The 2022 revision of World Health Organization classification of tumors of the urinary system and male genital organs: advances and challenges

Diagnostic workout of glandular malignant lesions of the bladder according to the 5th WHO classification

Glandular lesions involving the bladder are less common than conventional urothelial carcinoma, and they are often diagnostically challenging diseases, carrying different clinical outcomes. As a group, they encompass both primary and secondary neoplasms, with sometimes overlapping morphological features. In this scenario, proper clinical information is important, in that secondary involvement of the bladder may occur by direct extension or lymphatic/hematogenous spread from carcinomas at other sites, comprising prostate, colon, cervix, breast, and lung. According to the 5th edition of the WHO Classification of urological tumors, glandular morphology is a major hallmark of the following entities: urothelial carcinoma with glandular differentiation, adenocarcinoma, NOS, urachal carcinoma, and tumors of Mullerian type. The distinction among these entities, and between primary and secondary tumors, heavily relies on their biological and immunophenotypical features. This article will review glandular neoplasms of the bladder, highlighting their main immunophenotypical markers. Furthermore, molecular data associated with their pathogenesis, prognosis, and treatment will be described. The aim of this study is to provide a practical and comprehensive up-to-date overview of this complex topic.

Microsatellite instability and mismatch repair deficiency in bladder urothelial carcinoma: a Tunisian single-center study

BACKGROUND

Microsatellite instability (MSI) and deficiency in the human mismatch repair (MMR) system are critical drivers of genomic instability in various cancers. Tumors exhibiting MSI and MMR deficiency (dMMR) have prognostic implications and are associated with differential responses to immune checkpoint inhibitors. Given their key roles in tumorigenesis, investigating MMR protein expression and MSI in urothelial cancer of the bladder is essential to improve therapeutic strategies and deepen understanding of its molecular features. This study aimed to assess MMR protein expression and MSI in primary urothelial carcinoma of the bladder and to evaluate their associations with clinicopathological characteristics.

METHODS

A total of 49 primary urothelial carcinomas were analyzed for MMR expression using immunohistochemistry, and dMMR tumors underwent further analysis for MSI status using the markers of the Bethesda panel (BAT25, BAT26, D2S123, D5S346, and D17S250). The MMR expression and MSI findings were associated with clinicopathological parameters.

RESULTS

dMMR was identified in two high-grade urothelial carcinomas (4.1%), while the remaining cases demonstrated proficient MMR. Both dMMR tumors showed impaired immunoreactivity, with one tumor displaying a simultaneous loss of the MLH1/PMS2 heterodimer and the other showing isolated MSH6 loss. MSI analysis revealed instability in BAT26 in the MLH1/PMS2-deficient tumor and at D17S250 in the MSH6-deficient tumor. Both tumors exhibited low-level MSI (MSI-L). No relevant associations were found between MMR/MSI status and clinicopathological features (p > 0.05).

CONCLUSIONS

The identification of MSI-L and MMR deficiency in only two samples underscores the rarity of MSI in urothelial carcinoma among Tunisian patients. These findings emphasize the need for larger, multi-center studies to elucidate the MSI/dMMR molecular and clinical implications in bladder carcinoma.

Genomic profiling of urological malignancies using tissue-based next generation sequencing

Advances in understanding genomic drivers of human malignancies have evolved from morphologic evaluations to in-depth DNA and RNA analyses and gene expression profiling. In urologic malignancies, these molecular diagnostics are integral to patient management, aiding pathological diagnosis, providing prognostic and predictive relevance, and identifying therapeutic options for advanced diseases. For instance, renal cell carcinoma frequently harbors alterations in VHL, PBRM1, and BAP1, influencing therapeutic responses, while urothelial carcinoma is characterized by FGFR3 mutations and TERT promoter alterations, which have implications for targeted therapy. Prostate cancer commonly involves TMPRSS2-ERG fusions and BRCA2 mutations, affecting treatment strategies, and penile squamous cell carcinoma follows distinct HPV-dependent and HPV-independent pathways, with mutations in TP53 and CDKN2A genes. These advances in molecular pathology have deepened our understanding of these complex diseases and facilitated the introduction of novel targeted therapies. While these advances promise improved diagnosis, prognosis, and treatment options, many questions remain regarding the variable patient responses within the same histologic types. Addressing these will enable optimal management strategies and the development of personalized treatments targeting specific molecular alterations to improve patient outcomes.

The percentage abundance of sarcomatoid component has a prognostic role in grade 4 non-metastatic clear cell-renal carcinoma

PURPOSE

Sarcomatoid dedifferentiation represents one of the most aggressive features of clear cell renal cell carcinoma (ccRCC). In this study we evaluated whether grade 4-ccRCC subclassification based on the intratumoral abundance of sarcomatoid features could have a prognostic impact.

