Non-invasive detection of urothelial cancer through the analysis of driver gene mutations and aneuploidy

Current non-invasive approaches for detection of urothelial cancers are suboptimal. We developed a test to detect urothelial neoplasms using DNA recovered from cells shed into urine. UroSEEK incorporates massive parallel sequencing assays for mutations in 11 genes and copy number changes on 39 chromosome arms. In 570 patients at risk for bladder cancer (BC), UroSEEK was positive in 83% of those who developed BC. Combined with cytology, UroSEEK detected 95% of patients who developed BC. Of 56 patients with upper tract urothelial cancer, 75% tested positive by UroSEEK, including 79% of those with non-invasive tumors. UroSEEK detected genetic abnormalities in 68% of urines obtained from BC patients under surveillance who demonstrated clinical evidence of recurrence. The advantages of UroSEEK over cytology were evident in low-grade BCs; UroSEEK detected 67% of cases whereas cytology detected none. These results establish the foundation for a new non-invasive approach for detection of urothelial cancer.

Spectrum of genetic mutations in de novo PUNLMP of the urinary bladder

Our group and others have previously demonstrated the presence of TERT promoter mutations (TERT-mut) in 60-80% of urothelial carcinomas and some of their histologic variants. Five other genes have been frequently implicated in bladder cancer: FGRF3, TP53, PIK3CA, HRAS, and CDKN2A. In the current study, we sought to determine the prevalence of mutations in TERT and these five other genes in de novo papillary urothelial neoplasms of low malignant potential (PUNLMP) of the urinary bladder. A retrospective search of our archives for PUNLMP was performed and 30 de novo cases were identified and included in the study. We found mutations in TERT (TERT-mut) and FGFR3 (FGFR3-mut) to be the most common alterations in the cohort (63 and 60%, respectively). The majority of the TERT-mut-positive tumors (84%) had a g.1295228C > T alteration with the remaining tumors demonstrating g.1295250C > T. Approximately one fourth of tumors had TP53 mutations. These findings support the potential utility of a uniform genetic mutation panel to detect bladder cancers of various subtypes.

High prevalence of TERT promoter mutations in micropapillary urothelial carcinoma

Somatic activating mutations in the promoter of the telomerase reverse transcriptase (TERT) gene are the most common genetic alterations in urothelial carcinoma (UC) of the bladder and upper urinary tract. Little is known, however, about TERT-mutation status in the relatively uncommon but clinically aggressive micropapillary (MPC) variant. We evaluated the presence of TERT promoter mutations in MPC of the bladder and upper urinary tract. A retrospective search of our archives for MPC and UC with micropapillary features (2005-2014) was performed. All slides were reviewed to confirm the histologic diagnosis. Thirty-three specimens from 31 patients had FFPE blocks available for DNA analysis and were included in the study. Intratumoral areas of non-micropapillary histology were also evaluated when present. Samples were analyzed with Safe-SeqS, a sequencing error reduction technology, and sequenced using the Illumina MiSeq platform. TERT promoter mutations were detected in all specimens with pure MPC (18 of 18) and UC with focal micropapillary features (15 of 15). Similar to conventional UC, the predominant mutations identified occurred at positions -124 (C228T) (85 %) and -146 (C250T) (12 %) bp upstream of the TERT ATG start site. In heterogeneous tumors with focal variant histology, intratumoral concordant mutations were found in variant (MPC and non-MPC) and corresponding conventional UC. We found TERT promoter mutations, commonly found in conventional UC, to be frequently present in MPC. Our finding of concordant intratumoral mutational alterations in cases with focal variant histology lends support to the common oncogenesis origin of UC and its variant histology.

A comparison of the quality of life of the patients undergoing hemodialysis versus peritoneal dialysis and its correlation to the quality of dialysis

Over the years, there has been a steady increase in the number of patients requiring dialysis. However, no consensus exists between choosing either hemodialysis (HD) or peritoneal dialysis (PD) as the preferred method of dialysis for patients. In this study, we have compared the quality of life of the patients undergoing either HD or PD. This cross-sectional study was performed in the dialysis center of the Noor and Saint Ali Asghar University Hospital in Isfahan, Iran in 2012. Forty-six patients who underwent PD (28 males and 18 females) and 46 similar patients undergoing HD (26 males and 20 females) were compared. A standardized Persian version of the short form-36 (SF-36) tool was used to assess the quality of life and to assess the quality of dialysis weekly Kt/V in patients undergoing PD and single random Kt/V sampling in HD patients were assessed. Patients undergoing PD reported higher scores in physical functioning. The lowest scores in both groups were reported in mental health section. In physical functioning section, physical role functioning section and overall score of the SF-36 tool, PD patients reported significantly higher scores compared to the HD patients (P <0.05). There was no significant difference between the qualities of the dialysis in the two patient groups. Aspects of quality of life such as physical functioning, physical role functioning, bodily pain, general health perceptions, and overall score were significantly different between the two groups. If these results are substantiated by subsequent longitudinal studies, then the choice of dialysis could be better guided in patients by the quality of life issues.

