Prognosis and risk factors of patients with upper urinary tract urothelial carcinoma and postoperative recurrence of bladder cancer in central China

A new nomogram for predicting extraurothelial recurrence in patients with upper urinary tract urothelial carcinoma following radical nephroureterectomy

Purpose

We sought to develop and validate a nomogram for predicting extra-urinary recurrence (EUR) following radical nephroureterectomy (RNU) in patients with upper urinary tract urothelial carcinoma (UTUC).

Methods

Data from 556 UTUC patients post-RNU at the First Hospital of Jilin University were retrospectively analyzed. These patients were categorized into a training group (n=389) and a validation group (n=167). Variables significantly associated with prognosis were identified using univariate Cox regression and most minor absolute shrinkage and selection operator (LASSO) analysis. These independent predictors were incorporated into the nomogram to estimate extra-urinary recurrence-free survival (EURFS). Validation of the nomogram involved ROC curves, calibration plots, and decision curve analysis (DCA). Patients were stratified into two risk categories based on their nomogram scores to compare EURFS using the Kaplan-Meier method.

Results

Eight predictors were identified: T-stage, N-stage, tumor grade, local and nerve invasion, preoperative hemoglobin level, neutrophil-to-lymphocyte ratio (NLR), and creatinine, all proving to be independent predictors of EUR. A nomogram was created based on these eight factors, and using the ROC, calibration curves, and DCA, good prediction results were shown in both the training and validation groups. The training and validation groups also showed reliable predictive performance. In particular, there was a significant difference in survival between the high-risk and low-risk groups (P<0.0001). We have also built a network calculator that calculates patient survival time. The URL is https://haowu24.shinyapps.io/dynnomapp.

Conclusion

A nomogram for predicting distant metastases in UTUC patients was successfully developed, and its accuracy, reliability, and clinical value were demonstrated. This new tool helps to improve the clinical management of UTUC cases.

Effectiveness and safety of adjuvant treatment of tislelizumab with or without chemotherapy in patients with high-risk upper tract urothelial carcinoma: a retrospective, real-world study

BACKGROUND

Upper tract urothelial carcinoma (UTUC) is a rare subset of urothelial cancers with poor prognosis. No consensus exists on the benefit of adjuvant immunotherapy for patients with UTUCs after nephroureterectomy with curative intent and the existing studies are limited. Herein, this study aimed to evaluate the effectiveness and safety of adjuvant treatment of tislelizumab with or without chemotherapy in patients with high-risk UTUC.

METHODS

A retrospective study was conducted on 63 patients with high-risk UTUC who received tislelizumab with or without gemcitabine-cisplatin (GC) chemotherapy regimen after surgery between January 2020 and December 2022. Data on demographic and clinical characteristics, surgical, outcomes, prognostic factors, and safety were collected and analyzed.

RESULTS

Among the 63 patients with high-risk UTUC, the median age was 66 years (interquartile range 57-72), with 33 (52%) being male. The majority of patients with staged pT3 (44%) and pN0 (78%) disease. Fifty-one patients (81%) received tislelizumab plus GC chemotherapy, and 12 (19%) were treated with tislelizumab monotherapy. After the median follow-up of 26 months (range 1-47), 49 (78%) patients achieved stable disease. The 2-year disease-free survival (DFS) and 2-year overall survival were 78.68% (95% CI: 60.02-87.07%) and 81.40% (95% CI: 68.76-89.31%), respectively. The cycles of GC chemotherapy were independent prognostic factors for survival, with higher DFS (hazard ratio = 0.68, 95% CI, 0.50-0.93; p = 0.016) observed in the subgroup undergoing ≥ 3 cycles versus < 3 cycles of GC chemotherapy. Fifty-eight patients (92%) experienced at least one treatment-related adverse event (TRAE), with grade 3-4 TRAEs occurring in 13%. The most common grade 3-4 TRAEs were decreased white blood cells, thrombocytopenia, and ulcers.

CONCLUSIONS

The study demonstrates promising clinical benefits and a manageable safety profile of the tislelizumab-based adjuvant regimen for patients with high-risk UTUC. This suggests that adjuvant immunotherapy represents a potential therapeutic strategy for this population.

Tumor hypoxia in immune infiltration and prognosis of bladder cancer

Background

Bladder cancer (BC) is the sixth most common cancer and the ninth leading cause of cancer death among men in the world. Previous studies have shown that tumor hypoxia plays an important role in the occurrence and development of BC, but the role of tumor hypoxia in the prognosis and immune infiltration of BC remains unclear. Our aim was to perform a bioinformatics analysis combined with a clinical analysis to explore the roles of hypoxia in BC.

Methods

We acquired datasets (GSE13507, GSE5287, and GSE1827) containing mRNA expression information from BC cohorts from the Gene Expression Omnibus (GEO) and measured the Hypoxia score using the Gene Set Variation Analysis (GSVA). Then we used X-tile method and log-rank test and Pearson's correlation test to analyze the relation among the Hypoxia score and the clinicopathological and immunological characteristics of BC and used stepwise Cox regression analysis to establish a Prognostic model.

Results

Hypoxia was found to be closely associated with tumor grade, pathological type, invasion, and prognosis of BC in our study. Moreover, we determined that hypoxia was closely related to the infiltration abundance of multiple immune cells through a correlation analysis, and the tumor immune cell infiltration was further found to be significantly associated with the tumor grade and tumor type of BC. Furthermore, we constructed several models based on the Hypoxia score and tumor immune infiltration with C-indexes ranging from 0.703 and 0.888, which showed good performance in predicting the prognosis of BC.

Conclusions

Our study showed that hypoxia plays an important role in the progression, prognosis, and tumor immune infiltration of BC. Our models based on hypoxia and tumor immune infiltration play a guiding role in the prognosis and treatment of BC patients.

A curious case: Concurrent collecting duct renal cell carcinoma and upper tract urothelial carcinoma

A 71-year-old male presented to Urology with three weeks of overt haematuria and increasing lethargy. Contrast-enhanced CT scans revealed an 8 × 6cm partially exophytic lesion in the left kidney's upper pole, extending beyond the capsule and invading the superior cortical vein, accompanied by abnormal retrocrural lymph nodes. Signs of paraneoplastic syndrome prompted a left radical nephrectomy for symptom relief. Histological analysis identified high-grade collecting duct renal carcinoma and invasive urothelial cell carcinoma. Post-surgery, he was referred for oncological treatment but passed away within two months of the initial diagnosis.

Prognostic and clinical pathological significance of the systemic immune-inflammation index in urothelial carcinoma: a systematic review and meta-analysis

Background

A new non-invasive biomarker, the Systemic Immune-Inflammation Index (SII), has been proven to have prognostic value in multiple cancers. This systematic review and meta-analysis aimed to investigate the prognostic and clinical pathological significance of SII in urothelial carcinoma.

Methods

A comprehensive search was conducted across multiple databases, including PubMed, Web of Science, Embase, Cochrane Library, and CNKI. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS). Hazard ratios (HR) with 95% confidence intervals (CI) were calculated to evaluate the prognostic value of SII before treatment on survival outcomes, and odds ratios (OR) with 95%CI were used to assess the correlation between SII before treatment and clinical pathological features.

Results

This meta-analysis included a total of 10 studies (11 datasets) with 6,333 patients. The pooled analysis showed that high SII before surgery was significantly associated with poor survival outcomes in patients with urothelial carcinoma, including overall survival (OS) (HR=1.55, 95%CI 1.24-1.95, p<0.001), cancer-specific survival (CSS) (HR=2.74, 95%CI 1.67-4.49, p<0.001), recurrence-free survival (RFS) (HR=2.74, 95%CI 1.67-4.49, p<0.001), and progression-free survival (PFS) (HR=1.66, 95%CI 1.36-2.02, p<0.001). In addition, patients with elevated preoperative SII values were more likely to have adverse pathological features, including larger tumor size and advanced pathological T stage (p<0.001).

