Risk of secondary primary malignancies in survivors of upper tract urothelial carcinoma: A nationwide population-based analysis

BACKGROUND

To investigate the cancer types and risk factors of secondary primary malignancy (SPM) in patients with upper tract urothelial carcinoma (UTUC) in Taiwan.

METHODS

Using National Health Insurance Research Dataset and catastrophic illness registry, we enrolled newly diagnosed UTUC patients from 2000 to 2013. Those without catastrophic illness registration were excluded from the study. The cancer types and hazard ratios (HRs) of subsequent SPMs were calculated according to the antecedent malignancy. We analyzed the risk factors for developing SPMs using multivariate Cox proportional hazard models.

RESULTS

A total of 9050 UTUC patients were registered and 2187 (24.2%) patients developed SPMs during the study period. As compared with primary UTUC, the relative risk ratios of SPM was 2.5 folds and 18% higher in those with antecedent non-UC malignancy and with bladder cancer history, respectively. Totally, 387 (37.8%) of 1022 UTUC patients with antecedent non-UC malignancy developed subsequent SPM after UTUC diagnosis. The antecedent and subsequent cancer types are similar and kidney cancer is most common, followed by hepatoma. Multivariate analysis showed that a history of antecedent non-UC malignancy is the most unfavorable factor for SPM development (HR, 2.50; 95% CI, 2.23-2.81), followed by liver disease, male gender, antecedent bladder cancer history, age ≥ 75 years, and chronic kidney disease.

CONCLUSIONS

Our study, conducted in Taiwan and involving 9050 UTUC patients, meticulously examined the types of SPM and the associated risk factors. Our research unearthed several pivotal discoveries: a preceding history of non-UC malignancies emerged as the single most influential factor contributing to the occurrence of subsequent cancers, followed by liver disease, male gender, antecedent bladder cancer history, age ≥75 years, and chronic kidney disease. Futhermore, kidney cancer emerged as the predominant subsequent malignancy, closely trailed by hepatoma..

Controversies in terminology associated with management of BCG-unresponsive NMIBC in Asia-Pacific

OBJECTIVES

Examine the understanding of terminologies and management patterns of bacillus Calmette-Guérin (BCG)-unresponsive nonmuscle invasive bladder cancer (NMIBC) in six territories in Asia-Pacific.

METHODS

This study involved two phases: (1) a survey with 32 urologists and 7 medical oncologists (MOs) and (2) a factorial experiment and in-depth interviews with 23 urologists and 2 MOs. All clinicians had ≥8 years' experience managing NMIBC patients in Australia, Hong Kong, Japan, South Korea, Singapore, and Taiwan. Data from Phase 1 were summarized using descriptive statistics; content and thematic analyses applied in Phase 2.

RESULTS

In phase 1, 35% of clinicians defined BCG-unresponsive as BCG-refractory, -relapse and -resistant, 6% defined it as BCG-refractory and -relapse; 22% classified BCG-failure as BCG-refractory, -relapse, -resistant, and when muscle-invasive bladder cancer is detected. If eligible and willing, 50% (interquartile range [IQR], 50%-80%) of BCG-unresponsive patients would undergo radical cystectomy (RC), and 50% (IQR 20%-50%) of RC-eligible patients would receive bladder-sparing treatment or surveillance. In phase 2, we found that 32%, 88%, and 48% of clinicians, respectively, used "BCG-unresponsive," "BCG-refractory," and "BCG-relapse" in clinical practice but with no consistent interpretation of the terms. Compared with EAU definitions, 8%-60% of clinicians appropriately classified 9 tumor types that are persistent or recurrent after adequate BCG. Fifty percent of clinicians mentioned a lack of bladder-preserving treatment that outperforms RC in quality of life as a reason to retreat BCG-unresponsive patients with BCG.

CONCLUSIONS

Our study revealed varied understanding and application of BCG-unresponsive terminologies in practice. There is a need for a uniform and simple definition of BCG-unresponsive disease in Asia-Pacific.

Risk stratification and management of non-muscle-invasive bladder cancer: A physician survey in six Asia-Pacific territories

OBJECTIVES

Multiple clinical practice guidelines, conflicting evidence, and physician perceptions result in variations in risk stratification among patients with non-muscle-invasive bladder cancer (NMIBC). This study aims to describe the extent of this variation and its impact on management approaches in the Asia-Pacific region.

METHODS

We conducted a cross-sectional survey involving 32 urologists and seven medical oncologists with ≥8 years of experience managing early-stage bladder cancer patients across Australia, Hong Kong, Japan, South Korea, Singapore, and Taiwan. The physicians completed an anonymous questionnaire that assessed their risk stratification and respective management approaches, based on 19 NMIBC characteristics. For each NMIBC characteristic, they were required to select one risk group, and their most preferred management approach.

RESULTS

Our results demonstrated a higher consensus on risk classification versus management approaches. More than 50% of the respondents agreed on the risk classification of all NMIBC characteristics, but 42% or fewer chose the same treatment option as their preferred choice for all but two characteristics-existence of variant histology (55%) and persistent high-grade T1 disease on repeat resection (52%). Across territories, there was the greatest variation in preferred treatment options (i.e., no treatment, intravesical chemotherapy, or Bacillus Calmette-Guérin [BCG] treatment) for intermediate-risk patients and the highest consensus on the treatment of very high-risk patients, namely radical cystectomy.

