Bladder Cancer Relapse Research Articles

The biological characteristic and therapeutic prospect of bladder cancer stem cells

Bladder cancer (BC), arising from bladder epithelial cells, is the most prevalent malignant tumor of the urinary system. Its main pathological variants include transitional cell carcinoma (TCC), squamous cell carcinoma, and adenocarcinoma, with TCC further divided into non-muscle-invasive BC (NMIBC) and muscle-invasive BC (MIBC). NMIBC accounts for 70% of all BC cases and is characterized by a favorable prognosis yet a high recurrence rate (31 – 78%). Conversely, MIBC accounts for the remainder of BC cases, characterized by high heterogeneity and poor prognosis. Current treatment methods for BC predominantly encompass surgical resection, radiotherapy, chemotherapy, and immunotherapy. However, these methods lack specificity, exhibit limited clinical efficacy, and often yield unsatisfactory treatment outcomes, predisposing BC to recurrence. On the other hand, BC stem cells (BCSCs) are a subset of cells within heterogeneous BC, possessing robust abilities in self-renewal, differentiation, tumorigenicity, metastasis, and drug resistance. They play a pivotal role in the initiation, progression, metastasis, and relapse of BC, rendering them ideal targets for targeted therapy. Research efforts in this field are currently focused on investigating the evolutionary origins, biomarkers, mechanism governing stemness maintenance, drug resistance, metastasis, metabolic reprogramming, immune evasion, and targeted therapies related to BCSCs. This article provides a comprehensive review of the latest advancements in the biological characteristics and therapeutic prospects of BCSCs.

Photostable Cascade-Activatable Peptide Self-Assembly on a Cancer Cell Membrane for High-Performance Identification of Human Bladder Cancer.

Missed or residual tumor burden results in high risk for bladder cancer relapse. However, existing fluorescent probes cannot meet the clinical needs because of inevitable photobleaching properties. Performance can be improved by maintaining intensive and sustained fluorescence signals via resistance to intraoperative saline flushing and intrinsic fluorescent decay, providing surgeons with sufficiently clear and high-contrast surgical fields, avoiding residual tumors or missed diagnosis. This study designs and synthesizes a photostable cascade-activatable peptide, a target reaction-induced aggregation peptide (TRAP) system, which can construct polypeptide-based nanofibers in situ on the cell membrane to achieve long-term and stable imaging of bladder cancer. The probe has two parts: a target peptide (TP) targets CD44v6 to recognize bladder cancer cells, and a reaction-induced aggregation peptide (RAP) is introduced, which effectively reacts with the TP via a click reaction to enhance the hydrophobicity of the whole molecule, assembling into nanofibers and further nanonetworks. Accordingly, probe retention on the cell membrane is prolonged, and photostability is significantly improved. Finally, the TRAP system is successfully employed in the high-performance identification of human bladder cancer in ex vivo bladder tumor tissues. This cascade-activatable peptide molecular probe based on the TRAP system enables efficient and stable imaging of bladder cancer.

Detection of bladder cancer relapse after TURBT through urinary tumor DNA analysis: A prospective real-world evidence study.

e16605 Background: Bladder cancer is a common malignancy and detection of tumor recurrence is important to improve patient outcomes. Transurethral resection of bladder tumor (TURBT) is the standard treatment for early-stage bladder cancer, but the molecular detection of disease relapse remains a challenge. Reliable and non-invasive methods for monitoring the molecular changes in urine are crucial for timely intervention and disease management. Methods: In this study, 108 patients with early-stage bladder cancer who were selected for detection of disease relapse after the 1st TURBT (median timing 4.8 months after TURBT) were prospectively enrolled. The molecular recurrence in these patients was detected from the urinary tumor DNA (utDNA) using a targeted next-generation sequencing (NGS) assay (PredicineCARE). This assay identifies somatic alterations in utDNA, including single nucleotide variations (SNVs), gene fusions and copy number variations (CNVs), and based on these variations, the tumor fraction was called to identify molecular relapse in the patients. Results: 77 out of 108 (71.3%) patients were found to be tumor positive in utDNA with a tumor fraction ≥ 0.5%. The assay identified 525 SNVs and 32 CNVs in the tumor positive patients. The most frequently mutated genes in the urine samples were TP53 (38%), TERT (32%), KMT2D (28%), ARID1A (19%), FGFR3 (19%), PIK3CA (14%) and ERBB2 (12%). Conclusions: This study demonstrates the feasibility of using urine ctDNA assay to detect molecular recurrence in early-stage bladder cancer patients treated by TURBT. This information can be used to improve patient outcomes by enabling early detection of tumor recurrence and guiding treatment decisions. The findings of this study highlight the promising potential of urine-based NGS assays for cancer detection and disease surveillance.

