Large-scale pathway specific polygenic risk and transcriptomic community network analysis identifies novel functional pathways in Parkinson disease.

Polygenic inheritance plays a central role in Parkinson disease (PD). A priority in elucidating PD etiology lies in defining the biological basis of genetic risk. Unraveling how risk leads to disruption will yield disease-modifying therapeutic targets that may be effective. Here, we utilized a high-throughput and hypothesis-free approach to determine biological processes underlying PD using the largest currently available cohorts of genetic and gene expression data from International Parkinson's Disease Genetics Consortium (IPDGC) and the Accelerating Medicines Partnership-Parkinson's disease initiative (AMP-PD), among other sources. We applied large-scale gene-set specific polygenic risk score (PRS) analyses to assess the role of common variation on PD risk focusing on publicly annotated gene sets representative of curated pathways. We nominated specific molecular sub-processes underlying protein misfolding and aggregation, post-translational protein modification, immune response, membrane and intracellular trafficking, lipid and vitamin metabolism, synaptic transmission, endosomal-lysosomal dysfunction, chromatin remodeling and apoptosis mediated by caspases among the main contributors to PD etiology. We assessed the impact of rare variation on PD risk in an independent cohort of whole-genome sequencing data and found evidence for a burden of rare damaging alleles in a range of processes, including neuronal transmission-related pathways and immune response. We explored enrichment linked to expression cell specificity patterns using single-cell gene expression data and demonstrated a significant risk pattern for dopaminergic neurons, serotonergic neurons, hypothalamic GABAergic neurons, and neural progenitors. Subsequently, we created a novel way of building de novo pathways by constructing a network expression community map using transcriptomic data derived from the blood of PD patients, which revealed functional enrichment in inflammatory signaling pathways, cell death machinery related processes, and dysregulation of mitochondrial homeostasis. Our analyses highlight several specific promising pathways and genes for functional prioritization and provide a cellular context in which such work should be done.

Concomitant CIS on TURBT does not impact oncological outcomes in patients treated with neoadjuvant or induction chemotherapy followed by radical cystectomy.

BACKGROUND: Cisplatin-based neoadjuvant chemotherapy (NAC) for muscle invasive bladder cancer improves all-cause and cancer specific survival. We aimed to evaluate whether the detection of carcinoma in situ (CIS) at the time of initial transurethral resection of bladder tumor (TURBT) has an oncological impact on the response to NAC prior to radical cystectomy. PATIENTS AND METHODS: Patients were identified retrospectively from 19 centers who received at least three cycles of NAC or induction chemotherapy for cT2-T4aN0-3M0 urothelial carcinoma of the bladder followed by radical cystectomy between 2000 and 2013. The primary and secondary outcomes were pathological response and overall survival, respectively. Multivariable analysis was performed to determine the independent predictive value of CIS on these outcomes. RESULTS: Of 1213 patients included in the analysis, 21.8% had concomitant CIS. Baseline clinical and pathologic characteristics of the 'CIS' versus 'no-CIS' groups were similar. The pathological response did not differ between the two arms when response was defined as pT0N0 (17.9% with CIS vs 21.9% without CIS; p = 0.16) which may indicate that patients with CIS may be less sensitive to NAC or ≤ pT1N0 (42.8% with CIS vs 37.8% without CIS; p = 0.15). On Cox regression model for overall survival for the cN0 cohort, the presence of CIS was not associated with survival (HR 0.86 (95% CI 0.63-1.18; p = 0.35). The presence of LVI (HR 1.41, 95% CI 1.01-1.96; p = 0.04), hydronephrosis (HR 1.63, 95% CI 1.23-2.16; p = 0.001) and use of chemotherapy other than ddMVAC (HR 0.57, 95% CI 0.34-0.94; p = 0.03) were associated with shorter overall survival. For the whole cohort, the presence of CIS was also not associated with survival (HR 1.05 (95% CI 0.82-1.35; p = 0.70). CONCLUSION: In this multicenter, real-world cohort, CIS status at TURBT did not affect pathologic response to neoadjuvant or induction chemotherapy. This study is limited by its retrospective nature as well as variability in chemotherapy regimens and surveillance regimens.

