High-grade Invasive Bladder Cancer Research Articles

MP34-09 C-TERMINAL HYPER-PHOSPHORYLATION OF PTEN IS A MAJOR MECHANISM OF PTEN INACTIVATION IN BLADDER CANCER: IMPLICATIONS IN TUMOR SUPPRESSION AND MOLECULAR THERAPY

INTRODUCTION AND OBJECTIVES: Phosphatase and Tensin Homology (PTEN) antagonizes PI3-kinase/AKT and this activity relies on PTEN-membrane interaction. While loss of PTEN, along with p53 defects, triggers muscle-invasive bladder cancer (BC) in genetically engineered mice, PTEN deletion or mutation in human BC is rare, suggesting that PTEN is inactivated via a different mechanism. Hyperphosphorylation of PTEN’s C-terminus (PTEN-Cp) is thought to dissociate PTEN from the membrane, thus functionally inactivating PTEN. This study investigates the prevalence of PTEN-Cp and its effects on tumor suppression in BC cells. METHODS: Ten cell lines representing different grades/stages of human BC was assessed for PTEN-Cp using site-specific antibodies. cDNAs encoding (i) wild-type PTEN, (ii) mutated PTEN devoid of C-terminal phosphorylation sites and (iii) truncated PTEN lacking the C-terminus were transfected into UMUC3 and J82 BC cell lines that lack the PTEN gene. PTEN-Cp status, PI3K/AKT activation and BC cell proliferation were assessed in vitro and in vivo using xenograft models. PTEN-Cp was also assessed using Western blotting of freshly preserved human BC tissues. RESULTS: Prominent PTEN-Cp was observed in all BC cell lines except UMUC3 and J82 which lack the PTEN gene. Transfection of wild-type PTEN into UMUC3 and J82 inhibited cell growth, albeit only at serum-free or low-serum (2%) conditions. High-serum (10%) caused PTEN to undergo extensive PTEN-Cp, increased AKT activation and cell proliferation. Mutated PTEN devoid of C-terminal phosphorylation sites and truncated PTEN lacking the C-terminus exerted much greater inhibitory effects on AKT and cell growth of UMUC3 and J82. These effects were reproducible when the transfected cells were transplanted subcutaneously into xenograft models. Finally, surveying a cohort of fresh human BC tissues revealed that a great majority of lowgrade non-invasive and high-grade invasive BC expressed PTEN and whenever PTEN was expressed it was highly phosphorylated at the C-terminus. CONCLUSIONS: Our studies provide the first evidence demonstrating that hyper-phosphorylation at the C-terminus is a major mechanism of PTEN inactivation in human BC, that PTEN phosphorylation may serve as a useful biomarker for BC progression, and that the tail-less PTEN is a much more potent tumor suppressor than the fulllength PTEN when used in molecular therapy.

MP34-10 CROSSTALK BETWEEN DOWNSTREAM EFFECTORS OF RECEPTOR TYROSINE KINASE/RAS PATHWAY CAN BE DISRUPTED BY COMBINATORIAL INHIBITION: IMPLICATION IN TARGETED THERAPY