CONCLUSIONS

Our study revealed considerable variation in risk stratification and management of NMIBC in the region. It is critical to develop practical algorithms to facilitate the recognition of NMIBC and standardize the treatment of NMIBC patients.

Oct4 and Hypoxia Dual-Regulated Oncolytic Adenovirus Armed with shRNA-Targeting Dendritic Cell Immunoreceptor Exerts Potent Antitumor Activity against Bladder Cancer

Immunotherapy has emerged as a promising modality for cancer treatment. Dendritic cell immunoreceptor (DCIR), a C-type lectin receptor, is expressed mainly by dendritic cells (DCs) and mediates inhibitory intracellular signaling. Inhibition of DCIR activation may enhance antitumor activity. DCIR is encoded by CLEC4A in humans and by Clec4a2 in mice. Gene gun-mediated delivery of short hairpin RNA (shRNA) targeting Clec4a2 into mice bearing bladder tumors reduces DCIR expression in DCs, inhibiting tumor growth and inducing CD8+ T cell immune responses. Various oncolytic adenoviruses have been developed in clinical trials. Previously, we have developed Ad.LCY, an oncolytic adenovirus regulated by Oct4 and hypoxia, and demonstrated its antitumor efficacy. Here, we generated a Clec4a2 shRNA-expressing oncolytic adenovirus derived from Ad.LCY, designated Ad.shDCIR, aimed at inducing more robust antitumor immune responses. Our results show that treatment with Ad.shDCIR reduced Clec4a expression in DCs in cell culture. Furthermore, Ad.shDCIR exerted cytolytic effects solely on MBT-2 bladder cancer cells but not on normal NIH 3T3 mouse fibroblasts, confirming the tumor selectivity of Ad.shDCIR. Compared to Ad.LCY, Ad.shDCIR induced higher cytotoxic T lymphocyte (CTL) activity in MBT-2 tumor-bearing immunocompetent mice. In addition, Ad.shDCIR and Ad.LCY exhibited similar antitumor effects on inhibiting tumor growth. Notably, Ad.shDCIR was superior to Ad.LCY in prolonging the survival of tumor-bearing mice. In conclusion, Ad.shDCIR may be further explored as a combination therapy of virotherapy and immunotherapy for bladder cancer and likely other types of cancer.

Clinicopathologic Analysis of Micropapillary Urothelial Carcinoma of the Upper Urinary Tract: Implications for HER2-Targeted Therapy

Introduction/Background To determine the clinical significance of micropapillary urothelial carcinoma (MPUC) of the upper urinary tract (UTUC) and a potential therapeutic strategy. Patients and Methods A retrospective cohort study was conducted to examine the incidence of micropapillary UTUC from 2010 to 2018 and its clinicopathological characteristics. Clinical outcomes and cancer-specific survival (CSS) were compared between MPUC and conventional UTUC matched by stage within a 6-month variation of receiving surgery. Results A total of 24 MPUC cases were identified out of 901 cases (2.7%) of urothelial carcinoma (UC) of the renal pelvis and ureter. MPUC was significantly smaller (<3 cm) and associated with nodal metastasis compared with conventional UTUC (P = .017 & 0.021, respectively); however, no significant difference was observed for lymphovascular invasion, distant metastasis, or CSS (P > 0.50, respectively) compared with match controls. Six MPUC patients (25%) developed metastasis to the liver, lymph nodes, and lung during follow-up. Patients with HER2-positive MPUC (3 of 4) had a significantly higher risk of metastasis compared with HER2-negative MPUC (3 of 20; P = 0.035). Conclusions MPUC is an aggressive variant of UTUC and usually presents as a small locally advanced disease. HER2 immunohistochemistry may identify the subset of patients with micropapillary UTUC that are candidates for targeted therapy.

Interruption of the long non-coding RNA HOTAIR signaling axis ameliorates chemotherapy-induced cachexia in bladder cancer

BACKGROUND

Cisplatin-based chemotherapy is the first line of treatment for bladder cancer. However, cisplatin induces muscle wasting associated with NF-κB and cancer cachexia. HOTAIR, an oncogenic long non-coding RNA (lncRNA), promotes cancer progression in different cancers. Crosstalk between HOTAIR and NF-κB is documented. Prothymosin α (ProT) plays important roles in cancer progression and inflammation. However, the potential link between HOTAIR, ProT, and cisplatin-induced cancer cachexia remains unexplored. Here, we investigated the contribution of HOTAIR in cisplatin-induced cancer cachexia and dissected the potential signaling cascade involving the epidermal growth factor receptor (EGFR), ProT, NF-κB, and HOTAIR.

