Targeting the ATF6-Mediated ER Stress Response and Autophagy Blocks Integrin-Driven Prostate Cancer Progression.

Prostate cancer progression to the lethal metastatic castration-resistant phenotype (mCRPC) is driven by αv integrins and is associated with Golgi disorganization and activation of the ATF6 branch of unfolded protein response (UPR). Overexpression of integrins requires N-acetylglucosaminyltransferase-V (MGAT5)-mediated glycosylation and subsequent cluster formation with Galectin-3 (Gal-3). However, the mechanism underlying this altered glycosylation is missing. For the first time, using HALO analysis of IHC, we found a strong association of integrin αv and Gal-3 at the plasma membrane (PM) in primary prostate cancer and mCRPC samples. We discovered that MGAT5 activation is caused by Golgi fragmentation and mislocalization of its competitor, N-acetylglucosaminyltransferase-III, MGAT3, from Golgi to the endoplasmic reticulum (ER). This was validated in an ethanol-induced model of ER stress, where alcohol treatment in androgen-refractory PC-3 and DU145 cells or alcohol consumption in patient with prostate cancer samples aggravates Golgi scattering, activates MGAT5, and enhances integrin expression at PM. This explains known link between alcohol consumption and prostate cancer mortality. ATF6 depletion significantly blocks UPR and reduces the number of Golgi fragments in both PC-3 and DU145 cells. Inhibition of autophagy by hydroxychloroquine (HCQ) restores compact Golgi, rescues MGAT3 intra-Golgi localization, blocks glycan modification via MGAT5, and abrogates delivery of Gal-3 to the cell surface. Importantly, the loss of Gal-3 leads to reduced integrins at PM and their accelerated internalization. ATF6 depletion and HCQ treatment synergistically decrease integrin αv and Gal-3 expression and temper orthotopic tumor growth and metastasis. IMPLICATIONS: Combined ablation of ATF6 and autophagy can serve as new mCRPC therapeutic.

Drug-Induced Nephrotoxicity Assessment in 3D Cellular Models.

The kidneys are often involved in adverse effects and toxicity caused by exposure to foreign compounds, chemicals, and drugs. Early predictions of these influences are essential to facilitate new, safe drugs to enter the market. However, in current drug treatments, drug-induced nephrotoxicity accounts for 1/4 of reported serious adverse reactions, and 1/3 of them are attributable to antibiotics. Drug-induced nephrotoxicity is driven by multiple mechanisms, including altered glomerular hemodynamics, renal tubular cytotoxicity, inflammation, crystal nephropathy, and thrombotic microangiopathy. Although the functional proteins expressed by renal tubules that mediate drug sensitivity are well known, current in vitro 2D cell models do not faithfully replicate the morphology and intact renal tubule function, and therefore, they do not replicate in vivo nephrotoxicity. The kidney is delicate and complex, consisting of a filter unit and a tubular part, which together contain more than 20 different cell types. The tubular epithelium is highly polarized, and maintaining cellular polarity is essential for the optimal function and response to environmental signals. Cell polarity depends on the communication between cells, including paracrine and autocrine signals, as well as biomechanical and chemotaxis processes. These processes affect kidney cell proliferation, migration, and differentiation. For drug disposal research, the microenvironment is essential for predicting toxic reactions. This article reviews the mechanism of drug-induced kidney injury, the types of nephrotoxicity models (in vivo and in vitro models), and the research progress related to drug-induced nephrotoxicity in three-dimensional (3D) cellular culture models.

Circulating and intraprostatic sex steroid hormonal profiles in relation to male pattern baldness and chest hair density among men diagnosed with localized prostate cancers.