INTRODUCTION AND OBJECTIVES: Phosphatase and Tensin Homology (PTEN) antagonizes PI3-kinase/AKT and this activity relies on PTEN-membrane interaction. While loss of PTEN, along with p53 defects, triggers muscle-invasive bladder cancer (BC) in genetically engineered mice, PTEN deletion or mutation in human BC is rare, suggesting that PTEN is inactivated via a different mechanism. Hyperphosphorylation of PTEN’s C-terminus (PTEN-Cp) is thought to dissociate PTEN from the membrane, thus functionally inactivating PTEN. This study investigates the prevalence of PTEN-Cp and its effects on tumor suppression in BC cells. METHODS: Ten cell lines representing different grades/stages of human BC was assessed for PTEN-Cp using site-specific antibodies. cDNAs encoding (i) wild-type PTEN, (ii) mutated PTEN devoid of C-terminal phosphorylation sites and (iii) truncated PTEN lacking the C-terminus were transfected into UMUC3 and J82 BC cell lines that lack the PTEN gene. PTEN-Cp status, PI3K/AKT activation and BC cell proliferation were assessed in vitro and in vivo using xenograft models. PTEN-Cp was also assessed using Western blotting of freshly preserved human BC tissues. RESULTS: Prominent PTEN-Cp was observed in all BC cell lines except UMUC3 and J82 which lack the PTEN gene. Transfection of wild-type PTEN into UMUC3 and J82 inhibited cell growth, albeit only at serum-free or low-serum (2%) conditions. High-serum (10%) caused PTEN to undergo extensive PTEN-Cp, increased AKT activation and cell proliferation. Mutated PTEN devoid of C-terminal phosphorylation sites and truncated PTEN lacking the C-terminus exerted much greater inhibitory effects on AKT and cell growth of UMUC3 and J82. These effects were reproducible when the transfected cells were transplanted subcutaneously into xenograft models. Finally, surveying a cohort of fresh human BC tissues revealed that a great majority of lowgrade non-invasive and high-grade invasive BC expressed PTEN and whenever PTEN was expressed it was highly phosphorylated at the C-terminus. CONCLUSIONS: Our studies provide the first evidence demonstrating that hyper-phosphorylation at the C-terminus is a major mechanism of PTEN inactivation in human BC, that PTEN phosphorylation may serve as a useful biomarker for BC progression, and that the tail-less PTEN is a much more potent tumor suppressor than the fulllength PTEN when used in molecular therapy.

Loss of GATA3 in bladder cancer promotes cell migration and invasion

The transcription factor GATA3 is known as a breast tumor suppressor as well as a urothelial marker, and its loss is often seen in high-grade invasive bladder cancer. Nonetheless, GATA3 functions in bladder cancer cells remain largely unknown. In this study, we assessed the effects of GATA3 silencing via RNA interference on cell migration, invasion, and proliferation of bladder cancer. GATA3 expression was downregulated in all four bladder cancer lines examined, compared with a non-neoplastic urothelial line SVHUC. Knockdown of GATA3 in the bladder cancer lines (5637, TCC-SUP, J82) resulted in promotion of cell migration and invasion as well as increases in the expression of their related molecules, such as vascular endothelial growth factor, matrix metalloproteinase (MMP)-2, and MMP-9, and the activity of MMP-2 and MMP-9. GATA3 loss was also associated with an increasing level of a mesenchymal marker N-cadherin and a decreasing level of an epithelial marker β-catenin. Consistent with these findings, enforced expression of GATA3 in UMUC3 inhibited cell migration and invasion. However, GATA3 showed marginal effects on bladder cancer cell viability and the expression of cell cycle- or apoptosis-related molecules. Additionally, in contrast to bladder cancer lines, no significant effects of GATA3 silencing on cell migration were seen in SVHUC. These findings suggest that GATA3 plays an important role in the prevention of bladder cancer progression and metastasis by inhibiting cell migration and invasion as well as epithelial-to-mesenchymal transition.

A feasibility study of peritoneum preservation in radical cystectomy with extraperitonealization of orthotopic neobladder for invasive high-grade bladder cancer: a preliminary analysis

To describe a technique for radical cystectomy with extraperitonealization of orthotopic neobladder (RCEN) that reduces bowel-related complications by preservation of the peritoneum. Fifteen patients with non-metastatic bladder cancer underwent RCEN by a peritoneum preserving technique. The study included 13 patients with T1 high-grade bladder cancer and 2 with T2a bladder cancer. To compare perioperative outcomes including bowel-related complications, we also reviewed 15 patients who underwent traditional cystectomy with ileal Studer neobladder who were matched for age, sex, body mass index, American Society of Anesthesiologists (ASA) score, tumor stage, tumor grade, tumor size, and location. Female genital organs were preserved in five female patients who underwent the RCEN technique. There was no significant difference between the two cohorts (RECN vs. traditional technique) with respect to age, body mass index, ASA score, or tumor characteristics. The mean operative time was similar between the two groups. The patients who underwent RECN exhibited earlier recovery of normal gas pattern on plain abdominal X-ray during the postoperative period and an earlier resumption of normal diet. The mean hospital stay was shorter in the RECN group than the traditional group. The RECN technique preserving the whole peritoneum is a feasible approach that significantly reduces bowel-related complications in selected patients.