METHODS

A cohort of 212 patients with localized or locally advanced sarcomatoid ccRCC was identified. This population was stratified according to abundance of sarcomatoid features in low-sarcomatoid (LS = < 20% sarcomatoid component; n = 117) and high-sarcomatoid (HS = ≥ 20% sarcomatoid component; n = 95). Estimates of cancer-specific survival (CSS) and recurrence-free survival (RFS) were calculated according to the Kaplan-Meier method and compared with the log-rank test. Multivariable analysis was performed using the Cox proportional hazards regression model to identify the most significant variables for predicting CSS and RFS.

RESULTS

Kaplan-Meier survival curves stratified by abundance of sarcomatoid component, showed that CSS and RFS were significantly decreased in patients with sarcomatoid component ≥ 20% (both P < 0.0001). At multivariable analysis by Cox regression modeling, the abundance of sarcomatoid component was an independent adverse prognostic factor for CSS (P < 0.0001) and RFS (P < 0.0001).

CONCLUSION

ccRCC Subclassification based on the abundance of intratumoral sarcomatoid component has a clinical significance. Our study showed that ccRCC subclassification into HS versus LS groups had a prognostic impact in terms of CSS and RFS in non-metastatic ccRCC.

From Bench to Bladder: The Rise in Immune Checkpoint Inhibition in the Treatment of Non-Muscle Invasive Bladder Cancer

Non-muscle invasive bladder cancer (NMIBC) represents a significant clinical challenge due to its high recurrence rate and need for frequent monitoring. The current treatment modality is bacillus Calmette-Guérin (BCG) therapy combined with chemotherapy after transurethral resection of the bladder tumor (TURBT), which is highly effective in most patients. Yet, the cancer becomes resistant to these treatments in 30-40% of patients, necessitating the need for new treatment modalities. In the cancer world, the development of immune checkpoint inhibitors that target molecules, such as programmed cell death protein-1 (PD-1), its ligand, PD-L1, and Cytotoxic T-lymphocyte-associated protein-4 (CTLA-4), have revolutionized the treatment of many cancer types. PD-1/PD-L1 and CTLA-4 are shown to be upregulated in NMIBC in certain circumstances. PD-1/PD-L1 interactions play a role in immune evasion by suppressing T cell activity within the tumor microenvironment (TME), while the binding of CTLA-4 on T cells leads to downregulation of the immune response, making these pathways potential immunotherapeutic targets in NMIBC. This review seeks to understand the role of these therapies in treating NMIBC. We explore the cellular and non-cellular immune landscape in the TME of NMIBC, including Tregs, T effector cells, macrophages, B cells, and relevant cytokines. We also discuss the biological role of PD-1/PD-L1 and CTLA-4 while covering the rationale for these immunotherapies in NMIBC. Finally, we cover key clinical trials that have studied these treatments in NMIBC clinically. Such a study will be helpful for urologists and oncologists to manage patients with NMIBC more effectively.

Application of RNA sequencing in urologic malignancies: Advances and challenges

RNA sequencing became a key tool in identifying the differences between cells and their functions, aiding in the recognition of the functional elements disrupted during the disease process. In urologic malignancies, many studies aiming to provide comprehensive molecular classifications through the assessment of RNA expression or fusion analysis have been published. The distinctive presence of these molecular alterations related to cancer development, growth, and survival and the discoveries of these breakthrough studies provide insight into the development of personalized management and aid in the identification of new therapeutic targets.

Transcriptomic and proteo-metabolic determinants of the grading system in clear cell renal cell carcinoma

BACKGROUND

Pathological grade is a morphological parameter of clear cell-renal cell carcinoma (ccRCC) and an independent predictor of cancer-specific survival. The aim of this study was to identify grade-dependent metabolic signatures and corresponding gene and protein expression changes that connect variations in cancer metabolism with nuclear grade, especially in high-grade tumors.

METHODS

Forty ccRCC samples were collected and stratified according to nuclear grade: 23 low-grade (LG = G1-G2) and 17 high-grade (HG = G3-G4) samples. In addition, 122 patients with sarcomatoid ccRCC (sRCC) were classified according to the abundance of sarcomatoid features as low sarcomatoid (LS; sarcomatoid component<20%; n = 67) or high sarcomatoid (HS; sarcomatoid component≥20%; n = 55). Untargeted metabolomic analysis was performed. To study the relative changes in gene and protein expression in HG vs. LG ccRCC, data from 4 different datasets were downloaded and stratified according to nuclear grade. Immunohistochemistry and immunofluorescence were used to evaluate protein expression. Cancer-specific survival (CSS) and progression-free survival (PFS) were calculated using Kaplan-Meier analysis. Multivariate analysis was performed using a Cox regression model.

