Prostate Cancer, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Prostate Cancer include recommendations regarding diagnosis, risk stratification and workup, treatment options for localized disease, and management of recurrent and advanced disease for clinicians who treat patients with prostate cancer. The portions of the guidelines included herein focus on the roles of germline and somatic genetic testing, risk stratification with nomograms and tumor multigene molecular testing, androgen deprivation therapy, secondary hormonal therapy, chemotherapy, and immunotherapy in patients with prostate cancer.

Comparison of one-year efficacy and safety of atorvastatin versus lovastatin in primary hypercholesterolemia. Atorvastatin Study Group I

This double-blind study to evaluate long-term efficacy and safety of atorvastatin was performed in 31 community- and university-based research centers in the USA to directly compare a new 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor (reductase inhibitor) to an accepted drug of this class in patients with moderate hypercholesterolemia. Participants remained on a cholesterol-lowering diet throughout the study. One thousand forty-nine patients were randomized to receive atorvastatin 10 mg, lovastatin 20 mg, or placebo. At 16 weeks the placebo group was randomized to either atorvastatin or lovastatin treatment. At 22 weeks, patients who had not met low-density lipoprotein (LDL) cholesterol target levels doubled the dose of reductase inhibitor. Efficacy evaluation was mean percent change from baseline in LDL cholesterol, triglycerides, total cholesterol, high-density-lipoprotein cholesterol, and apolipoprotein B (apoB). Safety profiles as determined by change from baseline in laboratory evaluations, ophthalmologic parameters, and reporting of adverse events were similar for the 2 reductase inhibitors. After 52 weeks, the atorvastatin group maintained a significantly greater reduction in LDL cholesterol (-37% vs -29%), triglyceride (-16% vs -8%), total cholesterol (-27% vs -21%), and apoB (-30% vs -22%) (p <0.05). More patients receiving atorvastatin achieved LDL cholesterol target levels than did lovastatin patients (78% vs 63%, respectively), particularly those with coronary heart disease (37% vs 11%, respectively). Atorvastatin is highly effective and well tolerated in patients with primary hypercholesterolemia with no increased risk of adverse events.

NCCN Guidelines Insights: Prostate Cancer, Version 1.2021

The NCCN Guidelines for Prostate Cancer address staging and risk assessment after a prostate cancer diagnosis and include management options for localized, regional, and metastatic disease. Recommendations for disease monitoring and treatment of recurrent disease are also included. The NCCN Prostate Cancer Panel meets annually to reevaluate and update their recommendations based on new clinical data and input from within NCCN Member Institutions and from external entities. This article summarizes the panel’s discussions for the 2021 update of the guidelines with regard to systemic therapy for metastatic castration-resistant prostate cancer.

Low-dose combination therapy with colesevelam hydrochloride and lovastatin effectively decreases low-density lipoprotein cholesterol in patients with primary hypercholesterolemia

BACKGROUND

Colesevelam hydrochloride is a novel, lipid-lowering agent that binds bile acids with high affinity. A multicenter, randomized, double-blind, placebo-controlled, parallel-design study was conducted to assess the efficacy and tolerability of combination low-dose colesevelam and lovastatin treatment in patients with primary hypercholesterolemia.

HYPOTHESIS

Combination therapy with low doses of colesevelam and lovastatin decreases low density (LDL) cholesterol with minimal adverse events.

METHODS

Following a 4- to 6-week dietary lead in, 135 patients were randomized into five groups for a 4-week treatment period: placebo, colesevelam 2.3 g at dinner, lovastatin 10 mg at dinner, the combination of colesevelam and lovastatin given at dinner (dosed together), and combination treatment with colesevelam given at dinner and lovastatin administered at bedtime (dosed apart).

