Microenvironment-Derived FGF-2 Stimulates Renal Cell Carcinoma Cell Proliferation through Modulation of p27Kip1: Implications for Spatial Niche Formation and Functional Intratumoral Heterogeneity.

BACKGROUND/OBJECTIVE: Clear cell renal cell carcinoma (ccRCC) is characterized by a high degree of functional intratumoral heterogeneity (ITH). This is highlighted by the finding that tumor cell proliferation and intracellular signaling occur preferentially in the tumor periphery. The driving forces for such a spatial organization are largely unknown. Herein, we investigate the role of the tumor microenvironment in the control of tumor cell proliferation and functional ITH. METHODS: Conditioned media (CM) derived from nonmalignant peritumoral kidney tissue were used to stimulate RCC cells in vitro. A neutralization assay was used to characterize the role of FGF-2 in the CM. The molecular mechanisms underlying the action of CM on RCC cells were investigated using immunoblotting, flow cytometry and immunofluorescence microscopy. Lastly, a series of ccRCCs were stained for Ki-67 and p27Kip1, and expression was analyzed in both tumor periphery and center. RESULTS: We show that CM derived from nonmalignant kidney cells adjacent to an RCC can downregulate the expression of the CDK inhibitor p27Kip1 through enhanced protein degradation in an FGF-2-dependent fashion. FGF-2 functions mainly through the PI3K/AKT pathway downstream of its receptors, and RCC cells with constitutively high AKT activity show not only an enhanced degradation of p27Kip1 through the Emi1-Skp2 axis, but also a subcellular mislocalization of p27Kip1 to the cytoplasmic compartment. Such a mislocalization was also detected in the tumor periphery in vivo suggesting that p27Kip1 plays an important role in shaping this spatial niche. CONCLUSIONS: Our results suggest that the tumor microenvironment is involved in shaping the tumor peripheral niche by stimulating the enhanced proliferation that is characteristic for this zone.

Multiparametric MRI fusion-guided biopsy for the diagnosis of prostate cancer.

PURPOSE OF REVIEW: To discuss the timing, benefits, limitations and current controversies of multiparametric magnet resonance imaging (mpMRI) combined with fusion-guided biopsy and consider how additional incorporation of multivariable risk stratification might further improve prostate cancer diagnosis. RECENT FINDINGS: MpMRI has been proven advantageous over standard practice for biopsy-naïve men and men with previous biopsy in large prospective studies providing level 1b evidence. Upfront multivariable risk stratification followed by or combined with mpMRI further improves diagnostic accuracy. Regarding active surveillance, mpMRI in combination with fusion biopsy can support initial candidate selection and may help to monitor disease progression. mpMRI and fusion biopsy, however, do not spare failure and conflicting data exists to what extend (systematic) biopsies can be omitted. SUMMARY: Integration of mpMRI into the diagnostic pathway for prostate cancer is beneficial; yet more prospective and randomized data is needed to establish reliable procedure standards after mpMRI acquisition.

Multiparametric MRI and MRI/TRUS Fusion Guided Biopsy for the Diagnosis of Prostate Cancer.

Purpose of this chapter To demonstrate the timing, benefits, limitations and current controversies of multiparametric magnet resonance imaging (mpMRI) combined with fusion guided biopsy and consider how additional incorporation of multivariable risk stratification might further improve prostate cancer (PC) diagnosis. Recent findings MpMRI has been shown to add important information to the diagnostic pathway for prostate cancer. Fusion biopsy has also shown advantages in comparison to standard practice for biopsy-naïve men and men with previous biopsy in large prospective studies providing level 1b evidence. Adding upfront multivariable risk stratification followed by or combined with mpMRI diagnostic accuracy can further be improved. Regarding active surveillance (AS), mpMRI in combination with fusion biopsy can support initial candidate selection and may help to monitor disease progression. However, mpMRI and fusion biopsy are not without failure and conflicting data exists to what extend (systematic) biopsies can be omitted. Summary The integration of mpMRI into the diagnostic pathway for PC can add important information for further decision making, yet more prospective and randomized data is needed to establish reliable procedure standards after mpMRI acquisition.

