Do Not Learn a Technique, Learn the Biology Underlying the Disease: Techniques Evolve, Biology Prevails

The evidence available suggests that open and robot-assisted radical cystectomy lead to similar outcomes in bladder cancer. True advances will come from a better understanding of the biology of the disease, and a comprehensive, multimodal approach that aims to improve patient survival and quality of life is more critical than the surgical technique.

Associations of Luminal and Basal Subtyping of Prostate Cancer With Prognosis and Response to Androgen Deprivation Therapy

Importance

There is a clear need for a molecular subtyping approach in prostate cancer to identify clinically distinct subgroups that benefit from specific therapies.

Objectives

To identify prostate cancer subtypes based on luminal and basal lineage and to determine associations with clinical outcomes and response to treatment.

Design, Setting, and Participants

The PAM50 classifier was used to subtype 1567 retrospectively collected (median follow-up, 10 years) and 2215 prospectively collected prostate cancer samples into luminal- and basal-like subtypes.

Main Outcomes and Measures

Metastasis, biochemical recurrence, overall survival, prostate cancer–specific survival, associations with biological pathways, and clinicopathologic variables were the main outcomes.

Results

Among the 3782 samples, the PAM50 classifier consistently segregated prostate cancer into 3 subtypes in both the retrospective and prospective cohorts: luminal A (retrospective, 538 [34.3%]; prospective, 737 [33.3%]), luminal B (retrospective, 447 [28.5%]; prospective, 723 [32.6%]), and basal (retrospective, 582 [37.1%]; prospective, 755 [34.1%]). Known luminal lineage markers, such as NKX3.1 and KRT18, were enriched in luminal-like cancers, and the basal lineage CD49f signature was enriched in basal-like cancers, demonstrating the connection between these subtypes and established prostate cancer biology. In the retrospective cohort, luminal B prostate cancers exhibited the poorest clinical prognoses on both univariable and multivariable analyses accounting for standard clinicopathologic prognostic factors (10-year biochemical recurrence-free survival [bRFS], 29%; distant metastasis-free survival [DMFS], 53%; prostate cancer-specific survival [PCSS], 78%; overall survival [OS], 69%), followed by basal prostate cancers (10-year bRFS, 39%; DMFS, 73%; PCSS, 86%; OS, 80%) and luminal A prostate cancers (10-year bRFS, 41%; DMFS, 73%; PCSS, 89%; OS, 82%). Although both luminal-like subtypes were associated with increased androgen receptor expression and signaling, only luminal B prostate cancers were significantly associated with postoperative response to androgen deprivation therapy (ADT) in a subset analysis in our retrospective cohorts (n = 315) matching patients based on clinicopathologic variables (luminal B 10-year metastasis: treated, 33% vs untreated, 55%; nonluminal B 10-year metastasis: treated, 37% vs untreated, 21%; P = .006 for interaction).

Conclusions and Relevance

Luminal- and basal-like prostate cancers demonstrate divergent clinical behavior, and patients with luminal B tumors respond better to postoperative ADT than do patients with non–luminal B tumors. These findings contribute novel insight into prostate cancer biology, providing a potential clinical tool to personalize ADT treatment for prostate cancer by predicting which men may benefit from ADT after surgery.

Linking animal diseases and social instability

Social instability occurs as a consequence of war, civil strife or natural disasters such as earthquakes, floods and droughts. Animal diseases, including zoonoses, can be both a precursor to social instability and a result of social instability. Coping mechanisms, such as sound policies, trust in government, and robust infrastructure break down at times of civil instability. Such breakdowns often lead to a decline in both public health and the food and agricultural livestock base, thus creating a vicious cycle that involves inadequate nutrition, threatened livelihoods, and fewer opportunities for safe trade. This article is principally a discussion of a theoretical nature on the dynamics between animal diseases and social instability. Based on their experience of working for the Food and Agriculture Organization of the United Nations (FAO), the authors provide numerous examples of the connection between the two, mostly in countries that have fragile environments and are experiencing protracted crises. Disease has a direct and immediate effect on a community, but, in addition, if the community is not able to recover from the impact of a disease on their health and livelihoods, the consequences of an outbreak can persist even after the disease is no longer present. Stability, therefore, depends on a variety of factors, including the ability of a community to overcome the effects of a disease outbreak or other destabilising event. The FAO approach to helping families and communities to cope with the destabilizing effects of animal diseases is to build resilience, particularly amongst the most vulnerable households. This requires individuals and governments to gain a better understanding of what drives disease at the interface between human and animal health. In addition, it requires governments to invest in social protection programmes, establish a long-term risk reduction strategy that decreases vulnerability, and improve the sustainability of safe agricultural and marketing practices.

