Lymphovascular invasion is associated with oncologic outcomes following radical cystectomy for squamous cell carcinoma of the urinary bladder

Identify and validate RUNX2 and LAMA2 as novel prognostic signatures and correlate with immune infiltrates in bladder cancer

Background

Muscle-invasive bladder cancer (MIBC) develops lymph node (LN) metastasis or distant metastasis, leading to recurrence and poor prognosis. The five-year survival rate of MIBC with LN or distant metastasis is only 8.1%; therefore, there is an urgent need to identify reliable biomarkers for prognosis and treatment regimen for patients with bladder cancer (BLCA).

Methods

SEER database was used to select important clinical characteristics for MIBC. Then, weighted gene co-expression network analysis (WGCNA) was employed to identify differentially expressed genes (DEGs) to recognize significant co-expression modules by calculating the correlation between the modules and clinical data. Furthermore, Cox regression and lasso analysis were applied to screen prognostic hub genes and establish the risk predictive model. Bladder cancer cell lines (UMUC3 and 5637) were used for experimental validation in vitro.

Results

Cox analysis of 122,600 MIBC patients showed that the N stage was the most important clinical factor. A total of 4,597 DEGs were calculated between N0 and N+ patients, and WGCNA with these DEGs in 368 samples revealed that expression of turquoise was positively and strongly correlated with the N stage. Eight genes were identified as important prognostic candidates using lasso regression based on Cox analysis and STRING database. Combining GEO datasets, literature, and clinical factors, we identified LAMA2 and RUNX2 as novel prognostic biomarkers. CCK8 assay showed that depletion of LAMA2 or RUNX2 significantly inhibited the proliferation of BLCA cells, and flow cytometry indicated that knockdown of LAMA2 or RUNX2 induced the apoptosis of BLCA cells. Transwell assay also showed that silencing of LAMA2 or RUNX2 weakened the migration and invasiveness of BLCA cells.

Conclusions

We constructed a new eight-gene risk model to provide novel prognostic biomarkers and therapeutic targets for BLCA.

A tumor microenvironment preoperative nomogram for prediction of lymph node metastasis in bladder cancer

Background

Growing evidence suggests that tumor metastasis necessitates multi-step microenvironmental regulation. Lymph node metastasis (LNM) influences both pre- and post-operative bladder cancer (BLCA) treatment strategies. Given that current LNM diagnosis methods are still insufficient, we intend to investigate the microenvironmental changes in BLCA with and without LNM and develop a prediction model to confirm LNM status.

Method

"Estimation of Stromal and Immune cells in Malignant Tumors using Expression data" (ESTIMATE) algorithm was used to characterize the tumor microenvironment pattern of TCGA-BLCA cohort, and dimension reduction, feature selection, and StrLNM signature construction were accomplished using least absolute shrinkage and selection operator (LASSO) regression. StrLNM signature was combined with the genomic mutation to establish an LNM nomogram by using multivariable logistic regression. The performance of the nomogram was evaluated in terms of calibration, discrimination, and clinical utility. The testing set from the TCGA-BLCA cohort was used for internal validation. Moreover, three independent cohorts were used for external validation, and BLCA patients from our cohort were also used for further validation.

Results

The StrLNM signature, consisting of 22 selected features, could accurately predict LNM status in the TCGA-BLCA cohort and several independent cohorts. The nomogram performed well in discriminating LNM status, with the area under curve (AUC) of 75.1% and 65.4% in training and testing datasets from the TCGA-BLCA cohort. Furthermore, the StrLNM nomogram demonstrated good calibration with p >0.05 in the Hosmer-Lemeshow goodness of fit test. Decision curve analysis (DCA) revealed that the StrLNM nomogram had a high potential for clinical utility. Additionally, 14 of 22 stably expressed genes were identified by survival analysis and confirmed by qPCR in BLCA patient samples in our cohort.

Conclusion

In summary, we developed a nomogram that included an StrLNM signature and facilitated the preoperative prediction of LNM status in BLCA patients.