Complications of pelvic lymph node dissection for prostate cancer.

Pelvic lymph node dissection (PLND) represents the standard for detection of occult pelvic nodal metastases from prostate cancer, and may be performed separately from or at the time of radical prostatectomy. In addition to its potential for diagnostic staging, a PLND may be therapeutic in some patients. However, considerable debate centers on the appropriate candidates for the procedure, the extent and proper boundaries of dissection, optimal surgical approach, and absolute oncologic benefit. Several series suggest that there likely is limited benefit of PLND in low-risk patients and that PLND can be safely omitted in a high percentage of men undergoing contemporary radical prostatectomy. Furthermore, the value of PLND in patients with intermediate- and high-risk disease must be balanced against the potential morbidity of the procedure. In the setting of this debate, concern over morbidity directly attributable to this procedure is of paramount importance. This review focuses on the complications associated with PLND, including lymphocele, thromboembolic events, ureteral injury, nerve injury, vascular injury, and lymphedema.

Nomogram Predicting Bladder Cancer-specific Mortality After Neoadjuvant Chemotherapy and Radical Cystectomy for Muscle-invasive Bladder Cancer: Results of an International Consortium.

BACKGROUND: Cisplatin-based neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (MIBC) is associated with improved overall and cancer-specific survival. The post-NAC pathological stage has previously been reported to be a major determinant of outcome. OBJECTIVE: To develop a postoperative nomogram for survival based on pathological and clinical parameters from an international consortium. DESIGN, SETTING, AND PARTICIPANTS: Between 2000 and 2015, 1866 patients with MIBC were treated at 19 institutions in the USA, Canada, and Europe. Analysis was limited to 640 patients with adequate follow-up who had received three or more cycles of NAC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A nomogram for bladder cancer-specific mortality (BCSM) was developed by multivariable Cox regression analysis. Decision curve analysis was used to assess the model's clinical utility. RESULTS AND LIMITATIONS: A total of 640 patients were identified. Downstaging to non-MIBC (ypT1, ypTa, and ypTis) occurred in 271 patients (42 %), and 113 (17 %) achieved a complete response (ypT0N0). The 5-yr BCSM was 47.2 % (95 % confidence interval [CI]: 41.2-52.6 %). On multivariable analysis, covariates with a statistically significant association with BCSM were lymph node metastasis (hazard ratio [HR] 1.90 [95% CI: 1.4-2.6]; p < 0.001), positive surgical margins (HR 2.01 [95 % CI: 1.3-2.9]; p < 0.001), and pathological stage (with ypT0/Tis/Ta/T1 as reference: ypT2 [HR 2.77 {95 % CI: 1.7-4.6}; p < 0.001] and ypT3-4 [HR 5.9 {95 % CI: 3.8-9.3}; p < 0.001]). The area under the curve of the model predicting 5-yr BCSM after cross validation with 300 bootstraps was 75.4 % (95 % CI: 68.1-82.6 %). Decision curve analyses showed a modest net benefit for the use of the BCSM nomogram in the current cohort compared with the use of American Joint Committee on Cancer staging alone. Limitations include the retrospective study design and the lack of central pathology. CONCLUSIONS: We have developed and internally validated a nomogram predicting BCSM after NAC and radical cystectomy for MIBC. The nomogram will be useful for patient counseling and in the identification of patients at high risk for BCSM suitable for enrollment in clinical trials of adjuvant therapy. PATIENT SUMMARY: In this report, we looked at the outcomes of patients with muscle-invasive bladder cancer in a large multi-institutional population. We found that we can accurately predict death after radical surgical treatment in patients treated with chemotherapy before surgery. We conclude that the pathological report provides key factors for determining survival probability.

The avian nature of the brain and inner ear of Archaeopteryx.

