Muscle-Invasive Urothelial Carcinoma of the Bladder

Variation in Follow-Up after Radical Cystectomy for Bladder Cancer-An Inventory Roundtable and Literature Review

Background: Follow-up after radical cystectomy (RC) for bladder cancer can be divided into oncological and functional surveillance. It remains unclear how follow-up after RC should ideally be scheduled. The aim of this report was to gain insight into the organization of follow-up after RC in Europe, for which we conducted a roundtable inventory within the EAU Young Academic Urologists Urothelial Cancer working group. Methods: An inventory semi-structured survey was performed among urologists of the EAU Young Academic Urologists Urothelial Cancer working group to describe the organization of follow-up. The surveys were analyzed using a deductive approach. Similarities and differences in follow-up after RC for bladder cancer were described. Results: The survey included 11 urologists from six different European countries. An institutional follow-up scheme was used by six (55%); three (27%) used a national or international guideline, and two (18%) indicated that there was no defined follow-up scheme. Major divergent aspects included the time points of follow-up, the frequency, and the end of follow-up. Six centers (55%) adopted a risk-adapted follow-up approach tailored to (varying) patient and tumor characteristics. Laboratory tests and CT scans were used in all cases; however, the intensity and frequency varied. Functional follow-up overlapped with oncological follow-up in terms of frequency and duration. Patient-reported outcome measures were only used by two (18%) urologists. Conclusions: Substantial variability exists across European centers regarding the follow-up after RC for bladder cancer. This highlights the need for an international analysis focusing on its organization and content as well as on opportunities to improve patients' needs during follow-up after RC.

RITA1 drives the growth of bladder cancer cells by recruiting TRIM25 to facilitate the proteasomal degradation of RBPJ

Bladder cancer (BC) is one of the most prevalent malignancies worldwide, but it lacks effective targeted therapy due to its elusive molecular mechanism. Therefore, it is important to further investigate the molecular mechanisms that mediate BC progression. By performing a tumor tissue–based gene microarray and shRNA library screening, we found that recombination signal binding protein for immunoglobulin kappa J region (RBPJ) interacting and tubulin associated 1 (RITA1) is crucial for the growth of BC cells. Moreover, RITA1 is aberrantly highly expressed in BC tissues and is also correlated with poor prognosis in patients with BC. Mechanistically, we determined that RITA1 recruits tripartite motif containing 25 (TRIM25) to ubiquitinate RBPJ to accelerate its degradation via proteasome, which leads to the transcriptional inhibition of Notch1 downstream targets. Our results suggest that aberrant high expression of RITA1 drives the growth of BC cells via the RITA1/TRIM25/RBPJ axis and RITA1 may serve as a promising therapeutic target for BC.

Multiparametric MRI Evaluation of VI-RADS for Bladder Tumors Located at the Ureteral Orifice

Background The Vesical Imaging Reporting and Data System (VI-RADS) based on multiparametric MRI scans standardizes preoperative bladder cancer staging. However, limitations have been reported for VI-RADS, particularly for ureteral orifice tumors. Purpose To investigate the diagnostic performance and interobserver agreement of VI-RADS in evaluating muscle invasion for bladder tumors located at the ureteral orifice. Materials and Methods In this retrospective study, patients with histopathologically confirmed bladder cancer occurring at the ureteral orifice from January 2012 to November 2021 were analyzed. Two blinded radiologists independently scored multiparametric MRI scans according to VI-RADS. Interobserver agreement of the VI-RADS scores was evaluated with weighted κ analysis. Receiver operating characteristic curve analysis was used to evaluate the diagnostic performance of the VI-RADS scores in the prediction of muscle invasion. Results A total of 78 patients (mean age, 67 years ± 7 [SD]; age range, 46-90 years; 67 men) were included in the final analysis: 25 with non-muscle-invasive bladder cancer and 53 with muscle-invasive bladder cancer (MIBCa). At consensus reading, one (1%) case was scored as VI-RADS 1, 27 cases (35%) were scored as VI-RADS 2, six (8%) were scored as VI-RADS 3, 10 (13%) were scored as VI-RADS 4, and 34 (44%) were scored as VI-RADS 5. On comparison of the VI-RADS score with histopathologic findings, it was confirmed that the presence of muscle invasion was 0% (zero of one) for VI-RADS 1, 15% (four of 27) for VI-RADS 2, 83% (five of six) for VI-RADS 3, 100% (10 of 10) for VI-RADS 4, and 100% (34 of 34) for VI-RADS 5. The area under the receiver operating characteristic curve of VI-RADS in the detection of MIBCa was 0.96 (95% CI: 0.92, 1.00). Conclusion The Vesical Imaging Reporting and Data System could be used to accurately predict muscle invasion for bladder tumors occurring at the ureteral orifice. © RSNA, 2022 Online supplemental material is available for this article.

Bone scan with technetium 99m-methyl diphosphonate, the missing link in the initial staging of muscle-invasive bladder carcinoma

BACKGROUND

Accurate staging is crucial to determine the type of treatment for patients with bladder cancer (BCa), especially in high-risk cases. We aimed to assess the role of bone scan in the initial staging of muscle-invasive bladder carcinoma (MIBC).

MATERIAL AND METHODS

Forty-five patients with MIBC were referred to our tertiary clinic to perform a technetium 99m-methyl diphosphonate (Tc99m-MDP) bone scan from January 2019 to March 2020. The patients underwent bone scintigraphy with pelvic SPECT/CT before radical cystectomy. Whole-body scanning was performed 4 hours after Tc99m-MDP injection in both anterior and posterior views. Since the most common bone involvement site in these patients is the pelvic bones and the spine, pelvic SPECT/CT was performed in all patients.

RESULTS

Frequency of skeletal metastasis was 26.7%. Only 19% of the metastases were detected by previous pelvic CT/MRI images performed for routine staging. All the reported skeletal metastases by previous anatomical imaging methods were detected in the bone scan. There was no statistically significant correlation between bone metastasis and the patient's age, lymph nodes metastasis (LNM), hydronephrosis, and muscle-invasive type. The mean serum calcium level was 8.7 ± 0.57 in patients with bone metastasis and 8.87 ± 0.99 in patients without bone metastasis, which was not statistically significant.

CONCLUSION

Bone scan has higher diagnostic performance than conventional imaging methods for detecting bone metastases. It changed the management plan in 8.8% of our patients, so we conclude that performing a whole-body bone scan in the initial staging of MIBC would be helpful.

