Alfred Hobisch

Switch from antagonist to agonist of the androgen receptor blocker bicalutamide is associated with prostate tumour progression in a new model system

SummaryAdvanced prostate cancer is treated by androgen ablation and/or androgen receptor (AR) antagonists. In order to investigate the mechanisms relevant to the development of therapy-resistant tumours, we established a new tumour model which closely resembles the situation in patients who receive androgen ablation therapy. Androgen-sensitive LNCaP cells were kept in androgen-depleted medium for 87 passages. The new LNCaP cell subline established in this manner, LNCaP-abl, displayed a hypersensitive biphasic proliferative response to androgen until passage 75. Maximal proliferation of LNCaP-abl cells was achieved at 0.001 nM of the synthetic androgen methyltrienolone (R1881), whereas 0.01 nM of this compound induced the same effect in parental cells. At later passages (> 75), androgen exerted an inhibitory effect on growth of LNCaP-abl cells. The non-steroidal anti-androgen bicalutamide stimulated proliferation of LNCaP-abl cells. AR protein expression in LNCaP-abl cells increased approximately fourfold. The basal AR transcriptional activity was 30-fold higher in LNCaP-abl than in LNCaP cells. R1881 stimulated reporter gene activity in LNCaP-abl cells even at 0.01 nM, whereas 0.1 nM of R1881 was needed for induction of the same level of reporter gene activity in LNCaP cells. Bicalutamide that acts as a pure antagonist in parental LNCaP cells showed agonistic effects on AR transactivation activity in LNCaP-abl cells and was not able to block the effects of androgen in these cells. The non-steroidal AR blocker hydroxyflutamide exerted stimulatory effects on AR activity in both LNCaP and LNCaP-abl cells; however, the induction of reporter gene activity by hydroxyflutamide was 2.4- to 4-fold higher in the LNCaP-abl subline. The changes in AR activity were associated neither with a new alteration in AR cDNA sequence nor with amplification of the AR gene. Growth of LNCaP-abl xenografts in nude mice was stimulated by bicalutamide and repressed by testosterone. In conclusion, our results show for the first time that the non-steroidal anti-androgen bicalutamide acquires agonistic properties during long-term androgen ablation. These findings may have repercussions on the natural course of prostate cancer with androgen deprivation and on strategies of therapeutic intervention.

Regulation of prostatic growth and function by peptide growth factors

Polypeptide growth factors are positive and negative regulators of prostatic growth and function. Expression and biological effects of epidermal growth factor (EGF), transforming growth factors (TGFs) α and β, fibroblast growth factors (FGFs), and insulin‐like growth factors (IGFs) in the prostate have been extensively studied. EGF and TGFα, which share the same receptor, are strong mitogens for prostatic epithelial and stromal cells. Their paracrine mode of action in normal tissue and early‐stage tumors is apparently altered towards an autocrine stimulation in hormone‐independent tumors, which gain the ability to produce TGFα by themselves. TGFβ has a dual role in the regulation of prostatic growth. It inhibits growth of prostatic epithelial cells in culture and mediates programmed cell death after androgen withdrawal. However, advanced prostatic carcinomas become insensitive to the inhibitory effect of TGFβ. Several members of the FGF family have been identified in the prostate. They are mainly or exclusively expressed in the stromal cells, and stimulate the epithelial cells. In the rat Dunning tumor model, progression is accompanied by distinct changes in the expression of FGFs and their receptors. In the hyperplastic tissue, basic FGF (bFGF) is accumulated. This growth factor is also a potent angiogenic inducer, expression of which may determine the metastatic capability of a tumor. IGFs are paracrine growth stimulators in the normal and hyperplastic prostate. It is still under consideration whether prostatic cancer cells gain the ability to produce IGF‐I by themselves and thus shift to an autocrine mode of IGF‐I stimulation. Growth factors also interact with the androgen‐signaling pathway. IGF‐I in particular, other growth factors as well, can activate the androgen receptor.

Interleukin-6 and prostate cancer progression

Prostate cancer, while initially dependent on androgens for proliferation, progresses to an androgen-independent state. Evidence has been accumulating that interleukin-6 (IL-6) may contribute to prostate cancer progression. Serum levels of IL-6 correlate with prostate tumor burden and patient morbidity. The prostate tissue itself appears to be a source of IL-6 and its receptor. Furthermore, experimental data suggest that IL-6 is an autocrine and paracrine growth factor for androgen-independent prostate cancer cell lines. For example, inhibition of IL-6, with anti-IL-6 antibody, sensitizes androgen-independent prostate cancer cells to chemotherapeutic agents in vitro. Finally, IL-6 activates a variety of signal transduction cascades, some which stimulate androgen receptor activity, in prostate cancer cells. These data suggest that targeting IL-6 may have multiple benefits in prostate cancer patients.

