Muscle-invasive Tumors Research Articles

Validation of vesical imaging reporting and data system for assessing muscle invasion in bladder tumor.

To retrospectively determine the diagnostic values of vesical imaging reporting and data system (VI-RADS) score for detecting muscle-invasive bladder tumors. This study included 297 consecutive patients with 339 tumors who previously diagnosed and subsequently underwent multiparametric MR imaging between January 2015 and March 2019. Two radiologists assessed the scores of muscle-invasive tumors using cutoff values of ≥ 4 and ≥ 3. Cutoff values for VI-RADS scores were estimated from the best operating points of the areas under the receiver operating characteristic curve analyses using the Youden J statistic. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated to assess the utility of VI-RADS for diagnosing muscle-invasive tumors. Inter-observer agreement was excellent for three different MR imaging type at lesion level (k = 0.89 for T2W, k = 0.82 for DW, and k = 0.85 for DCE). At a cutoff value of 4, T2W and DW imaging had a diagnostic accuracy of 79.3% (269/339) for tumor lesions with muscle invasion, which was similar to an overall score of 80.2% (272/339). The overall VI-RAD score showed 80.2% accuracy (272/339), with a cutoff value of ≥ 4, yielding 91.3% sensitivity (85/93), 76.0% specificity (187/246), 83.3% PPV (85/102), and 78.9% NPV (187/237). When we considered an arbitrary overall score of ≥ 3 as the cutoff value, the accuracy was 63.7% (216/339); sensitivity, 94.6% (125/132); specificity, 43.9% (91/207); PPV, 51.6% (125/242); and NPV, 63.7% (91/97). VI-RADS has an overall good performance in the diagnosis of muscle-invasive tumors.

Préservation par chimioradiothérapie des cancers de vessie

When localized, the reference treatment of urothelial, muscle-invasive bladder tumours relies on radical cystectomy with reconstruction by enterocystoplasty if possible or Bricker bypass. Trimodal therapy combining transurethral resection of the tumour followed by concomitant chemotherapy may be considered as a therapeutic alternative to radical cystectomy in well-selected patients with unifocal tumours, stage T2, non-diverticular location, without in situ carcinoma or hydronephrosis and with macroscopically complete transurethral resection. The functional prognosis of the bladder and quality of life should be discussed with the patient as well as the need for salvage surgery for persistent tumour at a 45-Gy dose level, the latter being a highly unfavourable prognosis factor. On the other hand, this trimodal treatment is the reference in case of surgical contraindication. This article details the methods and results of the main series available in the literature in terms of local control, survival, bladder preservation rates and complications, as well as study prospects.

Abstract CT179: ATLAS: A Phase II, open-label study of rucaparib in patients with locally advanced or metastatic urothelial carcinoma