Diagnostic Accuracy of Transperineal MRI Fusion Biopsy in Comparison to Transrectal Biopsy with Regard to Incidental Histopathological Findings in Transurethral Resection of the Prostate.

OBJECTIVE: To investigate the diagnostic accuracy of transperineal MRI/transrectal ultrasound (TRUS) fusion prostate biopsy vs. transrectal prostate biopsy in transurethral resection (TUR) specimen of men undergoing TUR of the prostate (TURP) for symptomatic bladder outlet obstruction. MATERIAL AND METHODS: From a database of 3,509 men receiving prostate biopsy, all those undergoing TURP and negative prostate biopsy (n = 95; 45 transrectal, 50 transperineal fusion) were analysed. TURP specimens were compared with regard to incidental prostate cancer. RESULTS: Pre- and peri-interventional parameters in transrectal vs. fusion biopsy groups for age (65.2 ± 7.8 vs. 65.5 ± 7.3 years; p = 0.84), prostate specific antigen (10.7 ± 8.5 vs. 10.9 ± 8.7 ng/mL; p = 0.93), preoperative prostate volume (72.5 ± 26.1 vs. 71.8 ± 28.1 mL; p = 0.91) and resected weight (43.7 ± 21.9 vs. 41.4 ± 20.7 g; p = 0.61) showed no significant differences. Analysing the TURP specimen, 5 incidental T1a prostate cancers were found (3 Gleason 3 + 3 = 6; 2 Gleason 3 + 4 = 7, all in the transrectal biopsy group). Although, more biopsy cores were obtained in the MRI/TRUS fusion biopsy group (26 cores [interquartile range, IQR 24-28] vs. 14 cores [IQR 12-24], p < 0.01), there was no statistical impact of the obtained number of cores (p = 0.9) on diagnostic accuracy. Statistical analyses revealed significantly better diagnostic accuracy favoring image-guided fusion biopsy (p = 0.02). CONCLUSIONS: Our findings showed that a combination of MRI-targeted and systematic transperineal prostate biopsy improves patient safety. This is associated with a combination of transperineal biopsy technique and pre-interventional MRI.

TOP: Prospective Evaluation of a Volume Based, Computer Assisted Method for Transperineal Optimized Prostate Biopsy.

OBJECTIVE: This study is a prospective evaluation of a volume-based, computer-assisted method for transperineal optimized prostate (TOP) biopsy. The TOP algorithm automates core planning for systematic prostate biopsies using the 3-dimensional organ contour and an alterable volume for tumors to be excluded. SUBJECTS AND METHODS: MRI-transrectal ultrasound fusion biopsy with MRI-targeted biopsies (TBs) and systematic-TOP biopsies were performed on 172 men between October 2013 and March 2014. Systematic biopsies were placed according to TOP for detection of tumor volumes >0.5 mL with a minimum of 80% organ coverage in prostates up to 50 mL (70% in larger organs). RESULTS: Median 24 TOP cores and 3 MRI-TBs have been placed. Prostate cancer (PCa) was detected in 112 of 172 (65%) of men; TOP detected 109 (97%) and TB 62 (55%). Significant cancer (Gleason score ≥7) was detected in 75 (44%) of men and of these TOP detected 73 of 75 (97%) and TB 51 of 75 (68%). Overall, systematic-TOP sampling significantly outperformed TB for the detection of both, all PCa as well as significant PCa (p < 0.0001, p = 0.0005). CONCLUSION: The TOP method is innovative by integrating the individual prostate volume and PCa volume detection thresholds. In the present cohort, it diagnosed more significant tumors than TB alone. However, at the same time, more low-risk tumors are detected.

Mutations in TP53 or DNA damage repair genes define poor prognostic subgroups in primary prostate cancer.

