181 Service Evaluation of the Utilisation and Impact of PredictProstate on Clinical Decision-Making in a Prostate Cancer Specialist Multidisciplinary Service

Aim

Patients with low and intermediate risk prostate cancer must decide whether to undergo radical treatment. The PredictProstate tool uses patient characteristics to quantify the relative benefit of radical treatment. It has been introduced in our prostate cancer specialist multidisciplinary team meeting (pcSMDT) and in subsequent communication with patients to facilitate informed decision-making. The aim of this study was to assess the utilisation and utility of PredictProstate in informing treatment decisions for men referred to Cambridge University Hospitals (CUH) for consideration of radical prostatectomy (RARP).

Method

A retrospective chart review was conducted of patients referred to the CUH pcSMDT and robotic prostatectomy clinic (ROPD) between Sep 2019 and Aug 2021 for consideration of RARP. Data on patient characteristics, use of PredictProstate, and management decisions was collected from the EPIC EMR. A total of 841 patients were included in the analysis.

Results

The usage of PredictProstate in the pcSMDT increased in the second half of the study period (34.5% vs 23.8%, p<0.001). The use of PredictProstate for men with low and intermediate risk prostate cancer was associated with an increased likelihood of attending ROPD (75% vs 61%, p<0.001), but a reduced likelihood of RARP (41% vs 55%, p<0.01). These effects were most pronounced for men of favourable intermediate risk (80% vs 63%, p<0.004 and 34% vs 54%, p<0.07 respectively).

Conclusions

PredictProstate provides personalised prognostic data for patients. Its increased use for men with low and intermediate risk prostate cancer is associated with increased attendance at specialist surgical clinic and a reduced chance of undergoing RARP.

281 Impact of Using Risk Communication Tools in Counselling Patients with Newly Diagnosed Non-Metastatic Prostate Cancer

Introduction

There have been substantial advances in risk communication tools that help patients understand prognosis associated with prostate cancer and the benefit/gain from treatment. Over the last three years, two tools; Cambridge Prognostic Groups (CPG), and Predict Prostate (https://prostate.predict.nhs.uk), along with decision-making consultations with clinical nurse specialists (CNS) have been integrated into the new diagnosis pathway in our unit.

Method

Treatment decisions for patients with new non-metastatic prostate cancer were audited after (2019–2020) and before (2016–2017) new risk communication tools were implemented. Data were compared between the two time periods and also benchmarked against national level data from the National Prostate Cancer Audit (NPCA) (Parry et al 2020; PMID: 32460859). The main outcome measured was comparison of rates of over and under-treatment of disease.

Results

168 and 95 patients were included in the 2019–2020 and 2016–2017 cohorts, respectively. Following implementation there was a reduction in over-treatment (use of radical surgery/radiotherapy) in patients with low risk/CPG1 (23% to 4%). These rates were also better than the national average from NPCA data (4% vs 11%). In parallel, there was an increase in use of radical treatment (reduced under-treatment) in high risk and very high-risk/CPG4-5 disease (84% vs 73%). Again, these rates were also superior to national level data from the NPCA (84% vs 76%).

Conclusions

Incorporating personalised risk-communication tools and dedicated CNS counselling in our unit has reduced over-treatment of early disease and under-treatment of advanced disease. Wider uptake could enhance risk-appropriate treatment of patients with a new prostate cancer diagnosis.

Risk stratification for prostate cancer management: value of the Cambridge Prognostic Group classification for assessing treatment allocation

BACKGROUND

The five-tiered Cambridge Prognostic Group (CPG) classification is a better predictor of prostate cancer-specific mortality than the traditional three-tiered classification (low, intermediate, and high risk). We investigated radical treatment rates according to CPG in men diagnosed with non-metastatic prostate cancer in England between 2014 and 2017.

METHODS

Patients diagnosed with non-metastatic prostate cancer were identified from the National Prostate Cancer Audit database. Men were risk stratified according to the CPG classification. Risk ratios (RR) were estimated for undergoing radical treatment according to CPG and for receiving radiotherapy for those treated radically. Funnel plots were used to display variation in radical treatment rates across hospitals.

RESULTS

A total of 61,999 men were included with 10,963 (17.7%) in CPG1 (lowest risk group), 13,588 (21.9%) in CPG2, 9452 (15.2%) in CPG3, 12,831 (20.7%) in CPG4, and 15,165 (24.5%) in CPG5 (highest risk group). The proportion of men receiving radical treatment increased from 11.3% in CPG1 to 78.8% in CGP4, and 73.3% in CPG5. Men in CPG3 were more likely to receive radical treatment than men in CPG2 (66.3% versus 48.4%; adjusted RR 1.44; 95% CI 1.36-1.53; P < 0.001). Radically treated men in CPG3 were also more likely to receive radiotherapy than men in CPG2 (59.2% versus 43.9%; adjusted RR, 1.18; 95% CI 1.10-1.26). Although radical treatment rates were similar in CPG4 and CPG5 (78.8% versus 73.3%; adjusted RR 1.01; 95% CI 0.98-1.04), more men in CPG5 had radiotherapy than men in CPG4 (79.9% versus 59.1%, adjusted RR 1.26; 95% CI 1.12-1.40).

