Firas Aljabery

M2-macrophage infiltration and macrophage traits of tumor cells in urinary bladder cancer

BACKGROUND Tumor-associated macrophages (TAMs) constitute a subset of nonneoplastic cells in tumor stroma and influence cancer progression in solid tumors. The clinical significance of TAMs in urinary bladder cancer (UBC) is controversial. METHODS We prospectively studied 103 patients with stage pT1-T4 UBC treated with cystectomy and pelvic lymph node dissection. Tumor sections were immunostained with M2-specific macrophage marker CD163 and proliferation marker Ki-67. The expression of these markers in cancer cells as well as macrophage infiltration (MI) in tumor stroma was analyzed in relation to clinical data and outcome. RESULTS The mean rate of CD163 and Ki-67 expressed by cancer cells were 35% and 78%, respectively. With borderline significance, MI was associated with lower rate of lymph node metastasis (P = 0.06). CD163 expression in cancer cells was proportional to MI (P<0.014). Patients with CD163-positive tumors and strong MI had significantly longer cancer-specific survival (CSS) (76 months), compared to patient with CD163-positive tumors and weak MI (28 months) (P = 0.02). CONCLUSIONS M2-specific MI tends to be inversely correlated with LN metastasis and improved CSS in UBC. MI might have protective impact in CD163-positive tumors. Expression of CD163 in cancer cells is significantly correlated with MI and might have a tumor promoting impact.

Radio-guided sentinel lymph node detection and lymph node mapping in invasive urinary bladder cancer: a prospective clinical study

To investigate the possibility of detecting sentinel lymph nodes (SNs) in patients with urinary bladder cancer (BCa) intra‐operatively and whether the histopathological status of the identified SNs reflected that of the lymphatic field.

Treatment according to guidelines may bridge the gender gap in outcome for patients with stage T1 urinary bladder cancer

Abstract Objective: The aim of this investigation was to study differences between male and female patients with stage T1 urinary bladder cancer (UBC) regarding intravesical instillation therapy, second resection and survival. Materials and methods: This study included all patients with non-metastatic primary T1 UBC reported to the Swedish National Register of Urinary Bladder Cancer (SNRUBC) from 1997 to 2014, excluding those treated with primary cystectomy. Differences between groups were evaluated using chi-squared tests and logistic regression, and survival was investigated using Kaplan–Meier and log-rank tests and Cox proportional hazards analysis. Results: In all, 7681 patients with T1 UBC (77% male, 23% female) were included. Females were older than males at the time of diagnosis (median age at presentation 76 and 74 years, respectively; p < .001). A larger proportion of males than females underwent intravesical instillation therapy (39% vs 33%, p < .001). Relative survival was lower in women aged ≥75 years and women with G3 tumours compared to men. However, women aged ≥75 years who had T1G3 tumours and underwent second resection followed by intravesical instillation therapy showed a relative survival equal to that observed in men. Conclusions: This population-based study demonstrates that women of all ages with T1 UBC undergo intravesical instillation therapy less frequently than men, and that relative survival is poorer in women aged ≥75 years than in men of the same age when intravesical instillation therapy and second resection are not used. However, these disparities may disappear with treatment according to guidelines.

Cohort profile : The Swedish National Register of Urinary Bladder Cancer (SNRUBC) and the Bladder Cancer Data Base Sweden (BladderBaSe)

Purpose To monitor the quality of bladder cancer care, the Swedish National Register of Urinary Bladder Cancer (SNRUBC) was initiated in 1997. During 2015, in order to study trends in incidence, effects of treatment and survival of men and women with bladder cancer, we linked the SNRUBC to other national healthcare and demographic registers and constructed the Bladder Cancer Data Base Sweden (BladderBaSe). Participants The SNRUBC is a nationwide register with detailed information on 97% of bladder cancer cases in Sweden as compared with the Swedish Cancer Register. Participants in the SNRUBC have registered data on tumour characteristics at diagnosis, and for 98% of these treatment data have been captured. From 2009, the SNRUBC holds data on 88% of eligible participants for follow-up 5 years after diagnosis of non-muscle invasive bladder cancer, and from 2011, data on surgery details and complications for 85% of participants treated with radical cystectomy. The BladderBaSe includes all data in the SNRUBC from 1997 to 2014, and additional covariates and follow-up data from linked national register sources on comorbidity, socioeconomic factors, detailed information on readmissions and treatment side effects, and causes of death. Findings to date Studies based on data in the SNRUBC have shown inequalities in survival and treatment indication by gender, regions and hospital volume. The BladderBaSe includes 38 658 participants registered in SNRUBC with bladder cancer diagnosed from 1 January 1997 to 31 December 2014. The BladderBaSe initiators are currently in collaboration with researchers from the SNRUBC investigating different aspects of bladder cancer survival. Future plans The SNRUBC and the BladderBaSe project are open for collaborations with national and international research teams. Collaborators can submit proposals for studies and study files can be uploaded to servers for remote access and analysis. For more information, please contact the corresponding author.

