Integrin signaling potentiates transforming growth factor-beta 1 (TGF-ß1) dependent down-regulation of E-Cadherin expression - Important implications for epithelial to mesenchymal transition (EMT) in renal cell carcinoma.

Signal transduction through the transforming growth factor-beta 1 (TGF-ß1) pathway affects epithelial to mesenchymal transition (EMT), partly by modulation of E-Cadherin expression. The concurrent impact of extracellular matrix driven regulation of integrin signaling on EMT has not been well characterized. We assessed the cumulative effect and molecular mechanisms of TGF-ß1 and integrin signal transduction on E-Cadherin in a renal cell cancer (RCC) model. Stimulation of RCC cells with TGF-ß1 demonstrated a three-fold increased expression of integrin αv. A ligand of integrin αv-ß3, (cyclopentapeptide containing Arginyl-Glycyl-Aspartic acid motif, RGD), was used to mimic integrin signaling. Treatment of cells with RGD and TGF-ß1 demonstrated significantly greater E-cadherin depletion than either ligand alone. This cooperative action on E-Cadherin expression is regulated by transcription factor Snai1 and is followed on a cellular level by increased cellular mobility as evidenced in a wound healing assay. Subsequent silencing of potential downstream mediators of the cumulative action of RGD and TGF-ß1 was carried out by small interfering RNA transfection and confirmed by Western blotting and/or RT-PCR. SiRNA mediated silencing of FAK and PINCH1 independently abrogated the cumulative effect of RGD and TGF-ß1 on E-Cadherin expression. We have identified a novel mechanism through which extracellular matrix event transduction by integrins further augments TGF-ß1 related effects on EMT. Molecular machinery involved in the integrin αv-TGF-ß1 interplay may represent a therapeutic target in RCC.

Androgen receptor expression is associated with adverse pathological features in ureteral but not in pelvicalyceal urothelial carcinomas of the upper urinary tract.

PURPOSE: This study aims to determine the significance of androgen receptor (AR) expression in urothelial carcinoma of the upper urinary tract (UTUC). METHODS: AR expression was assessed on tissue microarrays containing specimens of 737 patients with UTUC who underwent radical nephroureterectomy with curative intent. AR expression was correlated with clinical and pathological tumor features as well as recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). RESULTS: Overall, AR was expressed in 11 % of tumors. AR expression was significantly associated with tumor necrosis as well as sessile and multifocal tumor growth but not with RFS, CSS or OS. AR was detected nearly twice as often in tumors of the ureter than of the pelvicalyceal system (p = 0.005). Subgroup analyses showed that the significant associations of AR with unfavorable pathologic features were exclusively attributable to tumors located in the ureter. However, in both ureteral and pelvicalyceal tumors, AR status was independent of RFS, CSS and OS. CONCLUSIONS: In this cohort of patients treated with RNU, AR expression was found in approximately 10 % of UTUCs, twice as often in ureteral than in pelvicalyceal tumors. While AR expression had no impact on postoperative prognosis, it was significantly associated with unfavorable pathologic features in ureteral tumors. Steroid hormone signaling might be relevant for future investigations of differences between ureteral and pelvicalyceal tumors.

Assessing treatment response after induction Bacillus Calmette-Guerin for carcinoma in situ of the urinary bladder: can post-induction random bladder biopsies be avoided?

OBJECTIVES: Patients diagnosed with bladder carcinoma in situ (CIS) and treated with intravesical Bacillus Calmette-Guerin (BCG) often undergo post-induction random bladder biopsies to assess treatment response. We sought to determine the correlation between post-induction urinary cytology/cystoscopy and histopathological findings obtained by random bladder biopsies. METHODS: Patients who were treated with BCG between 2006 and 2010 for CIS, had surveillance cystoscopy and cytology, and subsequently underwent random bladder biopsies were selected for analysis. Patients with a history of or concomitant urothelial cell carcinoma (UCC) stage T1 or higher were excluded. Cystoscopic finings were characterized as follows: negative - no mucosal erythema, raised lesions or papillary tumours; suspicious - mucosal erythema, but no raised lesions or papillary tumours; and positive - sessile or papillary tumours. The accuracy of cytology in predicting the results of subsequent random bladder biopsies was analysed. RESULTS: Of 21 patients included, surveillance cystoscopy findings were characterized as negative in nine, suspicious in seven and positive in five. Of 16 patients with negative/suspicious cystoscopy, 13 had agreement between cytology and biopsy, nine of whom were negative and four positive. Three of 16 patients had positive cytology, but negative biopsies; on further investigation of these three, one had CIS and two subsequent UCC. In the positive cystoscopy group, four of five patients had agreement between cytology and biopsy, two of whom were negative and two positive. One of the five patients had negative cytology, but a positive biopsy. CONCLUSION: Our data suggest foregoing random bladder biopsies in patients with negative urine cytology and no evidence of intravesical recurrence on cystoscopy following an induction course of BCG for CIS of the urinary bladder.

