Intravesical oncolytic virotherapy and immunotherapy for non-muscle-invasive bladder cancer mouse model.

OBJECTIVES: To test if intravesical instillation of both an anti-programmed cell death protein 1 (PD-1) inhibitor and an oncolytic reovirus would demonstrate a greater effect than either treatment alone, as non-muscle-invasive bladder cancer that is refractory to intravesical bacillus Calmette-Guérin can be treated by systemic anti-PD-1 immunotherapy and we previously demonstrated improved overall survival (OS) with six once-weekly instillations of intravesical anti-PD-1 in a murine model. MATERIALS AND METHODS: Using an orthotopic syngeneic C3H murine model of MBT2 urothelial bladder cancer, groups of 10 mice were compared between no treatment, intravesical anti-PD-1, intravesical oncolytic reovirus, or intravesical reovirus + anti-PD-1. A single intravesical treatment session was given. The primary outcome was OS, and the secondary outcomes included long-term immunity and tumour-immune profile. RESULTS: With a median follow-up of 9 months, all mice that received no treatment died with a median survival of 41 days, while the comparison median OS was not reached for reovirus (hazard ratio [HR] 14.4, 95% confidence interval [CI] 3.9-32.6; P < 0.001), anti-PD-1 (HR 28.4, 95% CI 7.0-115.9; P < 0.001), and reovirus + anti-PD-1 (HR 28.4, 95% CI 7.0-115.9; P < 0.001). Monotherapy with anti-PD-1 or reovirus demonstrated no significant differences in survival (P = 0.067). Mass cytometry showed that reovirus + anti-PD-1 treatment enriched monocytes and decreased myeloid-derived suppressor cells, generating an immuno-responsive tumour microenvironment. Depletion of CD8+ T cells eliminated the survival advantage provided by the intravesical treatment. CONCLUSIONS: Treatment of murine orthotopic bladder tumours with a single instillation of intravesical reovirus, anti-PD-1 antibody, or the combination confers superior survival compared to controls. Tumour-immune microenvironment differences indicated myeloid-derived suppressor cells and CD8+ T cells mediate the treatment response.

Implementation of a comprehensive prehabilitation program for patients undergoing radical cystectomy.

BACKGROUND: Coordinated preoperative optimization programs for radical cystectomy (RC) are limited and non-comprehensive. We evaluated the feasibility and acceptability of a coordinated, multi-faceted prehabilitation program for RC patients at a high-volume bladder cancer referral center. METHODS: We performed a narrative literature review for prehabilitation in bladder cancer management as of December 1, 2020, with specific emphasis on examining higher-level evidence sources. We selected domains with the highest level of evidence and recruited a multidisciplinary team of experts to design our program. We implemented a comprehensive prehabilitation program with a pre-defined order set as standard of care for all patients undergoing RC beginning February 1, 2021. Demographic and clinicopathologic data were collected prospectively. Rates of adherence to the prehabilitation program services were analyzed using Stata version 13. RESULTS: A total of 82 patients were enrolled between February - December 2021, of which 67 (81%) had undergone RC at data cutoff. Mean age was 68 years (SD 11) and 63 (76%) identified as male. Neoadjuvant chemotherapy (NAC) was utilized in 48 (59%) patients. The mean Charlson Comorbidity Index was 3.8 (SD 2.3). 100% of patients were screened for malnutrition, with 82% consuming nutritional supplements. Fifty-two percent of patients attended physical therapy pre-op. The 30-day and 30- to 90-day rates of complications were 56% and 40%, respectively. Resource length of stay (RLOS) declined after implementation of prehabilitation. CONCLUSIONS: Implementation of a comprehensive prehabilitation program at a high-volume bladder cancer referral center is feasible and has a modest effect on resource consumption and complications in our early experience.

Intensity of observation with active surveillance or watchful waiting in men with prostate cancer in the United States.