BACKGROUND: Mutations in DNA damage repair genes, in particular genes involved in homology-directed repair, define a subgroup of men with prostate cancer with a more unfavorable prognosis but a therapeutic vulnerability to PARP inhibition. In current practice, mutational testing of prostate cancer patients is commonly done late i.e., when the tumor is castration resistant. In addition, most sequencing panels do not include TP53, one of the most crucial tumor suppressor genes in human cancer. In this proof-of-concept study, we sought to extend the clinical use of these molecular markers by exploring the early prognostic impact of mutations in TP53 and DNA damage repair genes in men with primary, nonmetastatic prostate cancer undergoing radical prostatectomy (RPX). METHODS: Tumor specimens from a cohort of 68 RPX patients with intermediate (n = 11, 16.2%) or high-risk (n = 57, 83.8%) disease were analyzed by targeted next generation sequencing using a 37 DNA damage repair and checkpoint gene panel including TP53. Sequencing results were correlated to clinicopathologic variables as well as PSA persistence or time to PSA failure. In addition, the distribution of TP53 and DNA damage repair gene mutations was analyzed in three large publicly available datasets (TCGA, MSKCC and SU2C). RESULTS: Of 68 primary prostate cancers analyzed, 23 (33.8%) were found to harbor a mutation in either TP53 (n = 12, 17.6%) or a DNA damage repair gene (n = 11, 16.2%). The vast majority of these mutations (22 of 23, 95.7%) were detected in primary tumors from patients with high-risk features. These mutations were mutually exclusive in our cohort and additional data mining suggests an enrichment of DNA damage repair gene mutations in TP53 wild-type tumors. Mutations in either TP53 or a DNA damage repair gene were associated with a significantly worse prognosis after RPX. Importantly, the presence of TP53/DNA damage repair gene mutations was an independent risk factor for PSA failure or PSA persistence in multivariate Cox regression models. CONCLUSION: TP53 or DNA damage repair gene mutations are frequently detected in primary prostate cancer with high-risk features and define a subgroup of patients with an increased risk for PSA failure or persistence after RPX. The significant adverse impact of these alterations on patient prognosis may be exploited to identify men with prostate cancer who may benefit from a more intensified treatment.

Evolution of Salvage Radical Prostatectomy from Open to Robotic and Further to Retzius Sparing Surgery.

Salvage radical prostatectomy (sRP) has evolved from open to minimally invasive approaches. sRP can be offered to patients with local recurrence to improve biochemical recurrence (BCR)-free and overall survival. We evaluate oncological outcome and continence after retropubic (RRP), conventional (cRARP), and Retzius-sparing robotic (rsRARP) surgery. MATERIALS/METHODS: A total of 53 patients undergoing sRP between 2010 and 2020 were included. Follow-up included oncological outcome and continence. RESULTS: sRP was done as RRP (n = 25), cRARP (n = 7), or rsRARP (n = 21). Median blood loss was 900 mL, 500 mL, and 300 mL for RRP, cRARP, and rsRARP, respectively. At 12 months, 5 (20%), 0, and 4 (19%) patients were continent, 9 (36%), 3 (43%), and 7 (33%) had grade 1 incontinence, 5 (20%), 2 (29%), and 3 (14%) had grade 2 incontinence, and 3 (12%), 2 (29%), and 4 (19%) had grade 3 incontinence for RRP, cRARP, or rsRARP, respectively. During a mean follow-up of 52.6 months, 16 (64%), 4 (57%), and 3 (14%) developed BCR in the RRP-, cRARP-, and rsRARP-group, respectively. CONCLUSIONS: Over the years, sRP has shifted from open to laparoscopic/robotic surgery. RARP shows good oncological and functional outcome. rsRARP ensures direct vision on the rectum during preparation and can therefore increase safety and surgeon's confidence, especially in the salvage setting.

Standardized Magnetic Resonance Imaging Reporting Using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation Criteria and Magnetic Resonance Imaging/Transrectal Ultrasound Fusion with Transperineal Saturation Biopsy to Select Men on Active Surveillance.

