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Teng C, Lu W, Che J, Wu Y, Meng D, Shan Y. Association of Pro-Inflammatory Diet, Smoking, and Alcohol Consumption with Bladder Cancer: Evidence from Case-Control and NHANES Studies from 1999 to 2020. Nutrients 2024; 16:1793. [PMID: 38892724 PMCID: PMC11174752 DOI: 10.3390/nu16111793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND AND PURPOSE Diet might be a modifiable factor in preventing cancer by modulating inflammation. This study aims to explore the association between the dietary inflammatory index (DII) score and the risk of bladder cancer (BC). METHODS A total of 112 BC patients and 292 control subjects were enrolled in a case-control trial. Additionally, we tracked a total of 109 BC patients and 319 controls, whose propensity scores were obtained from the Nutrition Examination Survey (NHANES) database spanning from 1999 to 2020. The baseline index and dietary intake data were assessed using a food frequency questionnaire (FFQ). DII scores were calculated based on the dietary intake of 20 nutrients obtained from participants and categorized into four groups. The association between the inflammatory potential of the diet and BC risk was investigated using multivariate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS High DII scores were associated with a pro-inflammatory diet and a higher risk of BC, with higher DII scores positively associated with a higher risk of BC (quartiles 4 vs. 1, ORs 4.89, 95% CIs 2.09-11.25 p < 0.001). Specifically, this might promote BC development by inducing oxidative stress and affecting DNA repair mechanisms. This result was consistent with the NHANES findings (quartiles 4 vs. 1, ORs 2.69, 95% CIs 1.25-5.77, p = 0.006) and further supported the association of pro-inflammatory diet and lifestyle factors with the risk of BC. CONCLUSIONS Diets with the highest pro-inflammatory potential were associated with an increased risk of BC. By adjusting lifestyle factors, individuals might effectively lower their DII, thereby reducing the risk of developing BC. The results are consistent with the NHANES cohort.
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Affiliation(s)
- Chunying Teng
- Department of Food Science and Engineering, School of Chemistry and Chemical Engineering, Harbin Institute of Technology, Harbin 150001, China;
| | - Weihong Lu
- Department of Food Science and Engineering, School of Chemistry and Chemical Engineering, Harbin Institute of Technology, Harbin 150001, China;
| | - Jiawen Che
- School of Public Health, Wenzhou Medical University, Wenzhou 325000, China; (J.C.); (Y.W.); (D.M.)
| | - Yanhong Wu
- School of Public Health, Wenzhou Medical University, Wenzhou 325000, China; (J.C.); (Y.W.); (D.M.)
| | - Danqun Meng
- School of Public Health, Wenzhou Medical University, Wenzhou 325000, China; (J.C.); (Y.W.); (D.M.)
| | - Yujuan Shan
- School of Public Health, Wenzhou Medical University, Wenzhou 325000, China; (J.C.); (Y.W.); (D.M.)
- Southern Zhejiang Institute of Radiation Medicine and Nuclear Technology, Wenzhou Medical University, Wenzhou 325035, China
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2
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Rangel MMM, Linhares LCM, de Oliveira KD, Suzuki DOH, Maglietti FH, de Nardi AB. Evaluation of the safety and feasibility of electrochemotherapy with intravenous bleomycin as local treatment of bladder cancer in dogs. Sci Rep 2023; 13:21078. [PMID: 38030630 PMCID: PMC10687251 DOI: 10.1038/s41598-023-45433-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Local treatment of canine urothelial carcinoma (UC) of the bladder is a challenge. More than 90% of the cases invade the muscular layer, more than 50% develop on bladder sites with a difficult surgical approach and often requiring radical surgical procedures. This study aims to evaluate the safety and feasibility of electrochemotherapy (ECT) with intravenous bleomycin (BLM) as a local therapy for bladder UC. This prospective study included 21 dogs with spontaneous bladder UC. Regional/distant metastases and neoplastic infiltration of the serosa was considered the main exclusion criteria. We had no deaths during ECT or in the immediate postoperative period, and no suture dehiscence. Most dogs (19/21) developed mild adverse effects, whereas two dogs developed ureteral stenosis. Complete response (CR) was achieved in 62% of the cases (13/21), while partial response (PR) was achieved in 24% (5/21). The median survival and disease-free survival times were 284 and 270 days, respectively. Overall survival was significantly better in the dogs who achieved a CR. In conclusion, ECT was well-tolerated in dogs with UC, demonstrating its safety and feasibility. These data pave the way for new studies aimed at evaluating the effectiveness of ECT in canine bladder UC as a translational model for human disease.
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Affiliation(s)
| | - Laís Calazans Menescal Linhares
- School of Agricultural and Veterinary Sciences, São Paulo State University (UNESP) "Júlio de Mesquita Filho", Jaboticabal, São Paulo, Brazil.
| | | | - Daniela Ota Hisayasu Suzuki
- Institute of Biomedical Engineering, Federal University of Santa Catarina (UFSC), Florianopolis, Santa Catarina, Brazil
| | - Felipe Horacio Maglietti
- Instituto Universitario de Ciencias de la Salud. Fundación Barceló-CONICET, Buenos Aires, Argentina
| | - Andrigo Barboza de Nardi
- School of Agricultural and Veterinary Sciences, São Paulo State University (UNESP) "Júlio de Mesquita Filho", Jaboticabal, São Paulo, Brazil
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3
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Awad M, Harraz AM, Farg H, Gabr HS, Sharaf DE, Abou-El-Ghar M, El-Hefnawy AS, Osman Y. Microscopic hematuria and pelvic ultrasonography could rule out flexible cystoscopy during surveillance for T1-low grade non-muscle invasive bladder cancer. Arab J Urol 2023; 21:150-155. [PMID: 37521447 PMCID: PMC10373612 DOI: 10.1080/2090598x.2023.2202930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/09/2023] [Indexed: 08/01/2023] Open
Abstract
Purpose Cystoscopy (rigid/flexible [FC]) is the standard surveillance tool for non-muscle invasive bladder cancer (NMIBC). Nevertheless, it has its drawbacks. The objective of this study is to evaluate the performance of microscopic hematuria (MH), abdominal ultrasonography (US), and urine cytology (UC) as potential substitutes for FC in patients with T1-low-grade (T1-LG) NMIBC. Methods Over a 12-month period, patients attending our tertiary referral center for T1-LG NMIBC follow-up underwent urine analysis for MH and UC, and then US and FC were performed as outpatient surveillance procedures. Those with positive findings underwent inpatient rigid cystoscopy under anesthesia and biopsy. The negative predictive values (NPV) and sensitivity of different combinations of MH, UC, US, and FC were compared with the standard histopathology. Results In 218 evaluated patients, FC had the highest NPV (97.9%). However, this figure showed no statistically significant difference if compared with the combination of negative MH and US (93.8%) (difference = 0.04, p = 0.1) or the combination of MH, US, and UC (94.9%) (difference = 0.03, p = 0.2). The reported sensitivity results were similarly comparable between FC (94.2%) and the aforementioned combinations (90.4% and 92.3%; differences: 0.038 and 0.019; p = 0.4 and 0.7, respectively). Conclusions During the surveillance of NMIBC for patients diagnosed with T1-LG disease, the combination of MH/US has comparable sensitivity and NPV with FC. This non-invasive combination could be considered the first station that might preclude the need for FC in a considerable percentage of this group of patients.
