Invasive Urothelial Carcinoma Research Articles

Abstract CT085: Targeting androgen signaling in urothelial carcinoma

Abstract Background: Men are 3-4 times more likely to develop urothelial carcinoma (UC) than women, even after accounting for differences in smoking and occupational exposures. A potential cause for this difference may be androgen signaling. Testosterone receptors are present in up to 53% of UC in men and women. Androgen signaling promotes proliferation and chemotherapy resistance, while blocking androgen has been shown to sensitize UC to chemotherapy. When exposed to a chemical carcinogen, castrated male mice and androgen receptor (AR) knockout mice are less likely to develop UC. Additionally, men taking testosterone lowering agents for prostate cancer, who are concurrently treated for UC, have a 50% lower UC recurrence rate than men with normal testosterone signaling. In a study of 9 men and 1 woman with metastatic UC, all patients were treated with gemcitabine/cisplatin and concurrent enzalutamide. Patients’ testosterone levels were not medically lowered. Importantly, dihydrotestosterone, the native ligand for the AR, has higher affinity for the AR than enzalutamide. Interestingly, the only woman in the study (with presumably low dihydrotestosterone levels) had a complete response to therapy. No other complete responses were observed. The standard therapy for non-metastatic muscle invasive UC is chemotherapy followed by cystectomy. Currently this results in about a 35% pathologic complete response (pCR) rate. pCR is associated with improved overall survival. In our study (TASUC; NCT05839119), we add degarelix to standard neoadjuvant chemotherapy to treat men and women who have AR positive UC. Methods: The main eligibility criteria are: (1) Muscle-invasive urothelial carcinoma of the bladder (2) AR positive disease by nuclear staining on immunohistochemistry (3) pT2 - T4, N0 - N1, M0 (Stage II or IIIA disease) (4) Eligible for cisplatin-based chemotherapy (5) Eligible for cystectomy In this single-arm study, all patients receive standard of care gemcitabine/cisplatin neoadjuvant chemotherapy (4 cycles) with the addition of monthly degarelix during chemotherapy. The primary outcome is pCR rate at cystectomy. We are employing a Simon 2-stage minmax design. In stage I we will enroll 20 patients. If there are at least 7 pCRs (35%) we will enroll an additional 12 patients in stage II, for a total of 32 patients. This design will provide 80% statistical power to detect a change in pCR rate from 35% to 50% with a significance level of less than 0.20. If we observe at least 14 pCRs (of 32 patients) the study will be considered positive and we will plan a follow-up randomized, controlled phase II (or phase III) study. Exploratory outcomes include correlation of AR positivity with proliferation at diagnosis, identification of oncogenic androgen response elements from matched pre- and post- treatment tissue, and identification of gene signatures associated with pCR. We will also measure 2- and 5-year disease free survival. TASUC opened to accrual on October 2, 2023 and is actively recruiting. Citation Format: Mojisola Araoye, Anthony Mega, Galina G. Lagos, Benedito Carneiro, Sari Khaleel, Dragan Golijanin, SHELDON L. HOLDER. Targeting androgen signaling in urothelial carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT085.

Invasive Urothelial Carcinoma of the Ureter with Associated Obstructive Uropathy and Chronic Pyelonephritis: A Case Report and Literature Review

Introduction: urothelial carcinomas can develop from any urothelium lined surface in the body and they are the seventh most common cancers seen globally. Urothelial carcinoma of the upper urinary tract (involving the renal pelvis and ureter) is not common.
 Case Presentation: A 66-year-old male presented with recurrent left flank pain, recurrent urinary tract infection and occasional haematuria of six month's duration. Abdominal Computerized Tomography (CT) done showed moderate left hydro-ureter and hydro-nephrosis and a mass was seen in the lower one-third of the left ureter. Features seen at CT was suggestive of urothelial carcinoma of the distal left ureter.  No mass lesion or tumour was seen in the urinary bladder. Radical nephroureterectomy with excision of the bladder cuff was performed and the diagnosis was confirmed after histopathologic evaluation.
 Discussion: This case report highlights the rare presentation of invasive urothelial carcinoma of the ureter with associated obstructive uropathy and the role of radiologic imaging in diagnosis and thorough histopathologic evaluation in the determination of tumour grade and tumour stage and ultimate prognosis of patients.
 Conclusion: A high index of suspicion is needed for diagnosis based on presenting symptoms, and examination findings. Tumour grade and stage in upper urinary tract urothelial carcinoma are good predictors of clinical outcomes and prognosis.

