Adenocarcinoma in ectopic prostatic tissue at dome of bladder: a case report of a patient with urothelial carcinoma of the bladder and adenocarcinoma of the prostate.

We report a case of ectopic prostate tissue with an associated prostatic adenocarcinoma occurring in the dome of the urinary bladder. A 62-year-old man presented with a 4-month history of persistent microscopic hematuria following a urinary tract infection. Other complaints included frequent urination, but there was neither dysuria nor gross hematuria. Digital rectal examination revealed a smooth prostate of normal size. Cystoscopic examination revealed a sessile lesion of the anterior bladder neck and multiple smaller papillary lesions throughout the bladder. Following a transurethral resection of the bladder tumor with a diagnosis of muscle-invasive transitional cell carcinoma grade 3, a radical cystoprostatectomy was performed. The diagnosis of transitional cell carcinoma was confirmed, but in addition, a different lesion was also incidentally found in the dome of the bladder. This incidental lesion showed a prostatic adenocarcinoma arising from ectopic prostatic tissue within the bladder submucosa. The prostate also showed prostatic adenocarcinoma, but this was minimal, low grade, and confined to the prostate gland, and thus it was felt to be unlikely to have metastasized to the bladder dome. Adenocarcinoma arising in ectopic prostatic tissue is a rare finding and to our knowledge only 1 case has been previously described, occurring in the soft tissue adjacent to the prostate. We report the first case of adenocarcinoma arising in ectopic prostatic tissue within the bladder.

Mismatch repair expression in testicular cancer predicts recurrence and survival.

We investigated mismatch repair (MMR) gene expression in testicular cancer as a molecular marker for clinical outcome (recurrence, response to chemotherapy and death) using protein expression and specific genetic alterations associated with the presence or absence of MMR activity. One hundred sixty-two cases of paraffin-embedded testis cancer specimens were subjected to immunohistochemical analysis using monoclonal antibody for MLH1 and MSH2 MMR proteins and genetic analysis using specific polymorphic markers. The degree of MMR immunoreactivity and genetic instability in the form of loss of heterozygosity (LOH) and/or microsatellite instability (MSI) were determined by comparing matched normal and tumor tissue. The degree of immunohistochemical staining for MMR expression was associated with a shorter time to tumor recurrence, resistance to chemotherapy and death. Furthermore, clinical relapse and cancer specific death was also associated with tumors exhibiting a high degree of MSI, p = 0.01 and 0.04, respectively. In contrast, LOH was not associated with recurrence, resistance to chemotherapy or death. Therefore, MMR expression defines testis cancers with distinct molecular properties and clinical behavior, such that tumors with decreased MMR immunostaining and/or increased frequency of MSI have a shorter time to recurrence and death despite chemotherapy.

CDC4 gene expression as potential biomarker for targeted therapy in prostate cancer.

Targeted therapy of proteasome regulated gene expression has potential utility in cancer treatment since components of ubiquitin-mediated proteolysis are altered in human malignancy. Specific regulators of proteasome degradation such as F-box proteins of the SCF E3 ligase complex are ideal biomarkers for assessing therapeutic efficacy since these components determine substrate specificity. An F-box protein that appears to be important in this process is human Cdc4 (Fbw7) since expression is detected in a variety of human cancers including breast, colon, pancreas and uterus. The role of Cdc4 in tumorigenesis appears to be related at least in part to regulation of cyclin E since inactivating mutations of CDC4 in cancer cells leads to cyclin E overexpression and genomic instability. In order to investigate the potential biological and clinical consequences of proteasome inhibition with respect to Cdc4 mediated targeted proteolysis, we investigated CDC4 expression and genetic alterations in 53 primary human prostate cancers in addition to correlation with relevant histopathological and clinical parameters. We identified genetic alterations in 6% of our prostate cancers while differential expression of Cdc4 isoforms correlated with advanced pathological stage and clinical recurrence. Our data suggest that CDC4 expression in prostate cancer has important biological and clinical implications since genetic alterations, differential Cdc4 isoform expression, histopathological and clinical correlation were demonstrated in our analysis. Therefore molecular genetic analysis of CDC4 expression may be an important biomarker for concurrent or subsequent clinical investigation of proteasome targeted therapy in men with prostate cancer.

