Molecular mechanism of formation and destruction of a pseudo‑capsule in clear cell renal cell carcinoma

The process and molecular mechanisms underlying the formation and destruction of a pseudo-capsule (PC) in clear cell renal cell carcinoma (ccRCC) are poorly understood. In the present study, the PCs of surgical specimens from primary tumors and metastatic lesions in 169 patients with ccRCC, and carcinogen-induced ccRCC rat models were semi-quantified using the invasion of PC (i-Cap) score system. This was based on the relationship among the tumor, PC and adjacent normal tissue (NT) as follows: i-Cap 0, tumor has no PC and does not invade NT; i-Cap 1, tumor has a complete PC and does not invade into the PC; i-Cap 2, tumor with focal absences in the PC, which partially invades the PC but not completely through the PC; i-Cap 3, tumor crosses the PC and invades the NT; i-Cap 4, tumor directly invades the NT without a PC. The study suggested that PC formation was not observed without physical compression, and also revealed that tumor invasion into the PC was a prognostic factor for postoperative oncological outcomes. Higher i-Cap, Fuhrman grade and tumor size were independent poor prognostic factors for postoperative disease-free survival. mRNA expression arrays generated from carcinogen-induced ccRCC rat models were used to explore genes potentially associated with the formation and destruction of a PC. Subsequently, human ccRCC specimens were validated for four genes identified via expression array; the results revealed that collagen type 4A2, matrix metalloproteinase-7 and l-selectin were upregulated alongside the progression of i-Cap score. Conversely, endoglin was downregulated. In conclusion, the present study provides insights into the formation and destruction of a PC, and the results may aid the treatment and management of patients with ccRCC.

Depth of invasion to the bladder wall as a prognostic factor and its association with circulating cell-free DNA levels in patients with muscle-invasive bladder cancer

Background

Radical cystectomy (RC) is the standard surgical treatment for patients with muscle-invasive bladder cancer, but the prognosis is not favorable, and new prognostic factors need to be discovered. We investigated the potential of depth of invasion (DOI) as a prognostic factor in patients with muscle-invasive bladder cancer who underwent RC. Furthermore, we examined the association between preoperative levels of circulating cell-free DNA and DOI.

Materials and methods

We retrospectively reviewed patients who underwent RC between January 2007 and December 2017; those who received neoadjuvant chemotherapy were excluded. Depth of invasion was measured using hematoxylin-eosin-stained RC specimens.

Results

Of the 121 patients selected, 41 (33.9%) were eligible for analysis. The median follow-up period was 14 months and mean DOI was 17 mm (range, 2-75 mm). Long DOI (>17 mm) was significantly associated with shorter progression-free survival (hazard ratio, 14.5; 95% confidence interval, 3.9-53.97, p < 0.0001) and cancer-specific survival (hazard ratio, 18.97; 95% confidence interval, 4.04-88.99, p = 0.0002) compared with short DOI. Multivariate analysis revealed that DOI was an independent risk factor for cancer-specific survival. The levels of circulating cell-free DNA were significantly higher in patients with a longer DOI than in those with short DOI (65 vs. 20 ng/mL, respectively; p = 0.028).

Conclusions

Depth of invasion predicted with levels of circulating cell-free DNA and thus could be a useful prognostic factor.

Clinical Significance of the Highest Regional Bone Scan Index in Patients with Metastatic Castration-Resistant Prostate Cancer

Purpose

This study evaluated the clinical utility of the highest bone scan index (BSI), among other BSIs, for each bone metastatic site in patients with bone metastatic castration-resistant prostate cancer (bmCRPC).

Methods

Thirty patients, diagnosed with bmCRPC by bone scintigraphy, were included. Total BSI, the number of hot spots, and regional BSI on each hot spot from bone scintigraphy at diagnosis with bmCRPC were evaluated by VSBONE BSI®. Highest regional BSI was defined as the highest value among regional BSIs on each hot spot in each patient. Related factors to overall survival and skeletal-related events (SREs) were evaluated using the Cox proportional-hazards model.