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Affiliation(s)
- Mohamed Awad
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | - Ahmed M. Harraz
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | - Hashim Farg
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | - Hady S. Gabr
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | - Doaa E. Sharaf
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
| | | | | | - Yasser Osman
- Urology and nephrology center, Mansoura University, Mansoura, Egypt
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4
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Will repeat resection after initial transurethral en bloc resection benefit patients with high-risk non-muscle-invasive bladder cancer? A propensity score matching analysis. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04564-3. [PMID: 36585983 DOI: 10.1007/s00432-022-04564-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/27/2022] [Indexed: 01/01/2023]
Abstract
PURPOSE To evaluate the efficacy of repeat transurethral resection on restaging, preventing tumor recurrence and progression in high-risk non-muscle invasive bladder cancer patients who received initial en bloc resection. METHODS AND PATIENTS We reviewed retrospectively the clinical records of 330 consecutive patients who received en bloc resection for non-muscle invasive bladder cancer. Eligible patients with and without repeat transurethral resection were matched 1:1 by propensity score. Important covariates were balanced between the two groups. We compared the recurrence-free survival, progression-free survival, recurrence rate, and progression rate between groups. And the perioperative results regarding residual tumors and the safety of the repeat resection were also evaluated. RESULTS Finally, there are 245 patients included in our analysis with a median follow-up duration of 19 months (range 3-50). Detrusor muscle presented in 244 (99.6%) specimens at initial en bloc resection. And among them, 30 (12.2%) patients had undergone a repeat resection and 215 (87.8%) did not. After 1:1 propensity score matching, 30 pairs were further analyzed.No case of upstaging was identified in repeat resection. During the follow-up, recurrence was observed in 5 (16.7%) and 7 (23.3%) patients in reresection group and non-reresection group, respectively. And progression was found only in 1 (3.3%) patient in each group. The 1-year recurrence-free survival estimates were comparable (86.7% vs 83.3%, p = 0.86) between groups. CONCLUSION Our study demonstrates that repeat resection after initial transurethral en bloc resection for bladder tumor appears not to improve staging accuracy, recurrence, and progression.
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5
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Hu H, Zhou M, Yang B, Zhou S, Liu Z, Zhang J. A Systematic Review on the Role of Repeat Transurethral Resection after Initial en Bloc Resection for Non-Muscle Invasive Bladder Cancer. J Clin Med 2022; 11:jcm11175049. [PMID: 36078978 PMCID: PMC9456573 DOI: 10.3390/jcm11175049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
International guidelines recommend repeat transurethral resection of bladder tumors (reTURB) for selected patients with high-risk non-muscle invasive bladder cancer to remove possible residual tumors, restage tumors and improve the therapeutic outcome. However, most evidence supporting the benefits of reTURB is from conventional TURB. The role of reTURB in patients receiving initial En bloc resection of bladder tumor (ERBT) is still unknown. PubMed, Embase, Web of Science, The Cochrane Library, and China National Knowledge Infrastructure (CNKI) were systematically searched. Finally, this systematic review and meta-analysis included twelve articles, including 539 patients. The rates of residual tumor and tumor upstaging detected by reTURB after ERBT were 5.9% (95%CI, 2.0%–11.1%) and 0.0% (95%CI, 0.0%–0.5%), respectively. Recurrence-free survival, tumor recurrence and progression were comparable between patients with and without reTURB after initial ERBT. The pooled hazard ratios of 1-year, 2-year, 3-year and 5-year recurrence-free survival were 0.74 (95%CI, 0.36–1.51; p = 0.40), 0.76 (95%CI, 0.45–1.26; p = 0.28), 0.83 (95%CI, 0.53–1.32; p = 0.43) and 0.83 (95%CI, 0.56–1.23; p = 0.36), respectively. The pooled relative risks of recurrence and progression were 0.87 (95%CI, 0.64–1.20; p = 0.40) and 1.11 (95%CI, 0.54–2.32; p = 0.77), respectively. Current evidence demonstrates that reTURB after ERBT for bladder cancer can detect relatively low rates of residual tumor and tumor upstaging and appears not to improve either recurrence or progression.
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Affiliation(s)
- Henglong Hu
- Department of Urology, Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
| | - Mengqi Zhou
- Department of Urology, Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
- College of Life Science and Technology, Huazhong University of Science and Technology, 1037 Luoyu Road, Wuhan 430074, China
| | - Binrui Yang
- Department of Urology, Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
- College of Life Science and Technology, Huazhong University of Science and Technology, 1037 Luoyu Road, Wuhan 430074, China
| | - Shiwei Zhou
- Department of Urology, Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
- College of Life Science and Technology, Huazhong University of Science and Technology, 1037 Luoyu Road, Wuhan 430074, China
| | - Zheng Liu
- Department of Urology, Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
| | - Jiaqiao Zhang
- Department of Urology, Institute of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
- Correspondence: ; Tel.: +86-027-8366-5307
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Prediction of Bladder Cancer Treatment Side Effects Using an Ontology-Based Reasoning for Enhanced Patient Health Safety. INFORMATICS 2021. [DOI: 10.3390/informatics8030055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Predicting potential cancer treatment side effects at time of prescription could decrease potential health risks and achieve better patient satisfaction. This paper presents a new approach, founded on evidence-based medical knowledge, using as much information and proof as possible to help a computer program to predict bladder cancer treatment side effects and support the oncologist’s decision. This will help in deciding treatment options for patients with bladder malignancies. Bladder cancer knowledge is complex and requires simplification before any attempt to represent it in a formal or computerized manner. In this work we rely on the capabilities of OWL ontologies to seamlessly capture and conceptualize the required knowledge about this type of cancer and the underlying patient treatment process. Our ontology allows case-based reasoning to effectively predict treatment side effects for a given set of contextual information related to a specific medical case. The ontology is enriched with proofs and evidence collected from online biomedical research databases using “web crawlers”. We have exclusively designed the crawler algorithm to search for the required knowledge based on a set of specified keywords. Results from the study presented 80.3% of real reported bladder cancer treatment side-effects prediction and were close to really occurring adverse events recorded within the collected test samples when applying the approach. Evidence-based medicine combined with semantic knowledge-based models is prominent in generating predictions related to possible health concerns. The integration of a diversity of knowledge and evidence into one single integrated knowledge-base could dramatically enhance the process of predicting treatment risks and side effects applied to bladder cancer oncotherapy.
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Beyene A. A Retrospective Analysis of Clinical and Pathologic Characteristics of Recurrent Bladder Tumor in a Tertiary Hospital in Addis Ababa, Ethiopia. Ethiop J Health Sci 2021; 31:779-784. [PMID: 34703177 PMCID: PMC8512944 DOI: 10.4314/ejhs.v31i4.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/04/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Previous recurrences, tumor category (Ta, T1), the presence of CIS with superficial bladder tumors, the number of tumors, tumor size and multiplicity are predictors of bladder tumor recurrence. Recurrence is better predicted by multiplicity, size and previous recurrence. METHODS This is retrospective descriptive study. All patients with urinary bladder tumor admitted to TASH from January 1st, 2018 to December 31st, 2019 is the study population. Information was retrieved using structured questionnaire. RESULTS Most of the recurrent tumors 55 (76.4%) had huge size and were multiple 62 (86.1%) in the primary presentation. Most recurrent tumors 47 (65.3%) are low grade bladder tumors. About 17 (23.6%) were high grade tumor in their primary presentation. European studies showed size and multiplicity increase risk of recurrence. However, our patients have late presentations which probably made the proportion of recurrence higher. CONCLUSION Most of the recurrent bladder tumors have huge size and multiple in number at their initial presentation. All histological variants of Urothelial carcinomas recur.
