Lymphovascular Invasion Is Independently Associated With Overall Survival, Cause-Specific Survival, and Local and Distant Recurrence in Patients With Negative Lymph Nodes at Radical Cystectomy

Computational pathology: A survey review and the way forward

Computational Pathology (CPath) is an interdisciplinary science that augments developments of computational approaches to analyze and model medical histopathology images. The main objective for CPath is to develop infrastructure and workflows of digital diagnostics as an assistive CAD system for clinical pathology, facilitating transformational changes in the diagnosis and treatment of cancer that are mainly address by CPath tools. With evergrowing developments in deep learning and computer vision algorithms, and the ease of the data flow from digital pathology, currently CPath is witnessing a paradigm shift. Despite the sheer volume of engineering and scientific works being introduced for cancer image analysis, there is still a considerable gap of adopting and integrating these algorithms in clinical practice. This raises a significant question regarding the direction and trends that are undertaken in CPath. In this article we provide a comprehensive review of more than 800 papers to address the challenges faced in problem design all-the-way to the application and implementation viewpoints. We have catalogued each paper into a model-card by examining the key works and challenges faced to layout the current landscape in CPath. We hope this helps the community to locate relevant works and facilitate understanding of the field's future directions. In a nutshell, we oversee the CPath developments in cycle of stages which are required to be cohesively linked together to address the challenges associated with such multidisciplinary science. We overview this cycle from different perspectives of data-centric, model-centric, and application-centric problems. We finally sketch remaining challenges and provide directions for future technical developments and clinical integration of CPath. For updated information on this survey review paper and accessing to the original model cards repository, please refer to GitHub. Updated version of this draft can also be found from arXiv.

Predicting the Lymphovascular Invasion in Carcinoma Bladder at Transurethral Resection

INTRODUCTION

Bladder cancer is among the most common malignant neoplasms in the world. Transurethral resection of bladder tumor (TURBT) is considered the standard procedure for diagnosis, staging, and risk classification of bladder tumors. Lymphovascular invasion (LVI) is considered a poor prognostic factor. Its assessment of TURBT is very important for risk stratification and decision-making for further treatment. The purpose of our clinical study is to attempt to predict/assess the correlation between LVI and various preoperative (age, gender, history of smoking, hematuria, urine cytology, and hydronephrosis/hydroureteronephrosis), intraoperative (tumor number, size, and appearance - sessile/ pedunculated) and histopathological (tumor histology, grading, and muscle invasion) factors.

METHODOLOGY

In this prospective study, 75 patients with bladder tumors underwent TURBT (standard monopolar TURBT with 1.5% glycine as irrigation solution) in the Department of Urology at Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati between October 2021 and March 2023. Histopathological examination (HPE) reports were looked for the presence or absence of LVI. Accordingly, patients were divided into two groups, i.e., those with LVI and those without LVI. Various preoperative and intraoperative variables were analyzed for each subject in both groups. Statistically significant variables occurring in those patients with LVI compared to those without LVI were considered predictors of LVI in bladder tumors.  Results: Sixteen patients out of 75 (21.33%) had LVI on their histopathology examination. The mean age was 68.19 years in the group with LVI and 64.14 years in the group without LVI. A total of 60 men (80%) and 15 women (20%) were included in our study. Thirteen men (21.7%) and three women (20%) were found to have LVI. We observed a significant association between the appearance of the tumor and LVI. Fifty-four subjects in our study had sessile tumors. Fifteen out of them (27.8%) had LVI, while only one out of 21 patients (4.8%) with pedunculated tumors had LVI (p-value=0.028). 30% of subjects who had high-grade tumors on HPE also had LVI. On the contrary, only one of 25 patients (4%) with low-grade tumors had LVI (p-value=0.010). Our study also showed a significant association between muscle invasion and LVI. Thirty-four (45.3%) and 41 (54.7%) patients had muscle-invasive and non-muscle-invasive tumors, respectively. While 12 (35.3%) patients with muscle-invasive tumors had LVI, only four (9.8%) patients with non-muscle-invasive tumors showed LVI (p-value=0.007).

CONCLUSION

We observed that LVI of bladder tumors at first TURBT is significantly associated with tumor grade, tumor appearance, and depth of invasion of the tumor. Though statistically not significant, we further observed that LVI was more commonly found in smokers, patients with hematuria, and larger tumor sizes. We conclude that these factors can be used as reliable predictors of LVI of bladder tumors at their first TURBT.

Pathological Extramural Venous Invasion in High-stage Urothelial Carcinoma of the Bladder has Shorter Locoregional Recurrence-free Survival

Extramural venous invasion is an independent prognostic factor in colorectal cancers; the pathological identification of extramural venous invasion in bladder cancer remains unclear. By focusing on high-stage urothelial carcinoma of the bladder, we provide insights into the pathological identification of extramural venous invasion in this particular clinical context. Clinical and demographic details and pathological reports were extracted from electronic medical records. Histological sections were reviewed for the pathological identification of extramural venous invasion. Statistical analysis was done using SPSS version 23 software. Survival analysis was done using Kaplan-Meier method. In patients with available follow-up data, 62% (n = 21) exhibited pathologically evidenced extramural venous invasion, whereas 38% (n = 13) did not. The extramural venous invasion positive group showed trends toward more advanced and pathological staging and a higher occurrence of extra-nodal extension. Positive margins were more frequent in the extramural venous invasion positive group (33%) compared to the extramural venous invasion negative group (8%). However, these differences were not statistically significant. Notably, all instances of recurrence were in the extramural venous invasion positive group of patients. The extramural venous invasion positive group of patients showed a significantly shorter locoregional recurrence-free survival (P-value of 0.045). However, extramural venous invasion did not emerge as a significant factor in univariate analyses for recurrence-free survival. These findings highlight the potential role of extramural venous invasion as a prognostic factor in bladder cancer but underscore the need for further research with larger cohorts to confirm its significance.

A New Method of Artificial-Intelligence-Based Automatic Identification of Lymphovascular Invasion in Urothelial Carcinomas

The presence of lymphovascular invasion (LVI) in urothelial carcinoma (UC) is a poor prognostic finding. This is difficult to identify on routine hematoxylin-eosin (H&E)-stained slides, but considering the costs and time required for examination, immunohistochemical stains for the endothelium are not the recommended diagnostic protocol. We developed an AI-based automated method for LVI identification on H&E-stained slides. We selected two separate groups of UC patients with transurethral resection specimens. Group A had 105 patients (100 with UC; 5 with cystitis); group B had 55 patients (all with high-grade UC; D2-40 and CD34 immunohistochemical stains performed on each block). All the group A slides and 52 H&E cases from group B showing LVI using immunohistochemistry were scanned using an Aperio GT450 automatic scanner. We performed a pixel-per-pixel semantic segmentation of selected areas, and we trained InternImage to identify several classes. The DiceCoefficient and Intersection-over-Union scores for LVI detection using our method were 0.77 and 0.52, respectively. The pathologists' H&E-based evaluation in group B revealed 89.65% specificity, 42.30% sensitivity, 67.27% accuracy, and an F1 score of 0.55, which is much lower than the algorithm's DCC of 0.77. Our model outlines LVI on H&E-stained-slides more effectively than human examiners; thus, it proves a valuable tool for pathologists.

Does neo-adjuvant chemotherapy improve the negative effect of lymphovascular invasion in survival after radical cystectomy?

PURPOSE

There is a lack of studies in the literature to evaluate the impact of the specific benefit of the use of neo-adjuvant chemotherapy (NAC) on the negative effect of lymphovascular invasion (LVI) on prognosis. We aimed to evaluate the survival differences of patients according to the presence of LVI with and without administration of NAC before radical cystectomy (RC).