Real-Time FEM-Based Registration of 3-D to 2.5-D Transrectal Ultrasound Images

We present a novel technique for real-time deformable registration of 3-D to 2.5-D transrectal ultrasound (TRUS) images for image-guided, robot-assisted laparoscopic radical prostatectomy (RALRP). For RALRP, a pre-operatively acquired 3-D TRUS image is registered to thin-volumes comprised of consecutive intra-operative 2-D TRUS images, where the optimal transformation is found using a gradient descent method based on analytical first and second order derivatives. Our method relies on an efficient algorithm for real-time extraction of arbitrary slices from a 3-D image deformed given a discrete mesh representation. We also propose and demonstrate an evaluation method that generates simulated models and images for RALRP by modeling tissue deformation through patient-specific finite-element models (FEM). We evaluated our method on in-vivo data from 11 patients collected during RALRP and focal therapy interventions. In the presence of an average landmark deformation of 3.89 and 4.62 mm, we achieved accuracies of 1.15 and 0.72 mm, respectively, on the synthetic and in-vivo data sets, with an average registration computation time of 264 ms, using MATLAB on a conventional PC. The results show that the real-time tracking of the prostate motion and deformation is feasible, enabling a real-time augmented reality-based guidance system for RALRP.].

Abstract 3689: Identification of candidate therapeutic targets in BCG unresponsive bladder cancer- inflammatory subtypes of BCG unresponsive bladder cancer

Intravesical immunotherapy with Bacillus Calmette-Guérin (BCG) is used for the first line treatment of high risk non-muscle invasive bladder cancer. Despite high initial response rates (70%), recurrence is a major problem and many patients develop BCG unresponsive disease, for which the primary treatment option is definitive surgery (cystectomy). In order to define the biological properties of BCG unresponsive disease, we performed whole transcriptome RNAseq on 29 matched tumors obtained from patients before and after the development of BCG resistance. Unsupervised cluster analysis revealed the presence of two clusters - BCG cluster 1, containing 8 pre- and 19-post BCG treatment tumors, and BCG cluster 2, containing 21 pre- and 10- post BCG tumors (Fisher's exact test, p<0.01). To characterize the biological properties of the two clusters, we extracted the significantly differentially expressed genes and analyzed them by Ingenuity Pathway Analysis (Sigma). Interestingly, multiple immune response pathways (T cell receptor signaling, IL8 signaling, IL12-mediated signaling, IFN-gamma pathways, immune cell trafficking, etc) were significantly enriched (p<0.01) in the BCG cluster 1 that was enriched for BCG unresponsive tumors. To determine the potential relationship between BCG clusters 1 and 2 and the previously defined basal and luminal molecular subtypes, we generated a batch-corrected bladder cancer meta-dataset combining two publically available datasets (GSE48075 and GSE32894) consisting of mixtures of non-muscle invasive and muscle-invasive tumors. We performed consensus cluster analysis using the meta-data and identified 3 distinct molecular clusters. The results indicated that the gene expression signature that characterized BCG cluster 1 was also present in tumors assigned to the basal/SCC-like and p53-like/infiltrated tumors defined previously. Together, the results indicate that the tumors in BCG cluster 1 may be enriched with T cells and therefore may have increased sensitivity to immune checkpoint blockade. However, it is likely that alternative therapeutic targets will need to be identified for BCG unresponsive tumors that display the ‘immune desert' phenotype characteristic of BCG cluster 2.

