Growth fractions of transitional cell carcinomas of the bladder defined by the monoclonal antibody Ki-67

Omega-3 polyunsaturated fatty acids: a modified approach for chemo-prevention of bladder cancer in a rat model and molecular studies of antineoplastic mechanisms

OBJECTIVES

To test the chemo-preventative effects of omega-3 against bladder cancer (BC) induction in a rat model and its potential antineoplastic mechanisms.

MATERIAL AND METHODS

Ninety male Fisher rats were divided into three groups during a 22-week protocol: group 1 (control), group 2 (Placebo + N-butyl-N-4- hydroxybutyl nitrosamine (BBN) for induction of BC and group 3 received omega-3 (1200 mg/kg/day) + BBN. At the end, blood samples and bladder tissues were collected and checked for the presence of malignancy, markers of angiogenesis (VEGF relative gene expression), inflammation (IL-6), proliferation (KI-67 expressions), oxidative stress (serum MDA and serum SOD) and epigenetic control (miRNA-145 level).

RESULTS

At the end of the study, 60% and 86.6% rats survived in group 2 and 3 with significant weight loss among rats in group 2 when compared with other groups. In group 2, all rats developed visible bladder lesions of which five and 13 developed squamous cell carcinoma (SCC) and transitional cell carcinoma (TCC). In omega3-treated group, only one developed low grade SCC and one developed high grade non- invasive TCC. Bladders from omega-3-treated rats showed lower expression ofKI-67 (p < 0.05), VEGF (p < 0.001) and IL-6 (p < 0.001) and significant higher expression of mi-RNA (p < 0.001). Also, omega-3-treated group showed statistically significant lower MDA level (p < 0.001).

CONCLUSION

Omega-3 inhibits bladder tumor growth in the BBN-induced BC rat model, due to anti-inflammatory, antioxidant, anti-proliferative, and anti-angiogenic properties together with epigenetic control.

Ki-67 Antibody Immunostaining in Benign and Malignant Human Prostatic Disease

Indices of mitotic potential may improve prognostic discrimination in patients with malignant disease. Ki-67 is a monoclonal antibody directed against an unknown proliferation antigen which has been shown to be a measure of mitotic potential. Sixty-four benign and eighty malignant prostatic biopsies were stained with the Ki-67 antibody. Nuclear and cytoplasmic staining was identified in benign and malignant biopsies using immunoalkaline phosphatase and immunoperoxidase staining reactions. Nuclear staining was identified in 14 benign and 44 malignant biopsies. Nuclear staining for Ki-67 was seen in 36% of biopsies with Gleason histological score (GHS) 2-4, 71% with GHS 5-7 and 62%> with GHS 8-10. Nuclear staining was associated with advanced local disease stage, but not with metastatic disease stage. Clinical follow-up is required to establish the value of Ki-67 immunostaining as a prognostic determinant in prostatic cancer.

Biomarkers in bladder cancer: translational and clinical implications

Bladder cancer is associated with high recurrence and mortality rates. These tumors show vast heterogeneity reflected by diverse morphologic manifestations and various molecular alterations associated with these disease phenotypes. Biomarkers that prospectively evaluate disease aggressiveness, progression risk, probability of recurrence and overall prognosis would improve patient care. Integration of molecular markers with conventional pathologic staging of bladder cancers may refine clinical decision making for the selection of adjuvant and salvage therapy. In the past decade, numerous bladder cancer biomarkers have been identified, including various tumor suppressor genes, oncogenes, growth factors, growth factor receptors, hormone receptors, proliferation and apoptosis markers, cell adhesion molecules, stromal factors, and oncoproteins. Recognition of two distinct pathways for urothelial carcinogenesis represents a major advance in the understanding and management of this disease. Nomograms for combining results from multiple biomarkers have been proposed to increase the accuracy of clinical predictions. The scope of this review is to summarize the major biomarker findings that may have translational and clinical implications.

Markers of bladder cancer State of the art

Biomarkers are increasingly being applied to the clinical management of patients with bladder cancer. The biomarkers in current clinical use focus on bladder cancer detection. Biomarkers for prognosis and as intermediate endpoints for chemoprevention are being evaluated in clinical trials. This review provides an overview of the performance characteristics of current clinical markers and other markers that are currently under evaluation.

Fascin-1 expression in papillary and invasive urothelial carcinomas of the urinary bladder

Fascin-1 is an actin-bundling protein that plays an important role in cell motility and adhesion. The level of fascin-1 is low or undetectable in normal epithelial cells. However, overexpression is reported in transformed epithelial cells and in several common types of carcinomas [Bioessays. 2002;24:359-361]. Up-regulation of fascin-1 is associated with higher grades and with aggressive tumors with poorer prognoses. We found no report on the role or the protein expression of fascin-1 in urothelial carcinomas (UCs) of the urinary bladder. In this study, we examined by immunohistochemistry the expression of fascin-1 in the normal human transitional epithelium, benign vesical lesions, and different types of UCs. We found no detectable fascin-1 in the normal transitional epithelium. There was no increase of fascin-1 expression in cystitis cystica, cystitis glandularis, nephrogenic adenoma (n = 10), inverted papilloma (n = 5), and classic exophytic papilloma (n = 4) or in adjacent transitional epithelia associated with these conditions. Patchy or diffusely weak fascin-1 expression was observed in 42% (5/12) of superficial papillary UCs (Ta), and 95% (19/20) of invasive UCs (T2 or higher) demonstrated diffuse strong staining for fascin-1. The microinvasive foci in the lamina propria of UC (T1, n = 8) were also positive for fascin-1, although they were not as strongly stained as in the deeply invasive tumors. Interestingly, the neoplastic cells in the tips of microinvasive carcinomas were distinctly positive for fascin-1. There were significant numbers of fascin-1-positive cells (>50% of the neoplastic cells) in UCs in situ (n = 10). These findings suggest an association between increased fascin-1 expression and increased invasiveness of carcinomas in the urinary bladder.