BACKGROUND: Contemporary selection criteria for men with prostate cancer (PC) suitable for active surveillance (AS) are unsatisfactory, leading to high disqualification rates based on tumor misclassification. Conventional biopsy protocols are based on standard 12-core transrectal ultrasound (TRUS) biopsy. OBJECTIVE: To assess the value of magnetic resonance imaging (MRI)/TRUS fusion biopsy over 4-yr follow-up in men on AS for low-risk PC. DESIGN, SETTING, AND PARTICIPANTS: Between 2010 and 2018, a total of 273 men were included. Of them, 157 men with initial 12-core TRUS biopsy and 116 with initial MRI/TRUS fusion biopsy were followed by systematic and targeted transperineal MRI/TRUS fusion biopsies based on Prostate Cancer Research International Active Surveillance criteria. MRI from follow-up MRI/TRUS fusion biopsy was assessed using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) scoring system. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: AS-disqualification rates for patients on AS initially diagnosed by either 12-core TRUS biopsy or by MRI/TRUS fusion biopsy were compared using Kaplan-Meier estimates, log-rank tests, and regression analyses. We also analyzed the influence of negative primary MRI and PRECISE scoring to predict AS disqualification using Kaplan-Meier estimates, log-rank tests, and receiver operating characteristic (ROC) curve analysis. RESULTS AND LIMITATIONS: Of men diagnosed by 12-core TRUS biopsy, 59% were disqualified from AS based on the results of subsequent MRI/TRUS fusion biopsy. In the initial MRI fusion biopsy cohort, upgrading occurred significantly less frequently (19%, p<0.001). ROC curve analyses demonstrated good discrimination for the PRECISE score with an area under the curve of 0.83. No men with a PRECISE score of 1 or 2 (demonstrating absence or downgrading of lesions in follow-up MRI) were disqualified from AS. In our cohort, a negative baseline MRI scan was not a predictor of nondisqualification from AS. Limitations include transperineal approach and extended systematic biopsies used with MRI/TRUS fusion biopsy, which may not be representative of other centers. CONCLUSIONS: MRI/TRUS fusion biopsies allow a reliable risk classification for patients who are candidates for AS. The application of the PRECISE scoring system demonstrated good discrimination. PATIENT SUMMARY: In this study, we investigated the value of multiparametric magnetic resonance imaging (MRI) and MRI/transrectal ultrasound (TRUS) fusion biopsies for the assessment of active surveillance (AS) reliability using the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation criteria. Standard TRUS biopsies lead to significant underestimation of prostate cancer. In contrast, MRI/TRUS fusion biopsies allowed for a more reliable risk classification. For appropriate inclusion into AS, men should receive either an initial or a confirmatory MRI/TRUS fusion biopsy.

Combined Clinical Parameters and Multiparametric Magnetic Resonance Imaging for the Prediction of Extraprostatic Disease-A Risk Model for Patient-tailored Risk Stratification When Planning Radical Prostatectomy.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) facilitates the detection of significant prostate cancer. Therefore, addition of mpMRI to clinical parameters might improve the prediction of extraprostatic extension (EPE) in radical prostatectomy (RP) specimens. OBJECTIVE: To investigate the accuracy of a novel risk model (RM) combining clinical and mpMRI parameters to predict EPE in RP specimens. DESIGN, SETTING, AND PARTICIPANTS: We added prebiopsy mpMRI to clinical parameters and developed an RM to predict individual side-specific EPE (EPE-RM). Clinical parameters of 264 consecutive men with mpMRI prior to MRI/transrectal ultrasound fusion biopsy and subsequent RP between 2012 and 2015 were retrospectively analysed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariate regression analyses were used to determine significant EPE predictors for RM development. The prediction performance of the novel EPE-RM was compared with clinical T stage (cT), MR-European Society of Urogenital Radiology (ESUR) classification for EPE, two established nomograms (by Steuber et al and Ohori et al) and a clinical nomogram based on the coefficients of the established nomograms, and was constructed based on the data of the present cohort, using receiver operating characteristics (ROCs). For comparison, models' likelihood ratio (LR) tests and Vuong tests were used. Discrimination and calibration of the EPE-RM were validated based on resampling methods using bootstrapping. RESULTS AND LIMITATIONS: International society of Urogenital Pathology grade on biopsy, ESUR criteria, prostate-specific antigen, cT, prostate volume, and capsule contact length were included in the EPE-RM. Calibration of the EPE-RM was good (error 0.018). The ROC area under the curve for the EPE-RM was larger (0.87) compared with cT (0.66), Memorial Sloan Kettering Cancer Center nomogram (0.73), Steuber nomogram (0.70), novel clinical nomogram (0.79), and ESUR classification (0.81). Based on LR and Vuong tests, the EPE-RM's model fit was significantly better than that of cT, all clinical models, and ESUR classification alone (p<0.001). Limitations include monocentric design and expert reading of MRI. CONCLUSIONS: This novel EPE-RM, incorporating clinical and MRI parameters, performed better than contemporary clinical RMs and MRI predictors, therefore providing an accurate patient-tailored preoperative risk stratification of side-specific EPE. PATIENT SUMMARY: Extraprostatic extension of prostate cancer can be predicted accurately using a combination of magnetic resonance imaging and clinical parameters. This novel risk model outperforms magnetic resonance imaging and clinical predictors alone and can be useful when planning nerve-sparing radical prostatectomy.