Tissue microarray analysis of hMSH2 expression predicts outcome in men with prostate cancer.

PURPOSE: Mismatch repair genes are responsible for the coordinated correction of misincorporated nucleotides formed during DNA replication. Mismatch repair expression is altered in a subset of prostate cancers (PCs) and a recent study suggested that time to biochemical recurrence following prostatectomy correlated with the degree of hMSH2 immunohistochemical staining. We compared hMSH2 expression and survival in clinically organ confined PC. MATERIALS AND METHODS: A prostate tissue microarray was constructed using 243 specimens from patients who underwent radical prostatectomy with extended lymph node dissection for clinically organ confined PC with up to 12 years of followup. Immunohistochemistry was performed with anti-human MSH2 monoclonal antibody. Three independent observers evaluated hMSH2 expression on a scale of 0 to 4. Low expression was defined as a score of less than 2 and high expression was defined as a score of 2 or higher. Statistical analysis used the Fisher exact test, and Goodman and Kruskal gamma coefficient. RESULTS: Higher Gleason score significantly correlated with higher hMSH2 expression (p < 0.0002). Low hMSH2 expression correlated with increased overall, disease-free and biochemical disease-free survival (all p < 0.01). Analysis comparing low vs high hMSH2 expression was significant with respect to overall (p = 0.0004), disease-free (p = 0.005) and biochemical disease-free (p = 0.0177) survival. CONCLUSIONS: hMSH2 is differentially expressed in malignant prostate tissue and hMSH2 immunohistochemical staining intensity correlates with Gleason score, overall and disease-free survival. Taken together our results suggest that hMSH2 expression may be a useful prognostic biomarker for outcome in men with clinically organ confined PC.

Prostate specific antigen as a clinical biomarker for prostate cancer: what's the take home message?

Prostate specific antigen (PSA) continues to be challenged as a legitimate clinical biomarker in early detection of prostate cancer due to lack of specificity for malignant transformation. Skepticism surrounding the utility of serum PSA as a clinical marker is not new and many questioned its initial use in widespread prostate cancer screening due to non-specific expression and low predictive value for cancer detection. Despite these initial concerns, serum PSA measurement along with digital rectal examination (DRE) is currently the accepted practice for prostate cancer screening in the United States with hundreds of thousands of men undergoing serum PSA measurement annually. In contrast to its role for early detection, serum PSA measurement as a surrogate for prostate cancer recurrence (biochemical failure) following curative intent therapy has consummate clinical utility in post-treatment surveillance. As thousands of men each year are aggressively treated for potentially curable prostate cancer, development of simple and effective diagnostic tools for detecting treatment failures should be an important area of biomedical and clinical investigation. We have constructed and tested a home-based prostate cancer surveillance device for use by patients to detect PSA from blood obtained by finger stick. Our initial results suggest that home based PSA testing is feasible and may have clinical utility in management of men treated for prostate cancer.

Microsatellite instability and loss of heterozygosity have distinct prognostic value for testicular germ cell tumor recurrence.