Phenotype of Urine Sediment Cells in Patients with Bladder Cancer

Phenotype of urine sediment cells were studied in patients with bladder cancer depending on the cancer stage and recurrence prognosis. In T1N0M0 stage, the number of lymphocytes decreased, in T2N0M0 stage, the most pronounced shift was an increase in the number of erythrocytes. Irrespectively of the disease stage, we observed increased number of innate immunity cells and cells that inhibit antitumor immunity in the composition of the leukocyte fraction of urine sediment cells. At T1N0M0 stage, the epithelial-endothelial fraction was characterized by increased content of cells expressing CD13 marker (responsible for tumor growth and metastasis) and reduced number of cells expressing CD15 marker (responsible for intercellular adhesion). In patients developing relapse of bladder cancer, the number of lymphocytes was decreased in urine sediment cells and the number of epithelial and endothelial cells expressing CD13 marker was increased.

An Atypical Disease-Knowledge-Related Suicide by Means of Slashing the Hemodialytic Arteriovenous Fistula

A case of suicide committed by self-cutting the arteriovenous fistula in a patient on hemodialysis is presented. A 77-year-old man was found dead with a blood-stained kitchen knife in the bedroom by his daughter. The man suffered from severe chronic renal failure, for which he needed hemodialysis. Moreover, he was recently diagnosed with bladder cancer relapse. At autopsy, there was a single incised wound on the anterior surface of the left forearm, which showed a regular slash of the skin and the subcutaneous tissues. After the dissection, there was a small-sized lesion affecting the arteriovenous fistula wall. Furthermore, faint postmortem lividity and diffuse visceral pallor were observed. Consequently, the cause of death was identified as an acute hemorrhagic shock after self-cut of the arteriovenous hemodialytic fistula. This case is worthy of several medicolegal considerations: firstly, autopsy examination should always be required in cases with atypical injuries, providing important data to differentiate suicides from homicides. Secondly, disease-knowledge-related suicides are an emerging phenomenon, which deserve careful analysis. Lastly, it is important to identify patients with chronic diseases for whom psychological support is needed, preventing suicidal ideation and reducing suicide risk.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis from Urothelial Origin: a Case Report and Literature Review.

Urothelial carcinomas (UC) are the fourth most common tumours. Approximately, 50% of patients with invasive bladder cancer relapse after radical cistectomy (RC). In this report, we present the case of peritoneal carcinomatosis from bladder UC treated with cytoreductive surgery plus the administration of hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). A 34-year-old woman diagnosed with high-grade bladder cancer with peritoneal recurrence in 2017. She underwent cytoreductive surgery followed by HIPEC with mitomycin C. Histopathological results showed metastases from UC in the left ovary and right diaphragmatic peritoneum. In 2021, the patient underwent surgery after treatment with atezolizumab for abdominal wall recurrence. Today, the patient is alive and free of tumor recurrence 12months after the last surgery. Despite advances in surgical technique and patient selection, the risk of relapse remains high among patients with muscle-invasive bladder cancer. We face the case of a young female patient with local, peritoneal, and lymphatic recurrence of bladder cancer after RC who had a partial response to chemotherapy. The possibility of CRS + HIPEC is offered by the surgical oncology unit, referent in the management of peritoneal carcinomatosis. Surgery is capable of resecting residual tumor in patients with a partial response or who have been erroneously underdiagnosed. CRS + HIPEC might be a valid option to be considered in well-selected patients and to be performed in reference units. There is a need for more collaborative clinical trials and prospective studies addressing the role of surgery in patients with metastatic bladder cancer.