MATERIALS AND METHODS

We retrospectively evaluated data of the patients who underwent RC with pelvic lymphadenectomy and urinary diversion for bladder cancer recorded in the bladder cancer database of the Turkish Uro-oncology Association between 2007 and 2021. Patient demographics, follow-up time and overall survival (OS) were noted.

RESULTS

A total of 633 subjects included in the analyses. Median follow-up time was 24 months (IQR 12-54). Five years OS of the whole cohort was 55.1%. This was 54.7% and 59.9% in NAC- and NAC+ groups (P = 0.683), respectively. It was also 35.7% and 65.7% in LVI+ and LVI- patients (P < 0.0001), respectively. There was a significant difference between LVI+ and LVI- patients (33.2% vs. 68.2%, P < 0.0001) in NAC- group, but similar 5-year OS was found (53.2% vs. 64.5%, P = 0.552) in NAC+ group. In multivariable analyses, female gender, pN stages, presence of variant histology and LVI were significant independent predictive factors for OS in the whole cohort and in the NAC- group. However, gender association, pN stages and LVI lost significance in NAC+ group.

CONCLUSION

Presence of LVI significantly reduced OS, and the NAC treatment improved the negative effects of LVI on OS. Our findings encourage the use of NAC before RC.

The Effect of Lymphovascular Invasion on Short-Term Tumor Recurrence and Progression in Stage T1 Bladder Cancer

Introduction Lymphovascular invasion (LVI) is the most important stage for tumor spread and metastasis. The role of LVI in transurethral resection is not yet clear. In this study, the progression and recurrences of patients who underwent transurethral resection bladder tumor (TUR-BT) and T1 high-grade tumor and concomitant LVI were detected in pathology results and were evaluated. Methods Our study included 58 patients, who underwent TUR-BT with the suspicion of bladder cancer and were pathologically diagnosed with T1 stage bladder cancer and who did not undergo radical surgery, in the Urology Clinic of Afyonkarahisar Health Sciences University, Turkey. The patient's age, gender, tumor size, tumor grade, presence of LVI, second resection, recurrence, and progression rates at three months and one year were compared. Results LVI was detected in the pathology specimens of nine (15.5%) of the 58 patients who were included in the study. When the one-year progression was evaluated, progression to T2 tumor was detected in six (66.7%) patients in the group with LVI and five (10.2%) patients in the group without LVI, and the progression was significantly higher in the group with LVI (p=0.001). In logistic regression analysis, the only significant predictor for one-year progression was the presence of LVI (p=0.001). Conclusion According to the results of our study, the presence of LVI in the pathology specimens of patients with T1 high grade significantly increases the progression. Suggesting radical cystectomy and neoadjuvant chemotherapy to patients with LVI in the early period seems to be a more accurate approach, considering the course of the disease.

Radiomics nomogram for predicting disease-free survival after partial resection or radical cystectomy in patients with bladder cancer

OBJECTIVES

To create a MRI-derived radiomics nomogram that combined clinicopathological factors and radiomics signature (Rad-score) for predicting disease-free survival (DFS) in patients with bladder cancer (BCa) following partial resection (PR) or radical cystectomy (RC), including lymphadenectomy (LAE).

METHODS

Finally, 80 patients with BCa after PR or RC with LAE were enrolled. Patients were randomly split into training (n = 56) and internal validation (n = 24) cohorts. Radiomic features were extracted from T2-weighted, dynamic contrast-enhanced, diffusion-weighted imaging, and apparent diffusion coefficient sequence. The least absolute shrinkage and selection operator (LASSO) Cox regression algorithm was applied to choose the valuable features and construct the Rad-score. The DFS prediction model was built using the Cox proportional hazards model. The relationship between the Rad-score and DFS was assessed using Kaplan-Meier analysis. A radiomics nomogram that combined the Rad-score and clinicopathological factors was created for individualized DFS estimation.

RESULTS

In both the training and validation cohorts, the Rad-score was positively correlated with DFS (P < .001). In the validation cohort, the radiomics nomogram combining the Rad-score, tumour pathologic stage (pT stage), and lymphovascular invasion (LVI) achieved better performance in DFS prediction (C-index, 0.807; 95% CI, 0.713-0.901) than either the clinicopathological (C-index, 0.654; 95% CI, 0.467-0.841) or Rad-score-only model (C-index, 0.770; 95% CI, 0.702-0.837).

CONCLUSION

The Rad-score was an independent predictor of DFS for patients with BCa after PR or RC with LAE, and the radiomics nomogram that combined the Rad-score, pT stage, and LVI achieved better performance in individual DFS prediction.

ADVANCES IN KNOWLEDGE

This study provided a non-invasive and simple method for personalized and accurate prediction of DFS in BCa patients after PR or RC.

Sexual dimorphism in bladder cancer: a review of etiology, biology, diagnosis, and outcomes

Bladder carcinoma represents a prevalent malignancy, wherein the influence of sex extends across its incidence, biological attributes, and clinical outcomes. This scholarly exposition meticulously examines pertinent investigations, elucidating the nuanced impact of sex on bladder cancer, and posits cogent avenues for future research and intervention modalities. In the initial discourse, an exhaustive scrutiny is undertaken of the etiological underpinnings of bladder cancer, encompassing variables such as tobacco consumption, occupational exposures, and genetic aberrations. Subsequently, a comprehensive dissection unfolds, delving into the intricate biological disparities inherent in sex vis-à-vis the initiation and progression of bladder cancer. This analytical framework embraces multifaceted considerations, spanning sex hormones, sex chromosomal dynamics, metabolic enzymatic cascades, and the intricate interplay with the microbiome. Lastly, a synthesized exposition encapsulates the ramifications of gender differentials on the diagnostic and prognostic landscapes of bladder cancer, underscoring the imperative for intensified investigative endeavors directed towards elucidating gender-specific variances and the formulation of tailored therapeutic strategies.

An evaluation of lymphovascular invasion in relation to biology and prognosis according to subtypes in invasive breast cancer

Lymphovascular invasion (LVI) is associated with a poor outcome in breast cancer. The purpose of the present study was to evaluate the clinical significance of LVI in primary breast cancer and to investigate disease-free survival as a prognostic marker according to the breast cancer subtypes. This study examined 4,652 consecutive cases of invasive breast cancer excluding the patients with non-invasive cancer, stage IV and those who underwent neo-adjuvant therapy from February 2002 to February 2021. The clinicopathological characteristics and prognosis of LVI-positive and -negative tumors were compared. LVI was evaluated in H&E staining specimens from surgically resected samples. The LVI expression rates were 29.2% (low, 19.7%; high, 9.5%) in all primary cases. The LVI-positive rate was significantly associated with specimens with the following characteristics: ER/PgR-negative, HER2-positive, p53 overexpression, higher Ki-67 index values, higher nuclear grade, positive nodes and larger tumors. Moreover, the subtypes were significantly associated with LVI positivity; 20% in Luminal A, 34.6% in Luminal B, 40.9% in Lumina/HER2, 38.1% in HER2-enriched and 29.8% in triple negative (TN). There were significant differences in disease-free survival between LVI status in Luminal A, Luminal B and TN subtypes, but there was no difference in the Luminal/HER2 and HER2-enriched subtypes. A multivariate analysis revealed that LVI was a significant factor in Luminal B and TN subtypes. Overall, LVI was significantly associated with the advanced and aggressive characteristics in breast cancer. Luminal A type had a lower LVI rate, and HER2 type had a higher LVI rate. Moreover, LVI was a significant prognostic factor in Luminal B and TN subtypes. These data suggested that the LVI status was useful in predicting the prognosis in HER2 negative breast cancer cases.