RESULTS

The Warburg effect, in association with changes in Krebs cycle intermediates and related metabolites, was more prominent in HG ccRCC than in LG ccRCC. Additional alterations included metabolic reprogramming in the urea cycle and modulation of glutathione metabolism with the accumulation of reduced glutathione and carnitine derivatives in HG tumors, while the concentrations of long- and medium-chain fatty acids were greater in LG ccRCC. CSS and PFS were significantly decreased in patients with HS tumors. According to the multivariate analysis, the abundance of the sarcomatoid component was an adverse prognostic factor.

CONCLUSIONS

ccRCC is characterized by a particular grade-dependent metabolic reprogramming. Metabolic pathways and associated molecular alterations are grade-specific and could represent potential therapeutic targets, especially in HG tumors. sRCC subclassification based on the abundance of sarcomatoid components into HS vs. LS tumors have prognostic value.

Clinicopathologic and molecular characterization of primitive neuroectodermal tumors (PNET) in the female genital tract: a retrospective study of 8 cases

AIMS

This study aimed to investigate the molecular alterations in primitive neuroectodermal tumors (PNET) of the female genital tract.

METHODS

We retrospectively analyzed the clinicopathologic and immunohistochemical features of 8 gynecologic PNET cases (3 cervical, 1 vaginal, and 4 ovarian). Fluorescence in situ hybridization and targeted next-generation sequencing (NGS) were performed to identify molecular alterations in these tumors.

RESULTS

The cohort included 5 FIGO stage I, 1 stage III, and 2 stage IV tumors. Two patients with stage IV disease died at 8 and 12 months. The cervical/vaginal tumors consisted of small round blue cells arranged in sheets, with EWSR1 rearrangements and concurrent diffuse expression of membranous CD99 and nuclear FLI1. The ovarian tumors displayed diverse morphologic features resembling central nervous system (CNS) tumors, including embryonal tumor with multilayered rosettes (case 5), medulloblastoma (case 6), glioblastoma (case 7), and ependymoma (case 8). Three ovarian tumors were associated with teratomas. None of the ovarian tumors exhibited EWSR1 rearrangements or i(12p)/12p overrepresentation. NGS identified an EWSR1::exon11∼FLI1::exon6 fusion in one cervical PNET, with no additional molecular alterations. In contrast, three ovarian tumors lacked common genetic changes seen in CNS tumors but harbored several significant variants, including NTRK2 exon11 c.1019C > T (p.T340 M) (case 6), INPP4B exon23 c.2221G > A (p.V741 M) (case 7), and FANCG exon7 c.882_883insA (p.D295Rfs∗14) with MET 7q31 polysomy (case 8).

CONCLUSIONS

Our findings confirm that cervical/vaginal and ovarian PNET represent two distinct tumor types. Ovarian PNET have different pathogenetic pathways from their CNS and testicular counterparts most likely.

Tissue-Based Biomarkers Important for Prognostication and Management of Genitourinary Tumors, Including Surrogate Markers of Genomic Alterations

A better understanding of the molecular alterations that underlie urologic malignancies and advances in targeted therapies has impacted classification, prognostication, and treatment. In bladder tumors, these advances include the development of antibody-drug conjugates targeting nectin-4 and Trop-2, as well as human epidermal growth factor receptor 2 and immunotherapy. In prostate cancer, assessment of the percentage of Gleason pattern 4, presence of cribriform glands, and molecular alterations, including PTEN and mismatch repair protein loss, have become standard for clinical care. In renal malignancies, alterations in TSC1/2, mammalian target of rapamycin, anaplastic lymphoma kinase, and other genes impact classification and therapeutic decisions.

Concomitant medications in patients with metastatic urothelial carcinoma receiving enfortumab vedotin: real-world data from the ARON-2EV study

Patients with metastatic urothelial carcinoma (mUC) are typically elderly and often have other comorbidities that require the use of concomitant medications. In our study we evaluated the association of concomitant use of antibiotics (ATBs), proton pump inhibitors (PPIs), corticosteroids, statins, metformin and insulin with patient outcomes and we validated the prognostic role of a concomitant drug score in mUC patients treated with enfortumab vedotin (EV) monotherapy. Data from 436 patients enrolled in the ARON-2EV retrospective study were analyzed according to the concomitant medications used at baseline. Finally, the patients were stratified into three risk groups according to the concomitant drug score based on ATBs, corticosteroids and PPIs. Statistical analysis involved Fisher exact test, Kaplan-Meier method, log-rank test, and univariate/multivariate Cox proportional hazard regression models. Inferior survival outcomes were observed in ATB users compared to non-users (OS: 7.3 months, 95%CI 5.0 - 12.3 vs 13.7 months, 95%CI 12.2 - 47.3, p = 0.001; PFS: 5.1 months 95%CI 3.3 - 17.7 vs 8.3 months, 95%CI 7.1 - 47.3, p = 0.001) and also in corticosteroid users compared to non-users (OS: 8.4 months, 95%CI 6.6 - 10.0 vs 14.2 months, 95%CI 12.7 - 47.3, p < 0.001; PFS: 6.0 months 95%CI 4.6 - 7.9 vs 8.9 months, 95%CI 7.2 - 47.3, p = 0.004). In the Cox multivariate analysis, the concomitant drug score was a significant factor predicting both OS (HR = 1.32 [95% CI 1.03 - 1.68], p = 0.026) and PFS (HR = 1.23 [95% CI 1.01 - 1.51], p = 0.044). Our findings suggest detrimental impact of concomitant use of ATBs and corticosteroids on survival outcomes and the prognostic utility of the concomitant drug score in previously treated mUC patients receiving EV.