RESULTS

Combination colesevelam and lovastatin treatment decreased LDL cholesterol by 34% (60 mg/dl, p < 0.0001) and 32% (53 mg/dl, p < 0.0001) when colesevelam and lovastatin were dosed together or dosed apart, respectively. Both combination therapies were superior to either agent alone (p < 0.05). Decreases in LDL cholesterol exceeded the combined decreases observed for colesevelam alone (13 mg/dl, 7%) and lovastatin alone (39 mg/dl, 22%). Both combination treatments reduced total cholesterol by 21% (p < 0.0001) and apolipoprotein B by 24% (p < 0.0001). Neither combination treatment significantly altered high-density lipoprotein cholesterol or triglycerides. Adverse side effects were not significantly different among randomized groups.

CONCLUSIONS

Combination colesevelam and lovastatin was efficacious and well tolerated, resulting in additive decreases in LDL cholesterol levels whether or not both agents were administered simultaneously.

Efficacy and tolerability of fluvastatin extended-release delivery system: a pooled analysis

BACKGROUND

At high doses, the pharmacokinetics of fluvastatin immediate-release (IR) are nonlinear, possibly due to saturation of hepatic uptake. Fluvastatin delivery to the liver in a slower but sustained fashion would be expected to avoid hepatic saturation without elevating systemic drug levels.

OBJECTIVE

This pooled analysis compared the efficacy and tolerability of extended-release (XL) 80-mg and IR 40-mg formulations of fluvastatin in lowering low-density lipoprotein cholesterol (LDL-C) and triglyceride (TG) levels and raising high-density lipoprotein cholesterol (HDL-C) levels in patients with hypercholesterolemia.

METHODS

Data were pooled from 3 double-blind, randomized, active-controlled, multicenter, parallel-group studies that compared changes in lipid and apolipoprotein levels with fluvastatin XL 80 mg at bedtime (HS) with changes in fluvastatin IR 40 mg HS or BID in patients aged > or =18 years with primary hypercholesterolemia (consistently elevated LDL-C level [> or =160 mg/dL] and plasma TG levels < or =400 mg/dL). The primary efficacy variable was percent change in LDL-C from baseline.

RESULTS

The pooled analysis provided an intent-to-treat efficacy study population of 1674 patients. At 4 weeks, fluvastatin XL 80 mg HS reduced LDL-C levels by a mean of 36.3% (median 38%), significantly greater than a mean reduction of 25.9% (median 27%) seen with fluvastatin IR 40 mg HS, and an incremental additional mean reduction in LDL-C of 10.4% (P < 0.001). At 4 and 24 weeks, fluvastatin XL 80 mg HS provided an LDL-C reduction equivalent to fluvastatin IR 40 mg BID (P < 0.001 for noninferiority). Significant, dose-related changes in HDL-C, LDL-C:HDL-C ratio, total cholesterol, TG, and apolipoprotein A-I and apolipoprotein B levels also occurred. Mean HDL-C level increased by 8.7% and median TG level decreased by 19% with fluvastatin XL 80 mg HS (P < 0.001 and P < 0.05 vs fluvastatin IR 40 mg HS, respectively). Maximum mean increases in HDL-C level (21%) and median decreases in TG level (31%) with fluvastatin XL 80 mg HS occurred in patients with type IIb dyslipidemia and the highest baseline TG. Adverse events were mild, with similar frequency in all treatment groups.

CONCLUSIONS

Once-daily administration of fluvastatin XL 80 mg provides enhanced efficacy with an additional 10.4% reduction in LDL-C levels compared with fluvastatin IR 40 mg HS, and superior increases in HDL-C levels, particularly in patients with elevated TG levels (P < 0.05 vs fluvastatin IR 40 mg HS). Fluvastatin XL 80 mg HS has a good tolerability profile and is effective as starting and maintenance lipid-lowering treatment in patients with type II hypercholesterolemia.