Abstract Background: For patients with metastatic urothelial carcinoma (mUC) that has progressed on or after platinum-based chemotherapy (cisplatin or carboplatin) and/or immune checkpoint inhibitors, there are currently no standard treatments, emphasizing the urgent unmet need for additional treatment options. Based on analysis of The Cancer Genome Atlas bladder cancer dataset, ≈60% of muscle invasive bladder tumors have homologous recombination (HR) deficiency (HRD), as defined by high genomic loss of heterozygosity (LOH) or a deleterious mutation in a DNA repair pathway gene. Poly(ADP-ribose) polymerase (PARP) inhibitors such as rucaparib exert their antitumor activity through synthetic lethality in cancer cells with HRD. Tumors with HRD have been shown to be sensitive to PARP inhibitors in breast, ovarian, and prostate cancers, and PARP inhibitors are approved for the treatment of patients with breast or ovarian cancer. Although there are little data on their activity in mUC, we hypothesize that PARP inhibition may have antitumor activity in this tumor type. The ATLAS (NCT03397394) trial is evaluating the efficacy and safety of the PARP inhibitor rucaparib as monotherapy for patients with locally advanced (unresectable) urothelial carcinoma or mUC previously treated with 1-2 anticancer treatments for advanced/metastatic disease. Methods: Eligible patients must have received 1-2 prior treatments (eg, platinum-based chemotherapy, immune checkpoint inhibitor, and/or clinical trial agent) and have radiographic progression, measurable disease (RECIST version 1.1), and adequate organ function. Tumor HRD is not required as rucaparib may potentially benefit patients with HR-proficient or HR-deficient tumors; however, fresh tumor or recently obtained archival tissue is mandatory for central HRD profiling. Prior PARP inhibitor treatment is an exclusion criterion. All patients will receive rucaparib monotherapy (600 mg BID) until disease progression or other reason for discontinuation. The primary endpoint is confirmed objective response rate (investigator assessed per RECIST version 1.1) in the intent-to-treat and HRD-positive (signature based on tumor genomic LOH) populations. Secondary endpoints include response duration, progression-free survival, overall survival, safety, and pharmacokinetics. Exploratory endpoints include evaluating plasma and tumor samples for biomarkers associated with response and resistance to rucaparib. The study has >90% power to reject the null hypothesis (P=0.10) at a one-sided 5% significance level if the true response rate for rucaparib is 20%. ATLAS is currently enrolling at ≈65 sites in 6 countries (France, Germany, Italy, Spain, United Kingdom, and United States), with a target enrollment of 200 patients. Citation Format: Petros Grivas, Min Yuen Teo, Nicholas Vogelzang, Ajjai Alva, Yousef Zakharia, Nabil Adra, Alexandra Drakaki, Arif Hussain, Rafael Morales-Barrera, Andrea Necchi, Alejo Rodriguez-Vida, Susan Feyerabend, Sumati Gupta, Debra H. Josephs, Yohann Loriot, Sandy Srinivas, Kenton Wride, Daleen Thomas, Rachel Dusek, Andrew D. Simmons, Dale Nepert, Simon Chowdhury. ATLAS: A Phase II, open-label study of rucaparib in patients with locally advanced or metastatic urothelial carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT179.

Biological molecular layer classification of muscle-invasive bladder cancer opens new treatment opportunities

BackgroundMuscle-invasive bladder tumors are associated with a high risk of relapse and metastasis even after neoadjuvant chemotherapy and radical cystectomy. Therefore, further therapeutic options are needed and molecular characterization of the disease may help to identify new targets. The aim of this study was to characterize muscle-invasive bladder tumors at the molecular level using computational analyses.MethodsThe TCGA cohort of muscle-invasive bladder cancer patients was used to describe these tumors. Probabilistic graphical models, layer analyses based on sparse k-means coupled with Consensus Cluster, and Flux Balance Analysis were applied to characterize muscle-invasive bladder tumors at a functional level.ResultsLuminal and Basal groups were identified, and an immune molecular layer with independent value was also described. Luminal tumors showed decreased activity in the nodes of epidermis development and extracellular matrix, and increased activity in the node of steroid metabolism leading to a higher expression of the androgen receptor. This fact points to the androgen receptor as a therapeutic target in this group. Basal tumors were highly proliferative according to Flux Balance Analysis, which makes these tumors good candidates for neoadjuvant chemotherapy. The Immune-high group showed a higher degree of expression of immune biomarkers, suggesting that this group may benefit from immune therapy.ConclusionsOur approach, based on layer analyses, established a Luminal group candidate for therapy with androgen receptor inhibitors, a proliferative Basal group which seems to be a good candidate for chemotherapy, and an immune-high group candidate for immunotherapy.

EDITORIAL COMMENT

A visibly complete transurethral resection (TUR) of non–muscle-invasive bladder tumors is essential to achieve local control and optimize response to intravesical therapy. To remove bladder tumors, they must first be seen. And once detected, how does one verify all tumors have been completely resected? Cystoscopy and TUR are usually performed using white light imaging (WLI). WLI may not reveal every papillary tumor or mucosa involved with carcinoma in situ, leading to incomplete resection and treatment failures. As an adjunct to WLI, cystoscopy enhancement technologies have now entered clinical practice. One of these is narrow band imaging (NBI) cystoscopy. NBI filters white light into 2 narrow bands that enhances contrast between normal mucosa and mucosal vascular tumors (Ref#15 article).

Expression of CD133 and CD24 and their different phenotypes in urinary bladder carcinoma.