Results

The median follow-up time from diagnosis with bmCRPC was 29.0 months. During this time, 24 patients died, of which 22 patients died from prostate cancer. On univariate analysis, alkaline phosphatase (ALP) [Hazard ratio (HR): 5.96, 95% confidence interval (CI): 2.05-17.3] and highest regional BSI (HR: 2.01, 95% CI: 1.17-7.05) had significant correlation with overall survival. On multivariate analysis, ALP (HR: 4.79, 95% CI: 1.61-14.2) had significant correlation with overall survival. SREs were found in eight patients. Only the highest regional BSI (HR: 9.99, 95% CI: 2.46-40.6) significantly correlated with SREs on univariate analysis.

Conclusion

Highest regional BSI may provide important information regarding prognosis and SREs in patients with bmCRPC.

Organ-Specific and Mixed Responses to Pembrolizumab in Patients with Unresectable or Metastatic Urothelial Carcinoma: A Multicenter Retrospective Study

To investigate the organ-specific response and clinical outcomes of mixed responses (MRs) to immune checkpoint inhibitors (ICIs) for unresectable or metastatic urothelial carcinoma (ur/mUC), we retrospectively analyzed 136 patients who received pembrolizumab. The total objective response rate (ORR) and organ-specific ORR were determined for each lesion according to the Response Evaluation Criteria in Solid Tumors version 1.1 as follows: (i) complete response (CR), (ii) partial response (PR), (iii) stable disease (SD), and (iv) progressive disease (PD). Most of the organ-specific ORR was 30−40%, but bone metastasis was only 5%. There was a significant difference in overall survival (OS) between responders and non-responders with locally advanced lesions and lymph node, lung, or liver metastases (HR 9.02 (3.63−22.4) p < 0.0001; HR 3.63 (1.97−6.69), p < 0.0001; HR 2.75 (1.35−5.59), p = 0.0053; and HR 3.17 (1.00−10.0), p = 0.049, respectively). MR was defined as occurring when PD happened in one lesion plus either CR or PR occurred in another lesion simultaneously, and 12 cases were applicable. MR was significantly associated with a poorer prognosis than that of the responder group (CR or PR; HR 0.09 (0.02−0.35), p = 0.004). Patients with bone metastases benefitted less. Care may be needed to treat patients with MR as well as patients with pure PD. Further studies should be conducted in the future.

Severe subcutaneous emphysema caused by small injury to the abdominal wall during robot-assisted laparoscopic radical prostatectomy

A 67-year-old man underwent RARP in the Trendelenburg position with pneumoperitoneum at 12 mmHg. Gradual elevation of End-tidal CO2(EtCO2) began, and extensive subcutaneous emphysema was recognized when EtCO2 reached 58 mmHg. After interruption of pneumoperitoneum, careful observation of the surgical field led to detect an injury of the abdominal wall of 1 cm in length, suggesting the cause of severe subcutaneous emphysema. The injury was repaired and RARP was terminated without any cardiovascular problems. Attention should be paid that even minor abdominal wall injury could lead to severe subcutaneous emphysema which may cause respiratory or cardiovascular problems during laparoscopic surgeries.

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Severe subcutaneous emphysema with severe hypercarbia occurred during RARP.

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A small but deep abdominal wall injury cause severe subcutaneous emphysema.

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Minor abdominal wall injury lead to subcutaneous emphysema, which could be fatal.

External validation of a genitourinary cancer-specific prognostic scoring system to predict survival for patients with bone metastasis (modified B-FOM scoring model): Comparison with other scoring models in terms of accuracy

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Bone is one of major metastatic site in patients with genitourinary (GU) cancer.

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Accurately predicting survival of patients with bone metastasis (BM) is essential.

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This external validation study proved high predictive accuracy of B-FOM score.

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B-FOM score is a simple scoring model based on five prognostic factors.

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B-FOM score is higher accurate tool comparing to other previously reported scores.

Objective

We previously developed genitourinary (GU) cancer-specific scoring system for prediction of survival in patients with bone metastasis (the Bone-Fujimoto-Owari-Miyake [B-FOM] scoring model) based on five prognostic factors: the type of primary tumor (prostate cancer (PCa) vs renal cell carcinoma (RCC) and PCa vs urothelial carcinoma (UC)), poor performance status (PS), visceral metastasis, high Glasgow-prognostic score (GPS), elevated neutrophil-to-lymphocyte ratio (NLR). The aim of this study was to externally validate and further improve the performance of the B-FOM score.