Prognostic value of EGF receptor and tumor cell proliferation in bladder cancer: therapeutic implications

Changes in growth factor receptor expression may confer a growth advantage on tumour cells. Epidermal growth factor-receptor (EGF-R) has been associated with the genesis of bladder tumours. We sought a link between EGF-R expression and MIB-1 cell proliferation and examined their prognostic value in the progression of bladder cancer. Fresh frozen samples from 113 transitional cell carcinomas (TCC) of the bladder and 10 healthy bladders were studied by immunohistochemistry, using monoclonal antibodies for EGF-R expression and MIB-1 for cell proliferation. Qualitative and quantitative immunostaining were analyzed in relation to time to progression and compared with clinical and pathologic parameters for prognostic significance in univariate and multivariate analysis (stepwise logistic regression). EGF-R stained more intensively in invasive tumours. Median nuclear over-expression of MIB-1 was 28%. Progression free survival rate estimates (log rank test) were significantly lower in patients EGF-R positive and with MIB-1 score above 28% (P < 0.0001, P < 0.0001, respectively). Multivariate analysis indicated that MIB-1 immunostaining was the most significant independent variable and EGF-R expression had no additional prognostic value over clinical stage and grade and cell proliferation. The MIB-1 proliferation index is a stronger predictor of bladder tumour progression than is EGF-R over-expression. This marker yield significant prognostic information in addition to stage and grade and may be of value for the clinical management of superficial and invasive bladder carcinomas. The pattern of EGF-R immunostaining and its association with tumour progression makes it a candidate for antigrowth factor therapy.

[Comparative study of the expression of p53, Ki-67, bcl-2 and CK20 in superficial transitional carcinoma of the bladder: correlation with recurrence, histological grade, and clinical stage]

OBJECTIVE

We examined the presence of p53, Ki-67, bcl-2 and CK20, as detected by immunohistochemistry, and correlated with the classic variables (grade, stage and recurrence).

MATERIAL AND METHOD

The authors evaluated 57 superficial transitional cell carcinomas. Biopsy specimens examined included non recurrent transitional cell carcinomas (n = 36) and recurrent transitional cell carcinomas (n = 21). Association of bcl-2, p53, Ki-67 y CK20 index immunoreactivity with tumor grade, clinical stage and tumor recurrence was examined.

RESULTS

Ki-67 and p53 expression were related to the degree of differentiation and recurrence of the disease. bcl-2 and CK20 were not correlated with grade, stage and recurrence of the disease.

CONCLUSIONS

Positivity for Ki-67 and p53 increase with grade of the disease. P53 and Ki-67 are predictors of tumor recurrence for patients with superficial transitional cell carcinoma.

p53 protein and Ki-67 overexpression in urothelial dysplasia of bladder

Mutated tumor suppression gene p53 is a common genetic abnormality in most papillary or invasive transitional cell carcinomas (TCC). In these cases, overexpression of p53 protein is detectable in nuclei by immunohistochemical methods. Nuclear antigen Ki-67, a marker of cellular proliferation, has been shown to correlate with the growth of many human neoplasms, including TCC. Since overexpression of p53 protein and increased Ki-67 proliferative activity have been a consistent finding in TCC, p53 and Ki-67 expression may be used as markers of urothelial cells with significant genetic alterations. In this study, the authors have investigated whether there is increased p53 and Ki-67 expression in varying grades of urothelial dysplasia. Staining for p53 and Ki-67 using formalin-fixed, paraffin-embedded sections was performed using a Dako Autostainer, followed by counting positive cells using an automatic cellular imaging system (ACIS). The high-grade dysplasia/CIS group (n = 16) had a similar high percentage and intensity of p53 staining (45.3 +/- 4.3%; 28.2 +/- 6.1 arbitrary units [AU]) as the TCC group (n = 16. 53.6 +/- 3.9%; 36.8 +/- 5.7 AU), but revealed a significantly higher percentage and intensity of p53 staining than the low-grade dysplasia (n = 14, 25.6 +/- 3.3%; 12.2 +/- 2.0 AU) and benign group (n = 10, 10.0 +/- 3.3%; 5.8 +/- 1.7 AU). Percentage of p53-positive cells counted by ACIS was similar to that obtained by manual counting. In addition, expression of Ki-67 in all four groups paralleled p53 expression. The authors' data showing overexpression of p53 and Ki-67 in high-grade urothelial dysplasia/CIS similar to that observed in TCC support the notion that high-grade urothelial dysplasia/CIS is a precursor of invasive TCC.

Impact of p53 and Ki-67 in predicting recurrence and progression of superficial (pTa and pT1) urothelial cell carcinomas of urinary bladder

In predicting the aggressive behavior of bladder tumors, the histopathological characteristics of grade and invasive stage are of principal importance. However, for predicting tumor recurrence and progression, these are sufficient only to a limited extent, particularly in the case of superficial (pTa and pT1) urothelial cell carcinomas. New prognostic factors are therefore needed to avoid either insufficient or excessive treatment. In this retrospective study, we investigated the prognostic value of the p53 and Ki-67 immunoreactivity indices. The present study included 118 superficial urinary bladder tumors consisting of 58 recurrent and 60 non-recurrent cases. Twenty of the recurrent tumors progressed into a higher grade and/or invasive stage. Paraffin immunohistochemical analysis was carried out using anti-p53 and anti-Ki-67 antibodies on the initial tumor tissues. We concluded that there is a highly significant relationship between the p53 and Ki-67 immunoreactivities and the histological grade and pathological stage of the tumors (P < 0.0001). We observed a significant relationship between the presence of recurrence and progression and the p53 immunoreactivity index (P < 0.01 and P = 0.017, respectively) and Ki-67 immunoreactivity index (P < 0.0001 and P = 0.046, respectively). Positivity for p53 and Ki-67 can demonstrate the risk of recurrence (p53: sensitivity = 76%, specificity = 58%; Ki-67: sensitivity = 86%, specificity = 48%) and progression (p53: sensitivity = 80%, specificity = 46%; Ki-67: sensitivity = 85%, specificity = 36%; ). We believe that both of these immunohistochemical markers can be considered valuable in addition to classical histopathological prognostic parameters for predicting recurrence and progression risks.