Identification of a novel immune-related long noncoding RNA signature to predict the prognosis of bladder cancer

Tumour immune regulation has attracted widespread attention, and long noncoding RNAs (lncRNAs) play an important role in this process. Therefore, we evaluated patient prognosis by exploring the relationship between bladder cancer (BLCA) and immune-related lncRNAs (IRlncRNAs). Transcriptome data and immune-related genes were analysed for coexpression, and then, the IRlncRNAs were analysed to determine the differentially expressed IRlncRNAs (DEIRlncRNAs) between normal and tumour samples in The Cancer Genome Atlas. The screened lncRNAs were pairwise paired and combined with clinical data, and finally, a signature was constructed by Lasso regression and Cox regression in 13 pairs of DEIRlncRNAs. According to the Akaike information criterion (AIC) values of the 1-year receiver operating characteristic curve, BLCA patients were stratified into high- or low-risk groups. The high-risk group had a worse prognosis. A comprehensive analysis showed that differences in risk scores were associated with the immune status of BLCA-infiltrated patients. The identified signature was correlated with the expression of immune checkpoint inhibitor-related molecules and sensitivity to chemotherapeutic drugs. We also identified three BLCA clusters with different immune statuses and prognoses that are also associated with immunotherapy response and drug sensitivity. In conclusion, we constructed a powerful predictive signature with high accuracy and validated its prognostic value.

E-cadherin and N-cadherin Immunohistochemical Expression in Proliferating Urothelial Lesions: Potential Novel Cancer Predictive EMT Profiles

Cadherin switch (CS) outlined by downregulation of E-cadherin and upregulation of N-cadherin is an established epithelial-mesenchymal transition (EMT) hallmark, being a common signature in wound healing and carcinogenesis. It is intriguing to explore the EMT-associated CS pattern in precancerous phases as well as variably aggressive bladder cancer categories. In this study, we tested CS signified by a reduction in urothelial cells E-cadherin expression and/or aberrant N-cadherin expression in proliferative epithelial changes (PEC) associating inflammation, non-muscle-invasive bladder cancer (NMIBC), and muscle-invasive bladder cancer (MIBC). Immunohistochemical study of both E-cadherin and N-cadherin was performed for 60 cases: 15 PEC, 8 NMIBC, and 37 MIBC. CS patterns were analyzed: abnormal CS patterns were expressed as deviated, hybrid, co-negative, and full CS patterns. E-cadherin expression was significantly preserved in PEC (86.7%) followed by NMIBC (62.5%) and then MIBC (37.8%) (P=0.004), whereas N-cadherin showed obvious aberrant expression in MIBC (51.4%) as compared with PEC (33.3%) and NMIBC (25%). In the MIBC group, abnormal cadherin patterns were the highest (70.3%) and was associated with adverse prognostic indicators. In the context of NMIBC progression to MIBC, combined E and N-cadherin evaluation showed highest sensitivity (70.3%) and NPV (31.3%), whereas aberrant expression of N-cadherin presented highest specificity (75%) and positive predictive value (90.5%). For cancer prediction, combined E-cadherin and N-cadherin evaluation showed the highest sensitivity (64.4%); abnormal E-cadherin offered highest specificity (86.7%), positive predictive value (92.9%), and negative predictive value (40.6%). In posttherapy follow-up setting, a metastable EMT signature in the form of partial CS was noted and might reflect resistant dormant populations.

Survival Outcomes Associated with First and Second-Line Palliative Systemic Therapies in Patients with Metastatic Bladder Cancer

Background: Real-world data on palliative systemic therapies (PST) in treating metastatic bladder cancer (mBC) is limited. This study investigates current trends in treating mBC with first- (1L) and second-line (2L) chemotherapy (CT) and immunotherapy (IT). Methods: A chart review was conducted on patients diagnosed with stage II-IV bladder cancer in 2014–2016. Survival outcomes were compared between chemotherapy, immunotherapy, and supportive care. Results: out of 297 patients, 77% were male. 44% had stage IV disease at diagnosis. Median age at metastasis was 73 years. 40% of patients received 1L PST and 34% received 2L PST. Median overall survival (mOS) was longer in those receiving PST versus no treatment (p < 0.001). Patients receiving CT and IT sequentially had the longest mOS (18.99 months). First-line IT and CT mOS from treatment start dates were 5.03 and 9.13 months, respectively (p = 0.81). Gemcitabine with cisplatin (8.88 months) or carboplatin (9.13 months) were the most utilized 1L chemotherapy regimens (p = 0.85). 2L IT and CT mOS from treatment start dates were 6.72 and 3.78 months, respectively (p = 0.15). Conclusion: real-world mOS of >1.5 years in mBC is unprecedented and supports using multiple lines of PST. Furthermore, immunotherapy may be a comparable alternative to chemotherapy in both 1L and 2L settings.

LC-MS/MS method for the quantification of the anti-cancer agent infigratinib: Application for estimation of metabolic stability in human liver microsomes

Infigratinib (INF) is a novel small molecule, administered orally, which acts as a human fibroblast growth factor receptors (FGFRs) inhibitor. FGFRs are a family of receptor tyrosine kinases (RTK) reported to be upregulated in various tumor cell types. In 1 December 2020, BridgeBio Pharma Inc. announced FDA approval of INF as a New Drug Application, granting it Priority Review for the treatment of cholangiocarcinoma (CCA). Thus, the current study aimed to establish a validated LC-MS/MS method to estimate the INF concentration in the HLM matrix. In silico prediction of INF metabolism was done using the StarDrop® WhichP450™ module to verify its metabolic stability. An accurate and efficient LC-MS/MS analytical method was developed for INF metabolic stability evaluation. INF and duvelisib (DVB) (internal standard; IS) were eluted using an isocratic mobile phase with a C₁₈ column as a stationary reversed phase. The established LC-MS/MS method showed a linear range over 5-500 ng/mL (r² ≥ 0.9998) in human liver microsomes (HLMs). The sensitivity of the method was confirmed at its limit of quantification (4.71 ng/mL), and reproducibility was indicated by inter- and intra-day accuracy and precision (within 7.3%). The evaluation of INF metabolic stability was assessed, which reflected an intrinsic clearance of 23.6 µL/min/mg and in vitro half-life of 29.4 min. The developed approach in the current study is the first LC-MS/MS method for INF metabolic stability assessment. Application of the developed method in HLM in vitro studies suggests that INF has a moderate extraction ratio, indicating relatively good predicted oral bioavailability.

Preventive effect of pomegranate juice against chemically induced bladder cancer: An experimental study

OBJECTIVES

Pomegranate juice (PJ) is rich in important compounds with anti-cancer activities. This study aims to investigate the preventive effect of pomegranate juice (PJ) against bladder cancer (BC).

METHODS

Eighty male Sprague Dawley rats were randomly classified into 4 equal groups: (1) Normal controls; (2) PJ group: supplied by PJ for 12 weeks; (3) Cancer-induced group: intake 0.05% v/v N-butyl-N-(4-hydroxybutyl)-nitrosamine (BBN) for 8 weeks; (4) Cancer-prevented group: BBN + PJ. After 12 weeks, all rats were sacrificed and their urinary bladder tissues were subjected to histopathological and immunohistochemical (p53) examinations, expression of interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-α), hypoxia-inducible factor 1 (HIF-1) and the tumor protein p53 (TP53) and analysis of oxidative stress markers.