The Significance of Squamous Histology on Clinical Outcomes and PD-L1 Expression in Bladder Cancer

Objectives. To compare the clinicopathologic characteristics of urothelial carcinoma (UC), urothelial carcinoma with squamous differentiation (UCSD), and squamous cell carcinoma (SCC) of the bladder, which have been suggested to differ in terms of risk factors, immunophenotype, and prognosis. Methods. We evaluated the clinicopathologic features of radical cystectomy specimens between 1980 and 2015 with a diagnosis of SCC, UCSD, and UC. PD-L1 immunohistochemistry (clinically available clones 22C3, SP142, and SP263) was performed on SCC and UCSD. Multivariate Cox regression was used to identify prognostic factors. Kaplan-Meier curves were plotted to assess cancer-specific survival (CSS). Results. Of the 1478 cases, there were 1126 UC (76%), 217 UCSD (15%), and 135 SCC (9%). Bladder cancer was more common in men than women (80% vs 20%, P < .0001). However, a higher proportion of SCC and UCSD occurred in women (SCC-36%, UCSD-22%, UC-18%). Women were significantly more likely to be never smokers in all 3 cohorts (UC: 45% vs 16%, UCSD: 44% vs 12%, SCC: 40% vs 18%, P < .0001). Patients with SCC and UCSD were at a higher pathologic stage (>pT2) at the time of cystectomy (UCSD-74%, SCC 71%, UC-44%, P < .0001) and had worse CSS compared to patients with UC (P = 0.006). SCC had higher PD-L1 scores (all clones) than UCSD (P < .0001). PD-L1 22C3 (P = .02, HR: 0.36) and SP142 scores (P = .046, HR: 0.27) predicted CSS on Kaplan-Meier analysis for SCC cases. Conclusions. UC, UCSD, and SCC are associated with different risk factors, gender distributions, and clinical outcomes. PD-L1 is expressed in SCC and UCSD, suggesting some patients may benefit from targeted therapy.

Oncologic Outcomes of Squamous Cell Carcinoma Versus Urothelial Carcinoma With Squamous Differentiation After Radical Cystectomy for Bladder Carcinoma

INTRODUCTION

In this study we aim to compare clinicopathological characteristics and cancer specific survival between patients treated with radical cystectomy for pure squamous cell carcinoma (SCC) and urothelial carcinoma with squamous differentiation (SqD).

PATIENTS AND METHODS

We reviewed data of 1737 consecutive patients treated with radical cystectomy and urinary diversion between January 2004 and February 2014. Only patients with pure SCC or SqD were included in the analysis. Squamous differentiation was defined as intercellular bridges or keratinization in the tumor. Clinicopathological data and recurrence free survival (RFS) were compared between patients diagnosed with SCC and SqD.

RESULTS

SCC and SqD were found in 318 and 223 patients, respectively. Mean age was 57 ± 8.3 years in SCC and 58.8 ± 7.8 in SqD (P = .008). A higher proportion of female patients was observed in SCC group compared to SqD (31.8% vs. 22% P < .0001). Patients with SqD were more likely to have extravesical (58.3% vs. 46.2%: P = .006) and nodal positive disease (34.5% vs. 14.5%: P < .0001) than pure SCC patients. Bilharzial eggs were found in 61% of SCC vs. 46% of SqD (P = .001).; The median (IQR) follow up period for SCC and SqD was 63 (12-112) months and 23 months (9-74.7), respectively. The 5-year RFS for SCC and SqD were 77% and 59.8 %, respectively (P < .0001).; Multivariate cox regression analysis identified advanced pT stage (OR: 1.9, 95% CI: 1.3-2.86, P = .0001), nodal positive disease (OR: 1.6, 95% CI: 1.1-2.48, P = .01) and SqD histology (OR: 1.6, 95% CI: 1.14-2.31, P = .007 as independent predictors of 5-year RFS.

CONCLUSION

Patient with SCC had significantly higher 5-year RFS in comparison to SqD. The higher rate of extravesical disease and lymph node metastasis in SqD patients is indicative of aggressive behavior of this histologic type.

