High-grade Invasive Urothelial Carcinoma Research Articles

Reassessment of p53 immunohistochemistry thresholds in invasive high grade bladder cancer shows a better correlation with TP53 and FGFR3 mutations

FGFR3 mutations are frequently mutually exclusive of TP53 mutations in invasive high grade urothelial carcinoma (HGUC) and p53 immunohistochemistry is often used as a surrogate for TP53 mutations. A 10 % staining cut off has been used in HGUC for designation as p53 positive or negative however, a novel contemporary method we have previously proposed (0% or >50 % - abnormal vs. 1–49 % - wild type) has shown significant correlation with oncologic outcome as well. We aimed to compare how a ≥10 % vs. 0 % and ≥ 50 % cut off p53 assessment method correlates with TP53 and FGFR3 mutation status. Tissue microarrays created from three retrospective cohorts (two cystectomy cohorts (cohort A, n = 206 and cohort B, n = 91; one T1 transurethral resection cohort (cohort C, n = 47)) were stained with p53 and scored by two blinded reviewers using both p53 scoring schemes. 50 cases from cohort A were assessed for TP53 and FGFR3 mutation status using next generation sequencing and FGFR3 mutation status was separately assessed in cohorts B and C using SNaPshot methodology. 202 (58.7 %) and 142 (41.3 %) cases showed abnormal and wild type p53 staining, respectively. Using the 10 % cut off, 254 cases were positive (73.8 %) and 90 cases were negative (26.2 %). 27 (14.4 %) and 15 (30 %) assessed cases demonstrated FGFR3 and TP53 mutations, respectively; 19/27 FGFR3 mutated showed a wild type pattern of p53 expression while 15/15 TP53 mutated tumours showed an abnormal pattern of p53 expression. There was a significant correlation between the contemporary p53 scoring scheme and TP53 and FGFR3 mutations (p < 0.0001 and p = 0.002, respectively). Improved sensitivity, specificity, positive predictive value, and negative predictive value for TP53 mutation was also seen compared to the 10 % cut off; specifically, the sensitivity and negative predictive value were 100 %. These findings might be of clinical relevance in the era of precision medicine.

Large nested variant of urothelial carcinoma of urinary bladder: a clinicopathological analysis of five cases

Objective: To investigate the clinicopathologic features, diagnosis and differential diagnosis of large nested variant of urothelial carcinoma (LNUC) of urinary bladder. Methods: The clinical and pathologic data of five cases of LNUC of urinary bladder diagnosed between January 2014 and December 2018 at the Department of Pathology, Zhejiang Provincial People's Hospital were analyzed by immunohistochemistry (IHC) and Sanger sequencing. The relevant literature was reviewed. Results: All five patients were male with a mean age of 63 years (range, 48 to 81 years). The mean tumor size was 3.4 cm (range, 1.7 to 4.7 cm). Histologically, the invasive LNUC tumor cells formed medium to large sized nests of varying shapes, from regular round, bulbous, oval to irregularly fused, branched, dumbbell shaped glands, with mild stromal reaction. In all five cases, focal central necrosis and microcystic changes in the tumor nests were identified. Cytologically, the tumor cells were low grade in four cases; the remaining case was overall low grade with focal high grade areas. Mitoses were scarce. All cases possessed surface urothelial tumors, including three low-grade papillary carcinomas, one high-grade papillary carcinoma and one carcinoma in situ. Three of the LNUC were accompanied by small nested variant of urothelial carcinoma and two by conventional high grade invasive urothelial carcinoma. Perineural involvement and angiolymphatic invasion were each noted in four tumors. Radical cystectomy was performed in four cases with TNM stages as followings: pT3aN0M0 in two cases, pT4aN0M0 and pT4aN1M0 in one case each. The remaining case had transurethral bladder resection and was of pT2 stage. By IHC, all five cases were positive for CK7 and p40; four were positive for GATA3; two were positive for CK20; and the mean Ki-67 proliferation index was 18%. TERT promoter mutation status were successfully performed in three cases, with one showing mutation (C228T) and two were wild type. All patients received postoperative chemotherapy. At a follow-up of 2 to 11 months, one patient died of unrelated causes, two patients developed metastases, and two were alive with no evidence of disease. Conclusions: LNUC is a histologic subtype of urothelial carcinoma with deceptively benign features but aggressive behavior, and appreciation of its unique infiltration patterns can aid in diagnosis and differential diagnosis. LNUC tends to coexist with small nested variant of urothelial carcinoma, suggesting these may represent different manifestations of the same urothelial carcinoma subtype.

