Novel insights into the pharmacology of flavonoids.

Flavonoids are widely distributed secondary metabolites and currently consumed in large amounts in the daily diet. In this article, some of the most recent developments in flavonoid - and related polyphenolic compounds - pharmacology are discussed, with particular emphasis on very recent data, most of which are published in Phytotherapy Research, which highlight new aspects in flavonoid anti-inflammatory, antilipidemic, antihyperglycemic, antiviral, hepatoprotective, gastric antiulcer, cardioprotective, neuroprotective, antioxidant and anticancer actions. These updated data confirm the well-established diverse beneficial pharmacological actions and might support the perspective for a therapeutic use.

Therapeutic targeting of P2X4 receptor and mitochondrial metabolism in clear cell renal carcinoma models.

BACKGROUND: Clear cell renal cell carcinoma (ccRCC) is the most common subtype of renal cancer. Large-scale metabolomic data have associated metabolic alterations with the pathogenesis and progression of renal carcinoma and have correlated mitochondrial activity with poor survival in a subset of patients. The aim of this study was to determine whether targeting mitochondria-lysosome interaction could be a novel therapeutic approach using patient-derived organoids as avatar for drug response. METHODS: RNAseq data analysis and immunohistochemistry were used to show overexpression of Purinergic receptor 4 (P2XR4) in clear cell carcinomas. Seahorse experiments, immunofluorescence and fluorescence cell sorting were used to demonstrate that P2XR4 regulates mitochondrial activity and the balance of radical oxygen species. Pharmacological inhibitors and genetic silencing promoted lysosomal damage, calcium overload in mitochondria and cell death via both necrosis and apoptosis. Finally, we established patient-derived organoids and murine xenograft models to investigate the antitumor effect of P2XR4 inhibition using imaging drug screening, viability assay and immunohistochemistry. RESULTS: Our data suggest that oxo-phosphorylation is the main source of tumor-derived ATP in a subset of ccRCC cells expressing P2XR4, which exerts a critical impact on tumor energy metabolism and mitochondrial activity. Prolonged mitochondrial failure induced by pharmacological inhibition or P2XR4 silencing was associated with increased oxygen radical species, changes in mitochondrial permeability (i.e., opening of the transition pore complex, dissipation of membrane potential, and calcium overload). Interestingly, higher mitochondrial activity in patient derived organoids was associated with greater sensitivity to P2XR4 inhibition and tumor reduction in a xenograft model. CONCLUSION: Overall, our results suggest that the perturbed balance between lysosomal integrity and mitochondrial activity induced by P2XR4 inhibition may represent a new therapeutic strategy for a subset of patients with renal carcinoma and that individualized organoids may be help to predict drug efficacy.

Italian Prostate Biopsies Group: 2016 Updated Guidelines Insights.

AIM: To present a summary of the updated guidelines of the Italian Prostate Biopsies Group following the best recent evidence of the literature. MATERIALS AND METHODS: A systematic review of the new data emerging from 2012-2015 was performed by a panel of 14 selected Italian experts in urology, pathology and radiology. The experts collected articles published in the English-language literature by performing a search using Medline, EMBASE and the Cochrane Library database. The articles were evaluated using a systematic weighting and grading of the level of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation framework system. RESULTS: An initial prostate biopsy is strongly recommended when i) prostate specific antigen (PSA) >10 ng/ml, ii) digital rectal examination is abnormal, iii) multiparametric magnetic resonance imaging (mpMRI) has a Prostate Imaging Reporting and Data System (PIRADS) ≥4, even if it is not recommended. The use of mpMRI is strongly recommended only in patients with previous negative biopsy. At least 12 cores should be taken in each patient plus targeted (fusion or cognitive) biopsies of suspicious area (at mpMRI or transrectal ultrasound). Saturation biopsies are optional in all settings. The optimal strategy for reducing infection complications is still a controversial topic and the instruments to reduce them are actually weak. The adoption of Gleason grade groups in adjunction to the Gleason score when reporting prostate biopsy results is advisable. CONCLUSION: These updated guidelines and recommendations are intended to assist physicians and patients in the decision-making regarding when and how to perform a prostatic biopsy.

PSA declines and survival in patients with metastatic castration-resistant prostate cancer treated with enzalutamide: A retrospective case-report study.

