Update on meningiomas

Although meningiomas are the most common tumor in the central nervous system, their incidence, epidemiology, and clinical outcomes have historically been poorly defined. This has been attributed to their benign course, difficulty obtaining histologic diagnosis, and lack of uniform database registration. Their clinical behavior can range from a silent incidentaloma to a lethal tumor. Projections of an aging population should raise medical awareness of an expectant rise in the incidence of meningiomas. This disease increases with advancing age, has a female predilection, and exposure to ionizing radiation is associated with a higher risk for disease development. There have been minimal advances in treatment, except in radiation therapy. Although no U.S. Food and Drug Administration-approved systemic therapy exists, there are treatment options that include hydroxyurea and sandostatin. Currently, no molecularly targeted therapy has provided clinical benefit, although recurring molecular alterations are present and novel therapies are being investigated.

A framework to select clinically relevant cancer cell lines for investigation by establishing their molecular similarity with primary human cancers

Experimental work on human cancer cell lines often does not translate to the clinic. We posit that this is because some cells undergo changes in vitro that no longer make them representative of human tumors. Here, we describe a novel alignment method named Spearman's rank correlation classification method (SRCCM) that measures similarity between cancer cell lines and human tumors via gene expression profiles, for the purpose of selecting lines that are biologically relevant. To show utility, we used SRCCM to assess similarity of 36 bladder cancer lines with 10 epithelial human tumor types (N = 1,630 samples) and with bladder tumors of different stages and grades (N = 144 samples). Although 34 of 36 lines aligned to bladder tumors rather than other histologies, only 16 of 28 had SRCCM assigned grades identical to that of their original source tumors. To evaluate the clinical relevance of this approach, we show that gene expression profiles of aligned cell lines stratify survival in an independent cohort of 87 bladder patients (HR = 3.41, log-rank P = 0.0077) whereas unaligned cell lines using original tumor grades did not. We repeated this process on 22 colorectal cell lines and found that gene expression profiles of 17 lines aligning to colorectal tumors and selected based on their similarity with 55 human tumors stratified survival in an independent cohort of 177 colorectal cancer patients (HR = 2.35, log-rank P = 0.0019). By selecting cell lines that reflect human tumors, our technique promises to improve the clinical translation of laboratory investigations in cancer.

Collecting system invasion and Fuhrman grade but not tumor size facilitate prognostic stratification of patients with pT2 renal cell carcinoma

PURPOSE

The 7th edition of TNM for renal cell carcinoma introduced a subdivision of pT2 tumors at a 10 cm cutoff. In the present multicenter study the influence of tumor size as well as further clinical and histopathological parameters on cancer specific survival in patients with pT2 tumors was evaluated.

MATERIALS AND METHODS

A total of 670 consecutive patients with pT2 tumors (10.4%) of 6,442 surgically treated patients with all tumor stages were pooled (mean followup 71.4 months). Tumors were reclassified according to the current TNM classification, and subdivided in stages pT2a and pT2b. Cancer specific survival was analyzed using the Kaplan-Meier method, and univariable and multivariable analyses were used to assess the influence of several parameters on survival.

RESULTS

Tumor size continuously applied and subdivided at 10 cm or alternative cutoffs did not significantly influence cancer specific survival. In addition to N/M stage, Fuhrman grade and collecting system invasion also had an independent influence on survival. Integration of a dichotomous variable subsuming Fuhrman grade and collecting system invasion (grade 3/4 and/or collecting system invasion present vs grade 1/2 and collecting system invasion absent) into multivariate models including established prognostic parameters resulted in improvement of predictive abilities by 11% (HR 2.3, p <0.001) for all pT2 cases and 151% (HR 3.1, p <0.001) for stage pT2N0M0 cases.

CONCLUSIONS

Tumor size did not have a significant influence on cancer specific survival in pT2 tumors, neither continuously applied nor based on various cutoff values. To enhance prognostic discrimination, multifactorial staging systems including pathological features should be implemented. The prognostic relevance of the variable subsuming Fuhrman grade and collecting system invasion should be considered for future evaluation.

Outcome after bevacizumab clinical trial therapy among recurrent grade III malignant glioma patients

Although outcome following bevacizumab among recurrent grade IV malignant glioma patients is documented as poor by several analyses, outcome for recurrent grade III patients following bevacizumab therapy has not been specifically evaluated. We performed a pooled analysis of 96 recurrent grade III malignant glioma patients enrolled on three consecutive phase II bevacizumab salvage trials to evaluate overall outcome following bevacizumab trial discontinuation. Outcome on the three bevacizumab trials, which included similar eligibility, treatment and assessment criteria, was comparable. Forty-nine patients who progressed on bevacizumab trial therapy and remained alive for at least 30 days elected to receive additional therapy. These patients achieved a median PFS-6 and OS of 30.6% (95% CI: 18.4, 43.6) and 10.3 months (95% CI: 5.2, 11.7), respectively. Among patients who continued bevacizumab therapy (n = 23) after study progression, PFS-6 and median OS were 39.1% (95% CI: 19.9, 58.0) and 9.2 months (95% CI: 5.2, 13.6), respectively, compared to 23.1% (95% CI: 9.4, 40.3; P = 0.51) and 10.3 months (95% CI: 2.5, 14.4; P = 0.91) for patients who initiated non-bevacizumab containing therapy (n = 26). Outcome after discontinuation of bevacizumab therapy for recurrent grade III malignant glioma patients is associated with improved outcome compared to historical data for recurrent grade IV malignant glioma patients. Salvage therapies following bevacizumab failure have modest activity for grade III malignant glioma patients that is independent of further bevacizumab continuation.

Co-expression of metalloproteinases 11 and 12 in cervical scrapes cells from cervical precursor lesions

The metalloproteinases (MMP) 11 and 12 have been shown to be expressed in cervical cancer (CC). In order to extend our previous results, these MMPs were evaluated in cervical precursor lesions. One hundred seventeen cervical scrapes: thirty-six normal, thirty-six low grade squamous lesions (LSIL), thirty-six high grade (HSIL), nine CC; and, also ninety-nine paraffin-embedded cervical lesions: fifteen normal cervices, thirty eight LSIL, sixteen HSIL, and five CC were collected. The samples were analyzed for relative expression by real time RT-PCR or immunohistochemistry assay. We were able to identify a relative increased expression of MMP11 in 75% and 78% from LSIL and HSIL samples, respectively. While MMP12 expression was 64% and 75% in LSIL and HSIL, respectively. Positive samples for MMP11 expression were also positive for MMP12 expression and also increased according to illness progression. In the tissues, MMP11 or MMP12 expression was observed in the cytoplasm of the neoplastic cells, while in the normal epithelium was absent. The reaction was always stronger for MMP12 than MMP11. MMP11 expression was present in 77% and 66% of LSIL and HSIL, while MMP12 expression was 73% and 68%. There was a relationship between MMP11 or MMP12 expression and HPV infection. Our data are showing a relationship between diagnostic of precursor lesions and the MMP11 and 12 expressions, suggesting that their expression could be an early event in the neoplastic lesions of the cervix and could have clinical significance.

Human papillomavirus detection by PCR assay in a large series of high-grade squamous intraepithelial lesions with cytohistological correlation and follow-up

OBJECTIVE

High-grade squamous intraepithelial lesions (HSIL) are the precursors of invasive cervical carcinomas and are generally associated with the integration of mucosotropic human papillomavirus (HPV) DNA into the host cell genome. Detection of HPV is easy to perform nowadays, even in laboratories with limited technological capacity, and follow-up procedures for patients with HSIL are well established.

STUDY DESIGN

HPV detection was performed in a large group of patients with HSIL, and results were correlated with cytological, histological, and colposcopic findings. Discrepancies were examined and discussed.