Detection of carcinogen-induced bladder cancer by fluorocoxib A

BackgroundConventional cystoscopy can detect advanced stages of bladder cancer; however, it has limitations to detect bladder cancer at the early stages. Fluorocoxib A, a rhodamine-conjugated analog of indomethacin, is a novel fluorescent imaging agent that selectively targets cyclooxygenase-2 (COX-2)-expressing cancers.MethodsIn this study, we have used a carcinogen N-butyl-N-4-hydroxybutyl nitrosamine (BBN)-induced bladder cancer immunocompetent mouse B6D2F1 model that resembles human high-grade invasive urothelial carcinoma. We evaluated the ability of fluorocoxib A to detect the progression of carcinogen-induced bladder cancer in mice. Fluorocoxib A uptake by bladder tumors was detected ex vivo using IVIS optical imaging system and Cox-2 expression was confirmed by immunohistochemistry and western blotting analysis. After ex vivo imaging, the progression of bladder carcinogenesis from normal urothelium to hyperplasia, carcinoma-in-situ and carcinoma with increased Ki67 and decreased uroplakin-1A expression was confirmed by histology and immunohistochemistry analysis.ResultsThe specific uptake of fluorocoxib A correlated with increased Cox-2 expression in progressing bladder cancer. In conclusion, fluorocoxib A detected the progression of bladder carcinogenesis in a mouse model with selective uptake in Cox-2-expressing bladder hyperplasia, CIS and carcinoma by 4- and 8-fold, respectively, as compared to normal bladder urothelium, where no fluorocoxib A was detected.ConclusionsFluorocoxib A is a targeted optical imaging agent that could be applied for the detection of Cox-2 expressing human bladder cancer.

Clinical study of radical cystectomy under totally laparoscopy and ρ shape orthotopic ileal neobladder

Objective To explore the feasibility and advantages of totally laparoscopic radical cystectomy plus ρshape orthotopic ileal neobladder, and to summarize the experiences. Methods The clinical data of 11 patients with bladder cancer admitted to the second hospital of Hebei medical university from October 2018 to May 2019 were retrospectively analyzed. All patients were male, aged 33 to 77 years, with an average of 64.4 years. Body mass index ranged from 18.0 to 31.8 kg/m2, with an average of 23.2 kg/m2. One case underwent partial cystectomy and 10 cases underwent transurethral resection of bladder tumor, with 10 cases of invasive urothelial carcinoma and 1 case of adenocarcinoma. No case underwent neoadjuvant therapy, and all cases were clinically staged as cT2a-3bN0-2M0. Totally laparoscopic radical cystectomy and shape orthotopic ileal neobladder intraperitonealy were performed. The specific procedures were described as follows. After bladder resection, the ileal segment of 55 cm in length was intercepted at 25 cm from ileocecal valve, with the proximal part retaining 15 cm lumen as the input loop, and the distal part of 40 cm ileum being folded in 1∶1 ratio. The folded intestinal segment was made into a allantoic sac by using a linear incision closure device, forming a ρ shape with the input loop, bilateral ureters and the input loop. Anastomosis of wall, distal end of allantoic and urethra was performed.Record the perioperative data such as operation time, estimated bleeding, postoperative recovery, complications, and follow-up results. Result All of the 11 cases underwent successfully operation, and no cases were transferred to open surgery. The operation time ranged from 320 to 440 minutes, with an average of 357.1 minutes. The estimated amount of bleeding ranged from 100 to 300 ml, with an average of 207.1 ml. The total time of intestinal tract procedure was 80-100 minutes, with an average of 89.3 minutes, and the time of allantoic preparation was 14-19 minutes, with an average of 16.1 minutes. The pain score was 2-5 points at 4 hours after operation, with an average of 3.8 points, and 1-4 points at 24 hours after operation, with an average of 2.3 points. Postoperative exhaust time ranged from 2.5 to 3.5 days, with an average of 3.0 days.Catheter removed 21 days after operation, with 9 cases of urinary incontinence, including mild in 6 cases, moderate in 2 cases and severe in 1 case, with daytime pad of 0-3 and nighttime pad of 1-3.which improved gradually following pelvic exercise for 4-18 weeks. Postoperative hospital stay ranged from 7 to 13 days, with an average of 10.4 days. The drainage removal time was 4-11 days, with an average of 6.7 days. Postoperative pathology revealed 7 cases of high-grade invasive urothelial carcinoma, 3 case of low-grade invasive urothelial carcinoma and 1 case of adenocarcinoma. The tumors invade the prostate in adenocarcinoma patient, with left (3/13) and right (1/9) positive lymph nodes. One case of high-grade invasive urothelial carcinoma had both left (2/11) and right (1/9) positive lymph nodes, and the other cases were negative. The margin were negative in all patients. Pathological staging was pT2a-4aN0-2M0. Postoperative adjuvant chemotherapy with gemcitabine+ cisplatin regimen were performed in 9 patients.The follow-up period ranged from 3 to 29 weeks, with an average of 17.4 weeks, the patients with adenocarcinoma died of multiple organ failure at the 13th week after operation, and the other cases have no recurrence or metastasis. Dual J-tube was removed in 9 cases in the last follow-up, and the new bladder volume was estimated 300-350 ml, with residual urine of 0-43 ml and 19 ml of average. There is no stone formation in the new bladder.No hydronephrosis or ureteral dilatation aggravated. Conclusions Totally laparoscopic radical cystectomy plus shape orthotopic ileal neobladder simplify the procedure of making allantoic storage and shorten the procedure time. The patients suffered less pain and recovered quickly after operation.It is a safe and feasible surgical procedure based on this study. Key words: Cystectomy; Radical; Totally laparoscopic; ρ shape orthotopic ileal neobladder; Urinary diversion