Activation of cyclic AMP/PKA pathway inhibits bladder cancer cell invasion by targeting MAP4-dependent microtubule dynamics

ObjectiveWith the notorious reputation of the vicious invasion, the bladder cancer is the most common malignant tumor of the urinary system. Inhibiting invasion through microtubule dynamics interruption has emerged as an important treatment of bladder cancer. Here we investigated the role of the cyclic adenosine monophosphate/protein kinase A (cAMP/PKA) pathway in human bladder cancer cells invasion. Materials and methodsWith or without the treatment of various cAMP elevators, we assessed invasive and migrated capabilities of T24 and UM-UC-3, two high-grade invasive bladder cancer cell lines, using matrigel transwell inserts assay and scratch wound healing assay. The microtubule (MT) dynamics were examined by immunofluorescence and immunoblotting. Microtubule-Associated Protein 4 (MAP4) was silenced to investigate its role in tumor invasion. We also analyzed gene expression of MAP4 in 34 patients with bladder cancer using immunohistochemical staining assay. The interaction between PKA and MAP4 was examined by co-immunoprecipitation. ResultsWe used cAMP elevators and small interfering RNA of MAP4 here, found that both of them can potently inhibit the invasion and the migration of bladder cancer cells by disrupting microtubule (MT) cytoskeleton. Consistently, the bladder cancer grade is positively correlated with the protein level of MAP4. Furthermore, we found that cAMP/PKA signaling can disrupt MT cytoskeleton by the phosphorylation of MAP4. ConclusionOur results indicated that the cAMP/PKA signaling pathway might inhibit bladder cancer cell invasion by targeting MAP4-dependent microtubule dynamics, which could be exploited for the therapy of invasive bladder cancer.

Alterations of Histone H1 Phosphorylation During Bladder Carcinogenesis

There is a crucial need for development of prognostic and predictive biomarkers in human bladder carcinogenesis in order to personalize preventive and therapeutic strategies and improve outcomes. Epigenetic alterations, such as histone modifications, are implicated in the genetic dysregulation that is fundamental to carcinogenesis. Here we focus on profiling the histone modifications during the progression of bladder cancer. Histones were extracted from normal human bladder epithelial cells, an immortalized human bladder epithelial cell line (hTERT), and four human bladder cancer cell lines (RT4, J82, T24, and UMUC3) ranging from superficial low-grade to invasive high-grade cancers. Liquid chromatography-mass spectrometry (LC-MS) profiling revealed a statistically significant increase in phosphorylation of H1 linker histones from normal human bladder epithelial cells to low-grade superficial to high-grade invasive bladder cancer cells. This finding was further validated by immunohistochemical staining of the normal epithelium and transitional cell cancer from human bladders. Cell cycle analysis of histone H1 phosphorylation by Western blotting showed an increase of phosphorylation from G0/G1 phase to M phase, again supporting this as a proliferative marker. Changes in histone H1 phosphorylation status may further clarify epigenetic changes during bladder carcinogenesis and provide diagnostic and prognostic biomarkers or targets for future therapeutic interventions.