Conclusion

These findings suggest a significant association between high SII levels before treatment and poor survival outcomes, as well as certain clinical pathological features, in patients with urothelial carcinoma.

Preoperative C-reactive protein to albumin ratio as a novel prognostic biomarker for the oncological outcomes of radical nephroureterectomy

PURPOSE

This study aimed to evaluate the prognostic impact of the preoperative C-reactive protein to albumin ratio (CAR) on progression-free survival (PFS) and cancer-specific survival (CSS) in patients with upper urinary tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU).

METHODS

A retrospective analysis was conducted using data from a single-center nephroureterectomy registry between January 2011 and December 2017. Participants were categorized into high and low CAR groups based on the optimal CAR cut-off value determined using the Youden index. The primary endpoint was PFS, the time from RNU to metastasis or disease recurrence. The secondary endpoint was CSS, the time from RNU to UTUC-related death. Median PFS and CSS were compared between the high and low CAR groups using Kaplan-Meier analysis and log-rank test. Multivariable Cox proportional hazard regression analysis was performed to assess the prognostic significance of CAR, adjusting for known prognostic factors.

RESULTS

We included 491 patients with UTUC in the analysis. The optimal CAR cut-off value was determined to be 0.036, which resulted in classifying 49.3% (242/491) of patients into the high CAR group. The high CAR group had older patients (69.8 vs. 67.4, p-value = 0.01), advanced T and N stages (p-value<0.001), high-grade tumor (p-value = 0.03), and a higher incidence of preoperative hydronephrosis (p-value < 0.01) than the low CAR group. The high CAR group demonstrated significantly inferior median PFS (78.3 vs. 100.3 months, p-value < 0.01) and CSS (73.2 vs. 96.1 months, p-value < 0.01) than the low CAR group. Moreover, high CAR independently increased the risk of disease progression (hazard ratio [HR]: 1.80, 95% confidence interval [CI]: 1.23-2.64, p < 0.01) and UTUC-related mortality (HR: 1.79, 95% CI: 1.15, p < 0.01).

CONCLUSION

Pre-operative CAR is independently associated with poor PFS and CSS in patients with UTUC undergoing RNU. Moreover, CAR may be an independent UTUC prognostic factor, offering a cost-effective and minimally invasive marker. However, further validation through large-scale, multi-center studies is necessary to confirm these findings and determine the optimal CAR cut-off value.

Comparison of different prediction tools for the risk of intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma: a propensity-matched analysis

OBJECTIVE

To compare the predictive performance of the current clinical prediction models for predicting intravesical recurrence (IVR) after radical nephroureterectomy (RNU) in patients with upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively analysed upper tract urothelial carcinoma patients who underwent radical nephroureterectomy in our centre from January 2009 to December 2019. We used the propensity score matching (PSM) method to adjust the confounders between the IVR and non-IVR groups. Additionally, Xylinas' reduce model and full model, Zhang's model, and Ishioka's risk stratification model were used to retrospectively calculate predictions for each patient. Receiver operating characteristic (ROC) curves were generated, and the areas under the curves (AUCs) were compared to identify the method with the highest predictive value.

RESULTS

We included 217 patients with a median follow-up of 41 months, of which 57 had IVR. After PSM analysis, 52 pairs of well-matched patients were included in the comparative study. No significant difference was found in clinical indicators besides hydronephrosis. The model comparison showed that the AUCs of the reduced Xylinas' model for 12 months, 24 months, and 36 months were 0.69, 0.73, and 0.74, respectively, and those of the full Xylinas' model were 0.72, 0.75, and 0.74, respectively. The AUC of Zhang's model for 12 months, 24 months, and 36 months was 0.63, 0.71, and 0.71, respectively, the performance of Ishioka's model is that the AUC of 12 months, 24 months and 36 months was 0.66, 0.71, and 0.74, respectively.

CONCLUSION

The external verification results of the four models show that more comprehensive data and a larger sample size of patients are needed to strengthen the models' derivation and updating procedure, to better apply them to different populations.

Hub biomarkers in ultrasound-guided bladder cancer and osteosarcoma: Myosin light chain kinase and caldesmon

Bladder cancer and osteosarcoma are 2 types of cancers that originate from epithelial tissues inside the bladder and bone or muscle tissues. Ultrasound-guided biopsies provide crucial support for the diagnosis and treatment of bladder cancer and osteosarcoma. However, the relationship between myosin light chain kinase (MYLK) and caldesmon (CALD1) and bladder cancer and osteosarcoma remains unclear. The bladder cancer datasets GSE65635 and GSE100926, the osteosarcoma dataset GSE39058, were obtained from gene expression omnibus. Differentially expressed genes (DEGs) were screened and weighted gene co-expression network analysis was performed. The construction and analysis of protein-protein interaction network, functional enrichment analysis, gene set enrichment analysis. Gene expression heat map was drawn and immune infiltration analysis was performed. The comparative toxicogenomics database analysis were performed to find disease most related to core gene. Western blotting experiments were performed. TargetScan screened miRNAs that regulated central DEGs. We obtained 54 DEGs. Functional enrichment analysis revealed significant enrichment in terms of cellular differentiation, cartilage development, skeletal development, muscle actin cytoskeleton, actin filament, Rho GTPase binding, DNA binding, fibroblast binding, MAPK signaling pathway, apoptosis, and cancer pathways. Gene set enrichment analysis indicated that DEGs were primarily enriched in terms of skeletal development, cartilage development, muscle actin cytoskeleton, MAPK signaling pathway, and apoptosis. The immune infiltration analysis showed that when T cells regulatory were highly expressed, Eosinophils exhibited a similar high expression, suggesting a strong positive correlation between T cells regulatory and Eosinophils, which might influence the disease progression in osteosarcoma. We identified 6 core genes (SRF, CTSK, MYLK, VCAN, MEF2C, CALD1). MYLK and CALD1 were significantly correlated with survival rate and exhibited lower expression in bladder cancer and osteosarcoma samples compared to normal samples. Comparative toxicogenomics database analysis results indicated associations of core genes with osteosarcoma, bladder tumors, bladder diseases, tumors, inflammation, and necrosis. The results of Western blotting showed that the expression levels of MYLK and CALD1 in bladder cancer and osteosarcoma were lower than those in normal tissues. MYLK and CALD1 likely play a role in regulating muscle contraction and smooth muscle function in bladder cancer and osteosarcoma. The lower expression of MYLK and CALD1 is associated with poorer prognosis.

The impact of histological variants in patients with upper tract urothelial carcinoma treated with radical nephroureterectomy

OBJECTIVE

To investigate the impact of histological variants (HV) in patients with upper tract urothelial carcinoma (UTUC) and analyze the potential association between HV and postoperative bladder recurrence.

MATERIALS AND METHODS

The medical records of UTUC patients treated with RNU at our center from January 2012 to December 2019 were retrospectively analyzed. Patients were grouped according to the types of HV. Clinicopathological features and prognostic factors were compared among groups.