Methods

The external validation cohort comprised 309 patients with GU cancer with bone metastasis from multiple institutions. Clinical factors were analyzed using Kaplan-Meier method and COX regression hazard model. Performance of a modified B-FOM score was compared to that of other scoring models by the Kaplan-Meier method and the area under the curve (AUC) of receiver operating characteristic curves.

Results

The median follow-up period of development and validation cohort were 25 and 17 months, respectively. Kaplan-Meier curve demonstrated that the type of primary tumor (RCC and UC vs PCa), poor PS, presence of visceral metastasis, high GPS, elevated NLR were significantly associated with shorter cancer-specific survival. Risk groups were successfully stratified by the modified B-FOM score classification. Moreover, the AUC of the modified B-FOM scoring model for predicting mortality at 6, 12, and 24 months were 0.895, 0.856, and 0.815, respectively, which were the highest among evaluated models.

Conclusions

The B-FOM scoring model is a simple and accurate prediction tool. By using this scoring model at the time of the diagnosis of bone metastasis in patients with GU cancers, an individualized optimal treatment strategy can be selected.

Inhibitory Effect of Orally Administered 5-Aminolevulinic Acid on Prostate Carcinogenesis in the FVB-Transgenic Adenocarcinoma of a Mouse Prostate (FVB-TRAMP) Model

Background:

5-aminolevulinic acid (5-ALA) is a constituent of mitochondrial electron carriers, heme and cytochrome c, which are crucial for aerobic energy metabolism and cell apoptosis. We investigated the chemopreventive efficacy of 5-ALA against prostate cancer using the FVB-transgenic adenocarcinoma of mouse prostate (FVB-TRAMP) model.

Methods:

Samples were collected from 24 FVB-TRAMP mice at 12 and 20 weeks of age (named the first and second sets, respectively). Sixteen mice (from the first set) were randomly allocated into 3 treatment groups: 1) control (no treatment), 2) low dose of 5-ALA (30 mg/kg/day), and 3) high dose of 5-ALA (300 mg/kg/day). Similarly, 8 mice were divided into 2 treatment groups: 1) control and 2) high dose of 5-ALA (300 mg/kg/day). 5-ALA was orally administered to mice before cancer onset, from 6 weeks of age.

Results:

In the control group, prostate cancer was pathologically detected in 33 and 50 % of mice at 12 and 20 weeks, respectively, while 25% of 12-week old mice in the low-dose group were affected and none of the high-dose group mice developed prostate cancer. Immunohistochemical analysis showed higher expression of cytochrome c oxidase subunit 4 (COX4) in the prostate gland of the high-dose group compared to the control (P = 0.018). Similarly, enzyme-linked immunosorbent assay using lysed prostate tissue revealed higher amounts of cytochrome c in the prostate of the high-dose group compared to the control (P = 0.021). Furthermore, western blot analysis showed higher level of cleaved caspase-3 in mice in the high-dose group diagnosed with high-grade prostatic intraepithelial neoplasia.

Conclusion:

Our results suggest that oral 5-ALA may support the functional expression of mitochondrial cytochrome c and COX4, leading to caspase 3-dependent apoptosis in carcinogenesis in FVB-TRAMP mice. Future clinical studies are warranted to confirm the chemopreventive value of 5-ALA in prostate carcinogenesis.

Periprostatic fat thickness quantified by preoperative magnetic resonance imaging is an independent risk factor for upstaging from cT1/2 to pT3 in robot-assisted radical prostatectomy

OBJECTIVES

To analyze the correlation between periprostatic fat thickness on multiparametric magnetic resonance imaging and upstaging from cT1/2 to pT3 in robot-assisted radical prostatectomy.

METHODS

We retrospectively evaluated data from men with cT1/2 prostate cancer treated with robot-assisted radical prostatectomy at Nara Prefecture General Medical Center, Nara, Japan, between March 2013 and December 2017. We calculated the periprostatic fat thickness and subcutaneous thickness from preoperative multiparametric magnetic resonance imaging. We divided the cohort into two groups for analysis. Group 1 included patients upstaged from clinical to pathological stage, whereas group 2 included those without upstaging.

