Aristolochic acid-containing Chinese herbal medicine and upper urinary tract urothelial carcinoma in Taiwan: a narrative review

Aristolochic acid I abnormally activates the wnt7b/β-catenin signaling pathway and affects the repair of renal tubules

Aristolochic acid I (AAI), which is one of the main forms of aristolochic acid, can cause aristolochic acid nephropathy. Abnormal activation or inhibition of the Wnt7b/β-catenin signaling pathway may lead to the occurrence and development of kidney disease. This study aimed to investigate the effect of the Wnt7b/β-catenin signaling pathway on the damage and repair processes of renal tubular epithelial cells (RTECs) using mouse and zebrafish models of acute aristolochic acid intoxication. Our data revealed that after mice were exposed to 5 mg/kg/day AAI for 4 days and 6 days the expression of Wnt7b on the villi of RTECs increased, the expression of β-catenin on the cytoplasm decreased, and the expression of β-catenin in the nucleus increased. The protein expression levels of PCNA and Kim-1 increased. After zebrafish at 3 days post fertilization were exposed to 2, 4, and 8 μg/mL AAI for 24 h, the results indicated that treatment with AAI resulted in a decrease in the number of RTECs and the occurrence of apoptosis. Importantly, after knockout of the Wnt7ba gene, damage to RTECs in zebrafish larvae was aggravated, the mRNA expression level of PCNA decreased, and that of Kim-1 increased. In addition, we found that AAI exhibits developmental toxicity in fertilized zebrafish eggs. As a result, AAI leads to abnormal activation of the Wnt7b/β-catenin signaling pathway, which affects the repair of renal tubular injury by activating the downstream protein PCNA. The Wnt7ba gene may serve as a potential therapeutic target to promote repair after renal tubular injury.

Clinical and safety outcomes associated with aristolochic acid exposure: a systematic review and meta-analysis

Current studies have clearly shown that aristolochic acid (AA) exposure can induce a variety of diseases, such as kidney disease, liver cancer, and urinary tract cancer (UTC). However, no studies have systematically analyzed and integrated these results. Therefore, we aimed to elucidate the association between AA exposure and the risk of safety outcomes for AA-related overall disease and different types of disease it causes. We conducted an exhaustive search of PubMed, EMBASE, Web of Science, and the Cochrane Library for relevant material up to April 2024. For AA-related overall disease, AA exposure was significantly associated with an increased incidence of AA-related overall disease (OR: 1.289, 95% CI: 1.183-1.404). For different types of disease, AA exposure was significantly associated with increased incidence of kidney disease (OR: 1.279, 95% CI: 1.029-1.590), UTC (OR: 1.842, 95% CI: 1.376-2.465), and liver cancer (OR: 1.146, 95% CI: 1.040-1.262). No significant association was found between AA exposure and the incidence of brain disease (OR: 1.161, 95% CI: 0.989-1.362). This study systematically analyzed various safety outcomes associated with AA exposure to provide a solid scientific basis for future prevention strategies and clinical management.

Upper tract urothelial carcinoma: epidemiology, presentation, and high-risk endemic populations

PURPOSE OF THE REVIEW

Upper tract urothelial carcinoma (UTUC) only accounts for 5-10% of all urothelial cancers but these patients present with high stage disease and 2 out of 3 patients have evidence of muscle-invasion at time of diagnosis. Furthermore, 10% of UTUC patients have associated Lynch syndrome and therefore diagnosis of UTUC should prompt timely evaluation and familial counseling. The purpose of this review is to outline the current evidence on the epidemiology, presentation, and high-risk endemic populations of UTUC through review of contemporary publications occurring over the preceding 18 months.

RECENT FINDINGS

Both the American Urological Association (AUA) and European Association of Urology (EAU) have published updated guidelines within the last 18 months for the management of UTUC. Of note, the updated guidelines give special consideration to identifying patients with risk factors for Lynch syndrome and recommend universal histologic testing for those with high probability of having Lynch syndrome cancers as well as referral for genetic counseling and germline testing.

SUMMARY

UTUC is an overall rare malignancy but tends to present with advanced stage and muscle-invasion. A proper understanding of the epidemiology, presentation, and high-risk endemic populations is necessary to develop preventive and interventional strategies.