RESULTS

A total of 629 patients were included in the study: 458 (73%) patients had pure urothelial carcinoma (PUC) and 171 (27%) patients had UTUC with HV. Squamous differentiation was the most common type (124 cases, 19%), followed by glandular differentiation (29 cases, 5.0%). Patients with HV had a higher proportion of T3 and T4 pathologic stages (P < 0.001) as well as high-grade disease (P = 0.002). In the univariate analysis, squamous differentiation and glandular differentiation were significantly associated with worse cancer-specific survival (CSS) (HR 2.22, 95% CI 1.62-3.04, P < 0.001; HR 1.90, 95% CI 1.13-3.20, P = 0.016). However, the multivariate analysis showed that this association became non-significant. We found that HV were associated with recurrent muscle-invasive bladder cancer (MIBC) after RNU and all patients had T2 and T3 initial tumor stages (P = 0.008, P < 0.001).

CONCLUSION

We found that UTUC patients with HV were associated with biologically aggressive disease and recurrent MIBC after RNU. The detection of bladder recurrence following surgery needs to be given more attention in advanced UTUC patients with HV.

Synovial Metastasis From Urothelial Carcinoma of the Renal Pelvis Causing Recurrent Hemarthrosis: A Rare Presentation

Synovial metastases are rare for any malignancy. This case report discusses a case of synovial metastasis from urothelial carcinoma of the renal pelvis presenting with recurrent hemarthrosis. The diagnosis of malignant synovitis can be obtained by synovial fluid aspiration, which is a quick and minimally invasive method, especially when imaging is unyielding or unspecific. Unfortunately, the diagnosis is associated with a poor prognosis of about five months, and treatment is often palliative. While no clinical guidelines exist, a multimodal and multidisciplinary management approach can help address the physical and psychosocial losses suffered.

Correlation between the timing of diagnostic ureteroscopy for upper tract urothelial cancer and intravesical recurrence after radical nephroureterectomy

Objective

We aimed to evaluate the effect of the timing of diagnostic ureteroscopy (URS) on intravesical recurrence (IVR) following radical nephroureterectomy (RNU).

Patients and methods

The clinical data of 220 patients with upper tract urothelial carcinoma (UTUC) treated with RNU at our center from June 2010 to December 2020 were retrospectively analyzed. According to the timing of the URS, all patients were divided into three groups: the no URS group, the 1-session group (diagnostic URS immediately followed by RNU), and the 2-session group (RNU after diagnostic URS). Additionally, we analyzed IVR-free survival (IVRFS) using the Kaplan-Meier and Cox proportional regression methods.

Results

The median follow-up period of these 220 patents was 41 (range: 2-143) months. Among them, 58 patients developed IVR following RNU. Kaplan-Meier curve displayed a significantly higher IVR rate in both treatment groups than in the no-URS group (p=0.025). In the subgroup of patients with renal pelvis cancer, the incidence of IVR was significantly higher in both treatment groups than in the group without URS (p=0.006). In univariate Cox proportional regression analysis, the two treatment groups were risk factors for IVR compared to the no-URS group [p=0.027, hazard ratio (HR): 1.93, 95% confidence interval (CI): 1.08-3.46]. The two-stage group (p=0.032, HR: 1.98, 95% CI: 1.08-3.65), positive urine pathology (p<0.001, HR: 8.12, 95% CI: 3.63-18.15), adjuvant chemotherapy (p<0.001, HR: 0.20, 95% CI: 0.10-0.38), and positive margin (p<0.0001, HR: 7.50, 95% CI: 2.44-23.08) were all identified as independent predictors in the multivariate.

Conclusion

This study revealed that delayed RNU following diagnostic URS may increase the risk of postoperative IVR in patients with UTUC, preoperatively positive uropathology, and positive surgical margin were risk factors for IVR after RNU, while early postoperative chemotherapy may effectively prevent IVR. Delay of RUN after URS could increase the risk of IVR.

Adjuvant Radiotherapy for Upper Tract Urothelial Carcinoma: Systematic Review and Meta-Analysis

PURPOSE

Upper tract urothelial carcinoma (UTUC) is a rare form of malignancy comprising only 5% of urothelial cancers. The mainstay of treatment is radical nephroureterectomy (RNU) with bladder cuff excision. Neoadjuvant or adjuvant chemotherapy is often used in locally advanced disease. The role of adjuvant radiotherapy (RT), however, remains controversial. To further explore the potential role of adjuvant RT, we performed a systematic review and meta-analysis of the literature from 1990 to present.

METHODS AND MATERIALS

We identified 810 candidate articles from database searches, of which 67 studies underwent full-text review, with final inclusion of 20 eligible studies. Among the included studies, there were no randomized controlled trials and a single prospective trial, with the remainder being retrospective series. We performed quantitative synthesis of the results by calculating the pooled odds ratios (OR) for the primary outcome of locoregional recurrence (LRR) and secondary outcomes of overall survival (OS), cancer-specific survival (CSS) and distant recurrence (DR).

RESULTS

Adjuvant RT, which was mostly prescribed for locally advanced or margin-positive disease following RNU, significantly reduced locoregional recurrence risk OR 0.43 (95% CI: 0.23-0.70), and the effect remained significant even following subgroup analysis to account for adjuvant systemic therapy. The effect of adjuvant RT on 3-year OS, 5-year CSS and DR was non-significant. However, 5-year OS was unfavourable in the adjuvant RT arm, but study heterogeneity was high, and analysis of small-study effects and subgroups suggested bias in reporting of outcomes.

CONCLUSIONS

Adjuvant RT in the setting of locally advanced UTUC improves locoregional control following definitive surgery, but does not appear to improve OS. Higher-quality studies, ideally randomized controlled trials, are needed to further quantify its benefit in this setting, and to explore multi-modal treatments that include systemic agents given concomitantly or sequentially with RT, which may offer an OS benefit in addition to the locoregional control benefit of RT.

Bioinformatics analysis of key biomarkers for bladder cancer

Bladder cancer (BC) is one of the most prevalent genitourinary cancers. Despite the growing research interest in BC, the molecular mechanisms underlying its carcinogenesis remain poorly understood. The microarray datasets GSE38264 and GSE61615 obtained from the Gene Expression Omnibus (GEO) database were analyzed and differentially expressed genes (DEGs) were identified, which were then verified using a dataset from The Cancer Genome Atlas (TCGA). By taking the intersection of the two microarray datasets, the common DEGs were identified and these were selected as candidate genes associated with BC. The DEGs were further subjected to Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analysis, and the protein-protein interaction network was constructed. Further module analysis was performed using STRING and Cytoscape. A total of 362 DEGs were identified, including 13 hub genes, and the GO analysis revealed that these genes were mainly enriched in extracellular matrix organization, positive regulation of cell proliferation, angiogenesis and peptidyl-tyrosine phosphorylation. The expression changes of PTPRC, PDGFRA, CASQ2, TGFBI, KLRD1 and MT1X in the different datasets indicated that these genes were involved in the development of BC. Next, the differential expression of these genes was verified in the TCGA dataset, and ultimately, these 13 genes were determined to be related to the occurrence and development of BC. Finally, the cancer tissues and adjacent tissues of patients with BC were collected and subjected to reverse transcription-quantitative PCR, the results of which were consistent with the bioinformatics prediction. The present findings provide several vital genes for the clinical diagnosis and treatment of BC.

Updates on the Pivotal Roles of Mitochondria in Urothelial Carcinoma

Mitochondria are important organelles responsible for energy production, redox homeostasis, oncogenic signaling, cell death, and apoptosis. Deregulated mitochondrial metabolism and biogenesis are often observed during cancer development and progression. Reports have described the crucial roles of mitochondria in urothelial carcinoma (UC), which is a major global health challenge. This review focuses on research advances in the role of mitochondria in UC. Here, we discuss the pathogenic roles of mitochondria in UC and update the mitochondria-targeted therapies. We aim to offer a better understanding of the mitochondria-modulated pathogenesis of UC and hope that this review will allow the development of novel mitochondria-targeted therapies.

