Biology and management of bladder cancer

The relationship between the expression of E-cadherin and tumor recurrence and progression in high-grade stage T1 bladder urothelial carcinoma

OBJECTIVE

To evaluate the relationship between the expression of E-cadherin (E-CD) and tumor recurrence and progression in patients with high-grade stage T1 urothelial carcinoma of bladder.

METHODS

Fifty-two patients who had primary high-grade stage T1 urothelial carcinoma were enrolled to the study. The pathologic specimens of patients were evaluated and staged as T1a and T1b according to muscularis mucosae involvement by the tumor. The immunohistochemical demonstration of E-CD was accomplished by using immunoperoxidase method and all the specimens were examined under light microscope for E-CD level.

RESULTS

The mean age of the patients was 64.0 +/- 7.7 (range 36-81) years. The mean follow-up period was 56.4 +/- 19.4 (range 14-84) months. Among 52 patients, 27 (52%) of them were stage T1b and 25 (48%) were T1a tumors. The recurrence rates for T1a and T1b groups were 52% (n = 13) and 92.6% (n = 25), respectively (P < 0.05). The expression of E-CD was homogenous in 52% of pT1a and 14.8% of T1b tumors (P < 0.05). In T1a group with recurrence, homogeneous E-CD staining ratio was 30.7% (n = 4/13), but it was 75% (n = 9/12) in T1a patients without recurrence (P < 0.05). In T1b group with recurrence, the homogenous expression of E-CD was 12% (n = 3/25) and the expression of E-CD was heterogenous in 88% (n = 22/25) of them (P < 0.05). In T1a group, progression of the disease was detected in 28% (n = 7/25) of the patients, but disease progression was seen in 55.5% (n = 15/27) of T1b group patients (P < 0.05). In T1a group with progression, heterogeneous E-CD staining ratio was 85.7% (n = 6/7), but it was 80% (n = 12/15) in T1b patients with progression. The effects of tumor number, tumor size and carcinoma in situ presence on recurrence were evaluated within each group. It was determined that parameters such as tumor number and tumor size had no significant effect on recurrence of the groups. The mean survival rates were statistically different between the groups. On multivariate analysis only E-cadherin expression (P = 0.012, odds ratio 6.291, 95% confidence interval for odds ratio 1.303-4.72) and tumor stage (P = 0.003, odds ratio 11.58, 95% confidence interval for odds ratio 2.446-8.542) remained independently significant as predictors of recurrence.

CONCLUSION

E-CD expression was decreased in pathologic specimens of bladder tumor patients with muscularis mucosae involvement and this condition correlated well with tumor recurrence.

The effect of squamous and/or glandular differentiation on recurrence, progression and survival in urothelial carcinoma of bladder

INTRODUCTION

The effects of squamous and/or glandular differentiation in urothelial carcinoma of bladder on recurrence, progression and survival rate were evaluated in this study.

PATIENTS AND METHODS

Between 1998 and 2003, a total of 223 patients who had been treated with transurethral resection for bladder cancers were evaluated. The patients were divided into two groups as; Group I: tumor patients with squamous and/or glandular differentiation, Group II: patients without these findings.

RESULTS

Histologically 189 (84.7%) were conventional urothelial carcinoma and 34 (15.2%) were tumors with squamous and/or glandular differentiation. The mean age of the patients was 64.4 +/- 12.7 (range 36-81) years. Survival rates within a period of 46.23 +/- 14.8 (12-67) months were 76.47% for Group I and 89.94% for Group II (P = 0.027). The stage distribution as pTa, pT1, and >/=pT2 was 2 (5.9%), 18 (52.9%), and 14 (41.2%) in Group I and 101 (53.4%), 51 (27%) and 37 (19.6%) in group II, respectively (P = 0.001). There was a statistically significant tendency towards higher stage at presentation in Group I and the grade distribution was significantly higher in Group I than Group II (P < 0.001).

CONCLUSION

High recurrence rates and poor prognosis of these patients should be kept in mind in the follow-up period. In this respect, these patients should be followed up closely.

Targeting bladder tumor cells in vivo and in the urine with a peptide identified by phage display

Bladder cancer is one of the most common tumors of the genitourinary tract. Here, we use phage display to identify a peptide that targets bladder tumor cells. A phage library containing random peptides was screened for binding to cells from human bladder tumor xenografts. Phage clones were further selected for binding to a bladder tumor cell line in culture. Six clones displaying the consensus sequence CXNXDXR(X)/(R)C showed selective binding to cells from primary human bladder cancer tissue. Of these, the CSNRDARRC sequence was selected for further study as a synthetic peptide. Fluorescein-conjugated CSNRDARRC peptide selectively bound to frozen sections of human bladder tumor tissue, whereas only negligible binding to normal bladder tissue was observed. When the fluorescent peptide was introduced into the bladder lumen, in a carcinogen-induced rat tumor model, it selectively bound to tumor epithelium. Moreover, when the peptide was intravenously injected into the tail vein, it homed to the bladder tumor but was not detectable in normal bladder and control organs. Next, we examined whether the peptide can detect tumor cells in urine. The fluorescent peptide bound to cultured bladder tumor cells but not to other types of tumor cell lines. Moreover, it bound to urinary cells of patients with bladder cancer, while showing little binding to urinary cells of patients with inflammation or healthy individuals. The CSNRDARRC peptide may be useful as a targeting moiety for selective delivery of therapeutics and as a diagnostic probe for the detection of bladder cancer.

Sensitizing effect of galectin-7 in urothelial cancer to cisplatin through the accumulation of intracellular reactive oxygen species

To improve chemotherapeutic efficacy in urothelial cancer, it is important to identify predictive markers for chemosensitivity as well as possible molecules accelerating cell killing mechanisms. In this study, we assessed the possibility of galectin-7 to accelerate cis-diamminedichloroplatinum (CDDP)-induced cell killing in vitro and also to predict chemosensitivity against CDDP in urothelial cancer patients. The expression of galectin-7 was analyzed in five bladder cancer cell lines with different p53 status after treatment with CDDP. The roles of galectin-7 in chemosensitivity against CDDP were analyzed by transfection of the galectin-7 gene into several of these cell lines. Furthermore, the relationship between the expression of galectin-7 and the response to neoadjuvant chemotherapy was analyzed in 17 human bladder cancer specimens. Exposure to CDDP induced galectin-7 in cell lines with wild-type p53 but not in those with mutated p53. When the galectin-7 gene was transfected into cell lines with mutated p53, the sensitivity to CDDP increased compared with control transfectants. In addition, galectin-7-transfected cells exhibited more accumulation of intracellular reactive oxygen species and activation of c-Jun NH(2)-terminal kinase (JNK) and Bax than control transfectants. SP600125, an inhibitor of JNK, or antioxidant N-acetyl-L-cysteine inhibited the enhancement of chemosensitivity against CDDP by galectin-7 transfection. In clinical samples, the expression levels of galectin-7 were significantly lower in urothelial carcinomas compared with normal urothelium. When chemosensitivity was tested, its expression levels were higher in the chemosensitive group than in the chemoresistant group. Galectin-7 is a candidate for a predictive marker of chemosensitivity against CDDP, and the targeted expression of galectin-7 might overcome the chemoresistance of urothelial cancer.

Orbital Metastasis from Urothelial Carcinoma of the Urinary Bladder

Radical cystectomy with ileal conduit diversion remains the standard treatment for invasive bladder cancer. We report a patient with urothelial carcinoma of the urinary bladder and found metastasis to the orbit post radical cystectomy and ileal conduit diversion presenting as blurred vision and diagnosed by open biopsy. The orbit is an infrequent site of metastasis from bladder cancer cells. To the best of our knowledge, there are fewer than 10 case reports of orbital metastasis from urothelial carcinoma reported in the English medical literature.

Imaging of Bladder Cancer

Bladder cancer is a heterogeneous and frequently multifocal disease with a variable clinical course. The management of bladder cancer is therefore challenging and complicated. CT and MR imaging have replaced the traditional excretory urography and are emerging as the imaging modalities of choice for work-up of patients who have bladder cancer. Imaging provides essential diagnostic information for detection, staging, and post-treatment follow-up of bladder cancer.

Sequential gemcitabine and cisplatin followed by docetaxel as first-line treatment of advanced urothelial carcinoma: a multicenter phase II study of the Hellenic Oncology Research Group

BACKGROUND

The purpose of this study was to investigate the toxicity and efficacy of the sequential administration of gemcitabine (GMB) in combination with cisplatin (CDDP) followed by docetaxel (Taxotere) as first-line treatment of advanced urothelial carcinoma.

PATIENTS AND METHODS

Patients [aged </=70 years and performance status (PS) (Eastern Cooperative Oncology Group) 0-2] with previously untreated locally advanced/recurrent or metastatic urothelial carcinoma were eligible. Study treatment consisted of GMB (1000 mg/m(2), days 1 and 8) and CDDP (70 mg/m(2), day 1) (GP regimen), every 21 days for a total of four cycles followed by docetaxel (D; 100 mg/m(2), day 1) every 21 days for four cycles.