BACKGROUND: Population-based studies assessing various active surveillance (AS) protocols for prostate cancer, to date, have inferred AS participation by the lack of definitive treatment and use of post-diagnostic testing. This is problematic as evidence suggests that most men do not adhere to AS protocols. We sought to develop a novel method of identifying men on AS or watchful waiting (WW) independent of post-diagnostic testing and aimed to identify possible predictors of follow-up intensity in men on AS/WW. METHODS: A predictive model was developed using SEER watchful waiting data to identify men ≥66 years on AS between 2010-2015, irrespective of post-diagnostic testing, and applied to SEER-Medicare database. AS intensity among different variables including age, prostate-specific antigen (PSA) level, number of total and positive biopsy cores, Charlson comorbidity index, race (Black vs. non-Black), US census region, and county poverty, income, and education levels were compared using multivariable regression analyses for PSA testing, surveillance biopsy, and magnetic resonance imaging (MRI). RESULTS: A total of 2238 men were identified as being on AS. Of which, 81%, 33%, and 10% had a PSA test, surveillance biopsy, and MRI scan within 1-2 years, respectively. On multivariable analyses, Black men were less likely to have a PSA test (adjusted rate ratio [ARR] 0.60, 95% CI: 0.53-0.69), MRI scan (ARR 0.40, 95% CI: 0.24-0.68), and surveillance biopsy (ARR 0.71, 95% CI: 0.55-0.92) than non-Black men. Men within the highest income quintile were more likely to undergo PSA test (ARR 1.16, 95% CI: 1.05-1.27) and MRI scan (ARR 1.60, 95% CI 1.15-2.27) compared to men with the lowest income. CONCLUSIONS: Black men and men with lower incomes on AS underwent less rigorous monitoring. Further study is needed to understand and ameliorate differences in AS rigor stemming from sociodemographic differences.

Diagnostic renal mass biopsy is associated with individual categories of PADUA and RENAL nephrometry scores: Analysis of diagnostic and concordance rates with surgical resection.

BACKGROUND: Renal mass biopsy (RMB) is a safe and accurate method for diagnosis and clinical management of renal masses. However, the non-diagnostic rate is a limiting factor. We tested the hypothesis that imaging characteristics and anatomic complexity of the mass may impact RMB diagnostic outcome using the preoperative aspects and dimensions used for an anatomical (PADUA) classification and radius-exophytic/endophytic-nearness-anterior/posterior-location (RENAL) score. MATERIAL AND METHODS: Single institution, retrospective study of 490 renal masses from 443 patients collected from 2001 to 2018. Outcome measurements include (1) diagnostic and concordance rates amongst RMB types and RMB with surgical resection specimens; (2) association between diagnostic RMB and anatomical complexity of renal masses. The analysis was conducted in unselected masses and small renal masses (SRMs). RESULTS: RMB was performed by fine needle aspiration (FNA), core needle biopsy (CNB), or both (FNA+CNB). Non-diagnostic rate was significantly higher for FNA compared to CNB and FNA+CNB in both unselected and SRMs. Subset analysis in the FNA+CNB group showed similar diagnostic rates for FNA and CNB. In unselected masses, specificity for FNA, CNB, and FNA+CNB was 100%. Sensitivity was higher for CNB (90.1%, P = 0.002) and FNA+CNB (96.3%, P = 0.004) compared to FNA (66.7%). For unselected masses, endophytic growth predicted a non-diagnostic CNB. R.E.N.A.L location entirely between the polar lines (central) and entirely above the upper polar line predicted a diagnostic CNB. Sonography-guidance predicted a diagnostic FNA. For SRMs, non-diagnostic CNB was associated with endophytic growth, while diagnostic CNB was associated with renal sinus invasion and operator experience. More cystic masses were sampled by FNA, but diagnostic results were similar for FNA and CNB. CONCLUSIONS: Endophytic growth consistently predicted a non-diagnostic CNB in unselected and SRMs, whereas sonography-guidance predicted a diagnostic FNA. Cystic masses could be adequately sampled by FNA.

Characterization of perioperative androgen profiles in men with bladder cancer undergoing radical cystectomy.