Cyclin D1 expression in papillary superficial bladder cancer: its association with other cell cycle-associated proteins, cell proliferation and clinical outcome

Cyclin D1 contributes to regulate G1 progression by forming a complex with different cyclin-dependent kinases. It has oncogenic properties and is frequently overexpressed in several human tumor types. In our study, expression of cyclin D1 and Ki67, a proliferation marker, was evaluated by immunohistochemistry in human papillary superficial (pTa-pT1) bladder cancers and was correlated with p27(Kip1), p21(Waf1) and c-erbB-2 expression, with p53 gene status and protein expression, ploidy and cancer progression. Cyclin D1 expression was neither associated with tumor stage nor with tumor grade but high cyclin D1 expression (> or =25% positive nuclei) was significantly associated with p53 gene mutation (p = 0.012), low p21(Waf1) (p = 0.015) and high p27(Kip1) (p = 0.016) protein expression. Ki67 expression was not associated with tumor stage but a high proliferation index (> or =10% positive nuclei) was significantly associated with high tumor grade (p = 0.001) and with DNA aneuploidy (p = 0.005). There was no significant difference in proliferative activity between high and low cyclin D1 expressor tumors. Patients whose tumors showed high expression of cyclin D1 displayed a significantly longer disease-free survival (p < 0.001 by log-rank test). Increased Ki67 expression was significantly associated with shorter disease-free survival (p = 0.003). Both cyclin D1 (p = 0.027; RR = 1.898) and Ki67 (p = 0.047; RR = 1.932) protein expressions were independent predictors of reduced disease-free survival on a multivariate analysis that also included p27(Kip1) expression and tumor stage. The simultaneous presence of low cyclin D1, low p27(Kip1) and high Ki67 expression defined a "high-risk" group of patients who displayed a significantly increased risk of recurrence (p < 0.0001). These results suggest that evaluation of cell cycle-associated markers can help to identify high-risk patients and may affect the management of patients with papillary superficial bladder cancer.

[Prognostic value of P53, Ki67, and Rb protein in infiltrating bladder tumors]

OBJECTIVES

To determinate whether increased expression of the p53 and Ki67 and the of the tumour suppressor gene retinoblastoma (prot Rb), in an immunohistochemistry study, were associated with relapse in invasive bladder cancer.

MATERIALS AND METHODS

47 patients with invasive bladder cancer. 42 men and 5 women. Mean age 63 years old. Relapse in 19 patients (40%). Mean time until recurrence 8.5 months. p53 and Ki67 were study in 47 patients and prot Rb in 40 patients.

RESULTS

p53: Mean expression 41%. There were significant differences in the increased expression of p53 between patients with and without relapse (p = 0.03). A statistically significant association was then observed between patients with p53 > 20% (vs p53 < 20%) and adverse outcome of the disease (p = 0.04). Ki67 and prot Rb: There were no significant differences in relapse and progression free survival between Ki67 > 40% (vs Ki67 < 40%) and prot Rb < 10% (vs prot Rb > 10%). p53 expression showed a statistically significant correlation with Ki67 and prot Rb.

CONCLUSION

p53 is a good prognostic marker for the relapse and progression free survival in invasive bladder cancer.

S, Suaid HJ, Cologna AJ. EXPRESSÃO IMUNOHISTOQUÍMICA DO MIB-1 EM CARCINOMA DE CÉLULAS TRANSICIONAIS DE BEXIGA

A expressão do MIB-1 é um excelente marcador da atividade proliferativa e correlaciona-se com a agressividade biológica do carcinoma de células transicionais da bexiga.Correlacionamos a expressão do MIB-1 com a evolução dos pacientes. Revisamos 90 pacientes do HC-FMRP-USP entre 1980-2000, com idade entre 29 a 93 anos (média 71 anos);sendo 70 (77,8%) homens e 20 (22,2%) mulheres; e seguidos em média por 55 (2-231) meses. 45 (50%) tumores tinham grau I, 29 (32,2%) grau II e 16 (17,8%) grau III. Os tumores foram estadiados em pTA: 54 (60%), pT1: 8 (8,9%) e pT2-4: 28 (31,1%). Foi utilizado o anticorpo monoclonal anti-MIB-1 (Immunotech). Emprega-se o limite de 10% de núcleos corados como nível de corte para o MIB-1. Utilizamos para análise estatística os testes Mann-Whitney, Kaplan-Meier, e log rank, e nível de significância 5%. Expressaram MIB-1, 63 pacientes (70%) variando de 0 a 80%(mediana 5%, média 22,8%), com diferença significativa (P<0,05) entre tumores invasivos (pT2-4) e não invasivos (pT A-1) e entre os estádios pT A e pT1 (P=0,01). Houve associação com o grau dos tumores: significativa entre G1 e G2 (P<0,001) e G1 e G3 (P<0,001), e sem significância entre G2 e G3 (P=0,2). A relação do MIB-1 com o tamanho da lesão foi significante (P<0,02). As recidivas não foram preditas pelo índice MIB-1 (P=0,86), entretanto em pacientes MIB-1 positivos foi significantemente menor o intervalo livre de metástase (P=0.04), e a sobrevida entre tumores não invasivos (P=0.009) e na população total (P=0.0002), Há correlação entre a alta expressão do MIB-1 e os estádios invasivos, os graus avançados e os tumores maiores, contudo, não há diferença em tumores recidivados. O índice de positividade do MIB-1 não distinguiu os pacientes com menor tempo livre da doença, foi, contudo, significante para apontar aqueles com menor sobrevida e tempo livre de metástase.

[DNA ploidy determination with flow cytometry, Ki-67 index and overexpression of p53 protein in 121 T1 superficial bladder carcinomas. Retrospective studies. Part II: Prognostic value and usefulness in the indication for prophylactic treatment with BCG]

OBJECTIVE

Evaluate the utility of Ki-67 label index, p53 expression and flow cytometry-DNA ploidy in the selection of groups to be treated with prophylactic BCG and the prognostic value compared with the classic variables (grade, lymphatic permeation, multiplicity, volume, primary).

MATERIAL & METHOD

121 superficial bladder tumors T1. 10% Cut-off level for Ki-67 and p53. Aneuplody is defined as a tumor with DNA index different of 1 or more than 20% in G2-M phase. 71 (58.7%) received BCG.