Abstract 540: Genome-wide circulating tumor DNA for monitoring treatment response and metastatic relapse in bladder cancer

Abstract Background: Neoadjuvant chemotherapy (NAC) followed by radical cystectomy (CX), is gold standard treatment in localized muscle-invasive bladder cancer (MIBC). About 45% of patients with MIBC develop metastatic relapse within 2 years after CX. The response rate to chemotherapy and immune checkpoint inhibitors (ICI) is relatively low, and biomarker tests for monitoring response are needed. Furthermore, biomarkers for early detection of minimal residual disease (MRD) after CX is needed to enable earlier treatment initiation. Tumor-informed detection of mutations in cell-free DNA (cfDNA) from peripheral blood has shown promising results in its ability to monitor MRD. However, the low tumor fraction after surgery and limited input material obtained from a typical plasma sample limits the probability of detecting low metastatic burden scenarios. Here we implemented and applied locally a whole-genome sequencing (WGS) approach to circulating tumor DNA (ctDNA) monitoring for improving ctDNA detection. Methods: A total of 140 MIBC patients undergoing NAC and CX were enrolled, including a test cohort (n=19) and a validation cohort (n=120). cfDNA was extracted from ~1mL plasma (n=1100) and procured from longitudinal plasma sampling during NAC (response measure), pre-cystectomy (response measure), post-surgery (relapse monitoring) and during immunotherapy (ICI treatment). WGS was applied to tumor/germline pairs (coverage >30x/20x) and plasma cfDNA (>20x) facilitating detection of genome wide genomic alterations and quantification of ctDNA using the MRDetect method. Results: We developed a personalized tumor-informed WGS model by integrating genome-wide mutation and copy number variation data coupled with advanced signal processing and AI-based error suppression. Patient-specific somatic variant patterns were then used for detecting and measuring the ctDNA levels in low-input blood samples by WGS. The assay sensitivity allowed for detection of tumor fractions down to 8*10-5. Furthermore, in our test cohort of 19 patients, we detected ctDNA after CX in 7 of 8 patients with clinical relapse (88% sensitivity) and detected no ctDNA in 11 of 11 patients with no clinical relapse (100% specificity). We observed a positive lead-time for MRD-based recurrence detection compared to CT-based reccurence detection (9 months on average). The full dataset is currently being processed and will be presented at the AACR 2022 meeting. Conclusions: For precision oncology, we need to develop quantitative and non-invasive methodologies to help tailor the treatments to individual patients and monitor them for further clinical decision-making. The results indicate the clinical potential of personalized genome-wide mutation integration as an ultra-sensitive, non-invasive method for MRD detection and treatment response monitoring which could aid in clinical management of patients with bladder cancer. Citation Format: Iver Nordentoft, Karin Birkenkamp-Demtröder, Emil Christensen, Sunil Deochand, Dillon Maloney, Danielle Afterman, Tomer Lauterman, Noah Friedman, Imane Bourzgui, Nidhi Ramaraj, Zohar Donenhirsh, Ronel Veksler, Sia Viborg, Mads Agerbæk, Jørgen Bjerggaard Jensen, Jonathan Rosenfeld, Ravi Kandasamy, Iman Tavassoly, Boris Oklander, Asaf Zviran, Lars Dyrskjøt. Genome-wide circulating tumor DNA for monitoring treatment response and metastatic relapse in bladder cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 540.

Somatic Features of Response and Relapse in Non–muscle-invasive Bladder Cancer Treated with Bacillus Calmette-Guérin Immunotherapy

BackgroundHigh-risk non–muscle-invasive bladder cancer (NMIBC) is treated with bacillus Calmette-Guérin (BCG), but relapse is common. Improvement of patient outcomes requires better understanding of links between BCG resistance and genomic driver alterations. ObjectiveTo validate the prognostic impact of common genomic alterations in NMIBC pretreatment and define somatic changes present in post-BCG relapses. Design, setting, and participantsWe retrieved tumour tissues and outcomes for 90 patients with BCG-naive NMIBC initiating BCG monotherapy. Post-BCG tissue was available from 34 patients. All tissues underwent targeted sequencing of tumour and matched normal. Outcome measurements and statistical analysisAssociations between clinical outcomes and genomics were determined using Cox proportional hazard models. Results and limitationsOf the patients, 58% were relapse free at data cut-off, 24% had NMIBC recurrence, and 18% experienced muscle-invasive progression. The risk of relapse was associated with ARID1A mutation (hazard ratio [HR] = 2.00; p = 0.04) and CCNE1 amplification (HR = 2.61; p = 0.02). Pre- and post-BCG tumours shared truncal driver alterations, with mutations in TERT and chromatin remodelling genes particularly conserved. However, shifts in somatic profiles were common and clinically relevant alterations in FGFR3, PIK3CA, TSC1, and TP53 were temporally variable, despite apparent clonal prevalence at one time point. Limitations include the difficulty of resolving the relative impact of BCG therapy versus surgery on genomics at relapse and biopsy bias. ConclusionsSomatic hypermutation and alterations in CCNE1 and ARID1A should be incorporated into future models predicting NMIBC BCG outcomes. Changes in tumour genomics over time highlight the importance of recent biopsy when considering targeted therapies, and suggest that relapse after BCG is due to persisting and evolving precursor populations. Patient summaryChanges in key cancer genes can predict bladder cancer relapse after treatment with bacillus Calmette-Guérin. Relapses after treatment can be driven by large-scale genetic changes within the cancer. These genetic changes help us understand how superficial bladder cancer can progress to be treatment resistant.