Genomic characterization of non-schistosomiasis-related squamous cell carcinoma of the urinary bladder: A retrospective exploratory study

Background

Non-schistosomiasis related-squamous cell carcinoma of urinary bladder (NSR-SCCUB) is a rare tumor subtype distinct from urothelial carcinoma (UC). Studies assessing molecular biomarkers in bladder cancer have generally focused on UC, and genomic data of NSR-SCCUB is limited. We aim to provide additional insight into the molecular underpinnings of this rare entity.

Methods

NSR-SCCUB patients were identified retrospectively at Princess Margaret Cancer Centre between 2002 and 2017. Demographics, disease characteristics, therapeutic approaches, and outcomes were collected. Tissue samples were interrogated using the Oncomine Comprehensive Assay v3 (ThermoFisher). Kaplan-Meier method was used to estimate the disease-free survival and overall survival (OS).

Results

Overall, 11 patients with NSR-SCCUB were identified between 2002 and 2017 with adequate tissue samples. Median age was 71 years (45–86), predominantly male (63.6%). At time of diagnosis, 9 patients (81.8%) had muscle-invasive disease, 1 (9.1%) had non-muscle invasive, and 1 (9.1%) had advanced disease. Nine (81.8%) patients had radical cystectomy and pelvic lymph nodes dissection. Eight (72.7%) patients had pT3 or pT4 with N0, and 5 (45.5%) were grade 3. Median OS was 12.5 months (95% CI 7.7–17.2 months). Single nucleotide variants or insertion/deletions were identified in TP53, TERT, PIK3CA, PTEN, CREBBP, FBXW7, and FGFR3. Amplifications were found in CCND1, and EGFR.

Conclusions

NSR-SCCUB has potentially actionable genomic alterations with anticancer agents and many of these aberrations are also seen in UC. The recruitment of NSR-SCCUB patients harboring such mutations should be considered in biomarker driven urinary bladder cancer studies.

Predictive Nomogram and Risk Factors for Lymph Node Metastasis in Bladder Cancer

Lymph node metastasis (LNM) is an important prognostic factor for bladder cancer (BCA) and determines the treatment strategy. This study aimed to determine related clinicopathological factors of LNM and analyze the prognosis of BCA. A total of 10,653 eligible patients with BCA were randomly divided into training or verification sets using the 2004-2015 data of the Surveillance, Epidemiology, and End Results database. To identify prognostic factors for the overall survival of BCA, we utilized the Cox proportional hazard model. Independent risk factors for LNM were evaluated via logistic regression analysis. T-stage, tumor grade, patient age and tumor size were identified as independent risk factors for LNM and were used to develop the LNM nomogram. The Kaplan-Meier method and competitive risk analyses were applied to establish the influence of lymph node status on BCA prognosis. The accuracy of LNM nomogram was evaluated in the training and verification sets. The areas under the receiver operating characteristic curve (AUC) showed an effective predictive accuracy of the nomogram in both the training (AUC: 0.690) and verification (AUC: 0.704) sets. In addition, the calibration curve indicated good consistency between the prediction of deviation correction and the ideal reference line. The decision curve analysis showed that the nomogram had a high clinical application value. In conclusion, our nomogram displayed high accuracy and reliability in predicting LNM. This could assist the selection of the optimal treatment for patients.

Young age increases the risk of lymph-node metastasis in patients with muscle-invasive bladder urothelial carcinoma

BACKGROUND

The risk of positive lymph nodes in patients with muscle-invasive bladder urothelial carcinoma (MIBC) can be used to guide treatment recommendations. However, little is known about the effect of age on lymph node positivity (LN+). This study aimed to evaluate the effect of age on LN+ in MIBC.

METHODS

We analyzed patients with stage T2-T4 bladder urothelial carcinoma who had not received preoperative radiotherapy, had at least one lymph node examined, and underwent cystectomy between 1998 and 2015. The Cochran-Armitage trend test and logistic univariate and multivariate analyses were used to evaluate the effect of age on LN+ in all T stages.