Citation Format: Woonyoung Choi, Roger Li, Chinedu Mmeje, I-ling Lee, Shanna Pretzsch, Jolanta Bondaruk, Max Kates, Trinity Bivalacqua, Bogdan Czerniak, Ashish M. Kamat, Colin Dinney, Peter Black, David J. McConkey. Identification of candidate therapeutic targets in BCG unresponsive bladder cancer- inflammatory subtypes of BCG unresponsive bladder cancer [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 3689.

Modelling cost-effectiveness of a biomarker-based approach to neoadjuvant chemotherapy for muscle-invasive bladder cancer

OBJECTIVES

To model the cost-effectiveness of a biomarker-based approach to select patients for neoadjuvant chemotherapy (NAC) before radical cystectomy (RC) in muscle-invasive bladder cancer (MIBC).

PATIENTS AND METHODS

We obtained data from the most recent clinical studies on patients with locally advanced MIBC treated by RC, including stage distributions, overall survival (OS) estimates, associated costs, and utilisation/response to NAC. Additionally, we estimated the putative efficacy of three biomarkers to select patients for NAC: DNA-repair gene panel [ataxia telangiectasia mutated (ATM), retinoblastoma 1 (RB1), and Fanconi anaemia complementation group C (FANCC)], excision repair cross-complementation group 2 (ERCC2), and ribonucleic acid (RNA) subtypes. A decision analysis model was developed to evaluate the cost-effectiveness of biomarker-based approaches to select patients with MIBC for NAC. Comparison of cost-effectiveness included RC alone, unselected NAC plus RC, and NAC based on the three aforementioned biomarkers.

RESULTS

The DNA-repair gene panel-based approach to NAC was the most cost-effective strategy (mean OS of 3.14 years, $31 482/life year). Under this approach, 38% would undergo NAC, about twice the number of patients who are currently receiving NAC for MIBC. Such an approach would improve mean OS by 5.2, 1.6, and 4.4 months compared to RC alone, a hypothetical scenario where all patients received NAC, and compared to current estimates of NAC utilisation, respectively.

CONCLUSIONS

A biomarker-based strategy to identify patients with MIBC who should undergo NAC was more cost-effective than unselected use of NAC or RC alone. As further data becomes available, such a model may serve as a basis for incorporating biomarkers into clinical decision making.

Examining the Experience of Undergoing Group Cognitive Behavioral Therapy for Obsessive Compulsive Disorder: An Interpretative Phenomenological Analysis

This study used interpretative phenomenological analysis (IPA) to explore the lived experiences of five individuals diagnosed with obsessive-compulsive disorder (OCD) who underwent a group cognitive behavioral therapy (CBT) intervention program to address their symptoms. Two master themes were identified: experiences and processes of change and reflections on change. For all participants, the degree of group cohesion or connectedness they established with group members emerged as highly important in facilitating therapeutic progress. A number of technical elements of cognitive behavioral therapy (CBT) were also notable therapeutic factors, including questioning/rationalizing maladaptive interpretations about intrusions. However, the commonality of non-specific group processes as key features for subsequent therapeutic change prompts the need for further research in dynamics within CBT group interventions for OCD.

A Multicentered, Propensity Matched Analysis Comparing Laparoscopic and Open Surgery for pT3a Renal Cell Carcinoma

INTRODUCTION

To compare outcomes following laparoscopic renal surgery (LRS) and open renal surgery (ORS) in the treatment of pathologic T3a (pT3a) renal cell carcinoma (RCC) using a propensity matched analysis.

MATERIALS AND METHODS

The Canadian Kidney Cancer Information System is a prospectively maintained database for patients diagnosed with RCC from 15 Canadian institutions. Patients treated for nonmetastatic pT3a RCC between 2008 and 2015 were included. Propensity score matching for age, gender, tumor size, grade, histology, and surgical approach was performed to compare laparoscopic radical and partial nephrectomy (LRN or LPN) with open radical or partial nephrectomy (ORN or OPN). The primary endpoint was recurrence-free survival (RFS).