MATERIALS AND METHODS

Expression of ProT and HOTAIR transcripts and their correlations in tumor tissues of bladder cancer patients and bladder cancer cell lines were determined by RT-qPCR. Next, levels of phospho-EGFR, EGFR, phospho-NF-κB, and NF-κB were examined by immunoblot analysis in human bladder cancer cells treated with cisplatin. Expression of HOTAIR in cisplatin-treated cells was also assessed by RT-qPCR. Pharmacological inhibitors and overexpression and knockdown approaches were exploited to decipher the signaling pathway. The murine C2C12 myoblasts were used as an in vitro muscle atrophy model. The syngeneic murine MBT-2 bladder tumor was used to investigate the role of mouse Hotair in cisplatin-induced cancer cachexia.

RESULTS

Expression of ProT and HOTAIR was higher in bladder tumors than in normal adjacent tissues. There were positive correlations between ProT and HOTAIR expression in clinical bladder tumors and bladder cancer cell lines. Cisplatin treatment increased EGFR and NF-κB activation and upregulated ProT and HOTAIR expression in bladder cancer cells. ProT overexpression increased, whereas ProT knockdown decreased, HOTAIR expression. Notably, cisplatin-induced HOTAIR upregulation was abrogated by EGFR inhibitors or ProT knockdown. ProT-induced HOTAIR overexpression was diminished by NF-κB inhibitors. HOTAIR overexpression enhanced, whereas its knockdown reduced, cell proliferation, cachexia-associated pro-inflammatory cytokine expression, and muscle atrophy. Cachexia-associated symptoms were ameliorated in mice bearing Hotair-knockdown bladder tumors undergoing cisplatin treatment.

CONCLUSIONS

We demonstrate for the first time a critical role for HOTAIR and identify the involvement of the EGFR-ProT-NF-κB-HOTAIR signaling axis in cisplatin-induced cachexia in bladder cancer and likely other cancers. Our findings also provide therapeutic targets for this disease.

Dynamic changes of quality of life in muscle-invasive bladder cancer survivors

Background

To explore the dynamic changes and effects of radical cystectomy on quality of life in muscle-invasive bladder cancer survivors.

Methods

Patients with muscle-invasive bladder cancer were randomly recruited in this study. We used the World Health Organization Quality of Life-Brief questionnaire to assess consecutive patients’ quality of life. We applied kernel smoothing to illustrate the dynamic changes of the domain and item scores after treatment. Mixed-effects models were constructed to determine the effects of radical cystectomy on the scores of each item and domain of the World Health Organization Quality of Life-Brief questionnaire after controlling demographic and clinical factors.

Results

We collected 397 repeated measurements of the World Health Organization Quality of Life-Brief questionnaire from 109 muscle-invasive bladder cancer patients. Forty-two of them received radical cystectomy. Patients with radical cystectomy exhibited higher levels of education, less co-morbidities (i.e., diabetes and heart diseases), but were associated with more malignancies. Construction of mixed-effects models showed patients with radical cystectomy and those with bladder sparing had similar scores in the three main domains and their items, except that of certain items of physical domain. By applying kernel smoothing method, we found that stage III–IV patients consistently showed higher scores on sleep and rest after radical cystectomy for more than 5 years. In contrast, stage II patients receiving radical cystectomy did not show a higher score on the “sleep and rest” item compared with those with bladder sparing operation.

Conclusions

Radical cystectomy may result in sound sleep and rest, especially in those with stage III–IV bladder cancer.

Determinants and Dynamic Changes of Generic Quality of Life in Human Bladder Cancer Patients

We measured and determined the factors associated with long-term generic quality-of-life (QOL) changes in human bladder cancer patients. We utilized the World Health Organization QOL-Brief questionnaire to assess consecutive patients’ QOL at outpatient clinics of our hospital. A mixed-effects model was constructed to investigate the determinants of QOL changes according to each domain and individual item after controlling for demographic and clinical factors, as well as the effect of radical cystectomy. We also applied a kernel smoothing method to describe the long-term dynamic changes after the first definite treatment. In total, 1185 repeated measurements were collected from 343 bladder cancer patients. The mixed-effects models demonstrated that marital status, monthly income, and comorbidity with heart disease and diabetes were significant determinants among all the study participants. Regardless of the urinary diversion type, radical cystectomy contributed to lower scores for all four domains, mainly from 4–5 years after cystectomy, which declined significantly in patients who were older than 60 years. As for non-muscle-invasive bladder cancer (NMIBC) patients with preserved bladders, tumor recurrence was a major predictor for lower scores for sexual activity in the social domain. In summary, generic QOL can be independently influenced by many factors, not only cystectomy and tumor recurrence, which should be discussed with patients before treatment.

Low-pressure hydrodistension induces bladder glomerulations in female patients with interstitial cystitis/bladder pain syndrome

AIMS

The role of hydrodistension in the diagnosis of interstitial cystitis/bladder pain syndrome (IC/BPS) is controversial. This study evaluated the effect of low-pressure hydrodistension on glomerulation formation in female patients diagnosed with the disease.

METHODS

Sixty female patients with the clinical diagnosis of IC/BPS and 30 female controls without the disease underwent cystoscopy and hydrodistension. Cold-cup biopsy was taken from bladder posterior wall at sites with normal cystoscopic appearance before hydrodistension in the IC/BPS group. The tissue samples were processed for histology study. Low-pressure (40 cmH₂ O) hydrodistension for 2 min was performed and the appearance of glomerulations was compared between the two groups. High-pressure (80 cmH₂ O) hydrodistension for 8 min was then performed as a therapeutic measure for the IC/BPS patients. Further changes to the degree of glomerulations were recorded.