Automatic Characterization of Prostate Suspect Lesions on T2-Weighted Image Acquisitions Using Texture Features and Machine-Learning Methods: A Pilot Study

Background: Prostate cancer (PCa) is the most frequent neoplasia in the male population. According to the International Society of Urological Pathology (ISUP), PCa can be divided into two major groups, based on their prognosis and treatment options. Multiparametric magnetic resonance imaging (mpMRI) holds a central role in PCa assessment; however, it does not have a one-to-one correspondence with the histopathological grading of tumors. Recently, artificial intelligence (AI)-based algorithms and textural analysis, a subdivision of radiomics, have shown potential in bridging this gap. Objectives: We aimed to develop a machine-learning algorithm that predicts the ISUP grade of manually contoured prostate nodules on T2-weighted images and classifies them into clinically significant and indolent ones. Materials and Methods: We included 55 patients with 76 lesions. All patients were examined on the same 1.5 Tesla mpMRI scanner. Each nodule was manually segmented using the open-source 3D Slicer platform, and textural features were extracted using the PyRadiomics (version 3.0.1) library. The software was based on machine-learning classifiers. The accuracy was calculated based on precision, recall, and F1 scores. Results: The median age of the study group was 64 years (IQR 61-68), and the mean PSA value was 11.14 ng/mL. A total of 85.52% of the nodules were graded PI-RADS 4 or higher. Overall, the algorithm classified indolent and clinically significant PCas with an accuracy of 87.2%. Further, when trained to differentiate each ISUP group, the accuracy was 80.3%. Conclusions: We developed an AI-based decision-support system that accurately differentiates between the two PCa prognostic groups using only T2 MRI acquisitions by employing radiomics with a robust machine-learning architecture.

Primary adenocarcinoma of the urinary tract and its precursors: Diagnostic criteria and classification

Primary adenocarcinoma of the urinary bladder is a rare malignancy, comprising up to 2% of bladder cancers, predominantly in males. Its rarity and similarity to urothelial carcinoma and secondary adenocarcinomas pose diagnostic challenges. A comprehensive literature review was conducted on the diagnosis, classification, morphological and immunophenotypic characteristics, and molecular profiles of primary adenocarcinoma, urachal adenocarcinoma, and precursor lesions. Primary adenocarcinoma exhibits diverse morphological patterns, including enteric, mucinous, signet ring cell, and mixed types. Immunohistochemistry is useful in differentiating primary adenocarcinoma from metastatic adenocarcinomas and secondary involvement. Genetic studies reveal mutations common in colorectal and bladder adenocarcinomas (KRAS, TP53, PIK3CA) and novel primary adenocarcinoma-specific mutations (OR2L5). Urachal adenocarcinoma shares morphological features with primary adenocarcinoma but typically occurs in younger patients with unique genomic and distinct immunoprofile. Potential precursor lesions include villous adenoma, cystitis glandularis, and intestinal metaplasia, and warrant close clinical follow-up. Despite advances in histopathological and molecular diagnostics, primary adenocarcinoma remains challenging to diagnose due to its rarity and morphological heterogeneity. Ongoing research into its molecular characteristics is essential to refine diagnostic criteria and therapeutic approaches. Thorough clinical and pathological assessment is crucial for accurate diagnosis, classification, and clinical management.

