Urachal carcinoma: a large retrospective multicentric study from the French Genito-Urinary Tumor Group

Introduction

Urachal cancer (UrC) is a rare, non-urothelial malignancy. Its natural history and management are poorly understood. Although localized to the bladder dome, the most common histological subtype of UrC is adenocarcinoma. UrC develops from an embryonic remnant, and is frequently diagnosed in advanced stage with poor prognosis. The treatment is not standardized, and based only on case reports and small series. This large retrospective multicentric study was conducted by the French Genito-Urinary Tumor Group to gain a better understanding of UrC.

Material and Methods

data has been collected retrospectively on 97 patients treated at 22 French Cancer Centers between 1996 and 2020.

Results

The median follow-up was 59 months (range 44-96). The median age at diagnosis was 53 years (range 20-86), 45% were females and 23% had tobacco exposure. For patients with localized disease (Mayo I-II, n=46) and with lymph-node invasion (Mayo III, n=13) median progression-free-survival (mPFS) was 31 months (95% CI: 20-67) and 7 months (95% CI: 6-not reached (NR)), and median overall survival (mOS) was 73 months (95% CI: 57-NR) and 22 months (95% CI: 21-NR) respectively. For 45 patients with Mayo I-III had secondary metastatic progression, and 20 patients were metastatic at diagnosis. Metastatic localization was peritoneal for 54% of patients. Most patients with localized tumor were treated with partial cystectomy, with mPFS of 20 months (95% CI: 14-49), and only 12 patients received adjuvant therapy. Metastatic patients (Mayo IV) had a mOS of 23 months (95% CI: 19-33) and 69% received a platin-fluorouracil combination treatment.

Conclusion

UrC is a rare tumor of the bladder where patients are younger with a higher number of females, and a lower tobacco exposure than in standard urothelial carcinoma. For localized tumor, partial cystectomy is recommended. The mOS and mPFS were low, notably for patients with lymph node invasion. For metastatic patients the prognosis is poor and standard therapy is not well-defined. Further clinical and biological knowledge are needed.

Neuropsychological function and cerebral metabolites in HIV-infected youth

The effects of HIV on brain metabolites and cognitive function are not well understood. Sixteen HIV+youths (15 vertical, 1 transfusion transmissions) receiving combination antiretroviral therapy and 14 age-matched HIV- youths (13-25 years of age) were evaluated with brain two-dimensional (2D) magnetic resonance spectroscopy (MRS) at 3 Tesla (T) and a neuropsychological battery that assessed three cognitive domains (attention/processing speed, psychomotor ability, and executive function). The relationship between brain metabolite ratios and cognitive performance was explored. Compared to HIV- controls, HIV+ subjects had higher sycllo-inositol (Scy)/total creatine (tCr) (+32%, p = 0.016) and higher Scy/total choline (tCho) (+31%, p = 0.018) on 2D-MRS in the right frontal lobe. HIV+ subjects also had higher glutamate (Glu)/tCr (+13%, p = 0.022) and higher Glu/tCho (+15%, p = 0.048) than controls. HIV+ subjects demonstrated poorer attention/processing speed (p = 0.011, d = 1.03) but similar psychomotor and executive function compared to HIV- controls. The attention/processing score also correlated negatively with the ratio of N-acetylaspartate (NAA) to tCr on 2D-MRS (r = -0.75, p = 0.0019) in the HIV- controls, but not in the HIV+ subjects (Fisher's r-z transformation, p < 0.05). Our results suggest that attention/processing speed is impacted by early HIV infection and is associated with right hemisphere NAA/tCr. Scy and Glu ratios are also potential markers of brain health in chronic, lifelong HIV infection in perinatally infected youths receiving antiretroviral therapy.

Evolution of class A G-protein-coupled receptors: implications for molecular modeling

Class A or rhodopsin-like G-protein-coupled receptors (GPCRs) constitute the largest transmembrane receptor family of the human genome. Because of their biological and pharmaceutical importance, the evolutionary history of these receptors has been widely studied. Most studies agree on the classification of the 700 members of this family into a dozen of sub-families. However, the relationship between these sub-families remains controversial and the molecular processes that drove the evolution and diversification of such a large family have still to be determined. We review here the evolutionary analyses carried out on class A GPCRs either by phylogenetic methods or by multidimensional scaling (MDS). We detail the key molecular events driving the evolution of this receptor family. We analyze these events in view of the recently resolved crystal structures of GPCRs and we discuss the usefulness of evolutionary information to help molecular modeling.

