Cystoscopic Biopsies of Bladder Neoplasms

T1 papillary urothelial carcinomas of the urinary bladder run a variable clinical course, and an effective substaging system has not been defined yet. This study was conducted to devise an easy-to-use substaging method and to validate its prognostic value in T1 cancer on transurethral resection specimens. A total of 103 cases of T1 low-grade papillary urothelial carcinoma and 406 cases of T1 high-grade papillary urothelial carcinoma from a series of 1515 non-muscle-invasive bladder tumors treated by transurethral resection were studied. Substaging was performed using 0.5, 1.0, and 1.5 mm as thresholds to distinguish extensive from focal invasion. Correlations to recurrence, progression, cancer-specific mortality, and all-cause mortality were explored and compared with Ta tumors. All lamina propria invasions in low-grade papillary urothelial carcinomas were confined to 1.0 mm. The proportions of T1 high-grade papillary urothelial carcinoma invading beyond 0.5, 1.0 (T1>1 mm), and 1.5 mm were 53%, 32%, and 27%, respectively. No prognostic differences were found between Ta and T1 low-grade papillary urothelial carcinomas. T1>1 mm high-grade papillary urothelial carcinomas were associated with significantly greater risks for recurrence, progression, cancer-specific mortality, and all-cause mortality compared with T1≤1 mm and Ta tumors. Comparable statistical results could be obtained using 0.5 and 1.5 mm as cutoff points, but we recommend using 1.0 mm for practical consideration. Taking all non-muscle-invasive urothelial neoplasms of the bladder into consideration, 5 prognostically distinct categories can be established: (1) papillary urothelial neoplasms of low malignant potential; (2) low-grade papillary urothelial carcinoma Ta/1; (3) high-grade papillary urothelial carcinoma Ta; (4) high-grade papillary urothelial carcinoma T1≤1 mm; and (5) high-grade papillary urothelial carcinoma T1>1 mm. Our study demonstrates that the substaging of T1 bladder cancer is feasible, based on the evaluation of transurethral resection specimens, and can provide more precise prognostic information to identify a subset of patients with a more unfavorable prognosis.

BACKGROUND: Approximately one-half of all bladder tumors are noninvasive urothelial neoplasms with the pathologic grade being a substantial prognosticator for these lesions. In 2004, the World Health Organization (WHO) reviewed and adopted the 1998 consensus classification system for urothelial neoplasms developed by the International Society of Urological Pathology (ISUP), aiming to better correlate the morphologic features of these lesions with their clinical outcome. In this system, urothelial neoplasms are divided into invasive and noninvasive, and the latter are further subclassified into urothelial papillomas, papillary urothelial neoplasms of low malignant potential, and low-grade and high-grade papillary urothelial carcinomas. Urothelial papilloma (UP) is a rare tumor of the genitourinary tract, usually seen in younger patients as an isolated, small papillary lesion. It is considered benign with a recurrence rate of 0–31% and little risk of progression. However, most studies are based on a small number of cases. The present study evaluates the long-term clinicopathologic and outcome features in patients with UP that were diagnosed and treated at a single tertiary-care, academic facility after the adoption of the 2004 WHO/ISUP grading system.This is, to the best of our knowledge, the largest series on the long-term follow-up of urothelial papilloma. METHODS: All cases with a diagnosis of UP between 1998 and 2009 were retrieved from the in-house as well as consulting surgical pathology service archives of the Johns Hopkins Hospital (JHH). All cases with a history of a higher grade urothelial lesion prior to the initial UP diagnosis were excluded, including papillary and flat lesions like dysplasia. Also excluded were all the cases with a concomitant non-urothelial malignancy. Fifty-two “primary” UP cases were found that formed the current cohort, and were reviewed by two genitourinary pathologists. Electronic medical records were retrospectively reviewed for all cases. On follow-up, “recurrence” was defined as the development of any subsequent neoplastic urothelial lesion in the bladder, while “progression” was defined as the development of any subsequent flat or papillary neoplastic urothelial lesion of higher histological grade or stage. Data was analyzed using the software PASW Statistics version 18.0 (IBM Corp., Somers, NY). RESULTS: Recurrence and tumor progression were observed in 3.8% and 30.2% of patients, respectively. Considering tumor progression, the distribution of outcomes was as it follows: low-grade urothelial carcinoma, 11.5%; high-grade urothelial carcinoma, 7.7%; urothelial dysplasia, 5.8%; and papillary urothelial neoplasm of low malignant potential (PUNLMP), 5.8%. No cancer-specific death was observed in this cohort. DISCUSSION: The present study shows a low recurrence rate similar to previous studies; however we surprisingly noticed a significantly higher progression rate than previously reported. One problem is that most of the available literature discusses the low grade papillary urothelial lesions altogether, with less focus on the UPs. There are several hypotheses for explaining the difference in the results, including the difference in study population and the definition of recurrence and progression, the subjective interpretation of the diagnostic criteria, and the possible existence of underlying urothelial lesions that may have been poorly sampled. It is noteworthy that due to the absence of a standard follow-up procedure, the long-term follow-up information for the UP patients is difficult to obtain. Compared to other series, the higher incidence rate in our series could be due to the criteria we used to define “progression” and our more strict criteria for diagnosing the initial lesion as well as recurrence/progression during follow-up. Indeed, some authors consider that progression only includes recurrence to a papillary urothelial carcinoma, either invasive or noninvasive. In other series, not all recurrent cases were microscopically evaluated and the diagnosis of recurrence was based solely on cystoscopic findings. In our study, progression was defined as recurrence of disease with any higher grade lesion, either flat or papillary (including dysplasia, PUNLMP, or urothelial carcinomas) and only histopathologically proven cases were included in the study. Nevertheless, limitations of the present series include its retrospective design; some selection bias may also be expected since we have included consult cases along with in-house ones (almost 60% of the cases were retrieved from the consulting service at the JHH). CONCLUSIONS: Although none of our patients developed invasive urothelial carcinoma or died of urothelial carcinoma, we found a relatively high rate of recurrence and progression in our UP cohort compared to previous series. The development of a standardized follow-up protocol is encouraged.