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Affiliation(s)
- Andualem Beyene
- Dept. Surgery, School of Medicine, College of Health Sciences, Addis Ababa University
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8
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The Use of Urine Mycobacterium tuberculosis Complex Polymerase Chain Reaction as a Predictive Factor for Recurrence and Progression After Intravesical Bacillus Calmette-Guérin Therapy in Patients with Non-muscle‑invasive Bladder Cancer. EUR UROL SUPPL 2021; 27:10-18. [PMID: 34337512 PMCID: PMC8317891 DOI: 10.1016/j.euros.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 12/30/2022] Open
Abstract
Background Intravesical bacillus Calmette-Guérin (BCG) instillation is a standard treatment for non–muscle-invasive bladder cancer (NMIBC); however, not all patients benefit from BCG therapy. Currently, no surrogate marker exists to predict BCG efficacy, and thereby, identify patients who will benefit from this treatment. Objective To evaluate the utility of urine Mycobacterium tuberculosis complex polymerase chain reaction (MTC-PCR) assay as a predictive marker for recurrence and progression following BCG therapy. Design, setting, and participants A prospective analysis was carried out for of intermediate- or high-risk NMIBC patients who received BCG instillation for the first time. Urine samples, for MTC-PCR assay, were collected at baseline and annually for up to 10 yr after the last BCG instillation, including induction and maintenance therapy. The first postoperative sample for MTC-PCR was taken at 1 yr from the last instillation. Outcome measurements and statistical analysis A survival analysis was performed using the Kaplan-Meier method, and risk factors for recurrence and progression after BCG treatment were assessed using Cox regression analysis. Results and limitations During follow-up (median: 57 mo), 468/521 samples (89.8%) were MTC-PCR positive, and 108/123 patients (87.8%) exhibited MTC-PCR positivity at least once. Five-year recurrence- and progression-free survival in patients who were not MTC-PCR positive was significantly lower than in patients who were MTC-PCR positive at least once (p < 0.001). Using multivariable Cox regression analysis, MTC-PCR positivity at least once was a significant prognostic factor for recurrence (hazard ratio [HR]: 36.782, p < 0.001) and progression (HR: 47.209, p < 0.001). Conclusions Patients who were not MTC-PCR positive, even once after BCG therapy, were extremely likely to exhibit recurrence and progression. Urine MTC-PCR may be an extremely useful, noninvasive surrogate marker to predict recurrence and progression following BCG therapy. Patient summary Urine Mycobacterium tuberculosis complex polymerase chain reaction may be a novel biomarker capable of identifying patients at risk of recurrence and progression after bacillus Calmette-Guérin (BCG) immunotherapy.
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9
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Malde S, Grover S, Raj S, Yuan C, Nair R, Thurairaja R, Khan MS. A Systematic Review of the Efficacy and Safety of Outpatient Bladder Tumour Ablation. Eur Urol Focus 2021; 8:141-151. [PMID: 33602641 DOI: 10.1016/j.euf.2021.01.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/09/2021] [Accepted: 01/25/2021] [Indexed: 11/04/2022]
Abstract
CONTEXT Management of non-muscle-invasive bladder cancer (NMIBC) is costly and associated with negative health-related quality-of-life effects, in part because of the frequent need for repeated transurethral resections under general/regional anaesthesia. Outpatient-based diathermy or laser ablation is another option, but evidence for its efficacy is mixed and its use is controversial. OBJECTIVE To systematically review evidence regarding the efficacy and safety of outpatient diathermy and laser ablation for the treatment of recurrent NMIBC. EVIDENCE ACQUISITION The EMBASE, MEDLINE/PubMed, and Cochrane Library were searched from inception to June 26, 2020. All studies evaluating the use of diathermy or laser ablation for bladder tumours (new or recurrent) in an outpatient setting under local anaesthetic were included. Two reviewers independently screened all articles, searched the reference lists of retrieved articles, and performed the data extraction. The quality of evidence and risk of bias were assessed using the GRADE and ROBINS-I tools. EVIDENCE SYNTHESIS The search yielded 1328 studies. After excluding duplicates, 1319 titles and abstracts were screened and 17 studies (1584 patients) were eligible for inclusion in the final review. The majority of patients had small, low-grade tumours, but there was heterogeneity in the inclusion criteria. Overall, laser ablation and diathermy resulted in mean recurrence rates of 47% and 32% at follow-up of 22-38 mo, respectively, with a mean progression rate of 3-12% (low certainty of evidence). Both procedures were well tolerated, with low pain scores and low periprocedural complication rates (moderate certainty of evidence). CONCLUSIONS Outpatient diathermy and laser ablation have good short-term efficacy in patients with low-grade NMIBC and reduce the need for intervention under general/regional anaesthesia. The procedures are well tolerated with low complication rates. The overall certainty of evidence is low, with heterogeneity between studies and methodological limitations. However, we have highlighted the need for randomised trials with long-term follow-up using standardised risk classification and outcome measures. Despite these limitations, the findings will aid in patient counselling regarding this less invasive treatment option that avoids the morbidity of transurethral resection. PATIENT SUMMARY Outpatient diathermy and laser ablation have good success rates in treating recurrent low-grade bladder tumours in the short term, avoiding the need for more invasive procedures under general/regional anaesthesia, with low rates of side effects. Further studies are needed to determine whether these treatments remain safe and effective in the long term.
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Affiliation(s)
- Sachin Malde
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | | | | | - Cathy Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, ON, Canada
| | - Rajesh Nair
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ramesh Thurairaja
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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10
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Marcq G, Kassouf W. Adjuvant Intravesical Therapy: Bacillus Calmette-Guerin. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Sathe G, George IA, Deb B, Jain AP, Patel K, Nayak B, Karmakar S, Seth A, Pandey A, Kumar P. Urinary glycoproteomic profiling of non-muscle invasive and muscle invasive bladder carcinoma patients reveals distinct N-glycosylation pattern of CD44, MGAM, and GINM1. Oncotarget 2020; 11:3244-3255. [PMID: 32922663 PMCID: PMC7456616 DOI: 10.18632/oncotarget.27696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/14/2020] [Indexed: 12/19/2022] Open
Abstract
Clinical management of bladder carcinomas (BC) remains a major challenge and demands comprehensive multi-omics analysis for better stratification of the disease. Identification of patients on risk requires identification of signatures predicting prognosis risk of the patients. Understanding the molecular alterations associated with the disease onset and progression could improve the routinely used diagnostic and therapy procedures. In this study, we investigated the aberrant changes in N-glycosylation pattern of proteins associated with tumorigenesis as well as disease progression in bladder cancer. We integrated and compared global N-glycoproteomic and proteomic profile of urine samples from bladder cancer patients at different clinicopathological stages (non-muscle invasive and muscle-invasive patients [n = 5 and 4 in each cohort]) with healthy subjects (n = 5) using SPEG method. We identified 635 N-glycopeptides corresponding to 381 proteins and 543 N-glycopeptides corresponding to 326 proteins in NMIBC and MIBC patients respectively. Moreover, we identified altered glycosylation in 41 NMIBC and 21 MIBC proteins without any significant change in protein abundance levels. In concordance with the previously published bladder cancer cell line N-glycoproteomic data, we also observed dysregulated glycosylation in ECM related proteins. Further, we identified distinct N-glycosylation pattern of CD44, MGAM, and GINM1 between NMIBC and MIBC patients, which may be associated with disease progression in bladder cancer. These aberrant protein glycosylation events would provide a novel approach for bladder carcinoma diagnosis and further define novel mechanisms of tumor initiation and progression.