The role of membrane protein sulfhydryl groups in hydrogen peroxide-mediated membrane damage in human erythrocytes

The formation of spectrin-hemoglobin complex following treatment of red cells with hydrogen peroxide (H2O2) has previously been shown to be associated with alterations in cell shape, decreased membrane deformability and increased recognition of modified cells by anti-IgM immunoglobulin in a phagocytic assay by monocytes. Prior treatment with carbon monoxide completely inhibited the H2O2-associated membrane changes, indicating a role for oxidized hemoglobin in the complex formation. Also, in a cell-free system, blockage of sulfhydryl (SH) groups on purified spectrin by N-ethylmaleimide significantly reduced the complex formation, suggesting a role for SH groups of spectrin in crosslinking process. The present study was undertaken to examine the role of SH blockade by N-ethylmaleimide on intact red cells undergoing oxidative damage. Pretreatment of erythrocytes with N-ethylmaleimide at concentrations ranging from 0.1 to 0.2 mM resulted in decreased lipid peroxidation and spectrin hemoglobin crosslinking. Moreover, pretreatment with N-ethylmaleimide resulted in less marked alterations in cell shape and membrane deformability as well as reduced recognition of peroxidized cells by antiglobulin serum. N-Ethylmaleimide treatment had no effect on methemoglobin formation. Studies with 14C-labeled N-ethylmaleimide showed that over 50% of N-ethylmaleimide was incorporated into spectrin. Pretreatment of cells with higher concentrations of N-ethylmaleimide (over 0.2 mM) was associated with membrane dysfunction independent of H2O2. These results imply that blocking of reactive SH groups leads to reduced interaction of spectrin with oxidized globin. These data, along with our prior observations, indicate that SH groups on spectrin play an important role in hemoglobin oxidation-induced formation of spectrin-hemoglobin complex and the resultant deleterious effects on membrane properties.

The Genitourinary Pathology Society Update on Classification of Variant Histologies, T1 Substaging, Molecular Taxonomy, and Immunotherapy and PD-L1 Testing Implications of Urothelial Cancers

The Genitourinary Pathology Society (GUPS) undertook a critical review of the recent advances in bladder cancer focusing on important topics of high interest for the practicing surgical pathologist and urologist. This review represents the second of 2 manuscripts ensuing from this effort. Herein, we address the effective reporting of bladder cancer, focusing particularly on newly published data since the last 2016 World Health Organization (WHO) classification. In addition, this review focuses on the importance of reporting bladder cancer with divergent differentiation and variant (subtypes of urothelial carcinoma) histologies and the potential impact on patient care. We provide new recommendations for reporting pT1 staging in diagnostic pathology. Furthermore, we explore molecular evolution and classification, emphasizing aspects that impact the understanding of important concepts relevant to reporting and management of patients.

Long-term care personnel assess their attitudes and knowledge of the older adult

The purpose of this study was to compare long-term care employees' attitude and knowledge about myths of ageing and normal age changes, before and after exposure to formal educational sessions. The researchers investigated if there was a difference in knowledge level and change in attitudes of long-term care employees after educational sessions. The subjects for this study were defined as persons who had any contact with the residents at St Charles Care Center. The final data set used in the analysis contained 84 observations. Each participant attended three 1-hour classes which consisted of simulation of handicaps, normal age-related changes, and myths and realities of ageing. Overall, there was a significant increase in knowledge from the pre-test to the post-test. The study also tested for a negative (anti-aged) bias attitude and a positive (falsely pro-aged) bias attitude among the individuals. At the end of the study there was still a slight negative biased attitude towards ageing. The data suggest that continuing education is an effective means of influencing the knowledge and attitudes of personnel in long-term care facilities. Recommendation for future research should be that this study be replicated in another long-term care facility with the addition of a job satisfaction tool.

Efficacy and safety of an extended-release formulation of fluvastatin for once-daily treatment of primary hypercholesterolemia