Papillary Urothelial Neoplasm of Low Malignant Potential: Evolving Terminology and Concepts

Objective To summarize the anatomy,operation skill and experience of laparoscopic pelvic lymphadenectomy for the treatment of invasive bladder cancer.Methods From June 2008 to July 2011,43 patients including 29 males and 14 females; aged 40-77 years-old with 58.9±10.0 on average,who underwent laparoscopic radical cystectomy and pelvic lymphadenectomy were analyzed retrospectively.Among those patients,tumor recurrence 19 cases; there were 11 cases of multiple tumors,and the others were single tumor,including 9 cases on triangle,8 cases on right wall,6 cases on left wall,7 cases on bottom,2 cases on dome.The size of the tumors is between 1.0～7.5 cm with (3.0±1.4) cm on average.Preoperative staging showed 28 cases of T2,10 cases of T3 and 5 cases of T4.Biopsy pathological examination showed 22 cases of high-grade papillary urothelial carcinoma,20 cases of low-grade papillary urothelial carcinoma,and 1 case of carcinoma in situ.Results Laparoscopic pelvic lymphadenectomy can be performed through three different interfaces.Lateral surface follows the genitocrural nerve at the surface of psoas major muscle,and the far end is at the plain of the external iliac artery emerging out the pelvic cavity.Medial surface begins with the cleidoic umbilical artery,or circular cord-shape medial umbilical ligament in the lateral side of the bladder,extending to upper bladder artery which is the branch of the internal illiac artery.Anterior basal surface is pubic bone converged by the medial surface and the lateral surface,along with the pelvic wall to the pelvic bottom fascia.The operation time was 180-510 min with (320±88) min on average.The EBL was 50-1 500 ml with (342±291) ml on average,and 12 cases need blood transfusion with volume of 200-1 000 ml and (567±187) ml on average.All cutting edges were negative and average 5.6 lymph nodes were removed during the operation with lymph node positive rate of 7.0％ (3/43).Postoperative pathological examination showed 12 cases of low-grade papillary urothelial carcinoma,9 cases of high-grade papillary urothelial carcinoma,and 22 case of invasive urothelial carcinoma.There was no death during the perioperatire period,but 4 patients had postoperative complications.Thirty-six patients were followed up with average of (15.4±9.5) months.One patient died and 8 patients developed complications during the follow-up period,and the relapse free survival rate was 94.4％ (34/36).Conclusions Following the principles of open surgery and the 3 anatomical surface,laparoscopic pelvic lymphadenectomy for the treatment of invasive bladder cancer is technically safe and effective,and the clinical effectiveness was satisfied,with the advantages of minimal invasiveness,clear surgical field,less blood loss,and shorten operation time. Key words: Bladder cancer; Radical cystectomy; Laparoscopy; Pelvic lymphadenectomy