Archaeopteryx, the earliest known flying bird (avialan) from the Late Jurassic period, exhibits many shared primitive characters with more basal coelurosaurian dinosaurs (the clade including all theropods more bird-like than Allosaurus), such as teeth, a long bony tail and pinnate feathers. However, Archaeopteryx possessed asymmetrical flight feathers on its wings and tail, together with a wing feather arrangement shared with modern birds. This suggests some degree of powered flight capability but, until now, little was understood about the extent to which its brain and special senses were adapted for flight. We investigated this problem by computed tomography scanning and three-dimensional reconstruction of the braincase of the London specimen of Archaeopteryx. Here we show the reconstruction of the braincase from which we derived endocasts of the brain and inner ear. These suggest that Archaeopteryx closely resembled modern birds in the dominance of the sense of vision and in the possession of expanded auditory and spatial sensory perception in the ear. We conclude that Archaeopteryx had acquired the derived neurological and structural adaptations necessary for flight. An enlarged forebrain suggests that it had also developed enhanced somatosensory integration with these special senses demanded by a lifestyle involving flying ability.

The association between body size, prostate volume and prostate-specific antigen.

Increasing prostate volume contributes to urinary tract symptoms and may obscure prostate cancer detection. We investigated the association between obesity and prostate volume, prostate-specific antigen (PSA) and PSA density among 753 men referred for prostate biopsy. Among men with a negative biopsy, prostate volume significantly increased approximately 25% from the lowest to highest body mass index (BMI), waist or hip circumference or height categories. PSA was 0.7 ng/ml lower with a high waist-to-hip ratio. These associations were less consistent among subjects diagnosed with high-grade prostatic intraepithelial neoplasia or cancer. Our data suggest that obesity and height are independently associated with prostate volume..

Cross-disorder genome-wide analyses suggest a complex genetic relationship between Tourette's syndrome and OCD.

OBJECTIVE: Obsessive-compulsive disorder (OCD) and Tourette's syndrome are highly heritable neurodevelopmental disorders that are thought to share genetic risk factors. However, the identification of definitive susceptibility genes for these etiologically complex disorders remains elusive. The authors report a combined genome-wide association study (GWAS) of Tourette's syndrome and OCD. METHOD: The authors conducted a GWAS in 2,723 cases (1,310 with OCD, 834 with Tourette's syndrome, 579 with OCD plus Tourette's syndrome/chronic tics), 5,667 ancestry-matched controls, and 290 OCD parent-child trios. GWAS summary statistics were examined for enrichment of functional variants associated with gene expression levels in brain regions. Polygenic score analyses were conducted to investigate the genetic architecture within and across the two disorders. RESULTS: Although no individual single-nucleotide polymorphisms (SNPs) achieved genome-wide significance, the GWAS signals were enriched for SNPs strongly associated with variations in brain gene expression levels (expression quantitative loci, or eQTLs), suggesting the presence of true functional variants that contribute to risk of these disorders. Polygenic score analyses identified a significant polygenic component for OCD (p=2×10(-4)), predicting 3.2% of the phenotypic variance in an independent data set. In contrast, Tourette's syndrome had a smaller, nonsignificant polygenic component, predicting only 0.6% of the phenotypic variance (p=0.06). No significant polygenic signal was detected across the two disorders, although the sample is likely underpowered to detect a modest shared signal. Furthermore, the OCD polygenic signal was significantly attenuated when cases with both OCD and co-occurring Tourette's syndrome/chronic tics were included in the analysis (p=0.01). CONCLUSIONS: Previous work has shown that Tourette's syndrome and OCD have some degree of shared genetic variation. However, the data from this study suggest that there are also distinct components to the genetic architectures of these two disorders. Furthermore, OCD with co-occurring Tourette's syndrome/chronic tics may have different underlying genetic susceptibility compared with OCD alone.

Oxidative stress and motor neurone disease.

