HPV-positive clinically advanced squamous cell carcinoma of the urinary bladder (aBSCC): A comprehensive genomic profiling (CGP) study

BACKGROUND

Advanced bladder squamous cell carcinoma (aBSCC) is an uncommon form of urinary bladder malignancy when compared with the much higher urothelial carcinoma incidence. We studied the genomic alteration (GA) landscape in a series of aBSCC based on the association with human papilloma virus (HPV) to determine if differences in GA would be observed between the positive and negative groups.

METHODS

Using a hybrid capture-based FDA-approved CGP assay, a series of 171 aBSCC were sequenced to evaluate all classes of GA. Tumor mutational burden (TMB) was determined on up to 1.1 Mbp of sequenced DNA and microsatellite instability (MSI) was determined on up to 114 loci. Programmed cell death ligand -1 (PD-L1) expression was determined by IHC (Dako 22C3) with negative expression when PD-L1 was 0, lower expression of positivity set at 1 to 49%, and higher expression set at ≥50% expression.

RESULTS

Overall, 11 (6.4%) of the aBSCC were found to harbor HPV sequences (10 HPV16 and 1 HPV 11). HPV+ status was identified slightly more often in women (NS) and in younger patients (P = 0.04); 2 female patients with aBSCC had a prior history of SCC including 1 anal SCC and 1 vaginal SCC. HPV+ aBSCC had fewer GA/tumor (P < 0.0001), more inactivating mutations in RB1 (P = 0.032), and fewer inactivating GA in CDKN2A (P < 0.0001), CDKN2B (P = 0.05), TERT promoter (P = 0.0004) and TP53 (P < 0.0001). GA in genes associated with urothelial carcinoma including FGFR2 and FGFR3 were similar in both HPV+ and HPV- aBSCC groups. MTAP loss (homozygous deletion) which has emerged as a biomarker for PRMT5 inhibitor-based clinical trials was not identified in any of the 11 HPV+ aBSCC cases, which was significantly lower than the 28% positive frequency of MTAP loss in the HPV- aBSCC group (P < 0.0001). MTOR and PIK3CA pathway GA were not significantly different in the 2 groups. Putative biomarkers associated with immunotherapy (IO) response, including MSI and TMB status, were also similar in the 2 groups. PD-L1 expression data was available for a subset of both HPV+ and HPV- cases and showed high frequencies of positive staining which was not different in the 2 groups.

CONCLUSIONS

HPV+ aBSCC tends to occur more often in younger patients. As reported in other HPV-associated squamous cell carcinomas, HPV+ aBSCC demonstrates significantly reduced frequencies of inactivating mutations in cell cycle regulatory genes with similar GA in MTOR and PIK3CA pathways. The implication of HPV in the pathogenesis of bladder cancer remains unknown but warrants further exploration and clinical validation.

Reconnaissance of tumor immune microenvironment spatial heterogeneity in metastatic renal cell carcinoma and correlation with immunotherapy response

A clearer understanding of the tumor immune microenvironment (TIME) in metastatic clear cell renal cell carcinoma (ccRCC) may help to inform precision treatment strategies. We sought to identify clinically meaningful TIME signatures in ccRCC. We studied tumors from 39 patients with metastatic ccRCC using quantitative multiplexed immunofluorescence and relevant immune marker panels. Cell densities were analyzed in three regions of interest (ROIs): tumor core, tumor-stroma interface and stroma. Patients were stratified into low- and high-marker density groups using median values as thresholds. Log-rank and Cox regression analyses while controlling for clinical variables were used to compare survival outcomes to patterns of immune cell distributions. There were significant associations with increased macrophage (CD68⁺ CD163⁺ CD206⁺ ) density and poor outcomes across multiple ROIs in primary and metastatic tumors. In primary tumors, T-bet⁺ T helper type 1 (Th1) cell density was highest at the tumor-stromal interface (P = 0·0021), and increased co-expression of CD3 and T-bet was associated with improved overall survival (P = 0·015) and survival after immunotherapy (P = 0·014). In metastatic tumor samples, decreased forkhead box protein 3 (FoxP3)⁺ T regulatory cell density correlated with improved survival after immunotherapy (P = 0·016). Increased macrophage markers and decreased Th1 T cell markers within the TIME correlated with poor overall survival and treatment outcomes. Immune markers such as FoxP3 showed consistent levels across the TIME, whereas others, such as T-bet, demonstrated significant variance across the distinct ROIs. These findings suggest that TIME profiling outside the tumor core may identify clinically relevant associations for patients with metastatic ccRCC.