Germ cell tumor (GCT) is the most common genitourinary malignancy of men between the ages of 18 and 35 years. Therapy is ultimately successful in over 90% of patients, however significant morbidity and mortality can be associated with adjuvant treatment and relapse. Molecular markers that predict treatment response and/or poor outcome would have immediate clinical benefit since adjuvant treatment could be selectively reserved for patients at higher risk for relapse and those patients most likely to respond to treatment. In order to identify potential prognostic molecular markers, we evaluated 118 GCT for microsatellite instability (MSI), loss of heterozygosity (LOH) and MSH2 immunostaining to identify tumors associated with relapse and/or poor outcome following initial surgical, medical and/or radiation therapy. MSI in 3 or more markers and/or low MSH2 staining were associated with relapse while LOH in the absence of MSI and/or high MSH2 staining were not. Twenty-five percent of GCT exhibited genetic instability in 3 or more microsatellite markers (MSI+ tumors), 15% exhibited LOH in the absence of MSI (LOH only tumors) and 44% exhibited decreased or absent MSH2 immunostaining (low MSH2 staining tumors). Thirty-six patients (30%) relapsed and 27 of these patients (75%) had MSI+ and/or low MSH2 staining tumors. Only one patient (3%) with an LOH only tumor and no patients with high MSH2 staining and LOH only tumors relapsed. Therefore distinct GCT subpopulations identified by detection of MSI, LOH and MMR expression are associated with different clinical outcomes. MMR deficient testicular GCT with increased frequency of MSI had an increased association with tumor recurrence compared to GCT with an intact MMR system and LOH in the absence of MSI.

Mismatch repair gene expression and genetic instability in testicular germ cell tumor.

Human mismatch repair (MMR) genes encode highly conserved interacting proteins that correct replication errors predisposing to hereditary gastrointestinal and genitourinary malignancies. A subset of sporadic genitourinary tumors also exhibits MMR deficiency and can be identified by measuring the frequency of microsatellite instability (MSI) in cancer cell DNA. We investigated expression of the two most commonly mutated MMR genes, MSH2 and MLH1, in sporadic testicular germ cell tumor (GCT) in order to: (1) determine the expression pattern of MSH2 and MLH1 proteins in normal seminiferous tubules and histologically distinct GCT subtypes, (2) correlate MMR gene expression with genetic instability in GCT and (3) develop a panel of molecular markers that can identify genetically distinct subsets of GCT for prognostic assessment. MSH2 and MLH1 had differential staining patterns in normal seminiferous tubules and malignant tissues. MSH2 was expressed in all stages of spermatogenesis up to but excluding mature sperm whereas MLH1 was predominantly expressed in premeiotic germ cells. All histological GCT subtypes showed differential immunostaining for MSH2 and MLH1 however pure seminoma had statistically significant fewer low MSH2 staining tumors than other subtypes (p = 0.046). Twenty-five percent of GCT exhibited increased frequency of MSI (MSI+ tumors) with 73, 70 and 43% of MSI+ tumors exhibiting low MSH2, low MLH1 or low MSH2 and low MLH1 staining respectively. Fifteen percent of testicular GCT exhibited loss of heterozygosity (LOH) but no MSI (LOH only tumors). Only 28, 17 or 6% of LOH only tumors exhibited low MSH2, low MLH1 or low MSH2 and low MLH1 staining respectively.

Linking human genetics with molecular medicine: will hereditary renal cancer play a major role?

An inherited or familial predisposition to form kidney tumors represents less than 4% of all renal malignancies. However, hereditary renal cancer (HRC) syndromes offer important opportunities for gene discovery and function. Basic and clinical HRC investigation often provides unique insight into regulation of cell growth, cell proliferation, tumor invasion and metastasis. The genetics, biochemistry and physiology of renal tumorigenesis has been directly impacted and significantly expanded by HRC research over the last ten years. Mutations have been identified in several genes tightly linked to increased risk for development of renal cancer. Inheritance of these mutated genes causes specific hereditary syndromes often associated with clinically significant nonrenal manifestations. Molecular and biochemical alterations of most HRC gene products are also detected in sporadic renal cancer emphasizing the importance of HRC gene function in nonhereditary carcinogenesis. Despite these important molecular findings, the clinical contribution of HRC research has generally been limited to genetic screening and prognostic assessment. HRC patients and their physicians continue to face difficult decisions regarding cancer control and quality of life despite advances in minimally invasive surgical and radiological techniques. The ultimate challenge for clinicians and scientists will be translation of molecular and genetic research into clinical tools that impact diagnosis, treatment and prevention. This bench to bedside report describes the diagnosis, genetics, pathophysiology and current cancer treatment options available for HRC syndromes.

Decreased expression of bone morphogenetic protein (BMP) receptor type II correlates with insensitivity to BMP-6 in human renal cell carcinoma cells.