Co‑occurrence of clear cell renal cell carcinoma and bladder urothelial carcinoma: A case report and literature review

The co-occurrence of clear cell renal cell carcinoma (ccRCC) and bladder urothelial carcinoma (bUC) is rare, and owing to the lack of a unified treatment plan, the prognosis is poor. The present report describes the case of a 65-year-old male patient with a history of smoking and no history of malignant tumors who presented with hematuria at the Huanghe Sanmenxia Hospital Affiliated to Henan University of Science and Technology (Sanmenxia, China) in July 2021. Urinary system computed tomography urography revealed a right renal tumor, and cystoscopy revealed intravesical lesions. The patient underwent transurethral resection of a bladder tumor + laparoscopic partial nephrectomy + laparoscopic radical cystectomy and bilateral ureterostomy. Pathological examination revealed right-sided ccRCC (pT1aN0M0) and high-grade invasive bUC (pT2N0M0). After surgery, the patient underwent bilateral ureteral single J tube replacement in the outpatient clinic every 3 months. In September 2022, the patient presented with a mass on the right side of the neck. Further examination revealed a space-occupying lesion in the lower part of the left kidney and space-occupying lesions in the neck, axilla, mediastinal lymph nodes and liver. A neck lymph node puncture biopsy suggested UC, and the patient was diagnosed with metastatic UC (T4N0M1). The patient received tislelizumab (200 mg once every 3 weeks) + sunitinib (50 mg/day, administered for 4 weeks with a 2-week interval) for a total of 2 months and died of an advanced tumor in January 2023. In addition, the data of 36 patients with ccRCC and bUC from the literature were analyzed for the present report. The results showed that the median age at first onset was 56.5 years (range, 31-82 years) and the male-to-female ratio was 6:1. Smoking and male sex may be risk factors for this disease, which has a median survival time of 47.5 months. The survival analysis results showed that the pathological stage of bladder cancer may be associated with its prognosis. The present study reviews the potential risks, clinicopathological characteristics and treatment methods of co-occurrence of clear ccRCC and bUC. In conclusion, the high-risk factors for the co-occurrence of ccRCC and bUC were smoking and male sex, and the median survival time was 47.5 months. The pathological stage of bladder cancer may be related to the prognosis.

AMPK down-regulating Beclin-1 in prostate cancer patients with bone metastasis: An observational study

Bone metastasis is frequently seen in patients, particularly those with prostate cancer, showing a higher hazard that deteriorates the quality of life of patients, leading to poor prognosis, which eventually causes significant mortality in prostate cancer patients. The present study investigated the mechanism of prostate cancer with bone metastasis by utilizing prostate specimens from patients. A total of 418 patients were initially enrolled for clinical analysis, including age, prostate-specific antigen (PSA) levels, body mass index (BMI), prostate magnetic resonance imaging (MRI), and bone MRI, while pathological analysis included grade group and carcinoma of the prostate. Patients were divided into a prostate cancer with bone metastasis group (group 1, prostate cancer patients) and benign prostate patient group (group 2, control group) and underwent subsequent immunohistochemical (IHC) detection. Expression of AMPK/Beclin-1 signaling pathways was analyzed through immunohistochemistry. Finally, 46 patients with prostate cancer bone metastasis (prostate cancer patients) and 61 patients with benign prostate (control group) met the inclusion criteria. We examined the expression levels of Beclin-1 and AMPK in human prostate tissues by IHC and found that Beclin-1 levels were negatively correlated with AMPK in prostate cancer with bone metastasis (P < .05). The results of this study suggest that AMPK-Beclin-1 significantly reduces prostate cancer metastasis to the bone in human tissues.

Rare type of Bellini Duct Carcinoma in a Patient With Cacchi-Ricci Disease: A Case Report and Mini-Review

Medullary sponge kidney (MSK) is an uncommon kidney malformation, characterized by cystic dilatation of the precalyceal papillary collecting ducts. Urography and computed tomography scan represent the gold standard to detect this congenital disorder. A clear diagnosis is not always feasible, especially in the presence of a concomitant renal mass, which in turn can be difficult to detect in MSK patients. When conventional imaging is inconclusive, a renal biopsy can be considered in doubtful cases. Here, we report a unique case of a Bellini duct carcinoma in a patient with MSK and we review the literature on this complex condition.

Imaging in Renal Cell Carcinoma Detection

INTRODUCTION

Imaging in renal cell carcinoma (RCC) is a constantly evolving landscape. The incidence of RCC has been rising over the years with the improvement in image quality and sensitivity in imaging modalities resulting in "incidentalomas" being detected. We aim to explore the latest advances in imaging for RCC.

METHODS

A literature search was conducted using Medline and Google Scholar, up to May 2024. For each subsection of the manuscript, a separate search was performed using a combination of the following key terms "renal cell carcinoma", "renal mass", "ultrasound", "computed tomography", "magnetic resonance imaging", "18F-Fluorodeoxyglucose PET/CT", "prostate-specific membrane antigen PET/CT", "technetium-99m sestamibi SPECT/CT", "carbonic anhydrase IX", "girentuximab", and "radiomics". Studies that were not in English were excluded. The reference lists of selected manuscripts were checked manually for eligible articles.