An extended-release (ER) formulation of fluvastatin 80 mg has been developed for once-daily treatment of primary hypercholesterolemia in patients who require fluvastatin dosages of > 40 mg/day. The study aimed to determine the efficacy and safety of the new formulation and to assess the dose response over the range of 40 to 160 mg/day. After a 4-week placebo/dietary run-in period, 123 patients with primary hypercholesterolemia (Fredrickson type IIa/IIb) were randomized to receive fluvastatin 40, 80, or 160 mg/day for 6 weeks. The 40 mg/day dosage was administered as the marketed immediate-release (IR) capsule and the 80 mg/day dosage as 1 80-mg ER tablet. Patients receiving 160 mg/day were administered 80 mg/day (1 ER tablet) for the first 2 weeks, followed by 160 mg/day (2 ER tablets) for the remainder of the study. All doses were administered once daily at bedtime. The results showed a linear dose-response relation. Doubling the fluvastatin dosage resulted in a 6% greater mean percent reduction in low-density lipoprotein cholesterol (40 mg IR -29%; 80 mg ER -35%; 160 mg ER -41%). In the 160-mg ER group, 62% of patients achieved > or = 40% reductions in low-density lipoprotein cholesterol compared with 32% and 10% of patients in the 80-mg ER and 40-mg IR groups, respectively. Dose ordering of the response was also observed for the other lipid parameters. Fluvastatin ER was well tolerated. Thus, the new ER formulation of fluvastatin was effective and well tolerated in the once-daily treatment of primary hypercholesterolemia.

Effect of omega-3-acid ethyl esters on steady-state plasma pharmacokinetics of atorvastatin in healthy adults

BACKGROUND

Prescription omega-3-acid ethyl esters (P-OM3) have been used as adjunctive therapy to statin drugs in patients with mixed hyperlipidemia.

OBJECTIVE

To assess the effect of concomitant administration of 4 g P-OM3 on the steady-state pharmacokinetics of the maximum recommended daily dose of atorvastatin (80 mg) in healthy volunteers.

METHODS

This was a randomized, open-label, repeated-dose, two-way crossover, drug interaction study of two treatments: 4 g of P-OM3 with 80 mg atorvastatin daily or 80 mg atorvastatin daily, each administered for 14 days under fasting conditions to 50 healthy adults.

MAIN OUTCOME MEASURES

The primary determinants of drug interaction were the ln-transformed area under the plasma concentration versus time curve (AUCtau) and maximum measured steady-state plasma concentration (C(max,ss)) over the final 24 h dosing interval (day 14) for atorvastatin and 2-hydroxyatorvastatin. Safety assessment included clinical laboratory evaluations and adverse event reporting.

RESULTS

The extent and rate of exposure (AUCtau, C(max,ss)) to atorvastatin and its active metabolites following daily administration of P-OM3 with atorvastatin (80 mg) were similar to those following the administration of atorvastatin (80 mg) alone. Both treatments were well tolerated.

CONCLUSIONS

After 14 days of dosing, the rate and extent of exposure (AUCtau, C(max,ss)) to atorvastatin and its active metabolites were similar with both treatments, indicating that administration of P-OM3 did not affect the steady-state bioavailability of orally administered atorvastatin.

Electrochemistry of Ruthenium Ammine Complexes

The electrochemistry of ruthenium(III) penta- and tetraammine chloro complexes has been investigated. In each case, the ruthenium(III) species was found to undergo an initial one electron reduction step, followed by hydrolysis of the chloride(s) in the ruthenium(II) product. The rate constants for the substitution steps were evaluated by cyclic voltammetry. An aqueous 0.30 M methane sulfonate electrolyte of pH 2.0 was used at 25 °C.Values for the reversible "E1/2" (V υs. SCE) and first order rate constants for the (stepwise) replacement of the Cl− are: Ru(NH3)5Cl+, −0.282 V and 17 s−1; cis-Ru(NH3)4Cl2+, −0.328 V, 80 s−1, and 5 s−1; trans-Ru(NH3)4Cl2+, −0.412 V, 2 s−1, and 0.4 s−1.The electrochemistry of Ru(NH3)5SO22+was also investigated. In a 0.10 M CH3SO3H – 0.20 M CH3SO3Na electrolyte the ruthenium(II) species was found to undergo an initial one electron oxidation step with "E1/2" = +0.50 V, followed by a slow hydrolysis of the SO2 in the ruthenium(III) product with k = 2.4 × 10−2 s−1 at 25 °C.

