Non-muscle Invasive Urothelial Carcinoma Research Articles

MP44-15 ANXA10 AND ATP7A ARE THE MTOR PATHWAY DOWNSTREAM TO PREDICT THE RECURRENCE AND PROGRESSION IN NON-MUSCLE INVASIVE HIGH GRADE UROTHELIAL CARCINOMA OF THE BLADDER

You have accessJournal of UrologyBladder Cancer: Basic Research & Pathophysiology I1 Apr 2017MP44-15 ANXA10 AND ATP7A ARE THE MTOR PATHWAY DOWNSTREAM TO PREDICT THE RECURRENCE AND PROGRESSION IN NON-MUSCLE INVASIVE HIGH GRADE UROTHELIAL CARCINOMA OF THE BLADDER Byung Hoon Chi, Subin Jin, Young Mi Whang, Seung Hyun Ahn, Jae Duck Choi, Shin Young Lee, In Ho Chang, and Bongsuk Shim Byung Hoon ChiByung Hoon Chi More articles by this author , Subin JinSubin Jin More articles by this author , Young Mi WhangYoung Mi Whang More articles by this author , Seung Hyun AhnSeung Hyun Ahn More articles by this author , Jae Duck ChoiJae Duck Choi More articles by this author , Shin Young LeeShin Young Lee More articles by this author , In Ho ChangIn Ho Chang More articles by this author , and Bongsuk ShimBongsuk Shim More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1346AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The cross-talk of mammalian target of rapamycin (mTOR) pathway is clinical limitation of mTOR inhibitor for the treatment of urothelial carcinoma (URCa) of the bladder. This study is to search mTOR pathway downstream genes to overcome cross-talk at non muscle invasive high grade (HG)-URCa of the bladder. METHODS Gene expression patterns, gene ontology, and gene clustering by triple (p70S6K, S6K and eIF4E) siRNAs or rapamycin in 5637 and T24 cell lines were investigated by microarray analysis and we selected mTOR pathway downstream genes which were suppressed to siRNAs more than two fold, and rapamycin up-regulated or rapamycin down-regulated. And then we validated mTOR downstream genes with immunohistochemistry using tissue microarray of 125 non-muscle invasive HG-URCa patients whether genes can predict clinical aggressiveness and long-term outcomes, and knockout study to evaluate the synergistic effect with rapamycin. RESULTS In the microarray analysis, we selected mTOR pathway downstream genes which consisted of 4 rapamycin up-regulated (FABP4, H19, ANXA10, and UPK3A), and 4 rapamycin down-regulated (FOXD3, ATP7A, plexin D1 and ADAMTS5). In tissue microarray, FABP4 and ATP7A were more expressed at T1, and FOXD3 was at Ta. ANXA10 and ADAMTS5 were more expressed at 3 cm or less than 3cm. In Kaplan-Meier curve, ANXA10 was a significant predictor of recurrence, and FABP4 and ATP7A were significant predictors of progression of HG-URCa of the bladder. In multivariate Cox regression model, ANXA10 was a significant predictor of recurrence and ATP7A was a significant predictors of progression in non-muscle invasive HG-URCa of the bladder. In ATP7A knock out model, rapamycin treatment showed synergistic effect to inhibit cell viability, wound healing, and invasion ability compared to rapamycin only. CONCLUSIONS ANXA10 and ATP7A might be mTOR pathway downstream genes to predict recurrence and progression in non-muscle invasive high-grade urothelial carcinoma of the bladder and ATP7A knockout overcome the rapamycin coss-talk. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e569 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Byung Hoon Chi More articles by this author Subin Jin More articles by this author Young Mi Whang More articles by this author Seung Hyun Ahn More articles by this author Jae Duck Choi More articles by this author Shin Young Lee More articles by this author In Ho Chang More articles by this author Bongsuk Shim More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Next-generation sequencing of urine specimens: A novel platform for genomic analysis in patients with non-muscle-invasive urothelial carcinoma treated with bacille Calmette-Guérin.