Reply to S. Buti and S. Culine

The comments Buti1 and Culine2 regarding our article3 about the role of cetuximab with or without paclitaxel in patients with advanced urothelial cancer. Their comments highlight some of the challenges in conducting clinical trials in this area. Buti proposes an additional analysis comparing the study's overall survival to the expected survival on the basis of the distribution of patient characteristics using the Bellmunt criteria published in 2010.4 Using these criteria, seven patients in the combination arm of our study had zero risk factors, 13 patients had one risk factor, seven patients had two risk factors, and one patient had three risk factors. The small size of these subsets precludes a meaningful statistical comparison of survival. We did report the progression-free and overall survival of patients who received chemotherapy for metastatic disease and those who had visceral metastases. However, because of the small sample size, we believe these results should be considered hypothesis generating only, and we discuss this limitation in our article.3 We agree with Culine that time from prior chemotherapy may be an important prognostic factor. We have contributed data from this study to a pooled analysis that recently demonstrated that a shorter time from prior chemotherapy is associated with worse response.5 This information may be used to design additional studies. KRAS mutation status was not known to be predictive of response to cetuximab in advanced colorectal cancer when this study began enrolling patients in 2006. However, we would not recommend testing for KRAS mutational status as an entry criteria for future studies of this combination on the basis of the low probability of finding a KRAS mutation in a patient with metastatic urothelial cancer. Juanpere et al6 found just one KRAS mutation among the 33 patients within the cohort of high-grade invasive bladder cancer. A higher but still low frequency of KRAS mutations were found in superficial tumor samples, which have a lower probability for metastasis. Other investigators have also found a low frequency of KRAS mutations in patients with urothelial carcinoma.7,8 This study was designed as a noncomparative phase II study; therefore, each arm was investigated separately. We hope to test this combination in a randomized comparative fashion using paclitaxel as a control arm. Vinflunine, although available in Europe, is not available in the United States and is not a practical comparator arm. Our study met its prespecified primary end point, which demonstrated that the combination of cetuximab and paclitaxel extended progression-free survival compared with historical controls, providing the rationale for future testing of this combination in a larger randomized trial.

IJU this issue

Is inflammation related to any diseases? I asked this question when I read the Review and Original Articles in this issue. Carcinogenesis as a result of inflammation has been noted in stomach cancer in relation to Helicobacter pylori, liver cancer as a result of hepatitis virus, and, in the urological field, squamous bladder cancer linked to schistosomiasis. The Review Article by Nakai and Nonomura (Osaka, Japan) described the inflammation in normal prostate and prostate cancer tissues in relation to the initiation of prostate cancer. Proliferative inflammatory atrophy (PIA) is known to be associated with acute or chronic inflammation in the peripheral zone where prostate cancer predominantly develops. PIA might link inflammation and cancer. In an epidemiological view, a fat-rich diet is a risk factor of prostate cancer. Grilled meats produce heterocyclic amine and polycyclic aromatic hydrocarbons. These compounds induce inflammation of prostate tissues. Xenobiotics have received attention because of their estrogenic effects that might cause hypospadias and other congenital abnormalities. The role of estrogen in the initiation and the progression of prostate cancer will be further investigated. Does inflammation accelerate cancer progression? Patients with advanced cancer are associated with high fever and/or inflammatory reactions. Is inflammation the cause or the result of cancer progression? C-reactive protein (CRP) is widely used as a biomarker to monitor whole-body inflammation. Saito and Kihara (Tokyo, Japan) reviewed the role of CRP in urological cancers. CRP is a valuable prognosis factor that can be used in ordinary practice. CRP is generally produced by hepatocytes through the stimulation of cytokines including interleukin (IL)-6 and IL-1β. These cytokines play an important role, because they work as autocrine and/or paracrine growth factors in the cancer microenvironment. Therefore, CRP is not the cause of cancer progression, but the result of cytokines produced by cancer or immunological cells. Then, how are theses cytokines produced? For example, IL-6 is induced by the activation of transcription factors including NF-κB. However, the mechanism underlying NF-κB activation is diverse. Further investigation should be focused on why the inflammatory reaction is common in predicting the poor prognosis of all malignancies. A cancer microenvironment composed of cancer and mesenchymal cells can be conceived as an inflammatory environment where hematological cells target or help cancer cells. Choi et al. (Ansan, Korea) have shown CD74 expression in the microenvironment. CD74 is part of a receptor complex for macrophage migration inhibitory factor (MIF). They found that CD74 expression is increased in high-grade invasive bladder cancer. This implicates the immunological escape of cancer cells. Indeed, CD74 expression was correlated with the absence of tumor-infiltrating inflammatory cells and the presence of tumor-associated inflammatory cells. Milatuzumab is a humanized anti-CD74 antibody being evaluated for hematological malignancies. This study might have opened the gate for molecular-targeted therapy for invasive bladder cancer where no such agents are available at present. How do we treat inflammation? The answer depends on the disease that induced inflammation. Interstitial cystitis (IC) is a refractory inflammatory disease, the cause of which is unknown. Wada et al. (Hokkaido, Japan) have shown the effect of intrathecal administration of E-series prostaglandin 1 (EP1) receptor antagonist in a cyclophosphamide-induced cystitis rat model. EP-1 receptor antagonist is promising for future therapy. Another treatment strategy for IC comes from focusing on the defective urothelial lining in the bladder. The pathogenesis of IC involves the mucin glycosaminoglycan layer of the urothelium. Hyaluronic acid (HA) is a relevant component. Lai et al. (Taipei, Taiwan) showed the result of a comparative randomized trial to determine the optimization of the regimens, namely, four weekly intravesical instillations of 40 mg of HA followed by monthly instillations or 12 intravesical instillations every 2 weeks. Both groups had no differences in showing a significant improvement in symptom scores and Quality of Life Index. None declared.