The Genitourinary Pathology Society Update on Classification and Grading of Flat and Papillary Urothelial Neoplasia With New Reporting Recommendations and Approach to Lesions With Mixed and Early Patterns of Neoplasia

The Genitourinary Pathology Society (GUPS) undertook a critical review of the recent advances in bladder neoplasia with a focus on issues relevant to the practicing surgical pathologist for the understanding and effective reporting of bladder cancer, emphasizing particularly on the newly accumulated evidence post-2016 World Health Organization (WHO) classification. The work is presented in 2 manuscripts. Here, in the first, we revisit the nomenclature and classification system used for grading flat and papillary urothelial lesions centering on clinical relevance, and on dilemmas related to application in routine reporting. As patients of noninvasive bladder cancer frequently undergo cystoscopy and biopsy in their typically prolonged clinical course and for surveillance of disease, we discuss morphologies presented in these scenarios which may not have readily applicable diagnostic terms in the WHO classification. The topic of inverted patterns in urothelial neoplasia, particularly when prominent or exclusive, and beyond inverted papilloma has not been addressed formally in the WHO classification. Herein we provide a through review and suggest guidelines for when and how to report such lesions. In promulgating these GUPS recommendations, we aim to provide clarity on the clinical application of these not so uncommon diagnostically challenging situations encountered in routine practice, while also importantly advocating consistent terminology which would inform future work.

Pulsed-coil magnet systems for applying uniform 10-30 T fields to centimeter-scale targets on Sandia's Z facility

Sandia has successfully integrated the capability to apply uniform, high magnetic fields (10-30 T) to high energy density experiments on the Z facility. This system uses an 8-mF, 15-kV capacitor bank to drive large-bore (5 cm diameter), high-inductance (1-3 mH) multi-turn, multi-layer electromagnets that slowly magnetize the conductive targets used on Z over several milliseconds (time to peak field of 2-7 ms). This system was commissioned in February 2013 and has been used successfully to magnetize more than 30 experiments up to 10 T that have produced exciting and surprising physics results. These experiments used split-magnet topologies to maintain diagnostic lines of sight to the target. We describe the design, integration, and operation of the pulsed coil system into the challenging and harsh environment of the Z Machine. We also describe our plans and designs for achieving fields up to 20 T with a reduced-gap split-magnet configuration, and up to 30 T with a solid magnet configuration in pursuit of the Magnetized Liner Inertial Fusion concept.

Peritoneoscopy for the diagnosis of acute appendicitis in females of reproductive age

The diagnosis of acute appendicitis in women of reproductive age can be a difficult clinical problem. A retrospective audit found our incidence of normal appendix removal in this patient population to be 42%. This study was undertaken to determine if the selective use of peritoneoscopy would improve the accuracy of diagnosis and thereby reduce the need for celiotomy in these patients. Peritoneoscopy was performed on 21 patients, and acute appendicitis was confirmed in 12 cases. Tubo-ovarian pathology was found in 5 patients, no pathology was found in 4 patients, and an unnecessary celiotomy was avoided in 8 patients. The incidence of normal appendix removal was reduced to 15%. There were no serious complications associated with peritoneoscopy. Diagnostic peritoneoscopy should be liberally employed in women of reproductive age with suspected appendicitis.

Computationally Derived Cribriform Area Index from Prostate Cancer Hematoxylin and Eosin Images Is Associated with Biochemical Recurrence Following Radical Prostatectomy and Is Most Prognostic in Gleason Grade Group 2

BACKGROUND

The presence of invasive cribriform adenocarcinoma (ICC), an expanse of cells containing punched-out lumina uninterrupted by stroma, in radical prostatectomy (RP) specimens has been associated with biochemical recurrence (BCR). However, ICC identification has only moderate inter-reviewer agreement.

OBJECTIVE

To investigate quantitative machine-based assessment of the extent and prognostic utility of ICC, especially within individual Gleason grade groups.