Biopsies from patients with high-risk (HR) non-muscle-invasive urothelial carcinoma (NMIUC), especially flat urothelial carcinoma in situ, frequently contain scant diagnostic material or denuded mucosa only, and this precludes further extensive genomic analysis. This study evaluated the use of next-generation sequencing (NGS) analysis of urine cytology material from patients with HR NMIUC in an attempt to identify genetic alterations that might correlate with clinical features and responses to bacille Calmette-Guérin (BCG) treatment. Forty-one cytology slides from patients with HR NMIUC treated with intravesical BCG were selected for this study. Histological confirmation was available for all cases. The specimens were subjected to NGS analysis with a customized targeted exome capture assay composed of 341 genes. In this cohort, genomic alterations were successfully identified in all cytology samples. Mutations were detected down to a 2% allele frequency and chromosomal rearrangements including copy number alterations and gene fusions were identified. The most frequently altered genes included telomerase reverse transcriptase (TERT), tumor protein 53 (TP53), Erb-B2 receptor tyrosine kinase 2 (ERBB2), and chromatin remodeling genes such as lysine demethylase 6A (KDM6A) and AT-rich interaction domain 1A (ARID1A). For patients with matched tumor tissue, cytology specimens revealed all mutations detected in tissue as well as additional mutations, and this suggested that urine might more effectively capture the full genetic heterogeneity of disease than an individual cystectomy. Alterations in multiple genes correlated with clinical and histopathological features, including responses to BCG treatment, flat architecture versus papillary architecture, and smoking history. Urine specimens can replace tissue as a substrate for NGS analysis of HR NMIUC. Several genomic alterations identified in urine specimens might be associated with histological features and clinical characteristics. Cancer Cytopathol 2017;125:416-26. © 2017 American Cancer Society.

A phase I trial for the use of intravesical cabazitaxel, gemcitabine, and cisplatin (CGC) in the treatment of BCG-refractory nonmuscle invasive urothelial carcinoma of the bladder.

313 Background: Salvage intravesical chemotherapy has shown benefit in patients with high-risk non-muscle invasive bladder cancer who fail first line therapy. Our preclinical murine intravesical trial showed a combination therapy was superior to single-agents. Our objective was to investigate the safety of intravesical triple agent salvage chemotherapy consisting of cabazitaxel, gemcitabine and cisplatin (CGC). Methods: Patients with BCG refractory or recurrent high-risk non-muscle invasive bladder cancer who refused radical cystectomy were enrolled. All patients underwent a pre-treatment transurethral resection of bladder tumor and then received a 6-week regimen. All patients received the same dose of gemcitabine (2000mg) while the dose of cisplatin and cabazitaxel were escalated as shown in table 1. Toxicity was categorized according to CTC for Adverse Events v4 and included hematuria, dysuria, bladder spasm, urinary retention or frequency. A complete response (CR) was defined as a negative random bladder biopsy and negative cytology six weeks after treatment. Results: Median age of the 9 patients was 74 years (table 1) and the median number of prior intravesical therapies was 4 (range 2-5). All patients completed 6 weeks of induction CGC. Any local toxicity was found in 7 patients with 5 experiencing at least 1 grade 1 toxicity and 4 experiencing at least 1 grade 2 toxicity. Seven of eight patients were complete responders and initiated maintenance therapy. Conclusions: CGC appears to be a well-tolerated intravesical salvage chemotherapy regimen for the treatment of BCG-refractory NMIBC. Clinical trial information: NCT02202772. [Table: see text]

MicroRNA Expression Profile Identifies High Grade, Non-Muscle-Invasive Bladder Tumors at Elevated Risk to Progress to an Invasive Phenotype.

The objective of this study was to identify a panel of microRNAs (miRNAs) differentially expressed in high-grade non-muscle invasive (NMI; TaG3–T1G3) urothelial carcinoma that progress to muscle-invasive disease compared to those that remain non-muscle invasive, whether recurrence happens or not. Eighty-nine high-grade NMI urothelial carcinoma lesions were identified and total RNA was extracted from paraffin-embedded tissue. Patients were categorized as either having a non-muscle invasive lesion with no evidence of progression over a 3-year period or as having a similar lesion showing progression to muscle invasion over the same period. In addition, comparison of miRNA expression levels between patients with and without prior intravesical therapy was performed. Total RNA was pooled for microarray analysis in each group (non-progressors and progressors), and qRT-PCR of individual samples validated differential expression between non-progressive and progressive lesions. MiR-32-5p, -224-5p, and -412-3p were associated with cancer-specific survival. Downregulation of miR-203a-3p and miR-205-5p were significantly linked to progression in non-muscle invasive bladder tumors. These miRNAs include those implicated in epithelial mesenchymal transition, previously identified as members of a panel characterizing transition from the non-invasive to invasive phenotype in bladder tumors. Furthermore, we were able to identify specific miRNAs that are linked to postoperative outcome in patients with high grade NMI urothelial carcinoma of the bladder (UCB) that progressed to muscle-invasive (MI) disease.