RESULTS

Data on 220 patients meeting the inclusion criteria were included in the analysis. A total of 36 patients were upstaged from clinical T1 or T2 to pathological T3, whereas 184 patients were not upstaged. The upstaging was associated with prostate volume, Gleason score, prostate-specific antigen density, periprostatic fat thickness, Prostate Imaging Reporting and Data System score based on univariate analysis. Multivariate analysis showed prostate volume (P = 0.03, odds ratio 0.958, 95% confidence interval 0.921-0.996), Gleason score (P = 0.022, odds ratio 2.676, 95% confidence interval 1.153-6.213) and periprostatic fat thickness (P = 0.004, odds ratio 1.26, 95% confidence interval 1.079-1.471) as independent risk factors of upstaging.

CONCLUSIONS

Prostate volume, Gleason score and periprostatic fat thickness on multiparametric magnetic resonance imaging are significantly associated with and independent risk factors for upstaging from cT1/2 to pT3 in patients undergoing robot-assisted radical prostatectomy.

Simple suturing of the bladder neck muscle layer at the vesicourethral anastomosis site to the dorsal vein complex during anterior reconstruction led to a better postoperative urinary continence after robot-assisted laparoscopic prostatectomy

OBJECTIVES

To elucidate whether a modified technique for anterior reconstruction could improve urinary continence after robot-assisted laparoscopic radical prostatectomy (RALP).

METHODS

Among 325 consecutive patients who underwent RALP at our hospital, 297 patients were included in this retrospective study, who had complete records including the status of postoperative urinary continence. Among these 297 patients, 194 underwent anterior reconstruction by suturing the lateral bladder wall to the arcus tendineus of the pectineal fascia without fixation of the vesicourethral anastomosis site to the dorsal vein complex (DVC) (lateral-suture group). In the remaining 103 patients, simple suturing of the bladder neck muscle layer at the vesicourethral anastomosis site with DVC to immobilize the vesicourethral anastomosis site (immobilized group) was performed. Those who did not required a pad was defined as continent.

RESULTS

Operative and console times were significantly shorter in the immobilized group (242 vs. 268 min; p = 0.03, and 174 vs. 203 min; p = 0.009, respectively). Although there was no significant difference between the groups regarding the recovery of urinary continence within 3 months after RALP (21 vs. 22% at 1 month; p = 0.77, and 54 vs. 60% at 3 months; p = 0.33, respectively), more patients achieved urinary continence in the immobilized group than lateral-suture group after 6 months (71 vs. 83% at 6 months; p = 0.03 and 82 vs. 96% at 12 months; p = 0.001, respectively).

CONCLUSIONS

Simple suture of the bladder neck muscle layer at the vesicourethral anastomosis site to DVC led to a better urinary continence status 6 months or later after RALP.

Clinical Impact of Sarcopenia and Inflammatory/Nutritional Markers in Patients with Unresectable Metastatic Urothelial Carcinoma Treated with Pembrolizumab

Sarcopenia is a muscle loss syndrome known as a risk factor of various carcinomas. The impact of sarcopenia and sarcopenia-related inflammatory/nutritional markers in metastatic urothelial carcinoma (mUC) treated with pembrolizumab was unknown, so this retrospective study of 27 patients was performed. Psoas muscle mass index (PMI) was calculated by bilateral psoas major muscle area at the L3 with computed tomography. The cut-off PMI value for sarcopenia was defined as ≤6.36 cm²/m² for men and ≤3.92 cm²/m² for women. Neutrophil-to-lymphocyte ratio (NLR) ≥ 4.0 and sarcopenia correlated with significantly shorter progression-free survival (PFS) (hazard ratio (HR) 3.81, p = 0.020; and HR 2.99, p = 0.027, respectively). Multivariate analyses identified NLR ≥ 4.0 and sarcopenia as independent predictors for PFS (HR 2.89, p = 0.025; and HR 2.79, p = 0.030, respectively). Prognostic nutrition index < 45, NLR ≥ 4.0 and sarcopenia were correlated with significantly worse for overall survival (OS) (HR 3.44, p = 0.046; HR 4.26, p = 0.024; and HR 3.92, p = 0.012, respectively). Multivariate analyses identified sarcopenia as an independent predictor for OS (HR 4.00, p = 0.026). Furthermore, a decrease in PMI ≥ 5% in a month was an independent predictor of PFS and OS (HR 12.8, p = 0.008; and HR 6.21, p = 0.036, respectively). Evaluation of sarcopenia and inflammatory/nutritional markers may help in the management of mUC with pembrolizumab.

