Low-grade pTa Research Articles

Profiling energy metabolism in normal bladder tissue and non-muscle-invasive bladder cancer cases of different histological grades

Bladder cancer (BC) stands as the second most common urinary tract malignancy. Recent years have witnessed a growing interest in investigating energy metabolism to help with better understanding the energy sources harnessed by tumor cells. The aims of the present study are to feature and compare cell energy metabolism profiles among different histological grades of non-muscle-invasive BC (NMIBC) by adjusting their bioenergetic cellular indexes based on the specific tumor types. Forty urinary bladder tissue samples from patients both with and without a diagnosis of urothelial lesions were collected. Subsequently, samples were categorized into four groups comprising ten samples each, namely: normal (no urothelial lesions) group, low-grade pTa group, high-grade pTa group, and high-grade pT1 group. These tissue samples were examined by means of immunohistochemistry and Western blotting to assess proteins involved in cell energy metabolism. Based on the current findings, the normal and low-grade pTa groups presented clear preference for the oxidative phosphorylation pathway; consequently, they recorded high bioenergetic cellular index. On the other hand, both the high-grade pTa and pT1 groups presented proclivity towards the glycolytic pathway. These observations, mainly those associated with the bioenergetic cellular index, hold promising clinical relevance in the management of BC. Given the often aggressive and potentially debilitating nature of treatments applied to this neoplasia type, the current study offers invaluable insights on this topic and emphasizes changes in the bioenergetic cellular index at different NMIBC grades, which could serve as potential markers for both the diagnosis and prognosis of NMIBC patients.

Monoamine oxidase as a potential target for the development of new therapeutic strategies for bladder cancer.

e16611 Background: Bladder cancer (BC) is the most common malignancy of the urinary tract and one of the most prevalent cancers worldwide. As the overall prognosis of BC has not changed over the past 30 years, there is a pressing medical need to develop new diagnostic and therapeutic approaches. At present, efforts to deeply understand the pathogenic mechanisms that support urothelial carcinogenesis could help in identifying new therapeutic targets. Monoamine oxidases (MAOs) A and B are oxidative isoenzymes that catalyze the conversion of biogenic amines into their corresponding aldehydes and ketones through oxidative deamination. Recently, MAOs expression have been associated with metastasis and decreased overall survival in various types of cancer. However, the role of MAOs in BC is still poorly explored. This study characterized and compared the molecular profiles of MAO-A and MAO-B isoenzymes in the different histological stages of non-muscle (NMIBC) and muscle (MIBC) invasive bladder cancer, aiming the adaptation of these biomarkers as a criterion of clinical response, risk stratification and outcome prognosis. Methods: Sixty formalin-fixed paraffin-embedded samples of bladder were obtained from 34 to 96-year-old patients (mean 65 years) with BC diagnosis in University of Campinas and Paulinia Municipal Hospital/ Brazil. Subsequently, the samples were divided into 6 groups: pTis group, low-grade pTa group, high-grade pTa group, pT1 group and pT2 group; and submitted to immunohistochemistry analysis for MAO-A and MAO-B. The retrospective anonymous study was approved by the local ethics committee (Clinical Trial: RBR-6swqd2). Results: All stages and grades of NMIBC and pT2 (MIBC) showed positive immunoreactivity for both MAO-A and MAO-B. MAO-A immunoreactivities were significantly higher (p < 0.01) in the high-grade pTa, pTis and pT2 groups in relation to low-grade pTa and pT1. Likewise, MAO-B immunoreactivities were remarkably higher (p < 0.01) in the high-grade pTa and pT2 groups. No statistical differences were found between pTis and low-grade pTa for MAO-B. Interestingly, pT1 group showed the lowest (p < 0.01) MAO-A and MAO-B immunoreactivities in relation to other stages and grades of BC, probably due to disruption of the extracellular matrix, with consequent reduction in O2 delivery (hypoxia). Conclusions: These findings collectively characterize the contribution of MAOs in BC pathogenesis and suggest that MAOs have potential as a therapeutic target in BC.

Phase 2 KEYNOTE-057 cohort C: Pembrolizumab (pembro) with vibostolimab or favezelimab for patients (pts) with high-risk (HR) bacillus Calmette-Guérin (BCG)-unresponsive non–muscle-invasive bladder cancer (NMIBC).