The effects of oxidative stress within post mitotic cells such as neurones may be cumulative, and injury by free radical species is a major potential cause of the age-related deterioration in neuronal function seen in several neurodegenerative diseases. There is strong evidence that oxidative stress plays an important role in the pathogenesis of motor neurone disease (MND). Point mutations in the antioxidant enzyme Cu,Zn superoxide dismutase (SOD1) are found in some pedigrees with the familial form of MND. How mutations in this ubiquitous enzyme cause the relatively selective cell death of specific groups of motor neurones is not clear, although a number of hypotheses have been forwarded. These include (1) the formation of hydroxyl radicals, (2) the catalysis of reactions of the nitrogen centred oxidant species peroxynitrite, (3) toxicity of copper or zinc and (4) protein aggregation. Some experimental support for these different hypotheses has been produced by manipulating cells in culture to express the mutant SOD1 proteins and by generating transgenic mice which over-express mutant SOD1. Observations in these model systems are, in some cases at least, supported by observations made on pathological material from patients with similar SOD1 mutations. Furthermore, there are reports of evidence of free radical mediated damage to neurones in the sporadic form of MND. Several lines of evidence suggest that alterations in the glutamatergic neurotransmitter system may also play a key role in the injury to motor neurones in sporadic MND. There are several important subcellular targets, which may be preferentially impaired within motor neurones, including neurofilament proteins and mitochondria. Future research will need to identify the aspects of the molecular and physiological phenotype of human motor neurones that makes them susceptible to degeneration in MND, and to identify those genetic and environmental factors which combine to cause this disease in individuals and in familial pedigrees.

Clinical and pathologic findings in hereditary spastic paraparesis with spastin mutation.

OBJECTIVE: To describe a family with chromosome 2p-linked hereditary spastic paraparesis (HSP) associated with dementia and illustrate the cerebral pathology associated with this disorder. BACKGROUND: HSP comprises a heterogeneous group of inherited disorders in which the main clinical feature is severe, progressive lower limb spasticity. Nongenetic classification relies on characteristics such as mode of inheritance, age at onset, and the presence or absence of additional neurologic features. Several loci have been identified for autosomal dominant pure HSP. The most common form, which links to chromosome 2p (SPG4), has recently been shown to be due to mutations in spastin, the gene encoding a novel AAA-containing protein. RESULTS: The authors report four generations of a British family with autosomal dominant HSP in whom haplotype analysis indicates linkage to chromosome 2p. In addition, a missense mutation has been identified in exon 10 of the spastin gene (A1395G). Dementia was documented clinically in one member of the family, two other affected family members were reported to have had late onset memory loss, and a younger affected individual showed evidence of memory disturbance and learning difficulties. Autopsy of the demented patient confirmed changes in the spinal cord typical of HSP and also demonstrated specific cortical pathology. There was neuronal depletion and tau-immunoreactive neurofibrillary tangles in the hippocampus and tau-immunoreactive balloon cells were seen in the limbic and neocortex. The substantia nigra showed Lewy body formation. The pathologic findings are not typical of known tauopathies. CONCLUSIONS: The authors confirm that chromosome 2p-linked HSP can be associated with dementia and that this phenotype may be associated with a specific and unusual cortical pathology.

The expression of the glutamate re-uptake transporter excitatory amino acid transporter 1 (EAAT1) in the normal human CNS and in motor neurone disease: an immunohistochemical study.

A monoclonal antibody to excitatory amino acid transporter 1 (EAAT1) has been generated which robustly stains paraffin-embedded, formaldehyde-fixed as well as snap-frozen human post-mortem brain tissue. We have used this antibody to map the distribution of EAAT1 throughout normal human CNS tissue. In addition this antibody has been used to perform a semi-quantitative immunohistochemical analysis of the expression of EAAT1 in motor cortex and cervical cord tissue taken from motor neurone disease cases (n=17) and neurologically normal controls (n=12). By comparing the relative optical density measurements of identical regions of motor cortex and cervical spinal cord an increase in the expression levels of EAAT1 was observed in motor neurone disease tissue compared to the control tissue and in both motor cortex and cervical spinal cord (9-17% and 13-33% increases respectively). EAAT1 was observed to be the most abundant transporter in more "caudal" brain regions such as the diencephalon and brainstem and its expression in other regions was frequently more uniform than that of EAAT2. In the motor cortex, EAAT1 immunoreactivity was present in all grey matter laminae, with some staining of individual astrocytes in the white matter. In spinal cord, EAAT1 immunoreactivity was strongest in the substantia gelatinosa. In the ventral horn, motor neurones were surrounded with a dense rim of perisomatic EAAT1 immunoreactivity, and the neuropil showed diffuse staining. Additional studies using double-labelling immunocytochemistry demonstrated that astrocytic co-localisation of EAAT1 and EAAT2 may occasionally be seen, but was not widespread in the human CNS and that in general astrocytes were positive for either EAAT1 or EAAT2. These results demonstrate that the EAAT1 has a widespread abundance throughout all regions of the human CNS examined and that there exist discrete populations of astrocytes that are positive solely for either EAAT1 or EAAT2. Furthermore, there is evidence to suggest that altered EAAT1 expression in motor neurone disease follows a different pattern to the reported changes of EAAT2 expression in this condition, indicating that the role of glutamate transporters in the pathogenesis of motor neurone disease appears more complex than previously appreciated.