CONCLUSIONS

The CPG classification distributes men in five risk groups that are about equal in size. It reveals differences in treatment practices in men with intermediate-risk disease (CPG2 and CPG3) and in men with high-risk disease (CPG4 and CPGP5) that are not visible when using the traditional three-tiered risk classification.

Improving the safety and tolerability of local anaesthetic outpatient transperineal prostate biopsies: A pilot study of the CAMbridge PROstate Biopsy (CAMPROBE) method

OBJECTIVES

The aim of this study was to pilot the use of a bespoke device (CAMPROBE, the CAMbridge PROstate Biopsy) to enable routine outpatient free-hand local anaesthetic (LA) transperineal prostate biopsies.

MATERIALS AND METHODS

The CAMPROBE prototype was designed and built in our institution. Men on active surveillance due prostate resampling were invited to have a CAMPROBE biopsy as an alternative to repeat transrectal ultrasound-guided prostate biopsies (TRUSBx) as part of an approved trial (NCT02375035). Biopsies were performed using LA infiltration only, without sedation or additional analgesia. Patient-reported outcomes were recorded at day 0 and 7 using validated questionnaires and visual analogue scales (VAS). Complications were recorded prospectively.

RESULTS

Thirty men underwent biopsies with a median of 11 cores taken per procedure (interquartile range 10-12). There were no infections, sepsis or retention episodes. Haematuria and haematospermia occurred in 67% and 62% of patients, which are similar to rates reported for TRUSBx. Mean VAS for pain (0-10 scale) was less than 3 for every part of the procedure. All 30 men described the procedure as tolerable under LA. In total, 26/30 (86.7%) men expressed a preference for a CAMPROBE procedure over TRUSBx and a further 3 (10.0%) would have either.

CONCLUSIONS

In this small pilot study, the CAMPROBE device and method appears to be a safe, simple and well-tolerated out-patient transperineal replacement for TRUSBx. A major new National Institute for Health Research grant will allow its further development from a prototype to a single use, low-cost disposable device ready for multi-centre testing.

LEVEL OF EVIDENCE

1b: individual cohort study.

A comparison of operative and margin outcomes from surgeon learning curves in robot assisted radical prostatectomy in a changing referral practice

Introduction The aim of this study was to explore the impact of increasing proportions of high risk referrals on surgical margin outcomes of a surgeon's learning curve in robotic prostatectomy. Methods All patients in this study underwent robot assisted radical prostatectomy (RARP) performed by three different consultant urological surgeons. Data collected included preoperative clinical stage, Gleason score and prostate specific antigen levels, which were used to risk stratify patients according to National Institute for Health and Care Excellence criteria. Oncological clearance was assessed by overall and stage specific positive margin status. Comparisons were made between each surgeon for the first and second 50 consecutive cases. Results For the three surgeons, there was a progressive increase in the proportion of high risk cases referred accompanied by a corresponding decline in low risk disease (p<0.001). Postoperative pathology also showed an upward trend in pT3 cases across the three eras. There was no statistical difference in overall positive margin rates between the surgeons. The overall rates were 12%, 20% and 23% for the first 50 cases, and 32%, 36% and 21% for the second 50 cases for the three surgeons respectively. Conclusions Our series demonstrates an upward trend in the risk profile of men referred for robotic prostatectomy over a nine-year period. Despite this, there was minimal impact on pathological and surgical outcomes among our surgeons, who were at the initial stages of their RARP learning curve. Our results suggest that there is no requirement for an active case selection bias against patients with high risk disease for surgeons newly embarking on their RARP learning experience.

The Cambridge Prognostic Groups for improved prediction of disease mortality at diagnosis in primary non-metastatic prostate cancer: a validation study

BACKGROUND

The purpose of this study is to validate a new five-tiered prognostic classification system to better discriminate cancer-specific mortality in men diagnosed with primary non-metastatic prostate cancer.

METHODS

We applied a recently described five-strata model, the Cambridge Prognostic Groups (CPGs 1-5), in two international cohorts and tested prognostic performance against the current standard three-strata classification of low-, intermediate- or high-risk disease. Diagnostic clinico-pathological data for men obtained from the Prostate Cancer data Base Sweden (PCBaSe) and the Singapore Health Study were used. The main outcome measure was prostate cancer mortality (PCM) stratified by age group and treatment modality.

RESULTS

The PCBaSe cohort included 72,337 men, of whom 7162 died of prostate cancer. The CPG model successfully classified men with different risks of PCM with competing risk regression confirming significant intergroup distinction (p < 0.0001). The CPGs were significantly better at stratified prediction of PCM compared to the current three-tiered system (concordance index (C-index) 0.81 vs. 0.77, p < 0.0001). This superiority was maintained for every age group division (p < 0.0001). Also in the ethnically different Singapore cohort of 2550 men with 142 prostate cancer deaths, the CPG model outperformed the three strata categories (C-index 0.79 vs. 0.76, p < 0.0001). The model also retained superior prognostic discrimination in the treatment sub-groups: radical prostatectomy (n = 20,586), C-index 0.77 vs. 074; radiotherapy (n = 11,872), C-index 0.73 vs. 0.69; and conservative management (n = 14,950), C-index 0.74 vs. 0.73. The CPG groups that sub-divided the old intermediate-risk (CPG2 vs. CPG3) and high-risk categories (CPG4 vs. CPG5) significantly discriminated PCM outcomes after radical therapy or conservative management (p < 0.0001).