Is dose-dependent response to bacillus Calmette-Guérin treatment in urothelial carcinoma?

Bacillus Calmette-Guerin (BCG) intravesical instillation therapy has been established as a standard of care treatment for high-risk non-muscle invasive urothelial carcinoma (NMIUC). To date, many clinical have demonstrated a direct antitumor activity, prevention of tumor recurrence, reductions in tumor progression and, consequently, tumor specific mortality and improvement in overall survival. Nevertheless, the local adverse events arising from BCG intravesical account for about one-third of treatment discontinuations. Strategies to minimize the side effects are needed.

The Role of Cytologic Analysis in Follow-Up of Non-Muscle Invaisve Urothelial Cell Carcinoma in Relation to Cystoscopic Biopsy

Background: Bladder urothelial carcinoma has high recurrence rate so patients with bladder urothelial carcinoma have to be monitored thoroughly for disease recurrence, this makes bladder cancer one of the most expensive cancer types for the health care system. Voided urine cytology is the most commonly used noninvasive follow-up diagnostic tool. The purpose of this study was to assess the role of voided urine cytology for the follow-up of patients with non-muscle invasive urothelial carcinoma (NMIUC). Materials and methods: In total, 200 patients were enrolled in this study. Both urine cytology and cystoscopy were done for each patient every three months and end-point of the surveillance was at 9 months after the first collection of urine and first cystoscopy done. In each time we correlate the findings of urine cytology and cystoscopy. Results: The sensitivity of voided urine cytology was low while the specificity of voided urine cytology was high after their estimation every three months for nine months. The positive predictive value of voided urine cytology was 0.867, while the negative predictive value was 0.919 at the end point of surveillance. None of the 180 patients with negative results of both cytology and cystoscopy developed recurrence for 6 months after initial diagnosis. Conclusion: Cytology has higher specificity than sensitivity especially for high grade urothelial carcinoma and high predictive value but it still was not sufficiently good to be a substitute for cystoscopy. However, follow-up cystoscopy may be temporarily postponed for a period of 6 month if urine cytology is negative.

Identification of Downstream Genes of the mTOR Pathway that Predict Recurrence and Progression in Non-Muscle Invasive High-Grade Urothelial Carcinoma of the Bladder.

Microarray analysis was used to investigate the lack of identified mammalian target of rapamycin (mTOR) pathway downstream genes to overcome cross-talk at non-muscle invasive high-grade (HG)-urothelial carcinoma (UC) of the bladder, gene expression patterns, gene ontology, and gene clustering by triple (p70S6K, S6K, and eIF4E) small interfering RNAs (siRNAs) or rapamycin in 5637 and T24 cell lines. We selected mTOR pathway downstream genes that were suppressed by siRNAs more than 2-fold, or were up-regulated or down-regulated by rapamycin more than 2-fold. We validated mTOR downstream genes with immunohistochemistry using a tissue microarray (TMA) of 125 non-muscle invasive HG-UC patients and knockout study to evaluate the synergistic effect with rapamycin. The microarray analysis selected mTOR pathway downstream genes consisting of 4 rapamycin up-regulated genes (FABP4, H19, ANXA10, and UPK3A) and 4 rapamycin down-regulated genes (FOXD3, ATP7A, plexin D1, and ADAMTS5). In the TMA, FABP4, and ATP7A were more expressed at T1 and FOXD3 was at Ta. ANXA10 and ADAMTS5 were more expressed in tumors ≤ 3 cm in diameter. In a multivariate Cox regression model, ANXA10 was a significant predictor of recurrence and ATP7A was a significant predictor of progression in non-muscle invasive HG-UC of the bladder. In an ATP7A knock-out model, rapamycin treatment synergistically inhibited cell viability, wound healing, and invasion ability compared to rapamycin only. Activity of the ANXA10 and ATP7A mTOR pathway downstream genes might predict recurrence and progression in non-muscle invasive HG-UC of the bladder. ATP7A knockout overcomes rapamycin cross-talk.

Editorial Comment

The aim of the study by Golabesk et al 1 Golabesk T. Palou J. Rodriguez O. et al. Long-term bladder and upper urinary tract follow-up recurrence and progression rates of G1-2 non-muscle invasive urothelial carcinoma of the bladder. Urology. 2016; https://doi.org/10.1016/j.urology.2016.07.063 Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar was to evaluate the risk of long-term tumor recurrence and progression in patients with low- and intermediate-risk non-muscle-invasive bladder cancers to facilitate optimization in follow-up schedules, as the duration of follow-up in G1-2 tumors remains controversial, especially after 5 years of being recurrence-free. The goals of less rigid surveillance would be to spare patients from unnecessary cystoscopy and radiation, as well as to reduce cost.