RESULTS

Conventional Papanicolaou (Pap) screening detected 446 HSIL (0.20%) in 218,906 cervical smears. HPV detection by PCR was positive in 339/358 (94.7%) patients. The strains involved were: HPV 16 in 180 patients (53.1%), HPV 18 in 35 (10.3%), HPV 31/33 in 27 (8%), HPV 6/11 in 10 (2.96%), and an unidentified type in 73 (30%). For the last 97 patients (2006-2007), HPV typing was expanded with the following results: HPV 52 was detected in 9 patients (9.2%), HPV 58 in 6 (6.1%), HPV 51 in 4 (4.1%), HPV 68 in 2 (2.0%), and HPV 39 in 1 (1.0%). The number of nonidentified patients dropped to 9 (9.4%); in addition, 14/97 (14.4%) patients were infected with 2 or more viral types. Finally, 19 (5.3%) patients were HPV negative. Colposcopy revealed minor changes in 59 patients (17.3%), major changes in 264 (77.6%), and normal findings in 17 (5.1%). A biopsy was taken in 331/446 patients, and the diagnosis of HSIL or overt malignancy was histologically confirmed in 281 (84.9%) patients: CIN II in 46, CIN III in 224, and histologically upgraded in 11 (6 microinvasive squamous carcinomas, 1 squamous carcinoma, 2 in situ endocervical adenocarcinomas, and 2 microinvasive endocervical adenocarcinomas). Thirty-five patients (10.6%) were downgraded to CIN I and 15 (4.5%) patients had a negative biopsy. Follow-up in the negative-biopsy patients confirmed the existence of SIL in 11 patients [1 HSIL and 10 low-grade squamous intraepithelial lesions (LSIL)] while 4 were considered false positives (atrophic changes, 2; reactive changes, 2). After treatment, 31/331 (9.36%) patients displayed recurrence (HSIL in 29 and LSIL in 2). The viral strains involved in patients with recurrence were HPV 16 in 16 patients (51.6%); HPV 18 in 4 (12.9%); HPV 16 and 18 in 1 (3.2%); HPV 31 in 1 (3.2%); HPV 52 in 1 (3.2%); HPV 18, 31, and 58 in 1 (3.2%); HPV 68 in 1 (3.2%); HPV 51 and 73 in 1 (3.2%), and an unidentified type in 5 (16.1%). Follow-up in 14/19 HSIL and HPV-negative patients confirmed the existence of cervical pathology.

CONCLUSIONS

HPV detection improves diagnostic sensitivity and provides an ideal tool for monitoring the response to treatment in HSIL patients. The pathogenic relevance of HPV strain 18 may be greater than previously assumed.

HPV E6/E7 mRNA testing is more specific than cytology in post-colposcopy follow-up of women with negative cervical biopsy

BACKGROUND

In Norway, women with negative or low-grade cervical biopsies (normal/CIN1) are followed up after six months in order to decide on further follow-up or recall for screening at three-year intervals. A high specificity and positive predictive value (PPV) of the triage test is important to avoid unnecessary diagnostic and therapeutic procedures whereas a low risk of high-grade disease among triage negative women assures safety.

MATERIALS AND METHODS

At the University Hospital of North Norway, cytology and the HPV mRNA test PreTect HPV-Proofer, detecting E6/E7 mRNA from HPV types 16, 18, 31, 33 and 45, are used in post-colposcopy follow-up of women with negative or low-grade biopsy. In this study, women with negative biopsy after high grade cytology (ASC-H/HSIL) and/or positive HPV mRNA test in the period 2005-2009 were included (n = 520). Histologically confirmed cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) was used as study endpoint.

RESULTS

Of 520 women with negative or low-grade biopsy, 124 women (23.8%) had CIN2+ in follow-up biopsy. The sensitivity and specificity of the HPV mRNA test were 89.1% (95% CI, 80.1-98.1) and 92.5% (95% CI, 88.2-96.7), respectively. The ratios of sensitivity, specificity and PPV of HPV mRNA testing compared to repeat cytology for finding CIN2+ was 1.05 (95% CI: 0.92-1.21), 1.21 (95% CI: 1.12-1.32), and 1.49 (95% CI: 1.20-1.86), respectively. The PPV of mRNA was 77.3% (95% CI, 59.8-94.8) in women aged 40 or older.

CONCLUSION

Women with negative cervical biopsy require follow-up before resumption of routine screening. Post-colposcopy HPV mRNA testing was as sensitive but more specific than post-colposcopy cytology. In addition, the HPV mRNA test showed higher PPV. A positive mRNA test post-colposcopy could justify treatment in women above 40 years.

[Impact of predictive models and decision making in prostate cancer: An integral debate]

OBJECTIVES

To review the various methods to predict the risk of having prostate cancer, or that localized disease may be cured or progress after a given treatment.

METHODS

We performed a review of the various mathematic models known for the probability analysis of the event, with a critical analysis of weaknesses and strengths of each method. In a Medline update we review the most relevant papers referred to diagnosis and management of localized prostate cancer in its diagnosis and management sides, as well as the probability of developing metastatic disease and to die.

RESULTS

There are multiple methods and models to predict the various events in a patient candidate to diagnosis of prostate cancer, as well as to analyze the possibilities of success of a specific treatment, in many cases with an important exactness. We emphasize the heterogeneity in the methods, data and variables used for the analysis, basically about retrospective studies. Many of the most sophisticated methods, Neural Network or cart, do not present greater exactness than classic methods like logistic regression.

CONCLUSIONS

Predictive models are an important element for decision making in usual clinical practice, favoring the decision of a diagnosis or certain treatment is not taken in a random manner and therefore it is taken following scientific criteria. Waiting for more precise methods, we have to know no method is perfect, and therefore it is an important tool, which should not by pass personal knowledge or the experience of a specific working group.

Recent advancements in multimodality treatment of gliomas

Gliomas account for the vast majority of malignant adult brain tumors. Even though tremendous effort has been made to optimize treatment of patients with high-grade glioma, the prognosis remains poor, especially for patients with glioblastoma. The dismal prognosis conferred by these tumors is in part caused by the tendency to diffusely infiltrate into neighboring brain tissue, but also by the inherent resistance of these tumors to both chemotherapy and radiation. This article reviews the recent advancements in multimodality treatment of patients with gliomas, both in the primary and recurrent setting, with an emphasis on the emerging targeted therapies. Moreover, the external beam radiotherapy options, including intensity modulated radiotherapy and particle (proton and carbon ion) radiotherapy are reviewed.

[Usefulness of prostatic specific antigen (PSA) for diagnosis and staging of patients with prostate cancer]

The incorporation of prostatic specific antigen (PSA) to clinical practice revolutionized diagnosis and modified the epidemiology of prostate cancer(PCa). Although it lacks of many of the characteristics of an ideal tumor marker, it is the marker most used for diagnosis and follow up of any type of cancer. It represents the best clinical tool we currently have available for screening and staging of PCa. On the contrary, the greatest limitation PSA presents is its lack of tumor specificity. The use of PSA molecular derivatives and isoforms tries to solve, at least in part, its limitations. As a matter of fact, the use of % free PSA and PSAD significantly increases the test specificity for diagnosis and, the use of derivatives evaluating PSA temporary kinetics (PSAV and PSADT) represent very useful tools to estimate líquiprognosis during disease treatment and follow up. With the ongoing development of new markers for PCa, It is likely the role of PSA in diagnosis and staging of the disease will be modified.

Metabolic syndrome is associated with high grade Gleason score when prostate cancer is diagnosed on biopsy

BACKGROUND

To evaluate the association between metabolic syndrome (MS) and prostate cancer diagnosis and grade in patients undergoing prostate biopsy.

METHODS

From 2009 onwards, a consecutive series of patients undergoing 12-core prostate biopsy for PSA value ≥4 ng/ml and/or positive digital rectal examination (DRE) were prospectively enrolled. Body mass index (BMI), waist circumferences, and blood pressure were measured before the biopsy. Blood samples were tested for: PSA, fasting glucose, triglycerides, and cholesterol HDL. MS presence was defined according to Adult Treatment Panel III criteria.

RESULTS

One hundred ninety five patients were enrolled with a median age and PSA of 69 years and 5.6 ng/ml respectively. Median BMI was 27.6 kg/m(2) with 64 patients (33%) being classified as obese (BMI ≥ 30 kg/m(2) ). Eighty-six patients (44%) had MS. Eighty-three patients (43%) had cancer on biopsy; 37 (45%) with MS and 46 (55%) without (P = 0.48). PSA was independently associated with higher risk of cancer (OR 1.12/1 U PSA, P = 0.01). Out of 83 patients with prostate cancer, 42 (51%) had Gleason score 6 (12 (28.5%) presented a MS) and 41 (49%) a Gleason score ≥7 (25 (61%) presented a MS). The presence of MS was not associated with an increased risk prostate cancer (OR: 0.97, P = 0.94) but with an increased risk of Gleason ≥7 (OR: 3.82; P = 0.013).

