Pharmacological targeting of netrin-1 inhibits EMT in cancer

Epithelial-to-mesenchymal transition (EMT) regulates tumour initiation, progression, metastasis and resistance to anti-cancer therapy1-7. Although great progress has been made in understanding the role of EMT and its regulatory mechanisms in cancer, no therapeutic strategy to pharmacologically target EMT has been identified. Here we found that netrin-1 is upregulated in a primary mouse model of skin squamous cell carcinoma (SCC) exhibiting spontaneous EMT. Pharmacological inhibition of netrin-1 by administration of NP137, a netrin-1-blocking monoclonal antibody currently used in clinical trials in human cancer (ClinicalTrials.gov identifier NCT02977195 ), decreased the proportion of EMT tumour cells in skin SCC, decreased the number of metastases and increased the sensitivity of tumour cells to chemotherapy. Single-cell RNA sequencing revealed the presence of different EMT states, including epithelial, early and late hybrid EMT, and full EMT states, in control SCC. By contrast, administration of NP137 prevented the progression of cancer cells towards a late EMT state and sustained tumour epithelial states. Short hairpin RNA knockdown of netrin-1 and its receptor UNC5B in EPCAM+ tumour cells inhibited EMT in vitro in the absence of stromal cells and regulated a common gene signature that promotes tumour epithelial state and restricts EMT. To assess the relevance of these findings to human cancers, we treated mice transplanted with the A549 human cancer cell line-which undergoes EMT following TGFβ1 administration8,9-with NP137. Netrin-1 inhibition decreased EMT in these transplanted A549 cells. Together, our results identify a pharmacological strategy for targeting EMT in cancer, opening up novel therapeutic interventions for anti-cancer therapy.

Netrin-1 blockade inhibits tumour growth and EMT features in endometrial cancer

Netrin-1 is upregulated in cancers as a protumoural mechanism1. Here we describe netrin-1 upregulation in a majority of human endometrial carcinomas (ECs) and demonstrate that netrin-1 blockade, using an anti-netrin-1 antibody (NP137), is effective in reduction of tumour progression in an EC mouse model. We next examined the efficacy of NP137, as a first-in-class single agent, in a Phase I trial comprising 14 patients with advanced EC. As best response we observed 8 stable disease (8 out of 14, 57.1%) and 1 objective response as RECIST v.1.1 (partial response, 1 out of 14 (7.1%), 51.16% reduction in target lesions at 6 weeks and up to 54.65% reduction during the following 6 months). To evaluate the NP137 mechanism of action, mouse tumour gene profiling was performed, and we observed, in addition to cell death induction, that NP137 inhibited epithelial-to-mesenchymal transition (EMT). By performing bulk RNA sequencing (RNA-seq), spatial transcriptomics and single-cell RNA-seq on paired pre- and on-treatment biopsies from patients with EC from the NP137 trial, we noted a net reduction in tumour EMT. This was associated with changes in immune infiltrate and increased interactions between cancer cells and the tumour microenvironment. Given the importance of EMT in resistance to current standards of care2, we show in the EC mouse model that a combination of NP137 with carboplatin-paclitaxel outperformed carboplatin-paclitaxel alone. Our results identify netrin-1 blockade as a clinical strategy triggering both tumour debulking and EMT inhibition, thus potentially alleviating resistance to standard treatments.

Serum Prostate-Specific Antigen Determination in Prostatic Carcinoma

Prostate-specific antigen (PSA) is a tissue-specific glycoprotein identified by Wang in 1979. It is synthesized in the prostate independently of prostatic acid phosphatase (PAP). A total of 199 subjects were divided into four groups: controls aged less than 50 years, controls aged more than 50 years, patients with benign prostatic hyperplasia (BPH) and patients with prostatic carcinoma.

PSA cut-off value was set at 10 ng/ml (mean for the BPH group plus 2 SD). With this cut-off value PSA could not be used as an early predictor of prostatic carcinoma. The association of PSA and PAP in prostatic cancer increases the number of patients with positive biological markers.