RESULTS

Histology showed pathological changes in the normal-appearing IC/BPS bladder mucosa including urothelium denudation, inflammatory cell infiltration, stromal edema, fibrosis, and vascular congestion. Low-pressure hydrodistension induced significant glomerulation formation in the patient group (percentage of patients with Grades 0-4: 0%, 8.3%, 40%, 35%, 10%, respectively) while none in the controls. High-pressure hydrodistension further increased the glomerulation grading in the IC/BPS patients.

CONCLUSIONS

Structural changes are present in prehydrodistension IC/BPS bladder wall, which may not be macroscopically detectable. Hydrodistension at low pressure is adequate to disrupt the integrity of such diseased mucosa and offers a more discriminative test in the diagnosis of IC/BPS.

The significance of SMARCB1 in the pathogenesis of renal cell carcinoma with rhabdoid features

BACKGROUND

Renal cell carcinoma with rhabdoid features (RCC-RF) is an aggressive histologic variant in the adults and is usually unresponsive to standard chemotherapy.

METHODS

Expression of SMARCB1/INI1 was examined in primary RCC-RF (n = 5). Stable INI1 with/without prostaglandin E2 receptor 1 (EP1) knockdown cell lines were created in the ACHN and 786-O RCC cell lines and measured for epidermal growth factor receptor (EGFR)-related signaling pathways. Chemosensitivity to targeted drugs in vitro was tested after knocking down of INI1 in both cell lines. The outcome of co-targeting of INI1 and EP1 in RCC was examined using a tumorigenicity assay.

RESULTS

Expression of INI1 was markedly reduced at both transcriptional and translational levels in primary RCC-RF. Immunohistochemical expression of INI1 protein was lost in the nuclei of rhabdoid cells compared with conventional RCC (n = 8). Using two cell lines with different genetic background, we showed that knocking down of INI1 activates the EGFR signaling with up-regulated AKT and ERK pathways and sensitizes cancer cells to Erlotinib treatment in vitro. However, cell-line dependent effects were also demonstrated with reference to impact of INI1 or EP1 on cell growth, migration and response to Gefitinib or Everolimus treatment in vitro.

CONCLUSION

Inactivation of INI1 may play a role in the pathogenesis of RCC-RF. Erlotinib is recommended in the management of patients with INI1-related RCC.

Urothelial carcinoma with trophoblastic differentiation: Reappraisal of the clinical implication and immunohistochemically features

PURPOSE

To investigate the clinical implications of identifying urothelial carcinoma (UC) with trophoblastic differentiation (UCTD).

MATERIALS AND METHODS

A prospective cohort study was performed from 2010 to 2016 to examine the incidence of UCTD in urinary tract cancer and association with clinicopathological indicators and patient outcome.

RESULTS

UCTD was detected in 47 of 859 (5.5%) cases of UC of the bladder and 65 of 635 (10.2%) cases in the upper urinary tract. UCTD of the bladder was significantly associated with non-papillary, multiple, larger size ( > 3 cm), muscle invasion, and nodal metastasis (P ≤ 0.0001, respectively). A higher risk of recurrence (P = 0.005), progression (P < 0.0001), and patient death (P < 0.0001) was observed for UCTD than those with traditional, high-grade UC of the bladder. Among four patterns of expression, focal expression of β-human chorionic gonadotropin was frequently detected in papillary tumor (P < 0.005) and UCs of smaller than 3 cm (P = 0.03). Significant indicators in predicting poor disease-specific overall survival in multivariate statistical model were tumor staging (P = 0.001), followed by non-focal β-hCG expression (P = 0.049).

CONCLUSION

UCTD is more often identified in the upper urinary tract than in the bladder. UCTD of the bladder was significantly associated with higher risk of recurrence, progression, and patient death. Expression of β-hCG in non-focal patterns predicts a worse prognosis for patients with UCTD and deserves an individualized treatment planning.

Seminal Vesicle Schwannoma: Transrectal and Intraoperative Sonographic Findings

Schwannomas, namely neurilemmomas, are benign nerve sheath tumors and comprise the myelin sheaths around the peripheral nerves. Schwannomas commonly occur in the head and neck, or extremities, less found in the mediastinum and retroperitoneum, and rarely in the pelvis. We report a 40-year-old male presenting with an 18-month history of nocturia and urinary frequency. Transrectal ultrasound revealed a well-defined, 2.81 cm × 3.77 cm in size, homogeneous, hypoechoic mass in the tail of the left seminal vesicle, compatible with the finding of a well-demarcated mass at the left seminal vesicle with homogeneous contrast enhancement on computed tomography. He underwent laparoscopic excision of the mass via da Vinci robotic surgical system. Intraoperative sonography showed that the mass exhibited the majority of hypoechoic density with some hyperechoic spots inside. Pathology reveals schwannoma. Both of erectile and ejaculatory functions were claimed postoperatively. Our case report highlights the potential of either intraoperative or preoperative sonography in the assessment of the seminal vesicle schwannoma.