CONCLUSIONS

In our single center study, MS is associated with an increased risk of high grade Gleason score when prostate cancer is diagnosed on biopsy. However, these results should be confirmed in a larger multicenter study. .

Congenital intramedullary spinal cord tumours: a report of two cases

We present two different cases of congenital intramedullary tumours, one of a patient in whom treatment was started without pathological confirmation of a malignant tumour and the other of a primitive neuroectodermal tumour. Magnetic resonance imaging is the most useful tool in the diagnosis of malignant intramedullary tumours and differentiation from other types of spinal cord lesions.

Genetic variation in RNASEL and risk for prostate cancer in a population-based case-control study

BACKGROUND

Linkage studies have implicated chromosome 1q24 as a putative locus for hereditary prostate cancer. The RNASEL gene maps to 1q24 and has been associated with prostate cancer risk in multiple family-based linkage studies. The RNASEL gene product combats viral infection by degrading viral RNA and inducing apoptosis of infected cells. Few studies have evaluated the role of RNASEL variants in unselected or sporadic prostate cancer, or have considered the potential interaction between RNASEL variants and patient characteristics associated with past infection.

METHODS

Ten SNPs in the RNASEL gene were genotyped in 1,308 prostate cancer cases and 1,267 age-matched controls from prior population-based, case-control studies. The association between each SNP and haplotype with prostate cancer risk was calculated using logistic regression. Associations stratified by Gleason score were evaluated using polytomous regression. The likelihood ratio test was used to investigate effect modification.

RESULTS

Two RNASEL SNPs were associated with overall increases in prostate cancer risk (OR = 1.13 for each variant allele of rs12723593; OR = 1.88 for any variant allele of rs56250729). Risk estimates did not vary substantially by Gleason score, but there was effect modification for the variant allele of rs635261 by history of prostatitis (P = 0.02).

CONCLUSIONS

This study identified three RNASEL variants that are associated with risk for prostate cancer. Further research is required to confirm these results and to better understand the potential role RNASEL variants may play in the etiology of sporadic prostate cancer.

Minimally invasive radical prostatectomy: transition from pure laparoscopic to robotic-assisted radical prostatectomy

OBJECTIVES

The robotic-assisted laparoscopic approach to radical prostatectomy is increasingly utilized and has become well documented as an effective oncologic treatment modality. In this study, we report the initial experience of a single surgeon at a single institution with robotic-assisted laparoscopic prostatectomy (RALP) drawing a comparison to his prior experience with pure laparoscopic prostatectomy (LRP) METHODS: This is a retrospective review of surgical results from a single surgeon performing LRP and transitioning to RALP. Baseline characteristics and outcomes of two hundred seventy five patients undergoing RALP by a single, fellowship-trained, urologic oncologist were analyzed and compared to 45 patients undergoing LRP by the same surgeon. Patient, tumor, and operative characteristics as well as functional outcomes were evaluated. Validated questionnaires, including the International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF), were utilized in the assessment of urinary and sexual parameters.

RESULTS

Preoperative patient and tumor characteristics (age, PSA, Gleason score) were similar in both the LRP and RALP groups. Mean operative time (195 vs. 299 minutes), estimated blood loss (223 vs. 299 mL), need for blood transfusion (1.5% vs. 4.4%) and mean length of stay (1.95 vs. 2.63 days) were significantly reduced among patients undergoing RALP as compared to those undergoing LRP. In terms of functional outcomes, continence at 12 months was better among patients undergoing RALP as compared to LRP (94% vs. 82%). In preoperatively potent men undergoing bilateral nerve sparing procedures, RALP conferred 82% potency at 24 months as opposed to only 62% following LRP.

CONCLUSIONS

The combination of adjustment in surgical technique from LRP to RALP along with a concurrent institutional commitment to a successful robotic surgery program, has yielded superior operative, oncologic, and functional results.

Personalized approach to prostate cancer prognosis

Personalized medicine in the management of patients with prostate cancer consists of the integration of patient attributes such as age, genetic risk and co-morbidities with specific clinical-pathologic variables including serum prostate specific antigen (PSA), imaging and features from the diagnostic prostate needle biopsy or prostatectomy specimen including tumor differentiation (i.e. Gleason), volume and extent of disease (i.e. tumor length and / or percentage, number of positive cores at diagnosis or pathologic stage post surgery including margin status). Although the development of various clinical statistical instruments such as nomograms have provided a mechanism to interrogate these variables, most urologists rely on basic prognostic features of stage, grade and PSA along with clinical judgment to define and understand individual risk and predict health outcomes. In addition, unlike other tumor types such as breast cancer, there are no routine ancillary diagnostic studies performed on the prostate needle biopsy or prostatectomy specimen to support and refine the treatment decision process for the individual patient. In this review we will provide a summary of the current practice of predictive modeling in prostate cancer and explore how technical advances in functional histology have played a role in the development and incorporation of a systems based platform for providing a patient-specific risk profile useful for clinical decision making.

[Prostate biopsy: Diagnostic responsibility and recent changes]

In this bibliographic review we reexamine the different features in relation to indication, performance and interpretation of prostatic biopsy (PB). The main objective is to place methodological features involving PB in the current scientific scenario, establishing the correlation between the most relevant and analyzing the historic evolution this procedure has followed, particularly over the last two decades. Prostate biopsy has evolved to be a regular element in urologists` daily practice and its learning process has been simplified to the point it can be approached with adequacy during the first years of residency in Urology. This privileged position PB enjoys in daily practice and the performance obtained from it would have not been a reality without optimization of transrectal ultrasound or local anesthesia techniques, yet reviled in some forums, the real responsible of such success. The consensus reached in the various scientific associations, the clinical guidelines of which are widely consulted worldwide, is the best to support the current state of the art, being the starting point for the addition of new improvements to PB.

The correlation between TWIST, E-cadherin, and beta-catenin in human bladder cancer

PURPOSE

Epithelial-to-mesenchymal transition (EMT)- related factors are known to contribute to the invasion and migration of multiple cancers. However, the expression levels of and the relationship between TWIST, E-cadherin, and beta-catenin in bladder cancer are not yet known. Therefore, this study investigated the relationship between TWIST, E-cadherin, and beta-catenin in tissue specimens and cell lines of bladder cancer.

METHODS

Microarrays of bladder cancer tissue and bladder cancer cell lines were used to study the expression levels of TWIST, E-cadherin, and beta-catenin, with disease stage and grade using immunohistochemistry. Moreover, the siRNAs of TWIST, E-cadherin, and beta-catenin were transfected into the bladder cancer cell lines to study any relationship between these factors.

RESULTS

The levels of TWIST and beta-catenin were upregulated with increasing grade of malignancy. In contrast, the corresponding results for E-cadherin were just the opposite. Furthermore, inhibition of the expression of TWIST elevated the expression of E-cadherin, but reduced the expression of beta-catenin. However, reduction of beta-catenin by siRNA had no influence on TWIST, but up-regulated the expression of E-cadherin.

CONCLUSION

TWIST may act upstream of E-cadherin, which can indirectly regulate the expression levels of beta-catenin. The EMT factors TWIST, E-cadherin, and beta-catenin may be a cluster of biomarkers for the metastatic progression of bladder cancer.

Localised prostate cancer - current treatment options

BACKGROUND

A number of options are available to treat localised prostate cancer, with different side effect profiles, effect on quality of life and social costs.

OBJECTIVE

This article outlines the grading and staging of localised prostate cancer and explores the role of each of the treatment options currently available.

DISCUSSION

Treatment selection in localised prostate cancer depends on life expectancy and comorbidities, risk adapted assessment and patient preference. Risk assessment depends on the grade, stage and prostate specific antigen. Options for treatment of localised prostate cancer include active surveillance, radical prostatectomy, curative external beam radiation therapy and brachytherapy. Androgen deprivation therapy in combination with radiation therapy has been shown to increase survival in men with high and high/intermediate risk of occult metastases. Survival rates are essentially equivalent for each modality and are over 90% at 10 years and over 75% at 15 years.