269 Background: Bladder cancer is a common and deadly disease, but the molecular events leading to its initiation and progression are incompletely understood. We recently identified Ataxia-Telangiectasia Group D Associated (ATDC) as a novel oncogene which drives tumor proliferation and invasion in pancreatic carcinoma (Cancer Cell, 2009). In this study, we describe the role of ATDC as an oncogene in bladder cancer. Methods: To further determine the oncogenic role of ATDC, we generated ATDC transgenic (tg) mice in which ATDC expression was driven by a CMV promoter and characterized the resulting tumors. Results: The dominant phenotype in these mice was the development of both papillary and invasive urothelial carcinomas (9% and 20% respectively, average age of onset 10-12 months of age). Histologically, these tumors were indistinguishable from human urothelial carcinomas. Gene expression profiling of invasive tumors derived from ATDC tg mice demonstrated a marked overlap with gene signatures of human invasive bladder cancers. Analysis of a human bladder cancer tissue microarray (311 samples) showed elevated expression in 70% (173/252) of muscle-invasive carcinomas, whereas normal bladder had no expression. 22% (5/23) of papillary tumors also expressed elevated levels of ATDC. ATDC was the 11th most highly up-regulated gene in bladder cancers represented in the Oncomine gene expression database. ATDC tg mouse bladder tumors demonstrated loss of p53 signaling and down-regulation of PTEN expression, which was determined to be due to ATDC abrogation of p53 function by cytoplasmic sequestration and ATDC-mediated methylation of the PTEN promoter. Furthermore, ATDC knock-down in invasive cancer cell lines resulted in decreased proliferation, invasion and reactivation of p53-mediated signaling and PTEN expression. Conclusions: ATDC is a novel oncogene that is highly expressed in human bladder cancers and is sufficient to drive the development of invasive bladder tumors in tg mice. The mechanism by which ATDC drives bladder cancer formation involves alterations in p53 and PTEN pathways known to be important in bladder tumorigenesis.

Missense mutations of fibroblast growth factor receptor 3 (FGFR3) occur in up to 80% of low-grade papillary urothelial carcinoma of the bladder (LGP-UCB) suggesting that these mutations are tumor drivers, although direct experimental evidence is lacking. Here we show that forced expression of FGFR3b-S249C, the most prevalent FGFR3 mutation in human LGP-UCB, in cultured urothelial cells resulted in slightly reduced surface translocation than wild-type FGFR3b, but nearly twice as much proliferation. When we expressed a mouse equivalent of this mutant (FGFR3b-S243C) in urothelia of adult transgenic mice in a tissue-specific and inducible manner, we observed significant activation of AKT and MAPK pathways. This was, however, not accompanied by urothelial proliferation or tumorigenesis over 12 months, due to compensatory tumor barriers in p16-pRB and p19-p53-p21 axes. Indeed, expressing FGFR3b-S249C in cultured human urothelial cells expressing SV40T, which functionally inactivates pRB/p53, markedly accelerated proliferation and cell-cycle progression. Furthermore, expressing FGFR3b-S243C in transgenic mouse urothelium expressing SV40T converted carcinoma-in-situ to high-grade papillary urothelial carcinoma. Together, our study provides new experimental evidence indicating that the FGFR3 mutations have very limited urothelial tumorigenicity and that these mutations must collaborate with other genetic events to drive urothelial tumorigenesis.

Aims: To evaluate whether ki-67 labelling index (LI) has independent prognostic value for survival of patients with bladder urothelial tumours graded according to the 2004 World Health Organisation classification. Methods:...