TPS591 Background: The PD-1 inhibitor pembro showed antitumor activity in cohort A of the phase 2 KEYNOTE-057 study (NCT02625961), with 41% of pts with HR BCG-unresponsive carcinoma in situ (CIS) of the bladder ± papillary tumors achieving a CR at 3 months with a median DOR of 16.2 months. Based on these results, pembro was approved in the United States for treatment of pts with BCG-unresponsive HR NMIBC with CIS ± papillary tumors who are ineligible for or have elected not to undergo radical cystectomy (RC). However, novel combinations that improve the efficacy of pembro are needed. Immune checkpoints TIGIT and LAG-3 have been shown to contribute to treatment resistance in many cancers, and their inhibition may enhance the activity of pembro. Cohort C of KEYNOTE-057 will evaluate the efficacy and safety of coformulations of pembro and TIGIT inhibitor vibostolimab or LAG-3 inhibitor favezelimab in pts with HR BCG-unresponsive NMIBC with CIS ± papillary tumors. Methods: Key eligibility criteria include adults with histologically confirmed HR NMIBC that is unresponsive to BCG (defined as persistent or recurrent CIS alone or with Ta/T1 ≤12 months of completion of adequate BCG therapy) who are ineligible for or elect not to undergo RC, have CIS ± papillary tumors at baseline (CIS alone, Ta + CIS or T1 + CIS), and have an ECOG score of 0-2. Approximately 60 pts will be randomly assigned 1:1 to Arm 1 (coformulation of pembro 200 mg and vibostolimab 200 mg) or Arm 2 (coformulation of pembro 200 mg and favezelimab 800 mg) IV Q3W (≤35 administrations) until central pathology-confirmed ≥T1 at any time point or persistent or recurrent CIS or high-grade ≥Ta at the 24-week efficacy review or thereafter. Pts with central pathology–confirmed low-grade pTa at any time point may continue treatment following resection of visible tumors. In the absence of disease persistence/recurrence or progression, treatment will continue until unacceptable toxicity, decision to withdraw, or administrative reasons. Tumor evaluations will be performed Q12W until year 2, then Q24W thereafter for up to 5 years. The primary efficacy end point is 12-month CR rate of HR NMIBC as determined by cystoscopy, cytology, biopsy, and radiologic imaging by central pathology and radiology review. Secondary efficacy end points include DOR of HR NMIBC in responders; overall CR rate and CR rate at 3 and 6 months; PFS to worsening of grade, stage, or death; PFS to muscle-invasive or metastatic disease or death; and OS. The safety objective will characterize the safety and tolerability in all pts who received ≥1 dose of study treatment. Efficacy will be evaluated in all pts who received ≥1 dose of study treatment and have a baseline evaluation consisting of pre-enrollment cystoscopy, TURBT/biopsy, urine cytology, and baseline CT urography imaging. Clinical trial information: NCT02625961 .

Reducing the Frequency of Follow-up Cystoscopy in Low-grade pTa Non–muscle-invasive Bladder Cancer Using the ADXBLADDER Biomarker

BackgroundNon–muscle-invasive bladder cancer (NMIBC) is one of the most expensive cancers owing to frequent follow-up cystoscopies for detection of recurrence. ObjectiveTo assess if the noninvasive ADXBLADDER urine test could permit a less intensive surveillance schedule for patients with low-grade (LG) pTa tumor without carcinoma in situ (CIS) at the previous diagnosis. Design, setting, and participantsIn a prospective, double-blind, multicenter study, 629 patients underwent follow-up cystoscopy, transurethral resection of bladder tumor/biopsy of suspect lesions, and ADXBLADDER testing. Outcome measurements and statistical analysisDiagnostic test accuracy and decision curve analysis were used to evaluate the impact of ADXBLADDER on decision-making on whether to perform follow-up cystoscopy. The primary endpoint was the negative predictive value (NPV) of ADXBLADDER for detection of high-grade and/or CIS (HG/CIS) recurrence and its impact on reducing unnecessary cystoscopies. Results and limitationsADXBLADDER had sensitivity of 66.7% (95% confidence interval [CI] 34.9–90.1%) and an NPV of 99.15% (95% CI 97.8–99.8%) for detection of HG/CIS recurrence. The probability of HG/CIS recurrence was 5.0% for ADXBLADDER-positive patients and 0.85% for ADXBLADDER-negative patients. For HG/CIS recurrence threshold probabilities between 0.85% and 5.0%, ADXBLADDER yields a net benefit with omission of cystoscopy for ADXBLADDER-negative patients. The corresponding net reduction in unnecessary cystoscopies ranges from 11 to 62 per 100 patients. ConclusionsPatients with LG pTa tumor at the previous diagnosis, for which the risk of HG/CIS recurrence is low and the ADXBLADDER NPV for ruling out HG/CIS recurrence is 99.15%, are ideally suited for a less intensive, personalized follow-up surveillance strategy using ADXBLADDER, with omission of cystoscopy for ADXBLADDER-negative patients. Patient summaryADXBLADDER is a urine test that can predict the probability of recurrence of bladder cancer. Patients diagnosed with low-grade cancer confined to the bladder mucosa are ideally suited for less intensive follow-up using this test, which could reduce unnecessary cystoscopy procedures for those with a negative result, potentially improve quality of life, and reduce overall health care costs.