Introduction: Several lines of evidence suggest the contribution of cancer stem cells (CSCs) to the tumorigenicity of bladder cancer. Although CD133 and CD24 CSC biomarkers are associated with survival disadvantages in some cancers, the biological attributes of a specific tumor alters the expression of these markers and any associated phenotypic characteristics.Aim: To analyze CD133 and CD24 expression and their different phenotypes in urinary bladder carcinoma.Material and methods: Expression of CD133 and CD24 and their divergent phenotypes were analyzed in patients with urinary bladder carcinoma (n=60) and correlated with clinicopathological parameters.Results: CD133+ and CD24+ tumor cells were more frequent in high grade, less differentiated carcinomas (18/22, and 15/17, p=0.022 and 0.01, respectively), muscle invasive tumors (20/22, p=0.017 and 17/17, p=0.001, respectively), and tumors with advanced stage (p=0.001 and 0.007, respectively). The expression of CD24 slightly correlated with lymphovascular invasion (p=0.04), whereas CD133 was associated with distant metastasis. The CD133+ CD24+ phenotype exhibited more aggressive tumorigenic behavior than other phenotypes.Conclusion: CD133+ and CD24+ cells correlated with determinants of aggressive behavior and may be involved in tumor progression and distant metastasis. The CD133+ subpopulation is likely to have a more potent tumorigenic capacity. Although divergent, the strong correlation between the two populations may support phenotypic plasticity among them. Compared to the CD133+ CD24− and CD133− CD24+ phenotypes, the CD133+ CD24+ phenotype is the most aggressive. These putative biomarkers can potentially aid in the selection of high-risk patients for more aggressive targeted therapy.

Comprehensive Multiparametric Magnetic Resonance Imaging After Transurethral Resection of Non Muscle-invasive Bladder Tumor; Can it Replace Second Look Biopsy? A Prospective Study

Comprehensive Multiparametric Magnetic Resonance Imaging After Transurethral Resection of Non Muscle-invasive Bladder Tumor; Can it Replace Second Look Biopsy? A Prospective Study

Effects of Long Noncoding RNA H19 Polymorphisms on Urothelial Cell Carcinoma Development.

Urothelial cell carcinoma (UCC) is one of the major malignancies of the genitourinary tract, and it is induced by carcinogenic epidemiological risk factors. H19 is one of the most crucial long noncoding RNAs (lncRNAs) and is involved in various types of bladder cancer. In this study, we examined H19 single-nucleotide polymorphisms (SNPs) to investigate UCC susceptibility and clinicopathological characteristics. Using real-time polymerase chain reaction, we analyzed five SNPs of H19 in 431 UCC patients and 431 controls without cancer. The results showed that patients with UCC carrying the H19 rs217727 CT + TT and rs2107425 CT + TT genetic variants had a high risk of developing muscle invasive tumors (pT2–T4) (p = 0.030; p = 0.025, respectively). With a median follow up of 39 months, CT+TT polymorphisms of rs2107425 were associated with worse disease-specific survival (adjusted hard ratio (AHR) = 2.043, 95% confidence interval (CI) = 1.029-4.059) in UCC patients aged older than 65 years. In conclusion, our results indicate that patients with UCC carrying the H19 rs217727 CT + TT and rs2107425 CT + TT genetic variants have a high risk of developing muscle invasive tumors. Thus, H19 polymorphisms may be applied as a marker or therapeutic target in UCC treatment.

Reduction of Muscle-Invasive Tumors by Photodynamic Therapy with Tetrahydroporphyrin-Tetratosylat in an Orthotopic Rat Bladder Cancer Model.