BackgroundPredicting the recurrence and progression of Non-muscle-invasive bladder cancer(NMIBC) is critical for urologist. Histological grade provides significant prognostic information, especially for prediction of progression. Currently, the 1973 and the 2004 WHO classification co-exist. Which system is better for predicting rumor recurrence and progression still a matter for debate.Methodology/Principal Findings348 patients diagnosed with Non-muscle invasive bladder cancer were enrolled in our retrospective study. Paraffin sections were assessed by an experienced urological pathologist according to both the 1973 and 2004 WHO classifications. Tumor recurrence and progression was followed-up in all patients. During follow-up, corresponding 5-year recurrence-free survival rates of G1, G2 and G3 were 82.1%, 55.9%, 32.1% and the 5-year progression-free survival rates were 95.9%, 84.4% and 43.3%, respectively. The 5-year recurrence-free survival rates of papillary urothelial neoplasm of low malignant potential (PUNLMP), low-grade papillary urothelial carcinoma(LGPUC) and high-grade papillary urothelial carcinoma (HGPUC) were 69.8%, 67.1% and 42.0% respectively and the 5-year progression-free survival rates were 100%, 90.9% and 54.8% respectively. In multivariate analysis, the 1973 WHO classification significantly associated with both tumor recurrence and progression(p = 0.010 and p = 0.022, respectively); the 2004 WHO classification correlated with tumor progression(p = 0.019), while was not proved to be a variable that can predict the risk of recurrence(p = 0.547). Kaplan-Meier plots showed that both the 1973 WHO and the 2004 WHO classifications were significantly associated with progression-free survival (p<0.0001, log-rank test). For prediction of recurrence, significant differences were observed between the tumor grades classified using the 1973 WHO grading system (p<0.0001, log-rank test), while a significant overlap was observed between PUNLMP and LG plots using the 2004 WHO grading system(p = 0.616, log-rank test).Conclusion/SignificanceBoth the 1973 WHO and the 2004 WHO Classifications are effective in predicting tumor progression in Non-muscle invasive bladder cancer, while the 1973 WHO Classification is more suitable for predicting tumor recurrence.

In normal urothelium, superficial umbrella cells express four major integral membrane proteins, uroplakins UPIa, UPIb, UPII, and UPIIIa, which compose urothelial plaques. In the apical plasma membrane, urothelial plaques form microridges. During neoplastic changes, microridges are replaced by microvilli, while uroplakin expression is retained. We correlated individual uroplakin expression with apical plasma membrane structure, cytokeratin 20 expression, and urothelial cell proliferation (Ki-67). Male Wistar rats were treated with 0.05% N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN) in drinking water, which caused flat hyperplasia with mild dysplasia, low-grade papillary urothelial carcinoma, invasive low- and high-grade papillary urothelial carcinoma and invasive squamous cell carcinoma with extensive keratinization, grade 2. During urothelial carcinogenesis, UPII expression was the most decreased in all urothelial lesions, while UPIa, UPIb, and UPIIIa expression was differently altered in different types of lesions. Superficial cells were covered with microvilli and ropy ridges, while microridges were disappearing. The expression of cytokeratin 20 was decreased and limited to superficial urothelial cells. Proliferation indices were increased, except for invasive squamous cell carcinoma with extensive keratinization. Our results indicate that during urothelial carcinogenesis the expression of UPII is diminished, suggesting that UPIb/UPIIIa heterodimer can still be formed, while heterodimer UPIa/UPII formation is disrupted. Correlation between decreased level of UPII expression and changed apical plasma membrane structure suggests that diminished expression of UPII hinders the urothelial plaque formation.

Combinations of Urinary Biomarkers for Surveillance of Patients with Incident Nonmuscle Invasive Bladder Cancer: The European FP7 UROMOL Project

Osteopontin (OPN) has been shown to play a significant role in regulating the aggressiveness of cancer cells and promote tumor growth. Evaluation of this phosphorylated extracellular glycoprotein expression may help estimate its use as a potential prognostic marker in tumorigenesis of different renal tumors. The objective of the present study was to characterize for the first time the expression pattern of OPN in primary renal tumors and correlate its association to tumor progression and survival. A total of 68 primary renal tumors (clear cell renal cell carcinoma, oncocytoma, renal cell carcinoma, invasive urothelial carcinoma, papillary renal cell carcinoma, chromophobe renal cell carcinoma, papillary urothelial carcinoma) were analyzed by immunohistochemical staining and Western blot methods. Expression of OPN in relation to grading, histologic type of tumor, and survival was statistically assessed. Study data demonstrated that OPN is differentially expressed in various renal tumor cells types. It was shown that OPN is predominantly expressed at the protein level in clear cell renal cell carcinoma when compared to other types of renal tumors. In conclusion, osteopontin may be involved in the pathogenesis of renal tumors. However, the role of OPN expression in predicting the biological response requires further evaluation.

