Lamina Propria Invasion Research Articles

Abstract B14: uPAR expression in the microenvironment of human urothelial neoplasia of the bladder is associated with invasive behavior and increases significantly with T-stage and grade

Abstract Introduction and objectives: More than 90% of bladder tumors are urothelial neoplasias, characterised as heterogeneous cell populations consisting of tumor cells, macrophages and stromal cells. At time of diagnosis, most neoplasias are non-invasive (stage Ta) or with invasion of lamina propria (stage T1). Despite advances in surgical techniques and intra-vesical therapy, patients with stage Ta and T1 have high recurrence and progression rates. Pathologic stage and grade, have limited ability to predict the invasive and metastatic potential, probably due to tumors of similar stage and grade having a significantly different biology. Biomarkers discriminating the microenvironment in non-invasive from invasive neoplasia are needed in order to improve curability. For this reason we have investigated one of the key players in proteolytic activity of invasive neoplasias, the plasminogen activation system. Components of this system: urokinase plasminogen activator (uPA), its cellular receptor (uPAR) and inhibitor (PAI-1), have prognostic, diagnostic and/or predictive value in several human cancers, but are poorly investigated in urothelial cancer. Materials and methods: Retrospectively collected, formalin fixed and paraffin embedded tissue samples (Haukeland University Hospital, Bergen) from 107 patients who underwent cystectomy for urothelial neoplasias in the period 1988-2005 were investigated. The material consists of 10 Ta, 24 T1, 73 T2-4 tumors, including 39 low-grade (LG) and 68 high-grade (HG) tumors. uPAR expression was investigated by immunohistochemistry using a polyclonal antibody against uPAR. uPAR expression was evaluated as either negative or positive. All cases were re-diagnosed by the same pathologist. Cancer cells were identified by staining for cytokeratin (CK-pan and CK7 combined), macrophages by CD68 and tumour associated myofibroblasts by α-smooth muscle actin (α-SMA). Results: 7/10 (70%) of the non-invasive neoplasias (stage Ta) showed no uPAR-immunoreactivity. The uPAR positive cells were only found in the surrounding stroma and not in cancer cells. In the neoplasias showing stromal- (stage T1) or muscular invasion (stage T2-T4), uPAR-positivity was found in 14/24 (58%) and 63/73 (86%) respectively. uPAR-positivity was found in 58/68 (85%) of HG tumors and in 17/39 (44%) LG tumors (p<0.001). uPAR-immunoreactivity was primarily seen in fibroblast-like cells (presumably myofibroblasts) and to a lesser extent in macrophages in the surrounding stroma as well as in some scattered cancer cells. There was a significant trend between uPAR-positivity and T-stage for cancer cells, macrophages and myofibroblasts (p<0.001). High correlations have been shown between uPAR-expression in tumor core and the invasive front for all three cell types (rs>0.57). Conclusions: This study demonstrated that uPAR-positivity in the complex microenvironment of human urothelial neoplasia of the bladder significantly increases with T-stage and grade. Myofibroblasts and macrophage expression of uPAR may be an early marker for invasive potential in urothelial neoplasia of the bladder. This may help in the identification of T1 neoplasias with high invasive potential. The expression of uPAR, as well as PAI-1 and uPA, will be investigated in a larger material and correlated with survival/clinical data. Our aim is to establish predictive and prognostic tools for use in clinical setting based on semi-quantitative immunohistochemical methodology. Citation Format: Line Hammer Dohn, Martin Illemann, Gunilla Høyer-Hansen, Hans von der Maase, Ib Jarle Christensen, Jorunn Litlekalsoey, Jens G. Hoestmark, Helle Pappot, Ole Didrik Laerum. uPAR expression in the microenvironment of human urothelial neoplasia of the bladder is associated with invasive behavior and increases significantly with T-stage and grade. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Invasion and Metastasis; Jan 20-23, 2013; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2013;73(3 Suppl):Abstract nr B14.

Role of immediate radical cystectomy in the treatment of patients with residual T1 bladder cancer on restaging transurethral resection