Aristolochia clematitis L. Ethanolic Extracts: In Vitro Evaluation of Antioxidant Activity and Cytotoxicity on Caco-2 Cell Line

Aristolochia sp. plants are used in traditional medicine because of their immunostimulatory and anticarcinogenic properties, despite their content of aristolochic acids (AAs), carcinogenic and nephrotoxic agents. Therefore, ethanolic extracts of Aristolochia clematitis leaves, a specie growing in Western Romania, were obtained to study antioxidant and cytotoxic effects. The antioxidant capacity of the extract was evaluated by five in vitro chemical-based assays, proving that ABTS assay was a better method for this type of evaluation showing an IC50 of 160.89 ± 0.21 µg/mL. Furthermore, the cytotoxic effects of the extract were established by an IC50 of 216 µg/mL for 24 h by MTT assay, followed by a cell-based assay on Caco-2 cells by the ABTS method. The antioxidant effects of the A. clematitis extract demonstrate potential therapeutic applications in complementary medicine.

Sarcoma incidence worldwide: regional differences in histology and molecular subtypes

PURPOSE OF REVIEW

There are numerous sarcoma subtypes and vary widely in terms of epidemiology, clinical characteristics, genetic profiles, and pathophysiology. They also differ widely between ethnic groups. This review focuses on the different incidence rates of sarcomas in different regions and the potential explanations for these disparities.

RECENT FINDINGS

In an intercontinental study using national cancer registry databases from France and Taiwan, the French population had a higher risk of liposarcomas, leiomyosarcomas, and synovial sarcomas, whereas the Taiwanese population had a higher incidence of angiosarcomas and malignant peripheral nerve sheath tumors. The anatomical distribution of these sarcomas also varied between these two regions. In France, most angiosarcoma cases occurred in the extremities and trunk, whereas in Taiwan, angiosarcoma cases in the abdomen and pelvis were more common. Another international study showed that in addition to the common known TP53 and NF1 germline mutations, genes involved in centromere and telomere maintenance were also involved in sarcomagenesis. We reviewed factors related to genetics, environmental effects, chemical exposure, and radiation exposure that could explain the differences in sarcoma incidence among different geographical or ethnic regions.

SUMMARY

Our understanding of the potential cause of sarcomas with different subtypes is limited. Establishing a comprehensive global database for patients with sarcomas from all ethnic groups is essential to deepen our understanding of the potential risk factors and the pathophysiology of all sarcoma subtypes.

Establishment of enzyme-linked immunosorbent assay for aristolochic acid

In recent years, the nephrotoxicity and carcinogenicity of aristolochic acid have attracted worldwide attention, and the traditional Chinese medicine containing this ingredient has been banned in many places, affecting the TCM industry. To meet this challenge, researchers have developed various detection methods, such as high-performance liquid chromatography, gas chromatography-mass spectrometry and thin-layer chromatography. A rapid detection method must therefore be developed to ensure safety. A polyclonal antibody capable of recognizing aristolochic acid was prepared, and an indirect competitive enzyme-linked immunosorbent assay (ic-ELISA) was established to detect the amount of aristolochic acid in the sample to be measured. Methods Using 1-(4-chlorophenyl) cyclobutylamine as a hapten, immunogens and coating antigens were obtained by coupling with bovine serum albumin (BSA) and chicken ovalbumin (OVA) using the active ester method. UV scanning confirmed the successful coupling of the conjugate, and New Zealand white rabbits were immunized. The obtained antibody serum was screened for the best antibody by ic-ELISA detection. Use the chessboard method to determine three optimal combinations of original coating concentration and antibody dilution ratio, establish a standard curve for each combination to obtain the best combination, and establish a rapid detection method. Finally, the standard aristolochic acid A was added to the purchased apple vinegar and canned coffee for recycling experiments to verify the detection method.By changing the antigen antibody concentration, the antibody showed the highest sensitivity to aristolochic acid standard at the original coating, 1000-fold dilution, IC50 of 24.88 ng/mL, limit of detection IC10 of 3.19 ng/mL, and detection range IC20-IC80 of 6.81-90.91 ng/mL. The recovery experiments under this conditions yielded a recovery rate of 92%-105%, within reasonable limits, indicating the success of the ELISA rapid detection method. Conclusion The enzyme-linked immunoassay method established in this paper can quickly detect the content of aristolochic acid in the sample to be tested, and the antibody prepared by this method has good broad-spectrum and can detect other aristolochic acid, such as aristolochic acid A, aristolochic acid B, aristolochic acid C, and aristolochic acid D.

Integrative multiomics enhancer activity profiling identifies therapeutic vulnerabilities in cholangiocarcinoma of different etiologies

OBJECTIVES

Cholangiocarcinoma (CCA) is a heterogeneous malignancy with high mortality and dismal prognosis, and an urgent clinical need for new therapies. Knowledge of the CCA epigenome is largely limited to aberrant DNA methylation. Dysregulation of enhancer activities has been identified to affect carcinogenesis and leveraged for new therapies but is uninvestigated in CCA. Our aim is to identify potential therapeutic targets in different subtypes of CCA through enhancer profiling.