RESULTS

Thirty-eight patients with a median age of 67 years were enrolled; 67% of them had PS 0 and 87% stage IV disease. Patients received a median of four GP and four D cycles per patient. Grade 3-4 neutropenia occurred in 27% and 63% patients with GP and D, respectively. Grade 3-4 thrombocytopenia occurred in 11% of patients, only with the GP regimen. Other toxic effects were mild. There was no toxic death. The objective response rate was 55.2% [95% CI: 39.45%-71.07%]. Five patients had complete response (13.15%) and 16 patients had partial response (42.1%), while nine patients had disease stabilization (23.7%) (intention-to-treat analysis). After a median follow-up period of 13 months (range 1.5-40.5 months), the median time to progression was 6.8 months (range 1-40.5 months), the median overall survival 13 months (range 1.5-40.5 months), and the 1-year survival rate 55.3%.

CONCLUSION

The sequential administration of GP followed by D is active and well tolerated as first-line treatment of advanced urothelial carcinoma and merits to be further evaluated.

Role of bone morphogenetic proteins in transitional cell carcinoma cells

Bone morphogenetic proteins (BMPs) are pleiotropic growth factors that signal through an interaction with the membrane receptors-type--IA, -IB, and -II (BMP-RIA, -RIB, and -RII, respectively). Although the prototypical members of this group of growth factors were isolated as osteoinductive factors, recently accumulated data have suggested that these factors regulate malignant cells. Herein, we review the data concerning BMPs in transitional cell carcinoma cells.

Searching cell-secreted proteomes for potential urinary bladder tumor markers

To search for biomarkers critical for bladder carcinoma diagnosis and prognosis, secreted proteomes of highly malignant U1 and pre-malignant U4 cell lines were initially analyzed. Proteins in the culture media of the U1 and U4 cell lines were systematically examined by SDS-PAGE combined with MALDI-TOF MS. Among them, expression of pro-u-plasminogen activator (pro-u-PA) was confirmed by Western blot analysis and further evaluated. In analyzing urine samples from bladder cancer patients and normal subjects, we established a statistically significant relationship between the low level and absence of pro-u-PA in urine with high stages and grades of the tumor samples. Constitutive expression of Ras dominant negative protein led to increased expression of pro-u-PA in culture media, indicating that the loss of pro-u-PA is associated with oncogenic transformation. Analysis of cancer-secreted proteomes can be a feasible, non-invasive and efficient strategy for searching potential bladder tumor biomarkers. Our work also has identified the loss of pro-u-PA in urine as potential marker of more advanced bladder carcinoma.

Ras-dependent recruitment of c-Myc for transcriptional activation of nucleophosmin/B23 in highly malignant U1 bladder cancer cells

U1 bladder cancer cells of high malignancy exhibited higher proliferation capacity than U4 premalignant cells. Higher expression of Ras, c-Myc, and nucleophosmin/B23 and greater c-Myc transactivation and nucleophosmin/B23 promoter activities were detected in U1 cells compared with U4 cells. Moreover, c-Myc and nucleophosmin/B23 were increased in U1 but not in U4 cells upon serum stimulation from quiescence. Likewise, only in U1 cells could serum stimulate transcriptional activity of nucleophosmin/B23 promoter and c-Myc response element. The increase of nucleophosmin/B23 promoter activity could be abrogated by mitogen-activated protein kinase/extracellular signal-regulated kinase activating kinase inhibitor and was associated with recruitment of c-Myc to the promoter. U1 cells constitutively expressing dominant-negative Ras reduced the levels of Ras, nucleophosmin/B23, and p-ERK, and consequently abolished the serum-induced up-regulation of nucleophosmin/B23 promoter activity and c-Myc promoter recruitment. Our results indicate that Ras and c-Myc play important roles in the up-regulation of nucleophosmin/B23 during proliferation of cells associated with a high degree of malignancy, thus outlining a signaling cascade involving these factors in the cancer cells.

Nucleophosmin/B23 regulates transcriptional activation of E2F1 via modulating the promoter binding of NF-kappaB, E2F1 and pRB

Expression of nucleophosmin/B23 and E2F1 and E2F1-dependent transcription increased in U1 bladder cancer cells upon serum stimulation from quiescence. Nucleophosmin/B23-siRNA treatment abrogated such increase of E2F1-dependent transcriptional activity. In identifying physiologically important factors that may occupy E2F1 promoter and regulate its activity in vivo, we found that the pattern of NF-kappaB, E2F1 and pRB recruitment to E2F1 promoter changed in a strikingly dynamic fashion as cells progressed from quiescence into serum-stimulated growth. E2F1 promoter activity in quiescent cells was associated with recruitment of NF-kappaB. NF-kappaB was replaced largely by E2F1 in concert with gene activation during the early stage (12 h) of serum stimulation. At late stage (24 h) of serum stimulation, pRB was then recruited to the E2F1-promoter complex to counterbalance its activity. Upon siRNA-mediated reduction of intracellular nucleophosmin/B23, E2F1 and pRB were recruited to the promoter with the dissociation of NF-kappaB concomitant with gene inactivation. Based on immunoprecipitation experiments, nucleophosmin/B23 was found to be associated with NF-kappaB in cells grown in serum-supplemented but not in serum-deprived medium. Furthermore, nucleophosmin/B23 could also be co-immunoprecipitated with ppRB at the early stage (12 h) but not at the late stage (24 h) of serum stimulation. The results demonstrate a novel mechanism for transcriptional regulation of E2F1 and identify the functional role of nucleophosmin/B23 in modulating the binding of NF-kappaB, E2F1 and pRB to activate E2F1 promoter.

Comprehensive profiling and localisation of the matrix metalloproteinases in urothelial carcinoma

The matrix metalloproteinases (MMPs) are endopeptidases which break down the extracellular matrix and regulate cytokine and growth factor activity. Several MMPs have been implicated in the promotion of invasion and metastasis in a broad range of tumours including urothelial carcinoma. In this study, RNA from 132 normal bladder and urothelial carcinoma specimens was profiled for each of the 24 human MMPs, the four endogenous tissue inhibitors of MMPs (TIMPs) and several key growth factors and their receptors using quantitative real time RT–PCR. Laser capture microdissection (LCM) of RNA from 22 tumour and 11 normal frozen sections was performed allowing accurate RNA extraction from either stromal or epithelial compartments. This study confirms the over expression in bladder tumour tissue of well-documented MMPs and highlights a range of MMPs which have not previously been implicated in the development of urothelial cancer. In summary, MMP-2, MT1-MMP and the previously unreported MMP-28 were very highly expressed in tumour samples while MMPs 1, 7, 9, 11, 15, 19 and 23 were highly expressed. There was a significant positive correlation between transcript expression and tumour grade for MMPs 1, 2, 8, 10, 11, 12, 13, 14, 15 and 28 (P<0.001). At the same confidence interval, TIMP-1 and TIMP-3 also correlated with increasing tumour grade. LCM revealed that most highly expressed MMPs are located primarily within the stromal compartment except MMP-13 which localised to the epithelial compartment. This work forms the basis for further functional studies, which will help to confirm the MMPs as potential diagnostic and therapeutic targets in early bladder cancer.

MANAGEMENT OF MUSCLE-INVASIVE BLADDER CANCER IN VICTORIA, 1990-1995

BACKGROUND

The management and outcomes of muscle-invasive bladder cancer are described in this article.

METHODS

A retrospective survey of medical practitioners involved in the management of bladder cancer was conducted. The survey obtained at least 5 years of follow-up data on all patients. The sample was taken from the public and private health sectors in Victoria. All were cases of muscle-invasive bladder cancer diagnosed between 1990 and 1995. The main outcome measures included reported management by staging, treatment and survival.

RESULTS

Completed questionnaires were returned for 743 (89.6%) of 829 cases. Of these, 523 (70.4%) were men, and the mean age was 72.7 years. More than 75% of the cases (560) presented with macroscopic haematuria. The majority (696, 94%) had transitional cell carcinoma. A variety of treatments were given in various sequences, with 231 cases (31.1%) having initial surveillance. Eventually, 303 cases (40.8%) proceeded to 'definitive' management with either radiotherapy (132, 17.8%) or cystectomy (171, 23.0%). In addition, chemotherapy was given to 254 patients (34.2%) at some time. Most patients (613, 82.5%) have subsequently died; 402 (54%) died from bladder cancer. Crude 5-year survival was 13.0%, and disease-specific survival was 27.7%. Multivariate analysis identified the following predictors of greater disease-specific survival: grade 1 or 2 histopathology (P = 0.0003), T2 primary (P < 0.0001), N0 disease (P = 0.04), M0 disease (P < 0.0001), radiation dose in BED(10) >70 Gy and cystectomy (P < 0.0001).

