Combined assessment of peritumoral Th1/Th2 polarization and peripheral immunity as a new biomarker in the prediction of BCG response in patients with high-risk NMIBC

Intravesical Bacille Calmette-Guérin (BCG) remains the most effective treatment for high-risk non-muscle-invasive bladder cancer (NMIBC), unfortunately there is no validated biomarker to predict clinical outcome. Here we tried to explore the possibility that a combination of the density of peritumoral infiltrating cells (Th1, Th2 and PD-L1) and the composition of peripheral immune cells (neutrophil and lymphocyte counts) could generate a more reliable prognostic biomarker. Twenty-two patients with high-risk NMIBC treated with BCG (10 BCG nonresponders and 12 BCG responders) were selected. BCG responders had significantly lower level of peritumoral T-bet⁺ cells with an associated higher GATA-3⁺/T-bet⁺ ratio (p = 0.04, p = 0.02, respectively). Furthermore, the immune polarization in tissue (GATA-3⁺/T-bet⁺ ratio) adjusted for the systemic inflammation (neutrophil-to-lymphocyte ratio) showed a significantly higher association with the BCG response (p = 0.004). A survival analysis demonstrated prolonged recurrence-free survival (RFS) in patients with a lower T-bet⁺/Lymphocyte ratio and higher GTR/NLR (p = 0.01). No association was observed between peritumoral PD-L1⁺ expression and the BCG response. In conclusion, alterations in overall immune function, both local and systemic, may influence the therapeutic response to BCG, therefore a combined analysis of tumoral (Th2/Th1 ratio) and peripheral (NLR) immune composition prior to treatment may be a promising approach to predict the BCG response in high-risk NMIBC patients.

Bladder cancer: Present and future

Bladder cancer has a high incidence and involves high associated morbidity and mortality. Since its initial clinical suspicion, early diagnostic confirmation and multimodal treatment involve different medical specialties. For this reason, we consider it important to spread the current consensus for its management. Recent advances in immunology and Chemotherapy make it necessary to expose and reflect on future perspectives.

BRCA1, RAP80, and AEG-1 mRNA expression in resectable muscle-invasive bladder cancer (MIBC) patients (p) treated with neoadjuvant cisplatin-based chemotherapy

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Background: Cystectomy remains the standard treatment in MIBC and only a minority of p are treated with neoadjuvant chemotherapy, suggesting that predictive markers of chemotherapy outcome are needed. Low BRCA1 mRNA expression is associated with an improvement in survival in bladder cancer p treated with cisplatin-based chemotherapy. However, BRCA1 function can be modulated by other DNA repair genes. RAP80 is required for the accumulation of BRCA1 to sites of DNA breaks, and cells depleted of RAP80 exhibit hypersensitivity to irradiation. AEG-1 can induce BRCA1 expression and cause chemoresistance. Methods: Paraffin-embedded pre-treatment tumor samples were collected by transurethral resection from 65 p with resectable MIBC stage T2-4N0M0 treated with neoadjuvant cisplatin-based chemotherapy. Gene expression levels of BRCA1, RAP80 and AEG-1 were quantified by real-time quantitative PCR. Expression levels were divided into terciles and correlated with median survival (MS). Results: 33 p were treated with cisplatin, methotrexate and vinblastine (CMV) and 32 p with cisplatin and gemcitabine. Chemotherapy was followed by cystectomy in 60 p. Overall MS was not reached and 5-year survival was 51%. MS was 45 months (m) and 5-year survival was 27% in 21 p with high BRCA1 mRNA levels vs 168 m and 59% in 44 p with low and intermediate levels (p=0.05). MS was 50 m in 15 p with high AEG-1 levels, 45 m in 15 p with intermediate levels, and was not reached in 18 p with low levels, although these differences were not statistically significant (p=0.3). No differences in MS were observed according to RAP80 mRNA levels. Conclusions: BRCA1 can be a useful marker to predict the efficacy of neoadjuvant chemotherapy. Cisplatin-based chemotherapy should be recommended in p with low/intermediate BRCA1 expression. Further studies with larger numbers of p are warranted to elucidate the role of AEG-1 in this setting.

[Diode laser enucleation of the prostate (Dilep): technique and initial results]

INTRODUCTION

we present our preliminary experience and results of practising the prostate enucleation technique using a diode laser (DiLEP) and intravesical morcellation, following the same principles of holmium laser enucleation (HoLEP).