RESULTS

Two hundred twenty-six (45%) patients underwent LRS (88% LRN and 12% LPN), and 275 (55%) underwent ORS (75% ORN and 25% OPN). After a median follow-up of 21.1 months, 155 (72 LRS and 83 ORS) patients experienced recurrence. The 3-year RFS was 63% and 50% for the LRS and ORS groups, respectively, p = 0.36. On subgroup analysis, there was no significant difference in RFS among patients who underwent radical nephrectomy (3-year RFS 61% in LRN compared with 46% in ORN group, p = 0.32) or partial nephrectomy (77% in LPN compared with 79% in OPN group, p = 0.82).

CONCLUSIONS

This study is the largest matched analysis comparing LRS and ORS for pT3a RCC. In matched patients, LRS showed no difference in oncologic outcomes compared with ORS and should be considered when technically feasible.

Could Changes in the Agricultural Landscape of Northeastern China Have Influenced the Long-Distance Transmission of Highly Pathogenic Avian Influenza H5Nx Viruses?

In the last few years, several reassortant subtypes of highly pathogenic avian influenza viruses (HPAI H5Nx) have emerged in East Asia. These new viruses, mostly of subtype H5N1, H5N2, H5N6, and H5N8 belonging to clade 2.3.4.4, have been found in several Asian countries and have caused outbreaks in poultry in China, South Korea, and Vietnam. HPAI H5Nx also have spread over considerable distances with the introduction of viruses belonging to the same 2.3.4.4 clade in the U.S. (2014–2015) and in Europe (2014–2015 and 2016–2017). In this paper, we examine the emergence and spread of these new viruses in Asia in relation to published datasets on HPAI H5Nx distribution, movement of migratory waterfowl, avian influenza risk models, and land-use change analyses. More specifically, we show that between 2000 and 2015, vast areas of northeast China have been newly planted with rice paddy fields (3.21 million ha in Heilongjiang, Jilin, and Liaoning) in areas connected to other parts of Asia through migratory pathways of wild waterfowl. We hypothesize that recent land use changes in northeast China have affected the spatial distribution of wild waterfowl, their stopover areas, and the wild-domestic interface, thereby altering transmission dynamics of avian influenza viruses across flyways. Detailed studies of the habitat use by wild migratory birds, of the extent of the wild–domestic interface, and of the circulation of avian influenza viruses in those new planted areas may help to shed more light on this hypothesis, and on the possible impact of those changes on the long-distance patterns of avian influenza transmission.

A prospective randomized pilot study evaluating an ERAS protocol versus a standard protocol for patients treated with radical cystectomy and urinary diversion for bladder cancer

PURPOSE

There is a lack of evidence demonstrating the benefits of using enhanced recovery after surgery protocols (ERAS). Here, we propose to use a randomized clinical pilot study to demonstrate the benefits and feasibility of implementing ERAS versus standard protocols (SP) in patients undergoing radical cystectomy (RC) and urinary diversion.

METHODS

27 consecutive patients undergoing RC were included in the study. 12 patients were prospectively randomized to follow an ERAS protocol and 15 patients followed an SP. Duration of hospital stay, time to first flatulence and bowel movement, complications and 30 day readmission rates, as well as subjective outcomes such as postoperative pain, nausea, bowel symptoms, quality of life (QoL), and patient experience and satisfaction were evaluated.

RESULTS

Patients following ERAS had a significantly shorter: hospital stay, time to flatulence, and time to bowel movement than patients following SP. No major complications were reported. Only one patient in the ERAS group was readmitted for bowel obstruction, and no patients were readmitted in the SP group. Patients under ERAS reported lower postoperative pain scores. Mean Functional Assessment of Cancer Therapy Bladder Cancer score decreased and mean Expanded Prostate Cancer Index Composite, bowel symptom score increased in the SP group at the time of discharge compared to prior to surgery.