Inadvertent radical nephrectomy leads to worse prognosis in renal pelvic urothelial carcinoma patients: A propensity score-matched study

Objective

To compare overall survival (OS) and cancer-specific survival (CSS) in renal pelvic urothelial carcinoma (RPUC) patients treated with radical nephroureterectomy (NU) and inadvertent radical nephrectomy (RN).

Patients and methods

In this retrospective study, patients with RPUC who underwent NU or RN diagnosed between 2004 and 2017 were identified from the Surveillance, Epidemiology, and End Results database. To adjust the confounders, the propensity score-matched analysis was conducted. The Kaplan–Meier method and log-rank test were performed to explore the effect of different surgical methods on OS and CSS.

Results

A total of 2197 cases were finally included in this analysis, among which, 187 (8.5%) patients were treated with RN and 2010 (91.5%) patients were treated with NU. Before matching, the survival analysis revealed that the OS (HR: 1.444, 95%CI: 1.197, 1.741) and CSS (HR: 1.522, 95%CI: 1.211, 1.914) of patients who received RN were worse than that of patients who received NU (p = 0.0001 and p = 0.0003, respectively). After matching, the RN group had a worse OS (HR: 1.298, 95%CI: 1.002, 1.682) than the NU group (p = 0.048). No significant difference was observed in CSS between the RN and NU groups (p = 0.282). The hierarchical analysis showed that there was no significant difference observed in OS and CSS in patients with tumor size ≤4.2 cm (p = 0.884 and p = 0.496, respectively). In tumor size &gt;4.2 cm, both OS (HR: 1.545, 95%CI: 1.225, 1.948) and CSS (HR: 1.607, 95%CI: 1.233, 2.095) of patients who received RN were worse than those of patients who received NU (p = 0.0002 and p = 0.0005).

Conclusion

RN could lead to worse oncological outcomes than NU in patients with renal pelvis urothelial carcinoma. Accurate diagnosis of renal pelvis urothelial carcinoma is extremely important.

Phase separation in immune regulation and immune-related diseases

Phase separation is an emerging paradigm for understanding the biochemical interactions between proteins, DNA, and RNA. Research over the past decade has provided mounting evidence that phase separation modulates a great variety of cellular activities. Particularly, phase separation is directly relevant to immune signaling, immune cells, and immune-related diseases like cancer, neurodegenerative diseases, and even SARS-CoV-2. In this review, we summarized current knowledge of phase separation in immunology and emerging findings related to immune responses as they enable possible treatment approaches.

Prognostic Significance of Organ-Specific Metastases in Patients with Metastatic Upper Tract Urothelial Carcinoma

Background: Existing data on metastatic upper tract urothelial carcinoma (mUTUC) are limited. In this study, we investigated the prognostic value of site-specific metastases in patients with mUTUC and its association with survival outcomes. Methods: We retrospectively collected data from the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2016. Kaplan−Meier analysis with a log-rank test was used for survival comparisons. Multivariate Cox regression was employed to predict overall survival (OS) and cancer-specific survival (CSS). Results: 633 patients were selected in this study cohort. The median follow-up was 6 months (IQR 2−13) and a total of 584 (92.3%) deaths were recorded. Within the population presenting with a single metastatic organ site, the most common metastatic sites were distant lymph nodes, accounting for 36%, followed by lung, bone and liver metastases, accounting for 26%, 22.8% and 16.2%, respectively. In patients with a single metastatic organ site, the Kaplan−Meier curves showed significantly worse OS for patients with liver metastases vs. patients presenting with metastases in a distant lymph node (p < 0.001), bone (p = 0.023) or lung (p = 0.026). When analyzing CSS, statistically significant differences were detectable only between patients presenting with liver metastases vs. distant lymph node metastases (p < 0.001). Multivariate analyses showed that the presence of liver (OS: HR = 1.732, 95% CI = 1.234−2.430, p < 0.001; CSS: HR = 1.531, 95% CI = 1.062−2.207, p = 0.022) or multiple metastatic organ sites (OS: HR = 1.425, 95% CI = 1.159−1.753, p < 0.001; CSS: HR = 1.417, 95% CI = 1.141−1.760, p = 0.002) was an independent predictor of poor survival. Additionally, survival benefits were found in patients undergoing radical nephroureterectomy (RNU) (OS: HR = 0.675, 95% CI = 0.514−0.886, p = 0.005; CSS: HR = 0.671, 95% CI = 0.505−0.891, p = 0.006) and chemotherapy (CHT) (OS: HR = 0.405, 95% CI = 0.313−0.523, p < 0.001; CSS: HR = 0.435, 95% CI = 0.333−0.570, p < 0.001). Conclusions: A distant lymph node was the most common site of single-organ metastases for mUTUC. Patients with liver metastases and patients with multiple organ metastases exhibited worse survival outcomes. Lastly, CHT administration and RNU were revealed to be predictors of better survival outcomes in the mUTUC cohort.

High Carbohydrate Antigen 19-9 Levels Indicate Poor Prognosis of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) occurs in urothelial cells from the kidney and the ureters. Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker for pancreatic and gastrointestinal cancers, and its high levels are associated with poor prognosis in bladder cancer. In this study, prospective patients enrolled in the registry of Seoul National University were retrospectively examined to determine the clinical significance of CA 19-9 in UTUC. In 227 patients, high serum CA 19-9 levels reflected a high tumor burden represented by high T and N stages, leading to adverse prognosis in metastasis-free or overall survival. Subsequently, propensity score matching analysis showed that the CA 19-9 level is an independent prognostic factor of UTUC.

Targeting TMEM88 as an Attractive Therapeutic Strategy in Malignant Tumors

According to authoritative surveys, the overall morbidity and mortality of malignant tumors show an upward trend, and it is predicted that this trend will not be well contained in the upcoming new period. Since the influencing factors, pathogenesis, and progression characteristics of malignant tumors have not been fully elucidated, the existing treatment strategies, mainly including surgical resection, ablation therapy and chemotherapy, cannot achieve satisfactory results. Therefore, exploring potential therapeutic targets and clarifying their functions and mechanisms in continuous research and practice will provide new ideas and possibilities for the treatment of malignant tumors. Recently, a double-transmembrane protein named transmembrane protein 88 (TMEM88) was reported to regulate changes in downstream effectors by mediating different signaling pathways and was confirmed to be widely involved in cell proliferation, differentiation, apoptosis and tumor progression. At present, abnormal changes in TMEM88 have been found in breast cancer, ovarian cancer, lung cancer, thyroid cancer and other malignant tumors, which has also attracted the attention of tumor research and attempted to clarify its function and mechanism. However, due to the lack of systematic generalization, comprehensive and detailed research results have not been comprehensively summarized. In view of this, this article will describe in detail the changes in TMEM88 in the occurrence and development of malignant tumors, comprehensively summarize the corresponding molecular mechanisms, and explore the potential of targeting TMEM88 in the treatment of malignant tumors to provide valuable candidate targets and promising intervention strategies for the diagnosis and cure of malignant tumors.

Assessment of Therapeutic Benefit and Option Strategy on Intravesical Instillation for Preventing Bladder Cancer Recurrence after Radical Nephroureterectomy in Patients with Upper Urinary Tract Urothelial Carcinoma

Objective

Upper urinary tract urothelial carcinoma (UUT-UC) is a very aggressive disease, characterized by 22%–50% of patients suffering from subsequent bladder recurrence after radical nephroureterectomy (RNU). Although the therapy of intravesical instillation is reported to be effective in preventing bladder recurrence, no study had been reported in Northeast China. The findings relating to the clinical effectiveness of intravesical instillation after RNU are somewhat controversial, and the best efficacy and least adverse effects of instillation drugs have not been widely accepted. Here, we aimed at evaluating the efficacy of intravesical instillation for the prevention intravesical recurrence systematically.