Evaluation of the Role of Early Second Look Cystoscopy after Complete Resection of Non-Muscle Invasive Bladder Tumors

Abstract Background most of the bladder cancers are non-muscle invasion at the time of diagnosis. Non-Muscle invasive tumors confined to the mucosa and invading the lamina propria are classified as stage Ta and T1, respectively, according to the Tumor, Node, Metastasis (TNM) classification system. Aim of the Study to determine the efficacy of early second look cystoscopy after complete resection of non-muscle invasive urinary bladder tumors and its impact on subsequent treatment policy. Patients and Methods this is a prospective clinical study that was done at Urology Department, Faculty of Medicine, Ain Shams University and Damanhur Oncology Centre. A total of 40 consecutive patients with newly diagnosed non-muscle invasive bladder cancer will be enrolled in this prospective study for second-look cystoscopy with TURBT in two to six weeks after initial TURBT and follow them up in one year. Results Single tumor was found in 22 cases (55%), while multiple tumors were recognized in 18 cases (45%) with average sizes ranging from 12mm to 70mm. Low-grade transitional cell carcinoma (TCC) was found in 26 cases (65%), whereas high-grade TCC was found in 14 cases (35%). Stage PTa tumors was found in 12 cases (30%) while 28 cases (70%) have had tumors of PT1 stage. All cases underwent an early second TURBT after (2-6) weeks which has reviled the following data. The majority of cases (28 cases) representing 70% of whole study population were free with no detection of any tumors either residual or recurrence. Residual tumors were detected in six cases (15%) all of which detected in patient with large primary tumor size exceeding 50mm or patients with multiple tumors. Whole detected residual tumors were found at edges of primary tumors ranging 2-5 mm in size which were completely resected and they were of the same stage and grade as the initial tumor. Conclusion Our findings in this study support the notion that second-look cystoscopy with or without TURBT is a prerequisite in patients with superficial bladder cancers except for patients with solitary, small low-grade pTa tumors. It is particularly highly recommended for patients with extensive and multiple tumors at the first TURBT

Value of separate tumor base biopsy in transurethral resection of bladder tumors

IntroductionThe aim of our study was to evaluate whether a biopsy from the tumor base after transurethral resection of bladder tumor (TURBT) has an impact on subsequent management of patients with bladder tumors. While tumor base biopsy at the completion of TURBT is a common practice, there is no definition of its role within the major international professional guidelines.Material and methodsWe retrospectively reviewed the records of consecutive patients undergoing TURBT between 2015 and 2019 at our institution. We recorded demographic and tumor characteristics of initial TURBT, tumor base biopsy and restaging TURBT pathology outcomes. The pathologic outcomes were correlated to assess the additional value of a separate tumor base biopsy.ResultsA total of 532 patients underwent TURBT. A separate tumor base biopsy after completion of TURBT was performed in 154 patients. The mean patient's age was 72.8 ±11.7 years (range 48–94) and 119 (77.2%) were men. In 40 patients (25.9%) muscle was absent in the pathological specimen of the tumor resection. Muscle was present in all but 6 (3.9%) tumor base biopsies. Of the 33 patients who underwent repeated transurethral resection for pT1 tumors, 2 had residual low-grade pTa, 1 had residual high-grade pT1, and 3 patients were upstaged to pT2.ConclusionsAlthough tumor base biopsy at the completion of TURBT is a common practice, our analysis fails to demonstrate any tangible benefit in the staging of bladder tumors. In our experience tumor base biopsy did not change the management in patients with superficial or muscle invasive disease.

Reduced immunohistochemical PTEN staining is associated with higher progression rate and recurrence episodes in non-invasive low-grade papillary urothelial carcinoma of the bladder.

Non-invasive low-grade papillary urothelial carcinoma (NILGPUC) of the bladder is regarded as a relatively indolent disease. However, its propensity for frequent recurrences constitutes a major clinical problem. Additionally, there is a progression risk of 10-15% to either a higher grade and/or a higher stage disease in these tumors. The molecular factors that will predict recurrence and progression in low-grade pTa bladder carcinoma have not yet been elucidated. Herein, we investigated the association of phosphatase and tensin homolog deleted on chromosome 10 (PTEN) alterations with recurrence and progression in NILGPUC using immunohistochemistry. Eighty-one cases of bladder cancer initially diagnosed as NILGPUC in a single institution with follow-up were encountered after searching medical records. Tissue microarrays (TMA) that contained both tumor and non-neoplastic mucosa from each case were constructed using paraffin blocks of transurethral resections. Sections from TMA blocks were stained immunohistochemically for PTEN protein and were evaluable in 76 cases. Any absence of staining was recorded and correlated with clinical findings. Ten patients (13.2%) showed progression and 41 (53.9%) showed recurrence. Reduced PTEN expression was observed in 29 cases (38.1%). Cases with reduced PTEN had higher progression rate compared to cases with intact PTEN (p = 0.026). Tumor relapse was more frequent in cases with reduced PTEN (65.5 vs 46.8%), but this difference was not statistically significant (p = 0.112). On the other hand, decreased PTEN expression was associated with higher number of recurrence episodes (p = 0.002). PTEN seems to have a link with the disease course in NILGPUC of the bladder.