Biomaterial 3D collagen I gel culture model: A novel approach to investigate tumorigenesis and dormancy of bladder cancer cells induced by tumor microenvironment

The high potential for cancer relapse has emerged as a crucial challenge of human bladder cancer treatment. To date, those stem-like bladder cancer cells (BCSCs) have been considered as seeds that induce frequent tumor recurrence. However, the cell origin of cancer stem cells (CSCs) is still a controversial issue, due in part to the findings that CSCs not only origin from normal stem cells but also converted from differentiated tumor cells. Here, we describe a biomaterial 3D collagen I gel culture system, where non-tumorigenic cells can obtain tumorigenic potential and revert back into CSCs through the integrin α2β1/PI3K/AKT/NF-κB cascade, resulting in the tumorigenesis in bladder tissues. Furthermore, inhibiting this integrin α2β1/PI3K/AKT/NF-κB signal pathways can significantly impair the tumorigenic capacity of CSCs. Simultaneously, in vivo studies demonstrate that IFN-γ secreted by T cells can trigger those CSCs into dormancy through the IDO/Kyn/AHR/P27 cascade, which elicit chemotherapy resistance and cancer relapse. To address the challenges of suppressing bladder tumor growth and preventing tumor reoccurrence, we use IDO and integrin α2β1 signal pathway inhibitors combine with chemotherapeutic agents to awaken dormant bladder CSCs and inhibit their tumorigenic ability as well as effectively eliminate CSCs. The therapeutic approaches we propose provide new insights for eradicating tumors and reducing bladder cancer relapse after therapy.

A SNP of miR-146a is involved in bladder cancer relapse by affecting the function of bladder cancer stem cells via the miR-146a signallings.

MiR‐146a‐5p in urine samples was recently reported to be possibly used as a prognostic marker for bladder cancer (BC). Interestingly, YAP1 and COX2 were both demonstrated to function as stem cell regulators in BC. Therefore, in this study, we aimed to establish the molecular mechanism underlying the role of miR‐146a, YAP1 and COX2 in BC relapse. We also studied the possibility of using the C > G genotype of miR‐146a rs2910164 SNP as an indicator of BC relapse. A total of 170 BC patients were assigned into different groups based on their genotypes of rs2910164 SNP. Kaplan‐Meier survival curves were plotted to compare the recurrence‐free rate among these groups. Real‐time PCR, Western Blot, bioinformatic analysis, luciferase assay and IHC assay were conducted to study the role of rs2910164 SNP in the progression of BC. Accordingly, GC/CC‐genotyped patients presented a higher risk of recurrence when compared with GG‐genotyped patients, while the expression of BC regulators was influenced by the presence of rs2910164. COX2 mRNA and YAP1 mRNA were, respectively, validated as direct target genes of miR‐146a, and the expression of YAP1 and COX2 mRNA/protein was both suppressed by miR‐146a precursors. The expression of ALDH1A1 mRNA/protein was inhibited upon the down‐regulation of YAP1, while the expression of let7 and SOX2 mRNA/protein was inhibited upon the down‐regulation of COX2. In conclusion, two signalling pathways, miR‐146a/YAP1/ALDH1A1 and miR‐146a/COX2/PGE2/let7/SOX2, were modulated by miR‐146a. As an SNP regulating the expression of miR‐146a, the rs2910164 G > C SNP could be utilized as a biomarker for BC relapse.