RESULTS

In uni and multivariate analysis positivity to Ki-67 is correlated with recurrence. Progression is correlated with lymphatic permeation (p .0003), volume (p .016), ploidy (p .022) and positivity to p53 (p .007). In multivariate analysis, volume and positivity to p53 are independent variables. None were of utility to prevent recurrence, but Ki-67 positive or aneuploid treated tumors had less progression (p .025 and p .009 respectively). The p53 negative treated tumors had less progression too.

CONCLUSIONS

Only Ki-67 is correlated with tumoral recurrence. P53 and tumor volume are correlated with stage progression. If the results are confirmed with bigger series, the Ki-67 positive and/or aneuploid tumors would obtain benefits of prophylactic treatment with BCG.

ANTÍGENO NUCLEAR DE PROLIFERAÇÃO CELULAR (PCNA) EM CARCINOMA DE CÉLULAS TRANSICIONAIS DE BEXIGA

O antígeno nuclear de proliferação celular (PCNA) foi descrito como marcador da atividade proliferativa. Correlacionamos a marcação do PCNA com a evolução dos pacientes com carcinoma de células transicionais de bexiga. Revisamos 90 pacientes do HC-FMRP-USP de 1980-2000; com idade variando de 29 a 93 anos e média de 71 anos; sendo 77,8% homens e 22,2% mulheres; seguimento médio de 55 meses (2-231 meses). Constatamos 50% de tumores grau I, (32,2%) grau II e 17,8% grau III; estadiados em pTA-60%, pT1-8,9% e >pT1 31,1%. Utilizamos o anticorpo primário Monoclonal Mouse Anti-Proliferating Cell Nuclear Antigen (PCNA) Clone PC10 (DAKO). Foram contadas 500 células (X400), e utilizado ponto de corte de 50%. A análise estatística foi realizada com o teste de Mann-Whitney. Kaplan-Meier e Logrank Oitenta e sete tumores (96,66%) expressaram PCNA (mediana 72.5%, média 60,16%). Observamos diferença não significativa (P=0,39) na imunomarcação do PCNA entre tumores pT2-4 e pTA-1. A comparação de medias entre G1 e G2 (P=0,087), G1 e G3 (P=0,11) e entre G2 e G3 (P=0,66) não mostraram significado estatístico,assim como entre tumores com recidiva e sem recidiva (P=0,84). Os indivíduos PCNA positivos não tiveram intervalo livre de doença significativamente diferente (P=0,86); entretanto foi significativa a diferença nas curvas de sobrevida (P=0,003) e nas curvas de intervalos livres de metástase (P=0,01). A expressão imunohistoquímica do PCNA não foi efetiva para diferenciar os tumores mais avançados e agressivos, assim como para predizer recidivas. Desta forma, apesar da correlação com o tempo livre de metástase e a sobrevida, não mostrou utilidade prática.

[Molecular biology in bladder cancer]

Progress of molecular biology with regard to etiopathogeny of tumours in general, and cancer of the bladder in particular, is taking place at such a vertiginous pace that practising urologists find themselves overwhelmed in terms of their ability to learn and keep updated in so complex a subject. The understanding of certain molecular factors with critical influence on the formation, growth and progression of a tumour of the bladder, is forcing us to make unbiased assessments on the role they will play in the evolution and survival of this neoplasia. It is anticipate they will be much more reliable than traditionally established morphological factors such as grade and stage. We also include a literature review with an analysis and elucidation of the role played by oncogenes, tumor suppressor genes, vascular density markers, telomerase etc., in the formation and growth of cancer of the bladder and their likely relationships with already established clinico-pathological factors.

Prognostic value of tumor-associated macrophage count in human bladder cancer

BACKGROUND

We determined the tumor-associated macrophage (TAM) count to investigate its importance in predicting clinical outcome or prognosis in patients with bladder cancer.

METHODS

The TAM count and microvessel count (MVC) were determined immunohistochemically in 63 patients with bladder cancer, including 40 superficial bladder cancers and 23 invasive bladder cancers. To examine the relationship between TAM count and clinical outcome or prognosis in bladder cancer, cystectomy rates, distant metastasis rates, vascular invasion rates and 5 year survival rates were compared between patients with low (< 67) and high (> or = 67) TAM counts.

RESULTS

The TAM count in invasive bladder cancers (154.22+/-11.98) was significantly higher than in superficial bladder cancers (49.05+/-7.76; P<0.0001). The MVC in invasive bladder cancers (71.55+/-10.44) was also significantly higher than in superficial bladder cancers (47.02+/-5.57; P<0.05). There was a positive correlation between TAM count and MVC (r=0.30; P=0.02). Immunohistochemical staining using CD68/horseradish peroxidase monoclonal antibody showed more infiltrating cells in invasive than superficial bladder cancers. Patients with a high TAM count (> or =67) showed significantly higher rates of cystectomy, distant metastasis and vascular invasion than those with a lower TAM count (<67). The 5 year survival rate estimated using the Kaplan-Meier method was significantly lower in patients with a high TAM count than in those with a low TAM count (P<0.0001).

CONCLUSIONS

Our results suggest that determination of TAM count in bladder cancer tissues is of value to predict the clinical outcome or prognosis and to select appropriate treatment strategies in patients with bladder cancer.

Urinary markers of malignancy

Transitional cell carcinoma (TCC) is the second most common malignancy in the genitourinary tract. The majority of urothelial tumors are superficial when the patient first presents, but despite adequate resection of the primary lesion the recurrence rate is particularly high. In a small but significant group of patients the tumor is primary invasive or subsequently can progress and leads to death. Voided urine can be easily obtained and therefore diagnostic urine tests would be ideal for screening or follow up of TCC. Although many urinary markers have been described, none of them is used routinely in clinical practice. Promising tumor markers still need to be evaluated in multi-center clinical studies. Larger prospective trials are necessary in order to identify prognostic indicators that would help to predict disease progression or response to different treatment modalities (BCG, chemo-, radiotherapy, etc.). Hopefully, new diagnostic urine tests will allow to identify patients who will most benefit from early cystectomy with or without adjuvant treatment, bladder sparing protocols or systemic treatment. In this paper we have reviewed the literature and discuss, from the clinician's point of view, the current status of various diagnostic tests for urinary markers. [Lee SJ, Lee WE, Chang SG, Lee CH, Kim JI. A comparative study of telomerase, Lewis X, BTA, NMP22 and urinary cytology in bladder tumor. J Urol 1999;161(suppl):152.]