Nomogram Predicting Bladder Cancer-specific Mortality After Neoadjuvant Chemotherapy and Radical Cystectomy for Muscle-invasive Bladder Cancer: Results of an International Consortium

BACKGROUND

Cisplatin-based neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (MIBC) is associated with improved overall and cancer-specific survival. The post-NAC pathological stage has previously been reported to be a major determinant of outcome.

OBJECTIVE

To develop a postoperative nomogram for survival based on pathological and clinical parameters from an international consortium.

DESIGN, SETTING, AND PARTICIPANTS

Between 2000 and 2015, 1866 patients with MIBC were treated at 19 institutions in the USA, Canada, and Europe. Analysis was limited to 640 patients with adequate follow-up who had received three or more cycles of NAC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A nomogram for bladder cancer-specific mortality (BCSM) was developed by multivariable Cox regression analysis. Decision curve analysis was used to assess the model's clinical utility.

RESULTS AND LIMITATIONS

A total of 640 patients were identified. Downstaging to non-MIBC (ypT1, ypTa, and ypTis) occurred in 271 patients (42 %), and 113 (17 %) achieved a complete response (ypT0N0). The 5-yr BCSM was 47.2 % (95 % confidence interval [CI]: 41.2-52.6 %). On multivariable analysis, covariates with a statistically significant association with BCSM were lymph node metastasis (hazard ratio [HR] 1.90 [95% CI: 1.4-2.6]; p < 0.001), positive surgical margins (HR 2.01 [95 % CI: 1.3-2.9]; p < 0.001), and pathological stage (with ypT0/Tis/Ta/T1 as reference: ypT2 [HR 2.77 {95 % CI: 1.7-4.6}; p < 0.001] and ypT3-4 [HR 5.9 {95 % CI: 3.8-9.3}; p < 0.001]). The area under the curve of the model predicting 5-yr BCSM after cross validation with 300 bootstraps was 75.4 % (95 % CI: 68.1-82.6 %). Decision curve analyses showed a modest net benefit for the use of the BCSM nomogram in the current cohort compared with the use of American Joint Committee on Cancer staging alone. Limitations include the retrospective study design and the lack of central pathology.

CONCLUSIONS

We have developed and internally validated a nomogram predicting BCSM after NAC and radical cystectomy for MIBC. The nomogram will be useful for patient counseling and in the identification of patients at high risk for BCSM suitable for enrollment in clinical trials of adjuvant therapy.

PATIENT SUMMARY

In this report, we looked at the outcomes of patients with muscle-invasive bladder cancer in a large multi-institutional population. We found that we can accurately predict death after radical surgical treatment in patients treated with chemotherapy before surgery. We conclude that the pathological report provides key factors for determining survival probability.

Biomarkers and new therapeutic targets in renal cell carcinoma

OBJECTIVE

Renal Cell Carcinoma (RCC) is the most common malignancy in adult kidneys. The American Cancer Society estimated 62,700 new cases and 14,240 deaths in 2018. Although early detection has improved in recent years, the treatment remains a challenge and reliable biomarkers for poor outcomes become necessary for the prevention of metastases and improve the quality of patients' life during and after treatment. Then, the current status of the search for new RCC biomarkers was discussed, as well as the latest discoveries in the RCC risk and metastatic treatment were discussed in this review.

MATERIALS AND METHODS

Extensive research was carried out in the online databases and full-free text articles published in the last 5 years, or more when convenient, were evaluated. Articles were included that addressed the proposed theme and were published in the English language.

RESULTS

The present state of knowledge on biomarkers for RCC carcinogenesis and progression is still much to be understood about RCC risk factors and molecular pathways resulting in metastatic progression. Newest RCC target therapies were discussed, mainly in relation to immunological therapy, and vaccines that have been tested in numerous trials with different cancer types.

CONCLUSIONS

The development of targeted therapies has revolutionized the treatment of advanced and metastatic cancers or non-responder patients. Combined therapy between classical chemotherapy and adjuvant immunotherapies has been modifying the cancer patients prognosis and bringing the hope of a cure in many cases.

The merits of cytology in the workup for upper tract urothelial carcinoma - a contemporary review of a perplexing issue

INTRODUCTION

The importance of upper tract cytology for evaluating tumors is unclear. We correlated upper tract cytology with histologic findings in patients who underwent nephroureterectomy for upper tract urothelial carcinoma (UTUC) at a single tertiary care referral center.