Plasmacytoid urothelial carcinoma of the bladder: MRI features and their association with survival

OBJECTIVES

Plasmacytoid urothelial carcinomas (PUC) of the bladder are rare variants known for diffuse and infiltrative spread, however their magnetic resonance imaging (MRI) features are not well established. We aimed to evaluate MRI features of PUC of the bladder and their association with survival.

METHODS AND MATERIALS

This retrospective single-center study included 41 patients with pathologically-proven bladder PUC of the bladder that underwent pre-treatment MRI between January 2000 and March 2020. Two radiologists reviewed MRIs independently followed by consensus with a third radiologist. On MRI, tumor extent, size, Vesical Imaging-Reporting and Data System (VI-RADS) scores (≥4, muscle-invasive; 5, extravesical extension [EVE]), pelvic peritoneal spread (PPS), hydronephrosis, pelvic adenopathy and clinicopathological factors of age, gender, pathological stage, and treatment type were extracted. Kaplan-Meier curves and Cox proportional-hazards models were used to evaluate association with survival.

RESULTS

Thirty-two men and 9 women (median age 70 years, IQR 64-76) were included. Most were muscle-invasive (n = 30 [73.2%]). On MRI, most tumors were diffuse (n = 28 [68.3%]), >5 cm (n = 30 [73.2%]), VI-RADS 4 to 5 (n = 36 [87.8%]) with features of EVE and (n = 31 [75.6%]) and PPS (n = 25 [61.0%]). Variables associated with survival were: Larger tumors (>5 cm; hazard ratio [HR] = 5.0; 95% confidence interval [CI] 1.6-15.5; P < 0.01), diffuse extent (HR = 4.0; 95% CI 1.4-11.2; P = 0.01), EVE (HR = 4.5; 95% CI 1.5-13.6; P < 0.01), PPS (HR = 3.0; 95% CI 1.2-7.4; P = 0.01), hydronephrosis (HR = 13.7; 95% CI 3.1-60.9; P < 0.01), pathologic stage (≥pT3 vs. pT1; HR = 5.6; 95% CI 1.3-22.0; P = 0.02), and margin positivity (HR = 4.4 [95% CI 1.2-16.4], P = 0.03).

CONCLUSION

PUCs of the bladder are commonly large, diffuse VI-RADS score 4 to 5 tumors with MRI features of EVE and PPS. These features and pathological stage were associated with survival.

The Accuracy of Transurethral Bladder Resection in Detecting Bladder Cancer Histological Variants and Their Prognostic Value at Radical Cystectomy

Objectives: to investigate the accuracy of transurethral resection of bladder tumours (TURBT) in detecting histological variants (BHV) at radical cystectomy (RC) and to evaluate the impact of TURBT before cystectomy on oncological outcomes. Methods: Data of 410 consecutive RCs were assessed. Positive and negative predictive values were used to assess the accuracy of TURBT in detecting BHV. Cohen’s Kappa coefficient was used to calculate the agreement grade. Logistic regression analysis predicted features based on the presence of BHV at TURBT. Multivariable backward conditional Cox regression analysis was used to estimate oncological outcomes. Results: A total of 73 patients (17.8%) showed BHV at TURBT as compared to 108 (26.3%) at RC. A moderate agreement in histological diagnosis was found between TURBT and RC (0.58). However, sensitivity and specificity in detecting BHV were 56% and 96%, respectively. Furthermore, positive predictive value (PPV) was 84.7% and negative predictive value (NPV) was 84.6%. Presence of BHV at TURBT was an independent predictor for pathologic upstage, albeit not a predictor for positive nodes or positive surgical margins. However, at multivariable analysis adjusted for all confounders, presence of BHV at TURBT was an independent predictor for recurrence after RC, but not for survival. Conversely, the presence of BHV at RC was an independent predictor for both recurrence and survival. Conclusion: There was a moderate agreement between TURBT and RC histopathological findings. TURBT, alone, could not provide an accurate and definitive histological diagnosis. Detection of BHV in TURBT specimens is not an independent predictor of oncological outcomes; indeed, only pathological features at RC are associated with worse survival. However, BHV presence in cystectomy specimens resulted as an independent predictor of both cancer-specific and overall mortality.

The staging performance of a modified tumor-node-metastasis staging system incorporated with lymphovascular invasion in patients with esophageal squamous cell carcinoma

BACKGROUND

Lymphovascular invasion (LVI) is recognized as an unfavorable prognostic factor for many solid tumors. However, its staging value has not been adequately illustrated in esophageal squamous cell carcinoma (ESCC).

METHODS

The clinicopathologic relevance and prognostic impact of LVI were retrospectively analyzed in 822 patients with surgically treated ESCC. Univariate and multivariate analyses were used to determine the independent prognostic factors. Subgroup analyses stratified by pathological stages, nodal status and invasive depth were conducted using Kaplan-Meier method and log-rank test. Multiple staging models based on overall survival (OS) were constructed using Cox regression and evaluated by Harrell's concordance index (C-index), integrated discrimination improvement (IDI), and net reclassification index (NRI).

RESULTS

LVI was detected in 24.6% of ESCC patients, and its prevalence increased with a higher pathological stage (p < 0.001). In multivariate analysis, LVI was found to be an independent prognostic factor for OS [Hazard ratio (HR) = 1.545, 95% CI, 1.201-1.986), and was associated with unfavorable outcomes in stage I to III ESCC, regardless of nodal status and invasive depth. The staging model that incorporated LVI as an independent factor achieved the greatest improvement in accuracy (ΔC-index: 2.9%), and the greatest added value (IDI 2.8%, p < 0.01; NRI 13.7%, p < 0.05) for prediction of OS in ESCC patients.

CONCLUSIONS

LVI can facilitate further survival stratification in ESCC patients. The adoption of LVI as an independent staging factor in the current cancer staging system should be considered and further validated.

Tumor cell invasion in blood vessels assessed by immunohistochemistry is related to decreased survival in patients with bladder cancer treated with radical cystectomy

Background

Lymphovascular invasion (VI) is an established prognostic marker for many cancers including bladder cancer. There is a paucity of data regarding whether the prognostic significance of lymphatic invasion (LVI) differs from blood vessel invasion (BVI). The aim was to examine LVI and BVI separately using immunohistochemistry (IHC), and investigate their associations with clinicopathological characteristics and prognosis. A secondary aim was to compare the use of IHC with assessing VI on standard HAS (hematoxylin-azophloxine-saffron) sections without IHC.

Methods

A retrospective, population –based series of 292 invasive bladder cancers treated with radical cystectomy (RC) with curative intent at Vestfold Hospital Trust, Norway were reviewed. Traditional histopathological markers and VI based on HAS sections were recorded. Dual staining using D2–40/CD31 antibodies was performed on one selected tumor block for each case.

Results

The frequency of LVI and BVI was 32 and 28%, respectively. BVI was associated with features such as higher pathological stages, positive regional lymph nodes, bladder neck involvement and metastatic disease whereas LVI showed weaker or no associations. Both BVI and LVI independently predicted regional lymph node metastases, LVI being the slightly stronger factor. BVI, not LVI predicted higher pathological stages. BVI showed reduced recurrence free (RFS) and disease specific (DSS) survival in uni-and multivariable analyses, whereas LVI did not. On HAS sections, VI was found in 31% of the cases. By IHC, 51% were positive, corresponding to a 64% increased sensitivity in detecting VI. VI assessed without IHC was significantly associated with RFS and DSS in univariable but not multivariable analysis.