Toward Personalised Liquid Biopsies for Urothelial Carcinoma: Characterisation of ddPCR and Urinary cfDNA for the Detection of the TERT 228 G>A/T Mutation.

Background:TERT promotor mutations are present in >75% of bladder tumours; these mutations are also detectable in urine. Previous studies have used urinary pellet DNA, and semi-quantitative methods unsuitable for detecting very low mutant allele frequencies.Objective:In this proof-of-principle study we use ddPCR to count the DNA molecules with wt and mutant TERT sequences in urinary cfDNA from patients whose bladder cancers harbour TERT mutations.Methods:Urinary cfDNA prepared from the urine from 104 bladder cancer patients was analysed. We determined the mutant allele frequency across stages and grades of disease, analysed concordance between cfDNA and tumour DNA, compared cfDNA with pellet DNA, and analysed the quantity and size distribution of cfDNA.Results:In 71 of 77 patients with a 228 G>A/T mutant tumour, the mutation was also detected in urinary cfDNA by ddPCR; all 6 “false negatives” were low grade pTa tumours. Overall concordance between tissue and cfDNA mutation status was 92%, and 100% was achieved for high grade disease. Median mutant allele frequencies in urinary cfDNA were 3.4, 13.4 and 32.1% in grade 1, 2 and 3 disease. The 228 G>A/T mutation was not detected in urinary cfDNA in 26 out of 27 mutation-negative patients (96% specificity).Conclusions:Concordance between tumour DNA and urinary cfDNA is high, and TERT 228 G>A/T ddPCR may prove useful for monitoring patients that harbour this mutation. Mutant allele frequencies in cfDNA are often high, but assays capable of detecting very low mutant allele frequencies will be required to achieve high sensitivity in low grade disease.

Urothelial neoplasm of the bladder in childhood and adolescence: a rare disease.

ABSTRACTPurpose:Bladder tumors are rare in children and adolescents. For this reason, the diagnosis is sometimes delayed in pediatric patients. We aimed to describe the diagnosis, treatment, and follow-up methods of bladder urothelial neoplasms in children and adolescents.Materials and Methods:We carried out a retrospective multicenter study involving patients who were treated between 2008 and 2014. Eleven patients aged younger than 18 years were enrolled in the study. In all the patients, a bladder tumor was diagnosed using ultrasonography and was treated through transurethral resection of the bladder (TURBT).Results:Nine of the 11 patients (82%) were admitted with gross hematuria. The average delay in diagnosis was 3 months (range, 0–16 months) until the ultrasonographic diagnosis was performed from the first episodes of macroscopic hematuria. A single exophytic tumor (1–4cm) was present in each patient. The pathology of all patients was reported as superficial urothelial neoplasm: two with papilloma, one with papillary urothelial neoplasm of low malignant potential (PUNLMP), four with low grade pTa, and four with low grade pT1. No recurrence was observed during regular cystoscopic and ultrasonographic follow-up.Conclusions:Regardless of the presence of hematuria, bladder tumors in children are usually not considered because urothelial carcinoma in this population is extremely rare, which causes a delay in diagnosis. Fortunately, the disease has a good prognosis and recurrences are infrequent. Cystoscopy may be unnecessary in the follow-up of children with bladder tumors. We believe that ultrasonography is sufficient in follow-up.