Adrenomedullin and its receptors expression in renal tumors

10568

Background: Adrenomedullin (AM) is a 52 amino acid peptide that has an important role on tumor cell proliferation and neoangiogenesis through its receptors CRLR/RAMP2 and CRLR/RAMP3. AM gene expression is stimulated by Hypoxia Inductible Factor-1 (HIF- 1) and 60–80% of the human conventional renal carcinomas (cRCC) display mutations in the tumor suppressor protein von Hippel-Lindau, which leads to constitutively elevated HIF-1. Methods: Tumors and non-malignant kidney tissues were obtained from patients who underwent unilateral nephrectomy. We studied VEGFA, AM and its receptors expression by quantitative RT-PCR in 62 frozen renal tumors including: 40 cRCC; 5 cRCC metastasis; 5 chromophobe carcinomas; 5 Papillary carcinomas; 2 oncocytomas; 2 collecting duct carcinomas; 2 normal adjacent renal tissue; 1 unclassified renal tumor. AM and AM-receptors expression was studied in 42 paraffin-embedded renal tumors by immunohistochemistry using rabbit anti-AM, anti-CRLR, anti-RAMP2 and anti-RAMP3 polyclonal antibodies. Effects of these anti AM or anti AM- receptors antibodies on cell proliferation were examined in vitro on BIZ cell line (cRCC cells). Results: VEGFA, AM and AM-receptors genes were overexpressed in cRCC compared to other renal tumors (Except AM gene in chromophobe carcinoma). Their expressions were independent of classical prognostic factors (such as Fuhrman Grade and pT status). In cRCC, there was a strong positive correlation between VEGF-A gene expression and AM (r=0.7; p=0.01) and AM-receptors genes expressions (RAMP2 r=0.61; p= 0.01 and RAMP3 r=0.58; p= 0.01). Immunohistochemistry confirmed a tumor expression of CRLR, RAMP2 and AM in more than 80% cRCC. RAMP3 was expressed by inflammatory cells but not by tumoral cells. The cell proliferation assay showed a significant inhibition of BIZ cell proliferation by AM antibody or AM-receptors antibodies. Conclusion: AM and its receptor CRLR/RAMP2 are overexpressed in cRCC. In vitro cell proliferation assay results support that AM inhibition may suppress cRCC growth, independently of potential antiangiogenic effects. Further studies on animal models are needed but AM pathway may be a potential therapeutic target in cRCC.

No significant financial relationships to disclose.

Immunohistochemical expression of ezrin correlates with Event-free and overall survival in osteosarcomas

10035

Background: Ezrin is a cytoskeleton linker protein that is actively involved in the metastatic process of cancer cells. We have searched for a pronostic value of ezrin and some of its partners: a-smooth actin and CD44H in 37 patients with an osteosarcoma. Methods: Automate immunohistochemistry (IHC) with anti-ezrin, a-smooth actin and CD44H antibodies was performed in 37 biopsies before chemotherapy, 16 resected tumors of “poor” responders and 13 metastases. In addition the mRNA levels of ezrin of 13 frozen biopies and 4 metastases were evaluated by real time quantitative RT PCR. All results were correlated to the following clinical data: response to chemotherapy, onset of metastasis, event-free survival (EFS) and overall survival (OS). Results: Ezrin expression by IHC was found in 62% of 37 biopsies in the different histological subtypes especially chondroblastic osteosarcomas while chondrosarcomas were negative. A good correlation was found between positive or negative samples by IHC and mRNA levels. Ezrin expression was recorded in 84.5% of metastastic samples. The mean expression of ezrin was higher in metastases than biopsies (mean expression 38.1% versus 17.32%; p=0.024) but the onset of metastasis was not statistically correlated to ezrin positivity on biopsy (p = 0.183). In multivariate analysis, ezrin was an independent prognostic marker for EFS and OS with p<0.001 and p=0.003 respectively and a-smooth actin for OS only (p=0.024). No prognostic value was found for CD44H. Conclusions: We have shown that ezrin is expressed in the different subtypes of osteosarcomas especially chondroblastic osteosarcomas. Other studies are required to confirm that ezrin could be a useful tool for differential diagnosis with chondrosarcoma. Ezrin was an independent prognostic factor for event-free and overall survival rate in multivariate analysis and its partner a-smooth-actin was also an independent prognostic factor for overall survival only. These data confirm the role of ezrin signalling pathway for tumor dissemination in osteosarcomas in vivo. This also might be of interest for therapeutic strategy to select patient for dose intensification or to use new anticancer agents such as rapamycin which reduces experimental lung metastases through an ezrin-related pathway.