Methods

In this retrospective cohort study, from October 2006 to September 2017, 158 UUT-UC patients underwent RNU were divided into 4 groups: epirubicin (EPB) instillation group, hydroxycamptothecin (HCPT) instillation group, bacillus Calmette–Guerin (BCG) instillation group, and noninstillation group. Cox univariate and multivariate analyses were employed to identify the risk factors for intravesical recurrence-free survival (IVRFS). The nomogram model was also applied to predict patient outcomes. Subsequently, to evaluate the clinical significance of intravesical instillation comprehensively, several databases including PubMed, Ovid, and Embase were searched and data from published studies with our results were combined by direct meta-analysis. Moreover, a network meta-analysis comparing instillation therapies was conducted to evaluate the clinical efficacy of different instillation drugs.

Results

In our retrospective cohort study, the Kaplan–Meier survival curve demonstrated noninstillation groups were associated with worsened IVRFS. Meanwhile, multivariate analysis indicated that intravesical instillation was independent protective factors for IVRFS (hazard ratio [HR] = 0.731). Moreover, calibration plots, receiver operating characteristic (ROC) curves, area under the curve (AUC) values, and the C-index showed the priority of nomogram's predictive accuracy. Next, direct meta-analysis including 19 studies showed that intravesical instillation could prevent the recurrence of bladder cancer with a pooled risk ratio (RR) estimate of 0.53. Subgroup analysis by study type, year of intravesical recurrence, first instillation time, and instillation times also confirmed the robustness of the results. Moreover, intraoperative instillation was associated with a decrease in the risk of bladder recurrence compared with postoperative instillation. Then, a network meta-analysis including 7 studies indicated that pirarubicin (THP) (surface under the cumulative ranking curve [SUCRA] = 89.2%) is the most effective therapy to reduce the risk of bladder recurrence, followed by BCG (SUCRA = 83.5%), mitomycin C (MMC) (SUCRA = 53.6%), EPB (SUCRA = 52.6%), and HCPT (SUCRA = 5.1%) after the analysis of the value ranking.

Conclusions

A maintenance schedule of intravesical instillation prevents the recurrence of bladder cancer after RNU in UUT-UC patients effectively. Large, prospective trials are needed to further confirm its value. Compared with other chemotherapy regimens, THP may be a promising drug with favorable efficacy to prevent bladder recurrence. As included studies had moderate risk of bias, the results of network meta-analysis should be applied with caution.

Crouching carcinoma, hidden ureter: A blind ending burnt out cancerous moiety

Background:

A 76-year-old male presenting with macroscopic haematuria was found to have a lobulated mass infiltrating along the urothelium at the site of insertion of the upper moiety of a complete duplex right kidney. Suspected of being upper tract urothelial carcinoma, cystoscopy, bilateral retrograde pyelograms and transurethral resection of bladder tumour were attempted. Intra-operative findings revealed no tumour burden in the bladder or left ureter. The insertion of the upper pole moiety of the right ureter was not identified intra-operatively. Pelvic MRI demonstrated a markedly dilated upper pole moiety of the right ureter with a soft tissue mass in its distal aspect. Interestingly, the distal portion of the ectopic upper pole moiety was found to insert into the bladder neck.

Objective and Methods:

We report on an unusual case of upper tract urothelial carcinoma arising from the upper moiety of a complete duplex kidney. Our aim was to demonstrate the importance of thorough investigation of suspected urothelial carcinomas occurring in association with variant upper tract anatomy.

Results and Conclusion:

This case demonstrates the importance of thorough radiological and endourological investigation of suspected upper tract urothelial carcinoma and the various congenital abnormalities that may complicate the surgical management of this common malignancy.

Level of evidence:

4 (case report)

Sinomenine Inhibits the Progression of Bladder Cancer Cells by Downregulating LncRNA-HEIH Expression

Background

Sinomenine has been reported to effectively repress the progression of lung cancer and breast cancer. However, the effects of sinomenine in bladder cancer are not well understood. The purpose of this study was to evaluate the effects of sinomenine in bladder cancer.

Methods

The mRNA expression of HEIH in bladder cancer cells was measured by RT-qPCR. T24 and SW780 cells were treated with sinomenine for 24 hours. Cell viability was detected by the MTT assay. Cell migration and invasion were detected by the transwell assay. Western blotting assay was performed to assess the protein expression of Bcl-2, Bax, and caspase-3.

Results

Sinomenine significantly suppressed cell viability in T24 and SW780 cells. Moreover, cell migration and invasion were significantly inhibited by sinomenine. Sinomenine accelerated the expression of Bax and caspase-3 but decreased the expression of Bcl-2. HEIH was upregulated in bladder cancer cells compared with normal bladder epithelial cells. Besides this, we noticed that HEIH knockdown blocked cell proliferation, migration, and invasion but facilitated cell apoptosis in bladder cancer cells. Additionally, HEIH reversed the suppression of the progression induced by sinomenine.

Conclusion

Sinomenine was observed to suppress cell progression of bladder cancer cells by inhibiting HEIH expression. Our findings suggested that the use of sinomenine might be an effective treatment for bladder cancer.

Retrospective evaluation of the impact of non-oncologic chronic drug therapy on the survival in patients with bladder cancer

Background Chronic drug therapy may impact recurrence and survival of patients with bladder cancer and thus be of concern regarding drug choice and treatment decisions. Currently, data are conflicting for some drug classes and missing for others. Objective To analyze the impact of common non-oncologic chronic drug intake on survival in patients with bladder cancer and radical cystectomy. Setting. Patients with bladder cancer and radical cystectomy (2004–2018) at the University Hospital Munich. Method Data from an established internal database with patients with bladder cancer and radical cystectomy were included in a retrospective study. Drug therapy at the time of radical cystectomy and survival data were assessed and follow-up performed 3 months after radical cystectomy and yearly until death or present. Impact on survival was analyzed for antihypertensive, antidiabetic, anti-gout, antithrombotic drugs and statins, using the Kaplan–Meier method, log-rank test and Cox-regression models. Main outcome measure Recurrence free survival, cancer specific survival and overall survival for users versus non-users of predefined drug classes. Results Medication and survival data were available in 972 patients. Median follow-up time was 22 months (IQR 7–61). In the univariate analysis, a significant negative impact among users on recurrence free survival (n = 93; p = 0.038), cancer specific survival (n = 116; p < 0.001) and overall survival (n = 116; p < 0.001) was found for calcium-channel blockers, whereas angiotensin-receptor-blockers negatively influenced overall survival (n = 96; p = 0.020), but not recurrence free survival (n = 73; p = 0.696) and cancer specific survival (n = 96; p = 0.406). No effect of angiotensin-receptor-blockers and calcium-channel blockers was seen in the multivariate analysis. None of the other studied drugs had an impact on survival. Conclusion There was no impact on bladder cancer recurrence and survival for any of the analyzed drugs. Considering our results and the controverse findings in the literature, there is currently no evidence to withhold indicated drugs or choose specific drug classes among the evaluated non-oncologic chronic drug therapies. Thus, prospective studies are required for further insight. Trail registration This is part of the trial DRKS00017080, registered 11.10.2019.