RESULTS

The main imaging modalities for RCC currently are ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). Contrast-enhanced US (CEUS) has emerged as an alternative to CT or MRI for the characterisation of renal masses. Furthermore, there has been significant research in molecular imaging in recent years, including FDG PET, PSMA PET/CT, 99mTc-Sestamibi, and anti-carbonic anhydrase IX monoclonal antibodies/peptides. Radiomics and the use of AI in radiology is a growing area of interest.

CONCLUSIONS

There will be significant change in the field of imaging in RCC as molecular imaging becomes increasingly popular, which reflects a shift in management to a more conservative approach, especially for small renal masses (SRMs). There is the hope that the improvement in imaging will result in less unnecessary invasive surgeries or biopsies being performed for benign or indolent renal lesions.

Contemporary Molecular Markers for Predicting Systemic Treatment Response in Urothelial Bladder Cancer: A Narrative Review

The search for dependable molecular biomarkers to enhance routine clinical practice is a compelling challenge across all oncology fields. Urothelial bladder carcinoma, known for its significant heterogeneity, presents difficulties in predicting responses to systemic therapies and outcomes post-radical cystectomy. Recent advancements in molecular cancer biology offer promising avenues to understand the disease's biology and identify emerging predictive biomarkers. Stratifying patients based on their recurrence risk post-curative treatment or predicting the efficacy of conventional and targeted therapies could catalyze personalized treatment selection and disease surveillance. Despite progress, reliable molecular biomarkers to forecast responses to systemic agents, in neoadjuvant, adjuvant, or palliative treatment settings, are still lacking, underscoring an urgent unmet need. This review aims to delve into the utilization of current and emerging molecular signatures across various stages of urothelial bladder carcinoma to predict responses to systemic therapy.

The combination of immune checkpoint inhibitors and antibody-drug conjugates in the treatment of urogenital tumors: a review insights from phase 2 and 3 studies

With the high incidence of urogenital tumors worldwide, urinary system tumors are among the top 10 most common tumors in men, with prostate cancer ranking first and bladder cancer fourth. Patients with resistant urogenital tumors often have poor prognosis. In recent years, researchers have discovered numerous specific cancer antigens, which has led to the development of several new anti-cancer drugs. Using protein analysis techniques, researchers developed immune checkpoint inhibitors (ICIs) and antibody-conjugated drugs (ADCs) for the treatment of advanced urogenital tumors. However, tumor resistance often leads to the failure of monotherapy. Therefore, clinical trials of the combination of ICIs and ADCs have been carried out in numerous centers around the world. This article reviewed phase 2 and 3 clinical studies of ICIs, ADCs, and their combination in the treatment of urogenital tumors to highlight safe and effective methods for selecting individualized therapeutic strategies for patients. ICIs activate the immune system, whereas ADCs link monoclonal antibodies to toxins, which can achieve a synergistic effect when the two drugs are combined. This synergistic effect provides multiple advantages for the treatment of urogenital tumors.

Long-Term Oncologic Outcomes of Off-Clamp Robotic Partial Nephrectomy for Cystic Renal Tumors: A Propensity Score Matched-Pair Comparison of Cystic versus Pure Clear Cell Carcinoma

Few data are available on survival outcomes of partial nephrectomy performed for cystic renal tumors. We present the first long-term oncological outcomes of cystic (cystRCC) versus pure clear cell renal cell carcinoma (ccRCC) in a propensity score-matched (PSM) analysis. Our "renal cancer" prospectively maintained database was queried for "cystRCC" or "ccRCC" and "off-clamp robotic partial nephrectomy" (off-C RPN). The two groups were compared for age, gender, tumor size, pT stage, and Fuhrman grade. A 1:3 PSM analysis was applied to reduce covariate imbalance to <10% and two homogeneous populations were generated. Student t- and Chi-square tests were used for continuous and categorical variables, respectively. Ten-year oncological outcomes were compared between the two cohorts using log-rank test. Univariable Cox regression analysis was used to identify predictors of disease progression after RPN. Out of 859 off-C RPNs included, 85 cases were cystRCC and 774 were ccRCC at histologic evaluation. After applying the PSM analysis, two cohorts were selected, including 64 cystRCC and 170 ccRCC. Comparable 10-year cancer-specific survival probability (95.3% versus 100%, p = 0.146) was found between the two cohorts. Conversely, 10-year disease-free survival probability (DFS) was less favorable for pure ccRCC than cystRCC (66.69% versus 90.1%, p = 0.035). At univariable regression analysis, ccRCC histology was the only independent predictor of DFS probability (HR 2.96 95% CI 1.03-8.47, p = 0.044). At the 10-year evaluation, cystRCC showed favorable oncological outcomes after off-C RPN. Pure clear cell variant histology displayed a higher rate of disease recurrence than cystic lesions.