[Treatment of attention deficit hyperactivity disorder in adults using virtual reality through a mindfulness programme]

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder, which presents a high comorbidity with anxiety and affective signs and symptoms. It has repercussions on the functioning of those suffering from it, who also have low therapy compliance and generate a significant cost both at a personal level and for society. Mindfulness is a psychological treatment that has proved to be effective for ADHD. Virtual reality is widely used as treatment in cases of phobias and other pathologies, with positive results.

AIMS

To develop the first treatment for ADHD in adults based on virtual reality and mindfulness, while also resulting in increased treatment adherence and reduced costs.

PATIENTS AND METHODS

We conducted a pilot study with 25 patients treated by means of virtual reality, in four 30-minute sessions, and 25 treated with psychostimulants. Measures will be taken pre-treatment, post-treatment and at 3 and 12 months post-treatment, to evaluate both ADHD and also depression, anxiety, functionality and quality of life. Data will be later analysed with the SPSS v. 20 statistical program. An ANOVA of independent groups will be performed to see the differences between treatments and also a test-retest to detect whether the changes will be maintained.

RESULTS AND CONCLUSIONS

It is necessary to use treatments that are effective, reduce costs and increase therapy adherence. Treatment with virtual reality is an interesting alternative to the classical treatments, and is shorter and more attractive for patients.

Seminal Vesicle Biopsy

Nowadays, because of early diagnosis of prostate cancer (PC) and the widespread use of nomograms to predict pathological stage of the tumour, seminal vesicle biopsy is considered as a useful tool only in case of clinical suspicion of seminal vesicle invasion. On the other hand, in last years some authors described their experience in less demolitive surgical procedures for PC, such as seminal sparing radical prostatectomy, in an attempt to improve both postoperative urinary continence and sexual function, as reported by Hauri and Montie, respectively. Patients, who may undergo to such procedure, could benefit from preoperative seminal vesicle biopsy, instead of rely on probability of seminal vesicle invasion indicated by nomograms only.

From November 2001 to June 2003, 135 patients with negative rectal examination and PSA ≤10, with no contraindications to radical prostatectomy, underwent transrectal ultrasound guided seminal vesicle biopsy at our Institution. We performed seminal-monolateral nerve sparing radical prostatectomy in patients with monolateral PC, Gleason score <7 and <4 positive biopsy cores, without seminal vesicles involvement. Patients with seminal vesicle invasion were addressed to radiotherapy.

Seminal vesicles biopsy showed in our hands good feasibility and low morbility; it was in general well tolerated by the patients.

All biopsy cores were adequate for histological examination.

Among patients with PC diagnosis, only one patient (4%), with serum PSA = 5 ng/mL and Gleason score = 6, had seminal vesicles involvement.

We performed seminal-nerve sparing radical prostatectomy in 21 patients, neither histological examination on frozen section nor final pathology showed seminal vesicle invasion in any case. Real usefulness of seminal vesicle biopsy remains controversial, but due to its good feasibility and low morbility it may play a role in the staging of selected patients.

High Risk Superficial Bladder Tumours: Is a Second Transurethral Resection after Intravesical Bcg Necessary?

According to some authors, residual tumour rate after superficial bladder cancer transurethral resection varies from 4–78%; among high risk superficial tumours (TaG3, T1G3, Tis) managed by transurethral resection of the bladder (TURB) and adjuvant immunotherapy, residual tumour rate varies from 57–76%.

This study was aimed to evaluate residual tumour and/or tumour recurrence in 56 patients diagnosed with high risk superficial bladder tumour, who underwent transurethral resection, adjuvant 6-weekly course of intravesical bacille Calmette-Guérin (BCG) and second TURB on the first resection sites, and in other sites suspicious for recurrence. Overall, 7/56 patients (12.5%) had residual tumour and/or recurrent disease at second TURB; no histological progression was recorded. Disease persistence or recurrence was not related to tumour multifocality at first diagnosis.

Our results appear to be consistent with other recent experiences, reporting low rates of residual tumour and disease progression in superficial bladder tumours after a first adequate resection and adjuvant immunotherapy.