Confirmation of 5p12 as a susceptibility locus for progesterone-receptor-positive, lower grade breast cancer

BACKGROUND

The single-nucleotide polymorphism (SNP) 5p12-rs10941679 has been found to be associated with risk of breast cancer, particularly estrogen receptor (ER)-positive disease. We aimed to further explore this association overall, and by tumor histopathology, in the Breast Cancer Association Consortium.

METHODS

Data were combined from 37 studies, including 40,972 invasive cases, 1,398 cases of ductal carcinoma in situ (DCIS), and 46,334 controls, all of white European ancestry, as well as 3,007 invasive cases and 2,337 controls of Asian ancestry. Associations overall and by tumor invasiveness and histopathology were assessed using logistic regression.

RESULTS

For white Europeans, the per-allele OR associated with 5p12-rs10941679 was 1.11 (95% CI = 1.08-1.14, P = 7 × 10(-18)) for invasive breast cancer and 1.10 (95% CI = 1.01-1.21, P = 0.03) for DCIS. For Asian women, the estimated OR for invasive disease was similar (OR = 1.07, 95%CI = 0.99-1.15, P = 0.09). Further analyses suggested that the association in white Europeans was largely limited to progesterone receptor (PR)-positive disease (per-allele OR = 1.16, 95% CI = 1.12-1.20, P = 1 × 10(-18) vs. OR = 1.03, 95% CI = 0.99-1.07, P = 0.2 for PR-negative disease; P(heterogeneity) = 2 × 10(-7)); heterogeneity by ER status was not observed (P = 0.2) once PR status was accounted for. The association was also stronger for lower grade tumors [per-allele OR (95% CI) = 1.20 (1.14-1.25), 1.13 (1.09-1.16), and 1.04 (0.99-1.08) for grade 1, 2, and 3/4, respectively; P(trend) = 5 × 10(-7)].

CONCLUSION

5p12 is a breast cancer susceptibility locus for PR-positive, lower grade breast cancer.

IMPACT

Multicenter fine-mapping studies of this region are needed as a first step to identifying the causal variant or variants.

Treatment of high-grade glioma in children and adolescents

Pediatric high-grade gliomas (HGGs)--including glioblastoma multiforme, anaplastic astrocytoma, and diffuse intrinsic pontine glioma--are difficult to treat and are associated with an extremely poor prognosis. There are no effective chemotherapeutic regimens for the treatment of pediatric HGG, but many new treatment options are in active investigation. There are crucial molecular differences between adult and pediatric HGG such that results from adult clinical trials cannot simply be extrapolated to children. Molecular markers overexpressed in pediatric HGG include PDGFRα and P53. Amplification of EGFR is observed, but to a lesser degree than in adult HGG. Potential molecular targets and new therapies in development for pediatric HGG are described in this review. Research into bevacizumab in pediatric HGG indicates that its activity is less than that observed in adult HGG. Similarly, tipifarnib was found to have minimal activity in pediatric HGG, whereas gefitinib has shown greater effects. After promising phase I findings in children with primary CNS tumors, the integrin inhibitor cilengitide is being investigated in a phase II trial in pediatric HGG. Studies are also ongoing in pediatric HGG with 2 EGFR inhibitors: cetuximab and nimotuzumab. Other novel treatment modalities under investigation include dendritic cell-based vaccinations, boron neutron capture therapy, and telomerase inhibition. While the results of these trials are keenly awaited, the current belief is that multimodal therapy holds the greatest promise. Research efforts should be directed toward building multitherapeutic regimens that are well tolerated and that offer the greatest antitumor activity in the setting of pediatric HGG.

Correlation of serum levels of vascular endothelial growth factor with TNM staging, histopathologic grading, and surgical therapy for oral squamous cell carcinoma

OBJECTIVE

This study aimed to assess the serum levels of vascular endothelial growth factor in oral squamous cell carcinoma patients before and after surgical therapy, to compare these values with those of healthy individuals using ELISA, and to evaluate if any correlation existed between vascular endothelial growth factor levels and TNM stage or histolopathologic grade of the tumor.

METHOD AND MATERIALS

The study included three groups: group A1 consisted of 31 oral squamous cell carcinoma patients who had not received any prior treatment; group A2 consisted of the same 31 oral squamous cell carcinoma patients who had undergone radical surgical excision 1 month prior but no adjuvant therapy; and group B (control group) consisted of 16 healthy individuals. The serum vascular endothelial growth factor levels were assessed using the ELISA kit.

RESULTS

The vascular endothelial growth factor levels of preoperative oral squamous cell carcinoma patients were found to be three times higher than those of controls, and this difference was found to be statistically significant. The postoperative vascular endothelial growth factor levels had decreased 1 month after surgery but did not decrease to baseline levels. The vascular endothelial growth factor levels increased progressively with the TNM stage and histologic grade of tumor, but no definite correlation between the two could be found.

CONCLUSION

Vascular endothelial growth factor is an important marker of angiogenesis, as the vascular endothelial growth factor levels of the oral squamous cell carcinoma groups remained significantly elevated compared to that of controls. Though no significant difference was found between the pre- and postoperative oral squamous cell carcinoma groups, it can be suggested that successful treatment may reduce serum vascular endothelial growth factor levels if the time period of postoperative sample collection is increased. Only then can the utility of vascular endothelial growth factor as marker for assessing the effectiveness of surgical therapy or as a prognostic indicator be commented upon.

Active surveillance: pitfalls to consider

With the pendulum swinging in low risk prostate cancer (PCa) to ideas of overtreatment and overdiagnosis more urologists are looking at Active Surveillance (AS) as a valid option for their low risk PCa patients. AS will undoubtedly hold a place as a management option in men with low risk PCa, however, it is critical to understand its limitations in its current form as highlighted in this article. We conducted a review of multiple computerized databases (Ovid, Medline, Pubmed, CINAHL, Cohrane Library database) with the keywords active surveillance, prostate neoplasm, and low risk PCa. Manual searches were also carried out. Assumptions of AS are discussed and their implications on selecting the appropriate AS candidate. As with any active treatment option offered to patients with PCa, those who are offered AS must be appropriately selected and counseled as to its risks and benefits.

Gene expression pathways of high grade localized prostate cancer

BACKGROUND

Despite advances in screening and local therapy, prostate cancer remains the second most common cause of cancer related death among American men, with those having high grade disease being at highest risk for prostate cancer mortality. Here we identify the genes and cellular pathways that distinguish high grade from low grade pathologically localized prostate cancer.

METHODS

Cancer cells from low grade (Gleason 3 + 3 = 6) or high grade (4 + 4 = 8) tumors of men with localized disease were isolated by laser capture micro-dissection. Expression profiling was conducted across 18,344 unique annotated genes and data were analyzed using packages from the R/Bioconductor project to determine differential gene expression and perform gene set enrichment analysis. Publically available expression data was retrieved and analyzed individually in the same manner and in cross platform meta-analyses.

RESULTS

Six hundred seventy genes were differentially expressed between Gleason sum 6 and 8 tumors with a false discovery rate of <5% (P < 0.0014) including genes previously shown to mediate prostate cancer survival, proliferation, and metastasis. Functional themes associated with Gleason grade included developmental processes, signal transduction, chemokine and embryonic stem cell pathways with specific enrichment of the androgen receptor, EGFR, TNF-alpha, and Notch signaling cascades.

CONCLUSIONS

In addition to androgen receptor signaling, growth factor, and cytokine mediated pathways are active in clinically localized high grade prostate cancer. The availability of therapeutics that selectively target these pathways encourages the development of clinical trials for their selective use in the neoadjuvant or adjuvant setting in men at high risk for disease progression.

[Origin of ovarian epithelial inclusions and its relationship with the development of low-grade serous carcinoma]

OBJECTIVE

To investigate the possible origin of ovarian epithelial inclusions and its relationship with the low-grade ovarian serous carcinoma.