DESIGN, SETTING, AND PARTICIPANTS

A machine learning approach was developed for ICC segmentation using 70 RP patients and validated in a cohort of 749 patients from four sites whose median year of surgery was 2007 and with median follow-up of 28 mo. ICC was segmented on one representative hematoxylin and eosin RP slide per patient and the fraction of tumor area composed of ICC, the cribriform area index (CAI), was measured.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The association between CAI and BCR was measured in terms of the concordance index (c index) and hazard ratio (HR).

RESULTS AND LIMITATIONS

CAI was correlated with BCR (c index 0.62) in the validation set of 411 patients with ICC morphology, especially those with Gleason grade group 2 cancer (n = 192; c index 0.66), and was less prognostic when patients without ICC were included (c index 0.54). A doubling of CAI in the group with ICC morphology was prognostic after controlling for Gleason grade, surgical margin positivity, preoperative prostate-specific antigen level, pathological T stage, and age (HR 1.19, 95% confidence interval 1.03-1.38; p = 0.018).

CONCLUSIONS

Automated image analysis and machine learning could provide an objective, quantitative, reproducible, and high-throughput method of quantifying ICC area. The performance of CAI for grade group 2 cancer suggests that for patients with little Gleason 4 pattern, the ICC fraction has a strong prognostic role.

PATIENT SUMMARY

Machine-based measurement of a specific cell pattern (cribriform; sieve-like, with lots of spaces) in images of prostate specimens could improve risk stratification for patients with prostate cancer. In the future, this could help in expanding the criteria for active surveillance.

A brief intensive cisplatin-based outpatient chemotherapy regimen with filgrastim and megestrol acetate support for advanced non-small cell lung cancer: results of a phase II trial

To evaluate the efficacy and toxicity of a brief, intensive cisplatin-based outpatient chemotherapy regimen with filgrastim and megestrol acetate support for patients with stage IIIB and IV non-small cell lung cancer (NSCLC) and a favorable performance status. Thirty patients with no prior chemotherapy were enrolled in this phase II protocol. Patients received cisplatin 50 mg/m2, ifosfamide 2 g/m2, mesna, and a 7-day course of oral etoposide beginning on days 1, 15, 29, 43. and 57 for a total treatment duration of 10 weeks. Filgrastim was administered for 7 days after each course of oral etoposide. Megestrol acetate 250 mg PO was administered throughout the duration of chemotherapy. Thirty patients were evaluable for toxicity and 27 for response. Among those evaluable for response, partial remission occurred in 11 (41%) patients, and median survival was 10.5 months. Nadir neutrophil count of < 500/mm3 occurred in 19 (63%) patients. Weight loss occurred in only nine patients (median 3.4 kg, range 1.6-7.3). There was no difference between pre- and post-treatment weights (P=0.35). Two patients developed pulmonary embolism. Grade 3 or 4 non-hematologic toxicity occurred infrequently. This regimen appears to be similar in efficacy to the most active regimens reported by other investigators. Innovative features of the regimen include the brief treatment duration, the use of serial 7-day courses of filgrastim to facilitate weekly chemotherapy treatments, and the use of megestrol acetate to minimize constitutional symptoms. However the use of megestrol acetate in this setting may be associated with an increased risk of thromboembolic complications. This may provide a model for other palliative regimens specifically designed for patients with a favorable performance status and advanced NSCLC.

Clinicopathologic factors, treatment patterns, and outcomes in micropapillary urothelial carcinoma (UC)