Thus, our current practice in management of high risk superficial bladder tumour is oriented towards routine cystoscopy within 3 months after first bladder tumour resection, completed by cold biopsies on previous resection sites.

To our opinion, this approach provides adequate diagnostic reliability besides sparing the costs of a new resection and improving patients quality of life.

Y-neobladder: an easy, fast, and reliable procedure

OBJECTIVES

To describe the operative technique of a new, Y-shaped, ileal neobladder and report the clinical and functional outcomes to add a contribution to the most discussed issues about orthotopic neobladders, in particular related to the problem of the prevention of strictures of ureteral-neobladder anastomoses.

METHODS

Between January 1999 and June 2002, 50 patients (41 men and 9 women) underwent radical cystectomy and Y-shaped orthotopic neobladder reconstruction. The following parameters were considered: operative time, complications, and functional outcomes (evaluated with voiding chart and a questionnaire analyzing continence). Urodynamic studies were performed in the first 20 patients.

RESULTS

The operative time for neobladder reconstruction was 15 to 20 minutes. No severe complications or significant metabolic complications were recorded. Only 1 case of unilateral stricture of the ureteral-neobladder anastomosis was recorded (1% of renal units); the stricture was easily treated with a retrograde endoscopic approach. Daytime and nighttime continence was good or satisfactory in 90% and 85% of patients, respectively. One year after surgery, the average maximal neobladder capacity was 390 mL, and the average pressure at maximal capacity was 15 cm H2O.

CONCLUSIONS

The ileal Y-shaped orthotopic neobladder had good functional outcomes comparable to most popular orthotopic neobladders. Moreover, the surgical technique of the Y-neobladder is easy, rapid, and reliable. In particular, the Y-neobladder seemed to reduce, in our experience, the occurrence of strictures at the ureteral-neobladder anastomosis, because it permits a perfectly aligned anastomosis without mobilization of the ureters.

Relationship between neuroendocrine features and prognostic parameters in human prostate adenocarcinoma

PURPOSE

The biological behaviour of prostate cancer is highly variable and prediction by the commonly employed prognostic parameters is not sufficient. The concept of neuroendocrine (NE) differentiation in prostate adenocarcinoma has recently received increasing attention due to possible implications for prognosis and therapy.

MATERIALS AND METHODS

Core needle biopsies from 142 newly diagnosed patients were immunohistochemically examined for the coexistence of NE differentiation using an antibody against chromogranin A (CgA). Circulating CgA was available in 106 of these patients.

RESULTS

NE differentiation was found in 64 (45.1%) tumors. Among them 29 (20.4%) had CgA positive cells scattered or focally distributed in less than 5% per mm3 of tumor tissues, 26 (18.3%) between 5% and 10% and 9 (6.4%) more than 10%, respectively. There was a significant correlation between the extent of NE features and either Gleason score (P < 0.01) or stage of disease. Circulating CgA but not PSA correlated with immunohistochemical CgA (P < 0.03) particularly in metastatic cases.

CONCLUSIONS

These data support the concept that NE differentiation in human prostate cancer has a negative prognostic significance. Circulating CgA levels reflect immunohistochemical findings.

[Pelvic ultrasound monitoring of lymphocele in patients treated with radical prostatectomy]

Pelvic lymphoceles, occurred in patients undergone radical retropubic prostatectomy, are believed to increase the risk of deep venous thrombosis and so thromboembolic complications. The authors' aim is to evaluate the usefulness of pelvic ultrasonography in the diagnosis and in the possible early treatment of pelvic lymphoceles. Fifty-eight patients undergone radical prostatectomy and pelvic lymphadenectomy, between January '98 and December '99, underwent a pelvic ultrasonography in VII post-operative day. When a symptomatic or large (over 5 cm) lymphocele was found, it was treated with ultrasound (US) guided drainage. In the study, the following parameters were considered: lymphocele occurrence, size, location and treatment and thromboembolic complication. Statistical analysis was carried out with Fisher's exact test. Pelvic US showed a lymphocele in 23 out of 58 (40%) patients. Mean size was 5 cm. Deep venous thrombosis occurred in 4 patients, all with pelvic lymphoceles. No thromboembolic complications were recorded. In our experience, pelvic ultrasound has shown to be an easy e reliable tool for diagnosis and percutaneous treatment of pelvic lymphoceles.