CONCLUSION

Muscle-invasive bladder cancer in Victoria typically occurs in elderly patients, and a notable proportion of these patients do not proceed onto 'definitive' treatment. Disease stage, cystectomy and the use of high doses of radiation are associated with better outcomes. Chemotherapy was given to approximately one-third of patients at some point in their disease management. Our data are similar to population-based data from North America, and provide a baseline against which potential changes in management of bladder cancer can be compared.

Novel therapies in bladder cancer

The most effective non-surgical treatment for bladder cancer remains radiotherapy. The dramatic technical developments in radiotherapy have enabled greater accuracy and reliability based on three-dimensional imaging for both planning and verification. Particle therapy, in particular using protons, provides further opportunities for optimising radiation delivery and dose escalation. Novel fractionation schedules with both hyperfractionation and hypofractionation may have added benefits. Chemoradiation has been shown in one randomised-controlled trial to improve the results of radiotherapy alone, and requires further investigation. Hypoxia modification using carbogen and nicotinamide has also shown promising results in a phase II trial, and is now in phase III evaluation. Novel drug agents for bladder cancer are few, but the anti-EGFR agents and anti-angiogenic agents may have promise; the development of anti-apoptotic agents and antisense gene therapy may also become a component of the future multimodality management of this tumour.

Intravesical interleukin-12 gene therapy in an orthotopic bladder cancer model

OBJECTIVES

To evaluate the antitumor effect of intravesical cationic liposome-mediated interleukin-12 (IL-12) gene delivery in an orthotopic murine bladder cancer model, and to investigate the immunologic memory against tumors between IL-12 gene therapy and bacille Calmette-Guérin (BCG) therapy.

METHODS

Orthotopic murine bladder tumors were established by implanting 5 x 10(5) MBT-2 cells into the bladder of syngeneic female C3H mice. Intravesical IL-12 gene therapy was evaluated at varying doses: 0 microg (control) and 3, 5, and 10 microg (n = 8 for each group). Intravesical treatments were performed every 3 days and repeated six times beginning 5 days after tumor implantation. To compare the long-term, tumor-specific immunity between IL-12-treated mice (n = 18) and BCG-treated mice (n = 20), the animals surviving at day 60 and 10 new control mice were rechallenged with MBT-2 cells and received no additional treatment. On day 120, all surviving mice were killed and underwent necropsy.

RESULTS

In the IL-12 groups at doses of 0, 3, 5, and 10 microg, 0, 2, 3, and 3 mice survived, respectively. Mice in the 5-microg and 10-microg IL-12 groups survived significantly longer than did the control group. All mice cured by IL-12 treatment successfully rejected the rechallenge with MBT-2 cells; however, mice cured by BCG and the new control mice died of the rechallenged bladder tumors.

CONCLUSIONS

Intravesical IL-12 gene therapy, which induced long-lasting tumor-specific immunologic memory compared with BCG therapy, improved survival in an orthotopic bladder cancer model.

Upregulated MT1-MMP/TIMP-2 axis in the TSU-Pr1-B1/B2 model of metastatic progression in transitional cell carcinoma of the bladder

Muscle invasive transitional cell carcinoma (TCC) of the bladder is associated with a high frequency of metastasis, resulting in poor prognosis for patients presenting with this disease. Models that capture and demonstrate step-wise enhancement of elements of the human metastatic cascade on a similar genetic background are useful research tools. We have utilized the transitional cell carcinoma cell line TSU-Pr1 to develop an in vivo experimental model of bladder TCC metastasis. TSU-Pr1 cells were inoculated into the left cardiac ventricle of SCID mice and the development of bone metastases was monitored using high resolution X-ray. Tumor tissue from a single bone lesion was excised and cultured in vitro to generate the TSU-Pr1-B1 subline. This cycle was repeated with the TSU-Pr1-B1 cells to generate the successive subline TSU-Pr1-B2. DNA profiling and karyotype analysis confirmed the genetic relationship of these three cell lines. In vitro, the growth rate of these cell lines was not significantly different. However, following intracardiac inoculation TSU-Pr1, TSU-Pr1-B1 and TSU-Pr1-B2 exhibited increasing metastatic potential with a concomitant decrease in time to the onset of radiologically detectable metastatic bone lesions. Significant elevations in the levels of mRNA expression of the matrix metalloproteases (MMPs) membrane type 1-MMP (MT1-MMP), MT2-MMP and MMP-9, and their inhibitor, tissue inhibitor of metalloprotease-2 (TIMP-2), across the progressively metastatic cell lines, were detected by quantitative PCR. Given the role of MT1-MMP and TIMP-2 in MMP-2 activation, and the upregulation of MMP-9, these data suggest an important role for matrix remodeling, particularly basement membrane, in this progression. The TSU-Pr1-B1/B2 model holds promise for further identification of important molecules.

Cytokeratin-20 immunocytology in voided urine exhibits greater sensitivity and reliability than standard cytology in the diagnosis of transitional cell carcinoma of the bladder

OBJECTIVES

To investigate whether immunocytochemical detection of cytokeratin (CK)-20 could serve as a reliable diagnostic marker for transitional cell carcinoma (TCC) of the bladder.

METHODS

A total of 232 patients were enrolled in the study. Group 1 consisted of 144 patients with histologically confirmed TCC (62 at diagnosis and 82 in follow-up), and group 2 consisted of 88 subjects, including healthy volunteers and individuals with "non-TCC" conditions. Spontaneously voided urine specimens were obtained from each patient and submitted to immunocytologic and standard cytologic examination.

RESULTS

CK-20 immunocytology yielded an overall sensitivity of 65.3%, significantly greater than the sensitivity of urine cytology (54.2%, P = 0.013). A more detailed analysis revealed a sensitivity advantage for the former technique in the detection of primary (61.3% versus 51.6%, P = 0.046), recurrent (68.3% versus 56.1%, P = 0.027), Stage pT1 (81.8% versus 59.1%, P = 0.006), grade 2 (76.2% versus 61.9%, P = 0.031), and grade 3 (82.1% versus 67.9%, P = 0.039) tumors. Moreover, CK-20 immunocytochemistry demonstrated greater overall specificity than cytology (90.9% versus 86.4%, respectively), a difference stemming from the subgroup of lithiasis patients (100% versus 66.7%, P = 0.024). In terms of reliability, the positive and negative predictive values of the immunoassay were greater than those calculated for cytology (92.2% versus 86.7% and 61.5% versus 53.5%, respectively).

CONCLUSIONS

CK-20 immunocytology is more sensitive than standard cytology in the detection of TCC, particularly of Stage pT1, grade 2, and grade 3 tumors. In view of its high overall specificity and predictive accuracy, it is conceivable that the proposed immunoassay may progressively replace conventional cytologic screening in the diagnosis of bladder cancer.

Expression of thymidine phosphorylase in human superficial bladder cancer

BACKGROUND

The purpose of the present paper was to investigate the expression level of thymidine phosphorylase (TPase) in superficial bladder cancer tissues obtained by transurethral resection, and determine whether its expression correlates with tumor recurrence.

METHODS

From March 1998 to December 2001, 99 patients with superficial bladder cancer were diagnosed and treated at eight affiliated hospitals. Tissue specimens obtained by transurethral resection of superficial bladder cancer (TURBT) were applied to immunohistochemical study using anti-TPase antibody as well as pathological diagnosis. The data were subjected to statistical analysis.

RESULTS

Using MoAb 654-1 as the primary antibody, TPase was clearly stained in human bladder cancer tissues. The maximum TPase level measured by enzyme-linked immunosorbent assay (ELISA) method in normal bladder tissues was 18.7 U/mg protein. The TPase activity was 2.8-fold higher in tumors than in normal bladder samples (P = 0.037). The TPase positivity rates determined by immunohistochemical and ELISA methods were distinctly correlated (P = 0.046). For the recurrence-free rates in pT1 tumors treated by TURBT alone (n = 46), there were no statistically significant differences between Tpase-positive or -negative cases.

CONCLUSIONS

The TPase expression determined by ELISA and immunohistochemistry is significantly up-regulated in superficial bladder tumors compared with normal bladder samples. However, TPase expression by immunohistochemistry is not a predictive index of recurrence-free rate for superficial bladder cancer treated with TURBT alone.

Gene Expression Profiling of Progressive Papillary Noninvasive Carcinomas of the Urinary Bladder

PURPOSE

The aim of the present study was to define gene expression profiles of noninvasive and invasive bladder cancer, to identify potential therapeutic or screening targets in bladder cancer, and to define genetic changes relevant for tumor progression of recurrent papillary bladder cancer (pTa).

EXPERIMENTAL DESIGN

Overall, 67 bladder neoplasms (46 pTa, 3 pTis, 10 pT1, and 8 pT2) and eight normal bladder specimens were investigated by a combination of laser microdissection and gene expression profiling. Eight of 16 patients with recurrent noninvasive papillary bladder tumors developed carcinoma in situ (pTis) or invasive bladder cancer (> or = pT1G2) in the course of time. RNA expression results of the putative progression marker cathepsin E (CTSE) were confirmed by immunohistochemistry using high-throughput tissue microarray analysis (n = 776). Univariate analysis of factors regarding overall survival, progression-free survival, and recurrence-free survival in patients with urothelial bladder cancer was done.