MIB-1 as a proliferative marker in transitional cell carcinoma of the bladder: clinical significance and comparison with other prognostic factors

BACKGROUND

Staging and grading of transitional cell carcinoma of the bladder are generally viewed as indicators of prognosis and form the basis of therapy, but they do not predict outcome accurately. This study was designed to evaluate the value for predicting recurrence, progression, and survival of proliferation fraction in transitional cell carcinoma of the bladder determined by immunostaining of histopathologic specimens with the monoclonal antigen MIB-1.

METHODS

In a prospectively followed group of 301 patients with transitional cell carcinoma of the bladder, formalin fixed tumor specimens were immunostained and the MIB-1 labeling index was determined. Crude survival, progression free survival, and recurrence free survival (for patients with Ta and T1 tumors) were assessed in univariate and multivariate analysis according to stage, grade, mitotic index of the tumor, and patient age. The median value of continuous variables was used as a cutoff point in statistical analysis.

RESULTS

In univariate analysis there was a strong association between all included factors and crude survival, progression free survival, and recurrence free survival with a median follow-up period of 60 months. In multivariate analysis, crude survival and progression free survival were determined by stage (P = 0.0001) and age (P = 0.0001). Recurrence free survival for patients with Ta and T1 tumors was determined by MIB-1 labeling index (P = 0.0317), mitotic index (P = 0.0229), and age (P = 0.0001).

CONCLUSIONS

MIB-1 immunostaining in transitional cell carcinoma of the bladder correlated well with grade, stage, and clinical outcome. In multivariate analysis, proliferation fraction had prognostic value in predicting recurrence free survival for patients with Ta and T1 tumors, whereas stage and age appeared to be predictors of progression free survival.

Current Concepts in Biomarker Technology for Bladder Cancers

Background: Transitional cell carcinoma of the bladder (TCC) is the second most common malignancy of the urinary tract. More than 70% of treated tumors recur, and 30% of recurrent tumors progress. Currently, pathologic staging and grading are valuable prognostic factors for detecting and monitoring TCC. Urinalysis, cystoscopy, and cytology are either invasive or lack sensitivity and specificity. The availability of a noninvasive, reliable, and simple test would greatly improve the detection and monitoring of patients with TCC. Several biomarkers for bladder cancer have been proposed, but no single marker has emerged as the test of choice.

Approach: We undertook a comprehensive literature search using Medline to identify all publications from 1980 to 1999. Articles that discussed potential biomarkers for TCC were screened. Only compounds that demonstrated high sensitivity or specificity, significant correlation with TCC diagnosis and staging, and extensive investigation were included in this review.

Content: Potential biomarkers of disease progression and prognosis include nuclear matrix protein, fibrin/fibrinogen product, bladder tumor antigen, blood group-related antigens, tumor-associated antigens, proliferating antigens, oncogenes, growth factors, cell adhesion molecules, and cell cycle regulatory proteins. The properties of the biomarkers and the methods for detecting or quantifying them are presented. Their sensitivities and specificities for detecting and monitoring disease were 54–100% and 61–97%, respectively, compared with 20–40% and 90% for urinalysis and cytology.

Summary: Although urine cytology and cystoscopy are still the standard of practice, many candidate biomarkers for TCC are emerging and being adopted into clinical practice. Further research and better understanding of the biology of bladder cancer, improved diagnostic techniques, and standardized interpretation are essential steps to develop reliable biomarkers. It is possible that using the current biomarkers as an adjuvant modality will improve our ability to diagnose and monitor bladder cancer.

Cyclin E overexpression in transitional cell carcinoma of the bladder

We attempted to clarify the relationship between cyclin E to p27(Kip1), Ki-67 and clinicopathologic features in transitional cell bladder carcinoma. Immunohistochemical staining of archival tissue specimens of transitional cell bladder carcinoma obtained from 94 patients was performed by the labeled streptavidin-biotin-peroxidase method. Overexpression of cyclin E protein was observed in 38 of the 94 (40.4%) specimens, and was positively correlated with histological grade, Ki-67 LI and p27(Kip1) labeling index (LI). These data suggest that cyclin E may be associated with aggressive tumor growth, and may have a relationship with p27(Kip1) for the regulation of cell cycle progression in transitional cell bladder carcinoma.

Apoptosis, p53, bcl-2, and Ki-67 in invasive bladder carcinoma: possible predictors for response to radiochemotherapy and successful bladder preservation

PURPOSE

Several groups have reported the value of bladder preservation by a combined treatment protocol, including transurethral resection (TUR-B) and radiochemotherapy (RCT). As more experience is acquired with organ-sparing treatment, patient selection should be optimized. The purpose of this study was to investigate the role of several biologic markers that may predict response to RCT in muscle-invasive bladder carcinoma.

METHODS AND MATERIALS

The apoptotic index (AI), Ki-67, p53, and bcl-2 were evaluated by immunohistochemistry on pretreatment biopsies from 70 patients treated for invasive bladder cancer by TUR-B and RCT. Expression of each marker was correlated with initial response, local control, and cancer-specific survival with preserved bladder. An exploratory multivariate analysis was also performed that included clinical and immunohistochemical variables.

RESULTS

A high AI (> median = 1.6%) and a high Ki-67 index (> median = 8.8%), but not the p53- and bcl-2 expression, were significantly related to initial complete response (CR) and local control with preserved bladder after 5 years. When the AI and Ki-67 expression were considered simultaneously, the association with initial CR (p < 0. 001), local control (p = 0.0002), and cancer-specific survival with preserved bladder (p = 0.008) was highly significant. In an exploratory multivariate analysis (final model), only AI, Ki-67, and the combined AI/Ki-67 variable retained significance for local control with preserved bladder at 5 years.