METHODS

By comparatively evaluating the morphologic (secretory and ciliated cell distribution) and immunophenotypic [using paired box gene 8 (PAX8), tubulin, calretinin, and Ki-67 as first antibodies] attributes of ovarian epithelial inclusions, the normal tubal epithelium, and the ovarian tumors, all adnexal tissues from a total of 198 patients were studied, including 116 adnexae removed for non-neoplastic indications, 53 serous cystadenomas, 44 serous borderline tumors, and 41 low-grade serous carcinomas, which were collected from Qilu Hospital of Shandong University and University of Arizona in USA. Immunohistochemical single staining was used to detect the expressions of PAX8, tubulin, calretinin, and Ki-67 in the two groups, while immunohistochemical double staining of PAX8/calretinin was used to figure out the immunophenotype of various ovarian epithelial inclusions in a more intuitive way.

RESULTS

With immunohistochemical single staining of PAX8 and calretinin, the vast majority (90%, 54/60) of ovarian surface epithelia displayed a mesothelial phenotype [calretinin(+), PAX8(-)], whereas 10% (6/60) of the cases displayed foci with tubal phenotype [calretinin(-), PAX8(+)]. In contrast, most (79%, 728/921) of the ovarian epithelial inclusions displayed a tubal phenotype, though 21% (193/921) of the ovarian epithelial inclusions showed a mesothelial phenotype. It was further proved by immunohistochemical double staining of PAX8/calretinin. Secretory and ciliated cells were found in the ovarian epithelial inclusions with tubal phenotype. There was a progressive increase in the secretory/ciliated cells ratio and proliferative index, from ovarian epithelial inclusions/cystadenomas to borderline tumors to low-grade serous carcinoma, according to the expression of tubulin and Ki-67.

CONCLUSIONS

The findings make a strong argument that the ovarian epithelial inclusions displaying a tubal phenotype with PAX8(+), calretinin(-) is likely derived from fallopian tube rather than through Mullerian metaplasia from ovarian surface epithelium. The increasing trend of secretory/ciliated cells ratio and proliferative index from ovarian epithelial inclusions/cystadenomas to borderline tumors to low-grade serous carcinoma indicates that the latter is a clonal expansion of secretory cells. Genetic and molecular studies are needed to further confirm these findings.

Breast cancer and primary systemic therapy. Results of the Consensus Meeting on the recommendations for pathological examination and histological report of breast cancer specimens in the Marche Region

Primary systemic therapy (PST) adds some practical problems to the pathologic examination of neoplastic breast tissue obtained from patients before and after chemotherapy. Pathologists, oncologists, breast surgeons, radiotherapists and radiologists in the Marche Region held a Consensus Meeting in Ancona on May 13, 2010, in which 15 statements dealing with neoadjuvant chemotherapy were approved by all participants. The first two statements are related to the pre-PST phase and concern the technical procedures and the histological report of the core biopsy. The other statements deal with similar issues of the post-PST surgical specimen.

A critical assessment of the value of lymph node dissection at radical prostatectomy: A population-based study

OBJECTIVE

We tested relationship between pelvic lymph node dissection (PLND) status at the time of radical prostatectomy (RP) and survival in prostate cancer (PCa) patients.

METHODS

Overall, 127,824 PCa patients treated with RP between 1988 and 2006 were included. Univariable and multivariable Cox regression analyses were used to evaluate the impact of PLND status (pN0 vs. pNx vs. pN1) on cancer-specific mortality (CSM) and overall mortality (OM) rates.

RESULTS

In pT2 patients, the 5-, 10-, and 15-year CSM rates were: 0.4%, 1.7%, and 3.9% for pN0, 0.6%, 2.5%, and 4.7% for pNx, 2.7%, 11.9%, and 20.6% for pN1 patients (all P < 0.001). The 5-, 10-, and 15-year OM rates were: 5.4%, 16.3%, and 34.5% for pN0, 6.1%, 18.2%, and 35.3% for pNx, 11.5%, 32.7%, and 53.4% for pN1 (all P < 0.001). In multivariable analyses, pNx and pN1 stage increased CSM rate, respectively by 1.3- and 3.8-fold (both P < 0.001) relative to pN0. Similarly, pNx and pN1 increased OM rate respectively by 1.1- and 1.6-fold (both P < 0.001) relative to pN0. In pT3 patients, pNx stage did not significantly increase CSM or OM rates relative to pN0 (both P > 0.05).

CONCLUSIONS

Patients with localized PCa treated with RP without a PLND (pNx) have less favorable survival rate than their counterparts that do not harbor lymph node invasion at PLND. However, the difference is modest (0.8% at 10 years). In consequence, the related costs and benefits of this procedure should be weighted carefully. In addition, the survival benefit of PLND was not observed in locally advanced PCa patients.

Predicting prostate biopsy result in men with prostate specific antigen 2.0 to 10.0 ng/ml using an investigational prostate cancer methylation assay

PURPOSE

The inadequacies of prostate specific antigen testing have created a need for novel markers for prostate cancer screening. The investigational ProCaM™ prostate cancer methylation assay detects aberrant methylation of DNA in cells associated with prostate cancer. We describe a large, prospective, multicenter study done to verify the performance of this assay.

MATERIALS AND METHODS

The assay is designed to detect epigenetic modifications in the 3 markers GSTP1, RARβ2 and APC, which are indicative of prostate cancer. A total of 232 men with cancer and 283 without cancer from 18 clinical sites were evaluated by trained operators at central testing laboratories. Study inclusion criteria were age 40 to 75 years, total prostate specific antigen between 2.0 and 10.0 ng/ml, and a digital rectal examination result. All participants signed an informed consent form and underwent transrectal ultrasound guided needle biopsy with 10 or more cores.

RESULTS

Assay sensitivity was 60%, specificity was 80% and the informative rate was 97%. Assay predictive accuracy was higher than that of age, digital rectal examination, family history, prostate specific antigen, prior negative biopsy and prostate volume (AUC 0.73 vs 0.52 to 0.66, p <0.038). Risk factors plus the assay improved overall predictive power (AUC 0.79, p = 0.001). A man with a positive prostate cancer methylation result was 7.7 times more likely to have high grade cancer.

CONCLUSIONS

The prostate cancer methylation assay correlated with positive biopsy and with Gleason score. This assay has the potential to add value to the biopsy decision making process by improving current prostate cancer screening algorithms to more accurately identify men with prostate cancer.

DNA microarray analysis identifies CKS2 and LEPR as potential markers of meningioma recurrence

Meningiomas are the most frequent intracranial tumors. Surgery can be curative, but recurrences are possible. We performed gene expression analyses and loss of heterozygosity (LOH) studies looking for new markers predicting the recurrence risk. We analyzed expression profiles of 23 meningiomas (10 grade I, 10 grade II, and 3 grade III) and validated the data using quantitative polymerase chain reaction (qPCR). We performed LOH analysis on 40 meningiomas, investigating chromosomal regions on 1p, 9p, 10q, 14q, and 22q. We found 233 and 268 probe sets to be significantly down- and upregulated, respectively, in grade II or III meningiomas. Genes downregulated in high-grade meningiomas were overrepresented on chromosomes 1, 6, 9, 10, and 14. Based on functional enrichment analysis, we selected LIM domain and actin binding 1 (LIMA1), tissue inhibitor of metalloproteinases 3 (TIMP3), cyclin-dependent kinases regulatory subunit 2 (CKS2), leptin receptor (LEPR), and baculoviral inhibitor of apoptosis repeat-containing 5 (BIRC5) for validation using qPCR and confirmed their differential expression in the two groups of tumors. We calculated ΔCt values of CKS2 and LEPR and found that their differential expression (C-L index) was significantly higher in grade I than in grade II or III meningiomas (p < .0001). Interestingly, the C-L index of nine grade I meningiomas from patients who relapsed in <5 years was significantly lower than in grade I meningiomas from patients who did not relapse. These findings indicate that the C-L index may be relevant to define the progression risk in meningioma patients, helping guide their clinical management. A prospective analysis on a larger number of cases is warranted.

[Permanent implant brachytherapy for early, organ-confined prostate cancer]

PURPOSE

Implementation of permanent prostate implant (PPI) brachytherapy in Hungary and presentation of initial experience.

PATIENTS AND METHODS

Between December 2008 and 2010, thirty-nine patients with low (n=26) and intermediate (n=13) risk prostate cancer were treated with PPI. Their mean age and initial PSA were 66 year (51-80 year) and 9 ng/ml (3,2-15 ng/ml). Iodine-125 loose seeds were implanted under spinal anaesthesia using the FIRST system (Nucletron, The Netherlands). Needles were inserted into the prostate through the perineum according to the preplan based on transrectal ultrasound images. The treatment plan was modified according to updated positions of the needles on live US images. The prescribed dose to the prostate was 145 Gy. Seed loading was performed under real-time US assistance. Implanted sources were checked by X-ray and CT images. Patients were discharged one day after the implantation. On follow-up visits PSA and toxicity were registered.