High prevalence of DNA damage repair gene defects and TP53 alterations in men with treatment-naïve metastatic prostate cancer -Results from a prospective pilot study using a 37 gene panel.

BACKGROUND: Defects in DNA damage repair genes characterize a subset of men with prostate cancer and provide an attractive opportunity for precision oncology approaches. The prevalence of such perturbations in newly diagnosed, treatment-naïve patients with a high risk for lethal disease outcome, however, has not been sufficiently explored. PATIENTS AND METHODS: Prostate cancer specimens from 67 men with newly diagnosed early onset, localized high-risk/locally advanced or metastatic prostate cancer were included in this prospective pilot study. Tumor samples, including 30 prostate biopsies, were analyzed by targeted next generation sequencing using a formalin-fixed, paraffin-embedded tissue-optimized 37 DNA damage repair and checkpoint gene panel. RESULTS: The drop-out rate due to an insufficient quantity of DNA was 4.5% (3 of 67 patients). In the remaining 64 patients, the rate of pathogenic DNA damage repair gene mutations was 26.6%. The highest rate of pathogenic DNA damage repair and checkpoint gene mutations was found in men with treatment-naïve metastatic prostate cancer (38.9%). In addition, a high number of likely pathogenic mutations and gene deletions were detected. Altogether, one or more pathogenic mutation, likely pathogenic mutation or gene deletion affected 43 of 64 patients (67.2%) including 29 of 36 patients (80.6%) with treatment-naïve metastatic prostate cancer. Men with metastatic prostate cancer showed a high prevalence of alterations in TP53 (36.1%). CONCLUSIONS: This pilot study demonstrates the feasibility, performance and clinical relevance of somatic targeted next generation sequencing using a unique 37 DNA damage repair and checkpoint gene panel under routine conditions. Our results indicate that this approach can detect actionable DNA repair gene alterations, uncommon mutations as well as mutations associated with therapy resistance in a high number of patients, in particular patients with treatment-naïve metastatic prostate cancer.

Prediction of significant prostate cancer in biopsy-naïve men: Validation of a novel risk model combining MRI and clinical parameters and comparison to an ERSPC risk calculator and PI-RADS.