CONCLUSION

Patients with a high spontaneous AI and a high pretreatment Ki-67 index should be considered preferentially for treatment with RCT, whereas tumors with low proliferation and low levels of apoptosis are less likely to respond to RCT.

Prognostic value of the proliferative index determined by Ki-67 immunostaining in superficial bladder tumors

The biological behavior of urothelial carcinomas remains unpredictable. The objective of this study was to determine the prognostic value of Ki-67 index in superficial papillary bladder tumors and to correlate it with the S-phase fraction (SPF) measured by flow cytometry. Three hundred nineteen patients with newly diagnosed superficial (pTa, pT1) bladder tumors were included between September 1990 and April 1992. Patients with bladder carcinoma in situ alone were excluded. We observed 255 pTa tumors and 64 pT1 tumors, whereas 111 lesions were classified as grade G1 and 208 as grade G2-G3. Ki-67 immunostaining was performed on paraffin-embedded material using a 3-step immunoperoxidase procedure with the murine monoclonal antibody MiB1. The relation between Ki-67 expression and prognostic variables (stage, grade, tumor size, multifocality, age, and sex) was investigated by the chi-square test. Cox regression was used to describe the association between Ki-67 and tumor recurrence in 308 patients with follow-up while adjusting for potentially confounding prognostic variables. The frequency of high Ki-67 expression (> or =10%) increased with stage (P = .005) and grade (P = .001), but not with tumor size or multifocality. Two hundred one patients experienced tumor recurrence in a median follow-up of 68 months. Stage, grade, tumor size, and multifocality were all independent predictors of recurrence. Ki-67 index greater than 10% was found to be an independent predictor of tumor recurrence among patients with tumors larger than 3 cm in diameter (HR = 2.05, CI = 1.18-3.55), but not those with smaller size tumors. With regards to the DNA index, a significant but weak correlation was observed between Ki-67 expression and the SPF (Spearman's correlation coefficient = 0.23, P = .004). In addition, aneuploid tumors had significantly higher expression of Ki-67 (22.5%) than diploid tumors (10.1%) (P = .0006). Moreover, patients with DNA aneuploid bladder tumors were more likely to have more than 10% Ki-67-positive cells than those with diploid tumors. In patients with newly diagnosed pTa or pT1 bladder tumors, a Ki-67 index above 10% is an independent predictor of shorter time to recurrence only in those with tumors larger than 3 cm.

Proliferative pattern of exophytic and superficially invasive and noninvasive low-grade urothelial carcinomas

In urothelial low-grade carcinomas of the bladder stage pT1, prognosis in general is good. In a subset of these tumors infiltrating beyond the lamina muscularis mucosae, prognosis clearly worsens. Unfortunately, evaluation of the lamina muscularis mucosae often is very difficult or even impossible because of its incomplete extension. In an immunohistochemical study on 131 pTa and pT1 urothelial tumors without provable lamina muscularis mucosae, we evaluated the proliferative activity with the monoclonal antibody MIB-1 and the expression pattern of cytokeratins of high molecular weight with the monoclonal antibody 34betaE12. The highest proliferative indices were found in tumors with a diffuse expression pattern of MIB-1 and 34betaE12. A preliminary analysis of follow-up data showed that 70.6% of the pT1 GIb-GIa tumors that recurred showed a diffuse expression pattern for both markers. Whether these patients are candidates for a doser follow-up or even for a more radical therapy has to be subject to further follow-up studies.

Cyclin D1 protein overexpression is related to tumor differentiation, but not to tumor progression or proliferative activity, in transitional cell carcinoma of the bladder

PURPOSE

We attempted to clarify the significance of cyclin D1 in the development and progression of transitional cell carcinoma of the bladder in humans.

MATERIALS AND METHODS

Immunohistochemical staining of archival tissue specimens of transitional cell bladder carcinoma obtained from 163 patients was performed by the labeled streptavidin-biotin-peroxidase method.

RESULTS

Cyclin D1 protein overexpression was observed in 51 of the 163 specimens (31.3%). Cyclin D1 protein overexpression was showed a highly significant inverse correlation with the histological grade of malignancy (p < 0.01). Grade 3 tumors showed a highly significant low incidence of cyclin D1 protein overexpression as compared with grade 2 tumors (p < 0.01). There was no significant correlation between the overexpression of cyclin D1 protein and tumor stage or the Ki-67 labeling index.

CONCLUSION

Cyclin D1 in transitional cell bladder carcinoma was closely related to tumor differentiation but not to tumor progression. Transitional cell carcinoma of the bladder may utilize another pathway for proliferation that is independent of cyclin D1.

Cyclin D1 protein overexpression is related to tumor differentiation, but not to tumor progression or proliferative activity, in transitional cell carcinoma of the bladder

PURPOSE

We attempted to clarify the significance of cyclin D1 in the development and progression of transitional cell carcinoma of the bladder in humans.

MATERIALS AND METHODS

Immunohistochemical staining of archival tissue specimens of transitional cell bladder carcinoma obtained from 163 patients was performed by the labeled streptavidin-biotin-peroxidase method.

RESULTS

Cyclin D1 protein overexpression was observed in 51 of the 163 specimens (31.3%). Cyclin D1 protein overexpression was showed a highly significant inverse correlation with the histological grade of malignancy (p < 0.01). Grade 3 tumors showed a highly significant low incidence of cyclin D1 protein overexpression as compared with grade 2 tumors (p < 0.01). There was no significant correlation between the overexpression of cyclin D1 protein and tumor stage or the Ki-67 labeling index.

CONCLUSION

Cyclin D1 in transitional cell bladder carcinoma was closely related to tumor differentiation but not to tumor progression. Transitional cell carcinoma of the bladder may utilize another pathway for proliferation that is independent of cyclin D1.

Prognostic markers in bladder cancer: a contemporary review of the literature

PURPOSE

We provide a contemporary review of bladder tumor markers and summarize their role as prognostic indicators.

MATERIALS AND METHODS

A comprehensive review of the literature on prognostic markers for transitional cell carcinoma of the bladder was performed.