Diagnosis and management of upper tract urothelial carcinoma.

Urothelial carcinoma of the upper urinary tract (UTUC) is a rare disease, comprising only 5-10% of all urothelial malignancies. There is a paucity of high level evidence to guide treatment decisions due to the rarity of the disease. Through the creation of multi-institutional collaborations in recent years, our understanding of the natural history of UTUC and treatment algorithms has improved. However, our understanding of UTUC is mostly driven by extrapolation of findings and paradigms of urothelial carcinoma of the urinary bladder. With current imaging techniques and biopsy modalities, accurate diagnosis and staging remains difficult for this disease and prognostic models are limited in their ability to predict clinical outcomes. As such, over or under-treatment is common, highlighting the need for individualized treatment regimens which often require a multimodal approach. Endoscopic or radical resection represent the mainstays of treatment, while the role of intraluminal agents and systemic chemotherapy is yet to be clearly defined. Herein we review current concepts and management strategies as well as recent developments in UTUC.

Tissue-based molecular markers for renal cell carcinoma.

Since the introduction of targeted therapies in renal cell carcinoma (RCC), more individualized treatment options have become available. Molecular markers might support treatment planning due to more accurate individual risk stratification. Current molecular markers in RCC were reviewed to elucidate clinical impact and future perspectives. An English-language literature review of the Medline database (1990 to September 2010) of published data on tissue-based molecular markers and RCC was undertaken. Histological types, clinical and oncological behaviour are variable in renal masses. Molecular markers offer potential for additional information in tumour detection and diagnosis, prognostic and predictive values, as well as determination of therapeutic targets. Investigations on molecular biomarkers in RCC include hypoxia inducible factor (HIF-α), vascular endothelial growth factor (VEGF), carbonic anhydrase IX (CAIX), mammalian target of rapamycin (mTOR), survivin, B7-H1, p53, matrix metalloproteinases (MMP), Insulin-like growth factor II mRNA-binding protein 3 (IMP3), Ki-67, C-reactive protein (CRP), Vimentin, Fascin, platelet count, hemoglobin level and combinations of these factors. Although some markers offer promising results, utilization in daily practice is compromised due to limited specificity, predictive accuracy and tumour histology variablity. There is an imminent need for novel molecular markers that allow accurate histologic and biologic classification of RCC to improve upon current outcomes. It is very likely that a panel of molecular markers will be used to achieve a sufficient degree of certainty in order to guide clinical decisions. A large concerted effort is required to advance the field of RCC molecular marker through systematic discovery, verification, and validation.

Intraluminal crystalloids are highly associated with prostatic adenocarcinoma on concurrent biopsy specimens.

Prostatic crystalloids are intraluminal eosinophilic structures with variable size and shape. Their presence has been described in conjunction with the occurrence of prostatic adenocarcinoma (pCA). We herein report the association of crystalloids and pCA in a prospective trial utilizing an extended multi-site transrectal ultrasound-guided (TRUS) prostate biopsy protocol. Three hundred and forty-four consecutive patients were prospectively enrolled at the Dallas Veterans Administration Hospital from November 2002 to September 2003. Indications for biopsy included a prostate-specific antigen (PSA) > or =4 ng/ml and/or abnormal digital rectal exam. A single pathologist evaluated all biopsy cores and documented the presence or absence of significant histopathologic features. Univariate and multivariate logistic regression analysis were applied to test the association of these features with the presence of pCA on concurrent biopsy. Median number of core biopsies per patient was 12 (range 3-36). Overall cancer detection rate was 42.7%. pCA was diagnosed in 66 (81.5%) of 81 patients with crystalloids, 70 (69.3%) of 101 patients with high-grade prostatic intraepithelial neoplasia (HGPIN), and 32 (84.2%) of 38 patients with both HGPIN and crystalloids on biopsy. Multivariate analysis identified crystalloids (RR 4.53, 95% CI 2.30-8.88) and HGPIN (RR 3.20, 95% CI 1.84-5.57) as independent predictors of the presence of cancer on concurrent biopsy (P<0.001). In this prospective analysis, crystalloids were significantly associated with pCA on concurrent biopsy and more predictive of the presence of pCA than HGPIN. These findings suggest that the presence of crystalloids alone or in combination with HGPIN in prostate biopsies may be a more compelling indication for repeat biopsy than HGPIN alone.