Co-Exposure to Aristolochic Acids I and II Increases DNA Adduct Formation Responsible for Aristolochic Acid I-Mediated Carcinogenicity in Rats

The plant extract aristolochic acid (AA), containing aristolochic acids I (AAI) and II (AAII) as major components, causes aristolochic acid nephropathy (AAN) and Balkan endemic nephropathy (BEN), unique renal diseases associated with upper urothelial cancer. Recently (Chemical Research in Toxicology 33(11), 2804–2818, 2020), we showed that the in vivo metabolism of AAI and AAII in Wistar rats is influenced by their co-exposure (i.e., AAI/AAII mixture). Using the same rat model, we investigated how exposure to the AAI/AAII mixture can influence AAI and AAII DNA adduct formation (i.e., AA-mediated genotoxicity). Using ³²P-postlabelling, we found that AA-DNA adduct formation was increased in the livers and kidneys of rats treated with AAI/AAII mixture compared to rats treated with AAI or AAII alone. Measuring the activity of enzymes involved in AA metabolism, we showed that enhanced AA-DNA adduct formation might be caused partially by both decreased AAI detoxification as a result of hepatic CYP2C11 inhibition during treatment with AAI/AAII mixture and by hepatic or renal NQO1 induction, the key enzyme predominantly activating AA to DNA adducts. Moreover, our results indicate that AAII might act as an inhibitor of AAI detoxification in vivo. Consequently, higher amounts of AAI might remain in liver and kidney tissues, which can be reductively activated, resulting in enhanced AAI DNA adduct formation. Collectively, these results indicate that AAII present in the plant extract AA enhances the genotoxic properties of AAI (i.e., AAI DNA adduct formation). As patients suffering from AAN and BEN are always exposed to the plant extract (i.e., AAI/AAII mixture), our findings are crucial to better understanding host factors critical for AAN- and BEN-associated urothelial malignancy.

Tumor distribution affects bladder recurrence but not survival outcome of multifocal upper tract urothelial carcinoma treated with radical nephroureterectomy

Tumor multifocality and location are prognostic factors for upper tract urothelial carcinoma (UTUC). However, confounding effects can appear when these two factors are analyzed together. Therefore, we aimed to investigate the impact of tumor distribution on the outcomes of multifocal UTUC after radical nephroureterectomy. From the 2780 UTUC patients in the Taiwan UTUC Collaboration Group, 685 UTUC cases with multifocal tumors (defined as more than one tumor lesion in unilateral upper urinary tract) were retrospectively included and divided into three groups: multiple renal pelvic tumors, multiple ureteral tumors, and synchronous renal pelvic and ureteral tumors included 164, 152, and 369 patients, respectively. We found the prevalence of carcinoma in situ was the highest in the synchronous group. In multivariate survival analyses, tumor distribution showed no difference in cancer-specific and disease-free survival, but there was a significant difference in bladder recurrence-free survival. The synchronous group had the highest bladder recurrence rate. In summary, tumor distribution did not influence the cancer-specific outcomes of multifocal UTUC, but synchronous lesions led to a higher rate of bladder recurrence than multiple renal pelvic tumors. We believe that the distribution of tumors reflects the degree of malignant involvement within the urinary tract, but has little significance for survival or disease progression.

The prognostic and clinicopathological significance of Tim-3 and PD-1 expression in the prognosis of upper urinary tract urothelial carcinoma

OBJECTIVE

Upper urinary tract urothelial carcinoma (UTUC) is a relatively uncommon disease with few reported molecular markers. This study evaluated Tim-3 and PD-1 expression in primary UTUC and its impact on patients' clinical outcomes.

METHODS

Tim-3 and PD-1 protein expression was detected by immunohistochemistry in paraffin-embedded sections from 101 UTUC patients. The H-score was correlated with clinicopathologic outcomes and the long-term recurrence and survival rates.

RESULTS

T cell immunoglobulin mucin-3 (Tim-3) protein was overexpressed in UTUC cells, especially tumour-infiltrating lymphocytes (TILs) and endothelial cells. We found that 95% (95/101) of UTUC tissues had dysregulated Tim-3 expression, of which 44% (44/101) showed high expression. High Tim-3 expression (H-score≥100) was significantly correlated with advanced pathological grade, advanced T stage and tumour recurrence (P=0.016, 0.001 and < 0.001, respectively) and with poor intravesical recurrence-free survival (IRFS) and overall survival (OS) (P< 0.001 and 0.003). Moreover, another immune checkpoint molecule, programmed death receptor-1 (PD-1), was also assessed in our study. Among patients in the low Tim-3 expression subgroup, those with high PD-1 expression experienced intravesical recurrence (IVR) more often than those with low PD-1 expression (P< 0.001). However, the PD-1 expression level had no effect on prognosis in the high Tim-3 expression subgroup.

CONCLUSION

We confirmed that high Tim-3 protein expression can be used as an indicator of earlier IVR and shorter OS in patients with UTUC, while high expression of PD-1 is only related to earlier IVR. We showed that Tim-3 plays a more important role in tumour recurrence and progression than PD-1. Collectively, our findings support the use of Tim-3 and PD-1 as clinical prognostic factors indicating poor patient survival. Tim-3, alone or in combination with PD-1, could become a target for future UTUC therapies, but further prospective studies are needed.

Aristolochic acid-associated urinary tract cancers: an updated meta-analysis of risk and oncologic outcomes after surgery and systematic review of molecular alterations observed in human studies

BACKGROUND

The risk of primary aristolochic acid (AA)-associated urothelial carcinoma (AA-UC) has been summarized by a 2013-published meta-analysis. Given that additional evidence has been continuously reported by original studies, an updated meta-analysis is needed. Meanwhile, to complete the whole picture, a systematic review of molecular alterations observed in AA-urinary tract cancers (AA-UTC) was also performed.

METHODS

We searched PubMed, Embase and four Chinese databases up to October 2020. Observational studies comparing risk or oncologic outcomes of UTC between patients with and without AA exposure were eligible for systematic review and meta-analysis. Studies investigating molecular alterations in AA-UTC using human tissue samples were eligible for systematic review.

RESULTS

In total, 38 and 20 studies were included in the systematic review and meta-analysis, respectively. Exposure to AA led to an overall increased risks of primary UTC [UC and renal cell carcinoma (RCC)] (OR 6.085, 95% CI 3.045-12.160) and postoperatively recurrent UC (RR 1.831, 95% CI 1.528-2.194). Subgroup analysis of postoperative primary AA-upper tract UC (AA-UTUC) showed increased risks of bladder recurrence (adjusted RR 1.949, 95% CI 1.462-2.597) and contralateral UTUC recurrence (crude RR 3.760, 95% CI 2.225-6.353), worse overall survival (adjusted HR 2.025, 95% CI 1.432-2.865) and worse disease-specific survival (adjusted HR 3.061, 95% CI 1.190-7.872), but no effect on cancer-specific survival (adjusted HR 0.772, 95% CI 0.269-2.215). High mutation load with AA mutational signature presenting largely in the putative driver genes was observed in AA-UTUC. In contrast, AA mutational signature is rarely found in the mutated RCC driver genes and the mutation load in AA-RCC is low. Therefore, AA has different roles in the genesis of UTUC and RCC.

CONCLUSIONS

Implementing effective strategies to completely protect people from exposure to AA is urgently needed. Additionally, more effort should be made in identifying the precise carcinogenic mechanisms of AA to determine the future treatment strategies.

