Androgen receptor expression is associated with adverse pathological features in ureteral but not in pelvicalyceal urothelial carcinomas of the upper urinary tract

PURPOSE

This study aims to determine the significance of androgen receptor (AR) expression in urothelial carcinoma of the upper urinary tract (UTUC).

METHODS

AR expression was assessed on tissue microarrays containing specimens of 737 patients with UTUC who underwent radical nephroureterectomy with curative intent. AR expression was correlated with clinical and pathological tumor features as well as recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS).

RESULTS

Overall, AR was expressed in 11 % of tumors. AR expression was significantly associated with tumor necrosis as well as sessile and multifocal tumor growth but not with RFS, CSS or OS. AR was detected nearly twice as often in tumors of the ureter than of the pelvicalyceal system (p = 0.005). Subgroup analyses showed that the significant associations of AR with unfavorable pathologic features were exclusively attributable to tumors located in the ureter. However, in both ureteral and pelvicalyceal tumors, AR status was independent of RFS, CSS and OS.

CONCLUSIONS

In this cohort of patients treated with RNU, AR expression was found in approximately 10 % of UTUCs, twice as often in ureteral than in pelvicalyceal tumors. While AR expression had no impact on postoperative prognosis, it was significantly associated with unfavorable pathologic features in ureteral tumors. Steroid hormone signaling might be relevant for future investigations of differences between ureteral and pelvicalyceal tumors.

Diagnosis and management of upper tract urothelial carcinoma

Urothelial carcinoma of the upper urinary tract (UTUC) is a rare disease, comprising only 5-10% of all urothelial malignancies. There is a paucity of high level evidence to guide treatment decisions due to the rarity of the disease. Through the creation of multi-institutional collaborations in recent years, our understanding of the natural history of UTUC and treatment algorithms has improved. However, our understanding of UTUC is mostly driven by extrapolation of findings and paradigms of urothelial carcinoma of the urinary bladder. With current imaging techniques and biopsy modalities, accurate diagnosis and staging remains difficult for this disease and prognostic models are limited in their ability to predict clinical outcomes. As such, over or under-treatment is common, highlighting the need for individualized treatment regimens which often require a multimodal approach. Endoscopic or radical resection represent the mainstays of treatment, while the role of intraluminal agents and systemic chemotherapy is yet to be clearly defined. Herein we review current concepts and management strategies as well as recent developments in UTUC.

Diabetes mellitus without metformin intake is associated with worse oncologic outcomes after radical nephroureterectomy for upper tract urothelial carcinoma

AIMS

Evidence suggests a detrimental effect of diabetes mellitus (DM) on cancer incidence and outcomes. To date, the effect of DM and its treatment on prognosis in upper tract urothelial carcinoma (UTUC) remains uninvestigated. We tested the hypothesis that DM and metformin use impact oncologic outcomes of patients treated with radical nephroureterectomy (RNU) for UTUC.

METHODS

Retrospective analysis of 2492 patients with UTUC treated at 23 institutions with RNU without neoadjuvant therapy. Cox regression models addressed the association of DM and metformin use with disease recurrence, cancer-specific mortality and any-cause mortality.

RESULTS

A total of 365 (14.3%) patients had DM and 194 (7.8%) patients used metformin. Within a median follow-up of 36 months, 663 (26.6%) patients experienced disease recurrence, 545 patients (21.9%) died of UTUC and 884 (35.5%) patients died from any cause. Diabetic patients who did not use metformin were at significantly higher risk of disease recurrence and cancer-specific death compared to non-diabetic patients and diabetic patients who used metformin. In multivariable Cox regression analyses, DM treated without metformin was associated with worse recurrence-free survival (HR: 1.44, 95% CI 1.10-1.90, p = 0.009) and cancer-specific mortality (HR: 1.49, 95% CI 1.11-2.00, p = 0.008).

CONCLUSIONS

Diabetic UTUC patients without metformin use have significantly worse oncologic outcomes than diabetics who used metformin and non-diabetics. The possible mechanism behind the impact of DM on UTUC biology and the potentially protective effect of metformin need further elucidation.