Conclusions

Our findings indicate that BVI is strongly associated with more aggressive tumor features. BVI was an independent prognostic factor in contrast to LVI. Furthermore, IHC increases VI sensitivity compared to HAS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13000-021-01171-7.

A clinical-radiomics model incorporating T2-weighted and diffusion-weighted magnetic resonance images predicts the existence of lymphovascular invasion / perineural invasion in patients with colorectal cancer

PURPOSE

Lymphovascular invasion (LVI) and perineural invasion (PNI) are independent prognostic factors in patients with colorectal cancer (CRC). In this study, we aimed to develop and validate a preoperative predictive model based on high-throughput radiomic features and clinical factors for accurate prediction of LVI/PNI in these patients.

METHODS

Two hundred and sixty-three patients who underwent colorectal resection for histologically confirmed CRC between 1 February 2011 and 30 June 2020 were retrospectively enrolled. Between 1 February 2011 and 30 September 2018, 213 patients were randomly divided into a training cohort (n = 149) and a validation cohort (n = 64) by a ratio of 7:3. We used a 10000-iteration bootstrap analysis to estimate the prediction error and confidence interval for two cohorts. The independent test cohort consisted of 50 patients between 1 October 2018 and 30 June 2020. Regions of interest (ROIs) were manually delineated in high-resolution T2-weighted and diffusion-weighted images using ITK-SNAP software on each CRC tumor slice. In total, 3356 radiomic features were extracted from each ROI. Next, we used the maximum relevance minimum redundancy and least absolute shrinkage and selection operator algorithms to select the strongest of these features to establish a clinical-radiomics model for predicting LVI/PNI. Receiver-operating characteristic and calibration curves were then plotted to evaluate the predictive performance of the model in the training, validation, and independent test cohorts.

RESULTS

A multiparametric clinical-radiomics model combining MRI-reported extramural vascular invasion (EMVI) status and a Radiomics score for the LVI/PNI estimation was established. This model had significant predictive power in the training cohort (area under the curve [AUC] 0.91; 95% confidence interval [CI]: 0.85-0.97), validation cohort (AUC: 0.88; 95% CI: 0.79-89), and independent test cohorts (AUC 0.83, 95% CI 0.72-0.95). The model performed well in the independent test cohort with sensitivity of 0.818, specificity of 0.714, and accuracy of 0.760. Calibration curve and decision curve analysis demonstrated clinical benefits.

CONCLUSION

Multiparametric clinical-radiomics models can accurately predict LVI/PNI in patients with CRC. Our model has predictive ability that should improve preoperative diagnostic performance and allow more individualized treatment decisions.

Copy number variations in primary tumor, serum and lymph node metastasis of bladder cancer patients treated with radical cystectomy

The aim of the present study was to analyze copy number variations (CNV) of multiple oncogenes and tumor suppressor genes in genomic DNA from primary tumor tissue, lymph node metastasis and cell-free DNA (cfDNA) from serum of 72 urothelial carcinoma of bladder (UCB) patients treated with radical cystectomy (RC), using multiplex ligation-dependent probe amplification (MLPA). We hypothesized that primary tumor and lymph node metastasis show similar CNV profiles, and CNV are more present in lymph node metastasis compared to primary tumor tissue. Samples from 43 (59.7%) patients could be analyzed. In total, 35 (83%), 26 (68%) and 8 (42%) patients had CNV in primary tumor, serum and lymph node metastasis, respectively. MYC, CCND1, ERBB2 and CCNE1 displayed the most frequent amplifications. In particular, CNV in ERBB2 was associated with aggressive tumor characteristics. CNV in both ERBB2 and TOP2A were risk factors for disease recurrence. The current findings show that CNV are present in various oncogenes and tumor suppressor genes in genomic DNA from primary tumor, lymph node metastasis and cfDNA from serum. CNV were more present in genomic DNA from primary tumor tissue compared to cfDNA from serum and genomic DNA from lymph node metastasis. Patients with CNV in ERBB2 and TOP2A are at increased risk for disease recurrence following RC. Further studies are necessary to validate, whether these genes may represent promising candidates for targeted-therapy.

Stage T1 bladder cancer: diagnostic criteria and pitfalls

Accurate pathological staging is crucial for patient management. Patients with T1 bladder cancer are at risk of recurrence, progression, and death of cancer. Recognition of early invasion (stage T1 disease) in urothelial carcinoma remains one of the most challenging areas in urological surgical pathology practice. A logical roadmap to T1 diagnosis would include careful evaluation of histological grade, stromal epithelial interface, characteristics of the invading epithelium, and the stroma associated responses. Tangential sectioning, crush and cautery artifacts, and associated inflammatory infiltrate are commonly encountered problems and the source of pitfalls. In this review, we outline diagnostic criteria, common pitfalls, and different histological patterns of invasion into the lamina propria. Current recommendations on reporting of biopsy and transurethral resection specimens, molecular biomarkers, clinical implications of T1 cancer diagnosis and recent developments on the T1 substaging are also discussed. Most T1 bladder cancer patients will benefit from conservative management after restaging transurethral resection of bladder and bacillus Calmette-Guérin maintenance. Patients with high risk features, such as concurrent urothelial carcinoma in situ, increased depth of invasion, lymphovascular invasion, and variant histology among others, should be considered for early cystectomy.

Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada

BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.

Lymphovascular invasion and risk of recurrence in papillary thyroid carcinoma

BACKGROUND

Lymphovascular invasion (LVI) is an established adverse prognostic factor in many cancers, however, there are few studies assessing its significance in papillary thyroid carcinoma (PTC). We aimed to determine if LVI is an independent prognostic factor in PTC.

METHODS

We conducted a single institution retrospective analysis of 610 patients with PTC treated between 1987 and 2016. LVI was defined as the presence or absence of cancer cells in blood vessels and/or lymphatics on histopathology. Multivariate Cox regression analysis was used to evaluate the association between LVI and recurrence-free survival (RFS).

RESULTS

The study cohort included 481 (78.9%) females and 129 (21.1%) males, with a median age of 47.6 years and median follow-up of 3.4 years. LVI was present in 56 (9.2%) patients and was associated with nodal metastases (P < 0.001), extrathyroidal extension (P < 0.001), extranodal extension (P < 0.001), multifocality (P = 0.018) and microscopic positive margins (P < 0.001). On univariate analysis, LVI was associated with reduced RFS (hazard ratio (HR) 2.3; 95% confidence interval (CI) 1.3-4.3; P = 0.007). However, after adjusting for nodal stage (pN0, pN1a, pN1b) there was no association between LVI and RFS (HR 1.3; 95% CI 0.7-2.5; P = 0.398). Similar results were obtained in full multivariate models adjusting for additional prognostic factors (HR 1.2; 95% CI 0.6-2.4; P = 0.627).

CONCLUSION

LVI is strongly associated with other adverse prognostic factors in PTC, particularly the presence and extent of nodal metastases. However, after adjusting for these, LVI is not an independent predictor of recurrence.

The impact of histological variants on outcomes after open radical cystectomy for muscle-invasive urothelial bladder cancer: results from a single tertiary referral centre

OBJECTIVES

To evaluate the impact of histological variants on oncological outcomes of patients with muscle-invasive bladder cancer treated with open radical cystectomy and furthermore to determine any association between survival and each histotype of bladder cancer.

MATERIALS AND METHODS

Data from 525 consecutive patients with muscle-invasive bladder cancer treated with radical cystectomy between January 2008 and May 2019 were collected retrospectively. The Kaplan-Meier curves and multivariable analysis addressed the role of histological variants in recurrence, cancer-specific and overall mortality between all subgroups.