CONCLUSIONS

This validation study of nearly 75,000 men confirms that the CPG five-tiered prognostic model has superior discrimination compared to the three-tiered model in predicting prostate cancer death across different age and treatment groups. Crucially, it identifies distinct sub-groups of men within the old intermediate-risk and high-risk criteria who have very different prognostic outcomes. We therefore propose adoption of the CPG model as a simple-to-use but more accurate prognostic stratification tool to help guide management for men with newly diagnosed prostate cancer.

Association Of Plasma And Urinary Mutant DNA With Clinical Outcomes In Muscle Invasive Bladder Cancer

Muscle Invasive Bladder Cancer (MIBC) has a poor prognosis. Whilst patients can achieve a 6% improvement in overall survival with Neo-Adjuvant Chemotherapy (NAC), many do not respond. Body fluid mutant DNA (mutDNA) may allow non-invasive identification of treatment failure. We collected 248 liquid biopsy samples including plasma, cell pellet (UCP) and supernatant (USN) from spun urine, from 17 patients undergoing NAC. We assessed single nucleotide variants and copy number alterations in mutDNA using Tagged-Amplicon- and shallow Whole Genome- Sequencing. MutDNA was detected in 35.3%, 47.1% and 52.9% of pre-NAC plasma, UCP and USN samples respectively, and urine samples contained higher levels of mutDNA (p = <0.001). Longitudinal mutDNA demonstrated tumour evolution under the selective pressure of NAC e.g. in one case, urine analysis tracked two distinct clones with contrasting treatment sensitivity. Of note, persistence of mutDNA detection during NAC predicted disease recurrence (p = 0.003), emphasising its potential as an early biomarker for chemotherapy response.

Clinical management and research priorities for high-risk prostate cancer in the UK: Meeting report of a multidisciplinary panel in conjunction with the NCRI Prostate Cancer Clinical Studies Localised Subgroup

The management of high-risk prostate cancer has become increasingly sophisticated, with refinements in radical therapy and the inclusion of adjuvant local and systemic therapies. Despite this, high-risk prostate cancer continues to have significant treatment failure rates, with progression to metastasis, castrate resistance and ultimately disease-specific death. In an effort to discuss the challenges in this field, the UK National Clinical Research Institute’s Prostate Cancer Clinical Studies localised subgroup convened a multidisciplinary national meeting in the autumn of 2014. The remit of the meeting was to debate and reach a consensus on the key clinical and research challenges in high-risk prostate cancer and to identify themes that the UK would be best placed to pursue to help improve outcomes. This report presents the outcome of those discussions and the key recommendations for future research in this highly heterogeneous disease entity.

Factors influencing length of stay and suitability for early community discharge in the management of acute pyelonephritis

Objectives:

We assessed factors influencing length of stay and suitability for early discharge to community care in acute pyelonephritis (APN).

Methods:

APN patients admitted in 2011–2012 to a tertiary hospital were included in a retrospective study. Data collected included patient demographics, Charlson Comorbidity Index (CCI), admitting speciality, imaging, length of stay and any intervention.

Results:

A total of 266 patients were analysed with 83.1% managed by urologists and the rest by other specialties. Urology patients had a shorter mean stay of 4.7 days compared to 8.8 days for non-urology patients ( p < 0.001). The mean time to imaging was 0.5 days and 1.4 days for urology and other specialties, respectively ( p < 0.001). Twenty per cent of patients had urinary tract abnormalities on imaging but only 2.0% required intervention; 9.4% (25/266) had repeated imaging following an initial scan but none resulted in an intervention. A high CCI was a predictor of longer stays regardless of admitting speciality ( p < 0.001). Admission to non-urological specialities remained a significant predictor both of delayed imaging ( p = 0.001) and longer stays ( p < 0.001) even after correction for CCI.

Conclusion:

Time to imaging, comorbidity and admitting speciality are key factors influencing APN management. Rapid urological review and imaging could identify patients suitable for safe early discharge to community management.

Primary radical therapy selection in high-risk non-metastatic prostate cancer

As the incidence of prostate cancer rises, the detection and management of men with high-risk non-metastatic prostate cancer is becoming increasingly important. The benefits of radical treatment have been clearly shown in this group from a number of publications. The current mainstays of treatment are radical prostatectomy (with selective use of adjuvant radiation) and radical radiotherapy with concurrent androgen deprivation. The outcomes from these two approaches seem to be remarkably similar and are considered equally valid options for primary treatment. The choice of therapy is critically dependent on a number of factors, but ultimately left to the decision of the patients with advice from clinicians. Clinicians themselves, however, are known to be biased towards their particular skill set and experiences. Attempts at randomised comparisons between these two modalities have so far failed and are confounded by patient-clinician bias, the continual advances in therapy as well as the long natural history of the disease. In the lack of level 1 comparable evidence, this article explores the existing literature as to the key factors that should be considered in radical treatment selection for high-risk prostate cancer. These factors include disease aggressiveness, comorbidity and life expectancy, functional outcomes and the consequences of therapy failure with regards to salvage treatment. We propose that these factors may be useful in developing a decision guide for rationale radical therapy selection in the light of two apparently equally effective treatments. Ultimately, however, there is an urgent need for added clinical and biological markers that can provide a more precise approach to therapy selection.