BACKGROUND: Prior studies have demonstrated declines in androgen levels in men with cancer and patients undergoing anesthesia and surgery. In this study, we hypothesized that decreased serum androgen levels are prevalent in male patients undergoing radical cystectomy (RC) for bladder cancer and that it persists in the postoperative period. We characterized perioperative androgen hormonal profiles and examined for associated changes indicative of sarcopenia on computed tomography scans in men undergoing RC. METHODS: We implemented a prospective observational trial in men with newly diagnosed non-metastatic bladder cancer undergoing RC. Baseline pre-operative total testosterone (TT), free testosterone (FT), and luteinizing hormone (LH) were obtained on morning lab draws with 30 days of surgery. TT and FT were then repeated on postoperative days (POD) 2, 3, 30, and 90. The threshold for normal TT was defined as >300 ng/dl, consistent with the AUA Guidelines for Evaluation and Management of Testosterone Deficiency. We evaluated postoperative changes in weight and psoas muscle cross-sectional area using computed tomography scans to assess for sarcopenic changes. RESULTS: Univariable statistical analysis was performed. 25 patients were enrolled. The mean patient age was 68.9 years. The mean pre-operative TT was 308 ng/dl, and 12/23 (52.5%) patients had low testosterone. Mean TT onPOD 2 and 3 were 166 ng/dl and 161 ng/dl, respectively (range 24-345). 19/20 (95%) of men who had morning lab draws had decreased TT. The mean TT at 30 days was 253 ng/dl with 37.5% of men having low TT. Mean TT at 90 days was 306 ng/dl. The mean FT levels were 43 ng/dl, 29.25 ng/dl, 28.2 ng/dl, 40.89 ng/dl, and 42.62 ng/dl at baseline, POD 2, POD 3, POD 30, and POD 90, respectively. Mean LH at baseline was 9.9 IU/L. Average weight loss at 30- and 90- days postop was -4.29 and -4.38 kilograms, respectively. Weight loss was persistent with only 3/23 (13%) returning to their presurgery weight by 90 days. Despite significant declines in weight and perioperative TT, no significant differences in psoas muscle cross-sectional area were observed (net change -92 mm2, P= 0.13) CONCLUSIONS: Perioperative disruption of androgen levels is prevalent in men undergoing RC. Our trial demonstrates a pre-op, immediate postop, 30- and 90-day postoperative prevalence of low TT of 52%, 95%, 63%, and 37.5%, respectively. Significant changes in baseline weight were noted, although no significant changes in psoas muscle cross-sectional area were observed, limiting conclusions regarding a link between changes in androgens and sarcopenia in this setting.

Management of anticoagulation and antiplatelet agents in the radical cystectomy patient.

BACKGROUND: Bladder cancer is a disease of the older adult, and management of comorbid conditions requiring anticoagulation (AC) or antiplatelet agents (APA) around the time of radical cystectomy (RC) is a frequent clinical challenge. It is estimated that 10% of adult surgical patients are on chronic anticoagulation medications, and considerations surrounding the perioperative disruption, resumption, and modification or substitution of AC and APA in patients undergoing radical cystectomy are critical for the practicing urologist. METHODS: In our report, we performed a comprehensive literature review using PubMed to evaluate all available studies from 1950 to present. Additionally, we reviewed current multidisciplinary guideline papers from the American College of Surgeons, American College of Cardiology, and CHEST Society regarding perioperative management of anticoagulation and antiplatelet agents. RESULTS: Our keyword search yielded 35 articles from 1950 to 2019. We identified 16 studies pertaining specifically to evaluation and perioperative management of anticoagulation in patient undergoing RC. Many of the recommendations in this realm are informed by trial data outside the RC population in the general surgical population or general adult population. Current guidelines from the American College of Surgeons, American College of Cardiology/American Heart Association, and CHEST Society inform our recommendations heavily and are summarized in Table 1. CONCLUSIONS: Radical cystectomy remains both a mainstay of therapy for patients with muscle-invasive bladder cancer and a morbid procedure. Competing risks of perioperative hemorrhage and thromboembolic events make management of anticoagulation and antiplatelet agents an important and modifiable risk factor. Our review of the current literature highlights the knowledge gap that exists in management of these agents in the radical cystectomy patient. A multi-disciplinary approach to management of this clinical challenge remains a mainstay of treatment.

Side Effects of Intravesical BCG and Chemotherapy for Bladder Cancer: What They Are and How to Manage Them.