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Background: Micropapillary UC remains rare yet with an aggressive phenotype. Limited data exists regarding the optimal management of this variant in the contemporary era. Methods: A retrospective analysis was performed to identity patients (pts) with micropapillary UC at the Cleveland Clinic (1997-2017). Demographic, clinico-pathological, treatment regimens, and clinical outcomes, e.g. progression-free and overall survival (PFS and OS) data were collected. Results: A total of 102 pts with median age 70.5 (46-90) at diagnosis, 84%, men, 17% never smokers were identified. Stage at diagnosis for 68 pts with available data was T1 in 29, T2 in 36, T3 in 1, T4 in 2, N+ in 5, and M+ in 4 pts, respectively. Twelve pts were initially treated with intravesical therapy for NMIBC with 58% progressing to higher stage. Overall, 81% of pts had cystectomy; of those 19% had neoadjuvant chemotherapy (NAC; 81% cisplatin-based, median 3 cycles), 21 pts received adjuvant chemotherapy and 3 pts adjuvant radiation. Of 12 pts with available data, 4 had down-staging with NAC with 1 pCR. Pathologic stage was 0is, I, II, III, IV in 4%, 10%, 9%, 9%, and 67% respectively. Overall, 61 pts had recurrent or de-novo metastatic disease (most nodal/local-regional recurrence). For patients with recurrence post-surgery (n = 31), 35% received systemic chemotherapy, 16% had salvage surgery, 10% had salvage radiation, 19% had best supportive care, and the rest were lost to follow-up or refused treatment. The most common 1st-line regimen included platinum-doublet (46%), other combinations (23%), single-agent (23%) and immune checkpoint inhibitors (8%). Overall response (CR/PR) to 1st-line treatment was 38% and median PFS was 8 months (95%CI 0-16.4). Overall, 29 pts died with recurrent/metastatic disease with a median OS (from time of diagnosis) of 39.3 months (95%CI 28.4-50.2) Median OS (from time of diagnosis) for pts treated with cystectomy was 47.1 months (95%CI 23.9-50.2). Conclusions: Micropapillary UC was associated with advanced pathologic stage at cystectomy and limited use of NAC. Responses were noted with NAC and 1st line systemic treatment. Further validation can assist in prognostication and selection/stratification in future trials.

Prognostic value of DLL3 expression and clinicopathologic features in small cell bladder cancer (SCBC)

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Background: SCBC is rare with limited data on treatment and outcomes. DLL3, a Notch pathway protein, is expressed in small cell lung cancer (SCLC) and neuroendocrine tumors. Phase I/II trials of the anti-DLL3 antibody-drug conjugate, rovalpituzumab tesirine, are ongoing in SCLC and other solid tumors. DLL3 expression in SCBC and its prognostic implications are unknown. Methods: A retrospective review of clinicopathologic features of 63 patients (pts) with biopsy-confirmed SCBC at Cleveland Clinic (1993-2016) was conducted. Percentage (%) of small cell component (SC%) was defined by independent pathology review in all pts. The % of tumor cells expressing DLL3 (DLL3%) was assessed in 53 pts. Multivariable analyses (MVA) were used to identify predictors of overall survival (OS), progression-free survival (PFS) and time to progression (TTP) (p ≤ .05). Results: Median age was 71 (39-90), 83% were men, 77% current/former smokers, 41 (65%) had cystectomy and 22 (35%) only TURBT. Estimated median OS, PFS and TTP were 22.8, 13.7 and 21.1 months from diagnosis. Median SC% was 100% (5-100%) and 79% of tumors were ≥ 50% SC. DLL3 expression of any level was noted in 68% (36/53) of tumors; 58% of tumors had DLL3 expression in > 10% of cells. SC% correlated with DLL3% (r = 0.33, p = .01). In MVA, increased DLL3% was associated with shorter OS and PFS, while increased SC% was associated with shorter PFS and TTP. Higher pT at cystectomy was associated with shorter OS (Table). Conclusions: Higher DLL3 expression and SC% are associated with worse outcomes in SCBC. Most SCBC tumors express DLL3, a therapeutic target tested in clinical trials. Genomic, epigenetic, transcriptomic and PDL1 evaluation in SCBC are also being pursued to define molecular context. DLL3 expression and other prognostic factors. [Table: see text]

Molecular profiling of small cell bladder cancer (SCBC) to reveal gene expression determinants of an aggressive phenotype