High-resolution telomere fluorescence in situ hybridization reveals intriguing anomalies in germ cell tumors

Testicular germ cell tumor (TGCT) is the most common malignancy of young men. Most patients are completely cured, which distinguishes these from most other malignancies. Orchiectomy specimens (n=76) were evaluated using high-resolution (single-cell discriminative) telomere-specific fluorescence in situ hybridization (FISH) with simultaneous Oct4 immunofluorescence to describe telomere length phenotype in TGCT neoplastic cells. For the first time, the TGCT precursor lesion, germ cell neoplasia in situ (GCNIS) is also evaluated in depth. The intensity of the signals from cancerous cells was compared to the same patient's reference cells-namely, healthy germ cells (defined as "medium" length) and interstitial/somatic cells (defined as "short" telomere length). We observed short telomeres in most GCNIS and pure seminomas (P=.006 and P=.0005, respectively). In contrast, nonseminomas displayed longer telomeres. Lesion-specific telomere lengths were documented in mixed tumor cases. Embryonal carcinoma (EC) demonstrated the longest telomeres. A fraction of EC displays the telomerase-independent alternative lengthening of telomeres (ALT) phenotype (24% of cases). Loss of ATRX or DAXX nuclear expression was strongly associated with ALT; however, nuclear expression of both proteins was retained in half of ALT-positive ECs. The particular distribution of telomere lengths among TGCT and GCNIS precursors implicate telomeres anomalies in pathogenesis. These results may advise management decisions as well.

Detection of TERT promoter mutations in primary adenocarcinoma of the urinary bladder

TERT promoter mutations (TERT-mut) have been detected in 60% to 80% of urothelial carcinomas. A molecular urine-based screening assay for the detection of TERT-mut is currently being pursued by our group and others. A small but significant number of bladder carcinomas are adenocarcinoma. The current study assesses the incidence of TERT-mut in primary adenocarcinomas of urinary bladder. A retrospective search of our institutional pathology records identified 23 cystectomy specimens with a diagnosis of adenocarcinoma (2000-2014). All slides were reviewed by a senior urologic pathologist to confirm tumor type and select a representative formalin-fixed, paraffin-embedded block for mutational analysis. Adequate material for DNA testing was available in 14 cases (7 enteric type and 7 not otherwise specified). TERT-mut sequencing analysis was performed using previously described SafeSeq technique. Overall, 28.5% of primary adenocarcinoma harbored TERT-mut. Interestingly, 57% of nonenteric adenocarcinomas were mutation positive, whereas none of the enteric-type tumors harbored mutations. Similar to urothelial carcinoma, we found a relatively higher rate of TERT-mut among nonenteric-type adenocarcinomas further supporting the potential utility of TERT-mut urine-based screening assay for bladder cancer.

Global 5-Hydroxymethylcytosine Levels Are Profoundly Reduced in Multiple Genitourinary Malignancies

Solid tumors are characterized by a plethora of epigenetic changes. In particular, patterns methylation of cytosines at the 5-position (5mC) in the context of CpGs are frequently altered in tumors. Recent evidence suggests that 5mC can get converted to 5-hydroxylmethylcytosine (5hmC) in an enzymatic process involving ten eleven translocation (TET) protein family members, and this process appears to be important in facilitating plasticity of cytosine methylation. Here we evaluated the global levels of 5hmC using a validated immunohistochemical staining method in a large series of clear cell renal cell carcinoma (n = 111), urothelial cell carcinoma (n = 55) and testicular germ cell tumors (n = 84) and matched adjacent benign tissues. Whereas tumor-adjacent benign tissues were mostly characterized by high levels of 5hmC, renal cell carcinoma and urothelial cell carcinoma showed dramatically reduced staining for 5hmC. 5hmC levels were low in both primary tumors and metastases of clear cell renal cell carcinoma and showed no association with disease outcomes. In normal testis, robust 5hmC staining was only observed in stroma and Sertoli cells. Seminoma showed greatly reduced 5hmC immunolabeling, whereas differentiated teratoma, embryonal and yolk sack tumors exhibited high 5hmC levels. The substantial tumor specific loss of 5hmC, particularly in clear cell renal cell carcinoma and urothelial cell carcinoma, suggests that alterations in pathways involved in establishing and maintaining 5hmC levels might be very common in cancer and could potentially be exploited for diagnosis and treatment.