RESULTS

Hierarchical cluster analyses revealed no differences between pTaG1 and pTaG2 tumors. However, distinct groups of invasive cancers with different gene expression profiles in papillary and solid tumors were found. Progression-associated gene profiles could be defined (e.g., FABP4 and CTSE) and were already present in the preceding noninvasive papillary tumors. CTSE expression (P = 0.003) and a high Ki-67 labeling index of at least 5% (P = 0.01) were the only factors that correlated significantly with progression-free survival of pTa tumors in our gene expression approach.

CONCLUSIONS

Gene expression profiling revealed novel genes with potential clinical utility to select patients that are more likely to develop aggressive disease.

Urine markers for bladder cancer surveillance: a systematic review

INTRODUCTION

The follow-up of patients with urothelial cell carcinoma (UCC) of the bladder is done by cystoscopy and, in most cases, cytology. The last decade, many urine-based tests for UCC have been developed and tested in different populations. For the urological practice, considering the amount of follow-up cystoscopies, especially urine markers for recurrent disease would be useful. Therefore, we reviewed the literature on these markers for recurrent UCC and compared our findings with recent review-articles.

METHODS

We performed a PubMed search. In case of primary and recurrent disease, the study was included if the patients under surveillance were reported separately. Patients with no evidence of disease at surveillance cystoscopy were considered to determine specificity. A marker was included if at least 2 studies from 2 different institutions/authors were available.

RESULTS

The literature review yielded 64 articles. We found 18 markers (BTAstat, BTAtrak, NMP22, FDP, ImmunoCyt, Cytometry, Quanticyt, Hb-dipstick, LewisX, FISH, Telomerase, Microsatellite, CYFRA21-1, UBC, Cytokeratin20, BTA, TPS, Cytology) that met our criteria. BTAstat, NMP22, ImmunoCyt and cytology were evaluated in more than 750 patients. Telomerase, Cytokeratin20 and Hb-dipstick were tested in less than 250 patients. The highest median sensitivities were reported for CYFRA21-1 (85%), Cytokeratin20 (85%) and Microsatellite analysis (82%). The highest specificities were reported for Cytology (94%), BTA (92%) and Microsatellite analysis (89%). In comparison with recent reviews, median sensitivity was>or=5% lower for the surveillance group in 13/18 urine-based tests while specificity remained relatively constant between different patient groups.

CONCLUSIONS

To our knowledge, this is the first review that assesses sensitivity and specificity of urine markers solely for UCC surveillance. In our view, Microsatellite analysis, ImmunoCyt, NMP22, CYFRA21-1, LewisX and FISH are the most promising markers for surveillance at this time. Nevertheless, clinical evidence is insufficient to warrant the substitution of the cystoscopic follow-up scheme by any of the currently available urine marker tests. Future studies may test some of the most sensitive and specific assays to reduce the cystoscopy frequency. However, our results show that initiators of these studies should anticipate a lower sensitivity than reported in the current literature.

Restoration of bone morphogenetic protein receptor type II expression leads to a decreased rate of tumor growth in bladder transitional cell carcinoma cell line TSU-Pr1

Bone morphogenetic proteins (BMPs), potential regulators of cellular growth and metastasis that signal through an interaction with plasma membrane receptors, have been suggested to be important regulators of malignant cells. The present study was carried out to evaluate the potential role of BMP receptor (BMP-R) types IA, IB, and II in bladder transitional cell carcinoma (TCC) cells. Initially, we investigated the expression of these BMP-Rs in 30 archival tissues of human bladder TCC using immunohistochemistry; 10 benign bladder specimens were used for comparison. The results demonstrated that the expression of BMP-Rs is localized preferentially to the transitional epithelium and that there was a significant association between loss of BMP-RII expression and tumor grade. To find a cell line that can serve as a model system for clinical observation, we subsequently examined sensitivity to BMP-4 and expression of BMP-RII, BMP-RIA, and BMP-RIB in three human bladder cancer cell lines, TCC-Sup, RT4, and TSU-Pr1. Of the three cell lines, TSU-Pr1 exhibited a decreased level of BMP-RII expression and was resistant to the growth-inhibitory effect of BMP-4. Overexpression of BMP-RII in TSU-Pr1 cells not only restored BMP-4 responsiveness but also significantly decreased tumorigenicity in vivo. Taken together, these results demonstrate that human bladder TCC tissues have a frequent loss of BMP-RII expression and that overexpression of BMP-RII leads to restoration of BMP signaling and decreased tumor growth in the human bladder TCC cell line TSU-Pr1.

DNA double strand break repair in human bladder cancer is error prone and involves microhomology-associated end-joining

In human cells DNA double strand breaks (DSBs) can be repaired by the non-homologous end-joining (NHEJ) pathway. In a background of NHEJ deficiency, DSBs with mismatched ends can be joined by an error-prone mechanism involving joining between regions of nucleotide microhomology. The majority of joins formed from a DSB with partially incompatible 3' overhangs by cell-free extracts from human glioblastoma (MO59K) and urothelial (NHU) cell lines were accurate and produced by the overlap/fill-in of mismatched termini by NHEJ. However, repair of DSBs by extracts using tissue from four high-grade bladder carcinomas resulted in no accurate join formation. Junctions were formed by the non-random deletion of terminal nucleotides and showed a preference for annealing at a microhomology of 8 nt buried within the DNA substrate; this process was not dependent on functional Ku70, DNA-PK or XRCC4. Junctions were repaired in the same manner in MO59K extracts in which accurate NHEJ was inactivated by inhibition of Ku70 or DNA-PK(cs). These data indicate that bladder tumour extracts are unable to perform accurate NHEJ such that error-prone joining predominates. Therefore, in high-grade tumours mismatched DSBs are repaired by a highly mutagenic, microhomology-mediated, alternative end-joining pathway, a process that may contribute to genomic instability observed in bladder cancer.

Association of nucleophosmin/B23 mRNA expression with clinical outcome in patients with bladder carcinoma

OBJECTIVES

To determine whether nucleophosmin/B23 mRNA expression in bladder carcinoma predicts recurrence, progression, and survival.

METHODS

Real-time reverse transcriptase-polymerase chain reaction was performed on 50 fresh cancer specimens. The change in the cycle of threshold (Ct)was the difference in the Ct values derived from the nucleophosmin/B23 gene assayed and the 18S ribosomal RNA control [Ct (18S)-Ct (nucleophosmin/B23)].

RESULTS

Fifty patients diagnosed with bladder cancer were followed up postoperatively for a median of 24 months. Overexpression of nucleophosmin/B23 mRNA was observed in 37.1% of patients with Stage pT1 and 73.3% of those with pT2-T4 disease. Nucleophosmin/B23 overexpression was not associated with tumor grade (P = 0.163) but was associated with bladder cancer recurrence (68.2%) and progression (88.9%) when adjusted for the effects of clinical stage. Multivariate analysis revealed that the overall tumor stage and nucleophosmin/B23 mRNA overexpression were important prognostic indicators for bladder carcinoma (P <0.05). Patients with nucleophosmin/B23 mRNA overexpression were at a significantly greater risk of disease recurrence and progression than those with low expression of nucleophosmin/B23 mRNA.

CONCLUSIONS

Overexpression of nucleophosmin/B23 mRNA was independently associated with bladder cancer recurrence and progression. In patients with muscular invasion disease, overexpression of nucleophosmin/B23 mRNA was associated with the greatest risk of recurrence and progression, suggesting a potential rationale for early definitive therapy in these patients.

Chemotherapy and cystectomy for invasive transitional cell carcinoma of bladder

Invasive transitional cell bladder cancer is associated with occult metastasis. Approximately 50% of patients with clinically localized, invasive bladder cancer ultimately die of their disease. Systemic chemotherapy has been combined with radical cystectomy in an attempt to improve survival. Phase I and II trials have achieved tumor down-staging. Initial randomized trials did not show a statistically significant survival benefit from systemic single agent chemotherapy. More recently, two multi-center randomized trials have shown a significant survival benefit from neoadjuvant combination chemotherapy. Adjuvant chemotherapy trials, to date, have failed to show statistically improved survival, although most published studies have been methodologically flawed. For invasive, clinically nonmetastatic bladder cancer, neo-adjuvant chemotherapy followed by radical cystectomy is one of the new standards of care. The role of postsurgical systemic chemotherapy appears promising, but has not been proven in a randomized trial. Molecular prognostication is now being incorporated into the design of clinical trials of adjuvant chemotherapy for bladder cancer.

Clinical Case Notes. Orbital metastasis from transitional cell carcinoma of the bladder

Transitional cell carcinoma (TCC) is a common bladder tumour, 10-15% of which will exhibit invasive behaviour. About 50% of patients with invasive TCC will eventually develop distant metastases, usually to lymph nodes, lung or bones. The case is reported of bladder TCC metastasizing to the orbit.