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Affiliation(s)
- Gajanan Sathe
- Institute of Bioinformatics, International Technology Park, Bangalore 560066, India.,Manipal Academy of Higher Education (MAHE), Manipal 576104, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore 560029, India.,These authors contributed equally to this work and share the first authorship
| | - Irene A George
- Institute of Bioinformatics, International Technology Park, Bangalore 560066, India.,Manipal Academy of Higher Education (MAHE), Manipal 576104, India.,These authors contributed equally to this work and share the first authorship
| | - Barnali Deb
- Institute of Bioinformatics, International Technology Park, Bangalore 560066, India.,Manipal Academy of Higher Education (MAHE), Manipal 576104, India.,These authors contributed equally to this work and share the second authorship
| | - Ankit P Jain
- Institute of Bioinformatics, International Technology Park, Bangalore 560066, India.,These authors contributed equally to this work and share the second authorship
| | - Krishna Patel
- Institute of Bioinformatics, International Technology Park, Bangalore 560066, India.,School of Biotechnology, Amrita Vishwa Vidyapeetham, Kollam 690525, India
| | - Brusabhanu Nayak
- Department of Urology, All India Institute of Medical Sciences, New Delhi 110070, India
| | - Subhradip Karmakar
- Department of Biochemistry, All India Institute of Medical Sciences, New Delhi 110070, India
| | - Amlesh Seth
- Department of Urology, All India Institute of Medical Sciences, New Delhi 110070, India
| | - Akhilesh Pandey
- Institute of Bioinformatics, International Technology Park, Bangalore 560066, India.,Manipal Academy of Higher Education (MAHE), Manipal 576104, India.,Center for Molecular Medicine, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore 560029, India.,Department of Laboratory Medicine and Pathology, Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Prashant Kumar
- Institute of Bioinformatics, International Technology Park, Bangalore 560066, India.,Manipal Academy of Higher Education (MAHE), Manipal 576104, India
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12
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Xu J, Zheng J, Ma Y. Monopolar versus bipolar transurethral resection of bladder tumors: An updated systematic review and meta-analysis of existing studies. Medicine (Baltimore) 2020; 99:e21768. [PMID: 32846804 PMCID: PMC7447410 DOI: 10.1097/md.0000000000021768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To compare the efficacy and safety of bipolar and monopolar transurethral resection of bladder tumors (TURBT) in non-muscle invasive bladder cancer (NMIBC) treatment. METHODS This protocol established in this study has been reported following the preferred reporting items for systematic review and meta-analysis protocols. Web of Science, PubMed, EMBASE, and the Cochrane Library were searched for all randomized controlled trials comparing bipolar TURBT and monopolar TURBT in NMIBC treatment until 31st of June 2020. We will use a combination of Medical Subject Heading and free-text terms with various synonyms to search based on the eligibility criteria. Two investigators independently reviewed the included studies and extracted relevant data. The odds ratio and 95% confidence intervals of were used as effect estimate. I-square (I) test, substantial heterogeneity, sensitivity analysis, and publication bias assessment will be performed accordingly. Stata 15.0 and Review Manger 5.3 are used for meta-analysis and systematic review. RESULTS The results will be published in a peer-reviewed journal. CONCLUSION The results of this review will be widely disseminated through peer-reviewed publications and conference presentations. This evidence may also provide helpful evidence of the efficacy and safety of bipolar and monopolar transurethral resection of TURBT in NMIBC treatment. PROSPERO REGISTRATION NUMBER CRD42020151997.
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Affiliation(s)
- Jianeng Xu
- Urology Surgery Department, Jiashan First People's Hospital, Jiashan City, Zhejiang Province
| | - Junbiao Zheng
- Urology Surgery Department, Jiashan First People's Hospital, Jiashan City, Zhejiang Province
| | - Yucheng Ma
- Urology Surgery Department, West China Hospital, Nanchong, Sichuan, China
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13
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Elsawy AA, Harraz AM, Ghobrial FK, Abdullatef M, Ali-El-Dein B. Diagnostic performance and predictive capacity of early urine cytology after transurethral resection of nonmuscle invasive bladder cancer: A prospective study. Urol Oncol 2020; 38:935.e1-935.e8. [PMID: 32654947 DOI: 10.1016/j.urolonc.2020.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 05/31/2020] [Accepted: 06/13/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To prospectively evaluate the value of early urine cytology (EUC) after the primary transurethral resection of bladder tumor (TURBT) of nonmuscle invasive bladder cancer (NMIBC) for the prediction of positive biopsy findings on repeat TURBT. METHODS After approval of institutional review board, patients who underwent TURBT for NMIBC between February 2014 and July 2018 were included in the study. Patients with concomitant Carcinoma in Situ (CIS), upper tract urothelial tumors, biopsy proven muscle invasion, or low-risk NMIBC (single, primary, Ta, and G1 tumor) were excluded. Forty-eight hours after primary TURBT, EUC was retrieved and patients were scheduled for repeat TURBT 2 to 6 weeks later according to the predetermined protocol. The primary outcome was to determine the role of positive EUC to predict positive biopsy findings on repeat TURBT. RESULTS During the study period, 198 patients fulfilled the study inclusion criteria of which 49 (25%) had recurrent NMIBC. Primary TURBT pathology results showed T1 stage in 195 (98.5%) patients and high-grade malignancy in 158 (79.8%). Intermediate- and high-risk NMIBC were defined in 49 (25%) and 149 (75%) patients, respectively. EUC was positive in 114 patients; of whom 78 (68.4%) showed positive biopsy findings on repeat TURBT (P = 0.001). The sensitivity, specificity, negative, and positive predictive values of EUC for biopsy findings at repeat TURBT were 90% (95%CI: 87-94), 75% (95%CI: 71-79), 89% (95%CI: 85-94), and 68% (95%CI: 62-74), respectively. On mean (±SD) follow-up of 42(±13) months, tumor recurrence was encountered in 101 (53%) patients. On multivariate Cox regression analysis, EUC was significantly associated with tumor recurrence (HR = 4.6, 95%CI: 2.37-8.9, P < 0.001). CONCLUSIONS Positive EUC after primary TURBT for NMIBC is significantly associated with positive repeat TURBT for malignancy. EUC is an independent predictor of tumor recurrence. EUC might be implemented after primary TURBT to help refining indications of repeat biopsy and planning of further intervention.