RESULTS

The development of BC was: 0/20 (0%) in normal, PJ and cancer-prevented groups and 20/20 (100%) in cancer-induced group. Significant neoplastic lesions were observed in cancer-induced group. Mild preneoplastic alterations were noticed in 25% (5/20) of cancer-prevented group. p53 immunostaining were significantly elevated in the cancer-induced group, which was decreased in the cancer-prevented group. The relative expressions of IL-6, TNF-α, HIF-1 and TP53 were significantly lower in the cancer-prevented group compared to the cancer-treated group. Correction in the oxidative stress markers were also observed in the cancer-prevented group.

CONCLUSION

PJ possesses a promising inhibitory effect on BC development, probably due to its anti-oxidant and anti-inflammatory properties.

Development and Validation of a Model for Predicting Urethral Recurrence in Male Patients with Muscular Invasive Bladder Cancer After Radical Cystectomy Combined with Urinary Diversion

Purpose

Radical cystectomy (RC) is the primary treatment strategy for patients with muscular invasive bladder cancer (MIBC). However, the prognosis is poor and tumor recurrence is not rare, in particular, urethral recurrence (UR) in male patients who underwent RC combined with urinary diversion. Here, we have developed and validated a model for predicting UR in these patients.

Patients and Methods

The development cohort comprised 310 patients who underwent RC combined with urinary diversion at our center between 1 January 2007 and 31 December 2015. Clinicopathologic data of patients were comprehensively recorded. Multivariate Cox proportional hazard regression was used for building a predictive model with regression coefficients and backward stepwise selection applied by utilizing the likelihood ratio test with Akaike’s information criterion as the stopping rule. An independent cohort consisting of 131 consecutive patients treated from 1 January 2016 to 31 December 2017 was used for validation. The performance of this predictive model was assessed with respect to discrimination, calibration, and clinical usefulness.

Results

The predictors of this model included body mass index, history of transurethral resection of bladder tumor, tumor grade, tumor stage, and concomitant carcinoma in situ. In the validation cohort, the model showed good discrimination with a concordance index of 0.777 (95% CI, 0.618 to 0.937) and calibration. Decision curve analysis also demonstrated the clinical utility of the model.

Conclusion

The predictive model facilitated postoperative individualized prediction of UR in male patients with MIBC after RC combined with urinary diversion and it may therefore serve to improve follow-up strategies.

Tissue Profile of CDK4 and STAT3 as Possible Innovative Therapeutic Targets in Urinary Bladder Cancer

Bladder cancer represents a global health problem. It ranks ninth in worldwide cancer incidence. In Egypt, carcinoma of the bladder is the most prevalent cancer, Bladder cancer has the highest recurrence rate of any malignancy. Certainly, suitable molecular diagnostic markers are required to improve the early detection of bladder cancer and then to prolong survival of patients. The present study was aimed to explore the expression of CDk4 and STAT3 in bladder cancer tissues as prospective for target therapy. Our studied groups showed higher values of CDK4 and STAT3 expression in malignant tissues (SCC andUC collectively) compared to cystitis, however, significantly higher values of CDK4 and STAT3 expression were detected in UC group compared to SCC group. Urothelial carcinomas with papillary patterns showed lower parameters of CDK4 and STAT3 expression compared to the non-papillary variant, with significant differences. Higher grades of UC showed significantly higher parameters of CDK4 and STAT3 expression compared to low grade ones. Muscle invasion increases the level of CDK4 and STAT3 expression parameters, compared to non-muscle invasive UC.

Identification and characterization of in silico, in vivo, in vitro, and reactive metabolites of infigratinib using LC-ITMS: bioactivation pathway elucidation and in silico toxicity studies of its metabolites

Infigratinib (INF) is a novel, small molecule that is orally administered to inhibit human fibroblast growth factor receptors (FGFRs), which are a family of receptor tyrosine kinases that may be upregulated in different tumor cell types. On 6 January 2020, the FDA granted fast track designation to INF for first-line treatment of cholangiocarcinoma. Prediction of susceptible sites of metabolism and reactivity pathways (cyanide and GSH) for INF was performed by the Xenosite web predictor tool. Then, we report the characterization and identification of in vitro, in vivo, and reactive intermediates of INF using liquid chromatography ion trap mass spectrometry (LC-ITMS). Finally, an in silico toxicity assessment of INF metabolites was carried out using the StarDrop DEREK module showing structural alerts. Rat liver microsomes (RLMs) and isolated perfused rat liver hepatocytes were incubated with INF in vitro and the generated metabolites were collected by protein precipitation. In vivo metabolism was evaluated by time-course urine sampling from Sprague-Dawley rats administered a single INF oral dose. A similar volume of acetonitrile was added to each collected urine sample and both organic and aqueous layers were analyzed by LC-ITMS to detect in vivo INF metabolites. N-Ethyl piperazine rings and benzene at part A of the INF structure are metabolized to form iminium and 1,4-benzoquinone, respectively, which are very reactive toward nucleophilic macromolecules. Incubation of INF with RLMs in the presence of 1.0 mM KCN and 1.0 mM glutathione was used to evaluate reactive metabolites potentially responsible for toxicities associated with INF. There were seven in vitro phase I metabolites, three in vitro phase II metabolites, three cyano adducts, and three GSH conjugate metabolites of INF detected by LC-ITMS. In vivo INF metabolites identified included four in vivo phase I and three in vivo phase II metabolites. In vitro and in vivo phase I metabolic pathways included N-dealkylation, N-demethylation, O-demethylation, hydroxylation, and dechlorination, while the in vivo phase II metabolic reaction was a direct conjugation of INF with glucuronic acid and sulphate.

An in silico web designer tool was utilized to guide laboratory work for infigratinib metabolism. Sixteen metabolites of infigratinib and seven reactive intermediates (three iminium ions and four 1,4 benzoquinones) were characterized using LC-ITMS.

Preoperative CD4+CD25+/CD4+ and tumor diameter predict prognosis in male patients with bladder cancer

Aim: The value of the peripheral blood lymphocyte subpopulation ratios and tumor diameter for prognosis in bladder cancer (BC) patients needs to be explored. Materials & methods: A total of 161 male BC patients and 68 male normal controls were retrospectively reviewed. The value of combining predictor consisted of both CD4⁺CD25⁺/CD4⁺ and computed tomography urography tumor diameter (CTU-D) on stage, overall survival (OS) and recurrence probability was analyzed by logistic regression, Kaplan-Meier method and log-rank test. Results: The combining predictor was a statistically independent risk for stage; dramatic differences in OS and recurrence probability were found between the combining predictor-high (cut-off point >0.08) and combining predictor-low groups (cut-off point ≤0.08). Conclusion: The combining predictor could be a significant predictor for advanced stage, OS and recurrence probability in male patients with BC.