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder cancer patients with lamina propria invasion (T1 disease) and residual T1 disease on restaging transurethral resection of bladder tumour (re-TURBT) are at a very high risk for recurrence and progression. Despite this risk, most patients are treated with a bladder preserving approach and not immediate radical cystectomy (RC). In this study we have shown that a quarter of patients with T1 bladder cancer and residual T1 on re-TURBT who are treated with immediate RC are found to have carcinoma invading bladder muscle at RC and 5% have lymph node metastases. We have also found that >30% of patients treated with deferred RC after initial bladder-preserving therapy harbour carcinoma invading bladder muscle and almost 20% of these patients have lymph node metastases. Thus, immediate RC should be considered in all patients with T1 bladder cancer and residual T1 on re-TURBT. To report the overall survival (OS) and cancer-specific survival (CSS) of patients with residual T1 bladder cancer on restaging transurethral resection of the bladder tumour (re-TURBT). We performed a retrospective review of 150 evaluable patients treated for T1 bladder cancer with residual T1 disease found on re-TURBT between 1990 and 2007. Patients were treated with immediate radical cystectomy (RC) or a bladder-preserving approach (deferred or no RC). A univariate Cox proportional hazards regression model was used to test the association between treatment approach and survival. Residual T1 bladder cancer was found in 150 evaluable patients, of whom 57 received immediate RC and 93 were treated with a bladder-preserving approach. Fourteen out of 57 patients receiving immediate RC and 8/26 patients receiving deferred RC had carcinoma invading bladder muscle in the RC specimen. Three out of 57 and 5/26 patients had lymph node metastases in the RC specimen. Median follow-up was 3.74 years. Thirty-nine patients died during follow-up, 16 from bladder cancer. There was no significant association between immediate RC and CSS (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.43-3.09, P = 0.8) or OS (HR 0.79, 95% CI 0.4-1.53, P = 0.5). Because of the low number of events we cannot conclude whether RC offers a survival advantage in patients with residual T1 bladder cancer on re-TURBT. Since a quarter of patients had carcinoma invading bladder muscle, RC should be considered in these patients. A larger, preferably randomized, study with longer follow-up is needed.

Prognostic Significance of Substaging according to the Depth of Lamina Propria Invasion in Primary T1 Transitional Cell Carcinoma of the Bladder

PurposeTo evaluate the prognostic significance of the depth of lamina propria invasion in primary T1 transitional cell carcinoma (TCC) of the bladder.Materials and MethodsWe retrospectively reviewed the medical records of 183 patients with primary T1 TCC of the bladder who had undergone transurethral resection (TUR) at our institution. Substaging was defined according to the depth of lamina propria invasion as follows: T1a, superficial invasion of lamina propria; T1b, invasion into the muscularis mucosa (MM); T1c, invasion beyond the MM but not to the muscularis propria. The prognostic significance of various clinicopathological variables for recurrence and progression was analyzed.ResultsOf the 183 patients, substaging was T1a in 119, T1b in 57, and T1c in 7 patients. The recurrence rate was 32.8% for T1a and 40.6% for T1b/c, but there was no significant difference between the two groups. The progression rate was significantly different between the two groups: 5.8% in T1a and 21.9% in T1b/c (p=0.003). The cancer-specific mortality rate was also significantly different: 4.2% in T1a and 14.0% in T1b/c (p=0.036). In the univariate analysis, microscopic tumor architecture was the only significant prognostic factor for recurrence. In the univariate and multivariate analysis concerning progression, depth of lamina propria invasion and concomitant carcinoma in situ were significant prognostic factors.ConclusionsSubstaging according to the depth of lamina propria invasion in primary T1 TCC of the bladder was an independent prognostic factor for progression. This suggests that substaging would be helpful for guiding decisions about adjuvant therapies and follow-up strategies.

Severe Acute Colitis in an HIV-Positive Man Caused by Shigella flexneri

A 34-year-old human immunodeficiency virus-positive homosexual male presented with a 2-day history of worsening severe diarrhea and abdominal pain, fever, confusion, renal failure, and cardiovascular collapse. A computed tomographic scan showed edema and thickening of the entire colon, and a colectomy was performed. Gross and histologic findings of a diffusely edematous colon with mucosa showing preserved architecture, mixed inflammation in the lamina propria, attenuation and neutrophil invasion of the surface and upper gland epithelium, mucin depletion, patchy erosions, and luminal exudates were characteristic of an acute infectious colitis. Shigella flexneri was isolated from stool. Although more commonly seen in 2- to 10-year-olds and in developing countries, shigellosis is endemic in industrial countries and among adult homosexual males. Clinical manifestations are more severe in immunocompromised patients. Histologic findings are nonspecific but allow easy differentiation from idiopathic inflammatory bowel disease. Stool culture is essential to distinguish Shigella from other enteric pathogens that cause similar histologic changes and to select appropriate antibiotics.

High-grade papillary urothelial carcinoma of the urinary tract: a clinicopathologic analysis of a post–World Health Organization/International Society of Urological Pathology classification cohort from a single academic center

About one half of all bladder neoplasms are noninvasive, and in those, the histologic grade is a crucial prognosticator. Few single-center studies have assessed the recurrence, progression, and cancer-related mortality rates of noninvasive high-grade papillary urothelial carcinomas. With this aim, we evaluated the clinicopathologic and outcome features of 85 patients with high-grade papillary urothelial carcinoma. Median age was 68 years, and 80.5% were men. Tumor size ranged from 0.3 to 13.0 cm (median, 1.6 cm). Recurrence was found in 36.5% of the patients, whereas tumor progression, defined as invasion of lamina propria or beyond, was identified in 40% of all cases. When present, lesion reappearance involved mostly 1 to 2 episodes. Metastasis appeared in 20% of the patients, and 15% died of disseminated bladder cancer. All cancer-related deaths occurred in the group of patients with progression, whereas patients with recurrence showed similar outcomes to those with no recurrence. For patients with tumor progression, clinical stage was significantly associated with outcome (P = .002). As for prognosis, tumor size was strongly associated with progression (P < .01). In conclusion, recurrence, progression, and cancer-specific mortality rates were 36.5%, 40%, and 15%, respectively. All the patients who died of cancer had a history of tumor progression. Patients with recurrences showed similar outcomes to those with no recurrence. Tumor size was strongly associated with tumor progression and cancer-specific survival, whereas clinical stage was significantly associated with outcome in the progression group. In light of the high recurrence and progression rates of high-grade papillary urothelial carcinoma, strict clinical surveillance aimed to detect early recurrent lesions, especially in patients with larger tumors, is warranted.