Intravesical therapy for nonmuscle invasive bladder cancer decreases recurrence and progression but carries a high risk of side effects, which limit patient adherence. Appropriate management of the toxicities from intravesical therapy requires consideration of the agent used, the side effects experienced, and the timing of those side effects. Management strategies for intravesical toxicities ideally improve patient tolerance without sacrificing oncologic outcomes. This review aims to provide a comprehensive overview of the available evidence regarding the side effects of intravesical therapies for nonmuscle invasive bladder cancer and to propose practical strategies for toxicity management.

Molecular subtyping of bladder cancer: current trends and future directions in 2019.

PURPOSE OF REVIEW: Personalized medicine portends a future where patients receive therapy based on mutational and gene expression profiles intrinsic to their tumor. Recent advances in molecular subtyping of tumors have pushed us closer to using patient-specific data to guide therapy. The purpose of this review is to understand how these advances may be used to understand tumor development and direct therapeutic regimens clinically. RECENT FINDINGS: Multiple reports have identified specific molecular subtypes present in bladder cancer. A variety of classification schemes are currently being suggested based on different groups observations on gene expression, mutational profile, and histological variability. Notably, recent novel findings indicate standard of care with neoadjuvant platinum-based chemotherapy effectively removes the basal subtype specifically, indicating clinical data largely supports the use of molecular subtyping as a way to treat tumors. SUMMARY: Although varied classifications are present in the field currently, more work is required to truly define which subtypes are responsive to specific therapies. Current data supports the idea that molecular subtyping will benefit patients; however, these data also argue in favor of combinatorial therapy and molecular profiling throughout treatment.

Group effects on insecticide toxicity in workers of the Formosan subterranean termite, Coptotermes formosanus Shiraki.

Coptotermes formosanus workers were treated topically with insecticide and subsequently held individually or in groups to examine possible effects on insecticide toxicity. Chlorpyrifos, cypermethrin and chlordane toxicities were 1.4-, 1.5-, and 1.3-fold greater, respectively, among workers held in groups compared with those held individually after insecticide treatment. Experiments were conducted to examine how enhanced toxicity occurred among termites held in groups after topical insecticide treatment. When workers were treated topically with chlordane and immediately placed with untreated workers, significantly greater numbers of untreated workers were killed compared with controls at all ratios examined (insecticide-treated:untreated). These data indicated that workers treated topically with insecticide were capable of somehow transferring a lethal dose of insecticide to untreated workers confined in the vial. Chlordane was recovered from untreated workers which had been confined with chlordane-treated workers; significantly higher quantities of chlordane were recovered from dead workers exposed to chlordane-treated workers compared with surviving workers exposed to chlordane-treated workers. Possible mechanisms of insecticide transfer from insecticide-treated to untreated termites are discussed.

Insecticide susceptibility and detoxication enzyme activities among Coptotermes formosanus Shiraki workers sampled from different locations in New Orleans.

Coptotermes formosanus Shiraki worker termites were sampled from 20 locations in the City Park area of New Orleans, LA. The termites were subsequently assayed to determine their susceptibility to cypermethrin, chlordane and chlorpyrifos, and detoxication enzyme activity. Cypermethrin was most toxic against Formosan subterranean termite workers, chlorpyrifos exhibited intermediate toxicity and chlordane was least toxic. A comparison of insecticide susceptibility between the most and least tolerant colonies revealed 1.9-, 1.7- and 1.8-fold differences in susceptibility for cypermethrin, chlorpyrifos and chlordane, respectively. As with the bioassay data, although significant differences were noted, a great deal of overlap was observed among the colonies for total cytochrome P450 content (difference of 2.2-fold between high and low value) aldrin epoxidation (3.6-fold) and cytosolic esterase (3.9-fold) activity. No significant differences were observed among the colonies for methoxyresorufin O-demethylase or glutathione S-transferase activity. Conversely, microsomal esterase activity varied greatly; a 38-fold difference was observed between the most (Cf1776) and least (Cf1387) active colonies. However, no significant correlation was observed between insecticide susceptibility and microsomal esterase activity. In fact, no significant correlations were observed between any of the enzyme activities measured and insecticide susceptibility. These results are discussed in the context of insecticide selection and future control effectiveness.