Identification of pathologically insignificant prostate cancer is not accurate in unscreened men

Background:

Identification of men harbouring insignificant prostate cancer (PC) is important in selecting patients for active surveillance. Tools have been developed in PSA-screened populations to identify such men based on clinical and biopsy parameters.

Methods:

Prospectively collected case series of 848 patients was treated with radical prostatectomy between July 2007 and October 2011 at an English tertiary care centre. Tumour volume was assessed by pathological examination. For each tool, receiver operator characteristics were calculated for predicting insignificant disease by three different criteria and the area under each curve compared. Comparison of accuracy in screened and unscreened populations was performed.

Results:

Of 848 patients, 415 had Gleason 3+3 disease on biopsy. Of these, 32.0% had extra-prostatic extension and 50.2% were upgraded. One had positive lymph nodes. Two hundred and six (24% of cohort) were D'Amico low risk. Of these, 143 had more than two biopsy cores involved. None of the tools evaluated has adequate discriminative power in predicting insignificant tumour burden. Accuracy is low in PSA-screened and -unscreened populations.

Conclusions:

In our unscreened population, tools designed to identify insignificant PC are inaccurate. Detection of a wider size range of prostate tumours in the unscreened may contribute to relative inaccuracy.

Changing presentation of prostate cancer in a UK population--10 year trends in prostate cancer risk profiles in the East of England

BACKGROUND

Prostate cancer incidence is rising in the United Kingdom but there is little data on whether the disease profile is changing. To address this, we interrogated a regional cancer registry for temporal changes in presenting disease characteristics.

METHODS

Prostate cancers diagnosed from 2000 to 2010 in the Anglian Cancer Network (n=21,044) were analysed. Risk groups (localised disease) were assigned based on NICE criteria. Age standardised incidence rates (IRs) were compared between 2000-2005 and 2006-2010 and plotted for yearly trends.

RESULTS

Over the decade, overall IR increased significantly (P<0.00001), whereas metastasis rates fell (P<0.0007). For localised disease, IR across all risk groups also increased but at different rates (P<0.00001). The most striking change was a three-fold increase in intermediate-risk cancers. Increased IR was evident across all PSA and stage ranges but with no upward PSA or stage shift. In contrast, IR of histological diagnosis of low-grade cancers fell over the decade, whereas intermediate and high-grade diagnosis increased significantly (P<0.00001).

CONCLUSION

This study suggests evidence of a significant upward migration in intermediate and high-grade histological diagnosis over the decade. This is most likely to be due to a change in histological reporting of diagnostic prostate biopsies. On the basis of this data, increasing proportions of newly diagnosed cancers will be considered eligible for radical treatment, which will have an impact on health resource planning and provision.

Polymyalgia rheumatica following robotic radical prostatectomy

INTRODUCTION

Polymyalgia rheumatica (PMR) is an inflammatory syndrome of unknown etiology has also been associated with concurrent malignancy. Here we report PMR occurring de novo in a man following successful robotic radical prostatectomy.

PRESENTATION OF CASE

A 67-year-old gentleman underwent uneventful robotic assisted radical prostatectomy with complete excision of a T2(C) Gleason 7 tumour and a post-operative undetectable PSA. Three weeks after surgery he developed pain and weakness of the upper arms requiring increasing doses of opioids. Assessment identified a grossly elevated ESR and CRP consistent with a clinical diagnosis of PMR. Treatment with oral steroids led to a rapid resolution of symptoms.

DISCUSSION

There have been reported cases of polymyalgia rheumatica occurring following surgical procedures but not with robotic prostate surgery. It has been proposed that surgical tissue injury can cause a release of inflammatory markers. Surgical stress-related sympathetic activation can also stimulate lymphocyte dependent inflammatory reactions by modulation of cytokine production and lymphocyte expressed adrenergic receptors.

CONCLUSION

We present here the first reported case of PMR developing acutely after radical robotic prostatectomy. It is possible that the surgical procedure in this case had triggered polymyalgia rheumatica possibly through activation of immune-mediated systemic inflammatory responses.