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Affiliation(s)
- Amr A Elsawy
- Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
| | - Ahmed M Harraz
- Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Fady K Ghobrial
- Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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14
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Leow JJ, Catto JWF, Efstathiou JA, Gore JL, Hussein AA, Shariat SF, Smith AB, Weizer AZ, Wirth M, Witjes JA, Trinh QD. Quality Indicators for Bladder Cancer Services: A Collaborative Review. Eur Urol 2020; 78:43-59. [PMID: 31563501 DOI: 10.1016/j.eururo.2019.09.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/03/2019] [Indexed: 12/14/2022]
Abstract
CONTEXT There is a lack of accepted consensus on what should constitute appropriate quality-of-care indicators for bladder cancer. OBJECTIVE To evaluate the optimal management of bladder cancer and propose quality indicators (QIs). EVIDENCE ACQUISITION A systematic review was performed to identify literature on current optimal management and potential quality indicators for both non-muscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer. A panel of experts was convened to select a recommended list of QIs. EVIDENCE SYNTHESIS For NMIBC, preoperative QIs include tobacco cessation counselling and appropriate imaging before initial transurethral resection of bladder tumour (TURBT). Intraoperative QIs include administration of antibiotics, proper safe conduct of TURBT using a checklist, and performing restaging TURBT with biopsy of the prostatic urethra in appropriate cases. Postoperative QIs include appropriate receipt of perioperative adjuvant therapy, risk-stratified surveillance, and appropriate decision to change therapy when indicated (eg, bacillus Calmette-Guerin [BCG] unresponsive). For MIBC, preoperative QIs include multidisciplinary care, selection for candidates for continent urinary diversion, receipt of neoadjuvant cisplatin-based chemotherapy, time to commencing radical treatment, consideration of trimodal therapy as a bladder-sparing alternative in select patients, preoperative counselling with stoma marking, surgical volume of radical cystectomy, and enhanced recovery after surgery protocols. Intraoperative QIs include adequacy of lymphadenectomy, blood loss, and operative time. Postoperative QIs include prospective standardised monitoring of morbidity and mortality, negative surgical margins for pT2 disease, appropriate surveillance after primary treatment, and adjuvant cisplatin-based chemotherapy in appropriate cases. Participation in clinical trials was highlighted as an important component indicating high quality of care. CONCLUSIONS We propose a set of QIs for both NMIBC and MIBC based on established clinical guidelines and the available literature. Although there is currently a lack of level 1 evidence for the benefit of implementing these QIs, we believe that the measurement of these QIs could aid in the improvement and benchmarking of optimal care for bladder cancer. PATIENT SUMMARY After a systematic review of existing guidelines and literature, a panel of experts has recommended a set of quality indicators that can help providers and patients measure and strive towards optimal outcomes for bladder cancer care.
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Affiliation(s)
- Jeffrey J Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James W F Catto
- Academic Urology Unit, The University of Sheffield, Sheffield, UK
| | - Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John L Gore
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
| | - Ahmed A Hussein
- Department of Urology, Cairo University, Cairo, Egypt; Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Departments of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Angela B Smith
- Department of Urology, Lineberger Comprehensive Cancer Center, UNC-Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Alon Z Weizer
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Manfred Wirth
- Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - J Alfred Witjes
- Department of Urology, Radboud University, Nijmegen, The Netherlands
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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15
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Bastos DA, Mattedi RL, Barreiro R, dos Santos FF, Buzatto V, Masotti C, Souza JM, de Lima MZT, Friguglietti GW, Dzik C, Jardim DLF, Coelho R, Ribeiro Filho LA, Cordeiro MD, Nahas WC, de Mello ES, Chammas R, Reis LFL, Bettoni F, Galante PAF, Camargo AA. Genomic Biomarkers and Underlying Mechanism of Benefit from BCG Immunotherapy in Non-Muscle Invasive Bladder Cancer. Bladder Cancer 2020. [DOI: 10.3233/blc-200289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND: Optimal therapy for high-risk non-muscle invasive bladder cancer (NMIBC) includes intravesical instillation of Bacillus Calmette-Guérin (BCG). However, about 25-45% of patients do not benefit from BCG immunotherapy, and there is no biomarker to guide therapy. Also, many questions regarding BCG mechanisms of action remain unanswered. OBJECTIVE: To identify genomic biomarkers and characterize the underlying mechanism of benefit from BCG in NMIBC. PATIENTS AND METHODS: Pre-treatment archival index-tumors of 35 patients with NMIBC treated with BCG were analyzed by whole-exome sequencing (WES). Tumor mutation burden (TMB) and neoantigen load (NAL) were correlated with BCG response rate (RR) and recurrence-free survival (RFS). The presence of deleterious mutations in DNA damage response (DDR) genes was also compared between BCG-responsive (BCG-R, N = 17) and unresponsive (BCG-UR, N = 18) subgroups. RESULTS: TMB and NAL were higher in BCG-R compared to BCG-UR patients (median TMB 4.9 vs. 2.8 mutations/Mb, P = 0.017 and median NAL 100 vs. 65 neoantigens, P = 0.032). Improved RR and RFS were observed in patients with high vs. low TMB (RR 71% vs. 28%, P = 0.011 and mRFS 38.0 vs. 15.0 months, P = 0.009) and with high vs. low NAL (RR 71% vs. 28%, P = 0.011 and mRFS 36.0 vs. 18.5 months, P = 0.016). The presence of deleterious mutations in DDR genes was associated with improved RFS (mRFS 35.5 vs. 11.0 months, P = 0.017). CONCLUSIONS: In our cohort, improved outcomes after BCG immunotherapy were observed in patients with high TMB, high NAL and deleterious mutations in DDR genes. BCG may induce tumor-specific immune response by enhancing the recognition of neoantigens.
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Affiliation(s)
- Diogo A. Bastos
- Medical Oncology, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
- Oncology Center, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Romulo L. Mattedi
- Department of Pathology, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | - Rodrigo Barreiro
- Molecular Oncology Center, Hospital Sírio-Libanês, São Paulo, SP, Brazil
- Department of Biochemistry, Chemistry Institute, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Vanessa Buzatto
- Molecular Oncology Center, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Cibele Masotti
- Translational Oncology Center, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | - Jussara M. Souza
- Molecular Oncology Center, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | | | - Carlos Dzik
- Oncology Center, Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | - Rafael Coelho
- Department of Urology, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | | | - Maurício D. Cordeiro
- Department of Urology, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | - William C. Nahas
- Department of Urology, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | - Evandro S. de Mello
- Department of Pathology, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | - Roger Chammas
- Translational Oncology Center, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | | | - Fabiana Bettoni
- Molecular Oncology Center, Hospital Sírio-Libanês, São Paulo, SP, Brazil
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16
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Lilge L, Wu J, Xu Y, Manalac A, Molenhuis D, Schwiegelshohn F, Vesselov L, Embree W, Nesbit M, Betz V, Mandel A, Jewett MAS, Kulkarni GS. Minimal required PDT light dosimetry for nonmuscle invasive bladder cancer. JOURNAL OF BIOMEDICAL OPTICS 2020; 25:1-13. [PMID: 32529817 PMCID: PMC7289452 DOI: 10.1117/1.jbo.25.6.068001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/27/2020] [Indexed: 05/18/2023]
Abstract
SIGNIFICANCE Photodynamic therapy (PDT) could become a treatment option for nonmuscle invasive bladder cancer when the current high morbidity rate associated with red light PDT and variable PDT dose can be overcome through a combination of intravesical instillation of the photosensitizer and the use of green light creating a steep PDT dose gradient. AIM To determine how a high PDT selectivity can be maintained throughout the bladder wall considering other efficacy determining parameters, in particular, the average optical properties of the mucosal layer governing the fluence rate multiplication factor, as well as the bladder shape and the position of the emitter in relationship to the bladder wall. APPROACH We present three irradiance monitoring systems and evaluate their ability to enable selective bladder PDT considering previously determined photodynamic threshold values for the bladder cancer, mucosa and urothelium in a preclinical model, and the photosensitizer's specific uptake ratio. Monte Carlo-based light propagation simulations performed for six human bladders at the time of therapy for a range of tissue optical properties. The performance of one irradiance sensing device in a clinical phase 1B trial is presented to underline the impact of irradiance monitoring, and it is compared to the Monte Carlo-derived dose surface histogram. RESULTS Monte Carlo simulations showed that irradiance monitoring systems need to comprise at least three sensors. Light scattering inside the bladder void needs to be minimized to prevent increased heterogeneity of the irradiance. The dose surface histograms vary significantly depending on the bladder shape and bladder volume but are less dependent on tissue optical properties. CONCLUSIONS We demonstrate the need for adequate irradiance monitoring independent of a photosensitizer's specific uptake ratio.