Immunochemistry-based quantification of tumor-infiltrating lymphocytes and immunoscore as prognostic biomarkers in bladder cancer

BackgroundTumor-infiltrating lymphocytes (TILs) and the derived immunoscore (IS) have gained considerable attention over the last decade as prognostic markers in many solid cancers. However, in bladder cancer (BC), their prognostic value is not clearly established.MethodsThe present study aimed to quantify the TILs rates in BC, assess the derived immunoscore, and investigate their prognostic value. An immunochemistry-based quantification of the different subtypes of TILS was performed on paraffin-embedded blocks from patients with invasive urothelial carcinoma of the bladder. We have assessed the rates of TILs, respectively, on peri-tumoral (PT) and intra-tumoral (IT) areas and calculated for each case the corresponding IS which is the index: CD8+/CD3+ TILs. The IS was then classified as low (I0, I1) or high (I2, I3, I4). We included 30 cases in the analysis.ResultsThe median age of patients was 65 years with a sex ratio of 9. TILs densities and distribution were significantly variable between IT and PT areas CD3+ (p = 0.03) and CD8+ (p = 0.004) with the highest rates on the PT areas. In univariate analysis, a low density of CD8+ TILs was significantly associated with an advanced age (p = 0.05), with the presence of lympho-vascular invasion (p = 0.02) and with the absence of specific histological subtype (p = 0.05). A low immunoscore was significantly associated with the presence of lympho-vascular invasion (p = 0.004). No significant association was found between TILs subpopulations, the IS, and the other clinicopathological and survival data. The overall survival (OS) and disease-free survival (DFS) medians were slightly superior in highly T (CD3+/CD8+)-cell infiltrated tumors as well as tumors with a high IS densities. However, the univariate analysis showed that TILs and immunoscore did not impact overall survival (OS) and disease-free survival (DFS).ConclusionTILs and immunoscore might be effective prognostic tools in BC. However, standardized quantification methods and further investigation on larger samples are highly recommended to definitively attest the prognostic value of TILs and IS in BC.

Robotic Vaginal Hernia Repair for Recurrent Vaginal Prolapse Status Post-Radical Cystectomy with an Indiana Pouch.

Pelvic organ prolapse following a radical cystectomy is challenging to treat and recurrence of prolapse after primary repair is common owing to compromised pelvic floor support and tissue quality. Vaginal prolapse repairs are often preferred because of concern for patients' complex intraabdominal pathological conditions. However, for those with recurrent prolapse following colpocleisis, limited definitive treatment options exist. This surgical video presents a 64-year-old G4P4 with a history of radical cystectomy with an Indiana Pouch for invasive urothelial carcinoma who presented with recurrent stage IV vaginal prolapse two years following colpocleisis. Owing to thin vaginal tissue, a sacrocolpopexy with vaginal mesh could not be performed, thus, the patient underwent robotic-assisted vaginal hernia repair with a polypropylene-reinforced ovine tissue matrix attached to Cooper's ligament and the levator ani muscles. The surgery was free from complications and her postoperative Pelvic Organ Prolapse Quantification examination revealed a leading vaginal tissue remnant at the level of the hymen. The patient reported overall improved health and quality of life following surgery and recovery on postoperative validated questionnaires. Vaginal and pelvic floor hernia repair with a polypropylene-reinforced tissue matrix is a feasible definitive surgical treatment for patients with prior radical cystectomy in whom colpocleisis has failed.

A case of seronegative microscopic polyangiitis following the diagnosis of renal pelvic carcinoma.