Tissue stiffness contributes to YAP activation in bladder cancer patients undergoing transurethral resection.

Changes in the cellular microenvironment play a critical role in the development of bladder cancer (BC). Yes-associated protein (YAP), a central mediator of the Hippo pathway, functions as a nuclear sensor of mechanotransduction that can be induced by stiffness of the extracellular matrix (ECM), including stiffness resulting from surgical manipulations. We aimed to clarify the possible association between surgically-related ECM stiffness and YAP activation in BC patients. We compared 30 bladder cancer tissues with grade II (n = 15 recurrent and n = 15 newly diagnosed) with 30 adjacent healthy tissues. Atomic force microscopy showed that patients with recurrent BC had stiffer ECM than newly diagnosed patients (P < 0.05). Gene expression profiles showed that β1 integrin (ITGB1), focal adhesion kinase (FAK), CDC42, and YAP were upregulated in cancerous tissues (P < 0.05); additionally, β1 integrin activation was confirmed using a specific antibody. Nuclear localization of YAP was higher in recurrent cancerous tissues compared with newly diagnosed and it was positively associated with higher stiffness (P < 0.05). Our results suggest that postsurgery-induced ECM stiffness can influence integrin-FAK-YAP activity and thereby YAP trafficking to the nucleus where it contributes to BC progression and relapse.

Azacitidine for Post-Remission Therapy in Elderly Patients with Acute Myeloid Leukemia : Final Results of the Qoless AZA-Amle Randomized Trial

Azacitidine for Post-Remission Therapy in Elderly Patients with Acute Myeloid Leukemia : Final Results of the Qoless AZA-Amle Randomized Trial

P12 - Prognosis of bladder cancer relapse based on urinary peptides detected by mass spectrometry

P12 - Prognosis of bladder cancer relapse based on urinary peptides detected by mass spectrometry

Urinary peptide panel for prognostic assessment of bladder cancer relapse

Non-invasive tools stratifying bladder cancer (BC) patients according to the risk of relapse are urgently needed to guide clinical intervention. As a follow-up to the previously published study on CE-MS-based urinary biomarkers for BC detection and recurrence monitoring, we expanded the investigation towards BC patients with longitudinal data. Profiling datasets of BC patients with follow-up information regarding the relapse status were investigated. The peptidomics dataset (n = 98) was split into training and test set. Cox regression was utilized for feature selection in the training set. Investigation of the entire training set at the single peptide level revealed 36 peptides being strong independent prognostic markers of disease relapse. Those features were further integrated into a Random Forest-based model evaluating the risk of relapse for BC patients. Performance of the model was assessed in the test cohort, showing high significance in BC relapse prognosis [HR = 5.76, p-value = 0.0001, c-index = 0.64]. Urinary peptide profiles integrated into a prognostic model allow for quantitative risk assessment of BC relapse highlighting the need for its incorporation in prospective studies to establish its value in the clinical management of BC.