DCE and DW MRI in monitoring response to androgen deprivation therapy in patients with prostate cancer: a feasibility study

Androgen deprivation therapy (ADT) is a key primary treatment for advanced and metastatic prostate cancer and is an important neoadjuvant before radiotherapy. We evaluated 3.0 T dynamic contrast-enhanced MRI and diffusion-weighted (DW) MRI in monitoring ADT response. Twenty-three consecutive patients with prostate cancer treated by primary ADT were included. Imaging was performed at baseline and 3 months posttreatment with ADT. After 3 months therapy there was a significant reduction in all dynamic contrast-enhanced MRI parameters measured in tumor regions of interest (K(trans), k(ep), v(p), IAUGC-90); P < 0.001. Areas of normal-appearing peripheral zone showed no significant change; P = 0.285-0.879. Post-ADT, there was no significant change in apparent diffusion coefficient values in tumors, whilst apparent diffusion coefficient values significantly decreased in areas of normal-appearing peripheral zone, from 1.786 × 10(-3) mm(2) /s to 1.561 × 10(-3) mm(2) /s; P = 0.007. As expected the median Prostate-Specific Antigen (PSA) significantly reduced from 30 ng/mL to 1.5 ng/mL posttreatment, and median prostate volume dropped from 47.6 cm(3) to 24.9 cm(3) ; P < 0.001. These results suggest that dynamic contrast-enhanced MRI and diffusion-weighted MRI offer different information but that both could prove useful adjuncts to the anatomical information provided by T2-weighted imaging. dynamic contrast-enhanced as a marker of angiogenesis may help demonstrate ADT resistance and diffusion-weighted imaging may be more accurate in determining presence of tumor cell death versus residual tumor.

Risk profiles of prostate cancers identified from UK primary care using national referral guidelines

Objective:

Prostate cancer in the United Kingdom is mainly diagnosed from primary care referrals based on national guidelines published by the Department of Health. Here we investigated the characteristics of cancers detected through the use of these guidelines.

Methods:

A prospective two-centre study was established to assess men referred from the primary care based on the UK national guidelines.

Results:

The overall cancer detection rate was 43% (169 out of 397) with 15% (26 out of 169) of all cancers metastatic at presentation. Amongst 50–69-year-old men these rates were 34% (68 out of 200) and 15% (10 out of 68). Only 21% (25 out of 123) of men with local cancers had low-risk disease. In comparison to a historical cohort from 2001 (n=137) we found no overall differences in rates of metastatic disease, locally advanced tumours, or risk categories. Amongst 50–69-year-old men with local disease, however, we observed an increase in detection of low-risk cancers in a contemporary cohort (P=0.04). This was primarily because of the increased detection of low-stage organ-confined tumours in this group (P=0.02).

Conclusion:

Use of the UK prostate cancer guidelines detects a high proportion of clinically significant cancers. Use of the guidelines does not seem to have led to an overall change in the clinical characteristics of presenting cancers. There may, however, be a specific benefit in detecting more low-risk disease in younger men.

Expression of gonadotrophin releasing hormone receptor I is a favorable prognostic factor in epithelial ovarian cancer

The majority of epithelial ovarian cancers originate in the ovarian surface epithelium. The ovarian surface epithelium is a hormonally responsive tissue, and hormones are thought to play a key role in the development of this type of cancer. Gonadotrophin releasing hormone II is one of 2 isoforms which are thought to act through gonadotrophin releasing hormone receptor I, and gonadotrophin releasing hormone II has been shown to cause growth inhibition of cultured ovarian surface epithelium. The aim of this study was to investigate the expression levels and prognostic significance of gonadotrophin releasing hormone II and the gonadotrophin releasing hormone receptor I in epithelial ovarian cancer. Gonadotrophin releasing hormone II and gonadotrophin releasing hormone receptor I messenger RNA expression was examined in 23 cancers and 7 normal ovarian surface epithelium samples by quantitative real time polymerase chain reaction. An ovarian cancer tissue microarray containing 139 cases was constructed and immunohistochemical analysis of gonadotrophin releasing hormone II and gonadotrophin releasing hormone receptor I protein expression was performed and correlated with clinical outcome data. Gonadotrophin releasing hormone II messenger RNA expression was lower in cancer samples compared to normal ovarian surface epithelium samples (P < .05). Gonadotrophin releasing hormone II protein expression correlated with histologic subtype (25% serous versus 45% nonserous, P < .05) but not with overall survival. Gonadotrophin releasing hormone receptor I messenger RNA expression was highest in serous tumors when compared to non serous (P < .05) and normal tissue (P < .001). Expression of the gonadotrophin releasing hormone receptor I protein was also found to correlate with patient survival (P < .05). We have demonstrated gonadotrophin releasing hormone II and its receptor, gonadotrophin releasing hormone receptor I, are present in clinical ovarian samples, and that gonadotrophin releasing hormone receptor I protein expression is a favorable prognostic factor, suggesting these proteins play an important role in the development of epithelial ovarian cancer.