The incidence rate of malignancy in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is higher than that in the general population. Malignancy has been indicated to be a risk factor or inducer of AAV. Herein, we report the case of a healthy 84-year-old man with seronegative microscopic polyangiitis (MPA) after thediagnosis of renal pelvic carcinoma. Four weeks before admission, his estimated glomerular filtration rate (eGFR) was 85ml/min/1.73m2, and nohematuria or proteinuria was detected. Renal biopsy on admission revealed invasive urothelial carcinoma of the right renal pelvis. On day 15, his eGFR decreased to 30ml/min/1.73m2 without any incitement. The renal specimen extracted via right robot-assisted nephroureterectomy indicated the presence of ANCA-associated glomerulonephritis. On day 37, urinary protein/urinary creatinine level of 6.48g/gCre, serum albumin level of 2.1mg/dL, and eGFR of 20ml/min/1.73m2 indicated the presence of nephrotic syndrome. His blood sputum was analyzed via chest computed tomography, which revealed alveolar hemorrhage. Although his myeloperoxidase-ANCA was negative, he was diagnosed with MPA based on the 2022 American College of Rheumatology/European League Against Rheumatism classification criteria. This is the first case report of MPA orAAV complicated with renal pelvic carcinoma. The clinical indicators demonstrated that renal pelvic carcinoma preceded the onset of MPA. The spatial proximity of both diseases indicated that renal pelvic carcinoma had some influence on MPA development via the mechanism of inflammatory cytokines or neutrophil extracellular traps. Our report may be useful in elucidating the mechanism of MPA development.

Testing the external validity of the POUT III trial (adjuvant platnium-based chemotherapy in upper tract urothelial carcinoma) in a North American cohort

ObjectiveThe European POUT III randomized controlled trial provided level-one evidence that adjuvant platinum-based chemotherapy is the standard of care following nephroureterectomy (RNU) for locally invasive or node-positive upper tract urothelial carcinoma. We aim to assess this European randomized controlled trial's generalizability (external validity) to a North American cohort, using a nationwide database. Materials and MethodsTo compare trial patients with those seen in real-world practice, we simulated the trial inclusion criteria using data from the National Cancer Database (NCDB). We identified patients with histologically confirmed transitional cell carcinoma who underwent RNU. The available demographic characteristics of the NCDB cohort were compared with the POUT III trial cohort using Chi-squared test. ResultsThe NCDB cohort (n = 3,380) had a significantly higher proportion of older patients (age ≥ 80: 23.5% vs. 5%), and more males (68% vs. 56.2%) than the POUT cohort (Table 1, both p < 0.001). Additionally, the rate of advanced nodal disease was higher in the NCDB (N1 9.6%, N2 9.3%) than in the POUT (N1 6%, N2 3%) cohort (p < 0.001). A more extensive lymph node dissection was performed in NCDB vs. POUT patients (node≥10 10.9% vs. 3%, p < 0.001). Sensitivity analysis removing all subjects with a Charlson Comorbidity Index > 0 did not change the significance of any results. ConclusionsWhile the primary disease stage was similar, the rate of advanced nodal disease was significantly higher in NCDB, which might be explained partially by the more extensive lymph node dissection performed in the latter. These differences warrant caution when applying the POUT III findings to North American patients.

Clinico-pathological Outcomes of Muscle Invasive Carcinoma Bladder in Post Neoadjuvant Chemotherapy Radical Cystectomy

Background: Neoadjuvant chemotherapy (NAC) before radical cystectomy is advocated in patients with muscle invasive urothelial carcinoma of the bladder with the goal to improve survival by downstaging the primary tumour and eradicating micro-metastasis. The use of perioperative chemotherapy for bladder cancer, particularly in the neoadjuvant setting, remains limited. This study was designed to evaluate NAC plus RC regarding pathological response, perioperative morbidity and mortality outcomes. Methods: This is a prospective and retro prospective study that was carried out from Jan 2018 to Jan 2020 for patients with muscle invasive bladder carcinoma. All patients having operable muscle invasive bladder carcinoma, Eastern Cooperative Oncology Group (ECOG) performance status 0–1 were included. Patients found to have metastatic disease, recurrent disease, patient not able to tolerate NAC were excluded from the study. Results: Early complications occurred within 30 days after surgery &amp; pathological response rates, perioperative morbidity, and mortality were compared. Conclusions: A short course of neoadjuvant chemotherapy was associated to a low incidence of serious adverse events and did not increase the post-operative morbidity. Results suggest that non-urothelial tumour showed no response to Platinum based combination chemotherapeutic regimens. After NAC, residual local disease, persistent nodal disease and status of surgical margins are the most powerful prognostic factors for patients who underwent RC.