MP58-10 IFIT5 PROMOTES EMT VIA DOWN-REGULATION OF MATURE MIR-99A IN BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Basic Research & Pathophysiology II1 Apr 2018MP58-10 IFIT5 PROMOTES EMT VIA DOWN-REGULATION OF MATURE MIR-99A IN BLADDER CANCER Jun Huang, U-Ging Lo, Jer-Tsong Hsieh, Dalin He, and Kaijie Wu Jun HuangJun Huang More articles by this author , U-Ging LoU-Ging Lo More articles by this author , Jer-Tsong HsiehJer-Tsong Hsieh More articles by this author , Dalin HeDalin He More articles by this author , and Kaijie WuKaijie Wu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1842AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Relapse and progression of non-muscle invasive bladder cancer (BCa) after transurethral resection and intravesical Bacillus Calmette-Guerin (BCG) instillation remain major problems in BCa therapy. IFN-γ is increased after BCG treatment, and low dose of IFN-γ can increase BCa cell migration. It is known that IFN-γ can induce the expression of IFIT5 (interferon induced protein with tetratricopeptide repeats 5), however, the expression and function of IFIT5 in BCa are still unknown. METHODS Expression of IFIT5 in BCa tissues were investigated by immunohistochemical staining and database (TCGA and GEO) retrieving. Stable IFIT5 over-expression or knock-down BCa cell sublines were generated to investigate the role of IFIT5 on epithelial-mesenchymal transition (EMT), cell migration and invasion in vitro. MicroRNA PCR array and qRT-PCR were used to verify the specific microRNA regulated by IFIT5. Direct target of the specific microRNA was verified by dual luciferase reporter assay, and their relationship with IFIT5 was analyzed by western blot. Subcutaneous xenograft model was used to investigate the effects of IFIT5 on tumorigenesis and verify the in vitro data. RESULTS IFIT5 expression was higher in high-grade, carcinoma in situ (CIS)-positive or muscle-invasive BCa tissues, which predicted a poor survival of patients. Over-expression of IFIT5 in 5637 and 253J cells induced EMT, promoted cell migration and invasion, and decreased the expression of mature miR-99a, meanwhile knock-down of IFIT5 in UM-UC-3 and TCCSUP cells inhibited EMT, suppressed cell migration and invasion, and increased the expression of mature miR-99a. However, either over-expression or knock-down of IFIT5 had no effect on the expression of pre-miR-99a and pri-miR-99a. Furthermore, ICAM1 was shown as a direct target of miR-99a, and over-expression of miR-99a in IFIT5 over-expressing 5637 and 253J cells could reverse EMT, suppress cell migration and invasion, and decrease ICAM1 expression induced by IFIT5. In addition, overexpression of IFIT5 could enhance BCa tumorigenecity, and the expression of mature miR-99a was negatively regulated. CONCLUSIONS Interferon-induced gene IFIT5 may acts as an oncogene in BCa relapse and progression after BCG treatment, which induces EMT, promote cell migration and invasion, and increase the expression of ICAM1 via down-regulation of mature miR-99a. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e776 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jun Huang More articles by this author U-Ging Lo More articles by this author Jer-Tsong Hsieh More articles by this author Dalin He More articles by this author Kaijie Wu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Vaginal cuff recurrence after radical cystectomy: an under - studied site of bladder cancer relapse.

ABSTRACTIntroduction:Vaginal cuff recurrence of tumor following radical cystectomy is a rare site of disease recurrence, however it has never been specifically studied. The aim of the study is to evaluate incidence, risk factors, and long-term oncologic outcomes of vaginal cuff recur- rence in a cohort of female patients treated with radical cystectomy for invasive urothelial carcinoma of the bladder.Materials and Methods:From 1985 to 2012, a prospectively maintained institutional blad- der cancer registry was queried for vaginal cuff recurrence post radical cystectomy. Over- all mortality and cancer-specific mortality were reported using the Kaplan-Meier method for patients with vaginal cuff recurrence, recurrence at another local or distant site, and those without evidence of recurrence. Comparisons were performed using the log-rank test. Cox proportional hazards regression model was performed to assess predictors of vaginal cuff recurrence.Results:From 469 women treated with radical cystectomy for bladder cancer, 34 patients (7.3%) developed vaginal cuff recurrence, 130 patients (27.7%) had recurrence involving ei- ther a local or distant site, and 305 patients (65%) had no evidence of recurrence. The 5-year overall mortality-free survival rate was 32.4% for vaginal cuff recurrence, but 25.0% for other sites of recurrence. Cancer-specific mortality-free survival rate was 32.4% for vaginal cuff recurrence, and 30.3% for the other sites of recurrence. Multivariate Cox proportional hazards regression analysis demonstrated that the presence of tumor in posterior location at radical cystectomy (Hazard Ratio [HR], 0.353 [95% CI, 0.159-0.783]) and anterior vaginec- tomy, compared to no vaginectomy (HR, 2.595 [95% CI, 1.077-6.249]) were independently associated with vaginal cuff recurrence.Conclusion:Anterior vaginectomy, despite our best attempts, is perhaps not sufficient to prevent vaginal cuff recurrence. Therefore, follow-up evaluation is essential, and further studies are necessary to address the optimal approach for initial management.Patient Summary:Although vaginal cuff recurrence is an unusual site of recurrence, careful evaluation is needed before cystectomy and during follow-up to identify patients at risk.

Effects of increased Kindlin-2 expression in bladder cancer stromal fibroblasts.