Hemodialysis versus peritoneal dialysis, which is cost-effective?

There is an increasing need for renal replacement therapy due to the growing number of cases with chronic kidney disease leading to end-stage renal disease. Two modalities of dialysis available are hemodialysis (HD) and peritoneal dialysis (PD). In this study, we aimed to compare the financial aspects of HD with PD. A total of 53 patients on HD and 43 patients on PD were included in the study and were assessed for several financial aspects of dialysis. The data collected were analyzed using SPSS-18. A statistically significant difference was noted between the HD and PD groups in the need for diagnostic tests, drugs, hospitalization, etc, with PD being less expensive. We strongly suggest physicians in our area to use PD on a larger number of patients for better financial outcome.

Acute oxalate nephropathy following kidney transplantation: Report of three cases

Calcium oxalate (CaOx) crystal deposition is a common finding immediately after kidney transplantation. However, small depositions of CaOx could be benign while extensive depositions lead to poor graft outcome. Here we report three cases with end-stage renal disease (ESRD), bilateral nephrolithiasis, and unknown diagnosis of primary hyperoxaluria (PH) who underwent a renal transplant and experienced an early-onset graft failure. Although an acute rejection was suspected, renal allograft biopsies and subsequent allograft nephrectomies showed extensive CaOx deposition, which raised a suspicion of PH. Even though increased urinary excretion of CaOx was found in all patients, this diagnosis could be confirmed with further tests including genetic study and metabolic assay. In conclusion, massive CaOx deposition in kidney allograft is an important cause of poor allograft survival and needs special management. Furthermore, our cases suggest patients with ESRD and a history of nephrolithiasis should be screened for elevated urinary oxalate excretion and rule out of PH.

Germ Cell Tumor's Survival Rate in Young Patients

BACKGROUND

Germ cell tumors are neoplasms that originate from multi potential germ cells and can be intra or extra gonadal. According to pathologic classification, they have different subtypes. They account for 3% of pediatric malignancies and most commonly happen in children before the age of 15 years old. Epidemiologic evidence about pediatric germ cell tumors is scant in our region.

OBJECTIVES

The aim of current study was to determine demographic characteristics, recurrence and survival rate of germ cell tumor patients under the age of 21 years.

PATIENTS AND METHODS

During a 10-year period (1996 - 2006), 106 patients under the age of 21 years suffering from germ cell tumor were admitted to our centers. We extracted the data needed for our study from patients' medical records in the hospitals.

RESULTS

Thirty seven boys and 69 girls with a mean age of 8.4 ± 7.8 years were included. Most tumors were diagnosed before the age of one year (37%). The most common pathologic subtype was mature teratoma (44%). Ovary (35%) was the most common primary site. Surgery plus chemotherapy were used to treat 54 patients and BEP was the most common chemotherapy regimen. Metastasis and recurrent tumor were seen in 22% and 8% of cases, respectively. Four-year overall survival was 89%.

CONCLUSIONS

Our study showed that demographic characteristics of GCT patients in our population are similar to patients of other geographic regions in the world. Primary tumor site, histologic subtype and metastasis were significant prognostic factors for survival.

Evaluation of Endoglin as an Angiogenesis Marker in Glioblastoma

BACKGROUND AND OBJECTIVES

Angiogenesis is essential for growth and metastasis of solid malignancies. Tumor vessel count and expression of vascular endothelial growth factor (VEGF), a potent angiogenic factor, have been associated with prognosis. This study was designed to assess vessels density by using CD31 and CD105 (Endoglin) and their correlation with expression of VEGF and proliferative index (Ki67) in Glioblastoma multiforme (GBM).

METHODS

We examined these parameters in GBM specimens from 50 adult patients; referred to Al-Zahra hospital Pathology Lab between 2001 to 2006.These patients did not receive pre-operative therapy. Paraffin-embedded tumor specimens were immunohistochemically stained for CD31, CD105 (Endoglin), VEGF and Ki67 (proliferation index) monoclonal antibodies. Microvessel density (MVD) was evaluated by immunostaining for CD31 and CD105.Then the results were compared between the two and also with VEGF receptors and Ki67 index.