565 PROBING THE METHYLATION STATUS OF DIFFERENT TUMOR SUPPRESSOR GENES FROM BLADDER CANCER PATIENTS

You have accessJournal of UrologyBladder Cancer: Basic Research I1 Apr 2012565 PROBING THE METHYLATION STATUS OF DIFFERENT TUMOR SUPPRESSOR GENES FROM BLADDER CANCER PATIENTS Shumaila Bilgrami, shahid pervez, Sohail Qureshi, and Farhat Abbas Shumaila BilgramiShumaila Bilgrami Karachi, Pakistan More articles by this author , shahid pervezshahid pervez Karachi, Pakistan More articles by this author , Sohail QureshiSohail Qureshi Lahore, Pakistan More articles by this author , and Farhat AbbasFarhat Abbas Karachi, Pakistan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.640AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Promoter methylation induced silencing of tumor suppressor genes has been implicated for various genes in bladder cancer. We analyzed the promoter methylation in a panel of tumor suppressor genes involved in apoptosis, DNA repair, cell cycle control and progression in non-invasive and invasive bladder cancer. METHODS Promoter hypermethylation was investigated in the gene promoters of RASSF1a(Ras association domain family member 1), APC (Adenomatous Polyposis Coli), MGMT ( O-6-methylguanine-DNA methyltransferase), p16 and p15 in 43 non-invasive and low grade, 33 invasive and high grade bladder cancer and 10 cases with normal bladder mucosa/benign urologic disease using real-time methylation-specific PCR with SYBR green. In addition to the 86 tissue samples, DNA methylation analyses were also carried out in 16 plasma samples from patients with invasive high grade bladder cancer. RESULTS Promoter hypermethylation was frequently observed in RASSF1a, APC and MGMT genes (p-value<0.001) and was prominent in the invasive high grade bladder cancer tissues as compared to the non-invasive low grade group (p<0.001) and normal bladder mucosa (p-values 0.040, 0.000 and 0.003 for RASSF1a, APC and MGMT, respectively). When the data from16 plasma samples were compared to the corresponding tissue samples, only APC (p-value 0.006) and p16 (p-value 0.011) showed significance in paired-T test. CONCLUSIONS Our results suggest that promoter methylation analysis can serve as a valuable tool for monitoring progression of bladder cancers and assessing their spread. Although the data on plasma samples is preliminary, it has encouraged us to interrogate the DNA methylation status of an expanded panel comprised of oncogenes and tumor-suppressor genes in a larger number of samples. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e231 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shumaila Bilgrami Karachi, Pakistan More articles by this author shahid pervez Karachi, Pakistan More articles by this author Sohail Qureshi Lahore, Pakistan More articles by this author Farhat Abbas Karachi, Pakistan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The origins of urothelial carcinoma