Incidence of skeletal complications in patients with bone metastatic prostate cancer and hormone refractory disease: predictive role of bone resorption and formation markers evaluated at baseline

PURPOSE

We evaluated the incidence of skeletal complications in patients with bone metastatic prostate cancer and hormone refractory disease. We also assessed the predictive role of bone turnover markers determined at baseline.

MATERIALS AND METHODS

A total of 112 patients were consecutively enrolled in our study from July 1990 to July 1998 and followed until death or the last followup. Bone pain, disease extent in bone, serum prostate specific antigen, hemoglobin, and a panel of bone formation and resorption markers were assessed at baseline before any second line treatment.

RESULTS

Skeletal complications in 34 patients (30.3%, estimated yearly incidence 12.3%) involved vertebral deformity or collapse requiring spinal orthosis in 20 (17.9%), spinal cord compression in 7 (6.2%), pathological bone fracture in 10 (8.9%), symptomatic hypercalcemia in 1 (0.9%) and symptomatic hypocalcemia in 1 (0.9%). Median time to the evidence of the initial skeletal complication was 9.5 months. These adverse events did not influence overall survival. At baseline patients with eventual skeletal complications had greater bone pain (p = 0.02), a heavier tumor load in bone (p = 0.005), lower performance status (p = 0.05), and higher serum alkaline phosphatase (p <0.02) and urinary deoxypyridoline (p <0.05) than their counterparts. Multivariate analysis revealed that only urinary deoxypyridinoline was independently associated with the onset of these events (p <0.02). The scatterplot of urinary deoxypyridinoline values in patients with and without skeletal complications enabled us to detect a cutoff of 38 pM./mM. for predicting 51% of skeletal events with only an 8% false-positive rate.

CONCLUSIONS

Skeletal complications are common in patients with prostate cancer and hormone refractory disease. Bone loss is the major cause of onset. Baseline deoxypyridinoline at the cutoff point noted had moderate sensitivity but high specificity for predicting these adverse skeletal events.

Circulating neuroendocrine markers in patients with prostate carcinoma

BACKGROUND

Circulating neuroendocrine markers were measured in patients with prostate carcinoma (PC), prostatic intraepithelial neoplasia (PIN), and benign prostatic hypertrophy (BPH) with the goal to: 1) evaluate the differences in the expression of these markers in patients with benign, premalignant, and primary or metastatic PC; 2) evaluate their prognostic significance; 3) compare values in patients with hormone-naive and hormone-refractory disease; and 4) assess changes after androgen deprivation or chemotherapy.

METHODS

Serum neuron specific enolase (NSE) (immunoradiometric assay) and plasma chromogranin A (CgA) (enzyme-linked immunoadsorbent assay) were evaluated in 141 patients with BPH, 54 patients with PIN, and 159 patients with PC; 119 patients were bearing hormone-naive disease and 40 were bearing hormone-refractory disease. CgA was monitored in 31 patients submitted to androgen deprivation and in 24 patients receiving chemotherapy.

RESULTS

Supranormal CgA was observed more frequently in patients with American Urologic Association (AUA) Stage D2 disease (45.5%) compared with those with Stage D1 disease (33.3%), Stage C disease (16.7%), Stage A/B disease (18.8%), PIN (25.9%), and BPH (17.0%) (P < 0.02). Supranormal NSE did not change in any of the patient subgroups. Elevated CgA was observed in 36.0% of patients with metastases who had hormone-naive disease and in 45.0% of patients with hormone-refractory disease (P value not significant). Supranormal NSE and CgA values were predictors for poor prognosis in patients with hormone-refractory disease. Elevated baseline CgA values decreased > 50% in 1 of 12 patients who received luteinizing hormone-releasing hormone analogs and in 2 of 12 patients who underwent chemotherapy.