MATERIALS AND METHOD

we endoscopically treated benign prostate hyperplasia with DiLEP in 17 patients over a period of five months. They were all followed up for three months with flowmetry and IPSS. We have described the prostate enucleation and morcellation technique in detail, as well as the materials required to perform them. We have also commented on the lessons learned having practised on more than 300 cases with HoLEP, with a view to applying this new technology.

RESULTS

the mean age was 74.2 and the mean prostate volume was 61.26 (47-110) cc. The mean loss of haemoglobin was 2.1 (1.4-3.1) gr/dl. There were no major consequences or complications. All the patients were discharged from the hospital 24 hours after the operation. The improvement in the IPSS (22.3±4.1 vs. 7.1±1.06) and in the Q max (7.14±2.6 vs. 21.4±3.6) was sustainable.

CONCLUSIONS

It is the first description of the DiLEP technique for the surgical treatment of benign prostate hyperplasia. We believe the results obtained are promising and that they could signify some advantages as opposed to HoLEP. However, prospective randomized studies are required to confirm this opinion.

[Holmium laser enucleation of the prostate. Experience in Hospital Germans Trias i Pujol]

OBJECTIVES

Evaluate the introduction of the enucleation with Holmium laser in our center, including the surgeon's learning curve by the analysis of the patients.

MATERIALS AND METHODS

150 procedures have been analyzed in a retrospective manner with an average follow-up of 11 months. Qmax, IPSS and Qol have been determined before surgery, at 6 months and 12 months, realizing their statistic analysis. PSA was measured before surgery and after 3 months. Complications, surgical time and hospital stay have been analyzed.

RESULTS

Average patient age was 72, 4 years. Average prostatic size was of 71,3 gr (18-150). Average hospital stay was of 22 h. Qmax before surgery, 6 months, 12 months was of 7,53 ml/s, 23,24 ml/s and 21,62 ml/s being statistically significant (p<0,01). Transfusion rate was of 1,3% and urethral stenosis rate of 4%. IPSS improvement at 6 and 12 months was statistically significant as well (p<0, 01).

CONCLUSIONS

Enucleation with Holmium laser is a safe and effective technique with lower complication rate than TURP, included during the learning curve.

BRCA1 mRNA expression and outcome to neoadjuvant cisplatin-based chemotherapy in bladder cancer

BACKGROUND

neoadjuvant chemotherapy has shown a modest benefit in muscle-invasive bladder cancer patients; however, the subset of patients most likely to benefit has not been identified. BRCA1 plays a central role in DNA repair pathways and low BRCA1 expression has been associated with sensitivity to cisplatin and longer survival in lung and ovarian cancer patients.

PATIENTS AND METHODS

we assessed BRCA1 messenger RNA expression levels in paraffin-embedded pre-treatment tumor samples obtained by transurethral resection from 57 patients with locally advanced bladder cancer subsequently treated with neoadjuvant cisplatin-based chemotherapy. BRCA1 levels were divided into terciles and correlated with pathological response and survival.

RESULTS

a significant pathological response (pT0-1) was attained in 66% (24 of 39) of patients with low/intermediate BRCA1 levels compared with 22% (4 of 18) of patients with high BRCA1 levels (P = 0.01). Median survival was 168 months in patients with low/intermediate levels and 34 months in patients with high BRCA1 levels (P = 0.002). In the multivariate analysis for survival, only BRCA1 expression levels and lymphovascular invasion emerged as independent prognostic factors.

CONCLUSIONS

our data suggest that BRCA1 expression may predict the efficacy of cisplatin-based neoadjuvant chemotherapy and may help to customize therapy in bladder cancer patients.

[Importance of the tissue polypeptide antigen level in neoplastic patients. Its correlation with other tumor markers]

In order to know the behavior of the tissue polypeptide antigen (TPA) as a tumor marker, the authors determine its amount in serum by means of radioimmunoassay (TPA Prolifigen RIA) in 441 patients having respiratory, digestive, urogenital, hematopoietic, mammary and other malignant tumors. The obtained results indicate that: TPA has no tumor specificity; however it increases in tumors without any other known tumor marker. TPA has no diagnostic value, but it is useful for the following up of digestive, mammary, respiratory, ovarian and testicular cancer; amounts of TPA comprised between 90 and 120 U/l are not specific and have no clinical significance; and it is very useful the simultaneous determination of CEA and TPA in the respiratory, digestive and mammary malignant neoplasms to help the clinical data in the evaluation of tumor mass (CEA) and tumor activity (TPA) without indication of tumor localization.