Analysis of papillary urothelial carcinomas of the bladder with grade heterogeneity: supportive evidence for an early role of CDKN2A deletions in the FGFR3 pathway.

The dual pathway model of urothelial carcinogenesis does not fully explain grade and stage progression in patients with initial low-grade, non-muscle invasive urothelial carcinomas. Fibroblast growth factor receptor 3 (FGFR3) mutations are a hallmark of the low-grade pathway, with subsequent progression to muscle invasion occurring when FGFR3 mutant tumours exhibit a homozygous CDKN2A deletion. We hypothesized that grade heterogeneity represents the morphological manifestation of molecular changes associated with disease progression. We identified retrospectively 29 non-muscle invasive papillary urothelial carcinomas with grade heterogeneity (<20% high grade). Nineteen had sufficient material for immunohistochemistry, CDKN2A fluorescence in-situ hybridization and FGFR3 mutation analysis. Eight pure low-grade urothelial carcinomas (PLGUC) were also analysed. FGFR3 mutation was seen in 10 of 19 cases. A homozygous CDKN2A deletion was identified in the low-grade areas of eight of nine (88%) technically suitable FGFR3 mutant cases (including five pTa cancers), in five of nine FGFR3 wild-type carcinomas and in none of the PLGUC. Increased MIB-1 expression was seen in low-grade areas of 12 of 19, in high-grade areas of 17 of 19 cases with grade heterogeneity and in none of the PLGUC. p53 staining was increased in one of 19 low-grade and seven of 19 high-grade areas. Our findings show that grade heterogeneity in urothelial carcinoma is characterized by increased MIB-1 labelling, and particularly in the FGFR3 mutant pathway, with homozygous deletions of CDKN2A in low- and high-grade areas. This would suggest that CDKN2A deletion occurs prior to grade progression and supports the current convention to assign the highest grade to urothelial carcinomas with grade heterogeneity.

Is the Expression of p53, c-&lt;italic&gt;erb&lt;/italic&gt;-B2 and Ki-67 Influence the Prognosis of the Non-muscle Invasive Urothelial Bladder Cancer?

Purpose The immunohistochemial markers can be used to predict prognosis more accurately for several cancers. In non-muscle invasive urothelial carcinoma, p53, c-erb-B2 and Ki-67 are applicable. We investigated a retrospective analysis of the relation between the markers and clinical prognostic factors of urothelial bladder cancer. Materials and Methods Data from 268 non-muscle invasive urothelial bladder cancer (Ta, T1) patients from one single center were collected. Immunohistochemical evaluation was carried out on 268 (p53, c-erb-B2, Ki-67) cases. Clinical prognostic factors are as follows; number of tumor, tumor invasiveness, tumor grade and recurrence. The sum of all positivity of 3 markers was made as a new factor and evaluation of correlation between this factor and prognostic factors was also done. Statistical analysis was done by chi-squares test and Pearson's correlation test. Results Through chi-square test, there were significant relations between all markers and tumor invasiveness (p<0.001), tumor grade (p<0.001). Number of tumor is significantly related with Ki-67 (p=0.043). Recurrence is related with c-erb-B2 (p=0.010) and Ki-67 (p=0.043). There was also significant correlations between the sum of the markers and prognostic factors-tumor invasiveness (p<0,001), tumor grade (p<0.001) and recurrence (p=0.007). Conclusions In this study, evaluated markers were closely related with clinical prognostic factors and may contribute to decision making on risk-assessment and management strategy for non-muscle invasive urothelial bladder cancer. Key Words: Urinary bladder neoplasms; Immunohistochemistry; Risk assessment.