PD23-04 THE POTENTIAL UTILITY OF CHEMOKINE CXCL1 (GROα) AS A NOVEL DIAGNOSTIC AND PROGNOSTIC MARKER FOR BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Detection and Screening I1 Apr 2015PD23-04 THE POTENTIAL UTILITY OF CHEMOKINE CXCL1 (GROα) AS A NOVEL DIAGNOSTIC AND PROGNOSTIC MARKER FOR BLADDER CANCER Takashi Kobayashi, Yoshiyuki Matsui, Takuro Sunada, Takahiro Inoue, Tomomi Kamba, and Osamu Ogawa Takashi KobayashiTakashi Kobayashi More articles by this author , Yoshiyuki MatsuiYoshiyuki Matsui More articles by this author , Takuro SunadaTakuro Sunada More articles by this author , Takahiro InoueTakahiro Inoue More articles by this author , Tomomi KambaTomomi Kamba More articles by this author , and Osamu OgawaOsamu Ogawa More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1420AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Cystoscopy is a standard diagnostic and follow-up tool of bladder cancer (BCa), but it is invasive and painful for patients. Therefore, novel urinary molecular markers which are non-invasive but have a high sensitivity even for low-grade tumors have been explored. Here, we show an improved accuracy at measuring urinary CXCL1 (uCXCL1) by a newly developed ELISA system and at predicting the presence and prognosis of bladder cancer. METHODS We produced a monoclonal antibody against human CXCL1 by immunization of BALB/c mice with CXCL1 fusion protein and developed new ELISA system using that antibody. As a first part, CXCL1 levels were determined in the set of urine samples from total of 68 BCa patients (22 of low grade pTa, 21 of high grade pTa, 21 of pT1-pT3 and 4 of pTis), 43 other urological disease control samples and 20 healthy control samples. The sensitivity and specificity of uCXCL1 concentration normalized by urine creatinine (CXCL1/Cre) were compared with those of commercially available markers (NMP22 and BTATRAK). As a second part, urine CXCL1/Cre in 175 patients with BCa was measured and the predictive ability for intravesical recurrence after transurethral resection (TUR) was examined. RESULTS In the first part, the values of uCXCL1 increased according to stage of BCa. uCXCL1 was superior to NMP22 and BTA in sensitivity (81%, 37% and 79% for CXCL1, NMP22 and BTA, respectively) and had a high specificity (80%, 95% and 60%, respectively). AUC values of ROC curves were 0.875, 0.656 and 0.814 for CXCL1, NMP22 and BTA, respectively. Even for distinguishing BCa with other urological disease subjects, CXCL1 gave higher AUC values (0.633) than the conventional markers (0.514 and 0.621 for NMP22 and BTA, respectively). In the latter part, patients who showed higher CXCL1/Cre were significantly more likely to develop intravesical recurrence after TUR. CXCL1/Cre was also able to separate BCa patients with EORTC intermediate-risk into high and low probabilities of post-TUR recurrence equivalent to EORTC high- and low-risk group, respectively. In multivariate analysis, CXCL1/Cre was an independent predictor for post-TUR intravesical recurrence (p = 0.009). CONCLUSIONS We showed the usefulness of urinary CXCL1 as a novel urinary molecular marker for BCa detection and prediction of NMIBC recurrence using a new ELISA system, which would be able to reduce the frequency of cystoscopy and compensate for low sensitivity of urinary cytology in BCa patients. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e482 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Takashi Kobayashi More articles by this author Yoshiyuki Matsui More articles by this author Takuro Sunada More articles by this author Takahiro Inoue More articles by this author Tomomi Kamba More articles by this author Osamu Ogawa More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Stage, Grade and Behavior of Bladder Urothelial Carcinoma Defined by the MicroRNA Expression Profile

We identified miRNA expression profiles in urothelial carcinoma that are associated with grade, stage, and recurrence-free and disease specific survival. The expression of 14 miRNAs was evaluated by quantitative reverse transcriptase-polymerase chain reaction in surgical specimens from 30 patients with low grade, noninvasive (pTa) and 30 with high grade, invasive (pT2-3) urothelial carcinoma. Controls were normal bladder tissue from 5 patients who underwent surgical treatment for benign prostatic hyperplasia. Endogenous controls were RNU-43 and RNU-48. miRNA profiles were compared and Kaplan-Meier curves were constructed to analyze disease-free and disease specific survival. miR-100 was under expressed in 100% of low grade pTa specimens (p <0.001) and miR-10a was over expressed in 73.3% (p <0.001). miR-21 and miR-205 were over expressed in high grade pT2-3 disease (p = 0.02 and <0.001, respectively). The other miRNAs were present at levels similar to those of normal bladder tissue or under expressed in each tumor group. miR-21 over expression (greater than 1.08) was related to shorter disease-free survival in patients with low grade pTa urothelial carcinoma. Higher miR-10a levels (greater than 2.30) were associated with shorter disease-free and disease specific survival in patients with high grade pT2-3 urothelial carcinoma. Four miRNAs were differentially expressed in the 2 urothelial carcinoma groups. miR-100 and miR-10a showed under expression and over expression, respectively, in low grade pTa tumors. miR-21 and miR-205 were over expressed in pT2-3 disease. In addition, miR-10a and miR-21 over expression was associated with shorter disease-free and disease specific survival. miRNAs could be incorporated into the urothelial carcinoma molecular pathway. These miRNAs could also serve as new diagnostic or prognostic markers and new target drugs.