Overexpression of high mobility group box 1 contributes to progressive clinicopathological features and poor prognosis of human bladder urothelial carcinoma

Background

High mobility group box 1 (HMGB1), a versatile protein with intranuclear and extracellular functions, plays an important role in a variety of human cancers. However, the clinical/prognostic significance of HMGB1 expression in human bladder urothelial carcinoma (BUC) remains unclear. The aim of this study was to investigate the HMGB1 expression in human BUC with regard to its clinical and prognostic significance.

Patients and methods

HMGB1 mRNA and protein expressions in tumor and paired normal bladder tissues were detected in 20 BUC cases by quantitative real-time polymerase chain reaction (qRT-PCR) and Western blot. HMGB1 protein expression in 165 primary BUC tissues was evaluated by immunohistochemistry (IHC), and its correlations with clinicopathological characteristics and prognosis were also analyzed. Student’s t-test, χ² test, Kaplan–Meier plots, and Cox proportional hazard regression model were performed to analyze the data.

Results

By using qRT-PCR and Western blot, the upregulated expression of HMGB1 mRNA and protein was detected in BUC, compared with paired normal tissue (P<0.05). By using IHC, high HMGB1 expression was examined in 84 of 165 (51.0%) BUC cases. High HMGB1 expression was significantly correlated with poorer differentiation and higher T and N classification (all P<0.05). Univariate analysis showed that high HMGB1 expression was significantly associated with a shortened patients’ overall survival (OS) and disease-free survival (DFS; both P<0.001). In different subgroups of BUC patients, HMGB1 expression was a prognostic factor in patients with different histological grades or T classification (all P<0.05), pN− (both P<0.001) for OS and DFS, and pT1/pN− (P<0.05) for OS. HMGB1 expression, as well as pT and pN status, was an independent prognostic factor for both OS (P=0.001, hazard ratio [HR] =2.973, 95% confidence interval [CI] =1.550–5.704) and DFS (P<0.001, HR =3.019, 95% CI =1.902–4.792) in multivariate analysis.

Conclusion

Overexpression of HMGB1 may be a new independent molecular marker for the poor prognosis of patients with BUC.

Impact of surgical margin status on the outcome of bladder cancer treated by radical cystectomy: a meta-analysis

Data regarding the association between surgical margin status and the outcome of bladder cancer treated by radical cystectomy (RC) are conflicting. Therefore, the present meta-analysis was performed to assess the associations between the outcomes of bladder cancer, in terms of recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS), and the presence of positive surgical margins versus negative surgical margins following treatment with RC. Research articles published prior to April 2016 were identified from Pubmed, Embase and the Cochrane Library databases. A total of 36 articles were included, with a sample size of 38,384 bladder cancer patients. Of these, 4,354 patients were reported to have positive surgical margins. Significant associations were detected between positive surgical margins following RC and unfavorable RFS [summary relative risk estimate (SRRE), 1.63; 95% confidence interval (CI), 1.46-1.83; P = 0.105], CSS (SRRE, 1.82; 95% CI, 1.63-2.04; P = 0.001) and OS (SRRE, 1.68; 95% CI, 1.58-1.80; P = 0.805), by fixed or random effects models. The findings were consistent independently of age, sample size, publication year, follow-up duration, study type and geographical region. In summary, the present findings demonstrate that the presence of positive surgical margins is associated with poor survival outcomes in bladder cancer following RC, indicating that avoidance of positive surgical margins during surgery is helpful to improve the prognosis of patients with bladder cancer.

Standardization of the apparent diffusion coefficient value of bladder cancer across different centers: Applicability in predicting aggressive pathologic phenotypes

PURPOSE

We investigated whether the standardized apparent diffusion coefficient (ADC) value reflects bladder cancer characteristics across different centers.

METHODS

Ninety-eight bladder cancer patients underwent MRI at two institutions. Standardized tumor ADC (sT-ADC) was calculated by dividing absolute tumor ADC (aT-ADC) by that of gluteus maximus. We compared ADCs between MRI protocols according to grade and T-stage.

RESULTS

The differences in aT-ADC between MRI protocols were negated by sT-ADC. The best sT-ADC cut-offs to predict cancer aggressiveness in the development cohort worked in the validation cohort compared to the development cohort.

CONCLUSION

Standardized ADC overcomes the incompatibility between different MRI protocols.

Pretreatment neutrophil-to-lymphocyte ratio predicts worse survival outcomes and advanced tumor staging in patients undergoing radical cystectomy for bladder cancer

Objective

To determine the role of neutrophil-to-lymphocyte ratio (NLR) in prognosticating survival outcomes in patients with advanced/metastatic urothelial bladder cancer.

Methods

We retrospectively reviewed 84 patients undergoing radical cystectomy (RC) for UCB from January 2002 to June 2012. NLR was computed (median: 5 days) prior to surgery. No patients received neoadjuvant chemotherapy. NLR was analyzed as a continuous variable and a cut-off point of 2.7 was obtained, with a statistical receiver operating characteristics of 0.74. Kaplan–Meier curves, multivariate Cox proportional hazard and logistics regression models were used to predict NLR association with survival outcomes.

Results

The median follow-up period was 30.1 months (range: 3.2–161.7) owing to high recurrence rate and subsequent mortalities, compared to the median 64.7 months in patients alive at the end of study period. NLR ≥2.7 was associated with worse survival outcomes (5-year disease-specific survival: 22% vs 58%, p = 0.017, 95%CI: 1.193–6.009; 5-year overall survival: 23% vs 60%, p = 0.008, 95%CI: 1.322–6.147). Furthermore, on multivariate analyses, higher NLR was independently associated with higher recurrence rate (p = 0.007, HR =6.999, 95%CI: 1.712–28.606), higher T staging (p = 0.021, HR = 3.479, 95%CI: 1.212–9.990) and lymph node involvement (p = 0.009, HR = 4.534, 95%CI: 1.465–14.034).

Conclusion

This study suggests that NLR can be an inexpensive novel factor for patients risk stratification pre-operatively. This improves patient counseling and identifies patients who may benefit from multimodal treatment.

Urothelial generation and regeneration in development, injury, and cancer

Homeostatic maintenance and repair of the urothelium upon injury are required for a functional bladder in both healthy and disease conditions. Understanding the cellular and molecular mechanisms underlying the urothelial regenerative response is key to designing strategies for tissue repair and ultimately treatments for urologic diseases including urinary tract infections, voiding dysfunction, painful bladder syndrome, and bladder cancer. In this article, we review studies on urothelial ontogeny during development and regeneration following various injury modalities. Signaling pathways involved in urothelial regeneration and in urothelial carcinogenesis are also discussed. Developmental Dynamics 246:336-343, 2017. © 2016 Wiley Periodicals, Inc.

