The current status of tailor-made medicine with molecular biomarkers for patients with clear cell renal cell carcinoma

Appropriate use of multiple reliable molecular biomarkers in the right context will play a role in tailormade medicine of clear cell renal cell carcinoma (RCC) patients in the future. A total of 11,056 patients from 53 studies were included in this review. The article numbers of the each evidence levels, using the grading system defined by the Oxford Centre for Evidence-based Medicine, in 1b, 2a, 2b, and 3b were 5 (9%), 18 (34%), 29 (55%), and 1 (2%), respectively. The main goal of using biomarkers is to refine predictions of tumor progression, pharmacotherapy responsiveness, and cancer-specific and/or overall survival. Currently, carbonic anhydrase (CA9) and vascular endothelial growth factor (VEGF) in peripheral blood and p53 in tumor tissues are measured to predict metastasis, while VEGF-related proteins in peripheral blood are used to assess pharmacotherapy responsiveness with sunitinib. Furthermore, interleukin 8, osteopontin, hepatocyte growth factor, and tissue inhibitors of metalloproteinases-1 in peripheral blood enable assessment of responsiveness to pazopanib treatment. Other reliable molecular biomarkers include von Hippel–Lindau gene alteration, hypoxia-inducible factor-1a, CA9, and survivin in tumor tissues and VEGF in peripheral blood for predicting cancer-specific survival. In the future, studies should undergo external validation for developing tailored management of clear cell RCC with molecular biomarkers, since individual institutional studies lack the generalization and consistency required to maintain accuracy among different patient series.

Intraoperative ultrasonography with a surgeon-manipulated microtransducer during robotic radical prostatectomy

Intraoperative transrectal ultrasonography during laparoscopic radical prostatectomy has been reported to lead to a reduction in surgical margin rates. However, the use of a surgeon-controlled ultrasound probe that allows for precise manipulation and direct interpretation of the image by a console surgeon has yet to be studied. The aim of the present study was to show initial feasibility using the microtransducer with 9-mm scan length controlled by the console surgeon during robot-assisted radical prostatectomy in 10 patients. The transducer is designed as a drop-in probe with a flexible cord for insertion through a laparoscopic port, and is controlled by a robotic arm with the ultrasonographic image shown as a console Tile-pro display. Intraoperative localization of the biopsy-proven cancerous hypoechoic lesion was feasible in four out of four cases. The microtransducer facilitated identification of the bladder neck as well as the appropriate level of neurovascular bundle release. Negative surgical margin was achieved in all 10 cases (100%), even though five of 10 patients (50%) had extraprostatic (pT3) disease. Recovery of erectile function and continence was encouraging. In conclusion, intraoperative ultrasound navigation using a drop-type microtransducer is a novel technique that could enhance the incremental value of the standard information.

Increased active PTH(1-84) fraction as a predictor of poor mortality in male hemodialysis patients

We reported previously that serum parathyroid hormone [PTH(1-84)]/intact PTH[PTH(1-84) + PTH(7-84)] ratio provides the better marker for parathyroid function and bone turnover state than serum PTH level itself. The present study demonstrated that higher PTH(1-84)/intact PTH ratio, but not serum PTH(1-84) and intact PTH, predicted higher all-cause mortality in 177 male hemodialysis patients.

INTRODUCTION

We reported that PTH(1-84)/intact PTH ratio provides a clinically relevant marker for parathyroid function and the resultant bone turnover state. The purpose of our study was to investigate the association of PTH(1-84)/intact PTH ratio with all-cause mortality (ACM) in male hemodialysis patients.

METHODS

The study was performed for 70 months. Serum PTH in 177 male hemodialysis patients was measured with PTH(1-84)-specific whole PTH assay and intact PTH assay which cross-reacts with N-truncated PTH including PTH(7-84).

RESULTS

The patients (n = 177) were divided into higher and lower halves based on serum levels of PTH(1-84)/intact PTH ratio (cutoff value, 0.484), intact PTH (143.8 pg/mL), and PTH(1-84) (64.1 pg/mL). In Kaplan-Meier analysis, the higher group in whole PTH/intact PTH ratio had significantly higher ACM than the lower group (P = 0.020 by log-rank test), in contrast with the insignificant difference between the higher and lower groups in intact PTH and PTH(1-84). Multivariate Cox regression hazard analysis identified higher log [PTH(1-84)/intact PTH ratio], but not log intact PTH or log PTH(1-84) as a significant independent predictor [hazard ratio 14.428 (95% CI 2.486-83.728)] for ACM after adjustment for various factors including age, hemodialysis duration, presence/absence of diabetes mellitus, BMI, log C-reactive protein, serum albumin, calcium, and phosphate. The association existed between log [PTH(1-84)/intact PTH ratio] and ACM in those without vitamin D administration (n = 95).