BACKGROUND: Prospective cohort studies of circulating sex steroid hormones and prostate cancer risk have not provided a consistent association, despite evidence from animal and clinical studies. However, studies using male pattern baldness as a proxy of early-life or cumulative androgen exposure have reported significant associations with aggressive and fatal prostate cancer risk. Given that androgens underlie the development of patterned hair loss and chest hair, we assessed whether these two dermatological characteristics were associated with circulating and intraprostatic concentrations of sex steroid hormones among men diagnosed with localized prostate cancer. METHODS: We included 248 prostate cancer patients from the NCI Prostate Tissue Study, who answered surveys and provided a pre-treatment blood sample as well as fresh frozen adjacent normal prostate tissue. Male pattern baldness and chest hair density were assessed by trained nurses before surgery. General linear models estimated geometric means and 95% confidence intervals (95%CIs) of each hormone variable by dermatological phenotype with adjustment for potential confounding variables. Subgroup analyses were performed by Gleason score (<7 vs ≥7) and race (European American vs. African American). RESULTS: We found strong positive associations of balding status with serum testosterone, dihydrotestosterone (DHT), estradiol, and sex hormone-binding globulin (SHBG), and a weak association with elevated intraprostatic testosterone. Conversely, neither circulating nor intraprostatic sex hormones were statistically significantly associated with chest hair density. Age-adjusted correlation between binary balding status and three-level chest hair density was weak (r = 0.05). There was little evidence to suggest that Gleason score or race modified these associations. CONCLUSIONS: This study provides evidence that balding status assessed at a mean age of 60 years may serve as a clinical marker for circulating sex hormone concentrations. The weak-to-null associations between balding status and intraprostatic sex hormones reaffirm differences in organ-specific sex hormone metabolism, implying that other sex steroid hormone-related factors (eg, androgen receptor) play important roles in organ-specific androgenic actions, and that other overlapping pathways may be involved in associations between the two complex conditions.

Relationships between Circulating and Intraprostatic Sex Steroid Hormone Concentrations.

Background: Sex hormones have been implicated in prostate carcinogenesis, yet epidemiologic studies have not provided substantiating evidence. We tested the hypothesis that circulating concentrations of sex steroid hormones reflect intraprostatic concentrations using serum and adjacent microscopically verified benign prostate tissue from prostate cancer cases.Methods: Incident localized prostate cancer cases scheduled for surgery were invited to participate. Consented participants completed surveys, and provided resected tissues and blood. Histologic assessment of the ends of fresh frozen tissue confirmed adjacent microscopically verified benign pathology. Sex steroid hormones in sera and tissues were extracted, chromatographically separated, and then quantitated by radioimmunoassays. Linear regression was used to account for variations in intraprostatic hormone concentrations by age, body mass index, race, and study site, and subsequently to assess relationships with serum hormone concentrations. Gleason score (from adjacent tumor tissue), race, and age were assessed as potential effect modifiers.Results: Circulating sex steroid hormone concentrations had low-to-moderate correlations with, and explained small proportions of variations in, intraprostatic sex steroid hormone concentrations. Androstane-3α,17ß-diol glucuronide (3α-diol G) explained the highest variance of tissue concentrations of 3α-diol G (linear regression r2 = 0.21), followed by serum testosterone and tissue dihydrotestosterone (r2 = 0.10), and then serum estrone and tissue estrone (r2 = 0.09). There was no effect modification by Gleason score, race, or age.Conclusions: Circulating concentrations of sex steroid hormones are poor surrogate measures of the intraprostatic hormonal milieu.Impact: The high exposure misclassification provided by circulating sex steroid hormone concentrations for intraprostatic levels may partly explain the lack of any consistent association of circulating hormones with prostate cancer risk. Cancer Epidemiol Biomarkers Prev; 26(11); 1660-6. ©2017 AACR.

NCCN Guidelines Insights: Prostate Cancer Early Detection, Version 2.2016.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer Early Detection provide recommendations for prostate cancer screening in healthy men who have elected to participate in an early detection program. The NCCN Guidelines focus on minimizing unnecessary procedures and limiting the detection of indolent disease. These NCCN Guidelines Insights summarize the NCCN Prostate Cancer Early Detection Panel's most significant discussions for the 2016 guideline update, which included issues surrounding screening in high-risk populations (ie, African Americans, BRCA1/2 mutation carriers), approaches to refine patient selection for initial and repeat biopsies, and approaches to improve biopsy specificity.

NCCN Clinical Practice Guidelines Prostate Cancer Early Detection, Version 2.2015.