RESULTS

Of 525 patients, 131 (25.0%) showed a histological variant at radical cystectomy. With a median follow-up of 31 months, 209 (39.8%) recurrences, 184 (35.0%) cancer-related deaths and 260 (49.5%) overall deaths were reported. The presence of histological variant was associated with advanced tumour stage, the presence of concomitant carcinoma in situ, lymph node metastasis, lymphovascular invasion and positive surgical margins compared to pure urothelial bladder cancer (all p values < .008) and resulted as an independent risk factor for cancer-specific mortality (p = 0.001). Patients with a histological variant were at significantly higher risk for recurrence, cancer-specific mortality and overall mortality (all p values ≤ .001). Micropapillary, sarcomatoid or small cell differentiation was associated with reduced survival.

CONCLUSION

The presence of histological variants at radical cystectomy seems to be weakly associated with reduced survival compared to pure urothelial bladder cancer paired for pathologic stage. The association of histological variants with advanced and biologically aggressive tumours suggests the need for attention on the overall management of these patients, in particular for micropapillary, sarcomatoid and small cell differentiation.

The association of cigarette smoking and pathological response to neoadjuvant platinum-based chemotherapy in patients undergoing treatment for urinary bladder cancer - A prospective European multicenter observational study of the EAU Young Academic Urologists (YAU) urothelial carcinoma working group

OBJECTIVE

To prospectively study the impact of smoking on pathological response to neoadjuvant chemotherapy (NAC) in patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).

MATERIALS & METHODS

We collected standard clinicopathological variables, including smoking status (never, former, current) in patients undergoing NAC and RC for UCB at 12 European tertiary care centers between 12/2013-12/2015. Clinicopathological variables were compared according to smoking status. Multivariable logistic regression models were built to assess the association of smoking status and a) complete (no residual disease), b) partial (residual, non-muscle invasive disease), c) no pathological response (residual muscle invasive or lymph node positive disease). Kaplan-Meier and Cox regression analyses were employed to study the impact of response to NAC on survival.

RESULTS AND LIMITATIONS

Our final cohort consisted of 167 NAC patients with a median follow-up of 15 months (interquartile range (IQR) 9-26 months) of whom 48 (29%), 69 (41%), and 50 (30%) where never, former, and current smokers, respectively. Smoking was significantly associated with advanced age (p = 0.013), worse ECOG performance status (p = 0.049), and decreased pathological response to NAC (p = 0.045). On multivariable logistic regression analyses, former and current smoking status was significantly associated with lower odds of complete pathological response (odds ratio (OR) 0.37, 95% confidence interval (CI) 0.16-0.87, p = 0.023, and OR 0.34, 95% CI 0.13-0.85, p = 0.021), while current smoking status was significantly associated with a greater likelihood of no pathological response (OR 2.49, 95% CI 1.02-6.06, p = 0.045). Response to NAC was confirmed as powerful predictor of survival.

CONCLUSIONS

Smoking status is adversely associated with pathological response to NAC. Smokers should be informed about these adverse effects, counseled regarding smoking cessation, and possibly be considered for immunotherpeutics as they may be more effective in smokers.

Clinical markers of morbidity, mortality and survival in bladder cancer patients treated with radical cystectomy. A systematic review

Context: Radical cystectomy and pelvic lymph node dissection (RC and PLND) are an essential part of the treatment paradigm in high risk bladder cancer. However, these patients have high rates of morbidity and mortality related both to the treatment and to the disease.Objective: To provide overview of current literature about clinical markers that can be used to predict and improve BC-patient outcomes at the time of RC and PLND and to study if they are properly validated.Evidence acquisition: A systematic literature search was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria between January 1990 and October 2018 to identify English written original and review articles relevant to this topic. Prospective and retrospective studies were included.Evidence synthesis: There are several risk factors identified from non-randomised trials that can be improved before surgery to reduce perioperative mortality and morbidity. These include poor nutritional status, anaemia, renal function and smoking. Preoperative nomograms have also been developed to help decision-making and to inform patients about the risks of surgery. They can be used to estimate risk of postoperative mortality after RC and PLND with accuracy varying from 70 to 86%. These nomograms are largely based on retrospective data. Likewise, nomograms developed to calculate estimates about patient's overall and cancer specific survival have the same limitations.Conclusion: Clinical markers to predict morbidity, mortality and survival in patients with bladder cancer treated with RC and PLND may help to improve patient outcomes and treatment decision-making, but available data come from small retrospective trials and have not been properly validated. Prospective, multi-centre studies are needed to implement and disseminate predictive clinical markers and nomograms such that they can be utilised in treatment decision-making in daily practice.

Prognostic significance of previous tonsillectomy after radical cystectomy for bladder cancer

Introduction: To examine whether previous tonsillectomy (TE) impacts on survival after radical cystectomy (RC) for bladder cancer (BC).Patients and Methods: A total of 320 patients were staged cM0 and underwent RC for BC between 2002 and 2013. We retrospectively investigated whether patients had undergone TE prior to RC. Chi-square/Fisher-Exact test was carried out to compare clinicopathological features between the TE- and non-TE-group. Kaplan-Meier analysis with log-rank test was used to estimate recurrence-free survival (RFS) and multivariable Cox-regression analysis of risk factors of recurrence. The median follow-up was 31 months (interquartile range: 9-54).Results: A history of TE was present in 18 of the 320 patients (5.6%). All TEs were performed for benign conditions. TE prior to RC was associated with a history of appendectomy (p = 0.045), lower age at RC (p = 0.029), tumor unifocality (p < 0.001), advanced histopathological tumor stage (p = 0.015), non-pure urothelial carcinoma (p = 0.025), lymphovascular invasion (p = 0.035) and receipt of palliative chemotherapy (p = 0.004). The 3-year RFS was 39.2% for patients with previous TE and 62.4% for those without (p = 0.008). In multivariable analysis, adjusted for all significant parameters of univariable analysis, lymph-node tumor involvement (p = 0.017), positive surgical margins (p = 0.047), tumor grade (p = 0.032), advanced tumor stage (≥pT3a; p = 0.049) and a history of TE (p = 0.021) remained independent prognosticators of recurrence.Conclusion: In this series, previous TE was an independent predictor of recurrence after RC for BC. Further studies are needed to assess whether TE induces immunological alterations that might exert adverse effects on cancer progression of patients with invasive BC.

Radical cystectomy for pT1 urothelial carcinoma of bladder not amenable to TURBT: Long-term results

PURPOSE

This study sought to identify factors associated with survival of pT1 urothelial carcinoma of bladder (UCB) after radical cystectomy (RC).

METHODS

This study consists of 114 pT1 UCB [primary 83, recurrent 31, none were amenable to transurethral resection (TUR)] treated by radical cystectomy. Survival analysis using Cox regression tests were performed to identify factors associated with survival of pT1 UCB after RC.

RESULTS

Pelvic lymph node (LN) status, age and lymphovascular invasion (LVI) are associated with survival of pT1 UCB after RC; recurrent pT1 UCB of high grade origin (HGO) tends to have poorer CSS than primary pT1 UCB or recurrent pT1 UCB of low grade origin (LGO) (5-year and 10-year CSS rates was 75% and 73% for primary cases; 77% and 77% for recurrent pT1 UCB of LGO; and 56% and 37% for recurrent pT1 UCB of HGO, p = 0.078).

CONCLUSIONS

LN status, age and LVI were significantly associated with survival of pT1 UCB after RC. Recurrent pT1 UCB of HGO should be managed with radical cystectomy in a timely fashion given that these cases tend to have poorer CSS than primary pT1 UCB after RC, even if they did not progress to muscle-invasive bladder cancer (MIBC).