Study on the pathophysiological mechanism responsible for lower urinary tract symptoms associated with prostate cancer using an animal model

OBJECTIVES

To investigate the pathophysiological mechanism leading to lower urinary tract symptoms in prostate cancer (PCa) by using an animal model.

METHODS

An orthotopic PCa model in mice was established by injection of human DU145 cells into the prostate gland lateral lobe of NOD.CB17-Prkdc^scid /NcrCrlBltw (NOD-SCID) mice. Cancer growth was quantified by a luciferase-based in vivo imaging system (IVIS) serially every 7 days. Comparisons were made for urodynamic parameters, bladder histology, and biological markers until the sixth week. Bladder wall structural changes were assessed by the bladder wall thickness and degree of fibrosis. Biomarker expressions in bladder tissue including muscarinic acetylcholine receptor 2 (M₂ ), transient receptor potential cation channel subfamily V member 4 (TRPV4), BCL2-associated X protein (Bax), and caspase3 were evaluated by immunohistochemical staining and immunofluorescence confocal laser scanning microscopy.

RESULTS

DU145 cell growth in the prostate was successfully monitored by a luciferase-based IVIS. after orthotopic injection. Using our injection technique, no anatomical obstruction of the bladder outlet and urethra was noted up to 6 weeks after injection. The presence of PCa induced changes in urinary bladder histology, biomarkers, and urodynamic parameters. Cystometry showed features of detrusor overactivity with increased voiding frequency and high-amplitude voiding contractions from the fourth week onward. Histological analyses 4 weeks after DU145 injection demonstrated detrusor thickening and bladder wall fibrosis. Immunohistochemistry showed increased expressions of bladder M₂ , TRPV4, Bax, and caspase3 in the PCa mice as early as in the first or second week.

CONCLUSIONS

PCa can induce bladder microenvironment changes involving neural receptors and biological mediators leading to histological and functional alterations even in the absence of overt anatomical obstruction.

Dynamic Changes of Generic Quality of Life after Different Treatments for Localized Prostate Cancer

Generic quality of life (QoL) is an important issue in decision making related to the primary treatment of localized prostate cancer (PC). This study assessed the dynamic changes of QoL in patients with localized PC under different treatment modalities. From 2013 to 2018, we prospectively assessed QoL scores in patients with localized PC under unitary treatment using the World Health Organization Quality of Life (WHOQOL) BREF version. The trajectories of the QoL scores after different treatments were estimated using a kernel-smoothing method. Dynamic changes in the major determinants were analyzed using a mixed effects model. The clinical features of the participants in our institute were compared with PC patients in Taiwan’s cancer registry. A total of 196 patients were enrolled with 491 repeated assessments. The participants shared similar clinical characteristics with the PC patients in Taiwan as a whole. Patients with lower household incomes showed statistically significant lower scores on all four domains and related facets, while PC survivors with comorbidities of anxiety and/or diabetes appeared to be affected on the physical domain and related facets. After controlling for these determinants, patients under active surveillance or observation demonstrated significantly higher QoL scores in the physical and social domains, as well as several facets belonging to these domains, in mixed models compared with patients undergoing radical prostatectomy or radiotherapy within the first year. The generic QoL scores were higher within the first year in patients receiving active surveillance or observation after controlling other significant factors. The difference diminished after one year of post management. More studies are needed to corroborate our findings.

Additive Effects of Arsenic and Aristolochic Acid in Chemical Carcinogenesis of Upper Urinary Tract Urothelium

BACKGROUND

Aristolochic acids (AA) and arsenic are chemical carcinogens associated with urothelial carcinogenesis. Here we investigate the combined effects of AA and arsenic toward the risk of developing upper tract urothelial carcinoma (UTUC).

METHODS

Hospital-based (n = 89) and population-based (2,921 cases and 11,684 controls) Taiwanese UTUC cohorts were used to investigate the association between exposure to AA and/or arsenic and the risk of developing UTUC. In the hospital cohort, AA exposure was evaluated by measuring aristolactam-DNA adducts in the renal cortex and by identifying A>T TP53 mutations in tumors. In the population cohort, AA exposure was determined from prescription health insurance records. Arsenic levels were graded from 0 to 3 based on concentrations in well water and the presence of arseniasis-related diseases.

RESULTS

In the hospital cohort, 43, 26, and 20 patients resided in grade 0, 1+2, and 3 arseniasis-endemic areas, respectively. Aristolactam-DNA adducts were present in >90% of these patients, indicating widespread AA exposure. A>T mutations in TP53 were detected in 28%, 44%, and 22% of patients residing in grade 0, 1+2, and 3 arseniasis-endemic areas, respectively. Population studies revealed that individuals who consumed more AA-containing herbs had a higher risk of developing UTUC in both arseniasis-endemic and nonendemic areas. Logistic regression showed an additive effect of AA and arsenic exposure on the risk of developing UTUC.

CONCLUSIONS

Exposure to both AA and arsenic acts additively to increase the UTUC risk in Taiwan.

IMPACT

This is the first study to investigate the combined effect of AA and arsenic exposure on UTUC.