1651 Colon, Urothelial and Sebaceous Malignancy All in One: A Rare Presentation of Muir-Torre Syndrome

INTRODUCTION: Muir-Torre syndrome (MTS) is a rare autosomal-dominant condition and phenotypic variant of Lynch syndrome caused by mutations in DNA mismatch repair genes MSH2, MSH6, and MLH1. Clinical diagnostic criteria include the presence of at least one sebaceous gland neoplasm and one visceral malignancy, often colonic or genitourinary. Compared to Lynch syndrome, the prevalence of MTS is likely underreported. We present a unique case of a patient with incidental findings of multiple visceral malignancies associated with skin cancer. CASE DESCRIPTION/METHODS: A 57-year-old Caucasian man presented for surveillance colonoscopy. His family history was significant for father with colon cancer at age 50, lung, and renal cancer. The patient was diagnosed with sebaceous adenocarcinoma, invasive squamous cell, and basal cell carcinomas requiring excisional surgery at age 46. Screening colonoscopy at that time was normal, with repeat after 7 years noting diminutive sigmoid tubular adenomas that were resected. Current colonoscopy revealed 14 colon polyps, multiple with high grade dysplasia, and an invasive sigmoid adenocarcinoma. Staging CT A/P was negative for metastatic disease. CEA was normal. The patient opted for left hemicolectomy instead of total proctocolectomy. Tumor pathology revealed moderately differentiated adenocarcinoma with negative margins (pT4N0M0). Colon cancer genetic testing showed lack of expression of MSH2/MSH6 and germline MSH2 mutation, confirming the diagnosis of MTS. A month later he developed hematuria and acute kidney injury that culminated in a new diagnosis of invasive high-grade urothelial carcinoma. Neoadjuvant chemotherapy was started with plan for cystectomy. DISCUSSION: MTS is a rare condition that warrants early recognition, regular follow-up and observation for new malignancies. Our case highlights the importance of awareness and the need for early, universal screening in high-risk individuals. MTS patients should undergo screening colonoscopy at ages 20–25 with surveillance every year thereafter to offer mortality benefit. If colon cancer is diagnosed, total rather than partial colectomy is preferred due to a high metachronous cancer rate of 25%. Patients and relatives should be counseled on increased risk of future malignancies. Reconstruction of family history may allow for the identification and selection of patients in whom to proceed with clinical, molecular, and immunohistochemical analysis. Clinicians must therefore be cognizant of this disease and its enduring effects.

Amyloidosis of the bladder and association with urothelial carcinoma: report of 29 cases

The association of amyloidosis with certain neoplastic processes is well known. Amyloid uncommonly occurs in relationship with other epithelial neoplasms including urothelial carcinoma. Herein, we report 29 cases of amyloidosis in the bladder, 14 of which were found in relationship to urothelial carcinoma. With institutional review board approval. We searched pathology archives for cases of amyloidosis in the bladder. Clinical, laboratory, and surgical pathology records were reviewed, and data were recorded for all cases. Diagnosis of amyloid was made by Congo red stain showing apple-green birefringence on polarization microscopy and special studies in some cases. Twenty-nine cases of amyloid were identified in bladder specimens. Presentation as a mass lesion was the most common (n = 18). Immunohistochemical subtyping done in 17 cases showed transthyretin-type (n = 10), AL (n = 3), AA (n = 1), amyloid P (n = 1), and undetermined (n = 2) types of amyloid. Eighteen (62%) cases were classified as localized primary amyloidosis and 11 (38%) as secondary manifestation of systemic amyloidosis. In 14 (48%) cases, there was an associated urothelial carcinoma: 5 urothelial carcinoma in situ, 4 low-grade noninvasive papillary urothelial carcinoma, 2 high-grade noninvasive papillary urothelial carcinoma, and 3 high-grade invasive urothelial carcinoma. Associated urothelial carcinoma was present in 4 of 7 patients with systemic amyloidosis and 10 of 18 patients with localized amyloidosis, with the difference not being statistically significant (P = .45). Amyloidosis of the bladder is rare and presents as a mucosal mass or hematuria that may mimic urothelial carcinoma. In this study, we found urothelial carcinoma occurring in 48% of the cases in association with amyloidosis, a finding not previously reported. The relationship of amyloid in the bladder and urothelial carcinoma, although likely not causal, appears to be a unique finding not frequently seen with other solid tumors.

Invasive high-grade urothelial carcinoma of the bladder, renal pelvis, ureter, and prostatic urethra arising in a background of urothelial carcinoma with an inverted growth pattern: a contemporary clinicopathological analysis of 91 cases

Urothelial carcinoma with an inverted/endophytic growth pattern can occasionally mimic inverted urothelial papilloma and pose diagnostic challenges when assessing the presence or absence of invasion. Making these distinctions is critical for guiding appropriate treatment and improving patient outcomes. Here we conducted one of the largest studies to date of invasive high-grade urothelial carcinoma arising in a background of urothelial carcinoma with an inverted growth pattern. Primary sites examined included bladder, renal pelvis, ureter, and prostatic urethra. Clinicopathological parameters including extent of invasion, variant histology, presence of urothelial carcinoma in situ, and clinical follow-up were obtained. Ninety-one cases from 82 patients were included in the study. Lamina propria invasion was present in 81% of bladder, 60% of ureter, 20% of renal pelvis, and 100% of prostatic urethra cases. Muscularis propria invasion was identified in 19% of bladder, 14% of ureter, and 20% of renal pelvis cases. Urothelial carcinoma invaded periureteric fat in 29% of ureter cases and invaded the renal parenchyma in 60% of renal pelvis cases. Clinical follow-up was available for 77 of 82 (94%) patients with a mean duration of 18 months. Recurrent urothelial carcinoma persisted in 63 of 82 (77%) patients, 16 of 82 (19%) progressed with metastatic disease, and 20 of 77 (26%) patients with bladder involvement died of disease. This study further emphasizes the importance of distinguishing these tumors from benign mimickers of urothelial carcinoma. Recognition of invasive foci is also critical in view of the potentially high frequency of recurrence and the possibility of advanced disease in a subset of these patients.