RESULTS

Intense research efforts are being made to identify and characterize better various bladder cancers and their true biological potential. The need to predict which superficial tumors will recur or progress and which invasive tumors will metastasize has led to the identification of a variety of potential prognostic markers. Blood group antigens, tumor associated antigens, proliferating antigens, oncogenes, peptide growth factors and their receptors, cell adhesion molecules, tumor angiogenesis and angiogenesis inhibitors, and cell cycle regulatory proteins have recently been identified. The potential clinical applications of these tumor markers are under active investigation. Recent attention has focused on which tumor markers may predict the responsiveness of a particular bladder cancer to systemic chemotherapy.

CONCLUSIONS

At present conventional histopathological evaluation of bladder cancer (tumor grade and stage) cannot predict accurately the behavior of most bladder tumors. With a better understanding of the cell cycle, and cell to cell and cell to extracellular matrix interactions as well as improved diagnostic techniques (immunohistochemistry), progress is being made to identify and characterize other potential prognostic markers for transitional cell carcinoma of the bladder. The ultimate goal is to develop reliable prognostic markers that will accurately predict not only the course but also the response of a tumor to therapy. This information may then be used to dictate more aggressive treatment for tumors that are likely to progress and less aggressive treatment for those that are unlikely to progress. In the future these biological markers may also be used in gene therapy for the treatment of bladder cancer.

Prognostic significance of Ki-67 expression in transitional cell bladder carcinoma after radical cystectomy

We evaluated the prognostic significance of the Ki-67 labeling index (Ki-67 LI) in 75 patients with transitional cell carcinoma of the bladder who underwent radical cystectomy. Immunohistochemical staining of archival material was performed by the streptavidin-biotin method. Univariate survival analysis showed that Ki-67 LI (p < 0.001), histologic grade (p < 0.05), tumor stage (p < 0.001) and the number of positive lymph nodes (p < 0.001) significantly correlated with prognosis. Multivariate survival analysis indicated that the Ki-67 LI (p < 0.05), histologic grade (p < 0.01), tumor stage (p < 0.01), presence of lymph node metastases (p < 0.05) and use of neo-adjuvant therapy (p < 0.05) had independent prognostic value. The Ki-67 LI is an independent prognostic factor for patients with transitional cell bladder cancer treated by radical cystectomy.

Polyclonal Ki-67 expression in transitional cell carcinoma of the bladder

The proliferation kinetics of 101 cases of transitional cell carcinoma (TCC) and seven cases of transitional cell carcinoma-in-situ of the bladder were assessed following staining with polyclonal Ki-67 antibody (pKi-67). Labeling indices ranged from 49% to 60.2% with a mean value of 22.2% for all cases. A significant association between pKi-67 indices, tumor grade and tumor stage was observed, with significant differences between pKi-67 indices of Grade 1 and 3 tumors and Grade 2 and 3 tumors. Significant differences in labeling indices were also found between superficial (Ta) tumors and both musculoinvasive (T2/T3a) tumors and those infiltrating the perivesical fat (T3b). pKi-67 indices for carcinoma-in-situ were similar to those noted for Grade 1 TCC. No difference in pKi-67 index was found when tumors were classified according to the morphology of the tumor invasion front. It is concluded that pKi-67 index is a useful marker for tumor progression for vesical TCC and that this immunohistochemical stain may assist clinical assessment of the potential behaviour of tumors in individual cases.

The proliferation index of MIB-1 as a prognostic factor for patients with transitional cell carcinoma of the upper urinary tract

BACKGROUND

Recently, several reports have shown that immunohistochemical analysis using MIB-1 antibody, which recognizes Ki-67 (a human nuclear antigen expressed of proliferating cells), is a useful method for determining the proliferative activity of various cancers. In this study, the authors evaluated the prognostic usefulness of the proliferation index using MIB-1 antibody in transitional cell carcinoma of the upper urinary tract.

METHODS

Proliferation activity was investigated immunohistochemically using monoclonal antibody MIB-1 in formalin fixed, paraffin embedded tissues obtained from 67 specimens of renal pelvic and ureteral cancer. The MIB-1 proliferation index values were calculated from each sample as the percentage of positive nuclei expressed in tumor cells and the clinicopathologic correlation evaluated.

RESULTS

The MIB-1 proliferation index values were correlated with prognostic parameters such as pathologic stage ( < or = pT1 vs. > or = pT2, P < 0.0005), histologic grade (G1 vs. G2, P < 0.01; G1 vs. G3, P < 0.0001; G2 vs. G3, P < 0.001), and prognosis (P < 0.0001). When patients were subgrouped using index values, patients with higher indices ( > or = 24%) had significantly poorer survival (P < 0.0001). This was especially observed in the G2 group, in which 9 of 10 patients in the higher indices subgroup had a high incidence of recurrence and died. In contrast, only 2 of 29 patients in the lower indices subgroup died. The higher indices subgroup had significantly worse cause specific survival (P < 0.0001). Furthermore, with regard to the muscle invasive tumors ( > or = pT2), the higher indices subgroup also had significantly worse cause specific survival (P < 0.0001).

CONCLUSIONS

The results of the evaluation of prognostic parameters indicate that the MIB-1 proliferation index is a useful prognostic factor and may enhance the accuracy of conventional morphologic grading and pathologic staging systems.

Heterogeneity of chromosome 17 and erbB-2 gene copy number in primary and metastatic bladder cancer

To study the relationship of tumor genomic heterogeneity with bladder cancer phenotype and p53 gene alterations, 138 primary bladder tumors were examined by dual labeling fluorescence in situ hybridization (FISH) using probes for chromosome 17 centromere (p17H8) and p53 (17p13.1). The number of different aneusomic populations > 5% (and monosomic populations > 20%) of cells served as a marker for heterogeneity. Nuclear p53 overexpression and Ki67 labeling index (Ki67 LI) were determined by immunohistochemistry. The number of aneusomic populations was 0 in 53 tumors, 1 in 18, 2 in 47, 3 in 9, and > 3 in 11 tumors. Presence of aneusomy was associated with tumor grade and stage (P < 0.0001 each). Ki67 LI was low in disomic tumors (11.0 +/- 7.7), higher in tumors with 1-3 aneusomic populations (17.4 +/- 11.3), and highest in tumors with > 3 aneusomic populations (25.8 +/- 10.9; P = 0.02 for > 3 vs. 1-3 populations). Aneusomy and heterogeneity were associated with p53 alterations. Aneusomy was seen in 35% of tumors with neither p53 expression nor p53 deletion but in 97% of tumors with both p53 deletion and expression. Nine of 11 tumors with > 3 aneusomic populations exhibited both p53 deletion and overexpression. To study genomic heterogeneity in tumor progression, two recurrences and three metastases of a tumor with known erbB-2 amplification were examined for centromere 17 and erbB-2 copy number. A considerable heterogeneity in centromere 17 and erbB-2 gene copy number was found in both recurrences and metastases, indicating a marked genomic instability in these metastatic cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Urothelial neoplasms and tumoral markers