Prostate cancer represents a spectrum of disease that ranges from nonaggressive, slow-growing disease that may not require treatment to aggressive, fast-growing disease that does. The NCCN Guidelines for Prostate Cancer Early Detection provide a set of sequential recommendations detailing a screening and evaluation strategy for maximizing the detection of prostate cancer that is potentially curable and that, if left undetected, represents a risk to the patient. The guidelines were developed for healthy men who have elected to participate in the early detection of prostate cancer, and they focus on minimizing unnecessary procedures and limiting the detection of indolent disease.

Molecular markers for bladder cancer screening, early diagnosis, and surveillance: the WHO/ICUD consensus.

Due to the lack of disease-specific symptoms, diagnosis and follow-up of bladder cancer has remained a challenge to the urologic community. Cystoscopy, commonly accepted as a gold standard for the detection of bladder cancer, is invasive and relatively expensive, while urine cytology is of limited value specifically in low-grade disease. Over the last decades, numerous molecular assays for the diagnosis of urothelial cancer have been developed and investigated with regard to their clinical use. However, although all of these assays have been shown to have superior sensitivity as compared to urine cytology, none of them has been included in clinical guidelines. The key reason for this situation is that none of the assays has been included into clinical decision-making so far. We reviewed the current status and performance of modern molecular urine tests following systematic analysis of the value and limitations of commercially available assays. Despite considerable advances in recent years, the authors feel that at this stage the added value of molecular markers for the diagnosis of urothelial tumors has not yet been identified. Current data suggest that some of these markers may have the potential to play a role in screening and surveillance of bladder cancer. Well-designed protocols and prospective, controlled trials will be needed to provide the basis to determine whether integration of molecular markers into clinical decision-making will be of value in the future.

Prostate cancer early detection, version 1.2014. Featured updates to the NCCN Guidelines.

The NCCN Guidelines for Prostate Cancer Early Detection provide recommendations for men choosing to participate in an early detection program for prostate cancer. These NCCN Guidelines Insights highlight notable recent updates. Overall, the 2014 update represents a more streamlined and concise set of recommendations. The panel stratified the age ranges at which initiating testing for prostate cancer should be considered. Indications for biopsy include both a cutpoint and the use of multiple risk variables in combination. In addition to other biomarkers of specificity, the Prostate Health Index has been included to aid biopsy decisions in certain men, given recent FDA approvals.

Cellular immunotherapy study of prostate cancer patients and resulting IgG responses to peptide epitopes predicted from prostate tumor-associated autoantigens.

The immunogenicity of a cellular immunotherapy using genetically modified vaccines to express α(1,3)galactosyl epitopes (αGal) was evaluated in advanced prostate cancer (PC) patients. In this dose escalation phase I study, we report safety, feasibility, and immunologic data of an immunotherapy composed of 2 human PC cell lines engineered to express αGal epitopes (HyperAcute-Prostate, HAP, NewLink Genetics). Eight patients received up to 12 biweekly vaccinations with HAP. Enrolled patients (aged range, 53-85 y) had American Joint Committee on Cancer stage IV, any T, any N, M1, Eastern Cooperative Oncology Group PS≤2, at least 1 prior hormonal treatment and <3 prior chemotherapies, adequate bone marrow and organ function, and albumin ≥3.0 g/dL. Serum IgG antibodies to synthetic peptides overexpressed in PC were determined by enzyme-linked immunosorbent assay. Results indicate that HAP immunotherapy induced humoral immune responses to autoantigens in 2 of 8 patients. These patients developed IgG antibody to multiple epitopes overexpressed in PC after immunization. These responding patients received higher doses of the immunotherapy suggesting a dose response. Two immunogenic proteins (prostate-specific membrane antigen, hepsin) belong to the extracellular molecules family participating in malignant cell invasion. Median overall survival for patients was 25.1 months with 1 patient surviving over 70 months with stable PSA and bone metastasis before expiring of other causes. Three of 8 patients showed PSA stabilization (>100 d). In conclusion, HAP immunotherapy induces IgG responses to epitopes from autoantigens overexpressed in PC suggesting dose-dependent effect. HAP represents a viable immunotherapy approach to induce immune responses against tumor cells and may provide clinical benefit with minimal toxicity.

Ten-year follow-up of neoadjuvant therapy with goserelin acetate and flutamide before radical prostatectomy for clinical T3 and T4 prostate cancer: update on Southwest Oncology Group Study 9109.