CONCLUSIONS

This study shows the feasibility of a randomized pilot study assessing ERAS compared to SP post RC. ERAS protocol provided evidence of significant benefits over SP with similar complication rates. This study suggests the need for a clinical trial of assessing ERAS protocols after RC.

A Novel Mycoplasma sp. Associated with Phallus Disease in Goose Breeders: Pathological and Bacteriological Findings

In April 2014, poor fertility in a major commercial goose breeder operation in California triggered the submission of six live affected Toulouse ganders ( Anser anser ) to the California Animal Health and Food Safety Laboratory, Turlock branch (University of California-Davis). Toulouse were principally affected among all breeds, and their egg fertility dropped from 65.7% to less than 33.9% in the first 40 days of the 2014 breeding season. The flock consisted of 410 adult birds, 90 males and 320 females, between 2 and 5 yr of age. Inspection of the flock revealed that 44.4% of the Toulouse ganders had severe phallic deformities that prevented them from mating. At postmortem examination, severe yellowish fibrocaseous exudate disrupted the architecture of the phallus and occasionally produced fistulating tracts through the wall of the organ. Microscopically, multifocal lymphoid nodules were noted in the mucosa and submucosa of the phallus and were associated with extensive granulomatous reaction, intralesional bacteria, and spermatozoa. Mycoplasma spp. were isolated from the phallus of affected and nonaffected birds, and PCR protocols targeting the 16S-23S ribosomal RNA intergenic spacer regions and the RNA polymerase beta subunit gene were performed to identify the isolates. Three distinct species were identified on sequencing and analysis using the National Center for Biotechnology Information basic local alignment search tool: Mycoplasma cloacale , Mycoplasma anseris , and an unknown novel Mycoplasma sp. Additionally, Pasteurella multocida , in combination with other bacteria, was also isolated from the phallic lesions and identified as serotype 3 with a DNA profile of 1511 (National Veterinary Service Laboratory). This is the first report of these Mycoplasma spp. and other bacteria associated with reproductive disease in ganders in the United States.

Comprehensive Molecular Characterization of Urachal Adenocarcinoma Reveals Commonalities With Colorectal Cancer, Including a Hypermutable Phenotype

Purpose

Urachal adenocarcinoma is a rare type of primary bladder adenocarcinoma that comprises less than 1% of all bladder cancers. The low incidence of urachal adenocarcinomas does not allow for an evidence-based approach to therapy. Transcriptome profiling of urachal adenocarcinomas has not been previously reported. We hypothesized that an in-depth molecular understanding of urachal adenocarcinoma would uncover rational therapeutic strategies.

Patients and Methods

We performed targeted exon sequencing and global transcriptome profiling of 12 urachal tumors to generate a comprehensive molecular portrait of urachal adenocarcinoma. A single patient with an MSH6 mutation was treated with the anti-programmed death-ligand 1 antibody, atezolizumab.

Results

Urachal adenocarcinoma closely resembles colorectal cancer at the level of RNA expression, which extends previous observations that urachal tumors harbor genomic alterations that are found in colorectal adenocarcinoma. A subset of tumors was found to have alterations in genes that are associated with microsatellite instability (MSH2 and MSH6) and hypermutation (POLE). A patient with an MSH6 mutation was treated with immune checkpoint blockade, which resulted in stable disease.

Conclusion

Because clinical trials are next to impossible for patients with rare tumors, precision oncology may be an important adjunct for treatment decisions. Our findings demonstrate that urachal adenocarcinomas molecularly resemble colorectal adenocarcinomas at the level of RNA expression, are the first report, to our knowledge, of MSH2 and MSH6 mutations in this disease, and support the consideration of immune checkpoint blockade as a rational therapeutic treatment of this exceedingly rare tumor.

Abstract 5397: Characterizing the genomic landscape of bladder cancer with circulating tumor DNA

Background: Targeted agents are emerging as promising treatment options for patients with metastatic bladder cancer (BCa).  However, since the genomic landscape of BCa is highly heterogeneous, future clinical trial success will likely depend upon tumor molecular stratification and therefore require a practical method for somatic genome analysis. Circulating cell-free tumor DNA (ctDNA) collected from peripheral blood has been established in several major solid malignancies as a minimally-invasive tool to profile the tumor genome but is under-explored in BCa.