Down-regulated RBM5 inhibits bladder cancer cell apoptosis by initiating an miR-432-5p/β-catenin feedback loop

RNA-binding motif protein 5 (RBM5) acts as a tumor suppressor in various human cancers and presents with several important characteristics, such as the potentiation of apoptosis, inhibition of the cell cycle, and alternative splicing of Fas and caspase-2 precursor mRNA. However, its role in bladder urothelial carcinoma (BUC) remains unknown. In this study, we found that RBM5 expression was significantly down-regulated in BUC tissues when compared with the adjacent nontumor tissues. The down-regulation of RBM5 activates β-catenin, which binds to the T-cell factor/lymphocyte enhancer factor element of the miR-432-5p promoter and elevates the expression of miR-432-5p in bladder cancer cells. The up-regulated miR-432-5p directly targets 3'-UTR and depresses RBM5 expression. Thus, RBM5-miR-432-5p-β-catenin forms a feedback loop in regulating bladder cancer cell apoptosis. Our findings provide evidence that the regulatory feedback loop among RBM5, miR-432-5p, and Wnt-β-catenin is responsible for the progress of bladder cancer cells.-Zhang, Y.-P., Liu, K.-L., Wang, Y.-X., Yang, Z., Han, Z.-W., Lu, B.-S., Qi, J.-C., Yin, Y.-W., Teng, Z.-H., Chang, X.-L., Li, J.-D., Xin, H., Li, W. Down-regulated RBM5 inhibits bladder cancer cell apoptosis by initiating an miR-432-5p/β-catenin feedback loop.

OSblca: A Web Server for Investigating Prognostic Biomarkers of Bladder Cancer Patients

Bladder cancer (BC) is one of the most common malignant tumors in the urinary system. The discovery of prognostic biomarkers is still one of the major challenges to improve clinical treatment of BC patients. In order to assist biologists and clinicians in easily evaluating the prognostic potency of genes in BC patients, we developed a user-friendly Online consensus Survival tool for bladder cancer (OSblca), to analyze the prognostic value of genes. The OSblca includes gene expression profiles of 1,075 BC patients and their respective clinical follow-up information. The clinical follow-up data include overall survival (OS), disease specific survival (DSS), disease free interval (DFI), and progression free interval (PFI). To analyze the prognostic value of a gene, users only need to input the official gene symbol and then click the “Kaplan-Meier plot” button, and Kaplan-Meier curve with the hazard ratio, 95% confidence intervals and log-rank P-value are generated and graphically displayed on the website using default options. For advanced analysis, users could limit their analysis by confounding factors including data source, survival type, TNM stage, histological type, smoking history, gender, lymph invasion, and race, which are set up as optional parameters to meet the specific needs of different researchers. To test the performance of the web server, we have tested and validated its reliability using previously reported prognostic biomarkers, including KPNA2, TP53, and MYC etc., which had their prognostic values validated as reported in OSblca. In conclusion, OSblca is a useful tool to evaluate and discover novel prognostic biomarkers in BC. The web server can be accessed at http://bioinfo.henu.edu.cn/BLCA/BLCAList.jsp.

Influence of preoperative hydronephrosis and ureteral orifice involvement in the survival of patients undergoing radical cystectomy: A retrospective comparative study

OBJECTIVE

The aim of the present study was to evaluate the influence of preoperative hydronephrosis and ureteral orifice involvement (UOI) on survival of patients undergoing radical cystectomy (RC) for bladder cancer (BC).

MATERIAL AND METHODS

A total of 162 patients with BC underwent RC between January 2006 and March 2017. Patients were divided into two groups for both presences of preoperative hydronephrosis and orifice involvement at final pathology. Additionally, tumors with orifice involvement were subgrouped histopathologically after RC as those with only UOI and those with invasive to the ureter with an additional concurrent site at final pathology.

RESULTS

Preoperative hydronephrosis was detected in 57 patients. Preoperative and postoperative creatinine on month 3 were higher in the preoperative hydronephrosis (+) group (p<0.001). In addition, postoperative T stage, surgical margin positivity, invasion of urethra, and pathological upstaging were higher in this group. Cancer-specific survival (CSS) and overall survival (OS) were better in the hydronephrosis (-) group than in the hydronephrosis (+) group (p=0.001 and p=0.001, respectively). Preoperative hydronephrosis was found to be an independent factor in pathological upstaging. Patients were divided into two groups according to the presence of UOI. Group 1 consisted of patients without UOI, and group 2 with UOI. Preoperative hydronephrosis, hydronephrosis grade, and T stage were statistically higher in tumors with UOI. Moreover, CSS and OS were lower in group 2 than in group 1.

CONCLUSION

Preoperative hydronephrosis and UOI are predicting factors on survival of patients undergoing RC for BC. Preoperative hydronephrosis was found to be an independent factor in pathological upstaging.

Staging of bladder cancer

Urothelial carcinoma of the urinary bladder is a heterogeneous disease with multiple possible treatment modalities and a wide spectrum of clinical outcome. Treatment decisions and prognostic expectations hinge on accurate and precise staging, and the recently published American Joint Committee on Cancer (AJCC) Staging Manual, 8th edition, should be the basis for staging of urinary bladder tumours. It is unfortunate that the International Union Against Cancer (UICC) 8th edition failed to incorporate new data which is considered in the AJCC 8th edition. Thus, the AJCC 8th edition is the focus of this review. Several critical changes and clarifications are made by the AJCC 8th edition relative to the 7th edition. Although the most obvious changes in the 8th edition are in the N (i.e. perivesical lymph node involvement now classified as N1) and M (i.e. M1 is subdivided into M1a and M1b) categories, several points are clarified in the T category (e.g. substaging of pT1 should be attempted). Further optimisation, however, is required. No particular method of substaging pT1 is formally recommended. In this review, these modifications are discussed, as well as points, which require further study and optimisation.

The impact of lymphovascular invasion in patients with prostate cancer following radical prostatectomy and its association with their clinicopathological features: An updated PRISMA-compliant systematic review and meta-analysis

OBJECTIVE

Numerous studies have shown that lymphovascular invasion (LVI) is linked to biochemical recurrence (BCR) in prostate cancer (PCa) patients following radical prostatectomy (RP). However, the actual clinicopathological impacts of LVI remain unclear. Thus, we performed a meta-analysis to evaluate the pathologic and prognostic impacts of LVI in PCa patients.

METHODS

Following the guidance of the PRISMA statement, relevant studies were collected systematically from the PubMed, EMBASE, and Web of Science databases to identify relevant studies published before June 2018. The hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated to investigate the association of LVI with BCR and clinicopathological features.

RESULTS

A total of 20 studies including 25,570 patients (106-6678 per study) with PCa were incorporated into this meta-analysis. Overall pooled analysis suggested that LVI was associated with a higher BCR risk both in univariate (pooled HR=1.50, 95% CI: 1.34-1.68, P <.001) and multivariate analyses (pooled HR=1.25, 95% CI: 1.17-1.34, P <.001). In addition, LVI was closely correlated with extraprostatic extension (yes vs no: OR = 4.23, 95% CI: 1.86-9.61, P <.001), pathological GS (≥7 vs <7: OR = 5.46, 95% CI: 2.25-13.27, P <.001), lymph node metastases (yes vs no: OR = 18.56, 95% CI: 7.82-44.06, P <.001), higher pathological stage (≥ T3 vs < T2: OR = 6.75, 95% CI: 5.46-8.36, P <.001), positive surgical margin (positive vs negative: OR = 2.42, 95% CI: 1.57-3.72, P <.001) and seminal vesicle invasion (yes vs no: OR = 5.72, 95% CI: 2.45-13.36, P <.001).