Afferents from the auditory thalamus synapse on inhibitory interneurons in the lateral nucleus of the amygdala.

Physiological studies suggest that afferents to the lateral nucleus of the amygdala (LA) from the auditory thalamus initiate feedforward inhibition [Li et al. (1996b)]. This model of neural processing requires that thalamic afferents synapse directly onto inhibitory interneurons. To determine whether such synaptic contacts occur, we combined anterograde tract tracing with interneuron immunocytochemistry. The anterograde tracer biotinylated dextran amine (BDA) was injected into the auditory thalamus. Inhibitory interneurons in the LA were identified using antibodies directed against gamma aminobutyric acid (GABA) or one of the calcium binding proteins (CBPs), parvalbumin (PARV), calbindin (CALB), or calretinin (CALR), since CBPs identify distinct populations of GABAergic cells within the amygdala. The distribution of GABAergic and CBP interneurons in each subregion of the LA was examined by light microscopy and the relationships between thalamo-amygdala terminals and interneurons were examined by confocal and electron microscopy. Immunoreactive cells were distributed in all three subdivisions of LA, except for CALR-ir neurons, which were sparse in the dorsal subregion and were found mainly in the ventromedial and ventrolateral subregions. Confocal microscopy revealed some thalamo-amygdala terminals in close proximity to LA interneurons, while electron microscopy showed that thalamo-amygdala terminals made direct synaptic contacts onto distal dendritic processes of inhibitory neurons. These data provide morphological evidence that thalamic afferents synapse directly onto inhibitory interneurons in LA, and are consistent with the possibility that inputs from the auditory thalamus initiate feedforward inhibition in LA. This architecture could play an important role in the suppression of background neural noise, thereby enhancing the response of LA cells to incoming auditory stimuli.

Pollination-Induced Ethylene in Carnation (Role of Stylar Ethylene in Corolla Senescence).

In carnation (Dianthus caryophyllus L. cv White Sim) cell to cell communication between the pollen and pistil induces ovary development and corolla senescence. The production of elevated ethylene by the style is the first measurable postpollination response. This is followed by a wave of ethylene production from the other floral organs. To investigate the regulation of ethylene biosynthesis in pollinated flowers we measured ethylene production and the expression of 1-aminocyclopropane-1-carboxylate synthase and 1-aminocyclopropane-1-carboxylate oxidase transcripts in individual floral organs after pollination. Ethylene production by pollinated styles can be defined temporally by three distinct peaks. By pollinating a single style from a multistyle gynoecium, it was determined that the unpollinated style produces ethylene that corresponds to the first and third peaks observed from a pollinated style. Inhibition of ethylene action in the pollinated style by diazocyclopentadiene treatment prevented both pollination-induced corolla senescence and ethylene production from the ovaries and petals. Treatment with diazocyclopentadiene decreased stylar ethylene production during the second peak and completely inhibited the third peak of ethylene in both pollinated and unpollinated styles. This later auto-catalytic ethylene in styles is likely responsible for pollination-induced corolla senescence and ovary development.

Temporal and Spatial Expression of 1-Aminocyclopropane-1-Carboxylate Oxidase mRNA following Pollination of Immature and Mature Petunia Flowers.

Pollination of petunia (Petunia hybrida) flowers induces a rapid increase in ethylene production by styles, which subsequently leads to increased ethylene production by the corolla, inducing senescence. We have investigated the temporal and spatial expression of 1-aminocyclopropane-1-carboxylate (ACC) oxidase transcripts in petunia styles in an attempt to elucidate its role in increased ethylene biosynthesis following pollination. Previously, we reported that the development of petunia flowers was associated with increased ACC oxidase mRNA localized specifically in the stigmatic regions of the style (X. Tang, A.M.T. Gomes, A. Bhatia, W.R. Woodson [1994] Plant Cell 6: 1227-1239). The rapid increase in ethylene production by styles within the 1st h following pollination was correlated with the expression of ACC oxidase mRNAs during development. Pollination of petunia flowers prior to anthesis and the expression of ACC oxidase mRNA led to a substantial increase in ethylene production, but this was delayed by several hours in comparison with flowers at anthesis. This delayed increase in ethylene production by pollinated styles from immature flowers was associated with an increased ACC oxidase transcript abundance. Treatment with the ethylene action inhibitor 2,5-norbornadiene did not affect the early increase in ethylene production or the expression of ACC oxidase mRNAs. No differences in the rate of pollen germination or tube growth were detected when applied to stigmas from immature or mature flowers, indicating that the delay in ethylene production was likely the result of limited ACC oxidase activity. Localization of ACC oxidase mRNAs following pollination by in situ hybridization revealed an abundance of transcripts in transmitting tract tissue within 4 h of pollination of both immature and mature styles, in contrast to their localization in stigmatic cells during development.