RATIONALE: PSA responses have been associated with a survival benefit in patients treated with enzalutamide in retrospective analyses. PATIENT CONCERNS: However the prognostic value of PSA declines in highly pretreated patients receiving enzalutamide remains to be defined. DIAGNOSES AND INTERVENTATIONS: Medical records of patients with documented mCRPC treated with enzalutamide between September 2011 and August 2016 were reviewed at multiple participating centers and assessed for overall survival (OS), PSA variations, and other variables of interest. Univariable and multivariable analyses were conducted. OUTCOMES: A total of 129 patients received enzalutamide. PSA response rates (>50% PSA declines) were 58/119 (48.7%), 58/115 (50.4%), 54/110 (49.1%), and 47/91 (51.7%) at weeks 4, 8, 12, and 16, respectively. Having a PSA response was a statistically significant prognostic factor of improved OS at 8 and 12 weeks in univariable analysis, whereas it was significant at 12 weeks in the multivariable analysis. Patients treated with enzalutamide had a median OS of 7.8 months. LESSONS: Our study supports the prognostic value of PSA declines in heavily treated patients receiving enzalutamide.

Prognostic significance of multidrug-resistance protein (MDR-1) in renal clear cell carcinomas: a five year follow-up analysis.

BACKGROUND: A large number of renal cancer patients shows poor or partial response to chemotherapy and the mechanisms have not been still understood. Multi-drug resistance is the principal mechanism by which many cancers develop resistance to chemotherapic drugs. The role of the multi-drug resistant transporter (MDR-1/P-glycoprotein), the gene product of MDR-1, and that one of the so-called multi-drug resistance associated protein (MRP), two energy-dependent efflux pumps, are commonly known to confer drug resistance. We studied MDR-1 expression in selected cases of renal cell carcinoma (RCC), clear cell type, with long-term follow-up, in order to establish its prognostic role and its possible contribution in the choice of post-surgical therapy. METHODS: MDR-1 has been studied by standard LSAB-HRP immunohistochemical technique, in paraffin embedded RCC samples. Protein expression has been compared to clinical and histopathological data and to disease specific survival of RCC patients, by Kaplan-Meier curve and Cox multivariate regression analyses. RESULTS: Two groups of RCCs were obtained by esteeming MDR-1 expression and disease specific survival (obtained with Kaplan-Meier curve and Cox multivariate regression analyses): the first one presents low or absent MDR-1 expression and good survival; the second one is characterized by high MDR-1 expression and significant poor outcome (p < 0.05). Afterwards, we have found disease specific survival, adjusted for stages and independent of therapy: this difference of survival rates was statistically significant (p < 0.05). Stage adjusted disease specific survival rate, according to MDR-1 expression and therapy in patients affected by RCC in early stage (stage I), has revealed that the group of patients with high MDR-1 expression and without adjuvant therapy showed poor survival (p < 0.05). Cox multivariate regression analysis has confirmed that, in our cohort of RCC (clear cell type) patients, the strong association between MDR-1 and worse outcome is independent not only of the adjuvant therapy, but also of the other prognostic parameters (p < 0.05). CONCLUSION: In our opinion, the results of this study well prove the relationship between MDR-1 expression and worse clinical prognosis in RCC, because MDR-1 over-expressing RCCs can be considered a group of tumours with a more aggressive behavior. This finding outlines a possible role of MDR-1 as prognostic factor, dependent and independent of multidrug resistance. These results could be useful to predict cancer evolution and to choose the appropriate treatment: this is another step that can stimulate further promising and interesting investigations on broader study population.

Kulkarni Dorsolateral Graft Urethroplasty Using Penile Skin.

OBJECTIVES: To investigate the safety, efficacy, and versatility of dorsolateral graft urethroplasty using penile skin. MATERIALS AND METHODS: Between 2010 and 2013, 37 men with anterior urethral strictures underwent dorsolateral graft urethroplasty using penile skin by a single surgeon (EP). Inclusion criterion was patients with anterior urethral strictures. Exclusion criteria were lichen sclerosus-related strictures, absence of available penile skin because of previous surgery, and obliterative urethral strictures. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation. RESULTS: Mean (± standard deviation) patients age was 51 (±15.4) years. Stricture etiology was iatrogenic in 25 cases (67%), unknown in 10 (27%), trauma in 2 (6%). Stricture site was penile in 21 (57%) and peno-bulbar in 16 (43%). Median (range) stricture length was 5 cm (1-15). Of 37 patients, 30 (81%) had received previous treatments. Median (range) follow-up was 21 months (12-47). Of 37 patients, 34 (92%) had successful treatment and 3 (8%) had failed treatment. The 3 patients with failed treatment were treated with urethrostomy and are awaiting further reconstruction. Study limitations include the small sample size and the limited follow-up. CONCLUSION: With a mid-term follow-up time, the dorsolateral graft urethroplasty using penile skin is shown to be a safe, efficient, and versatile technique for the repair of short-mid-long anterior urethral strictures.

How can we improve prognostic models in renal cell carcinoma?