No significant financial relationships to disclose.

Implication of clinical and paraclinical covariates in the pharmacokinetics of high dose MTX (HD-MTX) in patients with osteosarcoma

12022

Background: Methotrexate (MTX) is a mainstay in the treatment of ostosarcoma. MTX is characterized by a narrow therapeutic window, combined with high intra- and inter-patient variabilities. In our institute, safe administration of high dose MTX is ensured by using bayesian, adaptive dosing with feedback strategy. In patients with osteosarcoma, up to 20g/patient MTX is administred following an 8h infusion. From the 6th hour, the dose is tailored according to individual pharmacokinetics parameters, determined in real-time from two early sampling times (T3.5, T4.5) and a reference population. This method enables accurate adjustment of most patients around a target Cend of 10−3 M/L. Still, 15–20% of the patients show reduced MTX elimination rate, thus leading to an overlasting hospitalization time with folate rescue required to prevent severe toxicities. In this work, we studied the relevance of clinical or pareaclinical covariates likely to be associated with the MTX clearance so as to identify patients at risk of impaired elimination with subsequent increase in iatrogeny. Methods: This retrospective study was performed on 49 patients treated with HD-MTX. Population PK parameters were computed using Apis and NonMem routines. The second objective was to predict for how long MTX plasma concentration would remain above 0.2 μM/L, the threshold associated with toxicity, upper which folinic acid is required. Finally, simplified sampling strategy for folate rescue protocol was developed. Results: two covariates (creatinemia and ALAT) have been identified as being correlated with MTX clearance. Besides, simulation of the 0.2μM/L threshold reaching showed that it was possible to predict accurately the time most patients can leave the hospital safely. This, would have led to reduce the hospitalization stay by at least one day in 25% of the patients, thus optimizing their life quality while being cost-effective. Conclusions: in this study, we showed that high dose MTX can be administred safely using an adaptive dosing with drug monitoring strategy. Besides, modelling of MTX PK parameters leads to an accurate estimation of the elimination pattern of this drug, thus enabling a planification of the time patients leave the hospital.

No significant financial relationships to disclose.

Population pharmacokinetic of total cisplatinum: Application to adaptative dosing with feed back in testicular cancer patient

2043

Background: Cisplatinum (CDDP) is major drug used in germ cell testicular cancer. Pharmacokinetics (PK)/pharmacodynamics relationships have been described after measurement of free CDDP in plasma, and subsequently, CDDP administration is standardized using body surface area (BSA) for only dose tailoring. Methods: Based on a rapid assay of total CDDP in plasma we have developed an alternative 120-hours continuous infusion schedule, coupled to a Bayesian adaptive dosing strategy. We present a retrospective evaluation of this schedule in 19 patients (66 courses) treated for testicular germ cell tumors. A NONMEM analysis was then performed to identify the covariates associated with total CDDP clearance. We compared doses effectively given to our patients with the ones calculated with BSA. Results: Plasma samples were analyzed to allow real-time Bayesian estimation of individual PK parameters with subsequent daily dose adjustment in order to reach a target Cend of 1.95 mg/l of total platinum. No statistical difference was observed between experimental and target values, and Cend adjustment was achieved with an overall 6.6% precision, a performance to be compared with the 54% inter-patient variability observed in drug clearance. Course number (CNB) was the only covariate to be correlated with total CDDP clearance. A weaker correlation was found with BSA, and only when considering first courses. Moreover, doses of CDDP administered were significantly higher than the ones classically normalized with BSA, thus leading to an overall greater exposure in our patients. Only few severe toxicities were reported, and all of the patients presented in this study were still alive and disease-free after a follow up of up to 15 years. Conclusions: Our alternative schedule is a convenient and safe strategy to ensure administration of optimal dose-intensity of CDDP, with limited side-effects in patients with testicular cancer. We demonstrate a linear correlation between course number and decrease of CDDP clearance (25%). This, highlights the critical importance of total drug accumulation on CDDP PK when several infusions are to be administered in a row, and therefore the need for developing dynamic dose individualization strategies that includes CNB.