The coexpression of fibroblast activation protein (FAP) and basal-type markers (CK 5/6 and CD44) predicts prognosis in high-grade invasive urothelial carcinoma of the bladder

High-grade urothelial carcinoma (UC) of the bladder is a heterogeneous disease with dismal prognosis. Bladder tumors with basal phenotype are intrinsically aggressive, and morphological parameters that define disease staging remain main prognosticators. We intend to evaluate the role of cancer-associated fibroblasts (CAFs) in the prognosis of bladder cancer and its association with basal and luminal phenotypes. Clinical and pathological parameters, including the immunohistochemical expression of fibroblast activation protein (FAP) and markers of basal (CK5/6, CD44) and luminal (CK20, GATA3) phenotypes, have been investigated in a series of 121 patients with UC of the bladder treated by radical cystectomy with lymph node dissection, and their implication in long-term cancer-specific survival has been evaluated. A cytoplasmic immunostaining of FAP in CAFs implies worse disease-specific survival (hazard ratio [HR] = 1.68; P = .048). FAP expression is associated with tumor staging (P < .0001), with best discrimination at T2a/T2b level, and with negative expression of markers of luminal phenotype, such as CK20 (P < .0001) and GATA3 (P = .005). In the multivariate analysis, simultaneous expression of FAP, CK5/6, and CD44 is a strong prognosticator of disease-specific survival (HR = 2.3; P = .001), together with nodal invasion (HR = 3.47; P < .0001) and bladder infiltration up to deep muscle or beyond (HR = 2.47; P = .02). There is no association between positive FAP expression in primary tumor and nodal disease (P = .22). FAP expression in CAFs favors tumor invasion in high-grade invasive UC of the bladder with basal phenotype. This new immunohistochemical marker could be added to the routine immunohistochemical protocol to predict clinical behavior in these patients.

Integrated Fourier Transform Infrared Imaging and Proteomics for Identification of a Candidate Histochemical Biomarker in Bladder Cancer

Histopathological differentiation between severe urocystitis with reactive urothelial atypia and carcinoma in situ (CIS) can be difficult, particularly after a treatment that deliberately induces an inflammatory reaction, such as intravesical instillation of Bacillus Calmette-Guèrin. However, precise grading in bladder cancer is critical for therapeutic decision making and thus requires reliable immunohistochemical biomarkers. Herein, an exemplary potential biomarker in bladder cancer was identified by the novel approach of Fourier transform infrared imaging for label-free tissue annotation of tissue thin sections. Identified regions of interest are collected by laser microdissection to provide homogeneous samples for liquid chromatography-tandem mass spectrometry-based proteomic analysis. This approach afforded label-free spatial classification with a high accuracy and without interobserver variability, along with the molecular resolution of the proteomic analysis. Cystitis and invasive high-grade urothelial carcinoma samples were analyzed. Three candidate biomarkers were identified and verified by immunohistochemistry in a small cohort, including low-grade urothelial carcinoma samples. The best-performing candidate AHNAK2 was further evaluated in a much larger independent verification cohort that also included CIS samples. Reactive urothelial atypia and CIS were distinguishable on the basis of the expression of this newly identified and verified immunohistochemical biomarker, with a sensitivity of 97% and a specificity of 69%. AHNAK2 can differentiate between reactive urothelial atypia in the setting of an acute or chronic cystitis and nonmuscle invasive-type CIS.

Clinical utility and concordance of upper urinary tract cytology and biopsy in predicting clinicopathological features of upper urinary tract urothelial carcinoma

Five percent of urothelial carcinoma occurs in the upper urinary tract (UUT), a challenging location to biopsy. We aim to evaluate concordance between biopsy, cytology, and resection specimens in a large upper tract urothelial carcinoma (UTUC) cohort. One hundred seventeen UTUC resections with UUT biopsy and/or cytology specimens from 2000 to 2016 were retrieved; pathologic material was re-reviewed, evaluated for concordance, and correlated with clinical information. Fourteen percent of preoperative biopsies, including 8 from the renal pelvis and 6 from the ureter, lacked neoplastic diagnoses. Seventy-seven percent of diagnostic biopsies included subepithelial tissue; 11% demonstrated reclassification of grade and 30% demonstrated reclassification of invasion status. Twenty-six percent of renal pelvis UTUC and 36% of ureter UTUC were invasive only on resection. Of 18 UTUCs reclassified from noninvasive high-grade papillary urothelial carcinoma to invasive high-grade papillary urothelial carcinoma, 39% had prior radical cystectomy (versus 8% invasive UTUC and 11% noninvasive UTUC with concordant biopsies). Most high-grade UTUC (88%) and some low-grade UTUC (58%) resections had abnormal cytology results. Biopsy-resection pairs with concordant invasion status and pairs with discordant invasion status showed similar rates of recurrence (38% versus 38%) and metastasis (25% versus 27%). Fourteen percent of UUT biopsies lacked diagnostic neoplastic material. Grade concordance between biopsy and resection was high (89%), but 30% of cases showed invasion only on resection. Subepithelial tissue was less commonly present in ureter biopsies, particularly from the midureter or proximal ureter. UTUC in patients with prior cystectomy were more likely to show invasion on resection but not biopsy.