The therapeutic improvements in renal cell carcinoma brought about by the transition from the 'cytokine era' to the 'targeted agents era', have not affected the peculiar prognostic heterogeneity of the disease, nor have they diminished the importance of risk group classification based on easily assessable and commonly available laboratory and clinical variables. In the landmark study conducted by Motzer et al. before biological agents were available, the median survival of patients in the good prognosis group was 20 months, while the patients in the poor-risk group had a median survival time of only 4 months. With the introduction of anti-VEGF agents, overall survival has approximately doubled in all risk classes. In a population-based analysis of 670 patients treated with anti-VEGF agents, either in the first-line setting or in the second-line setting after cytokines, stratification according to the Database Consortium model showed that patients in the favorable risk group had a median overall survival of 43.2 months, while patients in the poor-risk group had a median overall survival of 7.8 months.

Effect of Non-psychotropic Plant-derived Cannabinoids on Bladder Contractility: Focus on Cannabigerol.

There are anecdotal reports that some Cannabis preparations may be useful for bladder dysfunctions. Here, we investigated the effect of a number of non- psychotropic phytocannabinoids, namely cannabidiol (CBD), cannabigerol (CBG), cannabidivarin (CBDV), Δ9-tetrahydrocannabivarin (THCV) and cannabichromene (CBC) on mouse bladder contractility in vitro. CBG, THCV, CBD and CBDV, but not CBC, at concentration ranging from 10(-8) M to 10(-4) M, decreased (with similar potency), the contractions induced by acetylcholine without significantly modifying the contractions induced by electrical stimulation. The rank order of efficacy was CBG=THCV>CBD>CBDV. In depth studies on CBG showed that the effect of this phytocannabinoid on acetylcholine-induced contractions was not affected by CB1 or CB2 receptor antagonists. Additionally, CBG also reduced acetylcholine-induced contractions in the human bladder.

Third-Line Chemotherapy for Metastatic Urothelial Cancer: A Retrospective Observational Study.

The prognosis of locally advanced (T3/T4 or N1) and metastatic disease urothelial carcinoma is poor. In this retrospective study, we reviewed data about patients receiving third-line chemotherapy for metastatic disease, in view of the lack of data in this setting.We retrospectively analyzed medical records of patients with a pathologic diagnosis of urothelial carcinoma treated with systemic chemotherapy for metastatic disease at 4 participating Institutions between January, 2010, and January, 2015. Cox proportional hazards regression was used to evaluate the association of the chemotherapy agent used versus others with overall survival, adjusted for 5 externally validated prognostic factors in advanced urothelial carcinoma.Of 182 patients that received first-line chemotherapy/adjuvant chemotherapy as defined above, 116 patients (63.73%) received second-line salvage treatment. Fifty-two patients were finally included in this analysis, whereas 9 were excluded due to missing data. Third-line chemotherapy was based on cyclophosphamide, platinum, vinflunine, taxanes, and gemcitabine in 16, 12, 11, 10, and 3 patients, respectively. Median PFS (progression-free survival) and OS (overall survival) of the population were 13 (10-17) and 31 (28-36) weeks. Single-agent cyclophosphamide was associated with a PFS of 18 (13-22) and an OS of 38 (33-41) weeks, whereas platinum-based combinations were associated with a PFS of 5 weeks and an OS of 8 weeks. Multivariate analysis showed improved survival in patients treated with cyclophosphamide (hazard ratio (HR) = 0.42; 95% CI: 0.20-0.89; P = 0.025) and a worse survival in those treated with platinum-based regimens (HR: 4.37; 95% CI = 1.95-9.77; P < 0.01).We observed a significantly longer overall survival in patients receiving single-agent cyclophosphamide, with few grade 3 to 4 toxicities. Further studies should assess the efficacy of metronomic single-agent cyclophosphamide in advanced lines of treatment, as it may yield a survival benefit with low costs and no detrimental effects on quality of life.

[How to apply follow-up in relation to risk group]. / Come attuare il follow-up in rapporto alla categoria di rischio.

The term 'Non-muscle invasive bladder cancer' identifies a heterogeneous disease due to different natural history of its various appearances. T1 stage represents a non-predictable population, which might respond to non-operative treatment strategies or to the need of a more aggressive treatment, in order to avoid the progression to invasive, and possibly to metastatic stages. In the first year following transurethral resection of bladder (TURB), tumor recurrence is seen in up to 45% of the population; of this, 15% may progress to muscle invasive or metastatic disease, or both. In order to control the recurrence and progression and identify invasive tumors at the earliest possible stage, it is strongly necessary to define individual patient risk assessment follow-up. To obtain exact staging, besides a proper transurethral resection of bladder, a restaging transurethral resection of bladder should be performed in T1 patients. Data from literature support the immediate postoperative intravesical instillation of different chemotherapeutic agents in low-risk patients. Multifocal papillary lesions might require a more intensive adjuvant regimen, whereas intravesical immunotherapy using Bacillus Calmette-Guérin is recommended in patients at high risk of progression. Early cystectomy should be considered in patients with recurrent T1 tumors or refractory carcinoma in situ to avoid unfavorable tumor progression.