Abstract 4466: GULP1 is a potential tumor suppressor that modulates chemo-resistance through regulation of Nrf2-Keap1 signaling axis in urothelial carcinoma

Abstract By an integrated genomic approach, we recently identified engulfment adaptor PTB-domain-containing 1 (GULP1) as a potential tumor suppressor gene (TSG), selectively silenced in different types of solid tumors by promoter methylation (PM). Here, we aimed to test GULP1 PM in urothelial carcinoma (UC) and to functionally characterize GULP1 during UC initiation, progression and acquisition of chemo-resistance. Initially, using a panel of cell lines, we observed that silencing of GULP1 expression is mediated by PM in UC cell lines. Furthermore, to test if this phenomenon is clinically relevant, we first employed quantitative methylation specific PCR on 20 primary tumors and matched normal samples. We observed higher frequency of GULP1 PM in tumors (35.0%) than in matched normal tissues (10.0%). Secondly, additional 76 tumors of different stages and grades of UC were tested and the methylation frequency were similar in UCs (27.1%) and significantly higher than in normal urothelial tissues (9.5%). Interestingly, UC cases with GULP1 PM had a tendency of lymphatic/venous invasion (P = 0.066) when compared with cases without GULP1 PM. Moreover, to explore the correlation of GULP1 expression with different clinicopathological parameters, we performed immunohistochemical analyses on 2 different UC Tissue-Micro-Arrays. Overall GULP1 silencing was observed in 85% of UC cases and silencing is significantly more in muscle invasive UC (MIUCs) than in non-muscle invasive UC (NMIUCs) (P&amp;lt;0.001, Fisher's exact test). Numerous cell based assays revealed that GULP1 silencing confers growth advantage to tumor cells. Further mechanistic analysis revealed that GULP1 has a crucial role in the regulation of Nrf2-KEAP1 axis, maintaining actin cytoskeleton architecture and assisting KEAP1 to prevent Nrf2 nuclear translocation. By using RT2 pathway expression array analysis of ShGULP1 T24 cells and T24 cells, we discovered that GULP1 silencing induces activation of Nrf2 targets, such as heme oxygenase 1 (HMOX1). We further confirmed the inverse correlation between GULP1 and HMOX1 expression in numerous UC cell lines by forcefully modulating GULP1 expression. Since constitutive activation of Nrf2 signature has been defined as responsible for chemoresistance, we analyzed GULP1 PM and expression in cisplatin based therapy responsive and resistant primary UC samples; and in isogenic cisplatin sensitive and resistant T24 cell lines. Interestingly, GULP1 expression is lower both in resistant primary UC samples and in resistant T24 cell line. Altogether, our findings determined that GULP1 is an epigenetically silenced potential TSG in UC and its inactivation lead to malignant progression by constitutive activation of NRF2 pathway in UC carcinogenesis. Furthermore, GULP1 expression and/or PM may guide in selecting candidate patients for cisplatin based neo-adjuvant therapy. Citation Format: Elisa Guida, Masamichi Hayashi, Alexander Baras, Leonel Maldonado, Mariana Brait, Leonardo Reis, akira oki, Evgeny Izumchenko, trinity bivalaqua, george J. Netto, Wayne Koch, David Sidransky, mohammad O. Hoque. GULP1 is a potential tumor suppressor that modulates chemo-resistance through regulation of Nrf2-Keap1 signaling axis in urothelial carcinoma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4466.

Robot-Assisted Radical Cystectomy for Bladder Cancer in Octogenarians.

To evaluate perioperative morbidity and mortality rate, a 3-year recurrence-free survival, and cancer-specific mortality rate in patients older than 80 years undergoing robot-assisted radical cystectomy (RARC). We retrospectively collected data of 155 consecutive patients who received RARC for muscle-invasive or high-risk nonmuscle-invasive urothelial carcinoma of the bladder between 2003 and 2014 at a high-volume robotic center. Diversion was performed intra- or extracorporeally according to the surgeon's preferences. Complications were graded according to the Clavien-Dindo system. Logistic regression analyses were used to assess the impact of age on postoperative outcomes. Of 155 consecutive patients, 22 (14.2%) patients were 80 years or older. Octogenarians did not significantly differ from younger patients in ASA score (p = 0.4) and Charlson comorbidity index (p = 0.4). Prevalence of any grade and high-grade complications was similar in both groups (all p ≥ 0.6). Older patients had a significantly higher pathologic tumor grade (p = 0.04) and a lower use of pelvic lymphadenectomy (p < 0.001). No perioperative mortality rate was recorded within 90 days from surgery. Elderly patients had a similar risk of 3-year oncologic recurrence after surgery compared with their younger counterparts (odds ratio [OR] 1.63; p = 0.2). Conversely, the risk of cancer-specific mortality rate was significantly higher (OR 2.78; p = 0.02). Patients 80 years or older undergoing RARC for bladder cancer did not have a higher risk of peri- and postoperative morbidity and mortality rate and had a similar 3-year recurrence-free survival, suggesting that RARC can be safely performed in selected elderly patients by experienced surgeons.