BACKGROUND: Risk models (RM) need external validation to assess their value beyond the setting in which they were developed. We validated a RM combining mpMRI and clinical parameters for the probability of harboring significant prostate cancer (sPC, Gleason Score ≥ 3+4) for biopsy-naïve men. MATERIAL AND METHODS: The original RM was based on data of 670 biopsy-naïve men from Heidelberg University Hospital who underwent mpMRI with PI-RADS scoring prior to MRI/TRUS-fusion biopsy 2012-2015. Validity was tested by a consecutive cohort of biopsy-naïve men from Heidelberg (n = 160) and externally by a cohort of 133 men from University College London Hospital (UCLH). Assessment of validity was performed at fusion-biopsy by calibration plots, receiver operating characteristics curve and decision curve analyses. The RM`s performance was compared to ERSPC-RC3, ERSPC-RC3+PI-RADSv1.0 and PI-RADSv1.0 alone. RESULTS: SPC was detected in 76 men (48%) at Heidelberg and 38 men (29%) at UCLH. The areas under the curve (AUC) were 0.86 for the RM in both cohorts. For ERSPC-RC3+PI-RADSv1.0 the AUC was 0.84 in Heidelberg and 0.82 at UCLH, for ERSPC-RC3 0.76 at Heidelberg and 0.77 at UCLH and for PI-RADSv1.0 0.79 in Heidelberg and 0.82 at UCLH. Calibration curves suggest that prevalence of sPC needs to be adjusted to local circumstances, as the RM overestimated the risk of harboring sPC in the UCLH cohort. After prevalence-adjustment with respect to the prevalence underlying ERSPC-RC3 to ensure a generalizable comparison, not only between the Heidelberg and die UCLH subgroup, the RM`s Net benefit was superior over the ERSPC`s and the mpMRI`s for threshold probabilities above 0.1 in both cohorts. CONCLUSIONS: The RM discriminated well between men with and without sPC at initial MRI-targeted biopsy but overestimated the sPC-risk at UCLH. Taking prevalence into account, the model demonstrated benefit compared with clinical risk calculators and PI-RADSv1.0 in making the decision to biopsy men at suspicion of PC. However, prevalence differences must be taken into account when using or validating the presented risk model.

Prospective single center trial of next-generation sequencing analysis in metastatic renal cell cancer: the MORE-TRIAL.

AIM: Targeted therapies have substantially improved the survival of patients with metastatic clear cell renal cell cancer. No prognostic or predictive biomarkers are available. Comprehensive genetic profiling offers the opportunity to define prognostic and predictive signatures aiming at a more personalized approach to treatment. METHODS: In this prospectively conducted cohort study, tumor tissue and liquid biopsies are sampled at baseline and upon first and second progression under systemic treatment. Samples will be analyzed by whole-exome sequencing to generate prognostic and predictive patterns for systemic therapies. DISCUSSION: This study is aiming at exploring genetic profiles with prognostic and predictive value in metastatic renal cell cancer patients. Clonal evolution facilitating resistance to systemic treatment will be investigated by repeat biopsies.

Correlation between genomic index lesions and mpMRI and 68Ga-PSMA-PET/CT imaging features in primary prostate cancer.

Magnetic resonance imaging (MRI) and prostate specific membrane antigen (PSMA)- positron emission tomography (PET)/computed tomography (CT)-imaging of prostate cancer (PCa) are emerging techniques to assess the presence of significant disease and tumor progression. It is not known, however, whether and to what extent lesions detected by these imaging techniques correlate with genomic features of PCa. The aim of this study was therefore to define a genomic index lesion based on chromosomal copy number alterations (CNAs) as marker for tumor aggressiveness in prostate biopsies in direct correlation to multiparametric (mp) MRI and 68Ga-PSMA-PET/CT imaging features. CNA profiles of 46 biopsies from five consecutive patients with clinically high-risk PCa were obtained from radiologically suspicious and unsuspicious areas. All patients underwent mpMRI, MRI/TRUS-fusion biopsy, 68Ga-PSMA-PET/CT and a radical prostatectomy. CNAs were directly correlated to imaging features and radiogenomic analyses were performed. Highly significant CNAs (≥10 Mbp) were found in 22 of 46 biopsies. Chromosome 8p, 13q and 5q losses were the most common findings. There was an strong correspondence between the radiologic and the genomic index lesions. The radiogenomic analyses suggest the feasibility of developing radiologic signatures that can distinguish between genomically more or less aggressive lesions. In conclusion, imaging features of mpMRI and 68Ga-PSMA-PET/CT can guide to the genomically most aggressive lesion of a PCa. Radiogenomics may help to better differentiate between indolent and aggressive PCa in the future.