Tissue-based molecular markers for renal cell carcinoma

Since the introduction of targeted therapies in renal cell carcinoma (RCC), more individualized treatment options have become available. Molecular markers might support treatment planning due to more accurate individual risk stratification. Current molecular markers in RCC were reviewed to elucidate clinical impact and future perspectives. An English-language literature review of the Medline database (1990 to September 2010) of published data on tissue-based molecular markers and RCC was undertaken. Histological types, clinical and oncological behaviour are variable in renal masses. Molecular markers offer potential for additional information in tumour detection and diagnosis, prognostic and predictive values, as well as determination of therapeutic targets. Investigations on molecular biomarkers in RCC include hypoxia inducible factor (HIF-α), vascular endothelial growth factor (VEGF), carbonic anhydrase IX (CAIX), mammalian target of rapamycin (mTOR), survivin, B7-H1, p53, matrix metalloproteinases (MMP), Insulin-like growth factor II mRNA-binding protein 3 (IMP3), Ki-67, C-reactive protein (CRP), Vimentin, Fascin, platelet count, hemoglobin level and combinations of these factors. Although some markers offer promising results, utilization in daily practice is compromised due to limited specificity, predictive accuracy and tumour histology variablity. There is an imminent need for novel molecular markers that allow accurate histologic and biologic classification of RCC to improve upon current outcomes. It is very likely that a panel of molecular markers will be used to achieve a sufficient degree of certainty in order to guide clinical decisions. A large concerted effort is required to advance the field of RCC molecular marker through systematic discovery, verification, and validation.

Can contemporary targeted therapies provide clinically meaningful changes in renal cell carcinoma venous tumor thrombi?

390

Background: Renal cell carcinoma (RCC) tumor thrombus regression has been reported after treatment with contemporary targeted therapies. We sought to identify clinically meaningful changes in tumor thrombi in a series of patients treated with targeted therapies.

Methods: A University of Texas M. D. Anderson institutional database was queried for patients treated with targeted therapy while the primary RCC remained in situ. The subset of patients with a vascular tumor thrombus was assessed for radiographic responses of tumor thrombi. Pathology was obtained from a percutaneous biopsy or the surgical specimen. The modified Clavien system was used to grade complications within 12 months of surgery. Clinically meaningful changes were defined as changes in the anatomic thrombus level or changes altering surgical approach.

Results: A total of 178 patients were treated with targeted therapy with the primary tumor in situ. Venous tumor thrombus was present in 27% (n=48) and comprised our study cohort. The primary histology was clear cell in 75% of cases and 47/48 patients presented with metastatic disease. Prior to treatment, the tumor thrombus was within the renal vein (RV) in 60% (29/48-Level 0), the first 2 cm of the inferior vena cava in 10% (5/48-Level 1), > 2 cm above the RV in 21% (10/48-Level 2), at the level of the hepatics but below the diaphragm in 6% (3/48-Level 3), and above the diaphragm in 2% (1/48-Level 4). After a median duration of therapy of 2.75 months, clinically meaningful changes occurred in 25% of patients (12/48). Of these, progression occurred in 58% (7/12) while 42% (5/12) had regression of tumor thrombus. Fourteen patients (30%) received surgery after targeted therapy. Clavien categorized complications ≥ grade 3 occurred in 50% of surgical cases. No patient experienced a pulmonary embolism with treatment or during follow up.

Conclusions: To our knowledge,this is the largest reported series of RCC patients with an in-situ venous tumor thrombus treated with targeted therapy. Although no patient experienced a pulmonary embolism, the use of targeted therapy with the primary goal of obtaining clinically meaningful reductions in tumor thrombi does not appear to be a promising therapeutic option.

No significant financial relationships to disclose.

Loss of type III transforming growth factor-beta receptor expression is due to methylation silencing of the transcription factor GATA3 in renal cell carcinoma

Loss of transforming growth factor-beta receptor III (TbetaRIII) correlates with loss of transforming growth factor-beta (TGF-beta) responsiveness and suggests a role for dysregulated TGF-beta signaling in clear cell renal cell carcinoma (ccRCC) progression and metastasis. Here we identify that for all stages of ccRCC TbetaRIII expression is downregulated in patient-matched tissue samples and cell lines. We find that this loss of expression is not due to methylation of the gene and we define GATA3 as the first transcriptional factor to positively regulate TbetaRIII expression in human cells. We localize GATA3's binding to a 10-bp region of the TbetaRIII proximal promoter. We demonstrate that GATA3 mRNA is downregulated in all stages, of ccRCC, mechanistically show that GATA3 is methylated in ccRCC patient tumor tissues as well as cell lines, and that inhibiting GATA3 expression in normal renal epithelial cells downregulates TbetaRIII mRNA and protein expression. These data support a sequential model whereby loss of GATA3 expression through epigenetic silencing decreases TbetaRIII expression during ccRCC progression.