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Affiliation(s)
- Lothar Lilge
- University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- University of Toronto, Department of Medical Biophysics, Toronto, Ontario, Canada
- Address all correspondence to Lothar Lilge, E-mail:
| | - Jenny Wu
- University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Yiwen Xu
- University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Angelica Manalac
- University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Daniel Molenhuis
- University of Toronto, Department of Medical Biophysics, Toronto, Ontario, Canada
| | - Fynn Schwiegelshohn
- University of Toronto, Department of Electrical and Computer Engineering, Toronto, Ontario, Canada
| | | | - Wayne Embree
- Theralase Technologies Inc., Toronto, Ontario, Canada
| | - Michael Nesbit
- University of Toronto, Division of Urology, Department of Surgery, Toronto, Ontario, Canada
| | - Vaughn Betz
- University of Toronto, Department of Electrical and Computer Engineering, Toronto, Ontario, Canada
| | - Arkady Mandel
- Theralase Technologies Inc., Toronto, Ontario, Canada
| | - Michael A. S. Jewett
- University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- University of Toronto, Division of Urology, Department of Surgery, Toronto, Ontario, Canada
| | - Girish S. Kulkarni
- University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- University of Toronto, Division of Urology, Department of Surgery, Toronto, Ontario, Canada
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17
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Bipolar versus monopolar transurethral resection of non-muscle-invasive bladder cancer: a systematic review and meta-analysis of randomized controlled trials. World J Urol 2020; 39:1177-1186. [PMID: 32462303 DOI: 10.1007/s00345-020-03271-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/18/2020] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To compare the efficacy and safety of bipolar and monopolar transurethral resection of bladder tumors (TURBT) in non-muscle invasive bladder cancer (NMIBC) treatment. METHODS A systematic search of all Randomized Controlled Trials (RCTs), which compared bipolar TURBT (bTURBT) and monopolar TURBT (mTURBT) in NMIBC treatment, were performed in PubMed, Web of Science, Cochrane Library and Embase up to February 1, 2019. We evaluated their efficacy by operative time, hospitalization time, catheterization time, and recurrence rate. While obturator jerk, bladder perforation, thermal damage, and overall complications were used to evaluate their safety. RESULTS A total of 13 RCTs, involving 2379 patients, were included. There were no statistically significant differences in efficacy between bTURBT and mTURBT in NMIBC treatment, such as operative time (p = 0.12), hospitalization time (p = 0.13), catheterization time (p = 0.50), and recurrence rate (p = 0.88). Compared to the safety in mTURBT in NMIBC treatment, no significant advantages were observed in that in bTURBT as well, such as obturator jerk (p = 0.12), bladder perforation (p = 0.11), thermal damage (p = 0.24), and overall complications (p = 0.65). CONCLUSIONS Our analysis demonstrated that bTURBT has no significant advantages in efficacy and safety in NMIBC treatment compared to that in mTURBT. Thus, bTURBT could not completely replace mTURBT as a safer and more effective NMIBC treatment.
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18
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The contribution of ketone bodies to glycolytic inhibition for the treatment of adult and pediatric glioblastoma. J Neurooncol 2020; 147:317-326. [PMID: 32096068 DOI: 10.1007/s11060-020-03431-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/12/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Glioblastoma (GBM) remains one of the most lethal primary brain tumors in children and adults. Targeting tumor metabolism has emerged as a promising-targeted therapeutic strategy for GBM and characteristically resistant GBM stem-like cells (GSCs). METHODS Gene expression data was obtained from the online patient-histology database, GlioVis. GSC mitochondria morphology was examined by TEM. Cell viability and effect on GSC self-renewal was determined via MTS assay and neurosphere assay, respectively. Proteins were evaluated by Western Blot. RESULTS Enzymes necessary for ketone catabolism (BDH1, OXCT1 and ACAT1) are significantly downregulated in adult and pediatric GBM. GSC mitochondrial ultrastructure suggested defects in oxidative phosphorylation. Treatment of both GBM and GSC cell lines resulted in dose-dependent decreases in viability in response to glycolytic inhibitor 2-deoxy-D-glucose (2-DG), and ketone body Acetoacetate (AA), but not β-hydroxybutyrate (βHB). AA induced apoptosis was confirmed by western blot analysis, indicating robust caspase activation and PARP cleavage. AA reduced neurosphere formation at concentrations as low as 1 mM. Combined treatment of low dose 2-DG (50 μM) with AA resulted in more cell death than either treatment alone. The effect was greater than additive at low concentrations of AA, reducing viability approximately 50% at 1 mM AA. AA was found to directly upregulate mitochondrial uncoupling protein 2 (UCP2), which may explain this potential drug synergism via multi-faceted inhibition of the glycolytic pathway. CONCLUSION Targeting the metabolic pathway of GBM via glycolytic inhibition in conjunction with ketogenic diet or exogenous ketone body supplementation warrants further investigation as a promising adjunctive treatment to conventional therapy.
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19
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Knapp DW, Dhawan D, Ramos-Vara JA, Ratliff TL, Cresswell GM, Utturkar S, Sommer BC, Fulkerson CM, Hahn NM. Naturally-Occurring Invasive Urothelial Carcinoma in Dogs, a Unique Model to Drive Advances in Managing Muscle Invasive Bladder Cancer in Humans. Front Oncol 2020; 9:1493. [PMID: 32039002 PMCID: PMC6985458 DOI: 10.3389/fonc.2019.01493] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022] Open
Abstract
There is a great need to improve the outlook for people facing urinary bladder cancer, especially for patients with invasive urothelial carcinoma (InvUC) which is lethal in 50% of cases. Improved outcomes for patients with InvUC could come from advances on several fronts including emerging immunotherapies, targeted therapies, and new drug combinations; selection of patients most likely to respond to a given treatment based on molecular subtypes, immune signatures, and other characteristics; and prevention, early detection, and early intervention. Progress on all of these fronts will require clinically relevant animal models for translational research. The animal model(s) should possess key features that drive success or failure of cancer drugs in humans including tumor heterogeneity, genetic-epigenetic crosstalk, immune cell responsiveness, invasive and metastatic behavior, and molecular subtypes (e.g., luminal, basal). Experimental animal models, while essential in bladder cancer research, do not possess these collective features to accurately predict outcomes in humans. These key features, however, are present in naturally-occurring InvUC in pet dogs. Canine InvUC closely mimics muscle-invasive bladder cancer in humans in cellular and molecular features, molecular subtypes, immune response patterns, biological behavior (sites and frequency of metastasis), and response to therapy. Thus, dogs can offer a highly relevant animal model to complement other models in research for new therapies for bladder cancer. Clinical treatment trials in pet dogs with InvUC are considered a win-win-win scenario; the individual dog benefits from effective treatment, the results are expected to help other dogs, and the findings are expected to translate to better treatment outcomes in humans. In addition, the high breed-associated risk for InvUC in dogs (e.g., 20-fold increased risk in Scottish Terriers) offers an unparalleled opportunity to test new strategies in primary prevention, early detection, and early intervention. This review will provide an overview of canine InvUC, summarize the similarities (and differences) between canine and human InvUC, and provide evidence for the expanding value of this canine model in bladder cancer research.