A Prognostic Index Derived From LASSO-Selected Preoperative Inflammation and Nutritional Markers for Non-Muscle-Invasive Bladder Cancer

BACKGROUND

There is an urgent need to identify a robust predictor for BCG response in patients with non-muscle-invasive bladder cancer (NMIBC). We aimed to employ the Lasso regression model for the selection and construction of an index (BCGI) utilizing inflammation and nutrition indicators to predict the response to BCG therapy.

METHODS

After acquiring the ethics approval, we searched the electric medical records in our institution and performed data screening. Then, we developed the BCGI using a Lasso regression model and subsequently evaluated its performance in both the train and internal test datasets through Kaplan-Meier survival curves and Cox regression analysis. Then, we also evaluated the prognostic value of BCGI alongside the EAU2021 model.

RESULTS

The training dataset and internal test dataset contained 295 and 196 patients, respectively. Referring to the Lasso results, BCGI consisted of hemoglobin, albumin, and platelet count, which could significantly predict the recurrence of NMIBC patients who accepted BCG in train (P = .012) and test (P = .004) datasets. The BCGI also exhibited statistically prognostic value in no smoking history, World Health Organization high grade, and T1 subgroups, both in train and test datasets. In multivariable analysis, BCGI exhibited independent prognostic value in train (P = .012) and test (P = .012) datasets. Finally, we constructed a nomogram that consisted of smoking history, T stage, World Health Organization grade, tumor size, and BCGI. Then, BCGI demonstrated significant independent prognostic value in NMIBC patients treated with BCG, a result not observed with the EAU2021 score or classification.

CONCLUSION

Based on the results, we reasonably suggest that BCGI may be a useful predictor for NMIBC patients who accepted BCG. Furthermore, we have demonstrated the efficacy of constructing a prognostic index using clinical factors and a Lasso regression model, a versatile approach applicable to various medical conditions.

Iris metastasis from clear cell renal cell carcinoma: A case report

BACKGROUND

Clear cell renal cell carcinoma (ccRCC) is a common type of tumor that can metastasize to any organs and sites. However, it is extremely rare for ccRCC to metastasize to the iris. Here, we describe a rare case of iris metastasis from ccRCC with a history of left nephrectomy in 2010.

CASE SUMMARY

A 62-year-old male was admitted to the hospital due to blurred vision and red eyes, and a mass was found on the iris in the right eye. B-scan ultrasonography revealed a well-bounded high-density lesion at the corner of the anterior chamber at the 3-4 o'clock position. Phacoemulsification with simultaneous intraocular lens implantation and iridocyclectomy was performed in the right eye. The lesion was confirmed to be metastatic ccRCC by histological and immunohistochemical analyses. The patient was still alive at 9 mo after surgical treatment. Ocular metastasis can be an initial sign with a poor prognosis. Timely detection and treatment may improve survival. Clinicians should pay attention to similar metastatic diseases to prevent misdiagnosis leading to missed treatment opportunities.

CONCLUSION

This report of the characteristics and successful management of a rare case of iris metastasis from ccRCC highlights the importance of a comprehensive medical history, histopathology, immunohistochemistry, and clinical manifestation for successful disease diagnosis.

Mesenchymal-Epithelial Transition Kinase Inhibitor Therapy in Patients with Advanced Papillary Renal-Cell Carcinoma: A Systematic Review and Meta-Analysis

Papillary subtypes of renal-cell carcinoma (pRCC) represent 10-15% of the cases and commonly have MET alterations. This systematic review and single-arm meta-analysis evaluated MET inhibitor therapy (METi) efficacy and safety in adults with confirmed advanced pRCC. The search strategy included PubMed, Web-of-science, Cochrane, and Scopus. We used the DerSimonian/Laird random effect model for all analyses; p-value < 5% was considered significant, and heterogeneity was assessed with I2. Three clinical trials and six cohort studies were included with 504 patients; 31% were MET-driven. Our pooled analysis demonstrated an objective response rate (ORR) in MET-driven, MET-independent, and overall patients of: 36% (95%CI: 10-62), 0% (95%CI: 0-3), and 21% (95%CI: 1-41), respectively. One-year disease control and progression-free survival rates were, respectively, 70% (95%CI: 52-88) and 15% (95%CI: 10-20). Twelve- and twenty-four-month survival rates were, respectively, 43% (95%CI: 23-64) and 10% (95%CI: 0-30). The prevalence of adverse events of any grade and grades 3-5 were 96% (95%CI: 91-100) and 44% (95%CI: 37-50), respectively. We suggest METi has anti-tumor activity and is tolerable in patients with advanced pRCC.