AB065. Confocal laser endomicroscopy for diagnosing malignant bladder tumour: a pilot study

BackgroundTo perform an exploratory investigation on confocal laser endomicroscopy (CLE) in the diagnosis of malignant bladder tumour.MethodsFrom June 10 to July 11, 2017, patients initially diagnosed with bladder cancer by cystoscopy were hospitalised and had undergone white light cystoscopy (WLC) + CLE examination followed by transurethral resection of bladder tumour (TURBT) on suspected lesions. WLC and CLE imaging results were recorded and validated by pathologic specimens.ResultsLesions confirmed by histopathology were 3 low-grade non-invasive papillary urothelial carcinomas, 1 high-grade non-invasive papillary urothelial carcinoma, 1 low-grade invasive urothelial carcinoma, 1 high-grade invasive urothelial carcinoma, 1 carcinoma in situ (CIS), 1 high-grade dysplasia, 1 cystitis glandularis, 1 chronic inflammation, and 1 scar tissue. For CLE images in the normal urothelium, three layers of cells with different presentation were observed, namely, the superficial umbrella cells, the intermediate cells smaller in size and uniformly shaped, and the capillary network in the lamina propria. For non-invasive urothelial carcinoma, tumour cells appeared as papillary lesions growing from fibrovascular cores, with low-grade cells appearing monomorphic and more cohesively arranged, and high-grade cells relatively pleomorphic, more disorganised and with tortuous blood vessels in the fibrovascular core. For invasive urothelial carcinoma, tumour cells invaded the lamina propria, with uniform appearances, poor cohesion and indistinct cellular borders, and high-grade ones were more pleomorphic. CIS and inflammation both appeared as erythematous patch-like flat lesions under WLC and sometimes difficult to differentiate. Under CLE, the former appeared as dysplastic and disorganised cells with indistinct cellular borders, with intact lamina propria, and inflammatory cells were discovered as infiltrative clusters in the lamina propria that were uniformly shaped and loosely connected. Dysplasia appeared somewhat similar compared with CIS under WLC, but with lower cellular irregularity as confirmed with pathology. Cellular appearance and structure in scar tissue were similar to that in the normal urothelium, but superficial umbrella cells were more likely absent, with thinner cell layers, and inflammatory infiltration was sometimes discovered in the lamina propria.ConclusionsCLE provides real-time cellular imaging of the urothelium, and shows promising potential for clinical diagnosis, especially in differentiating flat urothelial lesions. Large prospective studies are required for further validation.

Confocal laser endomicroscopy for diagnosing malignant bladder tumour: a pilot study

Objective To perform an exploratory investigation on confocal laser endomicroscopy (CLE) in the diagnosis of malignant bladder tumour. Methods From June 10 to July 11, 2017, 6 male bladder cancer patients underwent white light cystoscopy (WLC)+ CLE examination, aging 64-86 years (median 72 years). All patients received TURBT on suspected lesions. WLC and CLE imaging results were recorded and validated by pathologic specimens. Results Lesions confirmed by histopathology were 3 low grade non-invasive papillary urothelial carcinomas, 1 high grade non-invasive papillary urothelial carcinoma, 1 low grade invasive urothelial carcinoma, 1 high grade invasive urothelial carcinoma, 1 carcinoma in situ (CIS), 1 high grade dysplasia, 1 cystitis glandularis, 1 chronic inflammation, and 1 scar tissue. For CLE images in the normal urothelium, three layers of cells with different presentation were observed, namely, the superficial umbrella cells, the intermediate cells smaller in size and uniformly shaped, and the capillary network in the lamina propria. For non-invasive urothelial carcinoma, tumour cells appeared as papillary lesions growing from fibrovascular cores, with low grade cells appearing monomorphic and more cohesively arranged, and high grade cells relatively pleomorphic, more disorganised and with tortuous blood vessels in the fibrovascular core. For invasive urothelial carcinoma, tumour cells invaded the lamina propria, with uniform appearances, poor cohesion and indistinct cellular borders, and high grade ones were more pleomorphic. CIS and inflammation both appeared as erythematous patch-like flat lesions under WLC and sometimes difficult to differentiate. Under CLE, the former appeared as dysplastic and disorganised cells with indistinct cellular borders, with intact lamina propria, and inflammatory cells were discovered as infiltrative clusters in the lamina propria that were uniformly shaped and loosely connected. Dysplasia appeared somewhat similar compared with CIS under WLC, but with lower cellular irregularity as confirmed with pathology. Cellular appearance and structure in scar tissue was similar to that in the normal urothelium, but superficial umbrella cells were more likely absent, with thinner cell layers, and inflammatory infiltration was sometimes discovered in the lamina propria. Conclusions CLE provides real-time cellular imaging of the urothelium, and shows promising potential for clinical diagnosis, especially in differentiating flat urothelial lesions. Large prospective studies are required for further validation. Key words: Bladder cancer; Cystoscopy; Confocal laser endomicroscopy; Pathological diagnosis

