number of small, tight papillary clusters, small acinar structure, scattered single cells, cytoplasmic features, nuclear-to-cytoplasmic ratio, nuclear pleomorphism, nuclear membrane irregularity, hyperchromasia, chromatin pattern and nucleoli.ResultsCompared to that of HGUC, cytology of MPUC showed large numbers of small, tight papillary clusters, small acinar structure, few numbers of single cells, and hyperchromatic nuclei. Other parameters were similar between the two groups; both groups showed similar cellularity, dense or vacuolated cytoplasm, moderate to severe nuclear pleomorphism, irregular nuclear membrane, coarse granular chromatin, and small and prominent nucleoli.ConclusionsThe urine cytology of MPUCs showed smaller and tighter papillary cell clusters, more small acinar structures, fewer numbers of scattered single cells, and more hyperchromatic nuclei than that of HGUC. These features can help to distinguish MPUC and HGUC and offer an early cytological diagnosis of MPUC.

Clinical application of transperitoneal laparoendoscopic single-site nephrectomy

Objective To verify the safety and feasibility of applying transperitoneal laparoendoscopic single-site surgery (LESS) nephrectomy in the treatment of kidney malignant and benign diseases.Methods From Nov.2010 to Jun.2012,we had used LESS nephrectomy technique treated four kidney tumors,one renal pelvic tumor and one atrophic kidney. Quadport was introduced into abdominal cavity through a paraumbilical incision. Conventional laparoscopic instruments,prebent laparoscopic instruments and flexible tip 5mm laparoscope were used. The standard laparoscopic transperitoneal nephrectomy technique was then performed.We evaluated this technique in respects of operative time,estimated blood loss,intraoperative complications,1st post-operative day pain (VAPS),drainage time,post-operative hospital stay and pathological results. Results The 6 procedures in this group were completed successfully with LESS nephrectomy. There was no additional trocar added,no conversion to conventional laparoscopic or open surgery.Application of Quadport and prebent instruments reduced the clash of instruments,both intracorporally and extracorporally.The average operative time were 181.7 (145.0 -235.0) min,average estimated blood loss were 78.3 (20.0 - 150.0) ml.There was no severe intraoperative complication.The average VAPS in the first post - operative day was 1.7 ( 1.0 - 2.0).The average drainage time was 2.8 ( 1.0 -4.0) d,post-operative hospital stays was 6.8 ( 1.0 - 10.0) d.There was no secondary bleeding or wound infection.Pathological results showed 3 cases of renal clear cell carcinoma,1 case of chromophobic carcinoma,1 case of high-grade urothelial carcinoma and 1 case of atrophic kidney.All the specimens in this group were surgical margin negative. Conclusions LESS nephrectomy is a safe and feasible treatment option for the treatment of kidney surgical diseases. Key words: Kidney neoplasm; Renal pelvic tumor; Renal atrophy; Laparoendoscopic single site surgery; Nephrectomy

Utility of GATA3 Immunohistochemistry in Differentiating Urothelial Carcinoma From Prostate Adenocarcinoma and Squamous Cell Carcinomas of the Uterine Cervix, Anus, and Lung

Distinguishing invasive high-grade urothelial carcinoma (UC) from other carcinomas occurring in the genitourinary tract may be difficult. The differential diagnosis includes high-grade prostatic adenocarcinoma, spread from an anal squamous cell carcinoma (SCC), or spread from a uterine cervical SCC. In terms of metastatic UC, the most common problem is differentiating spread of UC to the lung from a primary pulmonary SCC. Immunohistochemical analysis (IHC) for GATA binding protein 3 (GATA3), thrombomodulin (THROMBO), and uroplakin III was performed on a tissue microarray (TMA) containing 35 cases of invasive high-grade UC. GATA3 IHC was also performed on TMAs containing 38 high-grade (Gleason score ≥8) prostatic adenocarcinomas, representative tissue sections from 15 invasive anal SCCs, representative tissue sections from 19 invasive cervical SCCs, and TMAs with 12 invasive cervical carcinomas of the cervix [SCC (n=10), SCC with neuroendocrine features (n=1), and adenosquamous carcinoma (n=1)]. In addition, GATA3 IHC was performed on representative tissue sections from 15 pulmonary UC metastases and a TMA with 25 SCCs of the lung and 5 pulmonary non-small cell carcinomas with squamous features. GATA3, THROMBO, and uroplakin III were positive in 28 (80%), 22 (63%), and 21 (60%) cases of high-grade UC, respectively. All cases of GATA3-positive staining were nonfocal; 25 (89%) cases demonstrated moderate to strong staining, and 3 (11%) demonstrated weak staining. Of the 7 cases that failed to express GATA3, 5 were positive for THROMBO and/or uroplakin III, whereas 2 were negative for all 3 markers. None of the 38 high-grade prostatic adenocarcinomas was positive for GATA3. Weak GATA3 staining was present in occasional basal cells of benign prostate glands, in a few benign atrophic glands, and in urothelial metaplasia. Of the 15 cases of anal SCCs, 2 (7%) cases showed focal weak staining, and 1 (3%) showed focal moderate staining. Weak staining was also rarely observed in the benign anal squamous epithelium. Of the 31 uterine cervical carcinomas, 6 (19%) showed weak GATA3 staining (3 nonfocal and 3 focal), and 2 (6%) demonstrated focal moderate staining. Twelve (80%) of the metastatic UCs to the lung were positive for GATA3, with 11 cases showing diffuse moderate or strong staining and 1 case showing focal moderate staining. None of the pulmonary SCCs or non-small cell carcinomas with squamous features was GATA3 positive. GATA3 IHC is a sensitive marker for UC, and positive staining in UC is typically nonfocal and moderate or strong in intensity. GATA3 is also highly specific in excluding high-grade prostate adenocarcinoma. Although some cervical and anal SCCs can be GATA3 positive, unlike in UC, staining is more commonly focal and weak. GATA3 is also a useful maker when diagnosing metastatic UC to the lung.