Needle Tip Culture after Prostate Biopsy: A Tool for Early Detection for Antibiotics Selection in Cases of Post-Biopsy Infection

PURPOSE

To investigate biopsy needle tip culture after prostate biopsies for bacteria prediction and antibiotics selection.

MATERIALS AND METHODS

From May 2017 to April 2019, 121 patients who underwent a prostate biopsy were enrolled. All biopsy needle tips were sent for aerobic and anaerobic culture. Patients were divided into positive and negative culture groups. Perioperative data were recorded and compared between the two groups. The culture time and susceptibility of febrile patients were analyzed. Blood cultures were conducted for all patients who experienced fever after biopsy. The time and results of the needle and blood cultures were recoded for descriptive analysis.

RESULTS

There were 59 (48.8%) positive needle cultures. Other than fever (p = 0.023), there were no statistical significances in clinical data between the two groups. Fever occurred in eight patients, and seven febrile patients had positive needle cultures, six of whom had positive blood cultures. These six needle and blood cultures were consistent with the susceptibility test results. As compared to the waiting time for blood cultures, target antibiotics were administered at an average of 48.0 h earlier based on needle cultures. None of the patients with positive anaerobic cultures developed a fever, while all eight febrile patients had negative anaerobic cultures.

CONCLUSION

Fevers developed at statistically significant higher rate among those who had positive needle cultures. Needle and blood cultures were consistent with the susceptibility test results. Needle cultures can help us administer target antibiotics earlier to febrile patients without the need to wait for blood cultures.

Clinical Frailty Scale in Predicting Postoperative Outcomes in Older Patients Undergoing Curative Surgery for Urologic Malignancies: A Prospective Observational Cohort Study

OBJECTIVE

To examine the utility of the Clinical Frailty Scale (CFS) in predicting outcomes in older adults with urologic malignancies undergoing curative surgeries.

METHODS

This prospective observational cohort study was conducted in a university-based tertiary medical center. Patients aged 75 years or older who were scheduled to undergo curative surgery for a urologic malignancy from January 2017 to December 2017 were recruited. Patients were grouped according to the CFS scores. The primary postoperative outcome measures were a major complication within 30 days and a decline in the activities of daily living (ADL) within 30 days and 90 days. Multivariable analyses and the area under the receiver operating characteristic curve were performed to investigate the association between the CFS and postoperative outcomes.

RESULTS

A total of 82 patients, 50% women, were enrolled with mean age 81.6 years. The CFS was significantly associated with postoperative outcomes in a dose-response relationship. When compared with those with a CFS <5, patients with CFS scores ≥5 had a 10.3-times higher risk for a major complication, 8.5-times and 21.4-times higher risk for a decline in ADL within 30 days and 90 days. The area under the receiver operating characteristic curves for the CFS to predict a major complication, the 30-day decline in ADL and the 90-day decline in ADL were 0.60, 0.73, and 0.79.

CONCLUSION

A higher CFS score predicted a higher risk of poor outcomes in this population. It is recommended that patients with higher CFS scores, especially above 5, are needed to receive further multidisciplinary perioperative care.

United in Fight against prOstate cancer (UFO) registry: first results from a large, multi-centre, prospective, longitudinal cohort study of advanced prostate cancer in Asia

Objectives

To document the management of advanced prostate cancer including diagnosis, prognosis, treatment, and care, in real‐world practice in Asia using the United in Fight against prOstate cancer (UFO) registry.

Patients and Methods

We established a multi‐national, longitudinal, observational registry of patients with prostate cancer presenting to participating tertiary care hospitals in eight Asian countries. A total of 3636 eligible patients with existing or newly diagnosed high‐risk localised prostate cancer (HRL), non‐metastatic biochemically recurrent prostate cancer (M0), or metastatic prostate cancer (M1), were consecutively enrolled and are being followed‐up for 5 years. Patient history, demographic and disease characteristics, treatment and treatment decisions, were collected at first prostate cancer diagnosis and at enrolment. Patient‐reported quality of life was prospectively assessed using the European Quality of Life‐five Dimensions, five Levels (EQ‐5D‐5L) and Functional Assessment of Cancer Therapy for Prostate Cancer questionnaires. In the present study, we report the first interim analysis of 2063 patients enrolled from study start (15 September 2015) until 18 May 2017.

Results

Of the 2063 enrolled patients, 357 (17%), 378 (19%), and 1328 (64%) had HRL, M0 or M1 prostate cancer, respectively. The mean age at first diagnosis was similar in each group, 56% of all patients had extracapsular extension of their tumour, 28% had regional lymph node metastasis, and 53% had distant metastases. At enrolment, 62% of patients had at least one co‐morbidity (mainly cardiovascular disease or diabetes), 91.8% of M1 patients had an Eastern Cooperative Oncology Group performance score of <2 and the mean EQ‐5D‐5L visual analogue score was 74.6–79.6 across cohorts. Treatment of M1 patients was primarily with combined androgen blockade (58%) or androgen‐deprivation therapy (either orchidectomy or luteinising hormone‐releasing hormone analogues) (32%). Decisions to start therapy were mainly driven by treatment guidelines and disease progression. Decision to discontinue therapy was most often due to disease progression (hormonal drug therapy) or completion of therapy (chemotherapy).