PLAIN LANGUAGE SUMMARY

Risk, recurrence and survival outcomes after surgery and molecular changes possibly involved in the genesis of aristolochic acid-associated urinary tract cancers Background: The association between aristolochic acid (AA) and primary urothelial carcinoma (UC) has been summarized by a 2013-published meta-analysis. Given that additional evidence has been reported in the past 7 years, an updated meta-analysis is needed. Meanwhile, to complete the whole picture, a systematic review of molecular changes possibly involved in AA-mediated urinary tract carcinogenesis was also performed. Methods: We searched PubMed, Embase and four Chinese databases for human studies up to October 2020. Studies comparing the risk of urinary tract cancer (UTC) between patients with and without AA exposure and studies investigating the molecular changes in AA-associated UTC (AA-UTC) using human tissue samples were eligible for inclusion. Thirty-eight studies were finally included. Results: The results showed that exposure to AA was associated with a 6-fold increased risk of primary UTC (UC and renal cell carcinoma, RCC) and a 1.8-fold increased risk of postoperatively recurrent UC. After studies reporting primary AA-upper tract UC (AA-UTUC) were analyzed, a 1.9-fold increased risk of bladder recurrence and a 3.8-fold increased risk of contralateral UTUC recurrence was observed. Additionally, exposure to AA worsened the postoperative survival of patients with UTUC by a 2-fold increased risk of overall death and a 3-fold increased risk of death from other diseases and recurrences. However, there was no effect on death due to cancer. Lastly, AA seemed to play different roles in the etiology of UTUC and RCC based on the observations of different mutation loads and different distributions of AA-induced mutations in AA-UTUC and AA-RCC samples. Conclusions: Implementing effective strategies to completely protect people from exposure to AA is urgently needed. Moreover, more effort should be made in identifying the precise carcinogenic mechanisms of AA-UTC to determine the future treatment strategies.

Retroperitoneal laparoscopic partial resection of the renal pelvis for urothelial carcinoma: A case report

BACKGROUND

The standard treatment of transitional cell carcinoma of the upper urinary tract consists of radical nephroureterectomy with bladder cuff removal, which can be performed either in open or laparoscopy or robot-assisted laparoscopy. Treatment of chronic renal insufficiency patients with upper urothelial tumor is in a dilemma. Urologists weigh and consider the balance between tumor control and effective renal function preservation. European Association of Urology guidelines recommend that select patients may benefit from endoscopic treatment, but laparoscopic treatment is rarely reported.

CASE SUMMARY

In this case report, we describe a case of 79-year-old female diagnosed with urothelial carcinoma of the renal pelvis and adrenal adenoma with chronic renal insufficiency. The patient was treated with retroperitoneal laparoscopic partial resection of the renal pelvis and adrenal adenoma resection simultaneously.

CONCLUSION

Retroperitoneal laparoscopic partial resection of the renal pelvis is an effective surgical procedure for the treatment of urothelial carcinoma of the renal pelvis.

The Impact of Fluorescence in situ Hybridization on the Staging of Upper Tract Urothelial Carcinoma

OBJECTIVES

The aim of the study was to evaluate the impact of fluorescence in situ hybridization (FISH) diagnostics on the T stage in final histology specimen of patients undergoing radical nephroureterectomy (RNU) due to upper tract urothelial carcinoma (UTUC) at a large tertiary care center.

METHODS

We retrospectively analyzed patients who underwent RNU at our center between 2008 and 2020. Inclusion criteria were RNU due to UTUC. Urine cytologies were used for FISH analysis to detect chromosomal abnormalities. Pre-FISH group was defined as patients without access to routine preoperative urinary FISH testing (2008-2014), and FISH group was defined as patients with access to routine FISH testing. Primary outcome was T stage in final histology. Statistical analysis was performed by χ2 test and Mann-Whitney U test.

RESULTS

Out of 212 patients who underwent RNU at our center between 2008 and 2020, 155 patients were included into the final analysis. The median age was 71 (range 33-90) years, and 108 (69.7%) patients were male and 47 (30.3%) female. Age and gender were not differently distributed in both groups (age: p = 0.925; gender: p = 0.682). Organ-confined disease was found in 37/72 patients in the pre-FISH cohort and in 48/83 patients in the FISH cohort (p = 0.422). Within organ-confined disease, 18/37 patients revealed a T stage smaller than T1 in the pre-FISH cohort and 35/48 patients in the FISH cohort (p = 0.022).

CONCLUSIONS

Preoperative FISH diagnostics add important information to preoperative diagnostic workup of patients with UTUC. Within organ-confined disease, a significant shift toward T stages lower than T1 is observed. Further research is required to determine the impact of this shift on survival in UTUC.

Surgical and oncological outcome after laparoscopic versus open nephroureterectomy for non-metastatic, upper-tract urothelial carcinoma. A single-centre experience

Objectives:

We determined the surgical and oncological outcomes of laparoscopic nephroureterectomy (LNU) in comparison to open nephroureterectomy (ONU) and factors predicting bladder recurrence after nephroureterectomy.

Methods:

We retrospectively reviewed and compared the data of patients who underwent ONU or LNU for non-metastatic, upper-tract urothelial carcinoma from 2000 to 2016. The primary endpoint was to determine bladder cancer recurrence-free survival (BCRFS), cancer-specific survival (CSS), and overall survival (OS). The data were analysed using Student’s t-test, Chi-square test, and Kaplan-Meier curve.

Results:

Total of 50 patients, of which 24 had LNU and 26 had ONU, met the inclusion criteria. Median durations of follow-up were 4.2 and 6.5 years (p=0.1070) in LNU and ONU, respectively. Operative time, blood loss and hospital stay were significantly lower in the LNU group than in the ONU group (p=0.0001, p=0.0001, p=0.0018). Cancer-specific survival rate in the LNU was 75% and ONU was 73.3% (p=0.1902), whereas BCRFS and CSS were not significantly different in both groups (log-rank test; BCRFS: p=0.809 and CSS: p=0.802). Patients who underwent ureteroscopy with biopsy (p=0.001), had multifocality (p=0.001) and previous history of (H/O) bladder cancer (p=0.020) were at significant risk for developing bladder cancer recurrence after nephroureterectomy.

Conclusion:

Laparoscopic nephroureterectomy can benefit patients because of its minimal invasiveness, and oncologic outcomes are comparable to ONU. Preoperative ureteroscopy with biopsy, multifocality and previous H/O bladder cancer might be risk factors for bladder cancer recurrence.

Isolated Metastasis to the Brain From Upper Tract Urothelial Carcinoma

Isolated brain metastasis from cancers of urothelial origin are rare, especially after a long recurrence-free interval with few reports in the literature. We herein present the case of a 62 year old male with history of recurrent bladder cancers treated in 2004 and 2005 and a left distal ureteral high grade pT3aN1M0 urothelial cancer treated with distal ureterectomy and reimplant followed by adjuvant chemotherapy in 2014 who presented after a 5 year recurrence-free interval with tonic-clonic seizure. Further workup revealed an isolated 12.0 mm x 18.0 mm x 8.0 mm mass overlying the left parietal lobe with no other metastatic sites. The patient was treated with resection of the mass and adjuvant radiation therapy with pathology confirming metastatic carcinoma of urothelial origin. Though prognosis for patients with such a presentation remains poor, we provide a review of the current literature with respect to incidence, presentation and therapeutic considerations for such patients.