MATERIALS AND METHODS

137 patients underwent nephroureterectomy between 2004 and 2012. 18 patients were excluded (benign tumors, atrophic kidneys with the remaining 119 patients serving as our study population). Upper tract cytology from the renal pelvis and/or ureter were retrospectively reviewed and analyzed with final pathology data in the remaining patients with UTUC.

RESULTS

57% (68/119) had preoperative upper tract cytology collected. 73% (50/68) patients had abnormal cytology (positive, suspicious) with a sensitivity of 74% (which increased to 90% if atypical included), specificity of 50% and a positive predictive value of 98%. High grade tumors were more common than expected (77% high grade vs. 20% low grade). Abnormal cytology did not predict T stage or tumor grade. Interestingly, positive upper tract cytology was found in all of the UTUC CIS specimen.

CONCLUSIONS

Upper tract cytology has been utilized to support the diagnosis of upper tract urothelial carcinoma. Our data demonstrates that abnormal cytology correlates well with the presence of disease but does not predict staging or grading in these respective patients.

Prospective clinical trial of the merits of retroperitoneal lymph node dissection at the time of nephroureterectomy for upper tract urothelial carcinoma

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Background: The role of retroperitoneal lymph node dissection (RPLND) in patients with upper urinary tract urothelial carcinoma (UUT-UC) remains controversial. The purpose of this prospective study was to assess the safety and feasibility of RPLND at the time of nephroureterectomy (NU) and to determine the incidence of lymph node metastasis and hence the clinical merit of this procedure at the time of NU.

Methods: From March 2009 to October 2010, sixteen patients with UUT-UC underwent open (8), laparoscopic (4) or robotic (4) NU with modified RPLND. Each patient received the appropriate modified template dissection depending on the site of the UC. Demographic data, clinical and pathologic stage, histologic nodal status, perioperative complications and recurrence data were documented.

Results: On final pathology, 11 (69%) patients had pTa disease, 1 (6%) had pT1, 3(19%) had pT3 disease and 1 (6%) had a benign angioma. The average lymph node count was 8 (range 3–27). No patient had positive lymph node metastasis. The median operative time was 252 minutes (range 146–371). Average EBL was 342 ml (range 100–950). Median hospital stay was 7 days (4–18). Median follow up was 5 months (range 0–16). There were four bladder tumor recurrences and one recurrence in the opposite renal pelvis and ureter. Two patients with pT3 disease as well as the patient with recurrence in the opposite UUT received chemotherapy. Four patients (25%) were given blood transfusions (median 1.2, range 1–2), one patient (6%) developed a chylous leak which resolved in four weeks, one patient (6%) developed postoperative ileus and one patient (6%) had a bowel injury during lysis of adhesions necessitating resection and anastomosis of small bowel. There was no injury to major vessels or other solid organs.

Conclusions: Our preliminary results indicate that RPLND during NU for UUT-UC is a safe procedure with minimal morbidity. A larger prospective clinical trial as a multicenter study is required to adequately assess the pathological and treatment related outcomes.

No significant financial relationships to disclose.

Health behaviors and depressive symptoms in testicular cancer survivors

OBJECTIVES

Testicular cancer has one of the highest 5-year survival rates of all cancer sites. The survival period is marked by an increased risk of secondary cancer and cardiovascular events owing to treatment-related toxicities. The purposes of this cross-sectional study were to determine the prevalence of health behaviors and depressive symptoms and to assess the relationship between depression and health behaviors in survivors of testicular cancer.

METHODS

A total of 162 survivors of testicular cancer 2 to 10 years after their diagnosis completed a one-time telephone interview. The interview included a battery of questions from the Behavioral Risk Factor Surveillance System assessing health behaviors (smoking, physical activity, cholesterol screening, colorectal cancer screening, alcohol consumption, and fruit and vegetable intake) and the Centers for Epidemiological Studies-Depression (CES-D) questionnaire assessing depressive symptoms.

RESULTS

The interviews revealed a low prevalence of positive health behaviors among survivors of testicular cancer. The percentage (17.5%) of survivors of testicular cancer who scored above the cutoff on the CES-D was greater than that (11%) of large-scale population-based estimates in men aged 19 to 44 years. Smoking was significantly related to depression. Depressive symptoms (CES-D score) differed significantly depending on smoking status (current smokers, mean = 15.2; former smokers, mean = 6.2, P <0.001; and never smokers, mean = 8.7, P <0.001).

CONCLUSIONS

Given the increased risk of cancer and treatment-related morbidities of these survivors, the findings of this study suggest that healthcare professionals should encourage survivors of testicular cancer to engage in positive health behaviors and check for depressive symptoms.