Interleukin‐6 regulation of prostate cancer cell growth

Interleukin‐6 (IL‐6) is involved in regulation of immune reaction and cell growth and differentiation. It causes multifunctional responses ranging from inhibition of proliferation to promotion of cell survival. IL‐6 effects may depend on experimental conditions such as passage numbers and serum composition. IL‐6 signals in target tissues through the receptor that is composed of the ligand‐binding and signal‐transducing subunits. IL‐6 is expressed in benign and malignant prostate tissue and the levels of the cytokine and its receptor increase during prostate carcinogenesis. IL‐6 is considered a positive growth factor for most prostate cells. The only exemption seems to be the LNCaP cell line, in which IL‐6 causes growth arrest and induces differentiation function. In contrast, IL‐6 acts as an autocrine growth factor in the subline LNCaP‐IL‐6+ established after chronic treatment with IL‐6. IL‐6 is a candidate for targeted therapy in prostate cancer because of its association with morbidity. Activation of signaling pathways of Janus kinase/signal transducers and activators of transcription factors, mitogen‐activated protein kinase (MAPK), and phosphatidylinositol 3‐kinase has been reported in various prostate cancer cell lines. IL‐6 and the related cytokine oncostatin M induce activation of the androgen receptor (AR) in the absence of androgen. IL‐6 is also involved in regulation of vascular endothelial growth factor expression as well as neuroendocrine differentiation in prostate. Anti‐IL‐6 antibodies showed an inhibitory effect on the PC‐3 xenograft. However, the development of this therapy in prostate cancer is in early stages.

Immunohistochemical localization of interleukin‐6 and its receptor in benign, premalignant and malignant prostate tissue

Interleukin‐6 (IL‐6) is a pleiotropic cytokine that interacts with its receptor in prostate cells, thus regulating proliferative response and differentiation. It also activates the human androgen receptor in prostate cancer cell lines. In order to assess the significance of these findings in vivo, the expression of key elements of the IL‐6 signalling pathway, IL‐6 and its receptor, was investigated in tissue samples obtained on radical prostatectomy from prostate cancer patients. IL‐6 immunohistochemistry was performed on 17 frozen prostate cancer specimens. IL‐6 receptor immunostaining was evaluated in 21 paraffin‐embedded prostate tumour specimens. In both groups, adjacent areas of high‐grade prostatic intraepithelial neoplasia and benign tissue were also investigated. In benign prostatic epithelium, IL‐6 was localized predominantly in basal cells, whereas in prostate cancer tissues more IL‐6‐positive glandular cells were identified. No IL‐6 expression was detected in stromal cells on immunohistochemistry, although IL‐6 protein was measured in the supernatants obtained from cultured stromal cells by ELISA. IL‐6 receptor was expressed in benign prostatic tissue in both epithelial and stromal cells. Furthermore, IL‐6 receptor expression was observed in all tumour specimens investigated and the majority of Gleason patterns analysed had more than 50% of cells showing a positive reaction. IL‐6 and IL‐6 receptor expression patterns in high‐grade prostatic intraepithelial neoplasia lesions were similar to those observed in tumour tissues. Taken together, the results of the present study imply that there are paracrine and autocrine IL‐6 loops in benign and neoplastic prostate. Copyright

Androgen receptor status of lymph node metastases from prostate cancer.

To date androgen receptor (AR) expression and structure in human prostatic cancer have been studied in primary tumor specimens and in cell lines. Investigation of alterations in the androgen‐signalling transduction cascade in prostatic carcinoma metastases is important to improve our understanding of tumor progression towards androgen insensitivity. In the present study we have collected data comparing AR expression in both the primary tumors and the respective pelvic lymph node metastases. Formalin‐fixed and paraffin‐embedded tissues derived from the primary tumors and positive lymph nodes of 12 patients undergoing radical prostatectomy were immunostained for the AR and prostate‐specific antigen (PSA). AR expression was evaluated with the polyclonal antibody PG‐21, which is directed against amino acids 1–21 in the N‐terminal region of the AR. All primary tumors stained for the AR. In 8 of the 12 lymph nodes examined more than 50% of the tumor cells were AR positive and displayed a uniform staining pattern; in one lymph node metastasis remarkable heterogeneity in AR expression was observed. In two cases less than 10% of the tumor cells stained for the AR. In one case the lymph node metastasis was immunohistochemically negative for the AR, whereas the primary tumor obtained from the same patient displayed intense staining for the AR. PSA was expressed in all metastases and primary tumors. Our data demonstrate that loss of the AR in lymph node metastases from prostatic carcinoma is a rare event.

Expression, structure, and function of androgen receptor in advanced prostatic carcinoma

Endocrine therapy for prostate cancer aims to reduce the levels of circulating androgen or to inhibit androgen action by blocking the androgen receptor in the prostate, or both. Studies in various animal and human prostate cancer models suggested that there may be a downregulation of androgen receptor during prostate cancer progression. Recent work, however, showed androgen receptor expression in all stages of prostate cancer. The presence of mutant androgen receptors in a portion of prostate cancers and receptor activation in the absence of androgen or in the presence of low androgen concentrations is discussed within this context.