Kindlin-2 is a focal adhesion protein highly expressed in bladder cancer stromal fibroblasts. We investigated the prognostic significance of Kindlin-2 in bladder cancer stromal fibroblasts and evaluated the effects of Kindlin-2 on the malignant behaviors of tumor cells. Immunohistochemical staining of 203 paraffin-embedded bladder cancer tissues showed that Kindlin-2 expression correlated with advanced stage, high grade, and relapse of bladder cancer. Kaplan-Meier survival analysis demonstrated that patients exhibiting high Kindlin-2 expression had shorter survival times than those with low Kindlin-2 expression (p < 0.01). Multivariate analysis revealed that high Kindlin-2 expression leads to poor prognosis in bladder cancer. Using cancer-associated fibroblasts (CAFs) isolated from human bladder cancer tissue, we observed that Kindlin-2 knockdown decreased CAFs activation, resulting in decreased expression of α-smooth muscle actin (α-SMA) and the extracellular matrix protein fibronectin. Kindlin-2 suppression also reduced CAF-induced bladder cancer cell migration and invasion. Moreover, we found that Kindlin-2 activates CAFs and promotes the invasiveness of bladder cancer cells by stimulating TGF-β-induced epithelial-mesenchymal transition. These results support targeting Kindlin-2 and the corresponding activated CAFs in bladder cancer therapy.

JAK-mediated autophagy regulates stemness and cell survival in cisplatin resistant bladder cancer cells

BackgroundAutophagy is a critical process in acquiring drug resistance in solid tumors. However, the mechanisms by which autophagy modulate resistance to chemotherapy in bladder cancer remains poorly understood. Material and methodsWe have established cisplatin resistant patient derived primary cultured cells as well as T24 bladder cancer cells. The autophagy flux as well as the effect of chemotherapeutic agents, gemcitabine (GC) and mitomycin (MM) were evaluated in these cells. Side population analysis, tumorisphere assay and expression of stemness genes were also studied to evaluate the role of autophagy during chemoresistance. The role of cytokines in autophagy induced chemoresistance was demonstrated. ResultsOur results show that resistant cells have higher basal autophagic flux. GC and MM led to increase in autophagy and combination of autophagy inhibitors synergistically inhibited bladder cancer cell growth. When autophagy was inhibited, only IFN-γ level was decreased in cytokine array. Blocking IFN-γ decreased JAK2 expression and reduced the autophagy. Inhibition of JAK2 decreased the proportion of cancer stem cell enriched side population, tumor sphere forming ability and led to decrease in expression of stemness genes. Combined treatment with inhibitors of JAK2 and autophagy led to inhibition in cell growth, reduced the levels of inflammatory cytokines and decreased the resistance gene expression. ConclusionGC and MM treatment increased autophagy process via IFN-γ mediated JAK2 and STAT3 pathway. General significanceThese findings support a key role of the autophagy in drug resistance. Thus, autophagy-based, “customized” combinatorial approaches may effectively manage resistance and relapse in bladder cancer.

Abstract 4701: Acquisition of Oct-4 upregulation transactivates MDR1 and is associated with increased tumor recurrence in bladder cancer

Abstract Platinum-based drug like cisplatin is the standard first-line drug to treat patients with bladder cancer. However, tumors may recur and develop into multiple-drug resistant characteristics. The acquisition of resistance to conventional chemotherapy is a challenge in the treatment of bladder cancer relapse. Cancer stem cell (CSC) hypothesis has been an attractive theory. CSCs can resist therapeutic assaults, giving rise to multiple drug resistance and promotion of tumor relapse and metastasis. It has been shown that the fraction of cancer cells expressing MDR1 that functions as an energy-dependent drug efflux pump may be associated with Oct-4 expression. We have demonstrated that Oct-4 expression in bladder cancer predicts tumor progression. In the present study, we proposed that Oct-4 expression in bladder cancer increases MDR1 gene expression and thereby results in multiple drug resistance. We found a positive correlation between Oct-4 and MDR1 expression levels in clinical samples of bladder cancer. Furthermore, overexpression of Oct-4 increased MDR1 expression, which resulted in poor response to cisplatin in human bladder transitional cell carcinoma cells. Conversely, knockdown of Oct-4 reduced MDR1 expression and rendered cells hypersensitive to cisplatin. We also verified that Oct-4 transactivated the MDR1 gene promoter by binding to the Oct-4 response element (ORE). More importantly, Oct-4 and MDR1 gene expression could be induced by treatment with cisplatin, suggesting that Oct-4 is a member of the MDR1 enhanceosome. Our data can explain, in part, the high recurrence rate and drug resistance of bladder cancer. For clinical implication, we demonstrated that reduction of Oct-4 expression by all-trans retinoic acid, a derivative of vitamin A, improved sensitivity of bladder cancer cells to gemcitabine and cisplatin. In addition, we found that high expression levels of Oct-4 and MDR1 were associated with high tumor recurrence. Taken together, our results provide evidence that Oct-4 plays an important role in cisplatin-acquired resistance in bladder cancer. They also implicate Oct-4 as a therapeutic target. Note: This abstract was not presented at the meeting. Citation Format: Chia-Sing Lu, Ai-Li Shiau, Gia-Shing Shieh, Bing-Hua Su, Wu-Chou Su, Wen-Horng Yang, Chao-Liang Wu. Acquisition of Oct-4 upregulation transactivates MDR1 and is associated with increased tumor recurrence in bladder cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4701. doi:10.1158/1538-7445.AM2014-4701