Predictors of survival in patients undergoing post-chemotherapy retroperitoneal lymph node dissection

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Background: The majority of patients with testicular cancer have a favorable prognosis yet a subset of patients will succumb to this disease. The aim of this study was to identify the clinical and pathological parameters which predict the outcome of patients post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND). Methods: From 1980 to 2003, 236 patients with clinical stage IIA-III non-seminoma germ cell tumors (NSGCT) underwent a PC-RPLND. We retrospectively reviewed their medical records for pertinent clinical and treatment-related outcomes. The 5-year disease-specific and recurrence-free survival was 85% and 75%, respectively with the median length of follow-up following RPLND of 45 months (6 to 250 months). Results: The median age of patients at diagnosis was 28 years with all patients receiving systemic chemotherapy (median of 5 cycles) prior to RPLND. On multivariate analysis, predictors of disease-specific survival (DSS) included systemic symptoms at presentation (P = 0.05), elevated pre-RPLND serum alpha fetoprotein (AFP, P = 0.006) and ß-human chorionic gonadotropin (HCG, P = 0.004), post-operative complications (P = 0.03), and recurrence (P < 0.0001). Predictors of recurrence-free survival (RFS) included advanced clinical stage (IIC-III, P = 0.001) and presence of viable tumor in the RPLND specimen (P = 0.03). A pre-RPLND serum AFP > 9 ng/ml and HCG > 4.1 mIU/ml was found to predict DSS (P = 0.03 and 0.03, respectively). Conclusions: Survival of patients undergoing PC-RPLND can be predicted by pre-operative tumor markers, and by development of post-operative complications or recurrence. Advanced clinical stage and viable tumor in the surgical specimen predict RFS.

No significant financial relationships to disclose.

The tensile properties of tension-free vaginal tape and cadaveric fascia lata in an in vivo rat model

OBJECTIVE

To examine the tensile properties (break load and maximum average load), after in vivo implantation in a rat animal model, of tension-free vaginal tape (TVT) and cadaveric fascia lata (CFL), as pubovaginal slings of these materials have become popular for treating stress urinary incontinence.

MATERIALS AND METHODS

Twenty Sprague-Dawley rats (300-400 g) had 1 x 2 cm strips of commercially available TVT and CFL implanted on the right and left anterior abdominal wall, respectively. Half of the animals were then killed at 6 weeks and the remainder at 12 weeks, after which the strips of TVT and CFL were removed and their tensile properties measured using a tensiometer. The tensile strength of TVT and CFL strips maintained only in normal saline served as controls.

RESULTS

The TVT strips had a mean break load of 0.740 kg in the control and only 0.390 kg for CFL (P < 0.05). At 6 weeks the TVT material had a mean (sd) maximum average load of 0.634 (0.096) kg and a mean break load of 0.589 (0.249) kg, whereas the respective values for the CFL were 0.323 (0.198) and 0.167 (0.063) kg (P < 0.05). Similarly at 12 weeks, TVT had a greater mean maximum average and break load than CFL, at 0.742 (0.052) and 0.274 (0.126), and 0.737 (0.056) and 0.185 (0.128) kg, respectively.

CONCLUSION

This is the first study to assess the tensile properties of the currently used sling materials, TVT and CFL, in an in vivo model. TVT has a greater break load and maximum average load than CFL; the tensile strength of these materials does not decrease with time.

Tissue reaction of the rabbit urinary bladder to tension-free vaginal tape and porcine small intestinal submucosa

OBJECTIVES

To compare the histological tissue reactions of urinary bladder in close contact with polypropylene mesh tension-free vaginal tape (TVT) or porcine small intestinal submucosal (SIS) grafts, as the commercial availability of various materials has considerably simplified sling procedures for treating urinary incontinence, but erosion and infection after using artificial sling materials remain an important concern.

MATERIALS AND METHODS

Thirty female New Zealand rabbits were randomized to three groups, i.e. group A (TVT, 12 animals), group B (SIS, 12) and group C (surgical control, six). Through a laparotomy under anaesthesia and an aseptic technique, the bladder was approached at its dome, where a 0.5 x 1 cm piece of TVT or SIS was fixed in direct contact with the bladder wall. The control group underwent only bladder manipulation with no material applied. Half the animals in each group were killed after 6 weeks and the other half after 12 weeks. The urinary bladder was harvested and examined histologically.

RESULTS

The grafts in both groups were characterized by dense foreign-body type reactions and were mostly attached loosely to the bladder wall by a thin layer of fibrovascular tissue. More importantly, the bladder wall reactions showed no inflammation in all 12 animals in group A (TVT) but three of them had various grades of fibrosis. There was severe transmural inflammation in one animal in group B (SIS); one rabbit had grade I and two had grade II fibrosis. The controls, as expected, showed no bladder wall reactions.