Adjuvant chemotherapy for high-risk upper tract urothelial carcinoma: Results from the Upper Tract Urothelial Carcinoma Collaboration

5075

Background: There is relatively little literature regarding the use of adjuvant chemotherapy following radical nephroureterectomy in the management of patients with upper tract urothelial carcinoma (UTUC). Our goal was to determine the incidence of receipt of adjuvant chemotherapy in high-risk patients and the ensuing effect on overall- and cancer-specific survival. Methods: Using an international collaborative database, we identified 1390 patients who underwent nephroureterectomy for non-metastatic UTUC between the years of 1992 and 2006. Of these, 542 (39%) patients were classified as high-risk (pT3N0, pT4N0, and/or lymph node positive). These patients were separated into two groups—those who did and did not receive adjuvant chemotherapy—and were stratified by gender, age group, performance status, tumor grade and stage. Cox proportional hazard modeling and Kaplan-Meier analyses were used to determine overall- and cancer-specific survival amongst the cohorts. Results: Of the high-risk patients, 121 (22%) received adjuvant chemotherapy. Adjuvant chemotherapy was more commonly administered in the context of increased tumor grade and stage (p < 0.001). Median survival in the entire cohort was 24 months (range 0–231 months). There was no significant difference in overall- or cancer-specific survival between those who did and did not receive adjuvant chemotherapy; however age, performance status, tumor grade, and tumor stage were significant predictors of both overall and cancer-specific survival. Conclusions: Adjuvant chemotherapy is infrequently utilized in the treatment of patients with high-risk UTUC after nephroureterectomy. Despite this, it appears that adjuvant chemotherapy confers minimal impact on overall- or cancer-specific survival in this group.

No significant financial relationships to disclose.

Intraluminal crystalloids are highly associated with prostatic adenocarcinoma on concurrent biopsy specimens

Prostatic crystalloids are intraluminal eosinophilic structures with variable size and shape. Their presence has been described in conjunction with the occurrence of prostatic adenocarcinoma (pCA). We herein report the association of crystalloids and pCA in a prospective trial utilizing an extended multi-site transrectal ultrasound-guided (TRUS) prostate biopsy protocol. Three hundred and forty-four consecutive patients were prospectively enrolled at the Dallas Veterans Administration Hospital from November 2002 to September 2003. Indications for biopsy included a prostate-specific antigen (PSA) > or =4 ng/ml and/or abnormal digital rectal exam. A single pathologist evaluated all biopsy cores and documented the presence or absence of significant histopathologic features. Univariate and multivariate logistic regression analysis were applied to test the association of these features with the presence of pCA on concurrent biopsy. Median number of core biopsies per patient was 12 (range 3-36). Overall cancer detection rate was 42.7%. pCA was diagnosed in 66 (81.5%) of 81 patients with crystalloids, 70 (69.3%) of 101 patients with high-grade prostatic intraepithelial neoplasia (HGPIN), and 32 (84.2%) of 38 patients with both HGPIN and crystalloids on biopsy. Multivariate analysis identified crystalloids (RR 4.53, 95% CI 2.30-8.88) and HGPIN (RR 3.20, 95% CI 1.84-5.57) as independent predictors of the presence of cancer on concurrent biopsy (P<0.001). In this prospective analysis, crystalloids were significantly associated with pCA on concurrent biopsy and more predictive of the presence of pCA than HGPIN. These findings suggest that the presence of crystalloids alone or in combination with HGPIN in prostate biopsies may be a more compelling indication for repeat biopsy than HGPIN alone.

Vaginal vault fixation and prevention of enterocele recurrence by high midline levator myorraphy: physical examination and questionnaire-based follow-up

OBJECTIVES

To assess outcome following a vaginal repair (high midline levator myorraphy, HMLM) for vaginal vault prolapse.

METHODS

Women were identified who had undergone HMLM between December 1995 and September 1998. A structured telephone interview consisting of 5 questions was conducted in all those who could be reached. The most recent results of physical examination, based on office records, were also collected.

RESULTS

Thirty-five of 47 women completed the interview (average age 71 years, mean time since surgery, 27.9 months). Five patients had developed recurrent prolapse requiring repair (anterior enterocele in 3, vault prolapse in 1, symptomatic cystocele in 1). Recurrent cystoceles were noted on examination in 7 women (5 grade 1, 2 grade 2). Overall, 17 women were extremely satisfied with the result (>90% satisfied); 6 were dissatisfied (<50%). Five women were noted to have transiently reduced unilateral ureteral drainage intraoperatively, and all cases were resolved after the removal or replacement of one of the levator myorraphy sutures. One patient required re-exploration for ureteral obstruction, which resolved after replacement of a suture and stenting.

CONCLUSIONS

Levator myorraphy is safe, effective, and easily taught. The rate of recurrent prolapse associated with this technique is similar to other techniques for vaginal vault fixation, but it avoids the disadvantages of an abdominal approach and is more technically straightforward to perform than sacrospinalis fixation.