265 BK-Virus Positive Invasive High-Grade Urothelial Carcinoma in an 8-Year-Old Renal Transplant Recipient With BK Virus Nephropathy

Urothelial carcinoma is extremely rare in children and may be fundamentally different than in adults. Fewer than 30 cases have been reported in patients under 10 years old. BK polyomavirus infection is a major problem in transplantation, especially in renal transplant recipients. According to literature, 1%-10% of renal transplant recipients develop polyomavirus-associated nephropathy. The possibility that BK polyomavirus may be carcinogenic in humans is controversial, but SV40 large T antigen is known to inhibit tumor suppressors pRB and p53, and to transform some cell lines in culture. Adult renal transplant recipients have a 3-5x increased risk of urothelial carcinoma. The cystoprostatectomy specimen from an 8-year-old boy with a history of renal transplantation was processed according to standard procedure, and evaluated using H&E and immunohistochemical stains (IHC). Additional ancillary testing included molecular studies for BK virus using PCR for VP1 and identity testing using HLA typing. The patient was an 8-year-old ex 32-week gestation twin boy with a history of chronic kidney disease and developmental delay. He had end-stage renal disease of unclear etiology and underwent kidney transplantation five years earlier from a living non-related donor who was a smoker. He had been immunosuppressed since transplantation, and his course was complicated by uncontrolled BK viremia and BK nephropathy despite prolonged treatment. Five years after his renal transplant, he was noted to have gross painless hematuria. Biopsy of a bladder lesion showed high-grade urothelial carcinoma, and ureteroscopy of native and transplant ureters showed no gross malignancy. He underwent cystoprostatectomy and bilateral native nephroureterectomies with cutaneous ureterostomy from the transplant kidney. Histological examination of the bladder revealed invasive high-grade urothelial carcinoma with micropapillary features with invasion into muscularis propria. Lymphovascular invasion was also noted. The bilateral native kidneys were atrophic with simple cysts and chronic inflammation. The prostate, bilateral seminal vesicles, vas deferens, and distal transplant ureter cuff were negative for tumor. Immunohistochemical staining of the tumor for SV40 antigen showed strong and diffuse staining. In contrast, immunohistochemistry for viral protein VP1 was negative. Molecular testing for BK virus by PCR for VP1 was positive. Immunohistochemistry for mismatch repair proteins showed normal, preserved expression. Identity testing confirmed that the tumor cells belonged to the patient and not to the donor. BK virus positivity has been reported in rare cases of urothelial carcinomas, mainly in adult transplant patients. To our knowledge, this is the first reported incidence of BK virus-associated urothelial carcinoma in a pediatric patient. Absence of late VP1 expression by IHC in conjunction with positive SV40 staining and positive BK virus PCR is consistent with a non-productive BK virus infection. Pathologists should be aware that identity testing should be considered in transplant patients with urothelial carcinoma to confirm the genetic origin of the tumor. Micropapillary differentiation may be a feature of BK virus-associated carcinoma.

MP44-15 ANXA10 AND ATP7A ARE THE MTOR PATHWAY DOWNSTREAM TO PREDICT THE RECURRENCE AND PROGRESSION IN NON-MUSCLE INVASIVE HIGH GRADE UROTHELIAL CARCINOMA OF THE BLADDER