Photodynamic therapy (PDT) is a promising option for minimal-invasive treatment of bladder cancer. Efficacy of PDT in muscle-invasive urothelial cancer is still hampered by low tissue penetration of most photosensitizers due to short excitation wavelength. The novel light reactive agent tetrahydroporphyrin-tetratosylat (THPTS) is excitable at near-infrared (760 nm), allowing tissue penetration of up to 15 mm. Here, we established an orthotopic rat bladder cancer model and examined the effects of THPTS-PDT on tumor growth in vivo, and analyzed molecular mechanisms in vitro We examined pharmacokinetics and subcellular localization, and evoked cell death mode in cultured rat urothelial carcinoma cells (AY-27). We used female F344 Fischer rats for in vivo studies. Ten rats each were used for THPTS-PDT and light-only control. Bladders were evaluated by macroscopy and histology. Temperature-dependent THPTS uptake resulted in endosomal/lysosomal localization. PDT (0-50 μmol/L THPTS; 10 J/cm2) induced early onset of apoptosis leading to dose-dependent cytotoxicity in AY-27 cells. Single-time transurethral THPTS-PDT (100 μmol/L THPTS; 10 J/cm2) in F344 rats led to significant reduction of muscle-invasive tumor number (2/10 vs. 7/10 in controls) and total tumor volume (60% reduction) 2 weeks after PDT, while sparing healthy tissue. Here, we report for the first time effective tumor growth control by PDT in vivo THPTS is a promising new photosensitizer with the advantage of higher therapeutic depth and the potential of high-selective therapy in muscle-invasive urothelial cancer. This approach possibly allows minimal-invasive bladder preserving treatment of bladder cancer without systemic side effects.

Giant Muscle Invasive Dermatofibroma Clinically Mimicking a Malignant Tumor

Dermatofibromas are common benign fibrohistiocytic lesions, usually appearing as slow growing firm dermal nodules with a predilection for the extremities (mostly the lower legs). They are found mostly in middle-aged women and are usually smaller than 2 cm in diameter. Giant dermatofibromas exceeding 5 cm in diameter are rare. In recent years, reports have suggested a relationship between the primary size of dermatofibromas and rates of local recurrence and metastases after surgery. This relationship is however debated. The present report describes the case of a giant muscle invasive tumor in a 51-year-old female patient who presented with a large ulcerated mass in the right upper arm. The tumor appeared clinically malignant, measuring approximately 12 cm × 6 cm in size, with ulceration and invasion of surrounding muscle. Wide resection of the tumor was performed with myocutaneous flap-plasty. Histopathological examination showed evidence of a dermatofibroma. No recurrence, metastases, or other complications were noted at 5 years after surgery. The present case demonstrates that although dermatofibromas are essentially benign, they may present with atypical features including large size, ulceration, and muscle invasion, clinically mimicking malignant tumors.

Impact of RAGE polymorphisms on urothelial cell carcinoma clinicopathologic characteristics and long-term survival

ObjectivesUrothelial cell carcinoma (UCC) is a common malignancy of the urinary tract that is associated with environmental factors and genetic effects. Receptor for advanced glycosylation endproducts (RAGE) plays a vital role in chronic inflammation and tumorigenesis. This study explored the impact of RAGE gene polymorphisms on the clinicopathological status and prognosis of patients with UCC. Materials and methodsA total of 1,023 participants, including 431 patients with UCC and 592 healthy controls, were recruited for this study. Four polymorphisms of the RAGE gene, including -429T>C (rs1800625), -374T>A (rs1800624), Gly82Ser (rs2070600), and 1704G>T (rs184003), were examined using a real-time polymerase chain reaction with the TaqMan assay. ResultsWe found that individuals carrying at least 1 C allele at RAGE rs1800625 had a higher risk of developing UCC than those carrying a wild-type allele. Subgroup analysis revealed that among UCC patients aged younger than 65 years, those with a C allele at rs1800625 had a higher incidence of muscle invasive tumor and lymph node invasion. With a median follow-up of 39 months, TT polymorphisms of rs184003 were associated with worse disease-specific survival (HR = 7.58, 95% CI = 2.52–22.77, P < 0.001) and all-cause survival (HR = 6.45, 95% CI = 2.19–19.034, P < 0.001) in UCC patients aged younger than 65 years. ConclusionThis study is the first to report a correlation between RAGE polymorphisms and UCC risk. Individuals that carry at least 1 C allele at rs1800625 of RAGE are associated with a higher risk of UCC development, particularly if they belong to the categories previously identified. TT polymorphism at rs184003 is associated with worse disease-specific survival and overall survival in people aged ≤65 years.