Urinary nerve growth factor can predict therapeutic efficacy in children with monosymptomatic nocturnal enuresis

AIM

To determine the urinary levels of nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) in children with monosymptomatic nocturnal enuresis (MNE) and evaluate whether these factors can be used as biomarkers for the treatment outcome.

METHODS

NGF and BDNF levels were measured and compared in 38 children (28 boys and 10 girls) with MNE and 25 children (18 boys and 7 girls) with no urinary symptoms were assessed. The mean ages in the patient and control groups were 9 and 10 years, respectively (P = .49). The patients were treated with either alarm or desmopressin therapy.

RESULTS

The urinary NGF/creatinine and BDNF/creatinine ratios were significantly higher in the patient group than in the control group (P = .0003 and P = .0095, respectively). NGF and BDNF levels showed a significant positive correlation (P = .0020, r = 0.40). With respect to the degree of response, 19 patients (50%) showed complete response (CR) or partial response (PR), and 19 patients (50%) showed nonresponse (NR). The urinary NGF/creatinine and BDNF/creatinine ratios were significantly higher in the NR group than in the CR and PR groups (P = .0003 and P = .0003, respectively).

CONCLUSIONS

Urinary NGF/creatinine and BDNF/creatinine ratios were significantly higher in children with MNE than in healthy controls. Urinary NGF/creatinine can be predictive factors of a poor treatment outcome in children with MNE.

Rapidly progressing programmed cell death 1 inhibitor-related pneumonitis in a hemodialytic patient with metastatic renal cell carcinoma

Introduction

The efficacy and safety of nivolumab for patients receiving hemodialysis remain uncertain. Herein, we report a patient receiving a maintenance hemodialysis with life‐threatening interstitial pneumonitis caused by nivolumab for metastatic renal cell carcinoma.

Case presentation

A 61‐year‐old man with chronic kidney disease after nephrectomy for renal cell carcinoma was started on hemodialysis. Six months later, he developed multiple bone metastases and received pazopanib. Pazopanib, however, was not effective. We then switched to nivolumab as second‐line treatment. Five days after the first administration of nivolumab, he complained of respiratory discomfort and malaise with oxygen desaturation. Chest computed tomography demonstrated diffuse areas of ground glass opacity in both lung fields, suggesting programmed cell death 1 inhibitor‐related pneumonitis. Prompt corticosteroid therapy led to improvement of the symptoms.

Conclusion

Caution should be exercised on the administration of nivolumab to hemodialysis patients due to the risk of interstitial pneumonitis.

Postoperative cystogram findings predict recovery of urinary continence after robot-assisted laparoscopic radical prostatectomy

OBJECTIVES

To assess the association between postoperative cystogram findings and subsequent outcomes on urinary continence after robot-assisted laparoscopic radical prostatectomy (RALP).

METHODS

A retrospective review of 250 consecutive patients who were observed for at least 12 months after RALP. The postoperative cystogram findings examined were: the location of the bladder neck, degree of bladder abnormalities, and presence of outflow of contrast medium into the urethra during the filling phase of cystography. The continence status based on pad usage was recorded. Those who required no pad or only a safety pad were defined as continent.

RESULTS

Patients with a bladder neck location above the middle of the pubic symphysis height exhibited significantly higher continence levels than those with a lower bladder neck location at both postoperative 3 and 12 months (P < 0.0001 and P = 0.0002, respectively). The higher a bladder neck was located, the earlier the urinary continence was achieved after RALP (P < 0.0001). Patients without contrast outflow into the urethra during cystogram demonstrated a significantly more favorable continence status at the 3-month follow-up (P = 0.004). Patients without bladder abnormalities on postoperative cystogram demonstrated a significantly more favorable continence status at the 12-month follow-up than those with bladder abnormalities (P = 0.01).

CONCLUSIONS

Postoperative cystogram findings may predict recovery of urinary continence after RALP.