Glutamine synthetase activity and expression are not affected by the development of motor neuronopathy in the G93A SOD-1/ALS mouse.

The expression and activity of the enzyme glutamine synthetase (GS) were examined in the G93A/SOD-1 transgenic mouse model of progressive motor neuronopathy to investigate the mechanisms underlying degeneration of the motor neurones. Clinical signs appeared in G93A/SOD-1 mice at around 90 days, with severe spasticity and loss of self-righting reflex from 120 to 150 days of age. GS expression was examined using western blotting in primary astrocyte cultures derived from newborn (P1-2) G93A/SOD-1 mice and their non-transgenic littermates and in lower spinal cord from animals at 30, 60 and 90 days of age and disease end-stage (120-150 days). There were no differences in the levels of GS expression in the transgenic mice compared to the unaffected littermates at any of the disease stages examined. GS activity was measured spectrophotometrically in spinal cord extracts at these disease stages. There was a decrease in V(max) at 60 days compared to 30 days in both groups of mice (3.48+/-0.58 cf. 6.43+/-1.83 mmol/h/mg protein; non-transgenic littermates), with GS activity highest at end-stage (9.38+/-0.71 mmol/h/mg protein cf. 7.64+/-0.42 mmol/h/mg protein in littermates). Conversely, K(m) was transiently increased at 60 days (2.53+/-0.26 mM cf. 1.32+/-0.20 in littermates), remaining within the range of 30 day measurements from 90 days onwards. There were no differences in V(max) or K(m) values between the G93A/SOD-1 mice and their unaffected non-transgenic littermates at any of the disease stages examined. We conclude that there is no evidence that a change in glutamine synthetase activity or expression contributes to the progressive neurodegeneration observed in the G93A/SOD-1 mice.

Transfected synphilin-1 forms cytoplasmic inclusions in HEK293 cells.

The discovery of mutations in the gene for alpha-synuclein in familial Parkinson's disease (PD) has led to an increased interest in this pre-synaptic protein. Synphilin-1, a potential synuclein-binding protein, was cloned using yeast two-hybrid assays. The function of synphilin-1 is currently unknown, although it has been reported to be present along with alpha-synuclein in Lewy bodies in PD. In the present study, we monitored synphilin-1 aggregation directly using fusion proteins of synphilin-1 and green fluorescent protein (EGFP). Transfection of synphilin-EGFP fusion proteins formed cytoplasmic inclusions in HEK293 cells. Although these inclusions overlapped with the distribution of alpha-synuclein, they were unlike Lewy bodies in that they were not eosinophilic, and instead were membrane-bound, lipid-rich cytoplasmic inclusions.

Screening of AP endonuclease as a candidate gene for amyotrophic lateral sclerosis (ALS).

DNA extracted from CNS tissue of 84 patients was screened by single-stranded conformation polymorphism (SSCP) and heteroduplex analysis for mutations in the apurinic/apyrimidinic endonuclease (APE) gene. One mutation was identified and characterized as a 4bp deletion in the 3'UTR. A rare polymorphism was identified in exon 3 and a common polymorphism in the coding region of exon 5. These results suggest that APE mutations do not account for a large number of ALS cases.

Clinical significance of repeat sextant biopsies in prostate cancer patients.