Selective over-expression of fibroblast growth factor receptors 1 and 4 in clinical prostate cancer

Fibroblast growth factor receptors (FGFRs) mediate the tumourigenic effects of FGFs in prostate cancer. These receptors are therefore potential therapeutic targets in the development of inhibitors to this pathway. To identify the most relevant targets, we simultaneously investigated FGFR1-4 expression using a prostate cancer tissue microarray (TMA) and in laser capture microdissected (LCM) prostate epithelial cells. In malignant prostates (n = 138) we observed significant FGFR1 and FGFR4 protein over-expression in comparison with benign prostates (n = 58; p < 0.0001). FGFR1 was expressed at high levels in the majority of tumours (69% of grade 3 or less, 74% of grade 4 and 70% of grade 5), while FGFR4 was strongly expressed in 83% of grade 5 cancers but in only 25% of grade 1-3 cancers (p < 0.0001). At the transcript level we observed a similar pattern, with FGFR1 and FGFR4 mRNA over-expressed in malignant epithelial cells compared to benign cells (p < 0.0005 and p < 0.05, respectively). While total FGFR2 was increased in some cancers, there was no association between expression and tumour grade or stage. Transcript analysis, however, revealed a switch in the predominant isoform expressed from FGFR2IIIb to FGFR2IIIc among malignant epithelial cells. In contrast, protein and transcript expression of FGFR3 was very similar between benign and cancer biopsies. The functional effect of targeting FGFR4 in prostate cancer cells has not previously been investigated. In in vitro experiments, suppression of FGFR4 by RNA interference effectively blocked prostate cancer cell proliferation (p < 0.0001) and invasion (p < 0.001) in response to exogenous stimulation. This effect was evident regardless of whether the cells expressed the FGFR4 Arg388 or Gly388 allele. In parallel experiments, FGFR3 suppression had no discernible effect on cancer cell behaviour. These results suggest evidence of selective over-expression of FGFR1 and FGFR4 in clinical prostate cancer and support the notion of targeted inhibition of these receptors to disrupt FGF signalling.

Expression of GnRH type II is regulated by the androgen receptor in prostate cancer

GnRH II has important functional effects in steroid hormone-dependent tumours. Here we investigated the expression and regulation of GnRH II in prostate cancer. GnRH II protein was equally expressed in benign (73%) and malignant (78%) biopsies studied in a prostate tissue microarray (P = 0.779). There was no relationship between expression and clinical parameters in the cancer cohort. GnRH II was, however, significantly reduced in tumour biopsies following hormone ablation. This was further investigated in a prostate xenograft model where androgens increased GnRH II levels, while their withdrawal reduced it. In cell lines, we confirmed high levels of GnRH II in androgen receptor (AR)-positive LNCaP cells but low levels in AR-negative PC3 cells. In LNCaP cells, GnRH II induction by androgens was blocked by the AR inhibitor casodex, but not by cycloheximide treatment. Sequence analysis subsequently revealed a putative androgen response element in the upstream region of the GnRH II gene and direct interaction with the AR was confirmed in chromatin immunoprecipitation experiments. Finally, to test whether the effects of GnRH II were dependent on AR expression, LNCaP and PC3 cells were exposed to exogenous peptide. In both cell lines, GnRH II inhibited cell proliferation and migration, suggesting that its function is independent of AR status. These results provide evidence that GnRH II is widely expressed in prostate cancer and is an AR-regulated gene. Further studies are warranted to characterise the effects of GnRH II on prostate cancer cells and investigate its potential value as a novel therapy.

Loss of Sef (similar expression to FGF) expression is associated with high grade and metastatic prostate cancer

Fibroblast growth factors (FGF), and in particular FGF8, have been strongly implicated in prostate carcinogenesis. This study investigated the expression of Sef, a key inhibitory regulator of FGF signalling, in prostate cancer. In a panel of cell lines, hSef was detected in both androgen-dependent and independent cells but was significantly reduced in highly metastatic derivative clones. hSef expression was not influenced by androgenic stimulation. Forced downregulation of hSef by siRNA increased FGF8b induced cell migration (P=0.02) and invasion (P=0.007). Reduced hSef levels also enhanced FGF8b stimulated expression of MMP9 (P=0.005). mRNA in situ hybridization revealed hSef expression in 80% (8/10) of benign biopsies but in only 69% (23/33) of Gleason sum 4-7 and 35% (10/28) of Gleason sum 8-10 cancer biopsies (P=0.004). Quantitative PCR of microdissected glands confirmed this trend (P=0.001). hSef was expressed in 69% (27/39) of non-metastatic tumours but in only 18% (2/11) of metastatic tumours (P=0.004, n=50). hSef expression was next correlated with earlier data on FGF8b expression in a subgroup of cancers. In this cohort, 86% (19/22) of high-grade cancers expressed FGF8 but only 31% (7/22) expressed hSef. Positive FGF8 expression but a loss of hSef was observed in 88% (7/8) of metastatic tumours. In contrast, metastasis was evident in only 10% (1/10) of tumours, which co-expressed both FGF8 and hSef (P<0.001). These results suggest evidence that hSef is downregulated in advanced prostate cancer and might facilitate an enhanced tumorigenic response to FGFs. Further research into the role of hSef in cancer cell signalling and the mechanism of its downregulation may contribute to more effective targeting of growth factors in prostate cancer.