Urinary Met level as a novel biomarker for urothelial carcinoma of the bladder.

257 Background: To determine whether urinary soluble Met (sMet) can differentiate between benign conditions and bladder cancer (CaB), and in cases of bladder cancer, between different stages of transitional cell carcinoma (TCC). Methods: Urinary samples from patients with (Total: 63, pTa: 12, pTis: 22, pT1: 13, ≥ pT2: 16) and without (Total: 27) CaB from three different institutions were prospectively collected prior to cystosopy, TURBT or cystectomy. sMet levels were determined by electrochemiluminescence immunoassay and normalized to urinary creatinine values. Normalized sMet values were compared to final pathologic stage. AUC values were obtained comparing patients with and without TCC. Results: Urinary sMet levels accurately differentiated between patients with and without CaB (AUC: 78%, sensitivity, specificity and negative predictive value were: 68%, 78% and 95%, respectively), patients with no CaB and those with lamina propria invasion (AUC: 79%, sensitivity, specificity and negative predictive value were: 65%, 81% and 95%, respectively) and patients with no CaB and those with muscle invasive CaB (AUC: 85%, sensitivity, specificity and negative predictive value were: 75%, 83% and 97%, respectively). Conclusions: Urinary sMet levels accurately distinguish patients with CaB from those without, and between patients with different CaB stages. These results suggest that urinary sMet may have utility as a bladder cancer marker for screening, treatment follow-up and clinical trial design. No significant financial relationships to disclose.

E-cadherin expression in plasmacytoid, signet ring cell and micropapillary variants of urothelial carcinoma: comparison with usual-type high-grade urothelial carcinoma

Loss of E-cadherin expression has been linked to the invasive phenotypes of a variety of neoplasms, including lobular breast cancer. The expression of E-cadherin in variants of urothelial carcinoma relative to usual-type urothelial carcinoma, maximum depth of invasion and angiolymphatic invasion has not been well characterized. A total of eight cases of micropapillary urothelial carcinoma, four cases of plasmacytoid urothelial carcinoma, two cases of urothelial carcinoma with signet ring cell differentiation and two cases of urothelial carcinoma with mixed plasmacytoid and signet ring cell differentiation, all obtained from cystectomy/cystoprostatectomy cases, were identified. In all nine cases of usual-type invasive and noninvasive high-grade urothelial carcinoma were also included in the study. Immunohistochemical staining of E-cadherin was performed in all cases. Pathological parameters including depth of invasion and presence of angiolymphatic invasion were documented. Maximum depth of invasion: In micropapillary urothelial carcinoma, extravesical extension was seen in three of eight cases; muscularis propria invasion in four of eight cases; and lamina propria invasion in one of eight cases. In plasmacytoid urothelial carcinoma, extravesical extension was observed in two of four cases, and muscularis propria invasion and lamina propria invasion in one of four cases each. In urothelial carcinoma with signet ring cell differentiation, extravesical extension and muscularis propria invasion was seen in one of two cases each. In urothelial carcinoma with mixed plasmacytoid and signet ring cell differentiation, muscularis propria invasion and lamina propria invasion was observed in one of two cases each. In usual-type high-grade urothelial carcinoma, extravesical extension was seen in six of nine cases and noninvasive in three of nine cases. In angiolymphatic invasion, micropapillary urothelial carcinoma was observed in eight of eight cases; plasmacytoid urothelial carcinoma in two of four cases; urothelial carcinoma with signet ring cell differentiation in one of two cases; and urothelial carcinoma with mixed plasmacytoid and signet ring cell differentiation in one of two cases. Usual-type high-grade urothelial carcinoma was seen in six of nine cases. E-cadherin expression: All eight cases of micropapillary urothelial carcinoma were positive for E-cadherin in the micropapillary component and adjacent usual-type urothelial carcinoma. The four cases of plasmacytoid urothelial carcinoma, two cases of urothelial carcinoma with signet ring cell differentiation and two cases of urothelial carcinoma with mixed plasmacytoid and signet ring cell differentiation were all negative for E-cadherin. All nine additional cases of usual-type high-grade urothelial carcinoma were diffusely positive for E-cadherin. E-cadherin is diffusely positive in usual-type urothelial carcinoma and micropapillary urothelial carcinoma, irrespective of pathological stage and angiolymphatic invasion. Loss of E-cadherin expression may be a marker of plasmacytoid and signet ring cell differentiation in urothelial carcinoma.