OBJECTIVES: Six random systematic core biopsies (SRSCB) of the prostate is considered by many to represent the standard method of detecting prostate cancer. We sought to evaluate the sensitivity of the transrectal ultrasound (TRU)S-guided needle biopsies in 89 consecutive patients with a history of biopsy-proven prostate cancer. These patients underwent repeat biopsy prior to enrollment in an ongoing, randomized protocol. We also compared the clinical and pathological features of patients with SRSCB-documented prostate carcinoma and negative repeat-sextant biopsy. METHODS: Our study population consisted of 89 patients enrolled in our randomized, prospective study assessing the effect of androgen deprivation therapy in combination with radical prostatectomy for clinically localized prostate cancer. A comparison was made of the patients' rebiopsy results with initial biopsy. Patients having either a positive or negative rebiopsy were analyzed with respect to grade, T stage, prostate-specific antigen (PSA), PSA density (PSAD), organ-confined rate, and final surgical margin status. RESULTS: Repeat sextant biopsy was positive for prostate cancer in 71 (80%) patients and negative in 18 (20%) patients. There was no significant difference between patients with a negative or positive rebiopsy with respect to PSA or PSAD. There was a trend toward greater prostate volumes in the negative-rebiopsy group (P = 0.08) and lower clinical stage in the negative rebiopsy (P = 0.025) group. In patients with a negative repeat biopsy, the organ-confined (OC) rate was 77% (14/18 patients), as compared to the positive-rebiopsy group of 56% (40/71 patients) (P = 0.08). Similarly, the margin-positive rate in the negative-rebiopsy group was 17% (3/18 patients), as compared to the positive-rebiopsy group who had a margin-positive rate of 44% (31/71 patients) (P = 0.03). CONCLUSIONS: In patients with clinically localized disease, the sensitivity of SRSCB in detecting carcinoma is 80%. The results of this study highlight the potential sampling error of the SRSCB and the implication of a negative rebiopsy in patients with clinically significant prostate cancer.

Prognostic significance of prostate-specific antigen in stage T1c prostate cancer treated by radical prostatectomy.

OBJECTIVES: Increasingly, nonpalpable prostate-specific antigen (PSA)-detected (Stage T1c) tumors are being treated with curative intent. Presently, only limited information is available regarding pathologic findings correlated with preoperative PSA levels. Herein, we report the characteristics of Stage T1c tumors in a contemporary surgical series. METHODS: Clinical and pathologic results in 107 patients with Stage T1c tumors treated with radical prostatectomy were compared with those in 300 patients with palpable (Stage T2) tumors. Multivariate analysis was performed to determine which clinical variables independently predicted pathologic staging. RESULTS: Stage T1c tumors were equivalent to Stage T2 tumors with respect to organ-confined and margin-positive rates. PSA level was the strongest independent predictor of extracapsular and margin-positive rates (P = 0.003). The absence of palpability was not a significant predictor of pathologic outcome. Significantly higher rates of organ- and specimen-confined disease were seen in patients with PSA levels less than 10.0 ng/mL, particularly less than 7.0 ng/mL. Patients with serum PSA levels greater than 20 ng/mL were at high risk for positive margins (relative risk 5.42, P < 0.001). CONCLUSIONS: Stage T1c tumors represent a heterogeneous group of cancers. These tumors are pathologically similar to Stage T2 tumors, and patients should be offered similar treatment options. PSA level was the strongest predictor of pathologic stage, irrespective of tumor palpability. These results suggest that efforts directed toward identifying cancers, including nonpalpable tumors, in patients with early PSA elevations may result in improved rates of organ-confined disease. The impact of treatment on Stage T1c tumors remains to be defined.

Repeat transrectal ultrasound-guided prostate biopsy: a strategy to improve the reliability of needle biopsy grading in patients with well-differentiated prostate cancer.