Correlation of APE1 with VEGFA and CD163+ macrophage infiltration in bladder cancer and their prognostic significance

The present study sought to estimate the applicability of apurinic/apyrimidinic endodeoxyribonuclease 1 (APE1), vascular endothelial growth factor A (VEGFA) expression and CD163⁺ tumor-associated macrophage (TAM) ratio as prognostic factors in bladder cancer (BCa). A total of 127 patients with bladder urothelial cancer who underwent radical cystectomy at Daping Hospital were recruited between January 2013 and January 2017, including 45 cases of non-muscle invasive BCa (NMIBC) and 82 of MIBC. Immunohistochemical detection of APE1, VEGFA and CD163, as well as multiple immunofluorescence staining for APE1, VEGFA, CD163 and CD34, were performed on tissue samples. For APE1 and VEGFA, the staining was graded based on intensity (0–3), while CD163 was graded (0–3) based on the percentage of positively stained cells. The prognostic value of APE1, VEGF and CD163 was assessed using Kaplan-Meier and Cox regression analysis. The results suggested that in BCa, high APE1 expression was associated with high VEGFA expression and more infiltration of CD163⁺ TAM. Furthermore, high expression of APE1 was associated with lymphovascular invasion of BCa, as well as reduced survival time. This indicates that APE1 may be associated with CD163⁺ TAM infiltration in BCa, with VEGFA as a possible influencing factor.

Overexpression of lncRNA TINCR is associated with high-grade, invasive, and recurring tumors, and facilitates proliferation in vitro and in vivo of urothelial carcinoma of the bladder

OBJECTIVES

The aberrant expression of long noncoding RNAs (lncRNAs) plays roles in cancer development. In this work, we measured the expression of lncRNA terminal differentiation-induced non-coding RNA (TINCR) in urothelial carcinoma of the bladder (UCB), determined its impact on the proliferation of UCB in vitro and in vivo and identified its possible targets.

METHODS

The expression levels of genes were measured by Real-Time quantitative Polymerase Chain Reaction (qPCR). Cell proliferation, cell motility, and cell apoptosis were determined by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide, wound healing assay, and ELISA, respectively. Tumor growth in vivo was determined by xenograft formation assay in nude mice. The predicted binding site between TINCR and hsa-miR-125b was confirmed by dual luciferase reporter assay.

RESULTS

The expression levels of TINCR were higher in cancerous tissues than that in paired noncancerous tissues of UCB. Higher expression levels of TINCR were positively associated with high-grade, invasive, and recurring tumors. Depletion of TINCR retarded proliferation, decreased motility, increased apoptosis in UCB cells, and markedly reduced tumor growth in xenograft nude mice. The predicted binding site between TINCR and hsa-miR-125b was functional. TINCR downregulated hsa-miR-125b in UCB cells. Hsa-miR-125b mimic reversed the proliferation caused by TINCR up-expression in UCB cells.

CONCLUSIONS

Up-regulation of TINCR may act as an unfavorable indicator for the diseasing status of UCB. TINCR facilitates bladder cancer proliferation in vitro and in vivo. Hsa-miR-125b is a target for TINCR in UCB.

Pattern and risk factors of local recurrence after nephroureterectomy for upper tract urothelial carcinoma

Purpose

This study aims to identify predictive local recurrence risk factors and site-specific local recurrence pattern of upper tract urothelial carcinoma (UTUC) with different primary tumor locations.

Methods

Three hundred and eighty-nine UTUC patients with radical nephroureterectomy were included in this study. Univariate and multivariate Cox proportional hazards regressions were performed to measure the risk of local recurrence. We also mapped the position of local recurrence sites stratified by primary tumor locations.

Results

A total of 73 patients (18.7%) developed local recurrence within a median follow-up of 41 months (range, 3-80 months). For patients with local recurrence, the median interval of local recurrence was 9 months. Ureter tumor, multifocality, T stage, G grade, lymph node metastasis (LNM), lymph node dissection (LND), and lymph vascular invasion (LVI) were all significantly associated with increased local recurrence by univariable analyses (P < 0.05). Only multifocality, T3–4, G3, and LNM remained independent predictors of increased local recurrence by multivariable analyses. Adjuvant radiotherapy could reduce the local recurrence (HR = 0.177; 95% CI 0.064-0.493, P = 0.001). Patients with local recurrence had poorer cancer-specific survival (4-year cancer-specific survival rate 36 ± 7.5% vs 88.4 ± 2.2%, P = 0.000). We evaluated local recurrence pattern stratified by tumor locations. Para-aortic lymph node region was the most common recurrence area for all the patients. Left-sided UTUC had more than 70% recurrent lymph nodes in the left para-aortic region (LPA). For right-sided UTUC patients, recurrent para-aortic lymph nodes distributed in the LPA (33.3%), aortocaval (AC) (41.5%), and right paracaval (RPC) (25.2%) regions. Recurrence in the internal and external iliac regions was only found in the distal ureter group (P < 0.05). Renal pelvic fossa recurrence was only found in renal pelvic tumor (22.2%, P = 0.007). The ureter tumor bed recurrence rate was higher for ureter patients (P = 0.001).

Conclusions

Multifocality, T3–4, G3, and LNM are predictors of higher local recurrence rate of UTUC. Adjuvant radiotherapy can reduce local recurrence rate. Local recurrence patterns are different according to primary tumor locations.

LINC00958 Involves in Bladder Cancer Through Sponging miR-378a-3p to Elevate IGF1R

Background: LINC00958 is involved in bladder cancer, but its mechanism of action remains indistinct. This study further analyzed its potential targets, aiming to search for therapeutic targets. Materials and Methods: miR-378a-3p was predicted to bind to LINC00958 and IGF1R, which was verified by double-luciferase reporter analysis. The levels of LINC00958 and miR-378a-3p in bladder cancer tissues and cells, and their correlation were further analyzed. Then LINC00958, miR-378a-3p, and IGF1R in bladder cancer cells were up- or downregulated, and their effects on cell viability, migration, and invasion of cells were detected, respectively. Results: LINC00958 binds to miR-378a-3p whose target gene was IGF1R. The expression of miR-378a-3p was negative relative with the level of LINC00958 and IGF1R. Overexpressed miR-378a-3p restrained the activity, migration, and invasion of bladder cancer cells, which was the same as the effects of silent LINC00958 and downregulated IGF1R. Nonetheless, upregulated LINC00958 rescued the antitumor effect of overexpressed miR-378a-3p, whereas miR-378a-3p inhibitor acted as a cancer promoter to reverse the inhibition of downregulated IGF1R on cell activity, migration, and invasion. Conclusion: LINC00958 accelerated the propagation and metastasis of bladder cancer cells through sponging miR-378a-3p to elevate IGF1R, which might trigger a new direction for the treatment of bladder cancer.

Development and validation of a prognostic nomogram for patients with intravesical recurrence after radical nephroureterectomy for non-metastatic upper tract urothelial carcinoma

PURPOSE

To develop and validate a prognostic nomogram for patients with intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for non-metastatic upper tract urothelial carcinoma (UTUC).

METHODS

The clinical data of 468 patients registered in the surveillance, epidemiology and end results database between 2010 and 2015 were retrospectively analyzed. Multivariate analysis using the Cox proportional hazard model was used to determine independent prognostic factors for the development of a nomogram to predict the 1-, 3-, and 5-year probability of individual cancer-specific survival (CSS). Moreover, the nomogram was internally validated using receiver operating characteristic curves and calibration plots.

RESULTS

Age at IVR > 80 years, UTUC stage ≥ T3, bladder cancer (BC) stage T1, and muscle-invasive BC (stage ≥ T2) were identified as independent risk factors for CSS in patients with IVR after RNU, whereas a time interval of > 24 months between UTUC and BC was an independent protective factor. The 1-, 3-, and 5-year predictive accuracies of our nomogram were 0.74, 0.70, and 0.71, respectively. Additionally, 1-, 3-, and 5-year calibration curves demonstrated perfect agreement between the nomogram-predicted and the actual CSS.

CONCLUSIONS

This study developed and internally validated the first nomogram to date to predict individual prognosis in patients with IVR after RUN for UTUC. This nomogram can be used for patient counseling and for designing clinical trials.