RESULTS

The mean follow-up was 10 months (3-27 months), the median number of seeds was 53 (30-78), their mean activity was 0.48 mCi (0.41-0.52 mCi). The mean coverage of the prostate by the prescribed dose was 96% (92-98%). The mean percent dose of the prescribed dose that covered the 90% of the prostate (D90), 2 cm3 of the rectum (Dr2cm3) and 10% of the urethra (Du10) were 113% (104-121%), 85% (48-121%) and 124% (98-146%) respectively. Deviation from the requested dose-volume constraints never exceeded 3%. Acute >grade 2 proctitis, grade 2 and 3 cysto-prostatitis were observed in 0 (0%), 13 (33.3%) and 1 (2.6%) cases. Biochemical relapse occurred in one patient (2.6%).

CONCLUSION

This is a report of the first application of PPI in Hungary. The observed rate of acute proctitis was negligible, the rate and severity of acute cysto-prostatitis was tolerable. With the use of intraoperative planning, dose distributions met the dose-volume constraints in most of the cases. The biochemical control is excellent but the follow-up time is still short.

[Significance of glypican-3 immunohistochemistry in diagnosis of hepatocellular carcinoma]

OBJECTIVE

To explore the diagnostic significance of glypican-3 (GPC3) immunohistochemistry in hepatocellular carcinoma (HCC).

METHODS

Fourteen tissue microarray paraffin blocks were constructed, which comprised 731 samples from hepatic tumors and paratumor tissues, including 357 cases of HCC, 26 cholangiocarcinoma, 171 HCC adjacent hepatic tissue including cirrhosis, 93 hemangioma adjacent hepatic tissues, and 84 carcinomas metastatic to liver. GPC3 (Clone 1G12) protein was detected immunohistochemically in all of cases with positive controls.

RESULTS

GPC3 protein was positive in 72.0% HCC (257/357), but negative in the rest 374 of non-HCC cases, including cholangiocarcinoma, HCC adjacent hepatic tissue including cirrhosis, hemangioma adjacent hepatic tissues and metastatic carcinomas. GPC3 positive percentage was significantly correlated with histological grading of HCC (P < 0.01), highest in grade 3 (77.1%, 64/83) followed by grade 2 (73.3%, 187/255), grade 1 (6/12) and grade 4 (0).

CONCLUSIONS

GPC3 is a valuable diagnostic marker for hepatocellular carcinoma with sensitivity of 72.0%, and a differential diagnostic marker from tumor adjacent hepatic tissue and carcinomas metastatic to liver with specificity of 100%.

The role of frozen section in surgical staging of low risk endometrial cancer

BACKGROUND

The role of frozen section (FS) in intraoperative decision making for surgical staging of endometrial cancer is controversial. Objective of this study is to assess the agreement rate between the FS and paraffin section (PS); and the potential impact of the role of FS in the intra-operative decision making for the complete surgical staging in low risk endometrial cancer.

METHODS

This is a retrospective analysis of patients diagnosed with intra-operative FS stage I, grade I or II endometrial cancer from 1995-2004. FS results were compared with final pathology results with regard to tumor grade, depth of myometrial invasion, cervical involvement, lymphovascular invasion, and lymph node involvement. Agreement statistic with kappa was calculated using SPSS statistical software. Categorical variables were tested using chi-square test with p value of ≤0.05 being statistically significant.

RESULTS

Of the 457 patients with endometrial cancer, 146 were evaluated by intra-operative FS and met inclusion criteria. FS results were in disagreement with permanent section in 35% for the grade (kappa 0.58, p = 0.003), 28% for depth of myometrial invasion (kappa 0.61, p<0.0001), 13% for cervical involvement (kappa 0.78, p = 0.002), and 32% for lymphovascular invasion (kappa 0.6, p = 0.01). Permanent pathology upstaged 31.9% & 23.2% of FS stage IA, & IB specimen respectively. Lymph node dissection was done in 56.8%. Lymph node metastasis was identified in 8.4%. Use of intraoperative FS would have resulted in suboptimal surgical treatment in 13% stage IA and 6.6% of stage IB patients respectively by foregoing lymphadenectomy.

CONCLUSION

A significant number of patients with low risk endometrial cancer by FS were upstaged and upgraded on final pathology. Before placing absolute reliance on intraoperative FS to undertake complete surgical staging, the inherent limitation of the same in predicting final stage and grade highlighted by our data need to be carefully considered.

Saturation biopsy technique increase the capacity to diagnose adenocarcinoma of prostate in patients with PSA < 10 ng/ml, after a first negative biopsy

OBJECTIVE

Aim of this study was to evaluate if saturation biopsy (SB) technique increases the cancer detection rate in patients with PSA < 10 ng/ml, after a first negative biopsy.

MATERIAL AND METHODS

From January 2004 to January 2006, 780 patients underwent prostate ultrasound guided transrectal (UGT) core biopsy: 186 (23.8%) presented prostate cancer (PCa) while 594 pts (76.2%), were disease free. For 1 year all the patients with no evidence of cancer were observed according to a follow-up schedule including PSA every 3 months and DRE every 6 months. During this period 140 patients showed an increase of PSA (< 10 ng/ml) or a low PSA free/total. This group underwent a second prostate UGT core biopsy with SB technique. In all the patients we evaluated PCa detection rates (DR) according to the PSA range. We also checked peri/post-operative complication rate (total post-operative hospitalization time, haemoglobin loss, catheterisation rate, pain rate, QOL).

RESULTS

Of the 140 patients 50 (35.7%) had PCa showing a Gleason score (GS) of 4 or 5 in 26%, 6 or 7 in 75% and 8 to 10 in 9% respectively. Sectors apical biopsies carried out in the anterior horn of peripheral zone tissue presented over 70% (35 patients) of cancer detection rate. Rectal bleeding was the major common complication. Cancer was clinically significant in 47 patients (94%) but 34 (68%) presented an organ confined disease after radical surgery.

CONCLUSIONS

SB technique increases of 35.7% the cancer detection rate (DR) in patients with PSA < 10 ng/ml, after a first negative biopsy, showing a higher positivity (70% PCaDR) if the SB included the anterior horn of peripheral zone tissue. No significantly pain and side effects were observed.

Localized resectable genitourinary sarcoma in adult Korean patients: experiences at a single center

PURPOSE

To evaluate the clinicopathological characteristics and prognosis of localized resectable genitourinary sarcomas in adults.

MATERIALS AND METHODS

Between September, 1996 and November, 2008, 18 consecutive cases of adults (12 men and 6 women; median age 48.8 years) who were treated for primary genitourinary sarcomas were identified. The following variables were analyzed: patient age, gender, body mass index, American Society of Anesthesiologists (ASA) score, primary organ, tumor histology, size, necrosis, Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) grade, and surgical margin positivity. Recurrence- free survival and disease-specific survival were the study end-points.

RESULTS

The most common presenting symptom was a palpable mass (six cases, 33.3%), the most common site was the kidney (six cases, 33.3%), and the most common histological subtype was leiomyosarcoma (eight patients, 44.4%). Complete resection with negative surgical margins was achieved in 13 patients (72.2%). The median follow-up period was 49.9 months (range 6.4 to 147.6). The recurrence- free survival rates at 1, 3, and 5 years were 81.6%, 66.5%, and 66.5%, respectively. Recurrence-free survival only associated significantly with ASA score (p=0.018). The disease-specific survival rate at 1, 3, and 5 years was 88.9%, 76.2%, and 67.7%, respectively. Disease-specific survival was associated significantly only with FNCLCC grade (p=0.042).

CONCLUSION

Although genitourinary sarcomas in adults are a rare group of tumors with a poor prognosis, some patients may have a favorable prognosis. Our findings suggest that FNCLCC grade is the most important prognostic factor for these patients.