Overexpression of maelstrom promotes bladder urothelial carcinoma cell aggressiveness by epigenetically downregulating MTSS1 through DNMT3B

We have recently identified and characterized a novel oncogene, maelstrom (MAEL) from 1q24, in the pathogenesis of hepatocellular carcinoma. In this study, MAEL was investigated for its oncogenic role in urothelial carcinoma of the bladder (UCB) tumorigenesis/aggressiveness and underlying molecular mechanisms. Here, we report that overexpression of MAEL in UCB is important in the acquisition of an aggressive and/or poor prognostic phenotype. In UCB cell lines, knockdown of MAEL by short hairpin RNA is sufficient to inhibit cell growth, invasiveness/metastasis and suppressed epithelial-mesenchymal transition (EMT), whereas ectopic overexpression of MAEL promoted cell growth, invasive and/or metastatic capacity and enhanced EMT both in vitro and in vivo. We further demonstrate that MAEL could induce UCB cell EMT by downregulating a critical downstream target, the metastasis suppressor 1 (MTSS1) gene, ultimately leading to an increased invasiveness of cancer cells. Notably, overexpression of MAEL in UCB cells substantially enhanced the enrichment of DNA methyltrans-ferase (DNMT)3B and histone deacetylase (HDAC)1/2 on the promoter of the MTSS1, and thereby epigenetically suppressing the MTSS1 transcription. Downregulation of MTSS1 by MAEL in UCB cells is partially dependent on DNMT3B. Furthermore, we identify that beside the gene amplification of MAEL, miR-186 is a key negative regulator of MAEL and downregulation of miR-186 is another important mechanism for MAEL overexpression in UCBs. These data suggest that overexpression of MAEL, caused by gene amplification and/or decreased miR-186, has a critical oncogenic role in UCB pathogenesis by downregulation of MTSS1, and MAEL could be used as a novel prognostic marker and/or effective therapeutic target for human UCB.

Sarcopenia as a Novel Preoperative Prognostic Predictor for Survival in Patients with Bladder Cancer Undergoing Radical Cystectomy

PURPOSE

To investigate the prognostic significance of sarcopenia on long-term outcomes in patients with bladder cancer after radical cystectomy (RC).

METHODS

We retrospectively reviewed 136 patients undergoing RC for urothelial carcinoma at our institution. Prognostic impact of the preoperative clinical, laboratory, and radiologic parameters were evaluated by Cox proportional hazard model analyses, and a nomogram was developed to predict cancer-specific survival (CSS) after RC.

RESULTS

The mean follow-up was 46.7 months. Patients with sarcopenia had a significantly shorter CSS than those without sarcopenia. On univariate Cox analysis, clinical T stage, histology of transurethral resection of bladder tumor (TURBT) specimen, pretreatment hemoglobin, pretreatment neutrophil-to-lymphocyte ratio (NLR), pretreatment serum C-reactive protein level, pretreatment serum albumin level, presence of hydronephrosis, and presence of sarcopenia were associated with significantly worse CSS. On multivariate Cox stepwise analysis, sarcopenia (hazard rate [HR] = 2.3, p = 0.015), clinical T stage (cT4: HR = 5.3; p = 0.0096), presence of hydronephrosis (HR = 2.0; p = 0.033), histology of TURBT specimen (HR = 2.2, p = 0.044), and NLR (HR = 1.3; p = 0.0048) were significant independent predictors of an unfavorable prognosis Based on the results of the multivariate analysis, we developed a nomogram to predict 1-, 3-, and 5-year CSS after RC.

CONCLUSIONS

Sarcopenia, clinical T stage, presence of hydronephrosis, histology of TURBT specimen, and NLR are novel preoperative prognostic factors even after adjustment for other known preoperative predictors in patients undergoing RC for bladder cancer.

Elevated Derived Neutrophil-to-Lymphocyte Ratio Corresponds With Poor Outcome in Patients Undergoing Pre-Operative Chemotherapy in Muscle-Invasive Bladder Cancer

Background: Platinum-based pre-operative chemotherapy (POC) for muscle-invasive bladder cancer (MIBC) increases the complete pathological response rate at cystectomy and improves overall survival. However, 60% of MIBC patients still has muscle-invasive disease at cystectomy despite POC. Therefore, accurate prediction of response to POC is an important clinical need. We hypothesized that an elevated neutrophil-to-lymphocyte ratio (NLR) corresponds with adverse outcome in patients undergoing POC and radical cystectomy.

Objective: To explore the correlation between the NLR and outcome in MIBC patients treated by POC and radical cystectomy.

Methods: In 123 MIBC patients (urothelial carcinoma) who were treated by platinum-based POC and radical cystectomy, the derived NLR (dNLR) was retrospectively calculated by dividing the neutrophil count by the difference between leukocytes and neutrophil counts, prior to the start of chemotherapy. The correlation of the dNLR with pathological response at cystectomy and survival was analyzed by logistic regression analysis or the Kaplan-Meier method.

Results: The complete pathological response (ypT0N0Mx) rate was 28.5%, 8.9% obtained a partial response (ypTa/T1/TisN0Mx), and 62.6% were non-responders (stage ≥ ypT2 and/or N+). An elevated dNLR (>2.21) correlated with non-response to POC (OR 2.70, 95% confidence interval: 1.15–6.38, p = 0.02) but this effect was nullified when corrected for clinically node-positive disease and clinical T stage. Patients with an elevated dNLR had shorter progression-free and overall survival albeit non-significant (p = 0.42, and p = 0.45, respectively).

Conclusions: An elevated dNLR corresponded with poor outcome in terms of survival and non-response to POC in MIBC patients undergoing radical surgery. However, after correction for well-known prognostic factors, such as positive lymph node status at diagnostic imaging and clinical T stage, the correlation for the dNLR was nullified. Therefore, we conclude that the dNLR is insufficient to predict response to POC in this heterogeneous patient population.