Pembrolizumab-induced myocarditis with complete atrioventricular block and concomitant myositis in a metastatic bladder cancer patient: a case report and review of the literature

BackgroundThe cardiovascular system is among the least systems affected by immune-related adverse events. We report a rare life-threatening case of pembrolizumab-induced myocarditis with complete atrioventricular block and concomitant myositis in a metastatic bladder cancer patient.Case presentationAn 82-year-old Caucasian female with invasive urothelial carcinoma, started on first-line pembrolizumab, was admitted four days after receiving her second dose for severe asthenia, diffuse muscle aches, neck pain, and lethargy. In the emergency department, she had several episodes of bradycardia reaching 40 beats per minute associated with general discomfort and fatigue. Electrocardiography showed a third-degree atrioventricular heart block, while the patient remained normotensive. Cardiac damage parameters were altered with elevated levels of creatine phosphokinase of 8930 U/L, suggestive of immune checkpoint inhibitor-induced myositis, and troponin T of 1.060 ng/mL. Transthoracic echocardiography showed a preserved ejection fraction. Pembrolizumab-induced myocarditis was suspected. Therefore, treatment was initiated with high-dose glucocorticoids for 5 days, followed by a long oral steroid taper. A pacemaker was also implanted. Treatment resulted in the resolution of heart block and a decrease in creatine phosphokinase to the normal range.ConclusionLife-threatening cardiac adverse events in the form of myocarditis may occur with pembrolizumab use, warranting vigilant cardiac monitoring. Troponin monitoring in high-risk patients, along with baseline echocardiography may help identify this complication promptly to prevent life-threatening consequences.

Diagnostic Value of Urine Cytology in Pharmacologically Forced Diuresis for Upper Tract Urothelial Carcinoma Diagnosis and Follow-Up.

We performed a urine cytology analysis of a pharmacologically induced diuresis for the diagnosis of upper tract urothelial carcinoma. To evaluate the diagnostic value of cytology of pharmacologically forced diuresis, an initial cohort of 77 consecutive patients with primary upper tract urothelial carcinoma treated via radical surgery was enrolled. To evaluate pharmacologically forced diuresis cytology as a follow-up procedure, a second cohort of 1250 patients who underwent a radical cystectomy for bladder cancer was selected. In the first cohort, the sensitivity of cytology of pharmacologically forced diuresis in patients with invasive, high-grade, low-grade, and concomitant carcinoma in situ was 8%, 9%, 0%, and 14%, respectively. In the second cohort, cytology of pharmacologically forced diuresis was positive in 30/689 (4.3%) patients, in whom upper urinary tract recurrence was present in 21/30 (70%) of cases, and urethral recurrence was present in 8/30 (26%) of cases. As a follow-up tool, cytology of pharmacologically forced diuresis showed a sensitivity, specificity, and positive and negative predictive values of 60%, 99%, 70%, and 98%, respectively. Overall, as a diagnostic tool, the sensitivity of cytology of pharmacologically forced diuresis is slightly better in patients with invasive upper tract urothelial carcinoma and concomitant carcinoma in situ. As a follow-up method, positive cytology of pharmacologically forced diuresis is strongly related to cancer recurrence and can reveal urethral recurrence. Cytology of pharmacologically forced diuresis might be useful in cases with contraindications for imaging or when achieving endoscopic access to the upper urinary tract is difficult.

Prediction of Non-Muscle Invasive Papillary Urothelial Carcinoma Relapse from Hematoxylin-Eosin Images Using Deep Multiple Instance Learning in Patients Treated with Bacille Calmette-Guérin Immunotherapy.