Prognostic significance of carbonic anhydrase IX (CA-IX), endoglin (CD105) and 8-hydroxy-2'-deoxyguanosine (8-OHdG) in breast cancer patients

The aim of this study was to examine the prognostic significance of carbonic anhydrase IX (CA-IX), an endogenous marker for tumor hypoxia; endoglin (CD105), a proliferation-associated and hypoxia-inducible glycoprotein and 8-hydroxy-2'-deoxyguanosine (8-OHdG), an oxidative DNA lesion, in breast cancer patients. Immunohistochemical expressions of CA-IX, CD105 and 8-OHdG, analyzed on paraffin-embedded tumor tissues from forty female breast cancer patients, were used to assess their prognostic implication on overall survival (OS) and relapse-free survival (RFS). Patients with high CA-IX expression (above cut-off value) had a higher occurrence of relapse (P = = 0.002). High CA-IX expression was significantly associated with shorter RFS (P < 0.001, hazard ratio (HR) 0.21) and shorter OS (P < 0.001, HR 0.19). Lymph node negative patients with high CA-IX expression had worse RFS (P = 0.031, HR 0.14) and OS (P = 0.005, HR 0.05). Patients with grade I&II tumors and high CA-IX expression showed shorter RFS (P = 0.028, HR 0.28) and OS (P = 0.008, HR 0.20). Worse OS (P = 0.046, HR 0.28) was found in subgroup of patients with grade II tumors and high CA-IX expression. Among all three markers, only high CA-IX expression was strong independent prognostic indicator for shorter OS (HR 4.14, 95% CI 1.28-13.35, P = 0.018) and shorter RFS (HR 3.99, 95% CI 1.38-11.59, P = 0.011). Elevated expression of CA-IX was an independent prognostic factor for decreased RFS and OS and a significant marker for tumor aggressiveness. CD105 had week prognostic value; whereas, 8-OHdG, in this study, did not provide sufficient evidence as a prognostic indicator in breast cancer patients.

A randomized controlled trial of celecoxib to prevent recurrence of nonmuscle-invasive bladder cancer

Significant morbidity and expense result from frequent recurrences of nonmuscle-invasive bladder cancer (NMIBC) after standard treatment, and carcinoma in situ (Tis) is a poor prognostic factor. Predicated on observational and preclinical data strongly supporting cyclooxygenase-2 (COX-2) in the pathogenesis, and the activity of COX-2 inhibitors, in bladder cancer, we conducted a randomized, double-blind, placebo-controlled trial to determine whether celecoxib could reduce the time-to-recurrence (TTR) in NMIBC patients at high risk for recurrence. A total of 146 patients were randomized to celecoxib (200 mg) or placebo orally twice daily for at least 12 months. The average treatment duration was 1.25 years. Primary intent-to-treat analysis revealed celecoxib did not statistically significantly prolong TTR compared with placebo (P = 0.17, log rank) with a median follow-up of 2.49 years. The recurrence-free rate at 12 months with celecoxib was 88% (95% CI: 0.81-0.96) versus 78% (95% CI: 0.69-0.89) with placebo. After controlling for covariates with Cox regression analysis, recurrence rates did not differ between the two study arms (HR = 0.69; 95% CI: 0.37-1.29). However, celecoxib had a marginally significant effect on reducing metachronous recurrences (vs. placebo) with HR of 0.56 (95% CI: 0.3-1.06; P = 0.075). Celecoxib was well tolerated, with similar adverse events and quality-of-life in both arms. Our clinical trial results do not show a clinical benefit for celecoxib in preventing NMIBC recurrence but further investigation of COX-2 inhibitors in this setting is warranted.

Prospective assessment of prostate cancer aggressiveness using 3-T diffusion-weighted magnetic resonance imaging-guided biopsies versus a systematic 10-core transrectal ultrasound prostate biopsy cohort

BACKGROUND

Accurate pretreatment assessment of prostate cancer (PCa) aggressiveness is important in decision making. Gleason grade is a critical predictor of the aggressiveness of PCa. Transrectal ultrasound-guided biopsies (TRUSBxs) show substantial undergrading of Gleason grades found after radical prostatectomy (RP). Diffusion-weighted magnetic resonance imaging (MRI) has been shown to be a biomarker of tumour aggressiveness.

OBJECTIVE

To improve pretreatment assessment of PCa aggressiveness, this study prospectively evaluated MRI-guided prostate biopsies (MR-GBs) of abnormalities determined on diffusion-weighted imaging (DWI) apparent diffusion coefficient (ADC) maps. The results were compared with a 10-core TRUSBx cohort. RP findings served as the gold standard.

DESIGN, SETTING, AND PARTICIPANTS

A 10-core TRUSBx (n=64) or MR-GB (n=34) was used for PCa diagnosis before RP in 98 patients.

MEASUREMENTS

Using multiparametric 3-T MRI: T2-weighted, dynamic contrast-enhanced imaging, and DWI were performed to identify tumour-suspicious regions in patients with a negative TRUSBx. The regions with the highest restriction on ADC maps within the suspicions regions were used to direct MR-GB. A 10-core TRUSBx was used in a matched cohort. Following RP, the highest Gleason grades (HGGs) in biopsies and RP specimens were identified. Biopsy and RP Gleason grade results were evaluated using chi-square analysis.

RESULTS AND LIMITATIONS

No significant differences on RP were observed for proportions of patients having a HGG of 3 (35% vs 28%; p=0.50), 4 (32% vs 41%; p=0.51), and 5 (32% vs 31%; p=0.61) for the MR-GB and TRUSBx cohort, respectively. MR-GB showed an exact performance with RP for overall HGG: 88% (30 of 34); for TRUS-GB it was 55% (35 of 64; p=0.001). In the MR-GB cohort, an exact performance with HGG 3 was 100% (12 of 12); for HGG 4, 91% (10 of 11); and for HGG 5, 73% (8 of 11). The corresponding performance rates for TRUSBx were 94% (17 of 18; p=0.41), 46% (12 of 26; p=0.02), and 30% (6 of 20; p=0.01), respectively.

CONCLUSIONS

This study shows prospectively that DWI-directed MR-GBs significantly improve pretreatment risk stratification by obtaining biopsies that are representative of true Gleason grade.

[Salivary gland tumors: pathology and prognosis]

Due to their infrequency, diagnosis of salivary gland tumors remains a challenge for the practicing pathologist with respect to subtyping, grading and estimating patient prognosis. In a 3 center collaborative study of 288 cases with clinical follow-up information, it could be demonstrated that apart from clinical parameters like high patient's age, male sex and high tumor stage, the application of a 3-tiered grading system incorporating the histological tumor type is of high prognostic relevance. In immunohistochemical and molecular analyses overexpression of epidermal growth factor receptor (EGFR), high expression of human epidermal growth factor receptor 2 (HER2), amplification and gains of EGFR and HER2, absent expression of C-KIT, loss of maspin and of O(6)-methylguanine DNA-methyltransferase (MGMT) as well as MGMT promoter methylation turned out to be negative prognostic factors. In mucoepidermoid carcinomas the presence of a translocation t(11;19) was less relevant than recognizing different subtypes (classical type, eosinophilic, clear-cell and squamoid variants). Acinic cell carcinoma with mixed acinar-ductular differentiation as judged by expression of CK7 was characterized by a higher frequency of early relapse. The presented results underline the pathologist's role in the diagnosis and management of patients with salivary gland carcinomas.

Prostate cancer increases hyaluronan in surrounding nonmalignant stroma, and this response is associated with tumor growth and an unfavorable outcome

Our objective was to investigate whether the presence of a tumor increases hyaluronan (HA) levels in surrounding prostate tissues and whether this extratumoral HA influences tumor growth and outcome. From a series of 287 men diagnosed with prostate cancer at transurethral resection and followed up with watchful waiting, tissue microarrays were constructed, stained, and scored for HA. A high HA staining score in the tumor stroma or in nonmalignant prostate tissue stroma were both associated positively with higher Gleason score and larger tumor volume, and was associated with a poor outcome. HA staining score was not an independent marker for outcome (multivariate Cox, with Gleason score, tumor volume, stage, and HA variables). In an orthotopic rat prostate cancer model, hyaluronic acid synthase-1 mRNA levels and HA staining were increased in normal prostate tissue surrounding prostate cancer. Orthotopic prostate cancer growth was increased by intraprostatic injection of HA. In conclusion, cancer in the prostate apparently stimulates HA synthesis both in tumor stroma and in the surrounding normal tissue. This promoted tumor growth and was associated with an unfavorable outcome.