Evidence that prostate gonadotropin-releasing hormone receptors mediate an anti-tumourigenic response to analogue therapy in hormone refractory prostate cancer

Gonadotropin-releasing hormone analogue (GnRHa) therapy is an established method of androgen withdrawal in the treatment of prostate cancer. The present study investigated if the expression of prostate GnRH receptors (GnRHRs) might influence the response to GnRHa. GnRHR protein expression was first studied in a panel of prostate cancer cell lines. In androgen-dependent cells, GnRHR expression was unchanged following acute or chronic androgen withdrawal. In these cells, GnRHa significantly inhibited androgen-induced cell proliferation (p = 0.01). In contrast, GnRHa was unable to further suppress basal levels of cell proliferation induced by androgen withdrawal. In androgen-independent prostate cancer cells, variable levels of GnRHR expression were observed. In these cells, GnRHa treatment blocked cell proliferation (p = 0.001) and invasion (up to 70%) induced by fibroblast growth factor stimulation. Crucially, this effect was only evident in cells that expressed high levels of the GnRHR. GnRHa treatment also significantly inhibited the ability of these cells to recover from a cytotoxic insult (50% inhibition). The clinical significance of prostate GnRHR was tested by immunohistochemistry in a preliminary cohort of patients treated with GnRHa or surgical castration. There was no association between GnRHR expression and pathological grade, clinical stage, time to PSA nadir (p = 0.82) (n = 35) or progression to hormone refractory disease (p = 0.22) (n = 21), irrespective of the treatment method. GnRHa therapy in the presence of high GnRHR expression however, was found to be associated with longer disease-specific survival (mean survival 85 months, p = 0.002). In contrast, high GnRHR expression was not associated with survival among surgically castrated patients (mean survival 50 months, p = 0.7). Taken together, these data support the notion of a functional interaction between GnRHa and the GnRHR, which results in an anti-tumourigenic effect on prostate cancer cells. Findings from this report have direct implications for the use of GnRHR as a novel therapeutic target in hormone refractory prostate cancer.

FGF8 isoform b expression in human prostate cancer

Overexpression of fibroblast growth factor 8 (FGF8) mRNA has been previously described in prostate cancer. Of its four isoforms, FGF8b is thought to be the most important in carcinogenesis. We hypothesised that immunodetection of FGF8b in archival prostate cancer specimens is of potential prognostic value. Using a selected cohort of prostate tumours from transurethral (n=30) and radical prostatectomies (n=59), an optimised protocol for FGF8b immunoreactivity was used to corroborate expression with clinical parameters. No expression was observed in benign prostates (n=10). In prostate cancer, immunoreactivity was localised to the malignant epithelium with weak signals in the adjacent stroma. Expression of FGF8b in stage T1 and T2 cancers were 40 and 67%, respectively. In contrast, FGF8b expression was present in 94% of T3 and 100% of T4 cancers. By histological grade, FGF8b was found in 41% of low-grade cancers (Gleason score 4-6), 60% of intermediate-grade cancers (Gleason score 7 and 92% of high-grade cancers (Gleason score 8-10). The intensity of expression was significantly associated with stage (P=0.0004) and grade (P<0.0001) of disease. We further hypothesised that FGF8b overexpression resulted from enhanced transcription and translation rather than from abnormalities involving the FGF8 gene locus. This was tested by means of fluorescent in situ hybridisation in 20 cancer specimens to map the FGF8 gene locus. FGF8 gene copy number in benign and malignant nuclei was found to be similar (2.33+/-0.57 and 2.0+/-0.81, respectively P=0.51). Based on these findings, we propose a multicentre study on cohorts of patients to further evaluate FGF8b as a potential prognostic marker in prostate cancer.

Expression of RAC 3, a steroid hormone receptor co-activator in prostate cancer

RAC 3, one of the p160 family of co-activators is known to enhance the transcriptional activity of a number of steroid receptors. As co-activators are also known to enhance androgen receptor (AR) activity, we investigated the role of RAC 3 in the context of prostate cancer. In prostate cancer cell lines, we found variable levels of the RAC 3 protein with highest expression seen in AR-positive LNCaP cells, moderate expression in AR-negative PC 3 cells and low-level expression in AR-negative DU 145 cells. Immuno-precipitation studies showed that endogenous RAC 3 interacted with the AR in vivo and transfection assays confirmed that RAC 3 enhanced AR transcriptional activity. In clinical prostate tissue, we found strong RAC 3 mRNA expression and immuno-histochemistry demonstrated that in benign tissue, the protein was expressed predominantly in luminal cells, while in primary malignant epithelium it was more homogeneously expressed. In a series of 37 patients, the levels of RAC 3 expression correlated significantly with tumour grade (P = 0.01) and stage of disease (P = 0.03) but not with serum PSA levels. In addition moderate or high RAC 3 expression was associated with poorer disease-specific survival (P = 0.03). We conclude that RAC 3 is an important co-activator of the AR in the prostate and may have an important role in the progression of prostate cancer.

Laparoscopic pyeloplasty, initial experience in the management of UPJO

AIM

Laparoscopic pyeloplasty (LP) has emerged in the last 8 years as an alternative to open surgery. We here present the results of our series of patients and evaluate LP in the management of ureteropelvic junction obstruction (UPJO).

PATIENTS AND METHODS

Patients with UPJO confirmed by renogram and/or symptoms were offered surgical correction by LP. The risks, alternatives, and novelty of the technique at our centre were explained to obtain informed consent. Patients were assessed pre- and postoperatively and data including operative time, analgesic requirements, time to self care and full activity were recorded. Fifteen patients with a mean age of 38.4 years were recruited in whom 13 successful Anderson Hayes transperitoneal LPs were performed in 12 patients.