RESULTS

In total, 15,624 patients with MIBC were identified, including 747 patients aged ≤50 years (4.78%), 2614 patients aged 50-59 years (16.73%), 4914 patients aged 60-69 years (31.45%), 5225 patients aged 70-79 years old (33.44%), and 2124 patients aged > 80 years (13.59%). In T2-T4 staging, LN+ was negatively correlated with age. After adjustment for several covariates, multivariate logistic regression analysis revealed that age was an independent risk factor for LN+.

CONCLUSIONS

In this large SEER analysis, Young patients with MIBC have a higher risk of lymph node metastasis. This finding is worthy of further study and may eventually affect the treatment decisions of young patients.

Squamous Cell Carcinoma of the Bladder Is Not Associated With High-risk HPV

OBJECTIVE

To evaluate the clinical features, pathologic features, and prevalence of human papilloma virus (HPV) in squamous cell carcinoma (SCC) of the bladder. SCC of the bladder is known to be associated with conditions that cause chronic inflammation/irritation. The literature is inconsistent regarding the association of HPV with pure SCC of the bladder.

METHODS

A multi-institutional study identified cases of SCC of the bladder. Pure squamous histology and the absence of urothelial carcinoma in situ were required for inclusion. Clinical and pathologic features were collected, and tissues were evaluated for high-risk HPV using p16 immunohistochemistry and in situ hybridization.

RESULTS

We identified 207 cases of SCC of the bladder. Risk factors for bladder cancer included smoking (133/207, 64%) and chronic bladder irritation (83/207, 40%). The majority (155/207, 75%) of patients had > pT2 disease. Mean tumor size was 5.6 ± 3.0 cm and 36/207 (17%) patients had lymph node positive disease. p16 immunohistochemistry was positive in 52/204 (25%) cases but high-risk HPV was identified with in situ hybridization in only 1 (0.5%) case. Tumor size, stage, number of lymph nodes removed, number of positive lymph nodes, lymphovascular invasion, perineural invasion, and positive margins each were associated with cancer-specific mortality when adjusted for demographic factors. A multivariate analysis of variable importance further revealed sex and race as important factors in predicting cancer-specific mortality.

CONCLUSION

SCC of the bladder is an aggressive histologic subtype. Although bladder SCC can express p16, it is not typically associated with high-risk HPV, although rare cases can occur.

Radical cystectomy plus chemotherapy in patients with pure squamous cell bladder carcinoma: a population-based study

PURPOSE

To test the effect of perioperative chemotherapy (CHT) on overall mortality (OM) and cancer-specific mortality (CSM) in patients with locally advanced or metastatic squamous cell carcinoma of the urinary bladder (SCC UB).

METHODS

Within the Surveillance, Epidemiology and End Results database (1988-2016), we identified 1,018 SCC UB patients (664 T_3-4aN₀M₀, 197 TanyN_1-3M₀ and 156 T_4bN_0-3 or M₁), who underwent radical cystectomy with or without perioperative chemotherapy administration. Inverse probability of treatment-weighting (IPTW), Kaplan-Meier plots and Cox-regression models (CRMs) were used.

RESULTS

CHT was administrated in 116 (17.5%) T_3-4aN₀M₀, 77 (39.1%) TanyN_1-3M₀ and 47 (30.1%) T_4bN_0-3 or M₁ patients. IPTW-adjusted 2-year cancer-specific survival (CSS) was 66.5 vs. 71.5% (p = 0.19), 60.9 vs. 29.5% (p < 0.001) and IPTW-adjusted 1-year CSS was 46.2 vs. 31.1% (p = 0.03) for CHT vs. no CHT administration in T_3-4aN₀M₀, TanyN_1-3M₀ and T_4bN_0-3 or M₁, respectively. In multivariable IPTW-adjusted CRMs, chemotherapy was an independent predictor of lower CSM in TanyN_1-3M₀ (HR 0.44) and in T_4bN_0-3 or M₁ (HR 0.60), but not in T_3-4aN₀M₀ (p = 0.6) patients. Virtually the same results were obtained on OM, as well as without IPTW-adjustment and after stratification according to age and gender.