Properties of the peptides liberated from rice protein in sokujo-moto

In the supernatant of sokujo-moto, a high level of acid carboxypeptidase (ACP) activity and a large amount of peptides were observed, however, the amount of free amino acids liberated was small. In order to determine why these peptides were not hydrolyzed to any significant degree by the ACP, the properties of the peptides in sokujo-moto were investigated in this study. Peptides were fractionated from sokujo-moto by ion exchange column chromatography. ACP purified from rice-koji (rice overgrown with Aspergillus oryzae) was allowed to react with the peptides, and it was found that they were not hydrolyzed to any significant degree by the enzyme. Gel filtration chromatography was performed to ascertain the molecular size distribution of the peptides in sokujo-moto, and it was revealed that they were of low molecular sizes; molecular size: mainly in the range of 200-400, and chain length: 2-3. ACP purified from rice-koji was also allowed to react with various synthetic peptides, and it was found that ACP of rice-koji could not rapidly hydrolyze low-molecular-size peptides, such as dipeptides or tripeptides. Acid protease (AP) purified from rice-koji released peptides of molecular sizes mainly in the range of 300-600 or above from rice protein under acidic conditions (pH 3.6; the pH of sokujomoto). When AP and ACP were allowed to act at the same time on rice protein, mainly low-molecular-size peptides (molecular sizes mainly in the range of 200-400) were produced. From these results, it was estimated that AP released peptides with molecular sizes mainly in the range of 300-600 or above from rice protein and ACP degraded the relatively higher molecular size peptides among them to lower molecular size peptides; consequently only low-molecular-size peptides with molecular sizes mainly in the range of 200-400 were released in the supernatant of sokujo-moto.

Properties of TCA-Insoluble peptides in Kimoto (traditional seed mash for sake brewing) and conditions for liberation of the peptides from rice protein

It was found that a large amount of TCA (trichloroacetic acid)-insoluble peptides were liberated into the supernatant of kimoto on the 7th-10th day of mashing. These TCA-insoluble peptides had five polypeptide groups (12, 21, 31, 38, and 55 kDa) on SDS-PAGE (SDS-polyacrylamide gel electrophoresis), and a large amount of high molecular weight peptides, higher than 10,000, were observed upon gel filtration chromatography using TSKgel G2000swxl (Tosoh Co.). Four of these peptides (12, 21, 31, and 38 kDa on SDS-PAGE) appeared specifically in kimoto, and were not detected at all either in sokujo-moto or in the main mash for sake brewing. These TCA-insoluble peptides were fractionated from the supernatant of kimoto on the 9th day, and it was revealed that free amino acids were produced abundantly from them in the presence of the enzyme of rice-koji. Therefore, it was assumed that the peptides are related to the abundant production of free amino acids in kimoto. For the liberation of these TCA-insoluble peptides from rice protein, the enzyme of rice-koji was indispensable. The enzyme liberating the TCA-insoluble peptides from rice protein was purified from rice-koji, and was presumed to be identical with acid protease (AP) of rice-koji. The presence of a high concentration of glucose (higher than 20%) was also indispensable for the liberation of the TCA-insoluble peptides. Furthermore, it was revealed that the peptides were liberated from rice protein under a limited pH of around 4.5.

Influence of amino acid content in seed mash on peptide uptake by yeast cells in main mash in sake brewing process

It was found that the peptide content of the main mash in the sake brewing process, seeded with kimoto, was higher than in that seeded with sokujo-moto, although the peptide content in kimoto was lower than in sokujo-moto. We investigated the underlying reasons. As a result, we found that the high concentration of free amino acids originating from kimoto decreased the peptide uptake ability of yeast cells in the main mash seeded with kimoto.

Resolution and complementation of the labile L-leucine-pyruvate transaminase. An intermediate during enzyme formation under nitrogen starvation in Gluconobacter suboxydans

L-Leucine-pyruvate transaminase (mol. wt. 70 000) in Gluconobactersuboxydans synthesized during nitrogen starvation contained a labile form which changed to the stable one later. The labile enzyme (mol. wt. 70 000) dissocated to the two proteinaceous components: a cationic one (mol. wt. 10 000--20 000) and an anionic one (mol. wt. 50 000--60 000), during column chromatography on DEAE-cellulose. The enzyme activity was reconstructed when they were mixed. The reconstructed enzyme had almost the same molecular size and enzymatic properties as the labile and the native stable enzymes.