Loss of DAB2IP in RCC cells enhances their growth and resistance to mTOR-targeted therapies.

Targeted therapies using small-molecule inhibitors (SMIs) are commonly used in metastatic renal cell cancer (mRCC) patients; patients often develop drug resistance and eventually succumb to disease. Currently, understanding of mechanisms leading to SMIs resistance and any identifiable predictive marker(s) are still lacking. We discovered that DAB2IP, a novel Ras-GTPase-activating protein, was frequently epigenetically silenced in RCC, and DAB2IP loss was correlated with the overall survival of RCC patients. Loss of DAB2IP in RCC cells enhances their sensitivities to growth factor stimulation and resistances to SMI (such as mammalian target of rapamycin (mTOR) inhibitors). Mechanistically, loss of DAB2IP results in the activation of extracellular signal-regulated kinase/RSK1 and phosphoinositide-3 kinase/mTOR pathway, which synergizes the induction of hypoxia-inducible factor (HIF)-2α expression. Consequently, elevated HIF-2α suppresses p21/WAF1 expression that is associated with resistance to mTOR inhibitors. Thus combinatorial targeting both pathways resulted in a synergistic tumor inhibition. DAB2IP appears to be a new prognostic/predictive marker for mRCC patients, and its function provides a new insight into the molecular mechanisms of drug resistance to mTOR inhibitors, which also can be used to develop new strategies to overcome drug-resistant mRCC.

Association of perioperative blood transfusion with oncologic outcomes after radical nephroureterectomy for upper tract urothelial carcinoma.

BACKGROUND: To test the hypothesis that perioperative blood transfusion (PBT)impacts oncologic outcomes of patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). METHODS: Retrospective analysis of 2492 patients with UTUC treated at 23 institutions with RNU between 1987 and 2007.Cox regression models addressed the association of PBT with disease recurrence, cancer-specific mortality and any-cause mortality. RESULTS: A total of 510 patients (20.5%) patients received PBT. Within a median follow-up of 36 months (Interquartile range: 55 months), 663 (26.6%) patients experienced disease recurrence, 545 patients (21.9%) died of UTUC and 884 (35.5%) patients died from any cause. Patients who received PBT were at significantly higher risk of disease recurrence, cancer-specific mortality and overall mortality than patients not receiving PBT in univariable Cox regression analyses. In multivariable Cox regression analyses that adjusted for the effects of standard clinicopathologic features, PBT did not remain associated with disease recurrence (HR: 1.11; 95% CI 0.92-1.33, p = 0.25), cancer-specific mortality (HR: 1.09; 95% CI 0.89-1.33, p = 0.41) or overall mortality (HR: 1.09; 95% CI 0.93-1.28, p = 0.29). CONCLUSIONS: In patients undergoing RNU for UTUC, PBT is associated with disease recurrence, cancer-specific survival or overall survival in univariable, but not in multivariable Cox regression analyses.

Diabetes mellitus without metformin intake is associated with worse oncologic outcomes after radical nephroureterectomy for upper tract urothelial carcinoma.

AIMS: Evidence suggests a detrimental effect of diabetes mellitus (DM) on cancer incidence and outcomes. To date, the effect of DM and its treatment on prognosis in upper tract urothelial carcinoma (UTUC) remains uninvestigated. We tested the hypothesis that DM and metformin use impact oncologic outcomes of patients treated with radical nephroureterectomy (RNU) for UTUC. METHODS: Retrospective analysis of 2492 patients with UTUC treated at 23 institutions with RNU without neoadjuvant therapy. Cox regression models addressed the association of DM and metformin use with disease recurrence, cancer-specific mortality and any-cause mortality. RESULTS: A total of 365 (14.3%) patients had DM and 194 (7.8%) patients used metformin. Within a median follow-up of 36 months, 663 (26.6%) patients experienced disease recurrence, 545 patients (21.9%) died of UTUC and 884 (35.5%) patients died from any cause. Diabetic patients who did not use metformin were at significantly higher risk of disease recurrence and cancer-specific death compared to non-diabetic patients and diabetic patients who used metformin. In multivariable Cox regression analyses, DM treated without metformin was associated with worse recurrence-free survival (HR: 1.44, 95% CI 1.10-1.90, p = 0.009) and cancer-specific mortality (HR: 1.49, 95% CI 1.11-2.00, p = 0.008). CONCLUSIONS: Diabetic UTUC patients without metformin use have significantly worse oncologic outcomes than diabetics who used metformin and non-diabetics. The possible mechanism behind the impact of DM on UTUC biology and the potentially protective effect of metformin need further elucidation.