Interleukin-6 stimulation of growth of prostate cancer in vitro and in vivo through activation of the androgen receptor

It is hypothesized that ligand-independent activation of the androgen receptor is one of the mechanisms implicated in tumour progression. However, supportive evidence is limited to the effect of HER-2/neu that stimulates prostate cancer progression through activation of the androgen receptor. In the present study, we have asked whether the proinflammatory cytokine interleukin-6 (IL-6), which is known to stimulate androgen receptor activity and expression of its downstream target genes, may also induce growth of androgen-sensitive cells. We have found that IL-6 differentially regulates proliferation of LAPC-4 and MDA PCa 2b cells. In MDA PCa 2b cells, growth stimulation by IL-6 was reversed by administration of either the non-steroidal anti-androgen bicalutamide or the inhibitor of the mitogen-activated protein kinase pathway PD98059. Neither cell line was found to express endogenous IL-6. Interestingly, the treatment of those prostate cancer cells did not increase phosphorylation of STAT3. The effect of IL-6 on stimulation of androgen receptor activity in MDA PCa 2b cells was lower than that of androgen, comparable with findings reported by other researchers. However, growth of MDA PCa 2b xenografts in castrated animals treated with IL-6 was similar to that in non-castrated animals. In addition, bicalutamide showed an inhibitory effect on IL-6-regulated growth in vivo. Taken together, data in the present study demonstrate that IL-6 may cause growth of androgen receptor-positive tumours in vitro and in vivo through activation of the androgen receptor.

Expression and function of androgen receptor coactivators in prostate cancer

Human androgen receptor (AR) associates with coactivator or corepressor proteins that modulate its activation in the presence of ligand. Early studies on AR coactivators in carcinoma of the prostate were hampered because of lack of respective antibodies. Investigations at mRNA level revealed that most benign and malignant prostate cells express common coactivators. AR coactivators SRC-1 and TIF-2 are up-regulated in tissue specimens obtained from patients who failed prostate cancer endocrine therapy. Increased expression of these coactivators is associated with enhanced activation of the AR by the adrenal androgen dehydroepiandrosterone. Similar association between AR coactivator expression and high prostate cancer grade and stage was reported for RAC-3 (SRC-3). The transcriptional integrator CBP was detected in clinical specimens representing organ-confined prostate cancer, lymph node metastases and tumour cell lines. Agonistic effect of the nonsteroidal antiandrogen hydroxyflutamide was strongly potentiated in prostate cells transfected with CBP cDNA. A functional homologue of CBP, p300, is implicated in ligand-independent AR activation by interleukin-6. The AR coactivator Tip60, which is up-regulated by androgen ablation, is recruited to the promoter of the prostate-specific antigen gene in the absence of androgen in androgen-independent prostate cancer sublines. It was proposed that the cofactor ARA70 is a specific enhancer of AR action. However, research from other laboratories has demonstrated interaction between ARA70 and other steroid receptors. Although in some cases dominant-negative coactivator mutants inhibited proliferation of prostate cancer cells in vitro, confirmation from in vivo tumour models is missing. In summary, several abnormalities in AR coactivator expression and function are associated with prostate cancer progression.

LAPAROSCOPIC RETROPERITONEAL LYMPH NODE DISSECTION FOR CLINICAL STAGE I NONSEMINOMATOUS TESTICULAR CARCINOMA: LONG-TERM OUTCOME

PURPOSE We report the long-term oncological efficacy and morbidity of laparoscopic retroperitoneal lymph node dissection for testicular carcinoma. MATERIALS AND METHODS From August 1992 to September 1999, 73 consecutive patients underwent laparoscopic retroperitoneal lymph node dissection with modified unilateral template dissection. All lumbar vessels within the template were routinely transected in the initial 29 cases only. Patients with positive lymph nodes received 2 cycles of chemotherapy. RESULTS Operative time ranged from 150 to 630 minutes (mean 221) in our most recent 28 cases. All but 2 operations were completed as planned for a conversion rate of 2.7%. Minor intraoperative complications developed in only 6.8% of cases. In our last 44 patients there was no major and only 1 minor (2.3%) postoperative complication. Mean postoperative hospitalization was 3.3 days. Ejaculation was preserved in all patients. Lymph nodes were positive in 19 cases (26%). Mean followup in 47 patients with pathological stage I disease was 43.3 months (range 7 to 84). We noted 1 retroperitoneal recurrence due to false-negative histological findings but there were no other relapses. At a mean followup of 42.7 months (range 6 to 86) 17 patients with pathological stage II carcinoma treated with 2 cycles of adjuvant chemotherapy were also free of disease. CONCLUSIONS In our hands laparoscopic retroperitoneal lymph node dissection has not only proved its surgical efficiency, but also its oncological efficacy. Patient satisfaction is high. During long-term followup of more than 3 years not a single recurrence developed due to surgical failure.