OBJECTIVES: Gleason grade from prostate needle biopsy (PNB) specimens is important in guiding therapeutic decision making in patients with localized prostate cancer. Recent data from our institution suggest a significant discordance between Gleason grading from PNB versus the actual pathologic grade at radical prostatectomy (RRP). Of most concern is that a substantial proportion of patients with Gleason score of 6 or less from PNB actually have Gleason score of 7 or more at RRP. Under classic measurement theory, one useful way to improve the reliability of an inherently unreliable test is to repeat it. We investigated this strategy in an effort to reduce undergrading errors. METHODS: The control group of patients (n = 51) from our neoadjuvant androgen deprivation protocol was used as the test (two-biopsy) group in this study. These patients underwent two separate PNBs before RRP. We used the highest Gleason score from the two biopsies in these patients and compared the error rates with a concurrent group of patients treated at our institution (n = 226) who had only one set (single-biopsy group) of prostate biopsies. All pathologic slides were reviewed at our institution. Any PNB grade of 6 or less that was scored as 7 or more on final pathology was considered significant. RESULTS: Mean age, prostate-specific antigen levels, and stage distribution were not significantly different between these two groups. In the single-biopsy group, 165 patients had PNB Gleason score of 6 or less. Of these patients, 63 (38%) had final pathologic grade of 7 or more. In the two-biopsy group, 37 patients had PNB Gleason score of 6 or less. Of these patients, only 7 (19%) had final pathologic grade of 7 or more (P = 0.04). CONCLUSIONS: Prostate rebiopsy minimizes the inherent unreliability of PNB derived grade and should be considered for patients in whom watchful waiting or nomogram-based therapy has been selected.

Evaluating neoadjuvant therapy effectiveness on systemic disease: use of a prostatic-specific membrane reverse transcription polymerase chain reaction.

OBJECTIVE: An on-going study at the Memorial Sloan-Kettering Cancer Center assessed the effectiveness of androgen deprivation therapy (ADT) prior to surgical removal of the prostate. In this report, we evaluate the effectiveness of ADT on systemic disease by monitoring the presence or absence of circulating prostatic epithelial cells using a reverse transcription polymerase chain reaction (RT-PCR) assay for prostatic-specific membrane antigen (PSM). METHODS: PSM RT-PCR was performed on a total of 38 prostate cancer patients. There were 12 pT2 patients in the ADT group and 10 patients in the control pT2 group and 5 pT3 patients in the ADT group and 11 pT3 patients in the control group. RESULTS: For pT2 patients, 2 of the 12 patients (17%) were positive for circulating prostatic cells during androgen deprivation therapy but before radical retroprostatectomy (RRP). Within a 6-month period after RRP, 3 of 12 patients (25%) were positive. For the period between the 7th and 12th month after RRP, 6 of 12 patients (50%) were positive. For the period 12-36 months after RRP, 2 of the 12 patients (17%) remained positive for circulating prostatic cells. In contrast, the pT2 control group had higher positive rates in comparable periods: 4 of 10 patients (40%) were positive prior to surgery; 6 of 10 patients (60%) were positive during the 6 months following surgery. For the period between the 7th and 12th month following surgery, 4 of 7 patients (57%) were positive for PSM. Finally, 3 of 6 patients (50%) were positive for the period longer than 12 months. Regarding patients who have extraprostatic disease (stage pT3), the ADT group had a lower rate of circulating PSM positive cells. Before RRP and during androgen deprivation therapy, 1 out of 5 patients (20%) in the ADT group were positive as compared to 4 out of 11 patients for the control group. Within a 6-month period after RRP, the ADT group had 4 out of 9 (44%) patients positive for PSM as compared to 9 of 11 (82%) for the control group. For the period between the 7th and 12th months postsurgery, 1 of 5 patients (20%) of the ADT group were positive as compared to 4 of 7 (57%) of the control patients. CONCLUSIONS: These results indicate that patients with pT2 and pT3 lesions who receive neoadjuvant ADT are less likely to have circulating tumor cells detected compared to a control group both prior to and after surgery. In addition, irrespective of ADT or control group, there were increases in the detection of circulating tumor cells in the period after RRP, and this rise gradually decreased, suggesting that surgical manipulation may cause hematogenous dissemination of tumor cells and that ADT reduces such dissemination of tumor cells. Overall, these results indicate that the use of neoadjuvant ADT decreases the number of circulating prostatic cells. These data represent the initial results of an on-going study. As additional patients are added to the studies, attempts to correlate PSM positivity and serum PSA values postoperatively, recurrence, and margin positivity will be made.