Bladder Cancer: The Hormonal Dependence Enigma and a New Hormonal Player.

Dear Editor, Bladder cancer is considered to be a hormonal-independent malignancy. However, an increasing number of studies show that sex hormonesmight have an important role in the etiology or progression of specific urothelial carcinoma subtypes. The most important indication that bladder cancer might be influenced by sex hormone is that the incidence and risk of developing bladder cancer in men is notably greater comparing to women, even when established risk factors such as smoking, occupational exposure, and urinary tract infection are counterbalanced between the sexes. The effect of sex hormones in bladder tissues is documented during pregnancy and menopause where the bladder undergoes dramatic changes in structure, function, histology, and gene expression. Bladder tissues are shown to express androgen, estrogen, and progesterone receptors. Additionally, in animal models, estrogens are shown to inhibit and androgens to promote bladder cancer development even when carcinogenetic substances are used such as N-butyl-N-(4hydroylbutyl)nitrosamine [1]. Another indication of the hormonal contribution in bladder cancer development is the relatively lower risk of parous women to develop this malignancy compared to the nulliparous females. A human bladder tumor cell line, R198, was shown to develop under the effect of androgens while it regressed under the presence of estrogen [2]. Finally, there is also the report of a man who developed endometriosis of urinary bladder, after 5 years treatment with estrogen therapy for prostate cancer [3]. The lesion regressed after estrogen withdrawal, indicating a metaplasia potential of the urothelium under extreme changes of hormonal environment. Under these circumstances, we would like to report our experience of a 65-year-old woman treated for breast cancer who developed urothelial carcinoma at the trigone of the urinary bladder, 1 year after the onset of adjuvant hormonal therapy with third-generation non-steroidal aromatase inhibitor. The patient underwent modified radical mastectomy with ipsilateral axillary lymphadenectomy 4 years ago and subsequently chemotherapy (FEC and docetaxel) and radiotherapy. Three months after the onset of aromatase inhibitor treatment, the patient claimed to have aggravated hirsutism of both arms and no hair growth on the parietal skull following a pattern of androgenetic alopecia. A year since the onset of adjuvant hormonal therapy, a papillary protrusion was detected at the trigone of the urinary bladder. The histological report showed a non-muscle invasive low-grade papillary urothelial carcinoma, grade 1 by WHO-ISUP. One and a half year later, the patient was found to have bladder cancer relapse with the same histological urothelial tumor and the same androgenetic effects of the adjuvant hormonal therapy. The current hypothesis we propose is that the excessive androgen environment produced by the aromatase inhibitor in a postmenopausal woman with lack of the counterbalancing hormones (estrogen and progesterone) could contribute to the development of bladder cancer. There are some hypotheses which try to explain the hormonal dependence of bladder cancer and especially of the trigone of the urinary bladder. The trigone and the prostate have the same embryologic endodermic origin. This hypothesis is supported by the finding that the tumor cells of R198 cell line have some similar characteristics with human prostatic carcinomas [2]. Additionally, one of the ways that K. Ntzeros (*) :G. Louka Department of Urology, Hospital of Korinthos, Korinthos, Greece e-mail: konstantinos.ntzeros@gmail.com