CONCLUSIONS

This study suggests that LVI in histopathology is associated with a higher risk of BCR and advanced clinicopathological features in PCa patients and could serve as a poor prognostic factor in patients who underwent RP.

Lymphovascular invasion have a similar prognostic value as lymph node involvement in patients undergoing radical cystectomy with urothelial carcinoma

To determine the prognostic value of lymphovascular invasion (LVI) in patients with bladder cancer who underwent radical cystectomy. Total of 747 patients underwent radical cystectomy; of these, only 164 did not undergo lymph node dissection (LND). The patients were divided into 4 groups: N0, N1, LVI without LND, and non-LVI without LND. Patients in the N1 and LVI groups had significantly higher T stages and grades, as well 1.5- to 2-fold higher recurrence and mortality rates. Overall survival (OS) was significantly poorer in the N1 group, compared with the N0 and non-LVI groups (p = 0.001 and 0.012), and in the LVI group relative to the N0 and non-LVI groups (p = < 0.001 and <0.001). Recurrence-free survival (RFS) was also significantly poorer in the N1 group relative to the N0 and non-LVI groups (p = < 0.001 and <0.001), and in the LVI group relative to the N0 and non-LVI groups (p = < 0.001 and <0.001). Among patients undergoing radical cystectomy, the clinical results predicted by LVI were similar to those predicted by lymph node involvement. Therefore, the role of adjuvant chemotherapy or immunotherapy may need to be prospectively evaluated in LVI-positive patients regardless of T stage after radical cystectomy.

Management of High-grade T1 Urothelial Carcinoma

PURPOSE OF REVIEW

The optimal management of high-grade T1 (HGT1) urothelial carcinoma (UC) is complex given its high rate of recurrence, progression, and cancer-specific mortality as well as its clinical variability. Our current treatment paradigm has been supplemented by recent data describing the expanding options for salvage intravesical therapy, bladder preservation, and the promising role of molecular epidemiology. In the current review, we attempt to summarize and critically analyze these studies.

RECENT FINDINGS

Evidence describing new intravesical therapies has demonstrated an adequate safety profile and some efficacy in BCG-unresponsive patients who desire bladder preservation. However, response rates are still poor in this high-risk patient population, and it is important to keep these data in perspective when counseling patients. Concomitantly, the continued molecular characterization of non-muscle-invasive bladder cancer may suggest potential therapeutic targets as well as predictors of treatment response in the future. The integration of new intravesical therapies and molecular data into the current treatment paradigm for HGT1 urothelial carcinoma will be critical to improving oncologic outcomes in this particularly high-risk population.

Multidisciplinary Management of Muscle-Invasive Bladder Cancer: Current Challenges and Future Directions

The treatment of muscle-invasive bladder cancer (MIBC) is complex and requires a multidisciplinary collaboration among surgery, radiation, and medical oncology. Although neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) and lymph node dissection has been considered the standard treatment for MIBC, many patients are unfit for surgery or cisplatin-ineligible, and considerations for bladder-preservation strategies not only are increasingly recognized as optimal treatment alternatives, but also should feature in the range of management options presented to patients at the time of diagnosis. Apart from chemotherapy, immunotherapy has also been used with success in locally advanced and metastatic bladder cancer and is moving into the MIBC space. Prospective studies addressing trends in management that span systemic, surgical, and radiation options for patients are discussed in this article.

The Role of Hepsin in Endometrial Carcinoma

PURPOSE

Endometrial carcinoma is the sixth most common cancer in women worldwide and the most common invasive cancer of the female genital tract in developed countries. It is hoped that through a better understanding of the alterations implicated in endometrial cancer pathogenesis and prognosis, a more complete profile of risk factors and targeted therapy can be developed. Hepsin is a member of the type II transmembrane serine protease family. The importance of hepsin in prostate cancer has been demonstrated by several studies. However, the role of hepsin in endometrial carcinoma is yet to be identified. This study aimed to evaluate the immunohistochemical expression of hepsin in endometrial carcinoma, trying to explore its diagnostic and prognostic value.

MATERIALS AND METHODS

This retrospective study was conducted on 27 endometrial carcinoma and 18 endometrial hyperplasia cases. Immunohistochemical expression of hepsin was evaluated in tissue specimens and results were correlated with the available clinicopathlogic parameters.

RESULTS

Positive hepsin expression was seen in all (100%) carcinoma and 17/18 (94.44%) endometrial hyperplasia cases. The H-score of hepsin expression in endometrial carcinoma was significantly higher than that of hyperplasia cases (P=0.012). A significant negative association was found between hepsin expression in endometrial carcinoma cases regarding the grade and the size of tumors (P=0.018 and 0.008, respectively) as well as myometrial invasion (P=0.027).

CONCLUSIONS

Hepsin could play an important role in the pathogenesis and the early carcinogenesis of endometrial carcinoma and could serve as a prognostic biomarker in this tumor.

A systematic review and meta-analysis of lymphovascular invasion in patients treated with radical cystectomy for bladder cancer

PURPOSE

Lymphovascular invasion (LVI) is an important step in bladder cancer cell dissemination. We aimed to perform a systematic review and meta-analysis of the literature to assess the prognostic value of LVI in radical cystectomy (RC) specimens.

PATIENTS AND METHODS

A systematic review and meta-analysis of the last 10 years was performed using the MEDLINE, EMBASE, and the Cochrane libraries in July 2017. The analyses were performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.

RESULTS

We retrieved 65 studies (including 78,107 patients) evaluating the effect of LVI on oncologic outcomes in patients treated with RC. LVI was reported in 35.4% of patients. LVI was associated with disease recurrence (pooled hazard ratio [HR] = 1.57; 95% CI: 1.45-1.70) and cancer-specific mortality (CSM) (pooled HR = 1.59; 95% CI: 1.48-1.73) in all studies regardless of tumor stage and node status (pT1-4 pN0-2). LVI was associated with recurrence and CSM in patients with node-negative bladder cancer (BC). In patients with node-negative BC, LVI rate increased and was associated with worse oncologic outcome. LVI had a lower but still significant association with disease recurrence and CSM in node-positive BC.

CONCLUSIONS

LVI is a strong prognostic factor of worse prognosis in patients treated with RC for bladder cancer. This association is strongest in node-negative BC, but it is also in node-positive BC. LVI should be part of all pathological reporting and could provide additional information for treatment-decision making regarding adjuvant therapy after RC.

SPAG5 promotes proliferation and suppresses apoptosis in bladder urothelial carcinoma by upregulating Wnt3 via activating the AKT/mTOR pathway and predicts poorer survival

Sperm-associated antigen 5 (SPAG5) is involved in various biological processes. However, the roles of SPAG5 in bladder urothelial carcinoma (BUC) are unknown. This study showed that upregulation of SPAG5 was detected frequently in primary BUC tissues, and was associated with significantly worse survival among the 112 patients that underwent radical cystectomy (RC). Up and downregulating the expression of SPAG5 enhanced or inhibited, respectively, the proliferation of BUC cells in vitro and in vivo, and suppressed or enhanced, respectively, apoptosis in vitro and in vivo. Moreover, SPAG5 increased the resistance of BUC cells to chemotherapy-induced apoptosis. Mechanistic investigations showed that SPAG5 promotes proliferation and suppresses apoptosis in BUC at least partially via upregulating Wnt3 through activating the AKT/mTOR signaling pathway. The importance of the SPAG5/AKT-mTOR/Wnt3 axis identified in BUC cell models was confirmed via immunohistochemical analysis of a cohort of human BUC specimens that underwent RC. Collectively, our data suggested that in patients with BUC who underwent RC, high SPAG5 expression is associated with poor survival. In addition, targeting SPAG5 might represent a novel therapeutic strategy to improve the survival of patients with BUC.