FGFR3 and P53 characterize alternative genetic pathways in the pathogenesis of urothelial cell carcinoma

Fibroblast growth factor receptor 3 (FGFR3) and P53 mutations are frequently observed in bladder cancer. We here describe the distribution of FGFR3 mutations and P53 overexpression in 260 primary urothelial cell carcinomas. FGFR3 mutations were observed in 59% and P53 overexpression in 25%. Interestingly, FGFR3 and P53 alterations were mutually exclusive, because they coincided in only 5.7% of tumors. Consequently, we propose that they characterize two alternative genetic pathways in urothelial cell carcinoma pathogenesis. The genetic alterations were reflected in the pathology and the clinical outcome, i.e., FGFR3 mutations were found in low-stage/-grade tumors and were associated with a favorable disease course, whereas P53 alterations were tied to adverse disease parameters.

Fluorescence in situ hybridization performed on exfoliated urothelial cells in patients with transitional cell carcinoma of the bladder

OBJECTIVES

To evaluate comparatively fluorescence in situ hybridization (FISH) and cytology performed on exfoliated urothelial cells obtained from voided urine and bladder washings as a method of diagnosis and follow-up in patients with transitional cell carcinoma (TCC) of the bladder.

METHODS

Thirty patients with confirmed bladder TCC, 10 patients enrolled in cystoscopy follow-up for previous bladder tumors, and 10 patients with bladders free of tumor without a previous history of bladder TCC underwent cytologic examination and FISH performed on voided urine and bladder washing specimens. The FISH probes were targeted to chromosomes 7 and 9.

RESULTS

FISH had a sensitivity of 92% for high-grade tumors in both voided urine and bladder washing specimens, significantly greater than that of cytology at a sensitivity of 64% in voided urine and 67% in the bladder washing specimens (P = 0.02). The sensitivity of FISH and cytology were both low and not significantly different statistically from each other for the low-grade tumors. Monosomy of chromosome 9 correlated with early tumor recurrence. Polysomy of chromosomes 7 and 9 correlated with high-grade tumors (80% and 92%, respectively).

CONCLUSIONS

According to our results, with the local cytopathology expertise, FISH performed on urothelial cells from voided urine has a sensitivity that supersedes that of cytology, making the former a valuable complementary method in the diagnosis and follow-up of patients with bladder TCC.

Current bladder cancer tests: unnecessary or beneficial?

Bladder cancer is currently diagnosed using cystoscopy and cytology in patients with suspicious signs and symptoms. These same tests are used to monitor patients with a history of bladder cancer for recurrence. The recurrence rate for bladder cancer is high, thus necessitating long-term follow-up. Urine cytology requires an experienced cytopathologist and is costly. It has high specificity, but low sensitivity for low-grade bladder tumors. Recently many non-invasive bladder cancer tests, utilizing markers found in the urine, have been developed. The FDA has approved several of these for the use is bladder cancer diagnosis, and many others are undergoing development and investigation. An ideal bladder cancer test would be non-invasive, highly sensitive and specific, inexpensive, easy to perform, and yield highly reproducible results. Many of the tests reviewed meet some, but not all, of these criteria.

Analytical and clinical evaluation of a new urinary tumor marker: bladder tumor fibronectin in diagnosis and follow-up of bladder cancer

Bladder cancer is the fourth most common malignant neoplasm in men and the tenth most common in women. Cystoscopy presents the gold standard for detection and monitoring of bladder cancer. However, it is an invasive and expensive procedure. Therefore, development of biomarkers for the purposes of screening, diagnosis and prediction of the prognosis in bladder cancer is required. Bladder tumor fibronectin is one of the new urinary tumor markers. The aim of this study is to evaluate the diagnostic performance of urinary bladder tumor fibronectin in detecting and monitoring bladder cancer. A total of 75 patients with the diagnosis of bladder cancer, 20 patients with the diagnosis of benign prostatic hyperplasia, 7 patients with the diagnosis of prostate cancer between the years 1996-2000, and 28 age-matched healthy individuals, were enrolled in the study. The patients were diagnosed by cystoscopy, with histopathological evaluation of the tumor, as having superficial or invasive bladder cancer. Patients were followed-up clinically with data pertinent to disease recurrence and progression. Bladder tumor fibronectin (BTF; ng/ml) was determined by solid phase, two-site chemiluminescent immunometric commercial diagnostic assay developed for the Immulite automated immunoassay system (Diagnostic Products Corporation, Los Angeles, CA, USA). All measured values were normalized by urinary creatinine, and the obtained data were evaluated by receiver-operating characteristics (ROC) curve analysis. Optimal cut-off was established at 43.4 ng/mg. This cut-off rendered overall sensitivities of 72% and specificity of 82.1%. The analytical evaluation of the BTF test displayed promising results in terms of a non-invasive in vitro test in the diagnosis of bladder cancer. Although it was not satisfactory in prediction of recurrence or progression of the disease, it correlated well with the stage, one of the most reliable prognostic factors. In conclusion, the urinary bladder tumor fibronectin test warrants further clinical evaluation.

Detection of human telomerase reverse transcriptase mRNA in urine of patients with bladder cancer: evaluation of an emerging tumor marker

OBJECTIVES

To assess the value of the telomerase enzyme as a bladder cancer detection marker, we investigated the expression of the catalytic subunit of the complex (human telomerase reverse transcriptase [hTERT]) in the urine of patients with malignant or benign urinary lesions, as well as of healthy individuals, and compared the results with urine cytology.

METHODS

Spontaneously voided samples were obtained from two groups of subjects: group 1, 146 previously untreated patients with a histologic diagnosis of transitional cell carcinoma or other urothelial neoplasm; and group 2, 128 control individuals, either healthy or with a nonmalignant bladder disease. Total RNA extracts from sedimented urothelial cells were analyzed by a reverse transcriptase-polymerase chain reaction assay for the presence of a 146-bp hTERT transcript. Urine samples were also examined by standard cytology.

RESULTS

Expression of hTERT was detected in 134 (92%) of 146 patients with bladder cancer, and only 64 (44%) yielded a positive result by cytology (P <0.001). The sensitivity advantage of the former technique became particularly evident in the detection of low-grade transitional cell carcinoma (93% versus 28%, P <0.001). Accordingly, the negative predictive value of the molecular assay was markedly greater than the one calculated for cytologic screening (91% versus 60%). On the other hand, both methods were at least 96% specific, with their positive predictive indexes exceeding 94%.

CONCLUSIONS

Our findings suggest that the assessment of hTERT expression in urine sediments represents a reliable tool for the detection of primary urothelial neoplasms, equally specific, yet far more sensitive, than conventional cytology.

Detection of mucin 7 gene expression in exfoliated cells in urine from patients with bladder tumor

OBJECTIVES

To determine whether mucin (MUC) 7 gene expression can be used as a bladder tumor marker for transitional cell carcinoma in patients with bladder carcinoma.

METHODS

Cells from the urine of 65 patients with bladder cancer, 15 patients with a negative bladder biopsy for bladder cancer, and 30 healthy volunteers were compared for the following parameters: tumor stage, grade, size, and number, urinary cytology, and expression of MUC7. Nested reverse transcriptase-polymerase chain reaction (RT-PCR) was used to determine MUC7 expression (348 base pairs).

RESULTS

MUC7 in the urine samples of the control group was negative (no false-positive results, specificity 100%). Among the 15 patients with nonmalignant disease, MUC7 was negative in 13 (specificity 87%). In the 2 patients with positive MUC7, the histologic examination showed chronic inflammation. Among the 65 patients with bladder transitional cell carcinoma, MUC7 was positive in 44 (68%). Nested RT-PCR for MUC7 was positive in 25 (61%) of 41 with superficial stages (pTa and pT1) versus 16 (76%) of 21 patients with Stage pT2 or advanced stages. Nested RT-PCR for MUC7 was positive in 5 (42%) of 12 patients with grade 1 disease, 22 (65%) of 34 patients with grade 2 disease, and 17 (89%) of 19 patients with grade 3 disease. We demonstrated no correlation between MUC7 and the clinicopathologic features (tumor stage, grade, or size) of urinary bladder tumors.

CONCLUSIONS

Our results indicate that MUC7 is a potential marker for bladder cancer. This noninvasive detection method assesses urothelial cells from voided urine specimens using RT-PCR.

Concurrent cisplatin, 5-fluorouracil, leucovorin, and radiotherapy for invasive bladder cancer

PURPOSE

To investigate the tolerance and efficacy of a modified concurrent chemoradiation (CCRT) protocol for patients with invasive bladder cancer "unfit" for radical cystectomy.