CONCLUSION

Higher PTH(1-84)/intact PTH ratio, which provides a relevant marker for parathyroid function, may be a significant predictor of ACM in male hemodialysis patients.

Denonvilliers' space expansion by transperineal injection of hydrogel: implications for focal therapy of prostate cancer

We developed and assessed a technique of: (i) expanding Denonvilliers' space by hydrogel (polyethylene glycol) during focal cryoabation; and (ii) temperature mapping to ensure protection of the rectal wall. In a fresh cadaver, 20 cc of hydrogel was injected transperineally into Denonvilliers' space under transrectal ultrasound guidance. Successful expansion of Denonvilliers' space was achieved with a range of 9-11 mm thickness covering the entire posterior prostate surface. Two freeze-thaw cycles were used to expand the iceball reaching the rectal wall as an end-point. Intraoperative transrectal ultrasound monitoring and temperature mapping in Denonvilliers' space by multiple thermocouples documented real-time iceball expansion up to 10 mm beyond the prostate, and safety in protecting the rectal wall from thermal injury. The lowest temperatures of the thermocouples with a distance of 0 mm, 5 mm and 10 mm from the prostate were: -35°C, -18°C and 0°C (P < 0.001), respectively. In gross and microscopic examination, the hydrogel mass measured 11 × 40 × 34 mm, which was identical to the intraoperative transrectal ultrasound measurements, there was no infiltration of the hydrogel into the rectal wall or prostate and no injury to the pelvic organs. In conclusion, the expansion of Denonvilliers' space by transperineal injection of hydrogel is feasible and a promising technique to facilitate energy-based focal therapy of prostate cancer.

Salvage focal and salvage total cryoablation for locally recurrent prostate cancer after primary radiation therapy

OBJECTIVES

To present the oncological and functional outcomes of salvage focal (SFC) and salvage total (STC) cryoablation for recurrent prostate cancer (PCa) after failed primary radiotherapy.

PATIENTS AND METHODS

From March 2003 to August 2010, 50 men with biopsy-proven unilateral (n = 25) or bilateral (n = 25) radio-recurrent PCa underwent SFC or STC, respectively. Patients were assessed after treatment by prostate-specific antigen (PSA) testing, transrectal ultrasonography, biopsy and questionnaires. Biochemical failure (BF) was defined using the Phoenix criteria (PSA nadir + 2 mg/mL). Data were prospectively collected and retrospectively analysed.

RESULTS

The median pre-cryoablation PSA level and Gleason score were, respectively, 2.8 ng/mL and 7 for SFC, and 3.9 ng/mL and 7 for STC. The median follow-up was 31 and 53 months (P = 0.004) for SFC and STC, respectively. Oncological outcomes were as follows: no patient died; one patient who underwent STC developed bone metastases; eight patients who underwent SFC and three who underwent STC had BF and the 5-year BF-free survival rates were 54 and 86%, respectively. In those patients without BF, the mean PSA decreased by 86% for SFC and 90% for STC within the first year and remained stable. Functional outcomes were as follows: new onset urinary incontinence occurred in three (13%) patients in the STC group, whereas no patient in the SFC group developed incontinence (P = 0.10); Two of seven patients in the SFC group retained postoperative potency, but none of the four potent patients in the STC group recovered potency postoperatively (P = 0.48); one (4%) patient in the STC group developed a recto-urethral fistula, but none occurred in the SFC group (P = 0.48).

CONCLUSIONS

SFC and STC are feasible and safe with acceptable mid-term oncological outcomes. For carefully selected patients, SFC is an option that could be associated with lower treatment-related morbidity compared with STC. Although longer follow-up and more patient numbers are needed, our initial oncological and functional outcomes of SFC and STC are encouraging.