PURPOSE: Bone morphogenetic proteins (BMPs) are members of a family of pleiotropic growth factors that play a critical role during renal development as well as maintaining kidney homeostasis. In the present study, we investigated the potential role of BMP receptors (BMPRs) in renal cell carcinoma (RCC) cells. EXPERIMENTAL DESIGN: Immunohistochemistry was used to investigate the expression of BMPRs in human RCC tissues. As an in vitro model of RCC, three cell lines were used: 112, 117, and 181. Northern blot, immunoblot, and reverse transcription-PCR were used to study the expression of BMPRs in the cell lines. Finally, cells were transfected using LipofectAMINE. RESULTS: Normal human kidney tissues express the three BMPRs: types RIA, RIB, and RII. In contrast, human RCC cells frequently exhibit a loss of expression of BMP-RII. In tissue culture, BMP-6 inhibits in a dose-dependent manner the proliferation of 112 cells but not of 117 and 181 cells. Assays for BMPRs demonstrated that 117 and 181 cells express low levels of BMP-RII RNA. When these two BMP-6 resistant cell lines were infected with the adenovirus containing the constitutively active form of BMP-RIA or -RIB in combination with a BMP-6-responsive luciferase reporter construct, luciferase activity increased. Finally, when these cell lines were transfected with BMP-RII, BMP-6-sensitivity was restored. CONCLUSIONS: These results demonstrate that human RCC tissues frequently have decreased levels of expression of BMP-RII and that the human RCC cell lines 117 and 181 are resistant to the growth-inhibitory effect of BMP-6 because they have decreased levels of expression of BMP-RII.

Mismatch repair gene mutations in renal cell carcinoma.

We investigated the spectrum and genetic basis for mismatch repair (MMR) deficiency in renal cell carcinoma (RCC) by examining expression of four MMR genes important for hereditary and sporadic carcinogenesis. MMR deficiency was assessed using microsatellite instability (MSI) and genetic analyses of 25 cell lines derived from renal tumors. MMR gene alterations were detected using reverse transcription of RNA coupled with polymerase chain reaction (RT-PCR) and DNA sequencing. Three RCC lines with undetectable MLH1 were identified and investigated for MSI and inactivating mutations in the hMLH1 MMR gene. Genetic instability and hMLH1 mutations were identified in two RCC lines and their corresponding tumors. Genetic alterations affecting expression were limited to MLH1 since other MMR proteins (MSH2, MSH6 and PMS2) were detectable in our RCC lines. Complete inactivation of MMR is apparently uncommon in RCC and occurs predominantly through inactivating mutations in the hMLH1 gene.

Clinicopathologic implications of hMSH2 gene expression and microsatellite instability in prostate cancer.

Human mismatch repair (MMR) genes encode highly conserved interacting proteins that correct replication errors predisposing to hereditary gastrointestinal and genitourinary malignancies. We previously investigated expression of the prototype MMR gene hMSH2 in normal, benign prostatic hyperplasia and malignant prostate tissues (Velasco et al., Cancer 94:690-699, 2002). An association was detected between reduced hMSH2 staining and favorable outcome as determined by undetectable serum prostate specific antigen (PSA) after radical prostatectomy. We now investigate the association between clinicopathological variables and hMSH2 expression or microsatellite instability (MSI). A statistically significant association was found between tumors exhibiting MSI (MSI+ tumors) and lower preoperative serum PSA values, smaller tumor volumes and lower frequency of surgical specimens with extracapsular extension of tumor. No statistically significant association (P value less than or equal to 0.05) was found between hMSH2 staining and these clinicopathologic variables. Based on our analysis, we conclude that MMR deficiency has important clinicopathologic implications in prostate cancer. Furthermore, specific MMR genes may have different effects on prostate cancer biology.

Microsatellite instability and prostate cancer: clinical and pathological implications.