Influence of the laparoscopic approach on cancer-specific mortality of patients with stage pt3-4 bladder cancer treated with cystectomy

Introduction and aimThe main aim of the study was to establish the oncological safety of the laparoscopic approach to radical cystectomy for high-risk, non-organ-confined urothelial tumours. Material and methodsA retrospective cohort study of 216 stage pT3-4 cystectomies operated between 2003 and 2016; using an open approach (ORC, n=108), and using a laparoscopic approach (LRC, n=108). ResultsBoth groups have similar pathological features except, in G3 TUR, there were more lyphadenectomies and greater pN+, and more adjuvant chemotherapies using the LRC. The median follow-up of the series was 15 (IQR: 8–10.5) months. Sixty-eight point one percent of the series relapsed, with no differences between either group (p=0.11). The estimated differences for cancer-specific survival was greater in the LRC group (p=0.03), as was overall survival (p=0.009). There were no differences between either group in estimated recurrence-free survival (p=0.26). The type of surgical approach (p=0.03), pTpN stage (p=0.0001), and administration of adjuvant chemotherapy (p=0.003) were related to cancer-specific mortality (CSM) in the univariate analysis. Only the pTpN stage (p=0.0001), and not giving adjuvant chemotherapy (p=0.003) behaved as independent predictive factors of CSM. ConclusionThe type of surgical approach to cystectomy (ORC vs. LRC) did not influence CSM. Lymph node involvement and not giving adjuvant chemotherapy were identified as predictive factors of CSM. Our study supports the oncological safety of the laparascopic approach for cystectomy in patients with locally advanced muscle-invasive bladder tumours.

A three-gene methylation marker panel for the nodal metastatic risk assessment of muscle-invasive bladder cancer.

In this study, we aimed to identify a DNA methylation pattern suitable for prognosis assessment of muscle-invasive bladder cancer and to investigate metastasis-associated processes regulated by DNA methylation. Genome-wide methylation analysis was performed on 23 muscle-invasive bladder tumors by microarray analysis. Validation was performed by the qAMP technique in two different patient cohorts (n = 32 and n = 100). mRNA expression was analyzed in 12 samples. Protein expression was determined using tissue microarrays of 291 patients. Bladder cancer cell lines T24 and 253JB-V were used for functional analyses. Microarray analyses revealed KISS1R, SEPT9 and CSAD as putative biomarkers with hypermethylation in node-positive tumors. The combination of the three genes predicted the metastatic risk with sensitivity of 73% and specificity of 71% in cohort 1, and sensitivity of 82% and specificity of 54% in cohort 2. mRNA expression differences were detected for KISS1R (p = 0.04). Protein expression of KISS1R was significantly reduced (p < 0.001). Knockdown of SEPT9v3 resulted in increased cell migration by 28% (p = 0.04) and increased invasion by 22% (p = 0.004). KISS1R overexpression resulted in decreased cell migration (25%, p = 0.1). We identified a methylation marker panel suitable to differentiate between patients with positive and negative lymph nodes at time of cystectomy. This enables a risk assessment for patients who potentially benefit from extended lymph node resection as well as from neoadjuvant chemotherapy and could improve the survival rates. Furthermore, we examined the impact of putative markers on tumor behavior. Hence, KISS1R and SEPT9 could represent a starting point for the development of novel therapy approaches.

Improving the diagnosis of high grade and stage bladder cancer by detecting increased urinary calprotectin expression in tumor tissue and tumor-associated inflammatory response.

PurposeTo investigate whether measurement of urinary calprotectin can serve as a biomarker in the diagnosis of primary bladder cancer and to confirm its diagnostic role in determining high grade and stage disease.Materials and MethodsUrinary calprotectin was measured in spot urine samples from patients with primary bladder cancer and control subjects. To confirm levels in urine, tissue samples were also obtained from bladder tumor and healthy trigone of bladder by transurethral resection in both groups. Finally, calprotectin levels in tissue and urine of the patients and control subjects were compared and their diagnostic potential was investigated in high grade and stage bladder cancers.ResultsOf 82 participants, 52 were patients with bladder cancer and 30 were control subjects. The two groups were comparable in terms of age, smoking status, and comorbidities. Tissue and urinary calprotectin levels were significantly higher in the bladder cancer group. In subgroup analyses, urinary calprotectin levels were significantly higher in patients with high-grade, muscle-invasive tumors. After receiver operating characteristic analyses, the sensitivity and specificity of urinary calprotectin was 100% and 96.7%, respectively, in the diagnosis of primary bladder cancer. High grade and stage bladder cancers were detected with sensitivity and specificity of 70% and 74.2%, and 80% and 84.8%, respectively.ConclusionsUrinary calprotectin may be a valuable parameter in the diagnosis of primary bladder cancer with high sensitivity and specificity. Furthermore, it may be useful in the prediction of high grade and stage disease. However, more investigations are needed.