High‐grade bladder cancer: Association of the apparent diffusion coefficient with metastatic disease: Preliminary results

To assess the utility of apparent diffusion coefficient (ADC) values obtained from diffusion-weighted imaging (DWI) in distinguishing high-grade bladder cancer with and without metastatic disease. Seventeen patients with histologically confirmed high-grade bladder cancer who underwent pelvic magnetic resonance imaging (MRI) at 1.5T including DWI using b-values of 0, 400, and 800 sec/mm(2) were assessed. Histologic findings and follow-up imaging were used to establish the reference standard in terms of metastatic disease. Two radiologists independently recorded ADC of all lesions following a training session, with their results averaged. Mann-Whitney U-test, receiver operating characteristic (ROC) curve analysis and intraclass correlation coefficient (ICC) were used for data analysis. Metastatic disease was characterized as present or absent in eight and nine patients, respectively. ADC was significantly lower among cases with metastatic disease than among cases without metastatic disease, both within the entire cohort (1.07 ± 0.18 × 10(-3) mm(2)/s vs. 1.45 ± 0.22 × 10(-3) mm(2)/s; P = 0.002) and within the subset of patients with muscle-invasive tumor (1.06 ± 0.19 × 10(-3) mm(2)/s vs. 1.45 ± 0.23 × 10(-3) mm(2)/s; P = 0.017). Area under the ROC curve for identifying metastatic disease using ADC was 0.944, with optimal threshold of 1.21 × 10(-3) mm(2)/s, which was associated with a sensitivity of 87.5%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 90.0%. Interreader agreement for ADC was excellent (ICC = 0.91). In this preliminary study, ADC was significantly different between cases of high-grade urothelial carcinoma of the bladder with and without metastatic disease. These results may have value in assessing the metastatic potential of patients with localized high-grade tumors of the bladder.

Alterations in genes regulating cell cycle and apoptosis in high-grade urothelial carcinoma.

237 Background: Dysregulations of cell cycle and inhibition of apoptosis are crucial factors in tumorigenesis of multiple malignancies, including urothelial carcinoma (UC). Deletions of TP53 and CDKN2A and amplification of MDM2 have been observed in UC, but their exact frequency and functional consequence is less known. We sought to determine the frequency of copy number alteration (CNA) and mutations of genes that regulate cell cycle or apoptosis in a panel of 96 cases of high-grade UC (HGUC) of bladder. Methods: 96 frozen cases of HGUC were studied, including 11 bladder small cell carcinomas. DNA was isolated and analyzed for CNA by comparative genomic hybridization (CGH) using a one million oligonucleotide probe array from Agilent. The targeted genes included TP53, MDM2, CCND1, CCNE1, CDKN2A/B, E2F3 and Rb1. Traditional Sanger sequencing for mutations within TP53, Rb1, and CDKN2A was also performed. Results: The frequency of CNA and mutations are listed in the table. Overall, 54 of 96 cases (56%) showed CNA (45) or mutation (13). Deletion of CDKN2A/B and amplification of E2F3 were the most common alterations in cell cycle regulatory genes (13 cases each, 14%), followed by amplification of CCND1 (11 cases, 11%). There was no co-amplification of CCND1 and CCNE1 in any sample. Rb1 deletion was present in five cases. CNA in E2F3 and Rb1 were mutually exclusive in 14 of 16 cases (88%) and were both present in two cases only. Mutations in TP53 were noted in 13 cases and deletions in nine. Amplification of MDM2 was noted in four cases, none of which overlapped with TP53 deletions or mutations. Overexpression of E2F3 was significantly more common in small cell carcinoma (5/11) compared to conventional UC (8/85, p = 0.006). Conclusions: Regulators of cell cycle and apoptosis are amplified, deleted or mutated in more than half of cases (56%) of high-grade urothelial carcinoma. The overwhelming majority of these abnormalities are nonoverlapping. Amplification of E2F3 seems to be overrepresented in small cell carcinoma of bladder. [Table: see text] No significant financial relationships to disclose.