METHODS AND MATERIALS

Twenty-three muscle-invasive bladder cancer patients who were unfit for or unwilling to receive radical cystectomy were enrolled in this study. All patients had transitional cell carcinoma of bladder, and distribution of stage was 14 (61%), 1 (4%), and 8 (35%) for T3a, T3b, and T4, respectively. This study included a relatively old-age population, with the median age being 75 and 70% of patients over 70 years old. Patients were treated with maximal transurethral resection of the bladder tumor followed by curative CCRT. The chemotherapy (C/T) regimen was comprised of cisplatin, 50 mg/m(2) intravenously (i.v.) on Day 1; 5-fluorouracil (5-FU), 500 mg/m(2)/day by continuous i.v. infusion on Days 1-3; and leucovorin, 50 mg/day by continuous i.v. infusion on Days 1-3. Chemotherapy course was repeated at 21-day intervals. The radiation dose was 44-45 Gy to whole pelvis and 60-61.2 Gy to bladder, with a daily fraction of 1.8-2 Gy. The completeness of the CCRT protocol was defined as patients receiving at least 55 Gy of radiotherapy to the whole bladder and at least three courses C/T.

RESULTS

Seventy-four percent of patients (17/23) completed the CCRT protocol. Radiation Therapy Oncology Group (RTOG) Grade 3 acute toxicities were observed in 4 patients, which included leucopenia, vomiting, genitourinary (GU) tract infection, and diarrhea. No treatment-related deaths occurred during the CCRT period. RTOG Grade 3 or more late complications were observed in 3 patients; one of them died of radiation cystitis superimposed with GU infection. Of the 18 patients whose response to CCRT was evaluated, a complete tumor response was documented in 16 patients (89%). With a median follow-up of 3 years, the 3-year overall survival (OS) and disease-free survival (DFS) for all patients was 69% and 65% respectively. Meanwhile, the 3-year overall and DFS rates for patients who completed CCRT vs. those who did not complete CCRT were 82% vs. 33% and 75% vs. 33%, respectively (p = 0.18 for OS and p = 0.04 for DFS).

CONCLUSIONS

Concurrent cisplatin, 5-FU, leucovorin, and radiotherapy for treatment of invasive bladder cancer is a feasible and promising treatment even for relatively old patients. Our results are comparable to those in recent studies by using combined modality treatment or neoadjuvant chemotherapy plus radical cystectomy. Consequently, this novel protocol warrants a prospective clinical trial and may be a safe, effective alternative to radical cystectomy.

How important is urinary cytology in the diagnosis of urological malignancies?

OBJECTIVE

To audit clinical usefulness of urine cytology examination in a subspecialised urological unit setting.

PATIENTS AND METHODS

Data from the hospital information support system on urinary cytology examinations carried out at one centre was audited over a period of 15 months. Source of urine cytology specimens, clinical profile of patients and the findings of urinary cytology were analysed and collated.

RESULTS

A total of 1400 urinary cytology specimen on 900 patients were requested during 15 months study period. Urologists requested 1092 (78%) and non-urologists (general practitioners, physician or general surgeons) requested 318 (22%) specimens. The majority of specimens, 1115 (80%) did not show any cytological evidence of malignancy. 83 specimens (6%) showed cytological evidence of malignant cells consistent with origin from a urothelial malignancy. Among this group 87% (72) were more than 50 years of age and 60 (72%) had history of gross heamaturia. 159 (11.35) cases were reported as being suspicious of malignancy or showing atypical cells requiring further evidence. A total of 43 (3.04%) specimens were poorly preserved or insufficient for diagnosis. The positivity rate amongst urologist and non-urologists request was 56% and 6% respectively (p=0.00001 value). The source in 37 (86%) specimens reported, as poorly preserved or insufficient for diagnosis was non-urologists compared to 6 (14%) from urologists with significant p value (0.00001).

CONCLUSIONS

Urinary cytology for malignant cells is a contributory investigation in the diagnosis of urological malignancy. It should be only ordered in the proper clinical situation.

Molecular targeting and pharmacogenomics in the management of advanced bladder cancer

Bladder cancer is one of the malignancies for which considerable information is available regarding molecular pathogenesis and genetic predictors of natural history, as well as response to treatment. Loss of heterozygosity of chromosome 9 appears to be essential to the genesis of superficial bladder cancer, and mutation of the p53 suppressor gene frequently is associated with progression to invasive and metastatic disease. Many oncogenes, gene products, and suppressor gene mutations, including those of Ras, Myc, p53, Rb, p16, p21, thrombospondin-1, glutathione, and factors controlling expression and function of the epidermal growth factor receptor, have been shown to be involved in the biology of this disease. Retrospective studies have demonstrated that some of these factors have important roles as independent prognostic determinants or predictors of response to chemotherapy, and clinical trials have now been established to validate the utility of molecular prognostication in bladder cancer. Paradigms developed from the treatment of colorectal malignancy, in which the metabolism of cytotoxic agents is affected by genetic and racial factors, now are being applied to the management of bladder cancer. This review summarizes current knowledge in these evolving domains.

Progress in the chemotherapy of metastatic cancer of the urinary tract

Cytotoxic chemotherapy has an evolving role in the management of metastatic cancer of the bladder and urinary tract. The most responsive of these tumors are transitional cell carcinomas. Standard single agents (e.g., methotrexate, doxorubicin, mitomycin, ifosfamide, vinblastine, and cisplatin) have produced objective response rates of 15-25% and combination chemotherapy has resulted in objective regression in 40-75% of cases. The taxanes and gemcitabine are now being incorporated into combination regimens because they have activity against this disease, both in previously treated and untreated patients. In previously untreated patients, regimens incorporating gemcitabine and paclitaxel and a platinum complex, with or without ifosfamide or doxorubicin, produce median survival periods of 15-20 months. Contemporary experience with the methotrexate/vinblastine/doxorubicin/cisplatin regimen yields a median survival period of 18 months. Traditional cytotoxic regimens have been ineffective in the management of adenocarcinoma and squamous cell carcinoma of the bladder. However, regimens predicated on the taxanes and gemcitabine yield response rates of 30-40%, which may translate into improved survival. Nevertheless, stage migration may produce the semblance of improved survival, which may reflect reduced tumor burden (via reclassification) and case selection. Because historically controlled comparisons may introduce errors from case selection bias, stage migration, differences in duration of follow-up, and the evolution of supportive care, it is essential to validate the role of new agents in well structured, randomized clinical trials.

An organ-sparing treatment using combined intra-arterial chemotherapy and radiotherapy for muscle-invading bladder carcinoma

OBJECTIVE

We describe the results of an organ-sparing approach for the treatment of non-metastatic, invasive bladder carcinoma.

MATERIAL AND METHODS

Twenty-three patients (mean age 71 years; age range 47-87 years) with bladder carcinoma of clinical stage T2-T3N0M0 and histologically proven muscle invasion were examined between 1992 and 1998. The median duration of follow-up was 30 months. The treatment protocol for intra-arterial chemotherapy consisted of methotrexate 30 mg/m(2) and cisplatin 50 mg/m(2) in 7 patients and cisplatin 50 mg/m(2) in 16 patients, administered in three cycles via catheters inserted in the internal iliac arteries. Concomitantly, 41.4 Gy of radiotherapy was given to the lesser pelvis. Transurethral biopsy and urine cytology were performed after the completion of treatment; patients were followed observationally if residual tumor was absent, and underwent radical cystectomy if it was present.

RESULTS

At the end of treatment, 18 patients (78%) showed a complete response (CR) and the bladder was spared in all cases. Radical cystectomy was performed for 4 non-CR cases, with the result that 2 cases had residual superficial cancer and the other 2 had muscle-invading cancer histologically. Among the patients with a CR, 2 experienced intravesical recurrence. Overall, 2 patients died of cancer, 5 died of other causes and 2 died during treatment. The 5-year disease-specific survival rate was 70.3% and the overall survival rate 46.4%.

CONCLUSIONS

A bladder-sparing approach for the treatment of muscle-invading bladder carcinoma which utilizes combined intra-arterial chemotherapy and radiotherapy may arrest the decline in quality of life induced by urinary diversion and yield equivalent therapeutic benefit to that of radical cystectomy.

CD44 standard form expression as a predictor of progression in high risk superficial bladder tumors

OBJECTIVE

The purpose of this study was to assess the significance of the standard CD44 adhesion molecule expression in predicting progression of high risk superficial bladder carcinoma in the short term.

METHODS

Sixty-six patients (51 males and 15 females, aged 27 to 89 years (mean 64.75 years) with primary superficial transitional cell bladder cancer initially treated with transurethral resection (TURBT) were enrolled in the study. Only pTa/pT1 grade 2 multiple tumors as well as all grade 3 tumors were included in this study. All tumor samples obtained after the resection were immunohistochemically evaluated for the expression of the CD44 standard molecule. Fifty eight patients remained during the follow up period which ranged from 3 to 36 months (mean 11.8 months). Tumor progression in the short term was considered as the critical end point of interest in this study. The prognostic significance of tumor stage, grade, presence of carcinoma-in-situ (CIS) and expression of CD44 in determining the risk for progression, was studied with both univariate (log rank test) and multivariate (Cox proportional hazards) methods of analysis.