How Safe Could Open Extravesical Bladder Cuff Resection Guarantee Complete Removal of Ipsilateral Ureteral Orifice?

Objectives: The aim of this study is to report our 8-year experience in terms of the success rate of complete bladder buff resection procedures bladder cuff resection (BCR) and further oncological outcomes in patients under open extravesical BCR for the management of primary upper tract urothelial carcinoma (UTUC). Materials and Methods: We retrospectively reviewed patients with primary UTUC who undergone laparoscopic nephroureterectomy and open extravesical BCR in our center. Complete BCR procedures were not defined by any ureteral orifice remnant noted in postoperative cystoscopy surveillance. The rate of complete BCR procedures was calculated. Patients were divided into residual ureteral orifice group (RUO) and nonRUO group (NRUO) and the intravesical and local recurrences and distant metastasis were analyzed and compared across the two groups. Results: A total of 105 patients were reviewed. After operation, 67 of them (63.8%) had ipsilateral strict criteria of complete BCR procedures defined on cystoscopy. Shorter mean operative time was noted in the RUO group comparing to the NRUO group (145 ± 73 vs. 192 ± 107 min, P = 0.03). Bladder recurrence was significantly higher in the RUO group (RUO vs. NRUO: 59.7% vs. 26%, P = 0.001) during a median of 39.7 months follow-up. Most of the intravesical recurrences were superficial (94%) and more prone to be found near the RUO/scar in the RUO group rather than the NRUO group (59.7% vs. 26.3%, P = 0.04). The RUO group strongly predicted superficial intravesical recurrence (odds ratio: 4.04, 95% confidence interval: 1.57–10.37, P = 0.004). No significant difference was recorded in muscle invasive bladder tumor, local recurrence, contralateral urinary tract recurrence, or distal metastasis across the groups. Conclusions: Open extravesical BCR does not guarantee the complete removal of ipsilateral ureteral orifice. Increased risk of superficial intravesical recurrence is noted in patients with RUO.

Diagnostic utility of GATA3 immunohistochemical expression in urothelial carcinoma.

This study aims to explore the utility of GATA binding protein 3, a zinc finger transcription factor, expression in genitourinary carcinoma, especially urothelial carcinoma. It is a prospective study where 74 consecutive cases of urothelial carcinoma along with 10 cases each of prostatic adenocarcinoma (PC) and conventional clear cell renal cell carcinoma were included between August 2016 and January 2017. All the cases were histopathologically evaluated and immunohistochemically stained for GATA binding protein 3. Only nuclear positivity was considered as positive. Immunoreactivity score for GATA expression was calculated based on the staining intensity as well as percentage. The statistical analysis was done using Statistical Package for Social Sciences Version 15.0 statistical analysis software. P value of <0.05 was considered statistically significance. GATA3 expressions were seen in 77% of the cases of urothelial carcinoma, whereas none of the clear cell renal cell carcinoma and prostatic adenocarcinoma cases was GATA3 positive. GATA3 expression significantly correlated with histological grade and muscle invasion with a weaker or negative expression in high-grade muscle invasive tumor as compared to low-grade and noninvasive neoplasm. Significantly weaker expression of GATA3 was found in cases with severe nuclear pleomorphism, mitosis >10/10 hpf, presence of necrosis, and tumor-infiltrating lymphocytes. No significant change in the status of GATA3 expression was seen in follow-up cases between initial Transurethral resection of bladder tumor (TURBT) and post-recurrence TURBT or radical cystectomy specimens. GATA3 as a sensitive and specific marker for urothelial carcinoma can be effectively used to exclude other genitourinary malignancies, PC, and renal cell carcinoma, at metastatic site. This marker can also be effectively used in predicting the probable grade and invasion in biopsy material with poor morphological characteristics, thereby helping in appropriate management in such cases.