Under-expression of miR-100 may be a new Carcinogenic pathway for low-grade pTa Bladder Urothelial Carcinomas

Objectives: The pathways involved in the carcinogenesis of bladder urothelial carcinoma have been well established and are used for the development of new diagnostic and prognostic markers for the disease. The main genetic pathway for the development of low-grade pTa urothelial carcinomas is related to FGFR3 mutation. MicroRNAs have been related to processes involved in carcinogenesis in many organs, and miR-100 was recently shown to target FGFR3 messenger RNA. Our aim was to study the profile of expression of miR-100 and FGFR3 in low-grade, pTa bladder urothelial carcinoma. Methods and Materials: Using qRT-PCR, we studied the expression of miR-100 and FGFR3 in 30 patients who had undergone transurethral resection of low-grade, pTa bladder urothelial carcinoma. Results and Conclusion: There was under-expression of miR-100 and over-expression of FGFR3 in 100% of the specimens. Under-expression of miR-100 might be an alternative pathway for low-grade pTa urothelial bladder carcinogenesis and the identification of this molecular alteration may constitute a new diagnostic and prognostic marker for the disease.

Clinical Reliability of the 2004 WHO Histological Classification System Compared With the 1973 WHO System for Ta Primary Bladder Tumors

Histopathological grade remains the most important predictive factor for the prognosis of nonmuscle invasive bladder cancer. We defined the clinical reliability of the 2004 WHO and International Society of Urological Pathology histological classification system compared with that of the 1973 WHO system for Ta primary bladder tumors. We evaluated 270 consecutive patients with a first episode of low grade pTa bladder cancer at transurethral resection of the bladder between 2004 and 2008. Grade was assigned by a single uropathologist simultaneously as low grade, and as G1 or G2 according to the 2004 and 1973 WHO classification systems, respectively. All patients received a single early prophylaxis instillation of 50 mg epirubicin as the only adjuvant treatment. Followup included urine cytology and cystoscopy 3 months after resection and every 6 months thereafter for 5 years. Univariate and multivariate analysis of recurrence-free and progression-free survival was done with the Kaplan-Meier method and the log rank test. Mean patient age was 67.3 years (median 67, range 27 to 91). Of the patients 50 were female (18.1%) and 220 (81.9%) were male. According to the 1973 system, grade was G1 in 87 patients (32.2%) and G2 in 183 (67.8%). Median followup was 25 months (mean 27.4, range 3 to 72). The 5-year recurrence-free survival rate was 49.4% for the low grade population, and 62% and 40% for the G1 and G2 groups, respectively (p = 0.004). The 5-year progression-free survival rate was 93% for the low grade population, and 97.6% and 93.3% for the G1 and G2 groups, respectively (p = 0.06). The 1973 WHO classification system predicted the risk of recurrence in primary pTa cases more accurately than the 2004 WHO system. Each classification had the same accuracy when predicting the risk of progression. Our study confirms the clinical reliability of the new histological classification in clinical practice from a prognostic point of view.

Granzyme B is expressed in urothelial carcinoma and promotes cancer cell invasion

Granzyme B (GrB) is a serine proteinase known to be expressed by cytotoxic lymphocytes and to induce, in presence of perforin (Pf), apoptosis in target cells. Recently, GrB expression has been shown (often in absence of Pf) in nonlymphoid cells, but its function is not defined. In our study, we investigated GrB and Pf expression in bladder cancer cell lines and in urothelial carcinoma (UC) tissues by reverse transcription-polymerase chain reaction (RT-PCR), Western blot, ELISA, immunofluorescence and immunohistochemistry. We also assessed the function of GrB in UC cells; the in vitro function of GrB was examined by loss-of-function experiments. Our results revealed that GrB is expressed, in absence of Pf, in UC cells. Significant differences were found between GrB expression and both increasing pathological tumor spreading and high-grade vs. low-grade pTa tumors. Notably, GrB in UC tissues was concentrated at the cancer invasion front and was expressed in neoplastic cells undergoing epithelial-mesenchymal transition, a key event in carcinoma invasion. Indeed, GrB-positive cells also expressed Snail, N-cadherin or were negative for E-cadherin. GrB expressed in tumor cell lines was enzymatically active and capable of vitronectin cleavage, implying extracellular matrix (ECM) remodeling by GrB. Inhibition of GrB activity or Stealth RNA interference-mediated GrB gene silencing markedly suppressed bladder cancer cell invasion through matrigel. This data provides the first evidence for a role of GrB in promoting cancer cell invasion. Taken together, our findings suggest that GrB, via ECM degradation, contributes to the establishment of the UC invasive phenotype.