Micropapillary Variant of Urothelial Carcinoma

Micropapillary carcinoma (MPC) of urinary tract is an uncommon variant of urothelial carcinoma with significant diagnostic and prognostic implications. Though MPC shows characteristic microscopic features, there exists interobserver variability and also it needs to be differentiated from the metastasis from other organs. The prognosis is generally poor, depending on the proportion of the micropapillary component in some reports. Early cystectomy in cases with only lamina propria invasion may be indicated according to recent studies. This review outlines the general features of this entity and briefly comments on the controversies and the recent development.

16. Cytology of nephrogenic adenoma

<h3>Background</h3> Nephrogenic adenomas are benign lesions of the urothelial tract that are thought to arise from implantation of renal tubular epithelium in areas of chronic inflammation within the urothelium. Cytology of nephrogenic adenomas can be challenging as the cells seen can appear atypical, with papillary-like and glandular tissue fragments. In addition, variable background inflammation and degenerate cells can make the diagnosis difficult. <h3>Clinical</h3> We present the case of a 64-year-old man with biopsy proven high grade urothelial papillary carcinoma with superficial lamina propria invasion in 2009. He was treated with intravesical Bacillus Calmette-Guerin (BCG) therapy. Subsequent urine cytology reports ranged from ‘atypical cells', ‘cells suspicious for carcinoma' and ‘malignant urothelial carcinoma'. Multiple concurrent urothelial biopsies showed chronic inflammation and nephro-genic adenomas. Only one of these biopsies showed dysplasia. <h3>Cytology</h3> On review, multiple bladder, left pelvic and right pelvic washings showed similar features consistent with nephrogenic adenoma including glandular tissue fragments in a mild to moderate background of inflammation. The cells had enlarged hyper-chromatic nuclei, uniform nuclear membranes, and evenly distributed chromatin with clear cytoplasm, and occasional cells with cytoplasmic vacuoles. <h3>Discussion</h3> Distinguishing nephrogenic adenoma from malignant diagnoses is important in terms of ongoing surveillance and treatment. Recognition of nephrogenic adenomas in urine cytology can be difficult and as in this case can be mistaken for urothelial carcinoma. Other differentials include adenocarcinoma, either renal, urothelial or prostatic in origin, and reactive changes due to chemotherapy, instrumentation or surgery. Cytological features of nephrogenic adenoma may display atypia, however the cells usually do not reach the cytological criteria for malignancy. The presence of benign glandular tissue fragments in bilateral pelvic washings supports current theories that nephrogenic adenomas arise from implantation of renal tubular cells.

Dermokine as a novel biomarker for early-stage colorectal cancer

Colorectal cancer is a common disease that is usually detected at an advanced stage, because early-stage cancer is mostly asymptomatic and appropriate serologic biomarkers have not been established. We have previously identified dermokine (DK) as a peptide secreted by keratinocytes and we found that DK-β/γ was expressed in colorectal tumors. Therefore, we focused on DK-β/γ as a new candidate diagnostic serum marker for early colorectal cancer. DK-β/γ expression in human colorectal cancer cell lines and tissues was assessed by quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) and immunohistochemistry. We established an experimental enzyme-linked immunosorbent assay (ELISA) to detect DK-β/γ in the serum of colorectal cancer patients, and we compared the sensitivities of common diagnostic markers, carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, and serum p53 antibody (S-p53). Immunohistochemical staining of colon tumor tissue with anti-DK monoclonal antibody (mAb) revealed that DK-β/γ was more commonly expressed in the early stages of colorectal cancer (Tis-T1; i.e., cancer in situ, intraepithelial or invasion of lamina propria [Tis]; tumor invades the submucosa [T1]) than in late-stage tumors (T2-T4; i.e., tumor invades the muscularis propria [T2]; tumor invades through the muscularis propria into the subserosa, or into the nonperitonealized pericolic or perirectal tissues [T3]; tumor directly invades other organs or structures and/or perforates visceral peritoneum [T4]). Serum DK-β/γ levels were determined in 130 patients with colorectal cancer and 25 healthy volunteers. Serum DK-β/γ was detected in 33.3% of patients with early colorectal cancer (Tis-T1), which was higher than the rates for S-p53 (24.2%), CEA (9.1%), and CA19-9 (0%). The serum DK-β/γ test was complementary to the other marker tests. Therefore, when the combined four-marker test (DK/CEA/CA19-9/S-p53) was carried out, the diagnostic sensitivity for Tis and T1 tumors reached 60.6%. Serum DK-β/γ is the most promising of the existing tumor biomarkers for the diagnosis of early-stage colorectal cancer.