DESIGN

Integrative multiomics enhancer activity profiling of diverse CCA was performed. A panel of diverse CCA cell lines, patient-derived and cell line-derived xenografts were used to study identified enriched pathways and vulnerabilities. NanoString, multiplex immunohistochemistry staining and single-cell spatial transcriptomics were used to explore the immunogenicity of diverse CCA.

RESULTS

We identified three distinct groups, associated with different etiologies and unique pathways. Drug inhibitors of identified pathways reduced tumour growth in in vitro and in vivo models. The first group (ESTRO), with mostly fluke-positive CCAs, displayed activation in estrogen signalling and were sensitive to MTOR inhibitors. Another group (OXPHO), with mostly BAP1 and IDH-mutant CCAs, displayed activated oxidative phosphorylation pathways, and were sensitive to oxidative phosphorylation inhibitors. Immune-related pathways were activated in the final group (IMMUN), made up of an immunogenic CCA subtype and CCA with aristolochic acid (AA) mutational signatures. Intratumour differences in AA mutation load were correlated to intratumour variation of different immune cell populations.

CONCLUSION

Our study elucidates the mechanisms underlying enhancer dysregulation and deepens understanding of different tumourigenesis processes in distinct CCA subtypes, with potential significant therapeutics and clinical benefits.

TGFB1I1 promotes cell proliferation and migration in urothelial carcinoma

Urothelial carcinoma (UC) is common cancer worldwide with a high prevalence in Taiwan, especially in the upper urinary tract, including the renal pelvis and ureter, also classifying as upper urinary tract urothelial carcinoma. Here, we aim to find a representative prognostic marker that strongly correlates to this type of carcinoma. Transforming growth factor beta-1-induced transcript 1 (TGFB1I1) is a cofactor of cellular TGF-β1 and interacts with various nuclear receptors. The previous study showed that TGFB1I1 promotes focal adhesion formation, contributing to the epithelial-mesenchymal transition (EMT) with actin cytoskeleton and vimentin through TGFB1I1 regulation. We aim to reveal the role of TGFB1I1 in the tumorigenesis of UC. In silico and clinicopathological data of upper urinary tract urothelial carcinoma (UTUC) and urinary bladder urothelial carcinoma (UBUC) were accessed and analyzed for IHC staining regarding tumor characteristics, including survival outcome. Finally, an in vitro study was performed to demonstrate the biological changes of UC cells. In UTUC, overexpression of TGFB1I1 was significantly correlated with advanced tumor stage, papillary configuration, and frequent mitosis. Meanwhile, overexpression of TGFB1I1 was significantly correlated with advanced tumor stage and histological grade in UBUC. Moreover, the in vitro study shows that TGFB1I1 affects cell proliferation, viability, migration and wound healing. The EMT markers also decreased upon TGFB1I1 knockdown. In this study, we identified that TGFB1I1 regulates UC cell proliferation and viability and induces the EMT to facilitate cell migration in vitro, leading to its essential role in promoting tumor aggressiveness in both UTUC and UBUC.

Upper Tract Urothelial Carcinoma (UTUC) Diagnosis and Risk Stratification: A Comprehensive Review

Diagnosis and risk stratification are cornerstones of therapeutic decisions in the management of patients with upper tract urothelial carcinoma (UTUC). Diagnostic modalities provide data that can be integrated, to provide nomograms and stratification tools to predict survival and adverse outcomes. This study reviews cytology, ureterorenoscopy and the novel tools and techniques used with it (including photodynamic diagnosis, narrow-band imaging, optical coherence tomography, and confocal laser endomicroscopy), and biopsy. Imaging modalities and novel biomarkers are discussed in another article. Patient- and tumor-related prognostic factors, their association with survival indices, and their roles in different scores and predictive tools are discussed. Patient-related factors include age, sex, ethnicity, tobacco consumption, surgical delay, sarcopenia, nutritional status, and several blood-based markers. Tumor-related prognosticators comprise stage, grade, presentation, location, multifocality, size, lymphovascular invasion, surgical margins, lymph node status, mutational landscape, architecture, histologic variants, and tumor-stroma ratio. The accuracy and validation of pre-operative predictive tools, which incorporate various prognosticators to predict the risk of muscle-invasive or non-organ confined disease, and help to decide on the surgery type (radical nephroureterectomy, or kidney-sparing procedures) are also investigated. Post-operative nomograms, which help decide on adjuvant chemotherapy and plan follow-up are explored. Finally, a revision of the current stratification of UTUC patients is endorsed.