Large-scale Real-time Reverse Transcription-PCR Approach of Angiogenic Pathways in Human Transitional Cell Carcinoma of the Bladder: Identification of VEGFA as a Major Independent Prognostic Marker

Actors of the angiogenesis pathways are targets for the new promising targeted therapies already used in several malignancies. In bladder cancer, antiangiogenic molecules could also add to already existing treatment options. To evaluate the involvement of angiogenesis pathways in bladder carcinogenesis and identify new molecular markers having a clinical implication. Expression levels of 40 genes involved in angiogenesis were assessed by quantitative real time RT-PCR in 157 urothelial tumour bladder samples obtained from patients who underwent transurethral bladder resection or radical cystectomy between 2001 and 2005. Pathologic tumour staging showed: 73 non-muscle-invasive bladder tumours (30 low-grade pTa, 14 high-grade pTa, and 29 high-grade pT1), and 84 muscle-invasive tumours (> or = pT2), all of high grade. RT-PCR results were associated with a survival analysis. VEGFA, MET, CXCR4, and IL8 were significantly overexpressed in tumour samples as compared to normal bladder tissue. VEGFA overexpressions were found in 89% of non-muscle-invasive and 66% of muscle-invasive tumour samples. In univariate analysis, for invasive tumours, VEGFA overexpression was associated with a poorer outcome in both overall and disease-free survival (p=0.011 and 0.026 respectively) at a 13-mo median follow-up. Multivariate analysis retained T stage, N status, and VEGFA overexpression as independent prognostic factors in both overall and disease-free survival (p=0.02 and p=0.04, respectively, for VEGFA). This study shows that, in bladder cancer, VEGFA status could be used as a prognostic factor at the individual level. VEGFA overexpression could guide a rationalized use of the costly antiangiogenic therapies which could therefore become part of the treatment options in bladder cancer.

Superficial Bladder Tumors In Childhood

PURPOSE To present the clinical, histological features and the prognosis of superficial bladder tumors (SBT) in childhood. MATERIAL AND METHODS A total of 6 male children, 4-14 yrs old (mean age 11yrs.), treated at our Department between 1984 and 2006, were found to have SBT. Presenting symptoms included gross heamaturia in 5, irritative voiding and microscopic heamaturia in 1. Initial diagnosis was made by ultrasound. Cystoscopy confirmed the diagnosis and 5 patients underwent transurethral resection of the tumor which was solitary. The remaining patient underwent transvesical excision due to the presence of two exophytic lesions measuring 3,2 and 2,5 cm in diameter respectively. Follow up consisted of ultrasound which was performed every 3 months in the first year and every 6 months later. RESULTS Pathologic evaluation revealed low grade pTa transitional cell carcinoma (TCC) in 5 cases and nephrogenic adenoma (NA) in 1. The case with NA had been operated on obstructive megaureter in early infancy.During follow up (2-24 years), there was no evidence of relapse. CONCLUSIONS Despite the fact that S.B.T. are rare in childhood, all children presented with gross heamaturia must be investigated. Bladder ultrasound is the most sensitive scan in exophytic lesions > 3mm. The appropriate treatment option is transurethral resection of the tumor which mostly is solitary. During follow up there was no evidence of relapse.

Editorial Comment on: Large-scale Real-time Reverse Transcription-PCR Approach of Angiogenic Pathways in Human Transitional Cell Carcinoma of the Bladder: Identification of VEGFA as a Major Independent Prognostic Marker

Abstract Background Actors of the angiogenesis pathways are targets for the new promising targeted therapies already used in several malignancies. In bladder cancer, antiangiogenic molecules could also add to already existing treatment options. Objective To evaluate the involvement of angiogenesis pathways in bladder carcinogenesis and identify new molecular markers having a clinical implication. Design, setting, and participants Expression levels of 40 genes involved in angiogenesis were assessed by quantitative real time RT-PCR in 157 urothelial tumour bladder samples obtained from patients who underwent transurethral bladder resection or radical cystectomy between 2001 and 2005. Pathologic tumour staging showed: 73 non-muscle-invasive bladder tumours (30 low-grade pTa, 14 high-grade pTa, and 29 high-grade pT1), and 84 muscle-invasive tumours (≥ pT2), all of high grade. RT-PCR results were associated with a survival analysis. Results and limitations VEGFA , MET , CXCR4 , and IL8 were significantly overexpressed in tumour samples as compared to normal bladder tissue. VEGFA overexpressions were found in 89% of non-muscle-invasive and 66% of muscle-invasive tumour samples. In univariate analysis, for invasive tumours, VEGFA overexpression was associated with a poorer outcome in both overall and disease-free survival ( p =0.011 and 0.026 respectively) at a 13-mo median follow-up. Multivariate analysis retained T stage, N status, and VEGFA overexpression as independent prognostic factors in both overall and disease-free survival ( p =0.02 and p =0.04, respectively, for VEGFA ). Conclusions This study shows that, in bladder cancer, VEGFA status could be used as a prognostic factor at the individual level. VEGFA overexpression could guide a rationalized use of the costly antiangiogenic therapies which could therefore become part of the treatment options in bladder cancer.