The expression profile of p14, p53 and p21 in tumour cells is associated with disease-specific survival and the outcome of postoperative chemotherapy treatment in muscle-invasive bladder cancer

PURPOSE We investigated the effects of alterations in the biological markers p14, p53, p21, and p16 in relation to tumour cell proliferation, T-category, N- category, lymphovascular invasion, and the ability to predict prognosis in patients with muscle-invasive bladder cancer (MIBC) treated with cystectomy and, if applicable, chemotherapy. MATERIALS AND METHODS We prospectively studied patients with urinary bladder cancer pathological stage pT1 to pT4 treated with cystectomy, pelvic lymph node dissection and postoperative chemotherapy. Tissue microarrays from paraffin-embedded cystectomy tumour samples were examined for expression of immunostaining of p14, p53, p21, p16 and Ki-67 in relation to other clinical and pathological factors as well as cancer-specific survival. RESULTS The median age of the 110 patients was 70 years (range 51-87 years), and 85 (77%) were male. Pathological staging was pT1 to pT2 (organ-confined) in 28 (25%) patients and pT3 to pT4 (non-organ-confined) in 82 (75%) patients. Lymph node metastases were found in 47 patients (43%). P14 expression was more common in tumours with higher T-stages (P = 0.05). The expression of p14 in p53 negative tumours was associated with a significantly shorter survival time (P=0.003). Independently of p53 expression, p14 expression was associated with an impaired response to chemotherapy (P=0.001). The expression of p21 in p53 negative tumours was associated with significantly decrease levels of tumour cell proliferation detected as Ki-67 expression (P=0.03). CONCLUSIONS The simultaneous expression of the senescence markers involved in the p53-pathway shows a more relevant correlation to the pathological outcome of MIBC than each protein separately. P14 expression in tumours with non-altered (p53-) tumours is associated with poor prognosis. P14 expression is associated with impaired response to chemotherapy. P21 expression is related to decreased tumour cell proliferation.

Vesico-Uterine Fistula after TURB in pregnancy, a rare cause of genitourinary fistula

Vesico-uterine fistulas (VUFs) are rare genitourinary fistulas developing, in most cases, secondary to iatrogenic aetiologies such as repeated Caesarean sections (CSs) [1]. In this article, we report the first published case of a VUF after transurethral resection of the bladder (TURB) during pregnancy. A 38-year-old multiparous woman in her seventh pregnancy, having had three previous CSs, presented at the 20th week of gestation with macroscopic haematuria. She had a history of a uterine perforation, which had occurred about 15 years previously caused by an intrauterine device (IUD). The IUD had migrated to the bladder and was removed by laparotomy. After this surgery she had two subsequent pregnancies with delivery at term. At admission the vaginal ultrasound examination showed a normal intrauterine pregnancy and a polypoid tumour in the posterior wall of the urinary bladder. A cystoscopy confirmed the ultrasonography finding. A broad based solid non-specific tumour with calcification was found in the posterior wall of the bladder. The cytology was benign. Two cold biopsies were taken during the cystoscopy and these showed necrosis and calcification. Additionally a TURB was performed in order to exclude malignancy. The patient was admitted to the obstetric department two days later with suspected preterm rupture of the membranes at the 22nd week of gestation. The vaginal ultrasound as well as a new cystoscopy demonstrated the ballooning of the foetal membranes into the urinary bladder through an eight-millimetre defect in the bladder wall (Figure 1). The creatinine level in the watery discharge from the vagina corresponded to that of urine. The histopathology report from the TURB showed urothelial tissue with decidua components and necrosis. A decision was made to treat the patient and the pregnancy conservatively and not to interfere surgically at that time in order to prolong the pregnancy as long as possible. Antibiotic prophylaxis was given with Nitrofurantoin, initially 50mg once daily, increased to 50mg three times daily due to a culture positive for enterococcus faecalis. Serum C-reactive protein was <5mg/L. After one week in-hospital observation at the county hospital she was discharged and followed in the outpatient clinic. At 25 weeks of gestation she was referred to the University Hospital due to a shortening of the cervix to 14mm, preterm premature rupture of membranes and signs of foetal distress. An emergency CS was conducted and a premature girl was delivered. The fistula closure was performed at the same time. The uterus was separated from the bladder and a cystostomy was performed. The bladder and the uterus were sutured with absorbable sutures in one layer and the omentum major was interposed between them (Figure 2). After three weeks, the cystography showed no evidence of leakage and the transurethral catheter was removed. At the clinical control six months after the surgery the patient presented with some problems with dysuria and pain but no signs of urinary incontinence. During the six-month period, urinary tract infection had occurred twice. The mother and the baby were in a good general condition.