A Histone Deacetylase Inhibitor, OBP-801, and Celecoxib Synergistically Inhibit the Cell Growth with Apoptosis via a DR5-Dependent Pathway in Bladder Cancer Cells

The prognosis of muscle-invasive bladder cancer with metastasis is poor. There have been no therapeutic improvements for many years, and an innovative therapy for muscle-invasive bladder cancer has been awaited to replace the conventional cytotoxic chemotherapy. Here, we show a candidate method for the treatment of bladder cancer. The combined treatment with a novel histone deacetylase (HDAC) inhibitor, OBP-801, and celecoxib synergistically inhibited cell growth and markedly induced apoptosis through the caspase-dependent pathway in high-grade bladder cancer cells. Furthermore, the combined treatment induced expression of death receptor 5 (DR5). We identified that knockdown of DR5 by small interfering RNA (siRNA) significantly suppressed apoptosis by the combined treatment. Therefore, we conjectured that the apoptosis induced by OBP-801 and celecoxib is at least partially dependent on DR5. However, it was interesting that the combined treatment drastically suppressed expression of DR5 ligand, tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). These data suggest that there is no involvement of TRAIL in the induction of apoptosis by the combination, regardless of the dependence of DR5. Moreover, xenograft studies using human bladder cancer cells showed that the combined therapy suppressed tumor growth by upregulating expressions of DR5 and Bim. The inhibition of tumor growth was significantly more potent than that of each agent alone, without significant weight loss. This combination therapy provided a greater benefit than monotherapy in vitro and in vivo These data show that the combination therapy with OBP-801 and celecoxib is a potential novel therapeutic strategy for patients with muscle-invasive bladder cancer. Mol Cancer Ther; 15(9); 2066-75. ©2016 AACR.

Conditional ablation of TGF-β signaling inhibits tumor progression and invasion in an induced mouse bladder cancer model

The role of transforming growth factor-β (TGF-β) signaling in cancer progression is still under debate. To determine the function of TGF-β signaling in bladder cancer progression, we conditionally knocked out the Tgfbr2 in mouse model after a N-butyl-N-4-hydroxybutyl Nitrosamine induced bladder carcinogenesis. We found the ablation of TGF-β signaling could inhibit the cancer cell proliferation, cancer stem cell population and EMT, hence suppressed the invasive cancer progression, which is similar with the result of TGF-β receptor I inhibitor treatment. These findings recognize the roles and mechanisms of TGF-β signaling in bladder cancer progression in vivo for the first time.

A standardized protocol for identifying and counting lymph nodes harvested by pelvic lymph node dissection at the time of radical cystectomy

INTRODUCTION

Lymph node counts have become a surrogate measure for the extent and quality of pelvic lymph node dissection (PLND) at radical cystectomy, but little consideration has been given to the methodology of lymph node processing. We report results from a prospective series comparing a conventional protocol for processing PLND specimens to a fat-emulsifying protocol. We hypothesized that the rate of node positivity would increase with the fat-emulsifying protocol.

METHODS

Patients undergoing radical cystectomy for cTis-T4aN0-1M0 urothelial carcinoma of the bladder were eligible for this trial. Palpable lymph nodes were isolated from the PLND specimens in the conventional protocol. The remaining tissue was then processed with fat-emulsifying solution to identify further nodes visually. Nodal counts were compared between techniques.

RESULTS

The median number of nodes counted in the PLND specimens of 26 patients was 24.5 (range: 20-40) with conventional processing and 37 (range: 24-52) with the fat-emulsifying solution (p < 0.001). Three patients had lymph node positive disease detected by conventional means, and a single patient was found to have a single positive node by the fat-emulsifying solution alone. The study was closed early after conducting a futility analysis.

CONCLUSIONS

A fat-emulsifying protocol identified more lymph nodes than a conventional protocol and may be an appropriate method to standardize lymph node processing following PLND. However, we were unable to show that such a standardized approach significantly increased the rate of node positivity in patients undergoing radical cystectomy.

Balancing risk and benefit of extended pelvic lymph node dissection in patients undergoing radical cystectomy

PURPOSE

The optimal extent of pelvic lymph node dissection (PLND) during radical cystectomy (RC) in patients with urothelial carcinoma of the bladder (UCB) is the subject of ongoing debate. In this study, we compared local recurrence-free and overall survival, in addition to complication rates, after extended PLND (ePLND) compared to standard PLND (sPLND).

METHODS

We reviewed the charts of 314 patients who underwent RC for UCB between 2008 and 2013. ePLND was performed in 105 patients, and 105 matched patients who underwent standard PLND (sPLND) were selected based on clinical parameters. Local recurrence-free and overall survival rates were assessed using Kaplan-Meier survival analysis, and Cox proportional hazards models were used to assess potential determinants of these outcomes. Complications were assessed at 30 and 90 days using the Clavien-Dindo reporting system.

RESULTS

More lymph nodes were removed by ePLND (median 21) compared to sPLND (median 9; P < 0.001), but the rate of nodal involvement was not different. In multivariable analysis, ePLND was associated with a better local recurrence-free survival (HR = 0.63, P = 0.005), but was not an independent predictor of overall survival (HR = 1.06, P = 0.84). Estimated blood loss was greater with ePLND (1047.3 vs. 584.5 ml P < 0.001), but there was no significant difference in complications.

CONCLUSIONS

Extended PLND appears to reduce the risk of local recurrence, but was not an independent predictor of overall survival in this cohort. ePLND was associated with greater blood loss compared to sPLND, but not with other perioperative complications.

The prognostic significance of preoperative leukocytosis and neutrophil-to-lymphocyte ratio in patients who underwent radical cystectomy for bladder cancer

INTRODUCTION

We evaluated the prognostic effects of hematologic parameters of preoperative leukocytosis and neutrophil-to-lymphocyte ratio (NLR) in patients who underwent radical cystectomy for bladder cancer.

METHODS

We retrospectively reviewed the medical records of 363 patients who underwent radical cystectomy for bladder cancer between January 1990 and June 2013. In total, 286 patients were included in the study. Age, gender, pathologic stage, lymph node involvement, preoperative hydronephrosis, histologic sub-type, surgical margin status, and lymphovascular invasion were recorded for each patient. Univariate and multivariate analysis were performed to determine the prognostic value of the preoperative clinical and laboratory parameters on disease-specific survival (DSS). Additionally, the correlation between leukocytosis and other factors were evaluated.

RESULTS

According to the univariate analysis preoperative leukocytosis and NLR were detected as negative prognostic factors on DSS. Preoperative leukocytosis, NLR, stage, lymph node involvement, histologic subtype, grade and age were independent prognostic factors for DSS, on multivariate analysis. Patients with leukocytosis had higher stage, grade and lymphovascular invasion.

CONCLUSIONS

Inexpensive, reproducible, and readily available peripheral blood count components of white blood cell count and NLR were independent prognostic factors, which can stratify DSS risks in bladder cancer patients who underwent radical cystectomy.