CONCLUSION

In this descriptive analysis of reaction types elicited on the urinary bladder by these grafts, both materials appeared to be safe. Although TVT elicited fewer and less severe adverse reactions, no statistical conclusions can be drawn. The clinical significance of these findings should emerge from long-term clinical data when they become available.

Comparison of molecular and conventional strategies for followup of superficial bladder cancer using decision analysis

PURPOSE

Patients with superficial bladder cancer require long-term surveillance for recurrence. We compared the cost of cystoscopy and cytology (standard care) to that of urinary markers (modified care) for patients with a history of superficial bladder cancer.

MATERIALS AND METHODS

We constructed a decision analysis model that compared the 2 strategies for a hypothetical followup interval of 3 years. Probabilities required for the decision tree were based on a cohort of 361 patients diagnosed with superficial bladder cancer from 1987 to 1997. Sensitivity analyses were used to determine whether test sensitivity and specificity would affect cost thresholds. Costs for each strategy were then applied to actual practice patterns.

RESULTS

The cost of modified care ranged from $158 to $228 for each followup visit when using a urinary marker with a sensitivity and specificity of 95% and 77%, respectively. The cost of standard care was $240 for each followup visit. Based on sensitivity analyses the probability of disease recurrence and urinary marker accuracy were important determinants of expected costs. Mean number of followup assessments for patients followed more than 3 years was 4.3, 2.2 and 1.5 for years 1, 2 and 3, respectively. Cumulative costs of modified care were lower than those of standard care.

CONCLUSIONS

Urinary marker testing for followup of patients with superficial bladder cancer is less expensive than the standard method of cystoscopy and urinary cytology based on our model. Future studies will be required to consider other factors that could affect the cost advantage of urinary markers, including indirect costs, the psychosocial impact of testing and different surveillance frequencies.

7-Nitroindazole: a selective inhibitor of penile erection: an in vivo study in a rat animal model

OBJECTIVES

The neuronal isoform of nitric oxide synthase (nNOS) has been localized in neurons innervating the penis and is believed to be an important mediator of erection. Using the selective inhibitor 7-nitroindazole (7-NI), we evaluated the possible role of nNOS in penile erection using a rat animal model.

METHODS

Eighteen Sprague-Dawley rats were divided into three study groups. A sham group (n = 6) received the vehicle arachis oil, a low-dose group received 5 mg/kg (n = 6), and a high-dose group received 50 mg/kg (n = 6) of 7-NI prior to measurement of blood pressure and cavernous nerve stimulation-induced rise in intracavernous pressure.

RESULTS

A dose-dependent inhibition of erection by 7-NI was seen. Control animals had an intracavernous pressure rise of 55.5 +/- 4.0 cm H2O, whereas the low-dose group had 26.5 +/- 2.8 cm H2O and the high-dose group had 6.2 +/- 2.1 cm H2O. A partial recovery of erection was seen in the low- and high-dose groups after 3 hours. Blood pressure was unaffected by 7-NI administration.

CONCLUSIONS

7-NI induced a reversible, dose-dependent inhibition of erection without affecting blood pressure. This in vivo study provides further evidence of the role played by nNOS in erection.

Neurogenic erectile dysfunction: the course of nicotinamide adenine dinucleotide phosphate diaphorase-positive nerve fibers on the surface of the prostate

OBJECTIVES

Nitric oxide (NO) plays an important role as a neurotransmitter in the peripheral neural regulation of erection. A histochemical stain able to localize fibers releasing NO in combination with an in vivo study were used to evaluate the course and physiologic significance of the nerve fibers innervating the cavernous smooth muscle.

METHODS

Morphologic studies in 6 rats and 6 human cadavers were performed, tracing the course of branches of the cavernous nerve branches using a nicotinamide adenine dinucleotide phosphate diaphorase staining technique. Electrostimulations in rats were performed before and after transection of the anterolateral part of the prostate capsule.

RESULTS

Multiple nerve fibers were documented running on the lateral and ventral surfaces of the prostate distinct from the classically described dorsolateral neurovascular bundle. Transection of these fibers resulted in a loss of electrically induced intracavernous pressure (59.4 +/- 5.6 cm H2O versus 27.0 +/- 4.6 cm H2O).

CONCLUSIONS

These preliminary morphologic and physiologic studies support a significant role for these nerve fibers in erection.