It is now widely believed that there are two major pathways for urothelial carcinogenesis. One pathway usually involves mutation of FGF receptor 3 and gives rise to low-grade papillary tumors that frequently recur but seldom invade. By contrast, high-grade urothelial malignancies, including high-grade papillary urothelial carcinoma and urothelial carcinoma in situ (CIS) usually exhibit deletions or mutations of TP53. Urothelial CIS is the most likely precursor of high-grade invasive bladder cancer. It is a ‘flat lesion’ that may be relatively inconspicuous at cystoscopy, or even endoscopically undetectable. The clinical hazards associated with this elusive and biologically dangerous neoplasm have been increasingly well documented since the original studies by Melicow in 1952. Primary or secondary urothelial dysplasia is even more challenging to detect and diagnose than CIS. It is theorized that dysplasia may antedate the onset of CIS, but support for the putative progression of dysplasia to CIS is found in fewer than 20% of cases. Since many benign urothelial changes may resemble CIS at cystoscopy, in biopsies and even with molecular profiling, care must be exercised when making a diagnosis of CIS. For patients whose screening tests are worrisome for the presence of premalignant urothelial disease, newer bladder imaging modalities, including Raman spectral imaging and optical coherence tomography, may enable improved biopsy site selection. In this article, we discuss the above-noted topics, as well as other related issues, such as the possible role of papillary urothelial hyperplasia as a preneoplastic lesion and the roles of cancer stem cells and field cancerization in urothelial carcinogenesis.

Indications and Oncologic Outcome of Radical Cystectomy for Urothelial Bladder Cancer†

Abstract Context Radical cystectomy (RC) offers the best opportunity for ultimate cure of high-grade and high-risk invasive bladder cancer (BCa). Objective To review the available literature on indications for and oncologic outcomes of RC for urothelial carcinoma of the bladder. Evidence acquisition A database search of the US National Library of Medicine (PubMed) was performed for relevant medical articles using the Medical Subject Headings invasive bladder cancer and radical cystectomy with restrictions to English-language publications. Evidence synthesis Immediate or early RC should be offered as a treatment of choice to all patients with recurrent or multifocal high-grade T1 tumours, T1 tumours at high risk of progression, failures of bacillus Calmette-Guerin treatment, and muscle-invasive bladder tumours. RC offers excellent recurrence-free survival (RFS) and disease-specific survival rates as well as local tumour control in patients with organ-confined and node-negative disease. Tumour control in non–organ-confined tumours is still satisfactory, with long-term RFS rates of about 50%. For node-positive disease, surgery may only be curative in approximately one-fourth of patients. Conclusions Evidence from the literature supports early, aggressive surgical management for invasive BCa. Risk stratification of patients with BCa based on pathologic features at initial transurethral resection or at recurrence can select those patients most appropriate for RC early. In patients with organ-confined, lymph node–negative urothelial bladder carcinoma, excellent long-term survival rates can be achieved.

UP-3.007: Histone Deacetylase Inhibitor Trichostatin A Induces Apoptosis in Human Invasive Bladder Cancer through the Caspase Dependent Pathway

The prognosis of high grade invasive bladder cancer is poor and conventional platinum based chemotherapy like MVAC or G/C shows only limited effect especially reagrding cancer specific survival. In this study we explored antitumor effect of histone deacetylase inhibitor (HDI), trichostatin A (TSA) against invasive human bladder cancer cell lines, and its mechanism.

RETRACTED: Differential effects of valproic acid on growth, proliferation and metastasis in HTB5 and HTB9 bladder cancer cell lines

High grade invasive bladder cancer is a leading cause of cancer deaths and treatment options are limited for this type of cancer. Recent studies have reported anticancer effects of valproic acid in many cancers and also in superficial bladder cancer. Acute valproic acid administration suppressed cell proliferation in a time- and dose-dependent manner in two muscle-invasive human bladder cancer cell lines (HTB5 and HTB9), with accompanying G1 phase cell cycle arrest. A significant decrease in colony formation ability and invasiveness was seen with valproic acid treatment though the effectiveness varied with cell type. Our results suggest a role for valproic acid in inhibiting growth and invasion of muscle-invasive bladder cancer.