133 Histamine Deficiency Upregulates Cd11b+Ly6g+ Tumor-Associated Neutrophils and Promotes Colon Carcinogenesis

Background/aim: The anterior and posterior vagal trunks supply the each side of the gastric mucosa separately, and the denervation of either side does not impair the functional capacity of the other, leaving gastric acid output and circulating gastrin levels unchanged. In this study, we investigated the importance of the neural innervation and the brain-gut axis in cancer initiation by performing vagotomy in hypergastrinemic transgenic (INS-GAS) mice with a phenotype of spontaneous gastric cancer. Methods: Age/sex matched wild-type (WT) and INS-GAS mice were killed at 1, 2, 4, 6, 8, 10 and 12 months of age (at least 10 mice/ group) for histological examination of gastric cancer. INS-GAS mice at 6 months of age were randomized into 4 groups of surgery: unilateral anterior truncal vagotomy (29 mice), bilateral truncal vagotomy with pyloroplasty (24), pyloroplasty (27), and sham operation (25). Both the anterior and posterior sides of the stomachs were removed at 6 months postoperatively (i.e., 12 months of age) for pathological and immunohistochemical analyses. Results: Gastric cancer was found neither in WT mice regardless of age nor in INS-GAS mice that were <10 months of age. At 12 months of age, the incidence of gastric cancer was 78% in sham-operated INS-GAS mice and 86% in INS-GAS mice with pyloroplasty. Interestingly, in INS-GAS mice that underwent anterior vagotomy, the tumor incidence in the anterior side was 14% in contrast to 76% at posterior side. In INS-GAS mice that underwent bilateral vagotomy, the tumor incidence was reduced to 11-22%. The tumors in the innervated stomach showed high-grade dysplasia and lamina propria invasion, whereas in the denervated stomach, the tissue architecture appeared to be normal with numerous H+K+-ATPase-positive parietal cells. The thickness of mucosa was reduced in the denervated side compared to the innervated side. Degrees of inflammation, hyperplasia, metaplasia and gastric dysplasia were lower in the denervated anterior than the innervated posterior mucosa in INS-GAS mice with unilateral vagotomy. Proliferation (Ki67 and PCNA) and putative stem cell markers (Dclk1) were decreased. Markers for carcinogenesis (CD44 and β-catenin) and neuroendocrine differentiation (chromogranin A, PGP9.5 and synaptophysin) were downregulated, whereas M3 receptors were upregulated in the denervated mucosa of the stomach. Conclusions: Selective vagotomy inhibited gastric cancer initiation specifically in the area of denervation, demonstrating the importance of the neural niche in cancer In Vivo. We also suggest that a genetic predisposition to gastric cancer might be prohibited by the disruption of the brain-gut axis.

132 Galectin-3 Induces Human Pancreatic Stellate Cell Activation and IL-8 Production via NF-kB Signaling

Background/aim: The anterior and posterior vagal trunks supply the each side of the gastric mucosa separately, and the denervation of either side does not impair the functional capacity of the other, leaving gastric acid output and circulating gastrin levels unchanged. In this study, we investigated the importance of the neural innervation and the brain-gut axis in cancer initiation by performing vagotomy in hypergastrinemic transgenic (INS-GAS) mice with a phenotype of spontaneous gastric cancer. Methods: Age/sex matched wild-type (WT) and INS-GAS mice were killed at 1, 2, 4, 6, 8, 10 and 12 months of age (at least 10 mice/ group) for histological examination of gastric cancer. INS-GAS mice at 6 months of age were randomized into 4 groups of surgery: unilateral anterior truncal vagotomy (29 mice), bilateral truncal vagotomy with pyloroplasty (24), pyloroplasty (27), and sham operation (25). Both the anterior and posterior sides of the stomachs were removed at 6 months postoperatively (i.e., 12 months of age) for pathological and immunohistochemical analyses. Results: Gastric cancer was found neither in WT mice regardless of age nor in INS-GAS mice that were <10 months of age. At 12 months of age, the incidence of gastric cancer was 78% in sham-operated INS-GAS mice and 86% in INS-GAS mice with pyloroplasty. Interestingly, in INS-GAS mice that underwent anterior vagotomy, the tumor incidence in the anterior side was 14% in contrast to 76% at posterior side. In INS-GAS mice that underwent bilateral vagotomy, the tumor incidence was reduced to 11-22%. The tumors in the innervated stomach showed high-grade dysplasia and lamina propria invasion, whereas in the denervated stomach, the tissue architecture appeared to be normal with numerous H+K+-ATPase-positive parietal cells. The thickness of mucosa was reduced in the denervated side compared to the innervated side. Degrees of inflammation, hyperplasia, metaplasia and gastric dysplasia were lower in the denervated anterior than the innervated posterior mucosa in INS-GAS mice with unilateral vagotomy. Proliferation (Ki67 and PCNA) and putative stem cell markers (Dclk1) were decreased. Markers for carcinogenesis (CD44 and β-catenin) and neuroendocrine differentiation (chromogranin A, PGP9.5 and synaptophysin) were downregulated, whereas M3 receptors were upregulated in the denervated mucosa of the stomach. Conclusions: Selective vagotomy inhibited gastric cancer initiation specifically in the area of denervation, demonstrating the importance of the neural niche in cancer In Vivo. We also suggest that a genetic predisposition to gastric cancer might be prohibited by the disruption of the brain-gut axis.