Goal: Our aim was to identify the spectrum of clinically-informative genomic alterations detectable in plasma cell-free DNA (cfDNA) collected from patients with BCa.

Patient cohort and methodology: We recruited 45 patients with BCa, 14 with localized disease and 31 with metastatic disease, and collected whole blood samples for isolation of cfDNA. Isolation of plasma cfDNA was performed using the QIAAmp Circulating Nucleic Acid Kit, while germline control DNA was extracted from buffy coat using the DNEasy Kit (Qiagen). A custom targeted next-generation sequencing (NGS) strategy was employed to detect BCa- specific somatic alterations in ctDNA; samples underwent deep (>500X) targeted DNA sequencing using the NimbleGen SeqCap EZ Choice system and Illumina technology. Our custom panel included key tumor suppressors (e.g. TP53, RB1, CDKN2A), cell cycle drivers (e.g. CCND1, CCNE1), DNA repair genes (e.g. ATM, BAP1, ERCC2), PI3K pathway genes (e.g. PIK3CA, PTEN, AKT1), and other oncogenes (e.g. RAS/RAF, EGFR, ERBB2, PPARG, FGFR3).

Results: The majority of patients with metastatic BCa (18/31 patients, 24/43 samples) had robust evidence of somatic alterations and therefore ctDNA. Our findings were consistent with the known landscape of BCa, including mutations in TP53 and ARID1A (and other chromatin modifiers), hotspot activating mutations in PIK3CA, as well as typical copy number changes such as focal amplifications of ERBB2, KRAS, and CCNE1. In addition, we identified complex gene rearrangements including in one case an activating FGFR3 gene fusion. Some samples had evidence of very high mutation rates, indicative of somatic ‘hypermutation’. Interestingly, in contrast to the metastatic setting, 85% of patients with localized BCa had no evidence of ctDNA, despite elevated cfDNA yields in some patients.

Conclusion: The majority of metastatic BCa patients have high levels of ctDNA suitable for standard targeted sequencing approaches, while patients with localized muscle-invasive tumors appear not to harbor ctDNA at fractions greater than 1-2%. The robust detection of so-called ‘actionable’ copy number alterations, mutations and rearrangements in ctDNA provides an unparalleled opportunity for practical molecular stratification of patients in clinical trials of novel targeted agents.

Citation Format: Gillian R. Vandekerkhove, Tilman Todenhöfer, Matti Annala, Werner J. Struss, Kevin Beja, Amanda Wong, Scott North, Bernie Eigl, Peter Black, Alexander W. Wyatt. Characterizing the genomic landscape of bladder cancer with circulating tumor DNA [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5397. doi:10.1158/1538-7445.AM2017-5397

Quality indicators in the management of bladder cancer: A modified Delphi study

BACKGROUND

Survival in patients with bladder cancer has only moderately improved over the past 2 decades. A potential reason for this is nonadherence to clinical guidelines and best practice, leading to wide variations in care. Common quality indicators (QIs) are needed to quantify adherence to best practice and provide data for benchmarking and quality improvement.

OBJECTIVE

To produce an evidence- and consensus-based list of QIs for the management of bladder cancer.

METHODS

A modified Delphi method was used to develop the indicator list. Candidate indicators were extracted from the literature and rated by a 27-member Canadian expert panel in several rounds until consensus was reached on the final list of indicators. In rounds with numeric ratings, a frequency analysis was performed.

RESULTS

A total of 86 indicators were rated, 52 extracted from the literature and 34 suggested by the panel. After iterative rounds of ratings and discussion, a final list of 60 QIs spanning several disciplines and phases of the cancer care continuum was developed.

CONCLUSIONS

This is the first study to comprehensively produce common QIs representing structure, process, and outcome measures in bladder cancer management. Though developed in Canada, these indicators can be used in other countries with slight modifications to track performance and improve care.