Improving outcomes with radical cystectomy for high-grade invasive bladder cancer

It is clear that the optimal clinical outcomes in bladder cancer patients requiring radical cystectomy are related to standard histopathologic variables of tumor grade, stage and lymph node status. However, other less well defined variables are also critical to the successful outcomes of these patients. Patients with muscle invasive bladder cancer and treating physicians should avoid unnecessary and significant treatment delays. In addition, hospital and surgeon-volume/experience are thought to be factors that may too be important components that relate to the clinical outcomes of patients following surgery. Lastly, there is a growing body of literature to support the concept of an appropriate lymphadenectomy at the time of surgery, for both node-positive and node-negative bladder cancer patients. It is becoming more obvious that there are multiple variables involved in the clinical success and outcomes of patients with bladder cancer following radical cystectomy. As treating physicians and surgeons we must be aware of these components to ensure the best outcomes for our patients.

Radical cystectomy for invasive bladder cancer: long-term results of a standard procedure

Radical cystectomy with an appropriate lymphadenectomy remains the standard of therapy for high-grade invasive bladder cancer. This surgical approach provides the best survival rates with the lowest local recurrence rates and orthotopic diversion can be performed safely in most patients with an acceptable outcome and quality of life. Pathologic analysis of the bladder tumor and regional lymph nodes will help direct the need for adjuvant therapy in high-risk individuals. Equivalent long-term local control and survival are not seen with other forms of treatment including radiation therapy, chemotherapy, or a combination of the two. The rationale and clinical results of large, contemporary cystectomy series are presented, which provide a benchmark of outcomes with this form of surgical treatment.

Phase I study of intravesical recombinant fowlpox-GM-CSF (rF-GMCSF) and/or recombinant Fowlpox-TRICOM (rF-TRICOM) in patients with advanced bladder cancer

4755 Background: We have shown that TCC biopsies express high levels of IL10 mRNA and in preclinical models that this IL10 suppresses antigen presenting cell (APC) activity and antitumor immunity. To enhance APC activity and antitumor immunity, we are accruing a Phase I study of intravesical recombinant fowlpox encoding GMCSF, or LFA-3, ICAM-1, B7.1 (TRICOM) genes in pts with advanced bladder cancer. Methods: In this three arm study (A. rF-GMCSF, B. rF-TRICOM, C. Combination), pts with bladder cancer scheduled for cystectomy receive 4 weekly doses of intravesical virus (3 pts per dose level, initial dose 5.7 - 7 X 107 PFU). Study endpoints are toxicity, MTD, bioavailability (degree of gene transfer in cystectomy specimen); immunity to vector and reporter genes; and local cellular and cytokine responses in the bladder wall. Results: Six pts with high grade invasive bladder cancer have been treated in this ongoing study. Overall, treatment was well tolerated. 3/3 Arm B pts experienced transient elevations in liver transaminases with 1/3 reaching DLT. 2/3 each Arm A, B pts had similar stage and grade disease in cystectomy specimen as in pretreatment biopsy. 1/3 Arm A pts had no tumor identified in the bladder or nodes following treatment. 1/3 Arm B pts had no residual tumor in the bladder but 2/8 positive nodes. H&E staining of the cystectomy specimen showed variable immune cell infiltration of bladder wall and enlarged lymph nodes in both arms. Conclusions: Pts receiving intravesical rF-GMCSF and rF-TRICOM at the initial dose level tolerated therapy. Pathology showed variable immune infiltration of bladder wall, tumor, and enlarged draining lymph nodes. Bioavailability, immunohistochemistry and immune studies are ongoing. No significant financial relationships to disclose.

Cluster of allele losses within a 2.5 cM region of chromosome 10 in high-grade invasive bladder cancer.