Prognostic importance of lymphovascular invasion in urothelial carcinoma of the renal pelvis

BACKGROUND

The current study was conducted to assess the impact of lymphovascular invasion on the survival of patients with urothelial carcinoma of the renal pelvis.

METHODS

Patients with urothelial carcinoma of the renal pelvis who underwent radical nephroureterectomy from 2010 through 2015 were identified in the National Cancer Data Base. Patients were characterized according to demographic and clinical factors, including pathologic tumor stage and lymphovascular invasion. Associations with overall survival were assessed through proportional hazards regression analysis.

RESULTS

A total of 4177 patients were identified; 1576 had lymphovascular invasion. Patients with T3 disease and lymphovascular invasion had 5-year survival that was significantly worse than that of patients with T3 disease without lymphovascular invasion (34.7% vs 52.6; P < .001 by the log-rank test), and approached that of patients with T4 disease without lymphovascular invasion (34.7% vs 26.5%; P = .002). On multivariate analysis controlling for age, comorbidities, grade, lymph node status, surgical margin status, race, sex, and chemotherapy administration, patients with T3 disease and lymphovascular invasion also were found to have significantly worse survival compared with patients with T3 disease without lymphovascular invasion (hazard ratio, 1.7; 95% confidence interval, 1.4-1.91).

CONCLUSIONS

Lymphovascular invasion status is a key prognostic marker that can stratify the risk of patients with pT3 upper tract urothelial carcinoma further. Patients with this pathologic feature should be carefully considered for clinical trials exploring existing and novel therapies. Cancer 2018;124:2507-14. © 2018 American Cancer Society.

Study of Clinicopathological Spectrum and Pattern of Expression of Cyclooxygenase‑2 in Urothelial Carcinomas of Bladder

Introduction: Overexpression of cyclooxygenase-2 (COX2) in urothelial carcinoma of bladder (UCB) had been studied in the past by different workers and the results were contradictory. The objective of the present study was to evaluate the prognostic implication of COX2 expression in primary urothelial carcinomas of the urinary bladder and its correlation with clinical parameters, tumor stage, grade, and recurrence. Materials and methods: A total of 68 cases who underwent surgery for urothelial carcinoma in our medical college from January 2013 to December 2015 were evaluated in our study. Hematoxylin and eosin-stained slides were examined by two faculties applying standard reporting protocol. Tumor staging and grading was performed as per the WHO guidelines. Immunohistochemistry for expression of COX2 was performed to study any correlation of tumor grade with COX2 expression. The distribution of COX2 positivity was studied in tumors stratified according to established bladder cancer prognostic factor, for example, tumor size, grade, invasion, and spread. Results: Out of 68 cases, 42 cases showed COX2 positivity (61%). In low-grade cases of bladder carcinoma, COX2 positivity was 16 out of 24 cases (60%), and in high-grade cases, COX2 positivity was 10 out of 18 cases (64.28%).Conclusion: In the present study, the association of COX2 overexpression with advanced tumor invasion and tumor grade has been substantiated. Hence, COX2 expression can be taken as a prognostic factor along with other usual prognostic factors in patients of UCB.

A greater number of dissected lymph nodes is associated with more favorable outcomes in bladder cancer treated by radical cystectomy: a meta-analysis

The optimal extent of lymph node dissection (LND) is currently not established, and the debate regarding the association between the number of dissected nodes and the outcomes of bladder cancer treated by radical cystectomy (RC) is still ongoing. Therefore, the present meta-analysis was performed to clarify this potential relationship. Eligible studies were retrieved via an electronic search for studies published up to April 2016, and by manual review of the references. A total of 25 cohort studies involving 41,400 bladder cancer patients who underwent RC were included. The summary relative risk estimates (SRRE) based on the highest compared with the lowest categories of LND were estimated by variance-based meta-analysis. Heterogeneity among the study results was explored through stratified analyses. Overall, bladder cancer patients with the highest category of LND had 28%, 34% and 36% reduced risks, corresponding to overall survival (SRRE = 0.72; 95% CI, 0.64-0.80), cancer-specific survival (SRRE = 0.66; 95% CI, 0.54-0.80) and recurrence-free survival (SRRE = 0.64; 95% CI, 0.50-0.82), respectively, compared with patients with the lowest category of LND. In summary, the patients with a greater number of dissected lymph nodes had statistically significant survival advantages in terms of the outcomes of bladder cancer following RC. The number of dissected lymph nodes could be an independent prognostic factor for bladder cancer. These findings need to be validated in prospective and larger epidemiological studies with a longer follow-up period.

Patterns and predictors of recurrence after open radical cystectomy for bladder cancer: a comprehensive review of the literature

Purpose

To review the currently available literature reporting the patterns of recurrence and their predictive factors after open radical cystectomy (RC) for bladder cancer.

Methods

A review of the literature was performed using the MEDLINE, Scopus and Web of Sciences databases from January 1997 to May 2017. The PRISMA guidelines were followed for the conduct of the study.

Results

Local recurrence rate ranges between 30 and 54%. Distant recurrence is not often standardized and is reported in up to 50% of cases. The overall 5-year recurrence-free survival rates from 58 to 81%. The mean follow-up of studies included in the analysis ranged from 18 to 350 months. Details on the most important demographic and epidemiological, clinical, histologic and pathologic predictors of recurrence after radical cystectomy are provided through an evidence-based approach. The impact of the extension of lymph node dissection on recurrence after RC is investigated.

Conclusions

A correct prognostic assessment is essential for patients undergoing radical cystectomy for bladder cancer, thereby potentially improving their oncologic outcomes.

Electronic supplementary material

The online version of this article (10.1007/s00345-017-2115-4) contains supplementary material, which is available to authorized users.

Copy number variations of circulating, cell-free DNA in urothelial carcinoma of the bladder patients treated with radical cystectomy: a prospective study

The aim of the present study was to establish a rapid profiling method using multiplex ligation-dependent probe amplification (MLPA) and characterize copy number variations (CNV) in circulating, cell-free DNA (cfDNA) in 85 urothelial carcinoma of the bladder (UCB) patients treated with radical cystectomy (RC). MLPA was tested for the use of cfDNA extracted from serum and plasma by various commercial extraction kits. Eighteen probes served as reference to control denaturation, ligation and amplification efficiency. MLPA was exclusively suitable for cfDNA extracted from serum. Serum from 72 patients (84.7%) could be analyzed. Thirty-five patients (48.6%) had presence of CNV in cfDNA. The median CNV count in patients with presence of CNV was 2. Predominantly, CNV were located in the genes CDH1, ZFHX3, RIPK2 and PTEN in 15 patients (20.8%), 12 patients (16.7%), 9 patients (12.5%) and 7 patients (9.7%), respectively. CNV in TSG1, RAD21, KIAA0196, ANXA7 and TMPRSS2 were associated with presence of variant UCB histology (p = 0.029, 0.029, 0.029, 0.029, 0.043, respectively). Furthermore, CNV in miR-15a, CDH1 and ZFHX3 were associated with presence of incidental prostate cancer (p = 0.023, 0.003, 0.025, respectively). Patients with CNV in KLF5, ZFHX3 and CDH1 had reduced cancer-specific survival, compared to patients without CNV in these genes (pairwise p = 0.028, 0.026, 0.044, respectively). MLPA represents an efficient method for the detection of CNV among numerous genes on various chromosomal regions. CNV in specific genes seem to be associated with aggressive UCB biologic features and presence of incidental prostate cancer, and may have a negative impact on cancer-specific survival.