You have accessJournal of UrologyBladder Cancer: Basic Research & Pathophysiology I1 Apr 2017MP44-15 ANXA10 AND ATP7A ARE THE MTOR PATHWAY DOWNSTREAM TO PREDICT THE RECURRENCE AND PROGRESSION IN NON-MUSCLE INVASIVE HIGH GRADE UROTHELIAL CARCINOMA OF THE BLADDER Byung Hoon Chi, Subin Jin, Young Mi Whang, Seung Hyun Ahn, Jae Duck Choi, Shin Young Lee, In Ho Chang, and Bongsuk Shim Byung Hoon ChiByung Hoon Chi More articles by this author , Subin JinSubin Jin More articles by this author , Young Mi WhangYoung Mi Whang More articles by this author , Seung Hyun AhnSeung Hyun Ahn More articles by this author , Jae Duck ChoiJae Duck Choi More articles by this author , Shin Young LeeShin Young Lee More articles by this author , In Ho ChangIn Ho Chang More articles by this author , and Bongsuk ShimBongsuk Shim More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1346AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The cross-talk of mammalian target of rapamycin (mTOR) pathway is clinical limitation of mTOR inhibitor for the treatment of urothelial carcinoma (URCa) of the bladder. This study is to search mTOR pathway downstream genes to overcome cross-talk at non muscle invasive high grade (HG)-URCa of the bladder. METHODS Gene expression patterns, gene ontology, and gene clustering by triple (p70S6K, S6K and eIF4E) siRNAs or rapamycin in 5637 and T24 cell lines were investigated by microarray analysis and we selected mTOR pathway downstream genes which were suppressed to siRNAs more than two fold, and rapamycin up-regulated or rapamycin down-regulated. And then we validated mTOR downstream genes with immunohistochemistry using tissue microarray of 125 non-muscle invasive HG-URCa patients whether genes can predict clinical aggressiveness and long-term outcomes, and knockout study to evaluate the synergistic effect with rapamycin. RESULTS In the microarray analysis, we selected mTOR pathway downstream genes which consisted of 4 rapamycin up-regulated (FABP4, H19, ANXA10, and UPK3A), and 4 rapamycin down-regulated (FOXD3, ATP7A, plexin D1 and ADAMTS5). In tissue microarray, FABP4 and ATP7A were more expressed at T1, and FOXD3 was at Ta. ANXA10 and ADAMTS5 were more expressed at 3 cm or less than 3cm. In Kaplan-Meier curve, ANXA10 was a significant predictor of recurrence, and FABP4 and ATP7A were significant predictors of progression of HG-URCa of the bladder. In multivariate Cox regression model, ANXA10 was a significant predictor of recurrence and ATP7A was a significant predictors of progression in non-muscle invasive HG-URCa of the bladder. In ATP7A knock out model, rapamycin treatment showed synergistic effect to inhibit cell viability, wound healing, and invasion ability compared to rapamycin only. CONCLUSIONS ANXA10 and ATP7A might be mTOR pathway downstream genes to predict recurrence and progression in non-muscle invasive high-grade urothelial carcinoma of the bladder and ATP7A knockout overcome the rapamycin coss-talk. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e569 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Byung Hoon Chi More articles by this author Subin Jin More articles by this author Young Mi Whang More articles by this author Seung Hyun Ahn More articles by this author Jae Duck Choi More articles by this author Shin Young Lee More articles by this author In Ho Chang More articles by this author Bongsuk Shim More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Identification of Downstream Genes of the mTOR Pathway that Predict Recurrence and Progression in Non-Muscle Invasive High-Grade Urothelial Carcinoma of the Bladder.

Microarray analysis was used to investigate the lack of identified mammalian target of rapamycin (mTOR) pathway downstream genes to overcome cross-talk at non-muscle invasive high-grade (HG)-urothelial carcinoma (UC) of the bladder, gene expression patterns, gene ontology, and gene clustering by triple (p70S6K, S6K, and eIF4E) small interfering RNAs (siRNAs) or rapamycin in 5637 and T24 cell lines. We selected mTOR pathway downstream genes that were suppressed by siRNAs more than 2-fold, or were up-regulated or down-regulated by rapamycin more than 2-fold. We validated mTOR downstream genes with immunohistochemistry using a tissue microarray (TMA) of 125 non-muscle invasive HG-UC patients and knockout study to evaluate the synergistic effect with rapamycin. The microarray analysis selected mTOR pathway downstream genes consisting of 4 rapamycin up-regulated genes (FABP4, H19, ANXA10, and UPK3A) and 4 rapamycin down-regulated genes (FOXD3, ATP7A, plexin D1, and ADAMTS5). In the TMA, FABP4, and ATP7A were more expressed at T1 and FOXD3 was at Ta. ANXA10 and ADAMTS5 were more expressed in tumors ≤ 3 cm in diameter. In a multivariate Cox regression model, ANXA10 was a significant predictor of recurrence and ATP7A was a significant predictor of progression in non-muscle invasive HG-UC of the bladder. In an ATP7A knock-out model, rapamycin treatment synergistically inhibited cell viability, wound healing, and invasion ability compared to rapamycin only. Activity of the ANXA10 and ATP7A mTOR pathway downstream genes might predict recurrence and progression in non-muscle invasive HG-UC of the bladder. ATP7A knockout overcomes rapamycin cross-talk.

Synchronous and Metachronous Triple Primary Urogenital Cancer: A Case Report

Objectives: Triple primary urogenital cancer is infrequent. We report two such cases: synchronous and metachronous. Methods: A 70-year-old Caucasian man presented with hematuria. He had suspicious masses in the right kidney and bladder on computed tomography. He underwent cystoscopy with transurethral resection of large friable bladder mass, which showed invasive high-grade urothelial carcinoma on microscopy. He received 2 cycles of chemotherapy, …

Human epidermal growth factor receptor 2 expression in micropapillary urothelial carcinoma of the bladder: an analysis of 27 cases

The significance of human epidermal growth factor receptor 2 (HER2) overexpression in breast cancer is well established. However, only a few large studies have analyzed HER2 expression in invasive high-grade urothelial carcinoma (UCA). In this study, we sought to analyze the expression of HER2 in a large cohort of micropapillary UCA. A search was performed through our Urologic Pathology files and expert consult files of the senior author for cases of micropapillary UCA of the bladder. Twenty-seven cases were identified. The mean patient age was 68 years (range: 39-87 years). There were 26 male patients and 1 female patient. Twenty of 27 (74%) cases were positive for HER2. Eleven of 15 (73%) cases with angiolymphatic invasion were positive for HER2. Seven of 10 (70%) cases that developed metastasis were positive for HER2. Six of 11 (54%) cases with pT3 disease were positive for HER2, 8/10 (80%) cases with pT2 disease were positive for HER2, 5/5 (100%) cases with pT1 disease were positive for HER2, and the only case with pTa disease was positive for HER2. In our cohort, a significant number of patients with angiolymphatic invasion also had HER2 overexpression. Interestingly, although the majority of cases with advanced disease also demonstrated positive HER2 expression, it was more predominant in cases with less advanced disease. It is therefore highly conceivable that both patients with early or advanced micropapillary UCA of the bladder, including those with angiolymphatic invasion, may benefit from trastuzumab and other related therapeutic agents.