RESULTS

Kaplan-Meier survival curves indicated that a shorter median progression-free survival is expected for those patients with G3 bladder tumors (p = 0.0055), concomitant CIS (p = 0.0051), and loss of expression of CD44 (p = 0.0015), whereas a similar association with stage was not detected (p = 0.5793). The cox regression multivariate analysis did not yield a significant result for any of the studied parameters therefore no one of the factors taken into account can serve as an independent predictor of progression in superficial bladder cancer in the short term.

CONCLUSION

The immunohistochemically detectable loss of the expression of CD44 standard form from superficial bladder tumor samples may be, complementary to the established prognostic factors, a useful predictor of tumor progression in the short term.

[Neoplastic pathology of the urothelium]

Bladder cancer is one of the most common diseases treated by urologists. In this article, we will try to review some of the controversies and all the available data which come from the systematic review and meta-analysis.

Evaluation of cytokeratin-19 & cytokeratin-20 and interleukin-6 in Egyptian bladder cancer patients

OBJECTIVES

This study was designed to detect the expression of CK-19 and CK-20 in tissue specimens and IL-6 in the sera (as a noninvasive maneuver) of bladder cancer patients. Results were correlated with the clinico-pathologic parameters, Bilharziasis and the occurrence of relapse of the carcinoma among Egyptian bladder cancer patients.

METHODS

Subjects of this study were 50 cases of bladder carcinoma (19 cases were positive for Bilharziasis) as well as 20 cystitis cases as control (7 cases were positive for Bilharziasis). Messenger ribonucleic acid extracted from fresh frozen tissue specimens with bladder tumor and the control group were collected and subjected to RT-PCR to detect expression of the amplification bands of CK-19 and CK-20 (214 and 370 base pairs). In the mean time, Interleukin-6 was quantified in the sera of the patients using ELISA kit.

RESULTS

CK-19 and CK-20 RNAs were expressed in bladder cancer cases, but not expressed in the control group. They were significantly correlated to advanced tumor stage and grade, while CK-19 positivity, was also, correlated to tumor recurrence and tumor pathology being more in SCC than TCC. Moreover, IL-6 positivity was correlated to the occurrence of malignancy, advanced grade and pathology being more in SCC than TCC. ROC curve was utilized to choose the best cut-off for serum IL-6 (49.2 pg/mL). At the determined cut-off, the sensitivity was 66% and the specificity was 95%. Bilharziasis was found to be related to advanced stages and grades of bladder cancer.

CONCLUSION

CK-19, CK-20 and IL-6 were strongly associated with malignant phenotype of Egyptian bladder tissues, so they may be used as additional markers for assessment of bladder cancer patients.

DD23 Biomarker: a prospective clinical assessment in routine urinary cytology specimens from patients being monitored for TCC

BACKGROUND

A prospective clinical study was conducted to assess the ability of the DD23 murine monoclonal antibody to enhance detection of bladder cancer in routine alcohol fixed urine cytology samples.

METHODS

Prospectively, 308 bladder cytology specimens were obtained from patients with a history of bladder cancer with a mean age of 71.4+/-11.9 (27% female, 73% male). Data included 121 biopsy-confirmed results and 187 cystoscopy results to assess presence or absence of cancer. Thirty-five normal cytology specimens were obtained from asymptomatic men and women between 55-85 years of age. Separate slides from the alcohol fixed cytology specimens were stained using the Papanicolaou (Pap) and Feulgen staining procedures. The DD23 assay was performed using an avidin-biotin alkaline phosphatase immunocytochemical procedure, with a single urothelial cell exhibiting intense immunostaining sufficient to make a positive call.

RESULTS

Pap-Feulgen cytopathology for the 308 cases yielded an overall sensitivity of 65.5% and a specificity of 85.1%, and the DD23 biomarker alone yielded a sensitivity of 80.5% and a specificity of 59.7%. Analysis of the voided urines only (n=164) yielded sensitivities of 61.0% and 73.2% and specificities of 86.2% and 67.5% for cytopathology and DD23 alone, respectively. Results in 49 bladder wash urine cytology cases produced a sensitivity of 70.2% and 100% and specificities of 92.3% and 61.5% for cytopathology and DD23 alone, respectively. In 133 patients that underwent biopsy or had positive cystoscopy results, cytopathology yielded a sensitivity of 65.5% and a specificity of 69.6% while DD23 yielded a sensitivity of 80.5% and a specificity of 58.7%. In 25 biopsy-confirmed low-grade cancers, DD23 improved cancer detection from 32% to 72% when compared to cytopathology. The DD23 biomarker had a specificity of 85.7% in 35 age-matched normal asymptomatic control specimens.

CONCLUSIONS

The DD23 biomarker is an adjuvant test that provides improved detection of bladder cancer in cytology specimens and enhances the sensitivity of the cytopathology diagnosis, especially in low-grade cancers.

Gender-related differences in basal DNA damage in lymphocytes of a healthy Indian population using the alkaline Comet assay

The Comet assay, a sensitive, rapid and non-invasive technique, measures DNA damage in individual cells and has found wide acceptance in epidemiological and biomonitoring studies to determine the DNA damage resulting from lifestyle, occupational and environmental exposure. The present study was undertaken to measure the basal level of DNA damage in a normal, healthy Indian male and female population. Out of the 230 volunteers included in this study, 124 were male and 106 were female. All the individuals belonged to a comparable socio-economic background and aged between 20 and 30 years. They were also matched for their smoking and dietary habits. The period of sample collection was also matched. The results revealed a statistically significant higher level of DNA damage in males when compared to females as evident by an increase in the Olive tail moment [3.76+/-1.21 (arbitrary units) for males as compared to 3.37+/-1.47 for females (P<0.05)], tail DNA (%) [10.2+/-2.96 for males as compared to 9.40+/-2.83 for females (P<0.05)] and tail length (microm) [59.65+/-9.23 for males and 49.57+/-14.68 for females (P<0.001)]. To our knowledge, this report has, for the first time demonstrated significant differences in the basal level of DNA damage between males and females in a normal healthy Indian population.

Progression to detrusor-muscle invasion in bladder carcinoma is associated with polysomy of chromosomes 1 and 8 in recurrent pTa/pT1 tumours

Transitional cell carcinoma (TCC) provides a unique model of cancer recurrence and progression. Sequential tumours (n=100) from 57 patients with an index pTa or pT1 TCC were studied using fluorescence in situ hybridisation (FISH), to determine aberrations of chromosomes 1 and 8. Thirty-seven patients experienced recurrences; eleven developed muscle invasive tumours (pT2+). Polysomy of chromosomes 1 or 8 was associated with pT1 TCC (P=0.0017 and P=0.0037, respectively), but not with recurrence. Progression was associated with polysomy of chromosomes 1 (P=0.003) and 8 (P=0.011) in pTa/pT1 recurrences, but not with stage. In conclusion, patients who subsequently developed invasive TCC (pT2+) had significantly higher rates of aneusomy (90%) in their superficial cancers than those patients who did not progress (P=0.009). Investigation of sequential tumours in patients with recurrent and progressive TCC showed that polysomy of chromosomes 1 and 8 were linked to subsequent detrusor muscle invasion, but not recurrence per se.

Preoperative plasma levels of transforming growth factor beta(1) strongly predict clinical outcome in patients with bladder carcinoma

BACKGROUND

Elevated local and circulating levels of transforming growth factor (TGF)-beta(1) have been associated with cancer invasion, progression, and metastasis. The authors tested the hypothesis that preoperative plasma TGF-beta(1) levels would independently predict cancer stage and prognosis in patients with transitional cell carcinoma (TCC) of the urinary bladder.

METHODS

The study group consisted of 51 patients who underwent radical cystectomy for muscle-invasive or intravesical immuno- and/or chemotherapy refractory Tis, Ta, or T1 TCC (median follow-up, 45.7 months). Preoperative plasma levels of TGF-beta(1) were measured and correlated with pathologic features and clinical outcome. Transforming growth factor-beta(1) levels also were measured in 44 healthy men without any cancer.

RESULTS

The mean preoperative plasma TGF-beta(1) level in patients who eventually developed metastases to distant (11.9 +/- 0.9 ng/mL) or regional (9.6 +/- 2.4 ng/mL) lymph nodes was significantly higher than that in patients with nonmetastatic muscle-invasive TCC (5.4 +/- 1.1 ng/mL), which, in turn, was significantly higher than that in patients with nonmetastatic Tis, Ta, or T1 TCC (4.5 +/- 1.2 ng/mL) and healthy subjects (4.5 +/- 1.2 ng/mL; P < 0.001). Preoperative plasma TGF-beta(1) level was an independent predictor of lymphovascular invasion (P = 0.002), metastases to lymph nodes (P = 0.030), disease recurrence (P = 0.009), and disease specific survival (P = 0.015). In a subgroup of patients with muscle-invasive TCC, TGF-beta(1) level was associated with disease recurrence (P = 0.005) and death from bladder carcinoma (P = 0.001).