UBC® Rapid Test-A Urinary Point-of-Care (POC) Assay for Diagnosis of Bladder Cancer with a focus on Non-Muscle Invasive High-Grade Tumors: Results of a Multicenter-Study.

Objectives: UBC® Rapid Test measures soluble fragments of cytokeratins 8 and 18 in urine. We present results of a multicenter study using an updated version of UBC® Rapid Test in bladder cancer patients, patients with urinary bladder cancer positive history, and healthy controls. Material and Methods: In total 530 urine samples have been included in this study. Clinical urine samples were used from 242 patients with tumors of the urinary bladder (134 non-muscle-invasive low-grade tumors (NMI-LG), 48 non-muscle-invasive high-grade tumors (NMI-HG), and 60 muscle-invasive high-grade tumors (MI-HG)), 62 patients with non-evidence of disease (NED), and 226 healthy controls. Urine samples were analyzed by the UBC® Rapid point-of-care (POC) assay and evaluated by Concile Omega 100 POC Reader. All statistical analyses have been performed using R version 3.2.3. Results: Elevated levels of UBC® Rapid Test in urine are higher in patients with bladder cancer in comparison to the control group (p < 0.001). The sensitivity for the whole bladder cancer cohort was 53.3% (positive predictive value (PPV) 90.2%, negative predictive value (NPV) 65.2%) and was 38.8% (PPV 78.8%, NPV 72.1%) for non-muscle-invasive low-grade bladder cancer; 75.0% (PPV 72.0%, NPV 94.7%) for non-muscle-invasive high-grade bladder cancer and 68.3% (PPV 74.6%, NPV 91.8%) for muscle-invasive high-grade bladder cancer. The specificity for the statistical calculations was 93.8%. The cut-off value (10 µg/L) was evaluated for the whole patient cohort. The area under the curve of the quantitative UBC® Rapid Test using the optimal threshold obtained by receiver operating characteristics (ROC) analysis was 0.774. Elevated values of UBC® Rapid Test in urine are higher in patients with high-grade bladder cancer in comparison to low-grade tumors and the healthy control group. Conclusions: UBC® Rapid Test has potential to be a clinically valuable urinary protein biomarker for detection of high-grade bladder cancer patients and could be added in the management of NMI-HG tumors. UBC® Rapid results generated in both study centers in the present multicenter study are very similar and reproducible. Furthermore UBC® Rapid Test is standardized and calibrated and thus independent of used batch of test as well as study site.

Discordant molecular subtype classification in the basal-squamous subtype of bladder tumors and matched lymph-node metastases

Molecular subtypes of muscle-invasive bladder tumors have emerged as a promising research tool with potential to stratify patients for neoadjuvant treatment. Prior to radical cystectomy, the utility of molecular classification and biomarkers depend on concordance between tissue from transurethrally resected specimens and disseminated disease. We assess the concordance of molecular subtypes and a large number of potential biomarkers in 67 pairs of muscle-invasive bladder tumors and synchronous lymph-node metastases. Tissue cores were stained for 29 immunohistochemistry markers and immunohistochemistry-based molecular subtype classification was performed. Molecular subtype was determined by mRNA profiling for 57 bladder tumors and 28 matched lymph-node metastases. Full section immunohistochemistry was performed to assess intra-tumor subtype heterogeneity in discordant cases, and exome sequencing was performed for 20 sample pairs. Discordant subtype classification between the bladder tumor and lymph-node metastasis was generally rare (12/67, 18%), but most (7/12, 58%) involved the Basal/Squamous-like subtype. Discordant Basal/Squamous-like tumors showed either Urothelial-like or Genomically Unstable, luminal-like phenotype in the lymph-node metastasis. Full section immunohistochemistry revealed intra-tumor subtype heterogeneity for six discordant cases including four involving the Basal/Squamous-like subtype. Subtype concordance for non- Basal/Squamous-like tumors was 91%. RNA-based classification agreed with immunohistochemistry classification but quantitative assessment is necessary to avoid false detection of subtype shifts. Most high confidence cancer mutations were shared between samples (n = 93, 78%), and bladder tumor private mutations (n = 20, 17%) were more frequent than those private to the lymph-node metastasis (n = 7, 6%). We conclude that bladder tumors and lymph-node metastases have overall similar molecular subtype, biomarker expression, and cancer mutations. The main exception was tumors of the Basal/Squamous-like subtype where most cases showed discordant classification, some with evidence of intra-tumor heterogeneity. The data are of relevance for neoadjuvant treatment stratification and raises questions on the dynamics of molecular subtypes during bladder cancer progression.