A limited number of previous studies have indicated a low frequency of chromosome 10 allele losses and deletions in bladder cancers. We investigated the involvement of chromosome 10 in advanced bladder cancers. Loss of heterozygosity (LOH) was analysed in 19 microsatellite loci in 20 grade III invasive transitional cell carcinomas. Nine (45%) of the 20 tumors had at least one allele loss on the long arm of chromosome 10. The short arm of chromosome 10 was not affected. The most frequent LOH occurred at D10S215, where four (29%) of 14 of the informative cases had an allele loss. The minimal region with allele losses was located between the centromeric marker D10S1644 and the telomeric marker D10S541, which are separated by 2.52 cM. The results strongly suggest the existence within that region of a tumor suppressor gene or genes for advanced bladder cancer.

Occupation, smoking, and the risk of high-grade invasive bladder cancer in Missouri.

Numerous epidemiological studies have established that occupational exposures and smoking are the two major known risk factors for the development of bladder cancer. Using data from the Missouri Cancer Registry, we investigated the hypothesis that individuals with occupationally-related bladder cancer are more likely to have a more invasive form of the disease. Data were analyzed for 2,893 white males diagnosed with primary bladder cancer in Missouri between 1984 and 1988. Of the 1,415 cases whose occupational status was recorded, 236 (17%) were employed in high-risk occupations. Cases with high-grade disease were more likely to have been employed in a high-risk occupation, after adjustment for age and smoking (adjusted odds ratio [AOR] = 1.7, 95% confidence interval [CI] = 1.1-2.6). High-risk workers under 60 years of age were most at risk for developing high-grade bladder tumors (AOR = 2.3, 95% CI = 1.0-5.3). There was no overall association between high-risk occupation and late-stage disease (AOR = 1.1, 95% CI = 0.7-1.5), but it was present in the men younger than 60 years of age (AOR = 2.0, 95% CI = 1.0-3.8). No association was found between tobacco use and grade (AOR = 1.1, 95% CI = 0.8-1.5), but cases with late-stage disease were more likely to be smokers (AOR = 1.5, 95% CI = 1.1-1.9). When occupations were examined individually, motor vehicle operators, truck drivers, vehicle mechanics, other mechanics, and janitors were among those most likely to be diagnosed with high-grade or late-stage tumors. Although further studies are necessary to confirm these results, they suggest that surveillance and targeted screening of workers in high-risk occupations may result in a greater yield of early invasive cancers and possibly decrease the mortality associated with this disease.

Histological effect of preoperative irradiation in bladder cancer

Forty-seven patients with high grade invasive bladder cancer were treated with preoperative radiation therapy (910 rad by fast neutron or 3000 rad by X-ray for two weeks) followed by radical cystectomy and urinary diversion. Stage down effect was observed in 32% of patients when comparison was made between the clinical and pathological stages. Those who showed stage down effect had better prognosis when compared those without it. Histopathological effect of Grade 2B or Grade 3, according to the criteria described by Ohboshi and Shimosato, was noticed in 49% of the patients. Five year survival was as follows: 100% (PT0, PTis), 75% (PT1), 100% (PT2), 47% (PT3), 0% (PT4). These results clearly showed the improvement of prognosis compared to the historical control.

Current Perspectives in the Management of High-Grade Invasive Bladder Cancer.

Optimal management of high-grade invasive bladder cancer requires aggressive therapy, usually radical cystectomy with preoperative radiation therapy. Recent prospective studies have demonstrated that five-year survival rates for deeply invasive disease have improved to 45- 55% compared to a dismal less than 20% five-year survival for patients treated by definitive radiation therapy alone, or historical series in which cystectomy was used as single modality therapy. The incidence of pelvic lymph node involvement ranges from 10% in patients with P1 and P1S disease to 50% in patients with P3 disease and implies the need to treat the pelvic nodes by lymphadenectomy or adequate preoperative radiation therapy whenever cystectomy is indicated. The improvements in surgical technique, pre-, and postoperative management have resulted in operative mortality as low as 1% and early complication rates as low as 24% for patients treated by single-stage radical cystectomy with pelvic node dissection and urinary diversion. Despite these advances, 50% or more of patients with high-grade invasive bladder cancer die of distant metastases, usually within two years, implying the need to scrutinize adjuvant chemotherapy in carefull controlled prospective studies.