131 Epithelial Interleukin-4 Receptor is a Key Mediator of Murine Colon Tumorigenesis

Background/aim: The anterior and posterior vagal trunks supply the each side of the gastric mucosa separately, and the denervation of either side does not impair the functional capacity of the other, leaving gastric acid output and circulating gastrin levels unchanged. In this study, we investigated the importance of the neural innervation and the brain-gut axis in cancer initiation by performing vagotomy in hypergastrinemic transgenic (INS-GAS) mice with a phenotype of spontaneous gastric cancer. Methods: Age/sex matched wild-type (WT) and INS-GAS mice were killed at 1, 2, 4, 6, 8, 10 and 12 months of age (at least 10 mice/ group) for histological examination of gastric cancer. INS-GAS mice at 6 months of age were randomized into 4 groups of surgery: unilateral anterior truncal vagotomy (29 mice), bilateral truncal vagotomy with pyloroplasty (24), pyloroplasty (27), and sham operation (25). Both the anterior and posterior sides of the stomachs were removed at 6 months postoperatively (i.e., 12 months of age) for pathological and immunohistochemical analyses. Results: Gastric cancer was found neither in WT mice regardless of age nor in INS-GAS mice that were <10 months of age. At 12 months of age, the incidence of gastric cancer was 78% in sham-operated INS-GAS mice and 86% in INS-GAS mice with pyloroplasty. Interestingly, in INS-GAS mice that underwent anterior vagotomy, the tumor incidence in the anterior side was 14% in contrast to 76% at posterior side. In INS-GAS mice that underwent bilateral vagotomy, the tumor incidence was reduced to 11-22%. The tumors in the innervated stomach showed high-grade dysplasia and lamina propria invasion, whereas in the denervated stomach, the tissue architecture appeared to be normal with numerous H+K+-ATPase-positive parietal cells. The thickness of mucosa was reduced in the denervated side compared to the innervated side. Degrees of inflammation, hyperplasia, metaplasia and gastric dysplasia were lower in the denervated anterior than the innervated posterior mucosa in INS-GAS mice with unilateral vagotomy. Proliferation (Ki67 and PCNA) and putative stem cell markers (Dclk1) were decreased. Markers for carcinogenesis (CD44 and β-catenin) and neuroendocrine differentiation (chromogranin A, PGP9.5 and synaptophysin) were downregulated, whereas M3 receptors were upregulated in the denervated mucosa of the stomach. Conclusions: Selective vagotomy inhibited gastric cancer initiation specifically in the area of denervation, demonstrating the importance of the neural niche in cancer In Vivo. We also suggest that a genetic predisposition to gastric cancer might be prohibited by the disruption of the brain-gut axis.

130 Truncal Vagotomy Inhibited Gastric Cancer Initiation in the INS-GAS Mouse Model

Background/aim: The anterior and posterior vagal trunks supply the each side of the gastric mucosa separately, and the denervation of either side does not impair the functional capacity of the other, leaving gastric acid output and circulating gastrin levels unchanged. In this study, we investigated the importance of the neural innervation and the brain-gut axis in cancer initiation by performing vagotomy in hypergastrinemic transgenic (INS-GAS) mice with a phenotype of spontaneous gastric cancer. Methods: Age/sex matched wild-type (WT) and INS-GAS mice were killed at 1, 2, 4, 6, 8, 10 and 12 months of age (at least 10 mice/ group) for histological examination of gastric cancer. INS-GAS mice at 6 months of age were randomized into 4 groups of surgery: unilateral anterior truncal vagotomy (29 mice), bilateral truncal vagotomy with pyloroplasty (24), pyloroplasty (27), and sham operation (25). Both the anterior and posterior sides of the stomachs were removed at 6 months postoperatively (i.e., 12 months of age) for pathological and immunohistochemical analyses. Results: Gastric cancer was found neither in WT mice regardless of age nor in INS-GAS mice that were <10 months of age. At 12 months of age, the incidence of gastric cancer was 78% in sham-operated INS-GAS mice and 86% in INS-GAS mice with pyloroplasty. Interestingly, in INS-GAS mice that underwent anterior vagotomy, the tumor incidence in the anterior side was 14% in contrast to 76% at posterior side. In INS-GAS mice that underwent bilateral vagotomy, the tumor incidence was reduced to 11-22%. The tumors in the innervated stomach showed high-grade dysplasia and lamina propria invasion, whereas in the denervated stomach, the tissue architecture appeared to be normal with numerous H+K+-ATPase-positive parietal cells. The thickness of mucosa was reduced in the denervated side compared to the innervated side. Degrees of inflammation, hyperplasia, metaplasia and gastric dysplasia were lower in the denervated anterior than the innervated posterior mucosa in INS-GAS mice with unilateral vagotomy. Proliferation (Ki67 and PCNA) and putative stem cell markers (Dclk1) were decreased. Markers for carcinogenesis (CD44 and β-catenin) and neuroendocrine differentiation (chromogranin A, PGP9.5 and synaptophysin) were downregulated, whereas M3 receptors were upregulated in the denervated mucosa of the stomach. Conclusions: Selective vagotomy inhibited gastric cancer initiation specifically in the area of denervation, demonstrating the importance of the neural niche in cancer In Vivo. We also suggest that a genetic predisposition to gastric cancer might be prohibited by the disruption of the brain-gut axis.