Reply to Francesco Montorsi and Giorgio Gandaglia's Letter to the Editor re: Georg Jancke, Firas Aljabery, Sigurdur Gudjonsson, et al. Port-site Metastases After Robot-assisted Radical Cystectomy: Is There a Publication Bias? Eur Urol 2018;73:641–2

We thank Professor Montorsi and Doctor Gandaglia for their comments based on their vast experience with robotassisted radical cystectomy (RARC). We agree that the adoption of minimally invasive surgery in patients with muscle-invasive bladder cancer should not be discouraged. However, to further extend the debate, we would like to explain the setting in which our case series data were collected [1] and add a few thought-provoking facts. The 0.3% incidence of port-site metastases observed at nine centres of excellence [2] might not be at the same low level in a population-based setting. Five of the eight cases with port-site metastases after RARC occurred during the first 100 procedures, and the other three during the first 200 cystectomies performed with robot assistance in the respective institutions. This suggests an incidence that is at least twice as high (0.7%) during the learning curve, not taking into account clinical underreporting. Regarding oncological outcomes after RARC, positive bladder margins in 4–15% of cases in randomised studies have been reported [3–5]. Thus, it seems that this endpoint must also be carefully monitored when adopting RARC. This is further supported by the recent update with long-term oncological follow-up from another randomised investigation [6], which revealed a higher risk of abdominopelvic recurrences after RARC. In the current series, 50% of the patients received neoadjuvant chemotherapy, and four patients (aged 70, 71, 75, and 79 yr) underwent surgery without such pretreatment. We agree with Montorsi and Gandaglia that one or two of these elderly patients might have been treatable with cisplatin-based combination chemotherapy before cystectomy, which as of 2016 was administered to 59% of all patients with muscle-invasive disease aged 75 yr undergoing surgery in Sweden [7]. Although neoadjuvant

Neoadjuvant Chemotherapy Reinforces Antitumour T cell Response in Urothelial Urinary Bladder Cancer

Evidence indicates that neoadjuvant chemotherapy (NAC) may promote antitumour immune responses by activating T cells. The tumour-draining sentinel node (SN) is a key site to study tumour-specific T cell activation, being the primary immunological barrier against the tumour. In this prospective study, we set out to elucidate the effects of NAC on T cell subsets in the SNs of patients with muscle-invasive urothelial bladder cancer. We found that CD8+ effector T (Teff) cell exhaustion was reduced after NAC treatment, while cytotoxicity was increased. Additionally, in complete responders (CR patients), these cells were functionally committed effectors, as displayed by epigenetic analysis. In CD4+ Teffs, NAC treatment was associated with increased clonal expansion of tumour-specific SN-derived cells, as demonstrated by a specific cell reactivity assay. In contrast, we observed an attenuating effect of NAC on regulatory T cells (Tregs) with a dose-dependent decrease in Treg frequency and reduced effector molecule expression in the remaining Tregs. In addition, multicolour flow cytometry analysis revealed that CR patients had higher Teff to activated Treg ratio, promoting antitumoural T cell activation. These results suggest that NAC reinforces the antitumour immune response by activating the effector arm of the T cell compartment and diminishing the influence of suppressive Tregs. PATIENT SUMMARY: In this report, we analysed the effect of chemotherapy on immune cell subsets of 40 patients with advanced bladder cancer. We found that chemotherapy has a positive effect on immune effector T cells, whereas an opposite, diminishing effect was observed for immune-suppressive regulatory T cells. We conclude that chemotherapy reinforces the antitumour immune response in bladder cancer patients.

Tissue-resident memory T cells are epigenetically cytotoxic with signs of exhaustion in human urinary bladder cancer

Tissue‐resident memory T (TRM) cells are CD8+ T lymphocytes that reside in the tissues, including tumours. This T cell subset possesses a magnitude of cytotoxicity, but its epigenetic regulation has not been studied. Here, we investigate the impact of perforin DNA methylation in TRM cells and correlate it with their functional potential. Fifty‐three urothelial urinary bladder cancer (UBC) patients were recruited prospectively. The DNA methylation status of the perforin gene (PRF1) locus in TRM cells was investigated by pyrosequencing. Flow cytometry with ViSNE analysis and in‐vitro stimulation were used to evaluate TRM cell phenotypes. We discovered that tumour TRM cells have low DNA methylation in the PRF1 locus (32·9% methylation), which corresponds to increased numbers of perforin‐expressing TRM cells. Surprisingly, programmed cell death 1 (PD‐1) expression is high in tumour TRM cells, suggesting exhaustion. Following interleukin‐15 and T cell receptor stimulation, perforin and T‐bet expressions are enhanced, indicating that TRM cells from tumours are not terminally exhausted. Moreover, a high number of TRM cells infiltrating the tumours corresponds to lower tumour stage in patients. In conclusion, TRM cells from UBC tumours are epigenetically cytotoxic with signs of exhaustion. This finding identifies TRM cells as potential new targets for cancer immunotherapy.

Modulation of the inflammatory response after sclerotherapy for hydrocoele/spermatocoele

To investigate the modulation of the inflammatory response after sclerotherapy for hydrocoele/spermatocoele.