CONCLUSIONS

The use of perioperative CHT in patients with SCC UB confers survival benefit in the presence of T4b disease, lymph node or distant metastases. Conversely, patients with locally advanced disease but negative lymph node invasion do not benefit from its use. Pending higher quality data from prospective trials, these data should encourage the use of perioperative CHT in those high-risk patient groups.

Expression and prognostic value of PD-L1 in non-schistosoma-associated urinary bladder squamous cell carcinoma

Background

Non-schistosoma-associated urinary bladder squamous cell carcinoma (SqCC) has low incidence and is associated with chronic inflammation. Due to its unique etiology and pathology, expression of programmed cell death ligand 1 (PD-L1) in SqCC could be different from that of urothelial carcinoma, which may contribute to different responses to immunotherapy. In this study, we intended to explore the expression profile and prognostic value of PD-L1 in non-schistosoma-associated urinary bladder SqCC under the consideration of tumor-infiltrating lymphocytes’ (TILs) density.

Methods

We conducted a retrospective study to review 604 bladder cancer patients who received radical cystectomy (RC) from 2009 to 2013 in Peking University First Hospital. We enrolled 67 bladder SqCC patients in total, including pure SqCC (n=19) and mixed SqCC (n=48, with urothelial carcinoma). PD-L1 protein expression and TILs density were evaluated by immunohistochemistry.

Results

Nine female and 58 male patients (median age 67.4 years) were enrolled in the present study. There were 15 stage T1–2 patients and 52 stage T3–4 patients. 27 patients had N1–2 lymph node metastasis. Overall, 61.2% cases were PD-L1-positive. Dense TILs coincided with higher PD-L1 expression rate. Median survival time of PD-L1 positive cases was significantly higher than negative cases (P=0.026). During multivariate analysis, positive PD-L1 expression and dense TILs were independent protective factors affecting overall survival (OS, PD-L1: P=0.022; TILs: P=0.010) and progression free survival (PFS, PD-L1: P=0.018; TILs: P=0.009).

Conclusions

PD-L1 expression and dense TILs were frequently detected in urinary bladder SqCC tumors. Positive PD-L1 expression and dense TILs were correlated with better survival outcomes in non-schistosoma-associated urinary bladder SqCC. The immunotherapy targeting PD-L1 might be helpful to bladder SqCC patients.

Nomograms to predict individual prognosis of patients with squamous cell carcinoma of the urinary bladder

BACKGROUND

On the basis of some significant clinical parameters, we had an intent to establish nomograms for estimating the prognosis of patients with squamous cell carcinoma of the urinary bladder (SCCB), including overall survival (OS) and cancer-specific survival (CSS).

METHODS

The data of 1210 patients diagnosed with SCCB between 2004 and 2014,were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. The Cox proportional hazards regression model was applied to evaluate the association between variables and survival. Nomograms were constructed to predict the OS and CSS of an individual patient based on the Cox model. In the end, the performance of nomograms was internally validated by using calibration curves, concordance index (C-index), and k-fold cross-validation.

RESULTS

Several common indicators were taken into the two nomograms (OS and CSS), including age at diagnosis, marital status, sex, TNM stage, surgical approach, tumor size, and lymph node ratio while the OS nomogram additionally contained race, grade, and chemotherapy. They had an excellent predictive accuracy on 1- and 3- year OS and CSS with C-index of 0.733 (95% confidence interval [CI], 0.717-0.749) for OS and 0.724 (95% CI, 0.707-0.741) for CSS. All calibration curves showed great consistency between actual survival and predictive survival.

CONCLUSIONS

The nomograms with improved accuracy and applicability on predicting the survival outcome of patients with SCCB would provide a reliable tool to help clinicians to evaluate the risk of patients and make individual treatment strategies.