OBJECTIVE: To update the results with 10-year data of a phase II prospective trial of neoadjuvant hormonal therapy with goserelin acetate and flutamide followed by radical prostatectomy for locally advanced prostate cancer (SWOG 9109). The optimal management for clinical stage T3 and T4 N0,M0 prostate cancer is uncertain. MATERIALS AND METHODS: Sixty-two patients with clinical stage T3 and T4 N0,M0 prostate cancer were enrolled. Cases were classified by stage T3 vs T4 and by volume of disease (bulky >4 cm and nonbulky ≤ 4 cm). RESULTS: Fifty-five of 61 eligible patients completed the trial with radical prostatectomy after neoadjuvant androgen deprivation therapy (ADT). The median preoperative prostate-specific antigen value was 19.8 ng/mL, and 67% of patients had a Gleason score of ≥ 7. Among 41 patients last known to be alive, median follow-up is 10.6 years (range 5.1-12.6). In all, 38 patients have had disease progression (30/55, 55%) or died without progression (8/55, 15%) for a 10-year progression-free survival (PFS) estimate of 40% (95% CI 27-53). Median PFS was 7.5 years, and median survival has not been reached. The 10-year overall survival (OS) estimate is 68% (95% CI 56-80). CONCLUSIONS: In this small, prospective phase II study, neoadjuvant hormonal therapy with goserelin acetate and flutamide followed by radical prostatectomy achieves long-term PFS and OS comparable with alternative treatments. This approach is feasible and may be an alternative to a strategy of combined radiation and ADT.

Younger age is an independent predictor for poor survival in patients with signet ring prostate carcinoma.

Objective. The aim of this study was to examine the epidemiology, natural history, treatment pattern, and predictors of long-term survival of signet ring prostate carcinoma (SRPC) patients based on the analysis of the national Surveillance, Epidemiology, and End Results (SEER) database. Methods & Results. Between 1980 and 2004, a total of 93 patients with pathologically confirmed SRPC were identified. The mean age was 70 ± 11 years old. 82.8% of the patients had poorly or undifferentiated histology grade. 13.9% patients presented with metastatic disease. The 1-, 3-, and 5-year cancer-specific survival rates were 94.6%, 89.6%, and 83.8%, respectively. Using multivariate Cox proportional hazard model, younger age (40-50 versus age >70 yrs, P = .01), advanced tumor stage (distant versus local/regional, P = .02), and earlier diagnosis year (before 1995 versus after 1995, P = .01) were predictors of worse cancer specific survival. Conclusions. Despite more aggressive cancer therapy, younger SRPC patients had a worse cancer specific survival. This information could be useful when counseling these patients and emphasizes the need for new strategies and molecular-based therapeutic approaches for younger patients with SRPC.

The initiation of a preoperative and postoperative telemedicine urology clinic.

This work describes the establishment of a Telemedicine Urology Clinic at the VA Medical Center in Omaha, Nebraska to serve an underserved veteran population in rural Nebraska. Results from patient satisfaction surveys show that both the patient and the healthcare provider benefit from the telemedicine encounter for both the preoperative and the postoperative setting.

The approach to the difficult urethral catheterization among urology residents in the United States.

PURPOSE: To determine the prevalence of different approaches to the difficult urethral catheterization (DUC) among urology residents (UR) in the United States (US). MATERIALS AND METHODS: An email invitation to participate in an online survey regarding DUC was sent to 267 UR and to 22 urology program coordinators for them to forward to their residents. 142 UR completed the survey. RESULTS: After the initial unsuccessful attempt by a nurse, 92% of UR attempted a catheter prior to resorting to other modalities. The most common choice of the first catheter was a Coude (76%) size 18F (51%). For situations where multiple sizes and types of catheters (12-20F) were used without success, 3 scenarios were proposed: 1) Catheter passed the bulbomembranous urethra (BMU) and patient had previous history of transurethral resection of the prostate or radical retropubic prostatectomy, 2) Catheter passed the BMU and no urologic history, 3) Catheter did not pass the BMU and no urologic history. Flexible cystoscopy was used in 74%, 62% and 63%; blind passage of a glidewire was second with 15%, 23% and 20%; and blind use of filiforms and followers was chosen in 7%, 9% and 9% of the scenarios respectively. CONCLUSIONS: The most common approach to the DUC among UR in the US involves using an 18F Coude catheter first. After trying one or more urethral catheters, UR most commonly resort to flexible cystoscopy as opposed to the blind placement of glide wires or filiforms/followers.