Loss of type III transforming growth factor-beta receptor expression is due to methylation silencing of the transcription factor GATA3 in renal cell carcinoma.

Loss of transforming growth factor-beta receptor III (TbetaRIII) correlates with loss of transforming growth factor-beta (TGF-beta) responsiveness and suggests a role for dysregulated TGF-beta signaling in clear cell renal cell carcinoma (ccRCC) progression and metastasis. Here we identify that for all stages of ccRCC TbetaRIII expression is downregulated in patient-matched tissue samples and cell lines. We find that this loss of expression is not due to methylation of the gene and we define GATA3 as the first transcriptional factor to positively regulate TbetaRIII expression in human cells. We localize GATA3's binding to a 10-bp region of the TbetaRIII proximal promoter. We demonstrate that GATA3 mRNA is downregulated in all stages, of ccRCC, mechanistically show that GATA3 is methylated in ccRCC patient tumor tissues as well as cell lines, and that inhibiting GATA3 expression in normal renal epithelial cells downregulates TbetaRIII mRNA and protein expression. These data support a sequential model whereby loss of GATA3 expression through epigenetic silencing decreases TbetaRIII expression during ccRCC progression.

Reflujo pancreáticobiliar en pacientes con colelitiasis y sin colelitiasis: estudio comparativo / Pancreaticobiliary reflux in patients with cholelithiasis and without cholelithiasis: a comparative study

Background. Pancreaticobiliary reflux is a pathologic phenomenon occurring in patients with gallstones. However, the occurrence of pancreaticobiliary reflux has not been studied in patients without gallstones. The objective of this study was to measure the bile levels of amylase and lipase in patients without gallstones submitted to cholecystectomy as part of another surgical procedure, and to compare these values with patients submitted to cholecystectomy for gallstone disease. Patients and Methods. A prospective observational comparative study was designed. A sample of 136 consecutive patients was included. Amylase and lipase levels were measured in bile. Normal serum amylase levels at our institution are 28-100 U/L and for lipase are 13-60 U/L. There are no established normal levels for pancreatic enzymes in bile. However, we considered elevated the bile amylase and lipase levels whenever they were higher than normal plasma levels. Results. One-hundred three patients (76 percent) had gallstones and 33 (24 percent) liad healthy gallbladders without gallstones. According to normal plasma levels for amylase and lipase, these enzymes in bile were elevated in 83.5 percent patients with gallstones, compared to elevated levels of amylase in 6 percent patients and lipase in 3 percent patients without gallstones. Conclusions. Pancreaticobiliary reflux is a common phenomenon in patients with gallstones and occurs sporadically in patients without gallstones.

Introducción. El reflujo pancreáticobiliar es un fenómeno patológico que ocurre en pacientes con colelitiasis. La ocurrencia de este fenómeno no ha sido estudiada en pacientes sin colelitiasis. El presente estudio tiene por objetivo medir los niveles de amilasa y lipasa en la bilis de pacientes sin colelitiasis, colecistectomizados como parte de otro procedimiento quirúrgico y comparar estos valores con pacientes colecistectomizados por colelitiasis. Pacientes y Métodos. Se diseñó un estudio observacional y comparativo. Una muestra de 136 pacientes consecutivos fue incluida. Se midieron los niveles de amilasa y lipasa en la bilis. En nuestra institución los valores normales para amilasa son 28-100 U/L y para lipasa 13-60 U/L. No se han establecido valores normales de enzimas pancreáticas en la bilis. Para efectos del presente estudio, se consideró como elevados los niveles biliares de amilasa y lipasa cuando fueron mayores a los valores plasmáticos normales. Resultados. 103 pacientes (76 por ciento) tenían colelitiasis y 33 (24 por ciento) tenían vesículas normales sin cálculos. De acuerdo a los valores plasmáticos normales de amilasa y lipasa, estas enzimas se encontraron elevadas en 83,5 por ciento de los pacientes con colelitiasis comparados con valores elevados de amilasa en 6 por ciento en pacientes sin colelitiasis y de lipasa en 3 por ciento de estos pacientes. Conclusiones. El reflujo pancreaticobiliar es un fenómeno común en pacientes con colelitiasis y ocurre esporádicamente en pacientes sin colelitiasis.