RESULTS

CD105-MVD was significantly higher in Glioblastoma compared with peritumoral normal (14.28 vs. 6.68: P=0.012). We did not find such difference for CD31. The mean of CD105-MVD was significantly higher than CD31-MVD in Glioblastoma tissue (P<0.001) although there was a significant positive relationship between them (Pearson's r=0.630 P<0.001).The VEGF scoring for tumoral tissue was 12 % (score:1), 46% (score:2) and 42% (score:3).For peritumoral normal tissue were 92% (score:1) and 8% (score:2) . So they reach to statistical significance (Chi Square, P = 0001). Both MVD of CD105 and CD31 have significant relationship with VEGF (P<0.001).

CONCLUSION

We suggest that Endoglin can be used as a specific and sensitive marker for evaluation of angiogenesis in Glioblastoma.

Inflammatory myofibroblastic tumor: report of a rare case in kidney

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm mostly seen in the lungs, but also in extrapulmonary sites. The most common genitourinary site of IMT is the bladder, but it may rarely be seen in the kidneys. We report a case of a 15-year-old girl presented with flank pain and hematuria, in which computed tomography scan revealed a mass in the left kidney. The patient underwent left nephrectomy for a diagnosis of Wilms tumor. Further assessment of the tissue demonstrated a pathologic diagnosis of IMT. Despite improvements in imaging technology, the preoperative diagnosis of IMT remains difficult and surgery is the only way for the diagnosis and treatment. Considering the role of the pathologic examination in making the definite diagnosis of IMT, we should be aware of this entity and it must be considered in the differential diagnoses.

Limited knowledge of chronic kidney disease and its main risk factors among Iranian community: an appeal for promoting national public health education programs

BACKGROUND

The aim of this survey was to explore the baseline knowledge of the Iranian community about Chronic Kidney Disease (CKD) definition and its two main risk factors, i.e. diabetes and hypertension. This study also introduced a model of public education program with the purpose of reducing the incidence of CKD in high-risk groups and thereby decreasing the economic burden of CKD in Iran.

METHODS

This cross-sectional study was conducted on world kidney day 2013 in Isfahan, Iran. Self-administered anonymous questionnaires evaluating the knowledge of CKD and its risk factors were distributed among subjects who participated in a kidney disease awareness campaign. Chi-square test and logistic regression analysis were used to examine the differences in the level of knowledge across different socio-demographic groups.

RESULTS

The questionnaires were completed by 748 respondents. The majority of these respondents believed that "pain in the flanks" and "difficulty in urination" was the early symptoms of CKD. Roughly, 10.4% knew that CKD could be asymptomatic in the initial stages. Only 12.7% knew diabetes and 14.4% knew hypertension was a CKD risk factor. The respondents who had a CKD risk factor (i.e. diabetes and/or hypertension) were significantly more likely than respondents without CKD risk factor to select "unmanaged diabetes" [Odds Ratio (OR)= 2.2, Confidence Interval (CI) (95%): 1.4-3.6] and "unmanaged hypertension" [OR= 1.9, CI(95%): 1.2-3.0] as "very likely to result in CKD". No more than 34.6% of all respondents with diabetes and/or hypertension reported that their physician has ever spoken with them about their increased risk for developing CKD.

CONCLUSION

The knowledge of Iranian population about CKD and its risk factors is low. Future public health education programs should put efforts in educating Iranian community about the asymptomatic nature of CKD in its initial stages and highlighting the importance of regular renal care counseling. The high-risk individuals should receive tailored education and be encouraged to adopt lifestyle modifications to prevent or slow the progression of CKD.

Preventive Effect of Three Pomegranate (Punica granatum L.) Seeds Fractions on Cerulein-Induced Acute Pancreatitis in Mice

BACKGROUND

Acute pancreatitis (AP) refers to afflicted inflammation of pancreas with unfavorable adverse effects and developed multiple organ failures. Unfortunately, there is not a certain therapeutic method for this disease. Oxidative stress has a serious role in the pathogenesis of AP. Thus, decreasing of oxidative stress may prevent induction and progression of AP. Punica granatum L. has been extensively used in traditional medicine and possesses various active biological elements. Due to antioxidant and anti-inflammatory properties of pomegranate, it could be considered as a good candidate alternative medicine with beneficial effects on AP. In this study, we decided to study the protective effect of three fractions of pomegranate seeds on cerulein-induced AP.

METHODS

AP was induced in male Syrian mice by five intraperitoneal (i.p.) injection of cerulein (50 μg/kg) with 1 h intervals. Treatments with pomegranate freeze-dried powder (PFDP) and hydroalcoholic pomegranate seeds extract (PSE) at doses of 125, 250, 500 mg/kg (i.p.) were started 30 min before pancreatitis induction. Pomegranate seed oil fraction (PSOF) was orally administered (50, 100, 200 μL/kg) and continued for 10 days. Pancreatic tissue was evaluated for histopathological parameters and pancreatic myeloperoxidase (MPO) activity as well as lipase and amylase levels were measured in plasma.