Upregulation of dihydropyrimidinase-like 3 (DPYSL3) protein predicts poor prognosis in urothelial carcinoma

BACKGROUND

Dihydropyrimidinase-like 3 (DPYSL3) is a cytosolic phosphoprotein expressed in the nervous system and is crucial for neurogenesis. A previous study showed that increased DPYSL3 expression promotes tumour aggressiveness in pancreatic ductal adenocarcinoma, gastric cancer, and colon cancer. However, the role of DPYSL3 in affecting the biological behaviour of urothelial carcinoma (UC) is not yet understood.

METHODS

A UC transcriptomic dataset from the Gene Expression Omnibus and the Urothelial Bladder Cancer (BLCA) dataset from The Cancer Genome Atlas were used for the in silico study. We collected 340 upper urinary tract urothelial carcinoma (UTUC) and 295 urinary bladder urothelial carcinoma (UBUC) samples for the immunohistochemical study. Fresh tumour tissue from 50 patients was used to examine the DPYSL3 mRNA level. In addition, urothelial cell lines with and without DPYSL3 knockdown were used for the functional study.

RESULTS

The in silico study revealed that DPYSL3 correlated with advanced tumour stage and metastasis development while functioning primarily in the nucleobase-containing compound metabolic process (GO:0006139). DPYSL3 mRNA expression is significantly upregulated in advanced UC. Furthermore, overexpression of the DPYSL3 protein is significantly associated with the aggressive behaviour of UTUC and UBUC. DPYSL3 expression independently predicts disease-specific survival (DSS) and metastatic-free survival (MFS) in patients with UC. In non-muscle-invasive UBUC, DPYSL3 expression predicts local recurrence-free survival. UC cell lines with DPYSL3 knockdown exhibited decreased proliferation, migration, invasion, and human umbilical vein endothelial cells (HUVECs) tube formation but increased apoptosis and G1 arrest. Gene ontology enrichment analysis revealed that the enriched processes related to DPYSL3 overexpression in UC were tissue morphogenesis, cell mesenchyme migration, smooth muscle regulation, metabolic processes, and RNA processing. In vivo study revealed DPYSL3 knockdown in UC tumours significantly suppressed the growth of tumours and decreased MYC and GLUT1 protein expression.

CONCLUSIONS

DPYSL3 promotes the aggressiveness of UC cells by changing their biological behaviours and is likely associated with cytoskeletal and metabolic process modifications. Furthermore, DPYSL3 protein overexpression in UC was associated with aggressive clinicopathological characteristics and independently predicted poor clinical outcomes. Therefore, DPYSL3 can be used as a novel therapeutic target for UC.

Mutational signature and clonal relatedness of recurrent urothelial carcinomas with aristolochic acid

Urothelial carcinomas (UCs) are malignant tumors that arise from the lower and upper urinary tract and are characterized by multiple recurrences. Aristolochic acid (AA) is a potent nephrotoxin and human carcinogen associated with UC. East Asian populations with a high UC prevalence have an unusual genome-wide AA-induced mutational pattern. To address the genomic differences and clonal relatedness between primary and recurrent tumors in the UCs with AA pattern, we investigated the genomic differences and tumor microenvironment (TME) of AA and non-AA UCs. 17 UC patients were recruited, with nine documented AA exposure. Eleven of them showed recurrence. After-surgery tissues of primary and paired recurrent tumors were collected. Capture-based targeted deep sequencing was performed using a commercial panel consisting of 520 cancer-related genes. Tumor-infiltrating lymphocytes (TILs) were identified with an immunofluorescence-based microenvironment analysis panel (MAP). Hierarchical clustering based on the COSMIC signatures confirmed two significant subtypes: AA Sig and non-AA Sig. AA Sig was associated with AA-containing herbal drug intake, recurrence, and higher tumor mutation burden (TMB). The clonal architecture of UCs revealed three types of clonal evolution patterns. Non-AA Sig cohort showed shared clonal origin of primary and recurrent tumors. AA Sig showed heterogeneity and had multiple independent origins. Recurrent tumors as second primary tumors in AA Sig showed immunoreactive TME, indicating a better response with immune checkpoint inhibitor therapy. The AA mutational signature and unique immune profiles are helpful molecular markers to distinguish AA exposure from other carcinogens. These results also provide new insights into the origin of recurrent UCs that could affect treatment strategies.