AB176. Impact of squamous and/or glandular differentiation on recurrence and progression after transurethral resection for non-muscle invasive urothelial carcinoma of bladder

ObjectiveTo investigate the impact of squamous and/or glandular differentiation on recurrence and progression in patients with non-muscle-invasive urothelial carcinoma of bladder (NMIUCB) following transurethral resection (TURBT).MethodsA total of 869 patients with NMIUCB treated with TURBT at our institution from January 2006 to January 2011 were selected retrospectively for the analysis. Correlations among squamous and/or glandular differentiation with other clinical and pathological features were assessed by chi-square. Recurrence-free survival (RFS) and progression-free survival (PFS) curves were estimated using the Kaplan-Meier method. Univariate and multivariate analyses were performed through a Cox proportional hazards regression model.ResultsAmong 869 consecutive patients, 232 (26.7%) patients had squamous and/or glandular differentiation. High grade tumors were more common in patients with squamous and/or glandular differentiation than those with pure UCB (P<0.001). Correlations between age (P=0.115), gender (P=0.184), tumor size (P=0.223), tumor multiplicity (P=0.108), pathological tumor stage (P=0.909) and squamous and/or glandular differentiation were not statistically significant. There was a statistically prominent tendency towards higher recurrence rate and shorter RFS time in patients with squamous and/or glandular differentiation. However, no statistically significant differences were observed in progression rate and PFS between the two groups. On multivariate Cox regression analysis, squamous and/or glandular differentiation was identified as an independent prognostic predictor of recurrence (HR 1.46, 95% CI, 1.10–1.92, P=0.008).ConclusionsThe presence of squamous and/or glandular differentiation could be associated with higher recurrence rate and shorter RFS time in patients with NMUCB. It is an independent prognostic predictor of recurrence.

Non-muscle invasive high grade urothelial carcinoma of the bladder. Which factors can influence understaging at the time of radical cystectomy?

To evaluate the main factors which influence understaging in patients with T1G3 non-muscle invasive bladder cancer (NMIBC). 109 patients with T1/G3 underwent transurethral resection of bladder tumor (TURBT) and then radical cystectomy (RC) with pelvic lymph nodes dissection. A number of variables were considered when evaluating the detection of understaging. We considered the patients age and gender, as well as the size, number, location and morphology of their tumor. We also considered coexistence of bladder carcinoma in situ (CIS), microscopic vascular invasion and deep lamina propria invasion. The level of experience of the surgeon was also analyzed. in RC samples muscle invasion, that is understaging, was detected in 74 (67.9%) patients, while 35 (32.1%) patients were appropriately staged. In these cohort of patients with high grade tumors, understaging was associated with deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size &gt; 6 cm, tumor location (trigone and dome), presence of residual tumor; age, gender, tumor morphology, CIS associated, and experience of urological surgeon were not associated with clinical understaging. in our study, evaluating patients with high grade NMIBC at first TURBT, we identified some risk factors that need to be considered and that are able to increase the risk of understaging: deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size &gt; 6 cm, tumor location (trigone and dome), presence of residual tumor. When these risk factors are present, performing an early cystectomy, and not a re-TURBT, could lower the risk of worse pathological finding due to rapid disease progression of the high grade tumors, and can prolong survival.

The prognostic factors and predictive model of non-muscle invasive upper tract urothelial carcinoma: a survival analysis based on follow up over 5 years

Objective to evaluate the prognostic factors of non-muscle invasive upper tract urothelial carcinoma (NMIUTUC) and construct prognostic model for Chinese patients. Methods A retrospective study including 253 patients who were diagnosed with NMIUTUC in our hospital and received Radical nephroureterectomy (RNU) or partial ureterectomy during January of 2000 to December of 2013. Of all the 253 patients, 100 were male and 153 were female, average age was 67 (range: 25-90), 244 received RNU and 9 received partial ureterectomy. Results The median follow-up time was 55 (range: 4-151) months, and during follow-up, 40 (15.8%) patients were died for cancer, 84 (33.2%) patients developed intravesical recurrence. The independent prognostic factors of cancer-specific mortality were lymph nodes metastasis (P=0.046), main tumor locate in pelvis (P=0.044), ipsilateral hydronephrosis (P=0.039), higher chronic kidney disease (CKD) stage (P=0.008) and male gender (P=0.034), while patients with multifocality tumor or ipsilateral hydronephrosis more likely developed intravesical recurrence. Conclusion NMIUTUC has a better cancer-specific survival, the intravesical recurrence was equivalent to UTUC but later. Lymph nodes metastasis, main tumor locate in pelvis, ipsilateral hydronephrosis, CKD stage and male gender independently associated with cancer-specific mortality, while patients with multifocality tumor or ipsilateral hydronephrosis more likely developed intravesical recurrence. Key words: Non-muscle invasive upper tract urothelial carcinoma; Survival analysis; Prognostic factor; Nomogram