Tumeur urothéliale de vessie T1 : valeur pronostique du franchissement de la muscularis mucosae (T1a/T1b). Étude multicentrique du Comité de cancérologie de l’Association française d’urologie (CCAFU)

The aim of this multicenter study was to determine the prognostic value of the depth of invasion of lamina propria and more specifically the influence of the invasion of the muscularis mucosae on survival parameters in T1 bladder carcinoma. Six urological centers included patients between 1994 and 2004 who had an initial T1 bladder tumor. All T1 tumors were substaged according to the muscularis mucosae (MM) invasion into T1a (no invasion beyond the MM) and T1b (invasion beyond MM but preserving the muscle). Among the 387 patients included, 269 (69.5%) were found T1a and 118 (30.5%) T1b. Mean follow-up was 45.4 months. T1a and T1b groups were comparable except for tumor grade that was higher in T1b (p<0.001). Survival without recurrence was not significantly different between T1a and T1b groups (p<0.3) but T1a stage was found as an independent factor for survival without progression (RR=0.49; IC 95%=[0.71-0.90]), specific survival (RR=0.33; IC 95%=[0.16-0.67]) and global survival (RR=0.52; IC 95%=[0.32-0.85]). This study, the largest on the subject to our knowledge, have shown that muscularis mucosae invasion was a prognostic factor for survival without progression, specific survival, and global survival. We support that routine pathological assessment of the level of MM invasion in patients with stage T1 bladder cancer should be included in the histopathological report.

Risk factors for positive findings in patients with high‐grade T1 bladder cancer treated with transurethral resection of bladder tumour (TUR) and bacille Calmette‐Guérin therapy and the decision for a repeat TUR

To determine factors predictive of positive findings at the 3-month follow-up evaluation (after transurethral resection of bladder tumour [TUR] and bacille Calmette-Guérin [BCG] therapy) in patients with initial high-grade (HG)T1 bladder cancer, and to assess the depth of lamina propria (LP) invasion and effectiveness of BCG therapy. In all, 138 patients with initial HGT1-transitional cell carcinoma (TCC) were prospectively assigned, after TUR + BCG and according to depth of LP invasion, to a postBCG-TUR (T1b) or cystoscopy/cytology (T1a) at 3 months. Any finding at 3 months was considered positive. The predictive value of 11 clinical and pathological variables was assessed by chi-squared, Mann-Whitney U and multivariate logistic regression. Of the 138 patients (14 women, mean age 69 years), 42% had T1a and 58% T1b TCC. Tumour size and carcinoma in situ (CIS) were significantly associated with positive findings and present in 26% (36/138) of the patients. The postBCG-TUR (T1b cases), was positive in 31% (25/80), including seven infiltrating tumours. On multivariate analysis, again a tumour size of >3 cm (odds ratio, OR, 7.02) and associated CIS (OR 5.4) were significantly related to a positive postBCG-TUR. A secondary finding was that at 20.3 months; patients with T1a TCC, who did not undergo a repeat TUR, did not have increased progression; only 3% (two of 58) had progressed compared with 21% (17/80) of those with T1b/c TCC (P < 0.002). In initial HGT1-TCC, tumour size and CIS were predictive factors of positive findings at 3 months after the initial TUR + BCG therapy. Patients with HGT1-TCC invading the LP (T1b TCC) had a seven times higher risk of a positive repeat TUR if the initial tumour was >3 cm and a five-fold increased risk if associated with CIS. The repeat TUR after BCG therapy allowed confirmation of complete resection and pathological evaluation of the BCG response. Although data are still preliminary, the strategy of performing a repeat TUR only in cases with LP involvement, i.e. T1b TCC, did not increase the risk of progression in cases with T1a TCC.