Conclusion

In the UFO registry of advanced prostate cancer in Asia, regional differences exist in prostate cancer treatment patterns that will be explored more deeply during the follow‐up period; prospective follow‐up is ongoing. The UFO registry will provide valuable descriptive data on current disease characteristics and treatment landscape amongst patients with prostate cancer in Asia.

Sex hormones and oxidative stress mediated phthalate-induced effects in prostatic enlargement

Prostatic enlargement might affect up to 30% of men and can cause signs and symptoms in the lower urinary tract in the elderly. Imbalanced estrogen and androgen secretions are important in prostatic physiopathology. Phthalates-environmental endocrine disruptors-affect androgen secretion and disrupt sexual organs, including testes and the prostate, but the underlying mechanisms are unclear. Using European Association of Urology (EAU) guidelines, we recruited from urology clinics in southern Taiwan 207 elderly men diagnosed with benign prostatic hyperplasia (BPH) and prostatic enlargement between 2015 and 2017. We took blood and urine samples from all patients on the same day. We used multivariate linear regression, associations, and potential interactions after we had measured and analyzed oxidative stress (OS) markers, steroidal hormones, and 11 urinary phthalate metabolites, and then we adjusted for confounders. Di(2-ethylhexyl) phthalate (DEHP) metabolite levels, particularly urinary mono-(2-ethylhexyl) phthalate, were positively associated with androgen, estrogen, hormone ratios, inducible nitric oxide synthetase (iNOS), 8-hydroxy-2'-deoxyguanosine (8-OHdG), prostate specific antigen (PSA), and prostate volume (PV) (p < 0.05). PV and PSA were positively associated with androgen, estrogen, hormone ratios and OS markers (p < 0.05). The estimated percentages of exposure to phthalates in prostatic enlargement mediated by androgen, estrogen, and OS markers ranged from 3.5% to 63.1%. Exposure to DEHP promoted the progress of BPH by increasing dihydrotestosterone (DHT), estradiol (E₂), the converted enzymes aromatase and 5α reductase, and reactive oxygen species (ROS) (8-OHdG and iNOS) production. Sex hormones and OS might be important hyperplasia-promoters after a patient has been exposed to phthalates, especially to DEHP.

Incorporating Simplified Fournier's Gangrene Severity Index with early surgical intervention can maximize survival in high-risk Fournier's gangrene patients

OBJECTIVES

To determine the optimal surgical timing in high-risk patients with Fournier's gangrene by the Simplified Fournier's Gangrene Severity Index.

METHODS

From 1989 to 2018, 118 male patients diagnosed with Fournier's gangrene with complete medical records were retrospectively reviewed. Patients' demographics, laboratory parameters at initial diagnosis, Fournier's Gangrene Severity Index and Simplified Fournier's Gangrene Severity Index, and the time interval from emergency room arrival to surgical intervention were collected. The Fournier's gangrene patients were categorized into low-risk (Simplified Fournier's Gangrene Severity Index ≤2) and high-risk groups (Simplified Fournier's Gangrene Severity Index >2). Differences between the variables within the two groups were analyzed. The optimal surgical timing was analyzed with the receiver operating characteristic curve in high-risk Fournier's gangrene patients.

RESULTS

The overall mortality of 118 Fournier's gangrene patients was 14.4%. After risk stratification with the Simplified Fournier's Gangrene Severity Index scoring system, the mortality of low-risk and high-risk Fournier's gangrene patients was 1.3% and 41.0%, respectively. In the high-risk group, the time interval from emergency room arrival to surgical intervention was the only variable with a significant difference between survivors and non-survivors (P = 0.039). The optimal surgical timing was determined at 14.35 h, which allowed the highest sensitivity (0.688) and specificity (0.762) to affect mortality. The mortality was significantly lower in high-risk Fournier's gangrene patients with early surgical intervention compared with late intervention (23.8% vs 68.8%, P = 0.007).

CONCLUSIONS

The Simplified Fournier's Gangrene Severity Index is a quick and reliable screening tool for first-line physicians to identify high-risk patients with Fournier's gangrene (Simplified Fournier's Gangrene Severity Index >2) who have poor survival outcomes. We recommended early surgical intervention within 14.35 h to maximize the survival of high-risk Fournier's gangrene patients.

Prothymosin-α enhances phosphatase and tensin homolog expression and binds with tripartite motif-containing protein 21 to regulate Kelch-like ECH-associated protein 1/nuclear factor erythroid 2-related factor 2 signaling in human bladder cancer