Asociación de la colesterolosis vesicular con el índice de masa corporal y los niveles plasmáticos de colesterol / Association of gallbladder cholesterolosis to body mass index and levels of serum cholesterol

Background: The objective was to find an association between obesity, plasma cholesterol levels, and chelesterolosis of the gallbladder in patients submitted to elective cholecystectomy for gallstone disease. Patients and methods: A sample of 406 patients studied with total plasma cholesterol levels was submitted to cholecystectomy. According to biopsy results they were divided into two groups, 326 patients without cholesterolosis and 80 patients with cholesterolosis. Results: Cholesterol levels were higher in patients without cholesterolosis (209.4+- 53 vs 181.5 +- 37, p<0.0001). Most patients with cholesterolosis had a body mass index > 25kg/m2 compared to patients without cholesterolosis (59 percent vs 48 percent, p=0.036). A positive correlation between body mass index and hypercholesterolemia in patients with and without cholesterolosis was found. ROC curves analysis showed a positive association between hypercholesterolemia and choletithiasis (OR: 3.831; 95 percent CI: 2.260-5.004: area under ROC curve: 0.670), and negative with cholesterolosis (OR: 0.074; 95 percent CI: 0.026-0.394; area under ROC curve: 0.330). Conclusions: Most obese patients with cholesterolosis had normal values of cholesterol compared to eutrophic patients. Eutrophic patients without cholesterolosis had hypercholesterolemia, more frequently than obese patients. Consequently, obesity and hypercholesterolemia are independent, not related factors associated to the development of gallbladder cholesterolosis and gallstones.

Introducción: El objetivo del presente estudio fue encontrar una asociación entre obesidad, niveles plamáticos de colesterol y colesterolosis vesicular en pacientes operados electivamente por colelitiasis. Pacientes y Métodos: Se estudió una muestra de conveniencia de 406 pacientes consecutivos operados por colelitiasis, en los que se midieron niveles plasmáticos de colesterol. De acuerdo al resultado de la biopsia se dividieron en dos grupos: 326 pacientes sin colesterolosis y 80 pacientes con colesterolosis. Resultados: Los niveles de colesterol fueron mayores en pacientes sin colesterolosis (209,4 +- 53 vs 181,5 +- 37, p < 0,0001). La mayoría de los pacientes con colesterolosis tenía un índice de masa corporal > 325 kg/m2 comparados con los pacientes sin colesterolosis (59 percent vs 48 percent, p = 0,036). Se encontró una correlación positiva entre índice de masa corporal e hipercolesterolemia en pacientes con y sin colesterolosis. El análisis con curvas ROC demostró una asociación positiva de la hipercolesterolemia con colelitiasis (OR: 3,831; 95 por ciento IC: 2,260- 5,004: área bajo la curva: 0,670) y negativa con colesterolosis (OR: 0,074; 95 por ciento IC: 0,026- 0,394; área bajo la curva: 0,330). Conclusiones: La mayoría de los pacientes obesos con colesterolosis tuvieron niveles de colesterol normales comparados con pacientes eutróficos. Los pacientes eutróficos sin colesterolosis tuvieron hipercolesterolemia con mayor frecuencia que los pacientes obesos. Consecuentemente, la obesidad y la hipercolesterolemia son factores independeientes asociados al desarrollo de colelitiasis y colesterolosis vesicular.

Vaginal vault fixation and prevention of enterocele recurrence by high midline levator myorraphy: physical examination and questionnaire-based follow-up.

OBJECTIVES: To assess outcome following a vaginal repair (high midline levator myorraphy, HMLM) for vaginal vault prolapse. METHODS: Women were identified who had undergone HMLM between December 1995 and September 1998. A structured telephone interview consisting of 5 questions was conducted in all those who could be reached. The most recent results of physical examination, based on office records, were also collected. RESULTS: Thirty-five of 47 women completed the interview (average age 71 years, mean time since surgery, 27.9 months). Five patients had developed recurrent prolapse requiring repair (anterior enterocele in 3, vault prolapse in 1, symptomatic cystocele in 1). Recurrent cystoceles were noted on examination in 7 women (5 grade 1, 2 grade 2). Overall, 17 women were extremely satisfied with the result (>90% satisfied); 6 were dissatisfied (<50%). Five women were noted to have transiently reduced unilateral ureteral drainage intraoperatively, and all cases were resolved after the removal or replacement of one of the levator myorraphy sutures. One patient required re-exploration for ureteral obstruction, which resolved after replacement of a suture and stenting. CONCLUSIONS: Levator myorraphy is safe, effective, and easily taught. The rate of recurrent prolapse associated with this technique is similar to other techniques for vaginal vault fixation, but it avoids the disadvantages of an abdominal approach and is more technically straightforward to perform than sacrospinalis fixation.