Urothelial carcinoma with villoglandular differentiation: a study of 14 cases

Tumors of the urinary bladder may have a variety of histological patterns. Tumors with either glandular or villous features, such as villous adenomas, in situ adenocarcinomas, invasive adenocarcinomas, and variants of urothelial carcinoma such as micropapillary carcinomas have been described. However, urothelial carcinomas with both villous and glandular features have not been well characterized. We identified 14 cases of urothelial carcinoma with villoglandular differentiation. These cases were defined as having villoglandular features if they contained superficial finger-like processes lined by epithelium having true glandular lumina. Mean patient age at presentation was 70 years (range: 46–84 years) with a male predominance (5:1). A total of 3 cases (21%) were non-invasive, five cases (36%) had lamina propria invasion, five cases (36%) had muscularis propria invasion and one case (7%) had extravesicular extension. A concurrent high-grade papillary urothelial carcinoma component was identified in 11 cases (79%), micropapillary component in 5 (36%) cases, in-situ urothelial carcinoma component in 3 cases (21%), plasmacytoid component in 3 cases (21%), invasive adenocarcinoma in 2 cases, sarcomatoid carcinoma component in one case (14%), and small-cell carcinoma component in 1 case (7%). Cystitis cystica et glandularis was present in 3 cases (21%). Angiolymphatic invasion was identified in 3 cases (21%). Histologically, the villoglandular components were composed of finger-like processes lined by glands intimately admixed with high-grade urothelial carcinoma. Many of the glands had cribriform features lined by non-mucin producing cuboidal to columnar cells. Urothelial carcinoma with villoglandular differentiation are high-grade tumors typically seen in elderly males, characterized by superficial filliform processes lined by glands intimately admixed with high-grade urothelial carcinoma (in situ or invasive) and other aggressive variants of urothelial carcinoma. These relatively rare tumors should be recognized as a variant of urothelial carcinoma.

Staging and reporting of urothelial carcinoma of the urinary bladder

Significant progress has been made in the standardization of bladder neoplasm classification and reporting. Accurate staging using the American Joint Committee on Cancer/International Union Against Cancer (AJCC/UICC) TNM system is essential for patient management, and has been reinforced by clinical evidence in recent years. It is now recognized that ‘superficial’ bladder carcinomas are a heterogenous group of tumors with diverse biological and clinical manifestations. The term ‘superficial,‘ therefore, is no longer used for bladder tumor nomenclature. Recognition of diagnostic pitfalls associated with lamina propria invasion is critical for the evaluation of bladder tumor specimens. Neither the 1973 nor the 2004 WHO grading system appears to be useful for predicting the clinical outcome of invasive urothelial carcinoma. This review will discuss recent progress and controversial issues on the staging and substaging of bladder carcinomas. Essential elements for handling and reporting of bladder tumor specimens will also be discussed.

Evaluation of relationship between HIF-1α immunoreactivity and stage, grade, angiogenic profile and proliferative index in bladder urothelial carcinomas

Hypoxia-inducible factor-1alpha (HIF-1alpha) is a critical regulatory protein of cellular response to hypoxia. In this study, we evaluated the relationship of HIF-1alpha with clinicopathologic parameters such as tumor stage and grade, as well as angiogenic profile and proliferation index. The immunoreactivity of HIF-1alpha was assessed in 70 cases of primary bladder urothelial carcinoma. Vascular endothelial growth factor (VEGF) and microvessel density (MVD) were used to evaluate the angiogenic profile. MVD was calculated by immunohistochemical staining of endothelial cells with CD34. Proliferation index was determined by the percentage of Ki-67 nuclear staining in tumor cells. There was a significant relationship between HIF-1alpha immunoreactivity and stage, as well as histologic grade of the tumor (P < 0.001). HIF-1alpha immunoreactivity was also closely related to VEGF expression (P < 0.001), MVD (P = 0.002) and proliferation index (P < 0.001). VEGF, MVD and proliferation index were found to be closely related to tumor stage and histologic grade. There was no correlation between HIF-1alpha immunoreactivity and lamina propria (P = 0.13), muscularis propria (P = 0.009) or vascular invasion (P = 0.1). In this study, HIF-1alpha expression was found to be closely related to prognostic parameters in bladder urothelial carcinoma. For this reason, it may be a useful marker to determine the prognosis and to choose the appropriate treatment modality.

Growth pattern in superficial urothelial bladder carcinomas. Histological review and clinical relevance

The question of when an intraepithelial urothelial carcinoma becomes invasive into the lamina propria of the urinary bladder is an unresolved issue. Our objective was to analyse a series of consecutive superficial carcinomas to assess the importance of growth pattern in tumour recurrence and progression. The pathological staging of 200 superficial (pTa/pT1) bladder carcinomas was reviewed. Non-invasive lesions and tumours invading the lamina propria were distinguished. Both infiltrating and pushing patterns of growth were regarded as lamina propria invasion. A total of 35 (17.5%) pTa and 165 (82.5%) pT1 tumours were identified. Among pT1 tumours, 39 (23.6%) displayed the infiltrating pattern of invasion and 126 (76.4%) the pushing pattern. Differences in five-year recurrence-free (P = 0.01) and progression-free (P = 0.001) survival were demonstrated between pTa and pT1 tumours, and between pT1 infiltrating and pT1 pushing subcategories. Invasive growth pattern has a 1.86 times higher risk of tumour recurrence and 3.01 times higher risk of progression. The pT1 category of bladder carcinoma should include a group of tumours defined by its pushing pattern of growth. Some cases may have been previously considered pTa, but follow an intermediate clinical course between pTa and pT1 tumours with infiltrating growth pattern.