GABAergic inputs to the nucleus rotundus (pulvinar inferior) of the pigeon (columba livia).

The avian nucleus rotundus, a nucleus that appears to be homologous to the inferior/ caudal pulvinar of mammals, is the major target of an ascending retino-tecto-thalamic pathway. Further clarification of the inputs to the rotundus and their functional properties will contribute to our understanding of the fundamental role of the ascending tectal inputs to the telencephalon in all vertebrates, including mammals. We found that the rotundus contains a massive plexus of glutamic acid decarboxylase (GAD)-immunoreactive axons using antibodies against GAD. The cells within the rotundus, however, were not immunoreactive for GAD. The retrograde tracer cholera toxin B fragment was injected into the rotundus to establish the location of the afferent neurons and determine the source of the gamma-aminobutyric acid (GABA) inputs into the rotundus. In addition to the recognized bilateral inputs from layer 13 of the tectum, we found intense retrograde labeling of neurons within the ipsilateral nuclei subpretectalis (SP), subpretectalis-caudalis (SPcd), interstitio-pretecto-subpretectalis (IPS), posteroventralis thalami (PV), and reticularis superior thalami (RS). All the neurons of the SP, SPcd, IPS, and PV were intensely GAD-immunoreactive. The neurons of layer 13 of the tectum were not immunoreactive for GAD. Following the destruction of the ipsilateral SP/IPS complex, we found a major reduction in the intensity of the GAD axonal immunoreactivity within the ipsilateral rotundus, but this destruction did not diminish the intensity of the GAD-immunoreactivity within the contralateral rotundus. Our studies indicated that the source of the massive GAD-immunoreactive plexus within the rotundus was from the ipsilateral SP, SPcd, IPS, and PV nuclei. These nuclei, in turn, received ipsilateral tectal input via collaterals of the neurons of layer 13 in the course of their projections upon the rotundus. We suggest that the direct bilateral tecto-rotundal projections are excitatory, whereas the indirect ipsilateral projections from the SP/IPS and PV are mainly inhibitory, possibly acting via a GABA-A receptor.

Cloning of a DNA-binding protein that interacts with the ethylene-responsive enhancer element of the carnation GST1 gene.

Ethylene transcriptionally activates a glutathione S-transferase gene (GST1) at the onset of the senescence program in carnation (Dianthus caryophyllus L.) flower petals. A 126 bp region of the GST1 promoter sequence has been identified as an ethylene-responsive enhancer element (ERE). In this paper, we demonstrate the ability of nuclear proteins from senescing petals to recognize a 22 bp sequence within the ERE (ERE oligonucleotide). Mutation of the ERE oligonucleotide sequence significantly alters the strength of this nuclear protein-DNA association. The wild-type ERE oligonucleotide sequence was used to isolate a cDNA clone encoding a sequence-specific DNA binding protein. Nucleotide sequencing and deduced amino acid sequence analysis of this cDNA predicted a 32 kDa protein which we have designated carnation ethylene-responsive element-binding protein-1 (CEBP-1). The mRNA expression pattern of CEBP-1 suggests that it is not transcriptionally regulated by ethylene. The amino acid sequence homology of CEBP-1 with other plant nucleic acid binding proteins indicates a conserved nucleic acid binding domain. Within this domain are two highly conserved RNA-binding motifs, RNP-1 and RNP-2. An acidic region and a putative nuclear localization signal are also identified.