Prothymosin‐α (PTMA) is a small, acidic protein that is usually transported into the nucleus and involves many cellular and immunological functions. Previous studies demonstrated that aberrant location of PTMA expression exists in human bladder cancer, but the role of PTMA protein expression remains elusive. In this study, we created ectopic nuclear or cytoplasmic PTMA expression in human bladder cancer cells by infecting lentiviruses carrying wild type or deleted nuclear localization signal of the PTMA gene. The in vivo tumorigenesis assay showed PTMA protein with deleted nuclear localization signal promotes J82 xenograft tumor growth in mice and shortens their survival more so than the wild type. Chromatin immunoprecipitation showed that wild‐type PTMA protein binds to the PTEN promoter and enhances phosphatase and tensin homolog (PTEN) expression. Through immunoblot proteomics and in vivo ubiquitination studies, PTMA protein can bind with tripartite motif‐containing protein 21 (TRIM21) and block its ubiquitination. Also, TRIM21 can downregulate both forms of PTMA protein. In human bladder tumors, loss of nuclear PTMA expression was an unfavorable prognostic indicator for shorter disease‐free survival (hazard ratio, 1.54; P = 0.009). Our data support that nuclear PTMA protein serves as a tumor suppressor in bladder cancer through upregulating PTEN and orchestrating TRIM21 for the regulation of Nrf2 signaling.

History of Urinary Retention Is a Risk Factor for Infection after Prostate Biopsy: A Nationwide, Population-Based Cohort Study

BACKGROUND AND AIM

Infection or bleeding after transrectal prostate biopsy remains a concern of both patients and urologists. We explored the risk of association of certain co-morbidities with both complications.

PATIENTS AND METHODS

Using the Taiwan National Health Insurance Research Database, we identified patients undergoing prostate biopsy from 2000 to 2013. We used logistic multivariable regression to search for associations between post-biopsy hospitalization and the two co-morbidities within a year after biopsy.

RESULTS

Among 3,601 prostate biopsies, 100 infections (3.77%) and 52 (1.44%) bleeding-related emergency room visits and hospitalizations were recorded within 30 days after biopsy. The group having the biopsy as an inpatient exhibited older age (p < 0.0001) and a higher percentage of having diabetes mellitus (p = 0.015) than patients without either complication. The logistic multivariable regression analysis showed that urinary retention, freedom from diabetes, and performance as an outpatient procedure were independent risk factors for infection-related hospitalization (odds ratios 1.81, 1.96, and 1.72; p values 0.031, 0.037, and 0.010, respectively).

CONCLUSION

Patients with a recent history of urinary retention have a higher probability of infection-related hospitalization after prostate biopsy.

Macrophage activation syndrome with lung involvement complicating adult-onset Still's disease

Adult-onset Still's disease (AOSD) can progress into macrophage activation syndrome (MAS), which may be fatal. We report on a 19-year-old Han Chinese female, who presented with MAS-related pulmonary parenchymal involvement complicating AOSD, and further associated with disseminated intravascular coagulation and generalized tonic-clonic seizure. She was managed by high-dose corticosteroids and pulse cyclophosphamide therapy with a complete recovery of disease activity.

Abstract 5339: Epigenetic silencing of ANGPTL4 in tumor tissues and its overexpression in the urothelial carcinoma microenvironment

Urothelial carcinoma (UC) carcinogenesis has been hypothesized to occur through epigenetic repression of tumor suppressor genes (TSGs). By qRT-PCR array, we found that one potential TSG, ANGPTL4, was expressed at very low levels in all UC cell lines we examined. Previous studies had demonstrated that ANGPTL4 is highly expressed in some cancers, but downregulated, by DNA methylation, in others. Consequently, due to these seemingly conflicting functions in distinct cancers, the precise role of ANGPTL4 in the etiology of UC remains unclear. In this study, using methylation-specific PCR and bisulfite pyrosequencing, we show that ANGPTL4 is transcriptionally repressed by promoter hypermethylation in UC cell lines and primary tumor samples, as compared to adjacent noncancerous bladder urothelium. Functional studies further demonstrated that ectopic expression of ANGPTL4 potently suppressed UC cell proliferation, monolayer colony formation in vitro, and invasion, migration, and xenograft formation in vivo. As ANGPTL4 is a secreted factor, we therefore examined the circulating ANGPTL4 (cir-ANGPTL4) level in UC patients. Surprisingly, cir-ANGPTL4 was significantly higher in plasma samples from UC patients than normal control, suggesting it might be secreted from other cell types. More importantly, exogenous c-terminal fragment of ANGPTL4 (cANGPTL4) could promote cell proliferation and cell migration via activation of signaling through the Erk/FAK axis. We further confirmed that mouse xenograft tumor growth could be promoted by administration of exogenous cANGPTL4. Finally, immunohistochemistry demonstrated that ANGPTL4 was downregulated in tumor cells but overexpressed in tumor-adjacent stromal tissues including muscle and macrophages of muscle-invasive UC tissue samples. In conclusion, our data supports dual roles for ANGPTL4 in urothelial carcinoma progression, either as a tumor suppressor or oncogene, in response to microenvironmental context.

Citation Format: Michael WY Chan, Hsiao-Yen Hsieh, Yeong-Chin Jou, Chun-Liang Tung, Yuh-Shyan Tsai, Yuan-Hung Wang, Chen-Lin Chi, Ru-Inn Lin, Shih-Kai Hung, Yu-Ming Chuang, Shu-Fen Wu, Chin Li, Cheng-Huang Shen, Cheng-Da Hsu. Epigenetic silencing of ANGPTL4 in tumor tissues and its overexpression in the urothelial carcinoma microenvironment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5339.