The limited reproducibility of the grading of non-muscle invasive papillary urothelial carcinoma (NMIPUC) necessitates the search for more robust image-based predictive factors. In a cohort of 157 NMIPUC patients treated with Bacille Calmette-Guérin (BCG) immunotherapy, we explored the multiple instance learning (MIL)-based classification approach for the prediction of 2-year and 5-year relapse-free survival and the multiple instance survival learning (MISL) framework for survival regression. We used features extracted from image patches sampled from whole slide images of hematoxylin-eosin-stained transurethral resection (TUR) NPMIPUC specimens and tested several patch sampling and feature extraction network variations to optimize the model performance. We selected the model showing the best patient survival stratification for further testing in the context of clinical and pathological variables. MISL with the multiresolution patch sampling technique achieved the best patient risk stratification (concordance index = 0.574, p = 0.010), followed by a 2-year MIL classification. The best-selected model revealed an independent prognostic value in the context of other clinical and pathologic variables (tumor stage, grade, and presence of tumor on the repeated TUR) with statistically significant patient risk stratification. Our findings suggest that MISL-based predictions can improve NMIPUC patient risk stratification, while validation studies are needed to test the generalizability of our models.

Estimating the impact of adjuvant treatment with nivolumab on long-term survivorship rates compared with surveillance: Analyses of disease-free survival (DFS) from the phase 3 CheckMate-274 trial.

528 Background: Durable DFS and cure are the ultimate goals for the treatment of muscle invasive urothelial carcinoma (MIUC) with radical cystectomy. This analysis employed mixture cure models (MCMs) to estimate the underlying cure fraction among high-risk MIUC patients following radical resection in the Phase 3 CheckMate-274 study. Methods: MCMs were applied to patient-level DFS data from the trial (minimum follow-up: 31.6 months). Intention-to-treat (ITT) population and the subpopulation with tumor PD-L1 expression ≥1% were analyzed separately for nivolumab (NIVO) and placebo (PBO) arms. In MCMs, the patient populations were assumed to consist of two exclusive subgroups as cured and uncured. Cured subgroup was assumed to be free of disease recurrence and disease-related mortality risks. The uncured subgroup was at the risk of both disease recurrence and all-cause mortality. DFS for the cured subgroup was estimated using background mortality rates published by WHO matched to the trial’s demographic characteristics. DFS for the uncured subgroup was modelled using parametric distributions, which were characterized along with the cure fraction by maximum likelihood methods. Model selection was primarily based on clinical plausibility of estimated DFS for the uncured subgroup. Visual comparison of the fits from the MCMs to the reported DFS data from the trial and goodness-of-fit statistics also assisted model selection. Results: In the trial, 353 patients were treated with NIVO (mean age: 65.3; male: 75.1%; PD-L1≥1%: 39.7%) and 356 patients were in PBO control (mean age: 65.9; male: 77.2%; PD-L1≥1%: 39.9%). Selected models estimated almost all uncured patients to experience recurrence within 5 years. The estimated cure fraction in the ITT population ranged from 43.1%-45.1% in the NIVO arm (95% CI: 36.7%-51.6%), and 36.4%-37.0% in the PBO arm, (95% CI: 30.9%-43.0%) for clinically plausible models. Projected range of 10-year mean DFS for the ITT patients was 4.38-4.47 years in the NIVO arm and 3.61-3.64 years in the PBO arm. Estimated cure fractions in the PD-L1≥1% subpopulation ranged from 59.1%-61.0% in the NIVO arm (95% CI: 48.9%-72.0%), and 35.9%-36.9% in the PBO arm, (95% CI: 27.5%-45.9%). Projected range of 10-year mean DFS for the PD-L1≥1% subpopulation was 5.54-5.65 years in the NIVO arm and 3.54-3.57 years in the PBO arm. Conclusions: In the adjuvant treatment of MIUC, relative to radical resection only, systemic therapy with NIVO is associated with a 6-9 percentage points higher cure fraction in the ITT population. Tumor PD-L1≥1% expression was associated with higher cure fractions in the NIVO arm but had only negligible impact on the underlying cure fraction in the PBO arm. Clinical trial information: NCT02632409 .

Proliferation and immunohistochemistry for p53, CD25 and CK20 in predicting prognosis of non-muscle invasive papillary urothelial carcinomas.