CONCLUSIONS

CgA appears to reflect the neuroendocrine activity of PC better than NSE. Elevated CgA values correlate with poor prognosis and are scarcely influenced by either endocrine therapy or chemotherapy.

Intravesical bacillus calmette-guerin (BCG) as inducer of tumor-suppressing proteins p53 and p21 Waf1-Cip1 during treatment of superficial bladder cancer

PURPOSE

Previous in vitro investigations recorded an inhibition of cell proliferation by BCG when added to different cell cultures. The induction of apoptosis by BCG is controversial. Our study aimed to evaluate the influence of BCG on the expression of tumor suppressing proteins p53 and p21Waf1-Cip1 and apoptosis of the urothelial cells in vivo.

MATERIALS AND METHODS

Twenty-one cases of superficial bladder cancer, treated with TUR and subsequent intravesical BCG, were studied retrospectively. The assays evaluated the expression of p53 and p21Waf1-Cip1 by immunochemistry (IHC), and the presence of apoptosis by TUNEL assay. The estimates were performed, in each case, on the following specimens: one tumor sample and one non-neoplastic sample collected during the TUR which preceded the administration of BCG; one non-neoplastic sample collected 3 months after the diagnosis; and one non-neoplastic sample collected in the first 2 weeks after the completion of the treatment. Samples of 6 cancer recurrences detected during BCG were examined too.

RESULTS

As usual for non-neoplastic urothelium, the pre-BCG samples displayed poor p53 and p21Waf1-Cip1 immunoreactivity. By contrast, the samples collected during and in the aftermath of BCG showed an overall increase of the expression of both proteins. The rare occurrence of apoptosis proved to be chronologically unrelated to the BCG treatment.

DISCUSSION

The relationship between changes of the IHC features and BCG suggests that BCG, at least under some circumstances, can induce the activation of wild type p53 and p21Waf1-Cip1 in the urothelium. The mechanism of the BCG-p53 status interaction and its role in the antitumor activity of BCG remain to be clarified.

Imaging features

Diagnosis of urogenital tuberculosis is traditionally based on urography, but the last few decades have seen the contribution of new methods such as ultrasound, CT scan and NMR. In the authors’ experience urography is still first choice for diagnosing urogenital tuberculosis; ultrasound is a useful complement in assessing renal parenchymal lesions and is indispensable in defining lesions in the prostate and the epididymus. With regard to the CT scan, the authors consider it gives a better definition of anatomical ratios than ultrasound, being particularly useful with extensive lesions. The role of NMR is not yet well-defined, although it does not seem to offer any particular advantages compared to CT.

Molecular biology in uro-oncology: clinical application. Prognostic factors in bladder cancer

In the bladder cancer the most important prognostic factors are the stage, the grade, the presence or absence of lymph nodal metastasis, the response to therapy with B. C. G. etc.... In any case, even in the context of the same clinical stage, it is not possible to correctly evaluate the evolution of the disease. The Author did a literature revision and got a personal contribution about the effective utility of same biological prognostic factors. In a study about superficial bladder tumor using monoclonal antibody MIB-1 (Ki-67) a correlation between proliferation index (P.I.) and grade was noted. In particular the presence of a P.I. above 40% correlated with greater precocity and frequency of recurrences. A similar study showed that the expression of protein p21 correlated with a greater precociousness and with recurrence frequency. In conclusion, we have also carried out an evaluative study on the expression of oncosuppressor gene p53. In superficial bladder cancer this study showed up a correlation between the expression of protein p53 and a greater precociousness and frequency of recurrences.

Evaluation of c-ras oncogene product (p21) in superficial bladder cancer

OBJECTIVES

The aim of our study is the evaluation of the prognostic importance of p21 protein in superficial bladder cancer.

METHODS

One hundred and fourteen patients with an initial diagnosis of monofocal bladder cancer (stage Ta-T1) following TUR were investigated. On the tissue removed by TUR, besides the usual pathological evaluation, an immuno-histochemical investigation was carried out in order to ascertain the presence of c-ras oncogene product (protein p21). The actuarial curves concerning the time free from the first recurrence were computed, comparing different subgroups in regard to protein p21 presence, grade and stage of the tumour.