Although multifocal tumors and non-invasive/invasive components are commonly encountered in surgical pathology, their genetic relationship is often poorly characterized. We used next-generation sequencing (NGS) to characterize somatic alterations in a patient with five spatially distinct, high-grade papillary urothelial carcinomas (UCs), with one tumor harboring an underlying invasive component. NGS of 409 cancer-related genes was performed on DNA isolated from formalin-fixed paraffin-embedded (FFPE) blocks representing each papillary tumor (n = 5), the invasive component of one tumor, and matched normal tissue. We identified nine unique non-synonymous somatic mutations across the six UC samples, including five present in each carcinoma sample, consistent with clonal origin and limited intertumoral heterogeneity. Copy number and loss of heterogeneity (LOH) profiles were similar in all six carcinomas; however, the invasive carcinoma component uniquely showed focal CDKN2A loss and chromosome 9 LOH and did not harbor gains of chromosomes 5p or X that were present in the other tumor samples. Phylogenetic analysis supported the invasive component arising from a shared progenitor prior to the outgrowth of cells in the non-invasive tumors. Results were extended to three additional cases of upper tract UC with paired non-invasive/invasive components, which identified driving alterations exclusive to both non-invasive and invasive components. Lastly, we performed targeted RNA sequencing (RNAseq) using a custom bladder cancer panel, which confirmed gene expression signature differences between paired non-invasive/invasive components. The results and approaches presented here may be useful in understanding the clonal relationships in multifocal cancers or paired non-invasive/invasive components from routine FFPE specimens.

The antibody-drug conjugate enfortumab-vedotin acts by targeting nectin-4, a protein that is nearly ubiquitously expressed in conventional urothelial cancer. However, expression of nectin-4 in morphologic variants of urothelial carcinoma and nonurothelial histotypes was unknown. Immunohistochemistry for nectin-4 using was performed on 169 patients including 83 with nonmuscle invasive bladder cancer and 86 patients with muscle invasive bladder cancer. Staining was scored for intensity (0 to 3) and extent (% positive cells) using the histological score system, where >15 was considered positive. Overall, 72/83 (87%) samples of nonmuscle invasive urothelial carcinoma were positive, including 29/30 (97%) noninvasive papillary urothelial carcinomas, 7/8 (87.5%) carcinomas in situ, 36/45 (80%) papillary urothelial carcinomas invading the lamina propria. Overall, 50/86 muscle invasive tumors were positive, including 15/22 (68.2%) urothelial carcinomas, 7/10 (70%) squamous cell carcinomas, 3/11 (28%) micropapillary tumors, 4/6 (66%) adenocarcinomas, 2/4 (50%) nested carcinomas, 5/8 (63%) plasmacytoid, 1/10 (10%) sarcomatoid carcinomas, and 0/15 (0%) small cell carcinomas. Whole transcriptome RNA sequencing revealed that compared with conventional urothelial carcinomas, most sarcomatoid carcinomas and all but 2 small cell carcinomas expressed very low levels of nectin-4 mRNA but expressed significant levels of either trop2 or ERBB2, which are the molecular targets of 2 other antibody-drug conjugates-sacituzumab gavitecan (trop2) or trastuzumab deruxtecan (ERBB2/HER2). In summary, our study demonstrates that there is heterogeneity of expression of nectin-4 in morphologic variants of urothelial cancer and nonurothelial histotypes, and suggests that testing expression of nectin-4 should be considered in morphologic variants or nonurothelial histotypes found to have lower expression.

Context.—Distinguishing low-grade and high-grade noninvasive papillary urothelial carcinoma based on morphologic criteria can be challenging and adjunct markers are highly desirable. Survi...

Several studies have shown that men with lower urinary tract symptoms are more likely to experience erectile dysfunction. All except 1 of these studies were cross-sectional, limiting inferences about whether lower urinary tract symptoms precipitate erectile dysfunction. The association between lower urinary tract symptoms and incident erectile dysfunction was examined prospectively in the Health Professionals Follow-Up Study. Lower urinary tract symptoms were assessed biennially by the American Urological Association symptom index, which captures symptoms of frequency, urgency and force of urinary stream. Severe lower urinary tract symptoms was defined as a symptom score of 20 points or greater and no lower urinary tract symptoms was defined as a score of 7 points or less in men not treated for lower urinary tract symptoms. In 2000 the men were asked to rate erectile function for several periods. Erectile dysfunction was defined as poor or very poor function, or erectile dysfunction medication use, while no erectile dysfunction was defined as very good or good function and no erectile dysfunction medication use. We estimated the RR using Poisson regression, adjusting for age and other potentially confounding factors. We observed 3,953 incident erectile dysfunction cases among 17,086 men. Men with severe lower urinary tract symptoms in 1994 or earlier had a statistically significant 40% higher risk of erectile dysfunction subsequently than men without lower urinary tract symptoms. The risk of erectile dysfunction increased with increasing lower urinary tract symptom severity (p trend <0.0001). The positive association between lower urinary tract symptoms and erectile dysfunction was stronger in younger than in older men (p interaction = 0.03). This study provides evidence that men with lower urinary tract symptoms are more likely to have erectile dysfunction subsequently.