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Background: SCBC is rare and its underlying biology poorly understood. Molecular profiling can shed light on the biology and identify treatment targets and biomarkers. Methods: A retrospective review of 63 patients (pts) with biopsy-confirmed SCBC at Cleveland Clinic (1994-2015) was performed. Percentage of small cell component (SC%) was defined by independent pathology review. DLL3 and PD-L1 protein expression were measured by IHC in 53 pts. Gene expression analysis was done in 38 primary SCBC tumor samples, 1 metastatic sample, and 5 normal bladder tissue samples (44 total) from the same cohort using HTG EdgeSeq OBP Assay with probes for 2568 genes. Analysis was performed via the RNAseq workflow (Partek Genomics Suite). Results: Among 63 identified pts, median age was 71 (39-90), 83% were men, median SC% was 100% (range 5-100%), median follow-up was 16.6 months and estimated median overall survival (OS) was 22.8 months. Unsupervised hierarchical clustering of gene expression patterns from 44 samples produced 4 distinct clusters. Pts with tumors in cluster 1 (that also included normal samples) did not have metastasis at diagnosis or distant recurrence, both of which were over-represented in the other 3 clusters. Kaplan-Meier analysis revealed a trend towards longer OS in cluster 1 patients (log rank p = 0.065). Higher gene expression of PRC1, NCAM1 (CD56) and DLL3 correlated with higher SC%, as did lower gene expression of ERBB2, PD-L1 and HPGD (p < 0.01). PD-L1 protein expression (≥1% cells) was noted in 30% of pts but did not correlate with outcome, SC%, DLL3 protein expression, or PD-L1 gene expression. DLL3 protein expression (≥1% cells) was noted in 68% of pts and DLL3 > 10% correlated with decreased OS (p = .03). Higher DLL3 protein expression correlated with DLL3 gene expression (Spearman r = 0.70, p < .01) and with SC% (r = .33, p = .01). Conclusions: This is the first study to reveal distinct gene expression patterns that define aggressive behavior, metastatic potential and outcomes in SCBC. The prognostic value of differential gene expression networks and the presence of underlying genomic and epigenetic alterations is the subject of ongoing prospective validation in a larger cohort.

PTEN Hamartoma Tumor Syndrome: A Case of Renal Cell Carcinoma in a Young Female

PTEN Hamartoma-Tumor-Syndrome (PHTS) describes a series of conditions characterized by germline-mutation of the PTEN tumor-suppressor gene. PHTS patients have an increased lifetime risk of multiple malignancies, including thyroid, breast, and endometrial cancers. PHTS patients also have 20-30 fold increased risk of renal cell carcinoma (RCC) compared to age-matched controls. As with many hereditary RCC syndromes, tumors present early and multifocally. We present a case of one of the youngest patients diagnosed with RCC in PHTS and review the urologic implications of this syndrome.

The relationship between in vivo generated hemoglobin skeletal protein complex and increased red cell membrane rigidity

In vitro induced oxidative damage to normal human RBCs has previously been shown to result in increased membrane rigidity as a consequence of the generation of a protein complex between hemoglobin and spectrin. In order to determine if in vivo generated hemoglobin-spectrin complexes may play a role in increased membrane rigidity of certain pathologic red cells, we measured both these parameters in membranes prepared from hereditary xerocytosis (Hx), sickle cell disease (Sc), and red cells from thalassemia minor (beta thal). Membranes were prepared from density-fractionated red cells, and membrane deformability was measured using an ektacytometer. Hemoglobin-spectrin complex was determined by sodium dodecyl sulfate (SDS)-polyacrylamide gel analysis, as well as by Western blot analysis using a monoclonal antibody against the beta-subunit of hemoglobin. For these three types of pathologic red cells, progressive cellular dehydration was associated with increased membrane rigidity and increased content of hemoglobin-spectrin complex. Moreover, the increase in membrane rigidity appeared to be directly related to the quantity of hemoglobin-spectrin complex associated with the membrane. Our findings imply that hemoglobin-spectrin complex is generated in vivo, and this in turn results in increased membrane rigidity of certain pathologic red cells. The data further suggest that oxidative crosslinking may play an important role in the pathophysiology of certain red cell disorders.