Non-muscle invasive papillary urothelial carcinoma is a prevalent disease with a high recurrence tendency. Good prognostic and reproducible biomarkers for tumor recurrence and disease progression are lacking. Currently, WHO grade and tumor stage are essential in risk stratification and treatment decision-making. Here we present the prognostic value of proliferation markers (Ki67, mitotic activity index (MAI) and PPH3) together with p53, CD25 and CK20 immunohistochemistry (IHC). In this population-based retrospective study, 349 primary non-muscle invasive bladder cancers (NMIBC) were available. MAI and PPH3 were calculated manually according to highly standardized previously described methods, Ki-67 by the semi-automated QPRODIT quantification system, p53 and CD25 by the fully automated digital image analysis program Visipharm® and CK20 with the help of the semi-quantitative immunoreactive score (IRS). Survival analyses with log rank test, as well as univariate and multivariate Cox regression analyses were performed for all investigated variables. Age and multifocality were the only significant variables for tumor recurrence. All investigated variables, except gender, were significantly associated with stage progression. In multivariate analysis, MAI was the only prognostic variable for stage progression (p<0.001).

Glycocalyx analysis of bladder cancer: three-dimensional images in electron microscopy and vicia villosa lectin as a marker for invasiveness in frozen sections.

Introduction: The abnormal glycocalyx (GCX) on the surface of cancer cells has been reported to be tall and aberrantly glycosylated and has been linked to the progression and spread of cancer-a finding also observed in bladder cancer. However, the characteristics of GCX in various types of human bladder cancer remain unknown, and herein, we aimed to provide information on the diversity of glycan components in the GCX of bladder cancers and to shed light on their characteristics. Methods: We used scanning electron microscopy and lanthanum staining to examine the surface GCX of human bladder carcinomas in three-dimensional images, showing the bulky GCX in some carcinomas. We also examined glycan alterations in early to progressive stages of bladder cancers using 20 distinct lectin stains on frozen sections from transurethral resection of bladder tumors. Results and discussion: Distinctive Vicia villosa lectin (VVL) staining was observed in invasive urothelial carcinomas, including those with muscle invasion and variant components. In the clinical setting, cancers with atypia of grades 2-3 had a significantly higher VVL scoring intensity than those with grade 1 atypia (p < 0.005). This study identified that a specific lectin, VVL, was more specific to invasive urothelial carcinomas. This lectin, which selectively binds to sites of cancer progression, is a promising target for drug delivery in future clinical investigations.

Granulomatous myocarditis arising from intravesical Bacillus Calmette–Guérin therapy leading to death diagnosed by postmortem examination: a case report

BackgroundIntravesical Bacillus Calmette–Guérin (BCG) is used as a standard adjuvant therapy for non-muscle invasive urothelial cancer. Most patients tolerate the treatment well, with mild side effects. Systemic complications are extremely rare, occur due to BCG dissemination and are associated with immunocompromised state and urothelial breach.Case presentationWe present a case of a 78-year-old male, a former smoker, with history of non-muscle invasive urothelial carcinoma status post partial resection followed by intravesical BCG therapy. An autopsy was performed due to the sudden nature of his death. Autopsy showed multiple necrotizing granulomas in the brain, atrium, ventricles, lungs, kidneys, and urinary bladder. Stains for acid-fast bacilli and fungi were negative. In addition, bilateral lungs showed evidence of bronchopneumonia secondary to cytomegalovirus.ConclusionGranulomatous myocarditis arising from BCG therapy is extremely rare. Our patient with urothelial cancer treated with BCG developed multiorgan granulomas, most likely due to a hypersensitivity reaction to intravesical BCG. Arrhythmia induced by granulomatous myocarditis was the cause of his death. Although there have been few cases of systemic BCG-osis causing fatal sepsis leading to death, a cardiac cause of death is unique.

Management of Recurrent Leg Swelling in an Elderly Patient with Invasive Urothelial Carcinoma: Examining the Challenges of Post-Lymphovenous Anastomosis in Treating Cancer-Related Lymphedema

Management of Recurrent Leg Swelling in an Elderly Patient with Invasive Urothelial Carcinoma: Examining the Challenges of Post-Lymphovenous Anastomosis in Treating Cancer-Related Lymphedema

Laparoscopic vs. open surgical access radical cystectomy with subsequent orthotopic reconstruction in the treatment of invasive urothelial carcinoma of the bladder.