Conservative Surgical Treatment of Low-Grade Urothelial Carcinoma in the Renal Allograft Recipient: A Case Report

Development of urothelial carcinoma in a renal allograft is rare. We report the case of 52-year-old male patient who developed chronic renal failure secondary to Balkan endemic nephropathy and underwent renal allotransplantation. The patient who developed low-grade pTa urothelial carcinoma in the left contracted kidney at 3 years after transplantation and underwent nephroureterectomy. Three years later, the same neoplastic process was observed in the renal allograft. Preoperative estimation for allograft tumor recurrence and progression included percutaneous tumor biopsy followed by cytopathological, histological, and cytogenetic analysis. Cytopathology revealed well-differentiated urothelial tumor cells. Histopathologic analysis showed low-grade urothelial carcinoma. Cytogenetic examination demonstrated that the tumor originated from the recipient suggesting a low malignant potential of carcinoma. Based on these findings, we decided to perform a right-side nephroureterectomy and graft-sparing procedure, which resulted in preservation of allograft function. In this report we discussed the prognostic factors, which are the basis for rational therapeutic approaches in these patients.

Quantitative evaluation of telomerase subunits in urine as biomarkers for noninvasive detection of bladder cancer

The aim of our study was to prospectively evaluate the potential diagnostic value and clinical applicability of quantitative analysis of telomerase subunits gene expression in urine for noninvasive detection of bladder cancer. Expression levels of human telomerase reverse transcriptase (hTERT) and human telomerase RNA (hTR) were analyzed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) in urine samples from 163 subjects with bladder cancer and 237 controls (163 individuals with benign genitourinary diseases; 74 healthy subjects). The sensitivity, specificity and optimal cutoffs were determined and compared to the corresponding values obtained by voided urine cytology. Quantitative urinary hTR analysis detects bladder cancer with an overall sensitivity of 77.0%, whereas hTERT analysis reached a sensitivity of 55.2%. The majority of undetected tumors were small, low-grade pTa lesions. Both hTR and hTERT proved to be significantly more sensitive than cytology (34.5%; p < 0.001). Specificities for hTR, hTERT and cytology were 72.1%, 85.0% and 92.7%, respectively, in the total study population and 96.9%, 89.2% and 100%, respectively, in healthy subjects. Higher diagnostic accuracy was achieved by hTR than by hTERT analysis (p < 0.05). The specificity of hTR increased to 85.0% in the total population if urinary leukocyte contamination was excluded. These data suggest that quantitative hTR analysis is the most accurate telomerase-based test for bladder cancer detection and has the potential to replace cytology as a noninvasive biomarker for disease diagnosis and follow-up.

A SURVEILLANCE SCHEDULE FOR G1Ta BLADDER CANCER ALLOWING EFFICIENT USE OF CHECK CYSTOSCOPY AND SAFE DISCHARGE AT 5 YEARS BASED ON A 25-YEAR PROSPECTIVE DATABASE

In the absence of clear evidence, surveillance of low grade superficial bladder cancer by regular check cystoscopy may continue unnecessarily, or discharge from followup may occur empirically. We review the followup during a prospective 25-year period of patients presenting with G1Ta bladder cancer, and it is this analysis on which we base a safe schedule for discharge. A prospectively kept, computerized record of bladder cancers diagnosed between 1978 and 1985 and subsequently followed up at the Western General Hospital, Edinburgh was reviewed. A total of 115 patients with G1Ta disease were followed for a mean of 19.4 years. Tumor status at 3 months was the strongest prognostic factor for recurrence. Although the absence of tumor at 1 year was also a favorable prognostic sign, it was not for 5 years that the situation entirely stabilized (recurrence developed in 8 of 66 such patients between 1 and 5 years). Of those who did not have recurrence in 5 years, 98.3% patients remained tumor-free for 20 years. In contrast in those with recurrence at 3 months the recurrence rate was much higher. Overall 12% of patients experienced progression, mostly in year 1. None of the 8 who had their first recurrence after year 1 had disease progression. Patients with G1Ta disease who are free of recurrence for 5 years after presentation can be safely discharged. We propose to alter the regime for patients with no recurrence in year 1 and discharge them at 5 years.