ATF2 promotes urothelial cancer outgrowth via cooperation with androgen receptor signaling.

We investigated the functional role of ATF2, a transcription factor normally activated via its phosphorylation in response to phospho-ERK/MAPK signals, in the outgrowth of urothelial cancer. In both neoplastic and non-neoplastic urothelial cells, the expression levels of androgen receptor (AR) correlated with those of phospho-ATF2. Dihydrotestosterone treatment in AR-positive bladder cancer cells also induced the expression of phospho-ATF2 and phospho-ERK as well as nuclear translocation and transcriptional activity of ATF2. Meanwhile, ATF2 knockdown via shRNA resulted in significant decreases in cell viability, migration and invasion of AR-positive bladder cancer lines, but not AR-negative lines, as well as significant increases and decreases in apoptosis or G0/G1 cell cycle phase and S or G2/M phase, respectively. Additionally, the growth of AR-positive tumors expressing ATF2-shRNA in xenograft-bearing mice was retarded, compared with that of control tumors. ATF2 knockdown also resulted in significant inhibition of neoplastic transformation induced by a chemical carcinogen 3-methylcholanthrene, as well as the expression of Bcl-2/cyclin-A2/cyclin-D1/JUN/MMP-2, in immortalized human normal urothelial SVHUC cells stably expressing AR, but not AR-negative SVHUC cells. Finally, immunohistochemistry in surgical specimens demonstrated significant elevation of ATF2/phospho-ATF2/phospho-ERK expression in bladder tumors, compared with non-neoplastic urothelial tissues. Multivariate analysis further showed that moderate/strong ATF2 expression and phospho-ATF2 positivity were independent predictors for recurrence of low-grade tumors (hazard ratio (HR) = 2.956, P = 0.045) and cancer-specific mortality of muscle-invasive tumors (HR = 5.317, P = 0.012), respectively. Thus, ATF2 appears to be activated in urothelial cells through the AR pathway and promotes the development and progression of urothelial cancer.

Reduced Recurrence of Low-grade Papillary Bladder Tumors Associated With Asymptomatic Bacteriuria

ObjectiveTo determine tumor recurrence rate of low-grade, papillary, and non–muscle-invasive (TaLG) bladder tumors in patients who have asymptomatic bacteriuria (ABU). Microbes in the urine trigger immune responses like intravesical Bacillus Calmette-Guerin, suggesting that common bacteria may also exert an antitumor effect. MethodsWe investigated recurrence rates in 387 patients with low-grade, papillary noninvasive bladder tumors TaLG, with or without ABU. They were followed every 6 months for 36 months, and did not receive antibiotics or intravesical chemotherapy. Recurrent tumors were treated generally by outpatient fulguration. Before cystoscopy, patients submitted a voided urine sample for culture, stratified as no growth, <104, >104, or >105 CFU/mL single organism. Any degree of bacteria on culture was classified as ABU. We also measured absolute neutrophil counts (ANC) and the presence of pyuria, as surrogate indicators of local immune response. ResultsOf the 387 cases, 200 (52%) had ABU, including 102 (27%) with >104 CFU/mL bacteriuria. With absolute 3-year follow-up, 75% of patients with ABU survived tumor-free compared to 40% of 187 uninfected patients (P = .001). Sixty percent of patients with negative cultures recurred vs 25%, 14%, and 29% of patients with <104, >104, or >105 CFU/mL. (P = .001). Mean number of recurrent tumors in colonized patients was 4.2 vs 8.4 in uninfected patients (P = .009). ANC averaged 6.3 K/mcL in bacteriuric vs 4.1 K/mcL in uninfected patients (P = .01). ConclusionPatients with papillary TaLG tumors and chronic ABU had fewer recurrences, fewer numbers of recurrent tumors, and longer tumor-free survival times than similarly staged uninfected patients. Bladder-resident bacteria may reduce bladder tumor recurrences through local immune mechanisms.