CONCLUSIONS

The authors confirm that plasma TGF-beta(1) levels are elevated in patients with muscle-invasive TCC before cystectomy. Transforming growth factor-beta(1) levels are highest in patients with bladder carcinoma metastatic to lymph nodes and are a strong independent predictor of disease recurrence and disease specific mortality.

Utility of serial urinary tumor markers to individualize intervals between cystoscopies in the monitoring of patients with bladder carcinoma

BACKGROUND

Cross-section studies have shown the diagnostic characteristics of certain urinary tumor markers for the detection of bladder carcinoma. However, the role of serial urinary tumor markers in the monitoring of patients with bladder carcinoma in daily clinical surveillance has not been completely defined yet.

METHODS

The study comprised 1185 urine samples belonging to 232 patients with a previous bladder carcinoma: 106 patients under follow-up (Group 1) and 126 bladder carcinoma patients receiving intravesic instillations (Group 2). Patients were monitored with urinary tumor markers during a one-year follow-up period. Urine samples were collected before cystoscopies and in the intercystoscopic periods for patients in Group 1 and before intravesic instillations for patients Group 2. Urinary bladder carcinoma antigen (UBC), CYFRA 21-1 and nuclear matrix proteins (NMP22) were measured by immunoassays.

RESULTS

Monitoring of the disease with urinary tumor markers could detect recurrence sooner than scheduled cystoscopies in 27 patients (87%) for UBC, 27 patients (87%) for CYFRA 21-1, and 26 patients (84%) for NMP22 out of 31 Group 1 patients who recurred; and in 16 patients (67%) for UBC, 17 patients (71%) for cytokeratin fragments (CYFRA) 21-1, and 13 patients (54%) for NMP22 out of 24 Group 2 patients who recurred. The most relevant finding was that persistence of negative urinary markers during follow-up was largely indicative of disease free status in 65 of 75 (87%) patients of Group 1 and 31 of 102 (30%) cases of Group 2. Although false positive results were present, they were mainly associated with sporadic urinary tract infections in 10 of 75 (13%) cases of Group 1 and in 36 of 102 (35%) patients of Group 2; and with urine samples collected in the first two months at the beginning of intravesic therapy in 35 of 102 patients (34%) in Group 2.

CONCLUSIONS

Monitoring of bladder carcinoma patients with serial urinary tumor markers could anticipate detection of recurrence. Persistent negative results might postpone and reduce the number of cystoscopies. Once the limitations leading to false positive results are controlled by urinalysis and by starting sample collection when basal levels are reached in patients with intravesic therapy, urinary tumor markers might eventually individualize the intervals between cystoscopies in the surveillance of patients with bladder carcinoma.

Diagnostic performance of the urinary bladder carcinoma antigen ELISA test and multiparametric DNA/cytokeratin flow cytometry in urine voided samples from patients with bladder carcinoma

BACKGROUND

The objective of the current study was to comparatively analyze the sensitivity and specificity of flow cytometric DNA/cytokeratin 8/18 measurements and the urinary bladder carcinoma antigen (UBC) enzyme linked immunoabsorbent assay (ELISA) test for the detection of bladder carcinoma in voided urine samples.

METHODS

Eighty-one fresh urine voided samples, preserved frozen for a maximum period of 3 months, belonging to patients with an active bladder carcinoma (n = 37), patients who were free of disease as confirmed by cystoscopy (n = 19), patients receiving intravesical therapy (n = 17), and individuals with other benign and malignant conditions (n = 8), were collected. Flow cytometry measurements of thawed samples were based on the detection of cytokeratin (CK) 8+ and CK18+ cells using the 3F3 and 6D7 monoclonal antibodies alone or in combination with the measurement of cell DNA contents, after propidium iodide staining. Urinary bladder carcinoma antigen test was measured by ELISA.

RESULTS

Patients were grouped according to the presence (n = 44) or absence (n = 29) of bladder carcinoma as confirmed by cystoscopy, and taking cutoffs of 9.7 microg/L for UBC-ELISA, 75% for the percentage of 3F3 (+) and 6D7 (+) cells, and 10.6% for the proportion of hyperdiplod cells that suggested a specificity of 83%, the individual sensitivity obtained for each parameter was 77%, 5%, 9%, and 77%, respectively. The presence of DNA aneuploid populations showed a relatively low sensitivity (36%) although it was the most specific parameter (93%). Combining UBC antigen test with the proportion of cells showing DNA content higher than 2n increased to 89% the sensitivity of the UBC antigen alone. However, false-positive results for both techniques were found in individuals with urologic diseases other than bladder carcinoma and in patients receiving intravesical therapy.

CONCLUSIONS

The authors' results suggest that the combined use of the UBC antigen test and DNA/cytokeratin flow cytometry double stainings for the analysis of freshly obtained urine voided samples, cryopreserved to assure cellular integrity, is of great clinical utility for the detection of tumor recurrence in patients with bladder carcinoma.

Potent antitumor effects of CD154 transduced tumor cells in experimental bladder cancer

PURPOSE

Current intravesical immunotherapy for bladder cancer with bacillus Calmette-Guerin instillations is standard treatment for patients with high risk superficial tumors but relapses are common. We evaluated the tumor vaccine concept in murine bladder cancer by comparing tumor cell transduction with genes coding for the immunostimulatory molecules CD154, interleukin (IL)-12 and CD80 to design a novel vaccination strategy.

MATERIALS AND METHODS

Adenoviral vectors were used to transduce murine bladder cancer MB-49 cells with genes coding for CD154, IL-12 and CD80. Parental or transduced MB-49 cells were injected subcutaneously into syngeneic mice. The effects of transgene expression on tumorigenicity and the generation of protective immunological memory against challenge with parental tumor were studied.

RESULTS

All 76 animals injected with parental MB-49 cells had tumors within 8 to 12 days. Tumor cell expression of CD154 combined with IL-12 completely inhibited tumor outgrowth with all 21 mice tumor-free and CD154 transduction alone was almost as effective with 33 of 35 tumor-free. IL-12 production by tumor cells delayed tumor outgrowth and 4 of 10 mice remained tumor-free. Over expression of CD80 had no effect on tumorigenicity. CD154 expressing tumors were rapidly infiltrated with large numbers of CD4+ and CD8+ T cells. Mice vaccinated 4 times with adenoviral CD154 transduced MB-49 cells were completely protected against challenge with parental tumor. Co-injection of CD154 modified cells with parental MB-49 cells retarded tumor growth.

CONCLUSIONS

Our experimental results suggest that the potent antitumor effects of CD154 gene transduction should be considered for immunostimulatory gene therapy for bladder cancer.

Muscle-invasive transitional cell carcinoma of the urinary bladder: a population-based study of patterns of care and prognostic factors

PURPOSE

Population-based cancer registries can permit the study of the survivorship of all patients with a particular diagnosis regardless of patterns of referral and practice within a specific geographic distribution. The purpose of this study is to describe the patterns of care, outcome, and prognostic factors for bladder cancer in the northern region of the province of Alberta, Canada, between 1984 and 1993.

METHODS AND MATERIALS

Between 1984 and 1993, 184 patients from northern Alberta were identified from the Alberta Cancer Registry as having undergone curative treatment for biopsy-proven muscle-invasive transitional cell carcinoma of the bladder. Data were obtained, by retrospective chart review, regarding the staging, pathology, treatment, and outcome of patients treated in the northern Alberta cities of Edmonton, Grande Prairie, and Red Deer, regardless of the responsible treating institution. The prognostic significance of patient-, tumor-, and treatment-related variables were tested using univariate and multivariate analysis using the Cox proportional-hazard model.

RESULTS

As the primary treatment modality, 74 patients (40%) received radical radiotherapy (RT) without surgery; surgery was used alone in 81 patients (44%), and was combined with preoperative or postoperative radiotherapy in 29 patients (16%). Seventy-three (40%) patients also received concurrent, neoadjuvant, or adjuvant chemotherapy. The Kaplan-Meier estimate of median survival was 2.2 years, and the 5-year overall survival was 30%. Univariate analysis demonstrated the prognostic significance of T classification (p < 0.001), lymph node involvement (p < 0.001), complete response to RT (p = 0.001), hydronephrosis (p = 0.017), and vascular/lymphatic involvement (p = 0.035). Multivariate analysis revealed the following to have a significant association with survival: T classification (p = 0.001), lymph node involvement (p = 0.004), complete response to RT (p = 0.054), hydronephrosis (p = 0.019), and use of chemotherapy in the treatment regimen (p = 0.025).

CONCLUSION

The strongest prognostic factors in this study were tumor related, and no significant differences in survival were detected between patients treated with primary surgery vs. organ-preservation approaches. A survival advantage associated with the incorporation of chemotherapy into the management schema was detected on multivariate, but not univariate, analysis. Stratification of patients based on tumor characteristics is imperative in clinical trials for invasive bladder cancer. Novel treatment approaches are required to improve survival further in patients with apparently localized disease.