Clinical implications of intravesical recurrence after radical nephroureterectomy for upper urinary tract urothelial carcinoma.

To characterize the site and clinical implications of intravesical recurrence after radical nephroureterectomy for upper urinary tract urothelial carcinoma. Patients who underwent radical nephroureterectomy for upper urinary tract urothelial carcinoma between 2000 and 2011 at 12 institutions participating in the Tohoku Urological Evidence-Based Medicine Study Group were included in the present study. Those who underwent prior or simultaneous radical cystectomy were excluded. The site of intravesical recurrence was investigated, and the survival curves after radical nephroureterectomy were analyzed retrospectively using the Kaplan-Meier method. Multivariate analyses of factors predicting survival were carried out. A total of 534 patients were eligible for the present study. With a median follow up of 47months, 205 patients (38.4%) had intravesical recurrence. The intravesical recurrence-free survival rates at 1, 2, and 5years were 74.6%, 62.5% and 56.3%, respectively. In a subset of 137 patients with intravesical recurrence who did not have bladder cancer before or at the diagnosis of upper urinary tract urothelial carcinoma, the most frequent site of intravesical recurrence was around the cystotomy (52.6%), followed by at the posterior wall (39.4%) and at the bladder neck (35.8%). A total of 36 patients (17.6%) developed muscle-invasive bladder cancer after radical nephroureterectomy. On multivariate analyses for the subset of patients with non-muscle invasive (≤pT1) upper urinary tract urothelial carcinoma, intravesical recurrence was an independent predictor of cancer-specific survival (HR 4.27, P=0.016) and overall survival (HR 3.00, P=0.018). Most intravesical recurrences occur around the site of bladder mucosal injury within 1year after radical nephroureterectomy, providing important insight into the mechanism of intravesical recurrence. Intravesical recurrence after radical nephroureterectomy had an impact on oncological outcomes of patients with non-muscle invasive upper urinary tract urothelial carcinoma.

The Dose-Response Relationship of bacillus Calmette-Guérin and Urothelial Carcinoma Cell Biology

Attenuated mycobacterium bacillus Calmette-Guérin is widely used as intravesical immunotherapy of nonmuscle invasive urothelial carcinoma. Currently there are limited data on the relationship between bacillus Calmette-Guérin dose intensity and tumor response. We evaluated the dose-response relationship of bacillus Calmette-Guérin to nonmuscle invasive bladder cancer invitro using urothelial carcinoma cell lines and invivo using an orthotopic mouse model. Two human urothelial carcinoma cell lines were used to study the effect of bacillus Calmette-Guérin dose on the tumor cell response. Internalization, activation of signaling pathways, gene transactivation, cell viability, lactate dehydrogenase and HMGB1 release were study end points. An orthotopic tumor model was used to compare the effect of different doses on the antitumor efficacy of bacillus Calmette-Guérin. Bacillus Calmette-Guérin internalization by urothelial carcinoma cells increased as a function of time and dose with a plateau at higher doses and/or long exposure times. Intracellular signaling demonstrated a similar direct, dose dependent increase. Cytokine expression by urothelial carcinoma cells as a function of dose was variable. Some genes increased progressively but others showed a decrease at the highest dose. While nonviable cell number increased in proportion to dose, the number of cells undergoing necrotic cell death decreased at higher doses. A higher dose of bacillus Calmette-Guérin (1:200) showed a better antitumor effect than a standard dose (1:50) (p <0.01). Bacillus Calmette-Guérin dose has a direct impact on urothelial carcinoma cell biology. Increased dose intensity, particularly in nonresponders, may represent a strategy to increase bacillus Calmette-Guérin treatment efficacy.