Fortuitous discovery of a resectable primary mucinous adenocarcinoma of the seminal vesicle in a young patient: Case report

Primary seminal vesicle adenocarcinoma is an extremely rare tumor. Accurate recognition of malignant neoplasms of the seminal vesicle is a crucial condition to establish a correct treatment that leads to improvement of long-term survival. Diagnosis of seminal vesicle carcinoma is based on many methods including imaging, biology, and pathological assessment, especially by means of immunohistochemistry. Herein, we report a case of primary mucinous adenocarcinoma of the seminal vesicle mimicking a benign congenital cyst in a 25-year-old patient, fortuitously discovered on a pelvic computer tomography scan.

Precision Medicine in Bladder Cancer: Present Challenges and Future Directions

Bladder cancer (BC) is characterized by significant histopathologic and molecular heterogeneity. The discovery of molecular pathways and knowledge of cellular mechanisms have grown exponentially and may allow for better disease classification, prognostication, and development of novel and more efficacious noninvasive detection and surveillance strategies, as well as selection of therapeutic targets, which can be used in BC, particularly in a neoadjuvant or adjuvant setting. This article outlines recent advances in the molecular pathology of BC with a better understanding and deeper focus on the development and deployment of promising biomarkers and therapeutic avenues that may soon make a transition into the domain of precision medicine and clinical management for patients with BC.

Frequent Telomerase Reverse Transcriptase (TERT) Promoter and Fibroblast Growth Factor Receptor 3 (FGFR3) Mutations Support the Precursor Nature of Papillary Urothelial Hyperplasia of the Urinary Bladder

The precursor nature of papillary urothelial hyperplasia of the urinary bladder is uncertain. In this study, we investigated TERT promoter and FGFR3 mutations in 82 patients with papillary urothelial hyperplasia lesions. Thirty eight patients presented with papillary urothelial hyperplasia and concurrent non-invasive papillary urothelial carcinoma and 44 patients presented with de novo papillary urothelial hyperplasia. The prevalence of TERT promoter and FGFR3 mutation are compared between de novo papillary urothelial hyperplasia and those with concurrent papillary urothelial carcinoma. Mutational concordance between papillary urothelial hyperplasia and concurrent carcinoma were also compared. The TERT promoter mutations were detected in 44% (36/82) of papillary urothelial hyperplasia including 23 (23/38, 61%) papillary urothelial hyperplasia with urothelial carcinoma, and 13 (13/44, 29%) de novo papillary urothelial hyperplasia. The overall concordance of TERT promoter mutation status between papillary urothelial hyperplasia and concurrent urothelial carcinoma was 76%. Overall FGFR3 mutation rate of papillary urothelial hyperplasia was 23% (19/82). FGFR3 mutations were detected in 11 patients with papillary urothelial hyperplasia and concurrent urothelial carcinoma (11/38, 29%), and 8 patients with de novo papillary urothelial hyperplasia (8/44, 18%). Identical FGFR3 mutation status was detected in both papillary urothelial hyperplasia and urothelial carcinoma component in all 11 patients with FGFR3 mutations. Our findings provide strong evidence of genetic association between papillary urothelial hyperplasia and urothelial carcinoma. High frequency of TERT promoter and FGFR3 mutations suggests the precursor role of papillary urothelial hyperplasia in urothelial carcinogenesis.

Top 10 Clear Cell Head and Neck Lesions to Contemplate

BACKGROUND

Optically clear cytoplasm may occur in neoplastic and non-neoplastic conditions, either as a characteristic feature of a disease entity or as a morphologic rarity, potentially creating diagnostic dilemmas in various organ systems. In the head and neck, clear cell change can occur in lesions of salivary, odontogenic, thyroid, parathyroid, or sinonasal/skull base origin, as well as in metastases to these regions.

METHODS

This review elaborates the top ten clear cell lesions in the head and neck, emphasizing their distinguishing histologic, immunohistochemical, and molecular attributes, and presents a rational approach to arriving at an accurate classification.

RESULTS

Cytoplasmic pallor or clearing may be caused by accumulations of glycogen, lipid, mucin, mucopolysaccharides, water, foreign material, hydropic organelles, or immature zymogen granules. Overlapping morphologic features may present a diagnostic challenge to the surgical pathologist. Similarity in immunohistochemical profiles, often due to common cell type, as well as rare non-neoplastic mimics, furthers the diagnostic conundrum.

CONCLUSIONS

The top ten lesions reviewed in this article are as follows: (1) clear cell carcinoma (salivary and odontogenic), (2) mucoepidermoid carcinoma, (3) myoepithelial and epithelial-myoepithelial carcinoma, (4) oncocytic salivary gland lesions, (5) squamous cell carcinoma, (6) parathyroid water clear cell adenoma, (7) metastatic renal cell carcinoma (especially in comparison to clear cell thyroid neoplasms), (8) sinonasal renal cell-like adenocarcinoma, (9) chordoma, and (10) rhinoscleroma.