Radical cystectomy combined with extended lymph node dissection is the treatment of choice for muscle-invasive bladder cancer and can be performed using open, laparoscopic, or robot-assisted surgical access.

Stromal and Epithelial Architectural Alterations Mimicking Invasion (Pseudoinvasion) in Noninvasive Papillary Urothelial Carcinoma.

Retraction artifact, paradoxic maturation/differentiation, desmoplasia, and complex irregular growth are morphologic criteria of invasion in urothelial carcinoma. To describe changes mimicking invasion in noninvasive papillary urothelial carcinoma (NPUC). We reviewed 159 consecutive in-house patients with NPUC for either the presence of pseudoinvasion (irregular carcinoma nests within dense hyalinized stroma in the absence of other criteria of invasion) or precursor findings (stromal hyalinization not yet associated with epithelial architectural alteration). We assessed the correlation of these findings with age, sex, evidence of peripheral vascular disease, tumor grade, tumor infarction, and tumor size. We then followed up the patients clinically for tumor recurrence or progression. We identified 233 separate NPUCs (136 high grade and 97 low grade) in 125 men and 34 women. Of the 233 tumors, 26 (11.2%) had pseudoinvasion and 24 of 233 tumors (10.3%) had precursor findings. Except for complex irregular growth, no other criteria for invasion were seen. Pseudoinvasion and precursor findings were more common in men (47 of 183 [26%] versus 3 of 50 [6%]; P = .003), larger tumors (mean size, 2.6 versus 1.2 cm; P < .001), and tumors with infarction (33 of 50 [66%] versus 29 of 183 [15.8%]; P < .001). In multivariable analysis, tumor size (odds ratio, 1.49; P =.006), male sex (odds ratio, 6.48; P = .007), and the presence of infarction (odds ratio, 6.59; P < .001) were significant variables. Recurrence rates did not differ between patients with and without pseudoinvasion (31% [5 of 16] versus 42% [45 of 107], respectively; P = .41). None of the tumors with pseudoinvasion progressed to invasive carcinoma. Given the correlation with size and presence of infarcted papillae, we suggest the possibility of tumor ischemia/infarction as a plausible etiology of pseudoinvasion. Awareness of this phenomenon is important for the accurate diagnosis of invasion in papillary urothelial carcinoma.

The Role of c-MET as a Biomarker in Patients with Bladder Cancer Treated with Radical Chemo-Radiotherapy.

Bladder cancer is a highly aggressive cancer, and muscle invasive urothelial carcinoma (MIUC) requires aggressive strategy. Concomitant chemo-radiotherapy (CRT) appears as a therapeutic option that allows bladder sparing. No biomarker is currently available to optimally select patients for CRT. We retrospectively enrolled patients with MIUC who were treated in a curative setting with CRT. Based on c-MET expression in pre-treatment tumor tissue, patients were stratified into two groups: no expression of c-MET (group A) and expression of c-MET (group B). We evaluated the outcome of these patients based on c-MET expression. After a median follow-up of 40 months, 13 patients were enrolled in this analysis, 8 in group A and 5 in group B. The disease recurrence was 25% in group A and 100% in group B. Compared to group A, patients from group B experienced more frequent and more rapid recurrence in terms of metastases; the 3-year metastatic recurrence rate was 13% and 100%, respectively. The c-MET expression was also associated with a higher rate of cancer-related deaths. In this retrospective analysis, c-MET expression was associated with worse disease-free survival and survival in patients treated radically with CRT.

TRPS1 expression in primary and metastatic prostatic adenocarcinoma, muscle invasive bladder urothelial carcinoma, and breast carcinoma: Is TRPS1 truly specific and sensitive for a breast primary?