Down-regulation of HMGB1 expression by shRNA constructs inhibits the bioactivity of urothelial carcinoma cell lines via the NF-κB pathway

The high mobility group box 1 (HMGB1), which is a highly conserved and evolutionarily non-histone nuclear protein, has been shown to associate with a variety of biological important processes, such as transcription, DNA repair, differentiation, and extracellular signalling. High HMGB1 expression has been reported in many cancers, such as prostate, kidney, ovarian, and gastric cancer. However, there have been few studies of the function of HMGB1 in the malignant biological behaviour of bladder urothelial carcinoma (BUC), and the potential mechanism of HMGB1 in the pathogenesis of BUC remains unclear. Thus, in this study, we constructed plasmid vectors that are capable of synthesizing specific shRNAs targeting HMGB1 and transfected them into BUC cells to persistently suppress the endogenous gene expression of HMGB1. The expression of HMGB1, the bioactivity of BUC cells, including proliferation, apoptosis, cell cycle distribution, migration and invasion, and the effects of HMGB1 knockdown on downstream signalling pathways were investigated. Our data suggest that HMGB1 promotes the malignant biological behaviour of BUC, and that this effect may be partially mediated by the NF-κB signalling pathway. HMGB1 may serve as a potential therapeutic target for BUC in the future.

Loss of PPM1A expression enhances invasion and the epithelial-to-mesenchymal transition in bladder cancer by activating the TGF-β/Smad signaling pathway

The transforming growth factor-β (TGF-β) signaling pathway is believed to contribute to carcinoma development by increasing cell invasiveness and metastasis and inducing the epithelial-to-mesenchymal transition (EMT). Protein phosphatase PPM1A has been reported to dephosphorylate TGF-β-activated Smad2/3, thus inhibiting the TGF-β signaling pathway. In this study, we investigated the role of PPM1A in bladder cancer. PPM1A protein expression was analyzed in 145 bladder cancer specimens. The loss of PPM1A expression was predictive of poor survival and high muscle-invasiveness. PPM1A was more commonly deficient among muscle-invasive relapse samples compared to primary tumors in twenty paired bladder cancer tissues. Functional studies indicated that blockade of PPM1A through lentivirus-mediated RNA interference significantly promoted urinary bladder cancer (BCa) cell motility, the EMT in vitro and metastasis in vivo, and these effects were dependent on the TGF-β/Smad signaling pathway. The increase in p-Smad2/3 induced by TGF-β1 correlated with the degree of PPM1A depletion in BCa cells, which resulted in an altered expression profile of TGF-β-inducible genes. The correlations between PPM1A and biomarkers related to the TGF-β signaling pathway and tumor invasion were also detected in BCa samples. These results demonstrate that loss of PPM1A is associated with the development of tumor invasion in bladder cancer.

Sources of variation in follow-up expenditure after radical cystectomy

BACKGROUND

Follow-up care after radical cystectomy is poorly defined, with extensive variation in practice patterns. We sought to determine sources of these variations in care as well as examine the economic effect of standardization of care to guideline-recommended care.

METHODS

Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1992 to 2007, we determined follow-up care expenditures (time and geography standardized) for 24 months after surgery. Accounted expenditures included office visits, imaging studies, urine tests, and blood work. A multilevel model was implemented to determine the effect of region, surgeon, and patient factors on care delivery. We then compared the actual expenditures on care in the Medicare system (interquartile range) with the expenditures if patients received care recommended by current clinical guidelines.

RESULTS

Expenditures over 24 months of follow-up were calculated per month and per patient. The mean and median total expenditures per patient were $1108 and $805 respectively (minimum $0, maximum $9,805; 25th-75th percentile $344-$1503). Variations in expenditures were most explained at the patient level. After accounting for surgeon and patient levels, we found no regional-level variations in care. Adherence to guidelines would lead to an increase in expenditures by 0.80 to 10.6 times the expenditures exist in current practice.

CONCLUSION

Although some regional-level and surgeon-level variations in care were found, the most variation in expenditure on follow-up care was at the patient level, largely based on node positivity, chemotherapy status, and final cancer stage. Standardization of care to current established guidelines would create higher expenditures on follow-up care than current practice patterns.

Is Exam under Anesthesia Still Necessary for the Staging of Bladder Cancer in the Era of Modern Imaging?

Background:

The ability to accurately determine tumor stage in bladder cancer is critical because it impacts the management paradigm and overall prognosis. There is often discrepancy between clinical and pathologic staging. Historically, exam under anesthesia (EUA) has been recommended to assist in the staging of bladder cancer.

Objective:

In this era of modern imaging technology, we sought to determine if EUA still contributes meaningfully to the local staging of bladder cancer.

Methods:

We retrospectively reviewed the charts of 1898 patients from 1994–2013 in our radical cystectomy database at MD Anderson Cancer Center. There were 414 patients that had complete information including EUA and whose surgery was performed by one of two surgeons and included in the final analysis. Univariate and multiple logistic regression models were generated to determine the ability of EUA, imaging, and other patient characteristics to predict pathological fat extension at the time of cystectomy.

Results:

38% of patients had≥pT3 disease at the time of cystectomy. 30.9% of patients had findings on EUA suggestive of T3 disease and 28.7% had radiologic findings suggestive of T3 disease. In a model including age, BMI, ethnicity, year of operation, and neoadjuvant chemotherapy among other factors, the only factors predictive of pT3 disease were EUA and imaging (p = 0.002). The combination of EUA and imaging improved the accuracy of clinical staging compared to either modality alone.

Conclusions:

Despite modern advances in imaging, EUA contributes meaningfully to accurate determination of local bladder cancer stage.

Curative therapy for bladder cancer in routine clinical practice: a population-based outcomes study

AIMS

Definitive therapy of bladder cancer involves cystectomy or radiotherapy; controversy exists regarding optimal management. Here we describe the management and outcomes of patients treated in routine practice.

MATERIALS AND METHODS

Treatment records were linked to the Ontario Cancer Registry to identify all cases of bladder cancer in Ontario treated with cystectomy or radiotherapy in 1994-2008. Practice patterns are described in three study periods: 1994-1998, 1999-2003, 2004-2008. Logistic regression, Cox model and propensity score analyses were used to evaluate factors associated with treatment choice and survival.

RESULTS

In total, 3879 cases (74%) underwent cystectomy and 1380 (26%) were treated with primary radiotherapy. Cystectomy use increased over time (66, 75, 78%), whereas radiotherapy decreased (34, 25, 22%), P < 0.001. There was substantial regional variation in the proportion of cases undergoing radiotherapy (range 16-51%). Five year cancer-specific survival (CSS) and overall survival were 40 and 36% for surgical cases and 35 and 26% for radiotherapy cases (P < 0.001). In multivariate Cox model and propensity score analyses, there was no significant difference in CSS between surgery and radiotherapy (hazard ratio 0.99, 95% confidence interval 0.91-1.08); radiotherapy was associated with slightly inferior overall survival (hazard ratio 1.08, 95% confidence interval 1.00-1.16).

CONCLUSION

Utilisation of cystectomy for bladder cancer in routine practice has increased over time with no evidence of a significant difference in CSS between radiotherapy and cystectomy.