Clinical features and outcomes of 25 patients with primary adenosquamous cell carcinoma of the prostate.

The aim of the present study was to examine the epidemiology, natural history, treatment and long-term survival of patients with adenosquamous cell carcinoma of the prostate. The Surveillance, Epidemiology, and End Results (SEER) Program database was used to identify ASCC of prostate cases between January 1973 and December 2006. Survival probabilities were estimated using the Kaplan-Meier methods and compared using the log-rank test. A total of 25 patients with adenosquamous cell carcinoma of the prostate were identified during the study period. The median age was 74 years (range 53-98). Twenty percent of study subjects presented with metastatic disease. Among those patients with known grade (n=16), 75% had poorly or undifferentiated histology. A total of 40% of study subjects received radical prostatectomy, while 24% of the patients had primary radiation therapy. The 1-, 3-, and 5-year cancer specific survival rates for the entire cohort were 55.2%, 37.8%, and 30.3%, respectively. For patients who underwent prostatectomy, the 1-, 3-, and 5-year survival rates were 78%, 78%, and 63%, respectively. For the patients who did not receive prostatectomy, the 1-year survival rates were 38.7% and none survived to three years. Adenosquamous cell carcinoma is a rare aggressive subtype of prostate cancer with poor cancer specific survival. The development of new therapeutic approaches for this aggressive tumor is urgently needed.

Udp-glucose dehydrogenase as a novel field-specific candidate biomarker of prostate cancer.

Uridine diphosphate (UDP)-glucose dehydrogenase (UGDH) catalyzes the oxidation of UDP-glucose to yield UDP-glucuronic acid, a precursor for synthesis of glycosaminoglycans and proteoglycans that promote aggressive prostate cancer (PC) progression. The purpose of our study was to determine if the UGDH expression in normal appearing acini (NAA) from cancerous glands is a candidate biomarker for PC field disease/effect assayed by quantitative fluorescence imaging analysis (QFIA). A polyclonal antibody to UGDH was titrated to saturation binding and fluorescent microscopic images acquired from fixed, paraffin-embedded tissue slices were quantitatively analyzed. Specificity of the assay was confirmed by Western blot analysis and competitive inhibition of tissue labeling with the recombinant UGDH. Reproducibility of the UGDH measurements was high within and across analytical runs. Quantification of UGDH by QFIA and Reverse-Phase Protein Array analysis were strongly correlated (r = 0.97), validating the QFIA measurements. Analysis of cancerous acini (CA) and NAA from PC patients vs. normal acini (NA) from noncancerous controls (32 matched pairs) revealed significant (p < 0.01) differences, with CA (increased) vs. NA, NAA (decreased) vs. NA and CA (increased) vs. NAA. Areas under the Receiver Operating Characteristic curves were 0.68 (95% CI: 0.59-0.83) for NAA and 0.71 (95% CI: 0.59-0.83) for CA (both vs. NA). These results support the UGDH content in prostatic acini as a novel candidate biomarker that may complement the development of a multi-biomarker panel for detecting PC within the tumor adjacent field on a histologically normal biopsy specimen.

Tissue-based quantification of 8-hydroxy-2'-deoxyguanosine in human prostate biopsies using quantitative fluorescence imaging analysis.