A novel mutation (P236S) in the succinate dehydrogenase subunit B gene in a Japanese patient with a posterior mediastinal paraganglioma

Succinate dehydrogenase subunit B gene (SDHB) is associated with the development of hereditary paraganglioma (PGL) and pheochromocytoma (PCC). Here we describe a novel germline mutation in SDHB in a 69-year-old Japanese woman with a posterior mediastinal PGL. We summarize the clinical presentation, diagnostic work-up, and pathological features of a patient with a posterior mediastinal PGL and review the pertinent literature. Direct sequencing of SDHB and SDHD was performed. The patient presented with a posterior mediastinal tumor and was normotensive. She underwent abdominal tumor resection at the age of 38 years, but clinical and pathological diagnoses were unknown. She had no family history of hypertension, PGL, or PCC. Imaging studies suggested that the tumor was neurogenic. Endocrinological examinations showed normal plasma catecholamine levels. The tumor was completely removed without metastasis. Pathological findings confirmed PGL. Immunohistochemical staining showed that the tumor cells were positive for chromogranin A, synaptophysin, and CD56, and the Ki67 index was low (<1 %). The patient has not experienced recurrence or metastasis for the last 5 years. DNA sequencing revealed a novel P236S (c.843 C > T) mutation in SDHB. The P236S germline mutation in SDHB was associated with posterior mediastinal PGL. Strict follow-up of the patient is necessary because the SDHB mutation may be related to malignancy.

Potential of metastin and metastin receptor as biomarkers for urological cancers

AIM: To investigate the current state of the research of metastin and metastin receptor in the urological cancer field.

METHODS: For analyzing the value of metastin and metastin receptor as molecular biomarkers for the patients with urological cancer, MEDLINE database searches were performed using these terms: metastin, KISS1, kisspeptin, renal (cell) carcinoma (RCC), kidney cancer or urothelial cancer or bladder cancer or prostate cancer or testicular cancer (tumor). Since the articles were evaluated by the validity of the articles based on plausibility, credibility, and evidence levels, the articles were graded according to their level of evidence, using the grading system defined by the Oxford Centre for Evidence-based Medicine.

RESULTS: A total of six clinical studies published by individual institutions between 2003 and 2013 were included in this review. The article numbers for each of the evidence levels 2a and 2b were three (50%) and three (50%), respectively. Immunohistochemistry and reverse transcriptase-polymerase chain reaction using tumor tissues were performed to analyze in five articles (83%) and in one article (17%). The value of metastin and/or metastin receptor as molecular biomarkers in clear cell RCC, upper tract urothelial carcinoma, and bladder cancer was evaluated by multivariate analysis. Low expression of metastin receptor in clear cell RCC and low expression of metastin in upper tract urothelial carcinoma were significant risk factors for metastasis, and low metastin expression was an independent prognostic factor in bladder cancer.

CONCLUSION: Metastin and metastin receptor have potential as suitable molecular biomarkers for urological cancers. However, future studies of metastin and metastin receptor should undergo external validation to ensure consistency across different patient series, since individual institutional studies lack generalization.

Prostate swelling and shift during high intensity focused ultrasound: implication for targeted focal therapy

PURPOSE

We quantified prostate swelling and the intraprostatic point shift during high intensity focused ultrasound using real-time ultrasound.

MATERIALS AND METHODS

The institutional review board approved this retrospective study. Whole gland high intensity focused ultrasound was done in 44 patients with clinically localized prostate cancer. Three high intensity focused ultrasound sessions were required to cover the entire prostate, including the anterior zone (session 1), middle zone (session 2) and posterior zone (session 3). Computer assisted 3-dimensional reconstructions based on 3 mm step-section images of intraoperative transrectal ultrasound were compared before and after each session.

RESULTS

Most prostate swelling and intraprostatic point shifts occurred during session 1. The median percent volume increase was 18% for the transition zone, 9% for the peripheral zone and 13% for the entire prostate. The volume percent increase in the transition zone (p <0.001), peripheral zone (p = 0.001) and entire prostate (p = 0.001) statistically depended on the volume of each area measured preoperatively. The median 3-dimensional intraprostatic shift was 3.7 mm (range 0.9 to 13) in the transition zone and 5.5 mm (range 0.2 to 14) in the peripheral zone. A significant negative linear correlation was found between the preoperative presumed circle area ratio, and the percent increase in prostate volume (p = 0.001) and shift (p = 0.01) during high intensity focused ultrasound.

CONCLUSIONS

We quantified significant prostate swelling and shift during high intensity focused ultrasound. Smaller prostates and a smaller preoperative presumed circle area ratio were associated with greater prostate swelling and intraprostatic shifts. Real-time intraoperative adjustment of the treatment plan impacts the achievement of precise targeting during high intensity focused ultrasound, especially in prostates with a smaller volume and/or a smaller preoperative presumed circle area ratio.