Transurethral resection and degeneration of bladder tumour

INTRODUCTION

We evaluate the efficacy and safety of transurethral resection and degeneration of bladder tumour (TURD-Bt).

METHODS

In total, 56 patients with bladder tumour were treated by TURD-Bt. The results in these patients were compared with 32 patients treated by current transurethral resection of bladder tumour (TUR-Bt). Patients with or without disease progressive factors were respectively compared between the 2 groups. The factors included recurrent tumour, multiple tumours, tumour ≥3 cm in diameter, clinical stage T2, histological grade 3, adenocarcinoma, and ureteral obstruction or hydronephrosis.

RESULTS

Follow-up time was 48.55 ± 23.74 months in TURD-Bt group and 56.28 ± 17.61 months in the TUR-Bt group (p > 0.05). In patients without progressive factors, no tumour recurrence was found and overall survival was 14 (100%) in the TURD-Bt group; 3 (37.50%) patients had recurrence and overall survival was 5 (62.5%) in the TUR-Bt group. In patients with progressive factors, 8 (19.05%) patients had tumour recurrence, overall survival was 32 (76.19%) and cancer death was 3 (7.14%) in TURD-Bt group; 18 (75.00%) patients had tumour recurrence (p < 0.05), overall survival was 12 (50.00%) (p < 0.01) and cancer death was 8 (33.33%) (p < 0.05) in TUR-Bt group. No significant complication was found in TURD-Bt group.

CONCLUSION

This study suggests that complete resection and degeneration of bladder tumour can be expected by TURD-Bt. The surgical procedure is safe and efficacious, and could be predictable and controllable before and during surgery. We would conclude that for bladder cancers without lymph node metastasis and distal metastasis, TURD-Bt could be performed to replace radical TUR-Bt and preserve the bladder.

EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines

CONTEXT

The European Association of Urology (EAU) guidelines panel on Muscle-invasive and Metastatic bladder cancer (BCa) updates its guidelines yearly. This updated summary provides a synthesis of the 2013 guidelines document, with emphasis on the latest developments.

OBJECTIVE

To provide graded recommendations on the diagnosis and treatment of patients with muscle-invasive BCa (MIBC), linked to a level of evidence.

EVIDENCE ACQUISITION

For each section of the guidelines, comprehensive literature searches covering the past 10 yr in several databases were conducted, scanned, reviewed, and discussed both within the panel and with external experts. The final results are reflected in the recommendations provided.

EVIDENCE SYNTHESIS

Smoking and work-related carcinogens remain the most important risk factors for BCa. Computed tomography (CT) and magnetic resonance imaging can be used for staging, although CT is preferred for pulmonary evaluation. Open radical cystectomy with an extended lymph node dissection (LND) remains the treatment of choice for treatment failures in non-MIBC and T2-T4aN0M0 BCa. For well-informed, well-selected, and compliant patients, however, multimodality treatment could be offered as an alternative, especially if cystectomy is not an option. Comorbidity, not age, should be used when deciding on radical cystectomy. Patients should be encouraged to actively participate in the decision-making process, and a continent urinary diversion should be offered to all patients unless there are specific contraindications. For fit patients, cisplatinum-based neoadjuvant chemotherapy should always be discussed, since it improves overall survival. For patients with metastatic disease, cisplatin-containing combination chemotherapy is recommended. For unfit patients, carboplatin combination chemotherapy or single agents can be used.

CONCLUSIONS

This 2013 EAU Muscle-invasive and Metastatic BCa guidelines updated summary aims to increase the quality of care and outcome for patients with muscle-invasive or metastatic BCa.

PATIENT SUMMARY

In this paper we update the EAU guidelines on Muscle-invasive and Metastatic bladder cancer. We recommend that chemotherapy be administered before radical treatment and that bladder removal be the standard of care for disease confined to the bladder.

Surveillance of patients with bladder cancer following cystectomy: yield of CT urography

PURPOSE

To determine the yield of CT urography (CTU) in the surveillance of patients with bladder cancer following cystectomy.

MATERIALS AND METHODS

In this IRB-approved, HIPAA-compliant, retrospective study of 5,404 CT urograms performed at our institution between March 2000 and February 2011, 225 CT urograms were performed in 105 patients [79 men, 26 women; mean age 65 years (43-85)] following cystectomy for bladder cancer. Median follow-up after cystectomy was 63 months (range 1-234), median time between cystectomy and CTU was 39 months (range 0-229), median follow-up after CTU was 34 months (range 1-111). CTU examinations were reviewed by two radiologists in consensus and findings were categorized into those related to surgery, locoregional recurrence, metastases, or metachronous upper tract urothelial tumor (UTT).

FINDINGS

Findings were present in 69 (65.7 %) of 105 patients, including findings related to surgery in 60 (57.1 %) patients, locoregional recurrence or metastatic disease in 21 (20 %) patients, and UTT in 3 (2.9 %) patients. Of surgery-related findings, hydronephrosis (23/105, 21.9 %) and parastomal hernia (17/105, 16.2 %) were the most common findings. Visceral metastases (16/105, 15.2 %) and lymph node metastases (13/105, 12.4 %) were the most common manifestations of recurrent disease.

CONCLUSION

CTU findings in the surveillance of patients with bladder cancer after cystectomy are common and include those related to surgery, spread of the disease, and metachronous tumors. Our study supports current published guidelines on the use of CTU in these patients.

Omega-3 fatty acids inhibit tumor growth in a rat model of bladder cancer

Omega-3 (ω-3) fatty acids have been tested on prevention and treatment of several cancer types, but the efficacy on “in vivo” bladder cancer has not been analyzed yet. This study aimed at evaluating the chemopreventive efficacy of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) mixture in an animal model of bladder cancer. Forty-four male Wistar rats were divided into 4 groups during a 20-week protocol: control; carcinogen—N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN); ω-3 (DHA + EPA); and ω-3 + BBN. BBN and ω-3 were given during the initial 8 weeks. At week 20 blood and bladder were collected and checked for the presence of urothelium lesions and tumors, markers of inflammation, proliferation, and redox status. Incidence of bladder carcinoma was, control (0%), ω-3 (0%), BBN (65%), and ω-3 + BBN (62.5%). The ω-3 + BBN group had no infiltrative tumors or carcinoma in situ, and tumor volume was significantly reduced compared to the BBN (0.9 ± 0.1 mm³ versus 112.5 ± 6.4 mm³). Also, it showed a reduced MDA/TAS ratio and BBN-induced serum CRP, TGF-β1, and CD31 were prevented. In conclusion, omega-3 fatty acids inhibit the development of premalignant and malignant lesions in a rat model of bladder cancer, which might be due to anti-inflammatory, antioxidant, anti-proliferative, and anti-angiogenic properties.