Use of Artificial Intelligence and Machine Learning Algorithms with Gene Expression Profiling to Predict Recurrent Nonmuscle Invasive Urothelial Carcinoma of the Bladder

Due to the high recurrence risk of nonmuscle invasive urothelial carcinoma it is crucial to distinguish patients at high risk from those with indolent disease. In this study we used a machine learning algorithm to identify the genes in patients with nonmuscle invasive urothelial carcinoma at initial presentation that were most predictive of recurrence. We used the genes in a molecular signature to predict recurrence risk within 5 years after transurethral resection of bladder tumor. Whole genome profiling was performed on 112 frozen nonmuscle invasive urothelial carcinoma specimens obtained at first presentation on Human WG-6 BeadChips (Illumina®). A genetic programming algorithm was applied to evolve classifier mathematical models for outcome prediction. Cross-validation based resampling and gene use frequencies were used to identify the most prognostic genes, which were combined into rules used in a voting algorithm to predict the sample target class. Key genes were validated by quantitative polymerase chain reaction. The classifier set included 21 genes that predicted recurrence. Quantitative polymerase chain reaction was done for these genes in a subset of 100 patients. A 5-gene combined rule incorporating a voting algorithm yielded 77% sensitivity and 85% specificity to predict recurrence in the training set, and 69% and 62%, respectively, in the test set. A singular 3-gene rule was constructed that predicted recurrence with 80% sensitivity and 90% specificity in the training set, and 71% and 67%, respectively, in the test set. Using primary nonmuscle invasive urothelial carcinoma from initial occurrences genetic programming identified transcripts in reproducible fashion, which were predictive of recurrence. These findings could potentially impact nonmuscle invasive urothelial carcinoma management.

Prognostic significance of survivin, β-catenin and p53 expression in urothelial carcinoma.

Survivin, β-catenin, and p53 are well-known cell-cycle and apoptosis regulators of tumorigenesis. Urothelial carcinomas (UCs) are the most common of the human cancers. Compared to superficial tumors (Ta, CIS, or T1), invasive UCs are important with regard to recurrence, progression, and mortality. Therefore, we examined whether survivin, β-catenin, and p53 could be used as the biomarkers for the early prediction of the invasiveness of UCs and the overall survival of the patients. We investigated the prognostic expressions of those biomarkers in UC (n=147) and in non-muscle invasive UC (NMI-UC) (n=113), using tissue microarray and immunohistochemistry. Spearman's correlation analysis and multivariate Cox regression analyses were used for statistical interpretation. High expressions of β-catenin, survivin, and p53 were associated with a high T stage, recurrence, progression, mortality, low recurrence-free survival, low progression-free survival and low overall survival (p <0.01). Similar findings were achieved for recurrence and progression in the NMI-UC group, except for mortality. Moreover, a positive correlation was shown between p53 and β-catenin and between p53 and survivin (r=0.221, p <0.01; r=0.236, p <0.01, respectively). Survivin, p53, and β-catenin overexpression, as prognostic markers, might suggest that the UCs are biologically aggressive with the poor prognosis. Thus, dysregulation of those these cell-cycle and apoptosis regulators in bladder carcinoma could be used as a molecular marker to determine the best treatment strategy and could contribute to the development of targeted therapies.

Predictive Factors for Time to Progression after Hyperthermic Mitomycin C Treatment for High-Risk Non-Muscle Invasive Urothelial Carcinoma of the Bladder: An Observational Cohort Study of 97 Patients

Introduction: Hyperthermic mitomycin (HM) is a novel treatment modality for selected patients with high-risk non-muscle invasive bladder cancer (NMIBC). We sought to determine predictors of response to this therapy. Patients and Methods: A longitudinal, cohort study of 97 patients with high-risk NMIBC treated with ≥4 HM instillations on a prophylactic schedule was conducted. The primary outcome was time-to-progression survival; secondary outcomes were overall survival, cancer-specific survival, and adverse events. Descriptive statistics, Kaplan-Meier survival analyses, Cox proportional hazards modelling, and univariate and multivariable regression were performed. Results: The presence of initial complete response (CR; no evidence of disease at first check video-cystoscopy and urine cytology) post-HM treatment was an independent predictor of good response to HM. Female patients and those without carcinoma in situ (CIS) also appeared to respond better to the intervention. The overall bladder preservation rate at a median of 27 months was 81.4%; 17/97 (17.5%) patients died during the course of the study. Conclusions: High-risk NMIBC patients can be safely treated with HM and have good oncological outcome. However, those without an initial CR have a poor prognosis and should be counselled towards adopting other treatment methodologies such as cystectomy. Female gender and lack of CIS may be good prognostic indicators for response to HM.