The majority of urothelial neoplasms are superficial bladder carcinoma, the prognosis of which cannot be evaluated with current parameters. Several studies have tried to isolate one or more reliable markers. Although some results are satisfactory these markers have not however been used in the clinical practice. The Authors investigate recent reports, quoting those that, in their opinion, are the most interesting.

Correlation of morphometry, nucleolar organizer regions, proliferating cell nuclear antigen and Ki67 antigen expression with grading and staging in urinary bladder carcinomas

OBJECTIVE

To investigate the correlation of four different indicators of proliferation--mean nuclear area (MNA) morphometry, nucleolar organizer region (NOR) count, proliferating cell nuclear antigen (PCNA) and Ki67 antigen expression--in specimens of invasive and non-invasive urinary bladder carcinomas with the grading and staging of the tumour and to determine which indicator is most suitable for discriminating between non-invasive and invasive carcinomas.

MATERIALS AND METHODS

Biopsies of 58 urinary bladder carcinomas of different grade and stage (38 invasive, 20 non-invasive) and 11 carcinomata in situ were included in the study. Ten specimens of normal bladder mucosa served as controls. Analysis of indicators was performed on sequential serial paraffin sections of the same tissue, applying each test once to one of four serial sections.

RESULTS

In comparison to normal bladder mucosa the values of the four indicators were significantly greater (P < 0.001) in all carcinomata in situ and in carcinomas. Values also increased from grade 1 to grade 3 carcinomas, but indicator values were similar for carcinomata in situ and grade 2 carcinomas. All indicators correlated with each other and allowed a significant discrimination between grade 1 and 2 or grade 2 and 3 carcinomas. Non-invasive carcinomas (Ta) showed a significantly lower proliferative activity (P < 0.001) than invasive carcinomas but there were overlapping values within the invasive carcinomas (T1,T2 and T3/4).

CONCLUSIONS

MNA, NOR count, PCNA index and Ki67 index could be correlated with tumour grade, but not with stage, of transitional bladder carcinoma. Of the indicators studied the Ki67 antigen was the most useful in differentiating between invasive and non-invasive carcinomas. This could be of prognostic relevance, especially for the heterogeneous group of grade 2 carcinomas.

Expression of retinoblastoma gene product and p53 protein in bladder carcinoma: correlation with Ki67 index

OBJECTIVES

To determine whether loss of the tumour suppressor gene retinoblastoma (Rb) and increased expression of the p53 protein were associated with increased tumour cell growth fraction.

PATIENTS AND METHODS

Tumours from 105 patients (72 men, 33 women; median age 69 years, range 35-89) with newly diagnosed primary transitional cell bladder carcinoma were studied. Tumour samples were taken by means of cystoscopic resection. Expression of the retinoblastoma (Rb) and p53 gene products was assessed immunohistochemically in 98 of the carcinomas. The proportion of cells expressing the Ki67 antigen (Ki67 index which is a measure of growth fraction) was determined in 64 cases.

RESULTS

p53 protein was detectable in 50% and Rb protein in 82% of the tumours. Staining for p53 and lack of staining for Rb protein were associated with muscle-invasive growth and high tumour grade (G3). The Ki67 index varied over a wide range (1-47%), but there were significant differences between mean indices for poorly differentiated (G3) and well or moderately differentiated (G1/G2) tumours, and between indices for muscle-invasive and the remaining tumours. The mean Ki67 indices for Rb-negative tumours and p53-positive tumours were approximately twice those for Rb-positive and p53-negative tumours. Only 10% of the tumours expressed high levels of p53 protein and failed to express Rb.

CONCLUSION

These observations are consistent with the hypothesis that loss of Rb and mutation and overexpression of p53 are associated with an increased tumour cell growth fraction and that such changes may play a role in the de-regulation of cell proliferation in transitional cell carcinoma of the bladder.

The use of digital image analysis of chromatin texture in Feulgen-stained nuclei to predict recurrence of low grade superficial transitional cell carcinoma of the bladder

BACKGROUND

Identifying a marker enabling prediction of recurrence in the group of superficial transitional cell carcinomas (sTCCs) of the bladder remains an important challenge today. This report quantitatively describes chromatin patterns with respect to such sTCC recurrence.

MATERIALS AND METHODS

Twenty-nine patients with sTCCs who did not exhibit tumor recurrence within a minimum of 24 months were compared with 21 patients with sTCCs who exhibited tumor recurrence two or three times in a 24-month period, for a total of 74 sTCCs. Quantitative chromatin pattern description was performed by the digital cell image analyses of Feulgen-stained nuclei. Six morphonuclear parameters were thus described and subsequently used to determine a score, allowing biological behavior of sTCCs to be described, i.e., recurrence versus non-recurrence in one calculation step. DNA ploidy level was also determined in each sTCC by assessing its DNA histogram type.

RESULTS

Of 32 patients with Grade 1 pathologically classified pTa/pT1 tumors, DNA ploidy level determination permitted correct prediction of tumor nonrecurrence or recurrence of 13 (41%), whereas determination of the score values enabled prediction of nonrecurrence or recurrence of 25 (78%). Combining DNA ploidy level data and the score values enabled recurrence or nonrecurrence to be predicted for 29/32 of the patients (91%).

CONCLUSIONS

The quantitative description of chromatin patterns by digital cell image analysis of Feulgen-stained nuclei can provide helpful information, in addition to DNA ploidy level determination, in predicting tumor recurrence of low grade superficial transitional cell carcinomas of the bladder.