RESULTS

Mean operative time was 261 min and blood loss was minimal. Analgesic requirements were also minimal with patients requiring PCA for an average of 1.1 days. Average days to free fluids were 1.5 days and the mean hospital stay was 4.4 days. Average number of days to self care and full activity were 3.2 and 12.2 days, respectively. Patients in employment returned to work after an average of 4.4 weeks, In 9/10 cases with pre-operative loin pain, patients had symptom relief following surgery. Postoperative renogram at 6 months confirmed improved drainage in 12 LP procedures. At a mean follow up of 20 months, 11/12 patients remain symptomatically well.

CONCLUSIONS

In this series, LP operative times and outcome closely match those of larger series and the functional results are comparable to open pyeloplasty. We conclude that LP is a suitable first line option for UPJO surgery provided standard laparoscopic equipment and a trained urologist are available.

Insulin-like growth factor II and androgen receptor expression in the prostate

OBJECTIVE

To determine the effect of insulin-like growth factor (IGF)-II on androgen receptor (AR) expression in prostate tissue, as IGFs may be important in re-activating androgen-regulated genes in advanced prostate cancer because they can trans-activate the AR in the absence of ligand. Materials and methods Primary BPH stromal cells, LNCaP and U2OS cells were grown in full medium, medium devoid of growth factors and devoid medium supplemented with IGF-II. The relationship between IGF-II and AR expression was then investigated using the reverse-transcription polymerase chain reaction, and the effects of anti-androgens on IGF-II expression assessed using northern blot analysis.

RESULTS

IGF-II had no effect in benign tissue, but the AR expression doubled in LNCaP and U2OS cells after culture with IGF-II. Androgens had a minimal effect on IGF-II mRNA levels, but anti-androgens reduced IGF-II mRNA levels by more than half.

CONCLUSION

These findings support the idea of a complementary paracrine (IGF) and autocrine (androgen) growth loop in prostate tissue. The study suggests that IGF-II has a role in regulating AR expression in prostate cancer cells, and that the action of anti-androgens is mediated partly by an ability to suppress IGF-II expression.

Primary in situ extracorporeal shock wave lithotripsy in the management of ureteric calculi: results with a third-generation lithotripter

OBJECTIVE

To review the results of primary in situ extracorporeal shock wave lithotripsy (ESWL) for the treatment of ureteric stones using a third-generation lithotripter, the Dornier MFL 5000 (Dornier Medizentechnic, Germany).

PATIENTS AND METHODS

The study comprised a retrospective review of treatment outcome in 180 patients with 196 stones who were treated with primary in situ ESWL, assessing the success of this approach and establishing reasons for failure.

RESULTS

At the 3-month follow-up, 88% of patients were stone-free; 21 patients failed ESWL and were treated by ureteroscopic stone extraction with no complications. Stone-free rates were 90% for upper ureteric, 89% for middle-third and 86% for lower-third calculi. Twenty-one patients required auxiliary procedures in the form of JJ stenting or nephrostomy. Failure of ESWL was associated with stone size (>1.3 cm) but not location or inadequate treatment.

CONCLUSION

Where prompt access to ESWL is available, primary in situ ESWL remains an effective form of treatment for all ureteric calculi, although stone-free rates are lower for larger stones.

Transforming growth factor-beta1 up-regulates p15, p21 and p27 and blocks cell cycling in G1 in human prostate epithelium

Transforming growth factor-beta1 (TGFbeta1) is inhibitory to most epithelia, but its role in the control of proliferation of prostatic epithelium is unclear. In some cells, TGFbeta1 inhibition is achieved by up-regulation of cyclin-dependent kinase (cdk) inhibitors including p15, p21 and p27. Our aims were to determine whether the effects of TGFbeta1 on human prostatic epithelial cell cycle kinetics were mediated by alterations in the levels of the cdk inhibitors p15, p16, p21 and p27 and hypo-phosphorylated retinoblastoma protein (Rb). Human prostatic epithelial cells in primary culture were grown in the presence of TGFbeta1 (0-10 ng/ml) for up to 4 days and proliferation assessed using a [3H]thymidine uptake assay. Levels of p15, p16, p21 and p27 were measured at both mRNA and protein level by means of a reverse transcriptase PCR-based assay and Western analysis. Rb and cdk2 levels were measured. Exogenous TGFbeta1 (0-5 ng/ml) inhibited proliferation. This was associated with blocking of the cell cycle at G1, and up to 4-fold increases in p15, p21 and p27 mRNA levels, but no change was observed in p16 mRNA levels; these changes were not blocked by cycloheximide. Increased levels of p15, p21 and p27 protein were also accompanied by increased levels of hypo-phosphorylated Rb and decreased cdk2 kinase activity. TGFbeta1 has mainly inhibitory effects on benign human prostatic epithelium, which are caused by up-regulation of cdk inhibitors, hypo-phosphorylation of Rb and delaying of the cell cycle in G1.