RESULTS

The analysis of the results shows the importance of tumour stage as a predictor of recurrence, as well as that of the presence of c-ras products. This last factor increases the risk of recurrence almost 2-fold, in the same time lag, for c-ras-positive patients (p < 0.001). The prognostic significance of c-ras is independent of stage.

CONCLUSION

Our data underline the possibility of acquiring important information on the prognosis of superficial bladder cancer patients, pointing out the significance of c-ras oncogene product.

Monoclonal antibody Ki-67 in the study of the proliferative activity of bladder carcinoma

We studied the proliferative activity of bladder carcinoma using monoclonal antibody Ki-67, which is able to stain a nuclear antigen exclusively present in cells in the cell cycle, that is with activated deoxyribonucleic acid (DNA). We used this immunohistochemical technique on neoplastic tissue removed by transurethral resection from 101 patients. A significant correlation was observed (p less than 0.003) between cells with activated DNA and histological grading, even though within the context of each grade we observed tumors with a different proliferation index. Furthermore, we studied the location of the activated cells in the context of the tumor. In invasive tumors (stages T1 to T4) cells with activated DNA were always present at the base of implant of the tumor and in the neoplastic tissue that infiltrates the bladder wall. In regard to noninvasive tumors (stage Ta), in 57% of the cases most cells with activated DNA were present in the vegetative portion of the tumor and there were no recurrences at followup, while in 43% of the cases such cells were present also or especially at the base of implant of the tumor, near the lamina propria. In the latter patients we observed a 94% recurrence rate. These results suggest that the immunohistochemical assessment of the proliferative activity of transitional tumors of the bladder, using monoclonal antibody Ki-67, and the evaluation of the location of stained neoplastic cells provide a more reliable estimate of biological aggressiveness than that obtained with histopathological patterns alone.

[Coagulation and fibrinolytic activity of blood from the corpus cavernosum]

Thrombosis in cavernous bodies during erection-induced blood stasis is a exceptional phenomenon. This observation, induced the Authors to study coagulative and fibrinolytic activities of blood in cavernous bodies during pharmacologically induced erection. The results of the tests performed show that the blood of cavernous bodies has a fibrinolytic activity 3 times higher than peripheral blood (FPLA = 277 +- 83 mm2) and did not decrease when plasma was incubated with anti t-PA. During middle length erections, this activity is not expressed and the absence of thrombi formation seems to be due to a slowing of blood coagulation processes. On the other hand, during long-lasting erections, fibrinolysis is induced resulting in a local consumption like coagulopathy. Fibrinolysis in this district is not related to high t-PA plasma levels.

[Reliability of transrectal echography in the early diagnosis of prostatic carcinoma: our experience]

The Authors observed a group of 20 patients, each of them suffering from prostatic carcinoma clinically localized in only one lobe. All patients were investigated by trans-rectal US tomography, performed with a 5 MHz linear sound, and by prostatic biopsy in both lobes. The Authors evaluate US tomography results in comparison with biopsy executed on the apparently normal lobe and appreciable sensibility, specificity and predictive capability of this method. The Authors believe that trans-rectal US tomography, after having considered sensitivity and specificity values is not to propose as a screening method for early diagnosis of prostatic carcinoma.

[Indications for correction of varicocele]

In this paper are indicated the procedures to correct the varicocele, based on both the experience of the Authors and the data from the literature. In prepubertal subjects only varicoceles of II and III grade should be operated, meanwhile the I grade can be followed up because it can improve spontaneously. In young people, the asymptomatic varicocele diagnosed incidentally, for instance when people are controlled for military duty, should be operated in order to avoid possible dyspermic troubles. Infertile Adults with varicocele should be always surgically treated but which have either contemporary elevated serum FSH values or different untreated infertility causes. The age limits between which a varicocele can be successfully treated, in order to improve the infertility, are not yet precisely identified. Patients over 35 years are unlikely to recover fertility after operation.