Trichorhinophalangeal syndrome type 1 (TRPS1) has been reported to be a sensitive and specific immunohistochemical (IHC) marker for breast carcinomas, especially when determining primary site of origin. However, there is limited data on TRPS1 expression in prostate and bladder cancers.A two-phase study was performed with 1) an exploratory cohort analyzing TRPS1 gene alterations in prostate, bladder, and breast carcinoma and TPRS1 mRNA expression data in prostate and bladder carcinoma; and 2) TRPS1 and GATA3 IHC in a confirmatory cohort in prostate, bladder, and breast carcinoma samples.Gene alterations were identified in a subset of breast, bladder, and prostate carcinomas and mRNA was consistently detected. In the IHC cohort, 183/210 (87.1 %) of breast, 22/69 (31.9 %) of prostate, and 20/73 (27.4 %) of urothelial carcinomas showed staining with TRPS1. Intermediate to high expression of TRPS1 was observed in 173/210 (82.8 %) of breast, 17/69 (24.6 %) of prostate, and 15/73 (20.5 %) of urothelial carcinomas. Furthermore, in prostate cancer, 26.9 % of pelvic lymph node metastases and 50 % in sites of distant metastases showed expression. Increased TRPS1 mRNA expression (p = 0.032) and IHC expression (p = 0.040) correlated with worse overall survival in bladder cancer. By comparison, GATA3 IHC stained 136/210 (64.8 %) of breast, 0/69 (0 %) of prostate, and 63/73 (93 %) of bladder carcinomas. Intermediate to high expression of GATA3 was seen in 131/210 (62.4 %) of breast and 63/73 (93 %) of bladder carcinomas.This study shows there is significant staining of TRPS1 in bladder and prostate cancers. As a result, comprehensive studies are needed to establish the true specificity of TRPS1 IHC stain across various tumor types before its widespread clinical adoption.

Abstract B016: AI analysis of histological images accurately identifies luminal subtype urothelial carcinomas characterized by high PPARG expression

Abstract Background PPARG is a cell lineage determining transcription factor in muscle invasive urothelial carcinoma (MIUC), where high expression is associated with the luminal subtype (1, 2). As FX-909(2), a PPARG inverse agonist, enters the clinic, biomarkers that reflect the luminal subtype will reveal patients with the potential to respond to PPARG inhibition. The determination of luminal status is generally performed via RNA-seq and/or multiple immunohistochemistry stains, which are costly and time-consuming. However, MIUC biopsies are routinely stained with hematoxylin and eosin (H&amp;E). Machine learning (ML)-driven analyses of H&amp;E-stained tissue may enable the identification of patients with luminal MIUC and have advantages over the current molecular approach. Methods H&amp;E-stained slides from 367 unique primary MIUC cases from the TCGA BLCA dataset were split into training (70%), validation (15%), and held-out test (15%) sets by preserving the data distribution of patient metadata. A curated retrospective cohort of 42 localized, stage III-IV primary MIUCs was used as an independent test set. Molecular classification as luminal (luminal papillary, luminal, and luminal infiltrated subtypes) or non-luminal (basal-squamous and neuronal subtypes) was performed and used as ground truth(3). Pretrained artifact and tissue segmentation models were deployed on all images to identify artifact-free areas of cancer and cancer-associated stroma. An end-to-end (E2E) additive multiple instance learning model was trained to identify luminal cases using the training set. Top performing model iterations were compared on the validation set, and the optimal iteration was deployed on both test sets. Results We assessed the performance of our E2E model in predicting luminal status using the molecular subtypes derived from Robertson et al. as ground truth(3). The E2E model showed excellent performance when predicting luminal status in the TCGA validation, TCGA test, and independent test sets (AUROC = 0.96, 0.95, and 0.97, respectively). The accuracy in all three cohorts was 89-90%, with a sensitivity of 0.86-0.96, a specificity of 0.82-0.94, and an F1 score of 0.88-0.9. Conclusions We generated a robust ML model that accurately predicts luminal MIUC using H&amp;E-stained slides. Luminal MIUC is dependent on PPARG, and PPARG inverse agonism represents a promising therapeutic approach for MIUC. Coupled with the first-in-class FX-909 therapeutic entering the clinic, the strong performance of our model highlights the potential for its application as a precision biomarker to identify patients with advanced urothelial carcinoma likely to respond to PPARG inhibition.