PURPOSE OF REVIEW: The purpose of this review is to discuss early and recent reports investigating microsatellite instability and mismatch repair expression in prostate cancer. RECENT FINDINGS: Human mismatch repair genes encode highly conserved interacting proteins that suppress genetic instability by correcting misincorporated nucleotides and insertion/deletion mispairs formed during DNA replication. Mismatch repair deficiency causes genetic instability at microsatellite sequences because of the cell's inability to correct errors caused by DNA polymerase slippage at repetitive sequences. Microsatellite instability is characteristic of mismatch repair deficiency, and has been used as a surrogate marker for the inactivation of mismatch repair genes. Inherited mismatch repair gene mutations predispose to gastrointestinal and genitourinary malignancies in a cancer predisposition syndrome known as hereditary non-polyposis colorectal carcinoma. Although strong evidence for an inherited predisposition to prostate cancer does not exist in hereditary non-polyposis colorectal carcinoma, mismatch repair deficiency and mismatch repair gene mutations have been described in sporadic prostate cancer and prostate cancer cell lines. Early reports detected microsatellite instability in prostate cancer, and correlated this genetic alteration to clinical and pathological findings in men diagnosed with this malignancy. Recent reports have identified mismatch repair gene mutations, mismatch repair deficiency and differential mismatch repair gene expression in prostate cancer. In addition, a prognostic role for mismatch repair gene expression in prostate cancer has been suggested. SUMMARY: The early identification of microsatellite instability in prostate cancer led to more specific investigation of mismatch repair gene expression. Although additional research is required, mismatch repair gene expression may have important biological and clinical significance in prostate cancer.

Differential expression of the mismatch repair gene hMSH2 in malignant prostate tissue is associated with cancer recurrence.

BACKGROUND: Mismatch repair (MMR) genes are responsible for coordinated correction of misincorporated nucleotides formed during DNA replication. Inactivating mutations in MMR genes have been described in sporadic cancers and a hereditary cancer predisposition syndrome. Mismatch repair deficiency causes instability at microsatellites and increased mutation rates. Although microsatellite instability (MSI) has been described in high-grade and lymph node positive prostate carcinoma specimens, an analysis comparing hMSH2 expression, MSI, and outcome in clinically organ confined prostate carcinoma has not been reported. METHODS: Immunohistochemical analysis of benign and malignant prostate tissue from 101 patients was performed using a monoclonal antibody specific for the hMSH2 protein. Expression was correlated with MSI using dinucleotide repeat markers and laser-captured microdissected DNA from normal and tumor cells. hMSH2 protein expression and MSI were assessed with respect to pathologic stage, Gleason score, and time to detectable serum prostate specific antigen (PSA) after prostatectomy in patients with clinically localized prostate carcinoma. RESULTS: In normal glands, hMSH2 staining was minimal to low and confined to the basal cell layer. In 32% of benign prostatic hyperplasia cases, hMSH2 staining was increased in the basal and luminal cell layers whereas 71% of cancer specimens had uniform moderate to high staining. Microsatellite instability was detected in 60% of absent to low staining and 26% of moderate to high staining prostate carcinoma specimens. Differential staining in benign versus malignant prostate tissues was statistically significant (P < 0.001) as was the correlation between absent to low hMSH2 staining and presence of MSI (P = 0.028). Decreased risk for PSA recurrence after radical prostatectomy correlated with absent to low hMSH2 staining in malignant prostate tissue but was only marginally significant (P = 0.05 for 24 month recurrence and P = 0.08 for overall time to PSA recurrence). CONCLUSIONS: The results of the current study demonstrate differential hMSH2 expression in benign and malignant prostate tissue. Moreover, hMSH2 expression is altered in a subset of clinically localized prostate carcinoma specimens independent of pathologic stage and Gleason pattern. A statistically significant correlation between hMSH2 immunohistochemical staining intensity and MSI also was identified in prostate carcinoma specimens. Furthermore, the time to cancer recurrence as determined by detectable serum PSA after prostatectomy was associated with hMSH2 staining intensity. Taken together, our results suggest that hMSH2 gene expression in prostate carcinoma may be a useful prognostic marker for outcome in men with clinically organ confined prostate carcinoma.