No significant financial relationships to disclose.

Recovery of replication-competent virus from CD4 T cell reservoirs and change in coreceptor use in human immunodeficiency virus type 1-infected children responding to highly active antiretroviral therapy

Highly active antiretroviral therapy (HAART) suppresses plasma viremia in most patients with human immunodeficiency virus (HIV) infection. Prospective study of HIV-infected children (n=27) shows that, in 8 of 12 who responded to HAART (>/=0.5 log reduction in plasma HIV RNA), HAART restricted the number of coreceptors used by the predominant HIV isolate (mean number of coreceptors used at baseline was 4, vs. 1 coreceptor used at 6 months after treatment). This decrease was most striking in 6 of 8 children whose HIV coreceptor tropism changed from X4-tropic at baseline to R5-tropic. In 6 of 10 children tested, with plasma HIV RNA levels of <50 copies/mL, R5-tropic virus was isolated from CD4 T cell reservoirs. All the responding children had a significant increase in naive CD4 T cells (P<.05). These results show that persistent HIV T cell reservoirs are present in children and that HAART may influence the number and type of coreceptors used by the predominant virus isolate.

[Leiomyosarcoma of the inferior vena cava. Apropos of a new case]

A leiomyosarcoma was diagnosed in the mid portion of the inter-renal inferior vena cava. Survival was long (6 years) but required 14 reoperations to remove metastases. During the first operation, vascular integrity was reestablished with a cava-cava prosthesis after exeresis of the upstream cava without removal of the left renal vein ostium. The right renal vein was sectioned and directly implanted onto the prosthesis. The pathology report confirmed the diagnosis of leiomyosarcoma with multiple metastases presenting cytonuclear anomalies which worsened with time.

[Late and multiple endocrine metastases of an adenocarcinoma of the kidney]

Ten years after nephrectomy a renal cell carcinoma of the felt kidney, the patient presented successively pancreatic, adrenal gland, thyroid gland and contralateral renal metastases. Surgical exeresis was performed for the different metastases with a survival period of 7 years. No similar observation (non-necropsic discovery, surgical treatment, prolonged survival) of multiple metastasis of renal cell carcinoma to endocrine glands was found in the literature. The important role of modern imaging techniques are emphasized together with the need for long-term follow-up of operated renal cell cancer since the clinical course can be unpredictable. Long-term remission has been reported and surgical exeresis of metastasis should always be proposed when possible.

[Animal bites. Epidemiology and infection risks]

A review of 5,116 cases of animal bites (587 of which were studied prospectively) has shed some light on their epidemiological aspects and on the risk of infection they carry. It has also led to a more objective assessment of the real effect of the therapeutic and prophylactic measures usually applied in such cases. The most frequent wounds are those of the hands and face, the former rising an infectious problem, the latter a predominantly cosmetic problem. The overall risk of infection is 30 per cent, but it is increased, notably as regards pasteurellosis, in the case of cat bite. Precise and simple rules concerning the prevention of this risk cannot easily be given, but it seems that the systematic antibiotic treatment initially prescribed has not clearly proved effective. Similarly, early sutures do not significantly increase the risk of infection.

[High performance system for intracellular analysis]

A device is described, which allows intracellular microelectrode recording. It also has the possibility of injecting current without modifying the band pass, of eliminating artefacts, of controlling microelectrode resistance and capacity, measuring electrical membrane constants and, if need be, of unplugging the microelectrode.