Non-muscle invasive high grade urothelial carcinoma of the bladder. Which factors can influence understaging at the time of radical cystectomy?

To evaluate the main factors which influence understaging in patients with T1G3 non-muscle invasive bladder cancer (NMIBC). 109 patients with T1/G3 underwent transurethral resection of bladder tumor (TURBT) and then radical cystectomy (RC) with pelvic lymph nodes dissection. A number of variables were considered when evaluating the detection of understaging. We considered the patients age and gender, as well as the size, number, location and morphology of their tumor. We also considered coexistence of bladder carcinoma in situ (CIS), microscopic vascular invasion and deep lamina propria invasion. The level of experience of the surgeon was also analyzed. in RC samples muscle invasion, that is understaging, was detected in 74 (67.9%) patients, while 35 (32.1%) patients were appropriately staged. In these cohort of patients with high grade tumors, understaging was associated with deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size &gt; 6 cm, tumor location (trigone and dome), presence of residual tumor; age, gender, tumor morphology, CIS associated, and experience of urological surgeon were not associated with clinical understaging. in our study, evaluating patients with high grade NMIBC at first TURBT, we identified some risk factors that need to be considered and that are able to increase the risk of understaging: deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size &gt; 6 cm, tumor location (trigone and dome), presence of residual tumor. When these risk factors are present, performing an early cystectomy, and not a re-TURBT, could lower the risk of worse pathological finding due to rapid disease progression of the high grade tumors, and can prolong survival.

Role of isoenzyme M2 of pyruvate kinase in urothelial tumorigenesis.

The conversion of precancerous lesions to full-fledged cancers requires the affected cells to surpass certain rate-limiting steps. We recently showed that activation of HRAS proto-oncogene in urothelial cells of transgenic mice causes simple urothelial hyperplasia (SUH) which is persistent and whose transition to low-grade papillary urothelial carcinoma (UC) must undergo nodular urothelial hyperplasia (NUH). We hypothesized that NUH, which has acquired fibrovascular cores, plays critical roles in mesenchymal-to-epithelial signaling, breaching the barriers of urothelial tumor initiation. Using proteomics involving two-dimensional gel electrophoresis, immunoblotting with pan-phosphotyrosine antibody and MALDI-mass spectrometry, we identified isoform 2 of pyruvate kinase (PKM2) as the major tyrosine-phosphorylated protein switched on during NUH. We extended this finding using specimens from transgenic mice, human UC and UC cell lines, establishing that PKM2, but not its spliced variant PKM1, was over-expressed in low-grade and, more prominently, high-grade UC. In muscle-invasive UC, PKM2 was co-localized with cytokeratins 5 and 14, UC progenitor markers. Specific inhibition of PKM2 by siRNA or shRNA suppressed UC cell proliferation via increased apoptosis, autophagy and unfolded protein response. These results strongly suggest that PKM2 plays an important role in the genesis of low-grade non-invasive and high-grade invasive urothelial carcinomas.

Patterns and Significance of PIM Kinases in Urothelial Carcinoma.

The Provirus integrating site Moloney murine leukemia virus (Pim) family are proteins with serine/threonine kinase activity. Studies have demonstrated overexpression of Pims in cancer. To our knowledge, only a single study has examined Pim-1 in urothelial carcinoma. The aim of this investigation was to evaluate Pim-1, Pim-2, and Pim-3 in urothelial carcinoma and assess for expression that may contribute to disease progression and serve as a site for targeted therapy. This retrospective study included 137 cases taken from specimens from the University of Utah, Department of Pathology (2008 to 2011). Tissue was stained with antibodies against Pim-1, Pim-2, and Pim-3. Cases were classified into 3 groups, based upon current World Health Organization criteria (invasive high-grade urothelial carcinoma [IHG] [n=84], noninvasive high-grade urothelial carcinoma/carcinoma in situ [n=32], and noninvasive low-grade urothelial carcinoma [NILG] [n=21]). Cases were scored and recorded as positive or negative on the basis of the percentage of cells with cytoplasmic and/or nuclear staining. NILG showed higher expression of Pim-1 (relative expression rate [RER]=2.28; 95% confidence interval [CI], 0.183-0.764) and Pim-3 (RER=3.06; 95% CI, 0.423-0.816) compared with other lesions. IHG had lower expression of Pim-1 (RER=0.31; 95% CI, 0.401-0.844) and Pim-3 (RER=0.354; 95% CI, 0.322-0.816) and noninvasive high-grade urothelial carcinoma (NIHG) demonstrated increased expression of Pim-1 and (RER=2.09; 95% CI, 0.124-0.739) and Pim-2 (RER=1.70; 95% CI, 0.151-0.591). At least 1 Pim kinase protein was expressed at the following rates: 49% in IHG, 66% in NIHG, and 76% in NILG. A high percentage of urothelial carcinomas express Pim kinases. Pim expression differs in NILG, NIHG, and IHG lesions.