Inhibitory effect of standardized cannabis sativa extract and its ingredient cannabidiol on rat and human bladder contractility.

OBJECTIVES: To evaluate the effect of a Cannabis sativa extract enriched in cannabidiol (CBD) botanic drug substance (BDS) and pure CBD, on bladder contractility in vitro. Cannabis based-medicines, including CBD-enriched extracts, have been shown to reduce urinary urgency, incontinence episodes, frequency, and nocturia in patients with multiple sclerosis. METHODS: Strips were cut from male Wistar rats and the human bladder body and placed in organ baths containing Krebs solution. Contractions were induced by electrical field stimulation, acetylcholine, KCl, and α,ß-methylene adenosine triphosphate. RESULTS: CBD BDS significantly reduced the contractions induced by acetylcholine, but not those induced with electrical field stimulation, KCl, or α,ß-methylene adenosine triphosphate in the isolated rat bladder. The inhibitory effect of CBD BDS was not significantly modified by the cannabinoid or opioid receptor antagonists or by modulators of calcium levels, but it was increased by ruthenium red and capsazepine, 2 transient receptor potential vanilloid type-1 blockers. In humans, CBD BDS and pure CBD significantly reduced acetylcholine-induced contractions, an effect that was not changed by the transient receptor potential vanilloid type-1 blockers. CONCLUSIONS: Our data have suggested that CBD BDS reduces cholinergic-mediated contractility and that this effect is modulated by transient receptor potential vanilloid type-1 in rats but not in humans. CBD is the chemical ingredient of CBD BDS responsible for such activity. If confirmed in vivo, such results could provide a pharmacologic basis to explain, at least in part, the efficacy of Cannabis medicines in reducing incontinence episodes in patients with multiple sclerosis.

Matrix metalloproteinase-2 and -9 in the urine of prostate cancer patients.

The matrix metalloproteinase family of enzymes is comprised of critically important extracellular proteases whose activity has been implicated in a number of key normal and pathological processes. The latter include growth, progression and metastasis as well as dysregulated angiogenesis that is associated with these events. The MMPs are secreted by all types of cells, and they also carve through the extracellular matrix, allowing cancer cells to take root and metastasize. Endogenous inhibitors typically hold MMPs in check but in cancer, the balance shifts against the inhibitors and in favor of MMPs, which ultimately spill over from blood into urine. By gelatin zymography we verified MMP activity in concentrated urine of patients with prostate disease. Of these patients, 30 had cancer, consisting of 13 with Gleason score 6, 12 with Gleason 7, 2 with Gleason 8, 3 with Gleason 9 and 8 had benign prostate hyperplasia. Zymography showed 4 dominant gelatinolityc bands of 240, 130, 92 and 72 kDa in prostate disease. The most abundant lytic activity is at 92 kDa (MMP-9), whereas MMP-2 is present in lesser quantities. Moreover, MMP-9 activity is enhanced in the urine from patients with benign prostate hyperplasia compared with cancer patients. No correlation between gelatinolytic activity and Gleason score or pathological findings was found.

Effects of the antidepressant St. John's wort (Hypericum perforatum) on rat and human vas deferens contractility.

PURPOSE: Since sexual dysfunction related to vas deferens smooth muscle contractility is a possible side effect of St. John's wort (SJW) (Hypericum perforatum) we evaluated the effect of this herbal antidepressant on rat and human vas deferens contractility. MATERIALS AND METHODS: The effect of SJW was evaluated on contractions induced by electrical field stimulation or exogenous agonists (alpha,beta-methylene adenosine triphosphate and phenylephrine) in isolated rat and human vas deferens. RESULTS: SJW (1 to 300 microM) decreased in a concentration dependent manner the amplitude of electrical field stimulation and agonist induced contractions with the same potency, suggesting direct inhibition of rat vas deferens smooth muscle. Of the chemical constituents of SJW tested hyperforin but not hypericin or the flavonoids quercitrin, rutin and kaempferol inhibited phenylephrine induced contractions. SJW and hyperforin also inhibited phenylephrine induced contractions in human vas deferens CONCLUSIONS: The results of our study demonstrate that SJW directly inhibits rat and human vas deferens contractility. If confirmed in vivo, these results suggest that SJW might affect sexual function in humans. These results might explain delayed ejaculation described in patients receiving SJW.