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Affiliation(s)
- Deborah W Knapp
- Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN, United States.,Purdue University Center for Cancer Research, Purdue University, West Lafayette, IN, United States
| | - Deepika Dhawan
- Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN, United States
| | - José A Ramos-Vara
- Purdue University Center for Cancer Research, Purdue University, West Lafayette, IN, United States.,Department of Comparative Pathobiology, Purdue University, West Lafayette, IN, United States
| | - Timothy L Ratliff
- Purdue University Center for Cancer Research, Purdue University, West Lafayette, IN, United States.,Department of Comparative Pathobiology, Purdue University, West Lafayette, IN, United States
| | - Gregory M Cresswell
- Purdue University Center for Cancer Research, Purdue University, West Lafayette, IN, United States
| | - Sagar Utturkar
- Purdue University Center for Cancer Research, Purdue University, West Lafayette, IN, United States
| | - Breann C Sommer
- Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN, United States
| | - Christopher M Fulkerson
- Department of Veterinary Clinical Sciences, Purdue University, West Lafayette, IN, United States.,Purdue University Center for Cancer Research, Purdue University, West Lafayette, IN, United States
| | - Noah M Hahn
- Department of Oncology and Urology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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20
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Garrido-Abad P, Martin LG, Zarra KV, Menendez AD, Arjona MF. Metastatic non-muscle invasive bladder can-cer with cervical lymph node metastasis. Int Braz J Urol 2019; 45:1270-1274. [PMID: 31808417 DOI: 10.1590/s1677-5538.ibju.2018.0421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 01/08/2019] [Indexed: 11/21/2022] Open
Abstract
Bladder cancer is a common cancer that may present as superficial, invasive, or metastatic disease. Non-muscle-invasive bladder cancer (NMIBC) represents the majority of bladder cancer diagnoses, but represents a spectrum of disease with a variable clinical course, notably for significant risk of recurrence and potential for progression. NMIBC metastasis to distant organs without local invasion or regional metastasis is a very rare occurrence, so there are limi-ted case reports about early metastasis in the literature.
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Affiliation(s)
- Pablo Garrido-Abad
- Department of Urology, Hospital Universitario del Henares, Coslada, Universidad Francisco de Vitoria, Madrid, Spain
| | - Luis Garcia Martin
- Department of Urology, Hospital Universitario del Henares, Coslada, Universidad Francisco de Vitoria, Madrid, Spain
| | - Karen Villar Zarra
- Department of Pathology, Hospital Universitario del Henares, Coslada, Universidad Francisco de Vitoria, Madrid, Spain
| | - Ariel Diaz Menendez
- Department of Pathology, Hospital Universitario del Henares, Coslada, Universidad Francisco de Vitoria, Madrid, Spain
| | - Manuel Fernandez Arjona
- Department of Urology, Hospital Universitario del Henares, Coslada, Universidad Francisco de Vitoria, Madrid, Spain
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21
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van Osch FHM, Nekeman D, Aaronson NK, Billingham LJ, James ND, Cheng KK, Bryan RT, Zeegers MP. Patients choose certainty over burden in bladder cancer surveillance. World J Urol 2019; 37:2747-2753. [PMID: 30903352 PMCID: PMC6867982 DOI: 10.1007/s00345-019-02728-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/11/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Due to the high risk of recurrence of non-muscle invasive bladder cancer, all patients undergo regular cystoscopic surveillance for early detection. As cystoscopy is invasive, costly and increases the burden of the disease considerably, there is significant ongoing research and development into non-invasive urinary biomarker substitutes. This study aims to assess the level of sensitivity required before patients accept a new urinary biomarker. METHODS We studied the preferences for a hypothetical diagnostic urinary biomarker and compared this to usual care (cystoscopy) at different levels of sensitivity among 437 patients with bladder cancer (354 men and 83 women) from the UK Bladder Cancer Prognosis Programme. A standard gamble approach was used to estimate the minimally acceptable sensitivity (MAS) of the new biomarker. Additionally, non-parametric statistical analyses were performed to investigate the association between surveillance preference and various patient characteristics. RESULTS Almost half of patients (183, 43%) would not replace cystoscopy with a urinary biomarker unless it was 100% sensitive. The median MAS was 99.9999%, and nearly 85% of patients demanded a sensitivity of at least 99% before preferring a urinary biomarker test over cystoscopy. These results were consistent across all patient characteristics and demographic categories. CONCLUSIONS Our results indicate that patients demand urinary biomarkers as sensitive as cystoscopy before they would be willing to forego cystoscopy for bladder cancer surveillance.
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Affiliation(s)
- Frits H M van Osch
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
- Department of Complex Genetics, Nutrition and Translational Research in Metabolism (School NUTRIM), Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Duncan Nekeman
- Department of Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Neil K Aaronson
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Lucinda J Billingham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Nicholas D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - K K Cheng
- Department of Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Richard T Bryan
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Maurice P Zeegers
- Department of Complex Genetics, Nutrition and Metabolism in Translational Research (NUTRIM), Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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22
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Becker REN, Kates MR, Bivalacqua TJ. Identification of Candidates for Salvage Therapy: The Past, Present, and Future of Defining Bacillus Calmette-Guérin Failure. Urol Clin North Am 2019; 47:15-21. [PMID: 31757296 DOI: 10.1016/j.ucl.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Disease progression and recurrence are common among patients on Bacillus Calmette-Guérin (BCG) therapy, and options for bladder-preserving subsequent therapy remain limited. Ongoing efforts to develop better second-line bladder-sparing therapies rely on clinical trials of patients deemed to have failed management with BCG. This article describes historical definitions of BCG failure, as well as recent efforts to better delineate and refine the clinical criteria for identifying individual patients who will not benefit from further intravesical BCG therapy. It also reviews guidance from the most recent expert consensus panels and professional association guidelines regarding which patients should not receive additional BCG therapy.
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Affiliation(s)
- Russell E N Becker
- The James Buchanan Brady Urological Institute and Greenberg Bladder Cancer Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
| | - Max R Kates
- The James Buchanan Brady Urological Institute and Greenberg Bladder Cancer Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute and Greenberg Bladder Cancer Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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23
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Zhang J, Wang Y, Weng H, Wang D, Han F, Huang Q, Deng T, Wang X, Jin Y. Management of non-muscle-invasive bladder cancer: quality of clinical practice guidelines and variations in recommendations. BMC Cancer 2019; 19:1054. [PMID: 31694589 PMCID: PMC6836507 DOI: 10.1186/s12885-019-6304-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/28/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Bladder cancer (BC) has become a major worldwide public health issue, especially non-muscle-invasive bladder cancer (NMIBC). A flood of related clinical practice guidelines (CPGs) have emerged; however, the quality and recommendations of the guidelines are controversial. We aimed to appraise the quality of the CPGs for NMIBC within the past 5 years and compare the similarities and differences between recommendations for therapies. METHODS A systematic search to identify CPGs for NMIBC was performed using electronic databases (including PubMed, Embase, Web of Science), guideline development organizations, and professional societies from January 12, 2014 to January 12, 2019. The Appraisal of Guidelines Research & Evaluation (AGREE) II instrument was used to evaluate the quality of the guidelines. Intraclass correlation coefficient (ICC) analysis was performed to assess the overall agreement among reviewers. RESULTS Nine CPGs were included. The overall agreement among reviewers was excellent. The interquartile range (IQR) of scores for each domain were as follows: scope and purpose 69.44% (35.42, 85.42%); stakeholder involvement 41.67% (30.56, 75.00%); rigour of development 48.96% (27.08, 65.63%); clarity and presentation 80.56% (75.00, 86.11%); applicability 34.38% (22.92, 40.63%) and editorial independence 70.83% (35.42, 85.42%). The NICE, AUA, EAU and CRHA/CPAM clinical practice guidelines consistently scored well in most domains. It was generally accepted that the transurethral resection of bladder tumour (TURBT) and intravesical chemotherapy should be performed in the management of bladder cancer. The application of chemotherapy was highly controversial in high risk NMIBC. The courses of BCG maintenance were similar and included 3 years of therapy at full maintenance doses. CONCLUSIONS The quality of NMIBC guidelines within the past 5 years varied, especially regarding stakeholders, rigour and applicability. Despite many similarities, the recommendations had some inconsistencies in the details.