OBJECTIVES: To quantify 8-hydroxy-2'-deoxyguanosine (8-OHdG) in prostate stromal and acini tissue compartments from benign and cancer-containing prostate specimens using a new quantitative fluorescence imaging analysis protocol. METHODS: Prostate biopsy specimens from 20 age-matched benign (control) and cancer-containing tissue sections were used to quantify 8-OHdG. 8-OHdG was quantified within individual acini nuclei and the surrounding stroma nuclei. Paraffin sections were treated with RNAse and protease to expose the nuclear chromatin, reacted with anti-8-OHdG mouse monoclonal antibody bound to saturation and detected with secondary goat anti-mouse IgG labeled with Alex Fluor 488, and quantified with a calibrated quantitative fluorescence imaging analysis system. The results were analyzed using a paired Student's t test. RESULTS: 8-OHdG was successfully quantified within individual cellular compartments without the need for laser tissue dissection, using the mean pixel intensity of fluorescent-labeled 8-OHdG. Matched-pair analysis of the global expression of 8-OHdG, as well as the acini and stroma individually, revealed no difference between the cancerous and control prostatic tissue. All patients with prostate cancer and those with benign findings had significantly greater 8-OHdG within the acini compared with the surrounding stoma (P < .05). CONCLUSIONS: A protocol to quantify 8-OHdG in paraffin-embedded human prostatic tissue was successfully developed. 8-OHdG was not significantly elevated in the acini or stroma of cancer-containing prostatic tissue compared with age-matched benign prostatic tissue. Although 8-OHdG was significantly elevated in the acini nuclei compared with the surrounding stroma nuclei in both cancer-containing and benign prostatic tissue, it, by itself, was not a strong biomarker for prostate cancer risk assessment.

Difficult male urethral catheterization: a review of different approaches.

PURPOSE: To review and compare the different methods for difficult male urethral catheterization described in selected literature. MATERIALS AND METHODS: A PubMed search was done with the terms "difficult", "failed", or "complications" and "urethral catheterization", "transurethral catheterization", "Foley catheter", "urethral catheter" or "filiforms and followers". All articles addressing the issue of difficult adult male urethral catheterization were included. RESULTS: Six main approaches were identified on the 14 articles included for review: 1) Passage of either a Glidewire, guide wire or filiform under direct vision; 2) Blind passage of a filiform, guide wire, Glidewire or hydrophilic catheter; 3) "The Peel-away sheath placed on a cystoscope/resectoscope technique"; 4) "The rigid ureteroscope placed inside the 22F Foley technique"; 5) Suprapubic catheterization; and 6) "The instillation of 60 cc of saline through the catheter as it is advanced technique". CONCLUSION: There is a paucity of prospective data comparing the benefits, risks, success rates and complications of the different approaches for difficult Foley catheter placement. Our suggested approach starts with the initial attempt at urethral catheterization with an 18F coude and a 12F silicone catheter. If these fail, using a flexible cystoscope or the blind Glidewire technique are reasonable alternatives. If dilatation of a stricture is necessary, ureteric dilatators or a urethral balloon dilatator are recommended.

Phase III prevention trial of fenretinide in patients with resected non-muscle-invasive bladder cancer.

PURPOSE: The study aims to evaluate the efficacy and toxicity of fenretinide in preventing tumor recurrence in patients with transitional cell carcinoma (TCC) of the bladder. EXPERIMENTAL DESIGN: We conducted a multicenter phase III, randomized, placebo-controlled trial of fenretinide (200 mg/day orally for 12 months) in patients with non-muscle-invasive bladder TCC (stages Ta, Tis, or T1) after transurethral resection with or without adjuvant intravesical Bacillus Calmette-Guerin (BCG). Patients received cystoscopic evaluation and bladder cytology every 3 months during the 1-year on study drug and a final evaluation at 15 months. The primary endpoint was time to recurrence. RESULTS: A total of 149 patients were enrolled; 137 were evaluable for recurrence. The risk of recurrence was considered to be "low" in 72% (no prior BCG) and intermediate or high in 32% (prior BCG) of the evaluable patients. Of the lower-risk group, 68% had solitary tumors and 32% had multifocal, low-grade papillary (Ta, grade 1 or grade 2) tumors. The 1-year recurrence rates by Kaplan-Meier estimate were 32.3% (placebo) versus 31.5% (fenretinide; P = 0.88 log-rank test). Fenretinide was well tolerated and had no unexpected toxic effects; only elevated serum triglyceride levels were significantly more frequent on fenretinide (versus placebo). The Data Safety and Monitoring Board recommended study closure at 149 patients (before reaching the accrual goal of 160 patients) because an interim review of the data showed a low likelihood of detecting a difference between the two arms, even if the original accrual goal was met. CONCLUSIONS: Although well tolerated, fenretinide did not reduce the time-to-recurrence in patients with Ta, T1, or Tis TCC of the bladder.