RESULTS

The higher doses of three fractions (250 and 500 mg/kg for PFDP and PSE and doses of 100, 200 μL/kg for PSOF) significantly reduced amylase and lipase activity in serum (at least P < 0.01), pancreatic MPO activity (P < 0.001), edema, leukocyte infiltration and vacuolization in comparison to the control group (P < 0.05).

CONCLUSIONS

These results propose that pomegranate seeds fractions can prevent and/or treat the AP.

Carney complex presenting with a unilateral adrenocortical nodule: a case report

INTRODUCTION

Carney complex is an autosomal dominant syndrome with multiple neoplasms in different sites, including myxomas, endocrine tumors and lentigines lesions. To the best of our knowledge, this is the first report of Carney complex presenting with a unilateral adrenal adenoma associated with a pituitary incidentaloma.

CASE PRESENTATION

A 27-year-old Iranian woman was referred to our endocrinology clinic with amenorrhea and hirsutism, further confirming a diagnosis of adrenocorticotropic hormone-independent Cushing's syndrome. The cause was believed to be a right adrenocortical adenoma based on a computed tomography scan. Our patient underwent a right laparoscopic adrenalectomy and pathological examination revealed pigmented micronodular adrenal hyperplasia. Pituitary magnetic resonance imaging also documented a microadenoma that was considered to be an incidentaloma based on normal pituitary function tests. Recurrence of hypercortisolism led to a left laparoscopic adrenalectomy, providing further evidence for the diagnosis of primary pigmented nodular adrenocortical disease. Carney complex was established in light of her history of cardiac myxomas.

CONCLUSION

We present what we believe to be the first case of Carney complex presenting with a unilateral adrenocortical adenoma in association with a pituitary incidentaloma. Although primary pigmented nodular adrenocortical disease is rare as a component of Carney complex, it should be considered in the differential diagnosis of Cushing's syndrome. Rarely, adrenal and pituitary imaging can be misleading.

Granulomatous Interstitial Nephritis as a Manifestation of Crohn Disease

Granulomatous interstitial nephritis is a rare extraintestinal manifestation of Crohn disease that has been described previously in 4 patients. We report a 23-year-old man with a history of Crohn disease since age 6 years who was admitted to the hospital for weight loss, fever, and bloody diarrhea in the midst of a recent flare up during the past 2 months. Investigations revealed anemia, high erythrocyte sedimentation rate, high C-reactive protein level, and an elevated serum creatinine level. Histopathologic examination of tissue specimens obtained at renal biopsy demonstrated granulomatous interstitial nephritis. Crohn disease needs to be in the differential diagnosis of granulomatous interstitial nephritis and can be a manifestation of drug allergy or the Crohn disease itself.

Postoperative ileus in colorectal surgery: is there any difference between laparoscopic and open surgery?

Background: Postoperative ileus is a major complication of patients undergoing abdominal surgery. The purpose of this study was to determine the effects of operative time and the method of surgery on postoperative ileus.

Methods: After institutional review board approval, 121 patients were studied in two groups. Group 1 consisted of 86 patients with colorectal cancers and Group 2 included 35 patients with diverticulitis. Various surgical procedures were performed in both groups. In all patients, the nasogastric (NG) tube was removed after termination of surgery. Clear liquids were offered commencing on the first postoperative day, followed by a regular diet as tolerated. GI-1 was the postoperative time to toleration of clear liquids, whereas GI-2 was the postoperative time to first bowel movement or flatus and toleration of a regular diet. Statistical analysis was performed using a linear regression model by disease with the first bowel movement or flatus as the dependent variable and operative time and category as explanatory variables.

Results: Vomiting after oral feeding occurred in 18 (20.9%) patients with cancer and in 7 (20.0%) patients with diverticular disease. An NG tube was reinserted in 13 (15.1%) patients in the cancer group and in 3 (8.6%) patients in the diverticular disease group. In patients with cancer, the duration of operation was associated with GI-2 (P = 0.011), whereas in patients with diverticulitis, the duration of operation was associated with GI-1 (P = 0.001) and GI-2 (P = 0.044). In the diverticulitis group, a significant relationship was found between GI-2 and operative category (P = 0.03).

Conclusion: Longer operations led to more prolonged postoperative ileus after both laparoscopy and laparotomy, regardless of malignant or benign pathology. In anticipation of and/or following longer operations, surgeons should consider measures to shorten postoperative ileus.