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Affiliation(s)
- Jing Zhang
- Department of Urology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071 China
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071 China
- The First Clinical College of Wuhan University, Wuhan University, No. 99, Zhangzhidong Road, Wuchang District, Wuhan, 430072 China
| | - Yunyun Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071 China
| | - Hong Weng
- Department of Urology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071 China
| | - Danqi Wang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071 China
- School of Basic Medical Sciences, Wuhan University, No. 115, Donghu Road, Wuchang District, Wuhan, 430071 China
| | - Fei Han
- Emergency Department, Xuan Wu Traditional Chinese Medicine Hospital, No.8, Wanming Road, Xicheng District, Beijing, 10000 Beijing China
| | - Qiao Huang
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071 China
| | - Tong Deng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071 China
| | - Xinghuan Wang
- Department of Urology, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071 China
| | - Yinghui Jin
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, 430071 China
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24
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Taylor J, Becher E, Steinberg GD. Update on the guideline of guidelines: non-muscle-invasive bladder cancer. BJU Int 2019; 125:197-205. [DOI: 10.1111/bju.14915] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jacob Taylor
- Department of Urology; NYU Langone Health; New York NY USA
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25
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Garrido-Abad P, Martín LG, Zarra KV, Menéndez AD, Arjona MF. Metastatic non-muscle invasive bladder cancer with cervical lymph node metastasis. Int Braz J Urol 2019. [PMID: 31808417 PMCID: PMC6909866 DOI: 10.1590/s1677-5538.ibju.2018.0863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Bladder cancer is a common cancer that may present as superficial, invasive, or metastatic disease. Non-muscle-invasive bladder cancer (NMIBC) represents the majority of bladder cancer diagnoses, but represents a spectrum of disease with a variable clinical course, notably for significant risk of recurrence and potential for progression. NMIBC metastasis to distant organs without local invasion or regional metastasis is a very rare occurrence, so there are limited case reports about early metastasis in the literature.
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Affiliation(s)
- Pablo Garrido-Abad
- Hospital Universitario del Henares, Spain; Universidad Francisco de Vitoria, Spain
| | - Luis García Martín
- Hospital Universitario del Henares, Spain; Universidad Francisco de Vitoria, Spain
| | - Karen Villar Zarra
- Hospital Universitario del Henares, Spain; Universidad Francisco de Vitoria, Spain
| | - Ariel Díaz Menéndez
- Hospital Universitario del Henares, Spain; Universidad Francisco de Vitoria, Spain
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26
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Liu X, Zhang X, Bi J, Li Z, Zhang Z, Kong C. Caspase recruitment domain family member 10 regulates carbamoyl phosphate synthase 1 and promotes cancer growth in bladder cancer cells. J Cell Mol Med 2019; 23:8128-8138. [PMID: 31565867 PMCID: PMC6850932 DOI: 10.1111/jcmm.14683] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 08/21/2019] [Accepted: 09/01/2019] [Indexed: 12/22/2022] Open
Abstract
Bladder cancer, which can be divided into non‐muscle‐invasive and muscle‐invasive bladder cancer, is the most common urinary cancer in the United States. Caspase recruitment domain family member 10 (CARD10), also named CARD‐containing MAGUK protein 3 (CARMA3), is a member of the CARMA family and may activate the nuclear factor kappa B (NF‐κB) pathway. We utilized RNA sequencing and metabolic mass spectrometry to identify the molecular and metabolic feature of CARD10. The signalling pathway of CARD10 was verified by Western blotting analysis and functional assays. RNA sequencing and metabolic mass spectrometry of CARD10 knockdown identified the metabolic enzyme carbamoyl phosphate synthase 1 (CPS1) in the urea cycle as the downstream gene regulated by CARD10. We confirmed that CARD10 affected cell proliferation and nucleotide metabolism through regulating CPS1. We indicated that CARD10 promote bladder cancer growth via CPS1 and maybe a potential therapeutic target in bladder cancer.
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Affiliation(s)
- Xi Liu
- Department of Urology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Xiaotong Zhang
- Department of Urology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Jianbin Bi
- Department of Urology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Zhenhua Li
- Department of Urology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Zhe Zhang
- Department of Urology, The First Affiliated Hospital, China Medical University, Shenyang, China
| | - Chuize Kong
- Department of Urology, The First Affiliated Hospital, China Medical University, Shenyang, China
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27
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Coventry BJ. Therapeutic vaccination immunomodulation: forming the basis of all cancer immunotherapy. Ther Adv Vaccines Immunother 2019; 7:2515135519862234. [PMID: 31414074 PMCID: PMC6676259 DOI: 10.1177/2515135519862234] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 06/18/2019] [Indexed: 12/12/2022] Open
Abstract
Recent immunotherapy advances have convincingly demonstrated complete tumour removal with long-term survival. These impressive clinical responses have rekindled enthusiasm towards immunotherapy and tumour antigen vaccination providing 'cures' for melanoma and other cancers. However, many patients still do not benefit; sometimes harmed by severe autoimmune toxicity. Checkpoint inhibitors (anti-CTLA4; anti-PD-1) and interleukin-2 (IL-2) are 'pure immune drivers' of pre-existing immune responses and can induce either desirable effector-stimulatory or undesirable inhibitory-regulatory responses. Why some patients respond well, while others do not, is presently unknown, but might be related to the cellular populations being 'driven' at the time of dosing, dictating the resulting immune response. Vaccination is in-vivo immunotherapy requiring an active host response. Vaccination for cancer treatment has been skeptically viewed, arising partially from difficulty demonstrating clear, consistent clinical responses. However, this article puts forward accumulating evidence that 'vaccination' immunomodulation constitutes the fundamental, central, intrinsic property associated with antigen exposure not only from exogenous antigen (allogeneic or autologous) administration, but also from endogenous release of tumour antigen (autologous) from in-vivo tumour-cell damage and lysis. Many 'standard' cancer therapies (chemotherapy, radiotherapy etc.) create waves of tumour-cell damage, lysis and antigen release, thus constituting 'in-vivo vaccination' events. In essence, whenever tumour cells are killed, antigen release can provide in-vivo repeated vaccination events. Effective anti-tumour immune responses require antigen release/supply; immune recognition, and immune responsiveness. With better appreciation of endogenous vaccination and immunomodulation, more refined approaches can be engineered with prospect of higher success rates from cancer therapy, including complete responses and better survival rates.
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Affiliation(s)
- Brendon J. Coventry
- Discipline of Surgery and Cancer Immunotherapy Laboratory, University of Adelaide, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
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