Low expression of TBX4 predicts poor prognosis in patients with stage II pancreatic ductal adenocarcinoma

This study was designed to investigate the expression of the T-box transcription factor 4 (TBX4), a tumor biomarker that was previously identified by proteomics, in pancreatic ductal adenocarcinoma (PDAC) and evaluate its clinical utility as a potential prognostic biomarkers for PDAC. The expression of TBX4 was detected in 77 stage II PDAC tumors by immunohistochemistry, and the results were analyzed with regard to clinicopathological characteristics and overall survival. Moreover, Tbx4 promoter methylation status in primary PDAC tumors and normal adjacent pancreas tissues was measured by bisulfite sequencing. Among 77 stage II PDAC tumors, 48 cases (62.3%) expressed TBX4 at a high level. No significant correlation between TBX4 expression and other clinicopathological parameters, except tumor grade and liver metastasis recurrence, was found. The survival of patients with TBX4-high expression was significantly longer than those with TBX4-low expression (P = 0.010). In multivariate analysis, low TBX4 expression was an independent prognostic factor for overall survival in patients with stage II PDAC. TBX4 promoter methylation status was frequently observed in both PDAC and normal adjacent pancreas. We conclude that a low level of TBX4 expression suggests a worse prognosis for patients with stage II PDAC. Down-regulation of the TBX4 gene in pancreas is less likely to be regulated by DNA methylation.

Impact of immediate TRUS rebiopsy in a patient cohort considering active surveillance for favorable risk prostate cancer

INTRODUCTION AND OBJECTIVE

Active surveillance (AS) is an option for the management of favorable risk prostate cancer (CaP) in the PSA era. Published studies have reported variable inclusion criteria for cohort selection. Accurate assessment of individual patient risk in AS is dependent not only upon rigorous selection criteria, but also reliability of diagnosis at tissue biopsy. To date, the impact of immediate transrectal ultrasound (TRUS) rebiopsy in confirming candidates for AS has been incompletely defined.

METHODS

From a total of over 567 men, 67 met criteria for AS (Gleason <7, PSA <10, PSAD <0.15, <3 cores with <50% involvement of any 1 core). Fifty-two men agreed to a 12-core TRUS rebiopsy within 6 months of first diagnosis performed in clinic. Statistical analysis was performed using Wilcoxon signed rank test and logistic regression to determine predictors of rebiopsy characteristics, histopathologic outcomes, and impact on treatment choice.

RESULTS

Mean cohort age was 63.9 years (range 56-72 years), PSA 5.9 ng/ml (4.1-10), and PSA density 0.12 ng/ml/cc at initial biopsy. Tumor involved 1.1 cores and 3.2% (range 1%-5%) of the total tissue. Average time to rebiopsy was 2.7 months. Notably, 29 of 52 men (56%) demonstrated no evidence of CaP on repeat biopsy; 14 of 23 men with a positive repeat biopsy showed either an increase in cancer volume (2.8% mean increase) and 9 (18%) were upgraded to Gleason pattern 3+4 = 7. Rebiopsy demonstrated 9 (17%) patients exceeded AS criteria. Nine patients chose curative surgical intervention (radical prostatectomy) based on increased cancer volume or grade (4) or an elective desire for treatment (5). All had organ confined disease with negative margins on final pathologic analysis. Statistical review revealed that initial Gleason score, PSA density, and number of positive cores at first biopsy were not predictive of men with higher volume/grade on re-biopsy.

CONCLUSIONS

Immediate TRUS repeat biopsy after diagnosis frequently fails to redemonstrate prostate cancer confirming the favorable-risk nature of disease burden in this group being considered for AS. A subset of patients are upgraded (17%) leading to reconsideration of AS. We conclude this clinic-based approach provides valuable additional information to discriminate appropriate AS candidates.

[Clinicopathologic study and immunohistochemistry comparison of Pax2, p53 and Ki-67 in low- and high-grade ovarian serous carcinomas]

OBJECTIVE

To evaluate the two-tier system for the grading of ovarian serous carcinomas, and to analyze Pax2, p53, Ki-67 protein expression and their prognostic values for low- and high-grade ovarian serous carcinomas.

METHODS

A total of 38 cases of low-grade and 100 cases of high-grade ovarian serous carcinomas were selected based on the two-tier grading system. Immunohistochemistry was used to detect Pax2, p53 and Ki-67 protein expression in all cases. Correlation of the two-tier system with immunohistochemical results and prognostic parameters were performed.

RESULTS

(1) The overall survival, disease-free survival and 5-year survival rates were significantly higher in the low-grade serous carcinoma cases than in the high-grade cases (P < 0.05). (2) Significant differences in protein expressions were found between the low- and high-grade serous carcinomas. The high-grade serous carcinomas had a significantly higher expression level of p53 (55.0% vs 13.2%, P < 0.05) and Ki-67 (42.1% vs 13.7%, P < 0.05), while low-grade carcinomas had a significantly higher expression level of Pax2 (65.8% vs 13.0%, P < 0.05). (3) Pax2 positive cases had a significantly better overall survival and 5-year survival rates than Pax2 negative cases (P < 0.05). The expressions of p53 and Ki-67 were found to have little correlation with overall survival and disease-free survival (P > 0.05).

CONCLUSIONS

The two-tier system for the grading of ovarian serous carcinomas has a good prognostic value. There are significantly differences in expressions of Pax2, p53 and Ki-67 between low- and high-grade ovarian serous carcinomas. Compared with p53 and Ki-67, Pax2 is likely a better prognostic indicator for ovarian serous carcinoma.

Value of ultrasound in preoperative local staging in early breast cancer

PURPOSE

The purpose of this study was to determine the precision of breast ultrasound for the measurement of breast lesions compared to the histological measurement. A number of other dependent variables were also analyzed.

MATERIAL AND METHODS

460 patients with 445 malignant lesions were examined using breast ultrasound and the lesions were measured and compared to the histologically measured size. The data was further analyzed according to histology, tumor stage, age, grading and therapy.

RESULTS

Metric comparison showed good correlation between sonography and the pathologically measured size of breast lesions, especially in tumor stage T 1 and T 2 and within ductal invasive carcinomas. Higher tumor stages lead to imprecise measurements and the histological type of lobular invasive carcinoma also results in imprecise measurements. Age and grading do not influence measurement precision.

CONCLUSION

Breast ultrasound allows precise measurement of breast lesions especially at lower tumor stages. The higher the tumor stage, the more imprecise the measurement becomes. Multivariate analysis shows no cross impact between tumor stage and histological type with respect to the quality of measurement.

[Significance of MUM-1/IRF4 protein expression in follicular lymphoma]

OBJECTIVE

To study the expression of MUM-1/IRF4 and its significance in follicular lymphoma.

METHODS

Ninety-eight cases of follicular lymphoma were enrolled into the study. They were graded according to the 2008 WHO criteria. The expression of MUM-1/IRF4 protein and other markers (CD10, bcl-6, bcl-2 and Ki-67) was studied using tissue microarray and immunohistochemistry.

RESULTS

Amongst the 98 cases studied, there were 24 grade 1 cases, 30 grade 2 cases, 26 grade 3A cases and 18 were grade 3B cases. The rates of expression of MUM-1/IRF4, CD10, bcl-6, bcl-2 and Ki-67 (≥ 25%) were 39.8% (39/98), 62.2% (61/98), 80.6% (79/98), 87.8% (86/98) and 50.0% (49/98), respectively. MUM-1/IRF4 predominantly expressed in high-grade follicular lymphoma and showed a significantly positive correlation with lymphoma grade (r = 0.628, P = 0.000) and Ki-67 index (r = 0.473, P = 0.000). MUM-1/IRF4 expression had a significantly negative correlation with CD10 expression (r = -0.597, P = 0.000), but no correlation with bcl-6 and bcl-2 expression.

CONCLUSIONS

MUM-1/IRF4 expression is significantly higher in high-grade follicular lymphoma, indicating that these cases have a high proliferative activity, more aggressive behavior and poorer prognosis. MUM-1/IRF4, when strongly expressed, is another helpful marker for the diagnosis of high-grade follicular lymphoma.