Leopoldo A. Ribeiro-Filho

GENITAL TRAUMA DUE TO ANIMAL BITES

PURPOSE Animal bites to the external genitalia are rare. We retrospectively evaluated our experience with treating genital trauma caused by animal attacks. MATERIALS AND METHODS We studied the medical records of 10 patients treated in the surgical emergency department at our hospital who presented with genital injury caused by an animal bite from 1983 to 1999. Special attention was given to the severity of injury, surgical treatment, antibiotic prophylaxis and outcome. RESULTS Of the 2 men and 8 boys 8 were attacked by dogs, 1 by a horse and 1 by a donkey, respectively. In all cases initial local treatment involved débridement and copious wound irrigation with saline and povidone-iodine solution. Five patients who presented with minimal or no skin loss underwent primary skin closure, including 2 in whom urethral lacerations were surgically repaired. There was moderate to extensive tissue loss in 5 patients, including degloving penile injury in 2, traumatic spermatic cord amputation in 1, complete penile and scrotal avulsion in a 5-month-old infant, and partial penectomy in 1. Reconstructive procedures provided satisfactory cosmetic and functional results in 8 cases. Antibiotic prophylaxis was administered in all patients and no infectious complications developed. CONCLUSIONS Animal bite is a rare but potentially severe cause of genital trauma and children are the most common victims. Morbidity is directly associated with the severity of the initial wound. Because patients tend to seek medical care promptly, infectious complications are unusual. Management involves irrigation, débridement, antibiotic prophylaxis, and tetanus and rabies immunization as appropriate as well as primary wound closure or surgical reconstruction. Good functional and cosmetic results are possible in the majority of cases.

CpG hypermethylation of promoter region and inactivation of E-cadherin gene in human bladder cancer

Several studies have shown that E‐cadherin expression is lost during malignant transformation. We hypothesized that CpG methylation in the promoter region may inactivate the expression of the E‐cadherin gene in human bladder cancer. Normal and bladder cancer samples from 51 patients were compared in terms of E‐cadherin gene expression and methylation status by immunohistochemistry, methylation‐specific polymerase chain reaction (MSP), and bisulfite genome‐sequencing techniques. Ten different CpG sites (nt 863, 865, 873, 879, 887, 892, 901, 918, 920, and 940) in the promoter region were studied. Thirty‐five of 51 (69%) bladder cancer samples lacked E‐cadherin expression, whereas only six of 51 (12%) normal bladder samples lacked E‐cadherin immunoreactivity. MSP analysis of bladder cancer samples suggested that 43 of 51 (84%) showed methylation of the promoter region, whereas only 12 of 51 (24%) normal bladder samples showed hypermethylation. Sodium bisulfite genome‐sequencing analysis revealed that of 10 CpG sites, two sites (nt 892 and nt 940) showed 100% methylation in all the cancer samples analyzed. Other CpG sites were partially methylated (47–91%). Normal tissue showed only 12% methylation (range, 1–33%) on various CpG sites. Also supporting these data, E‐cadherin–negative bladder cancer cell lines restored expression of the E‐cadherin gene after treatment with the demethylating agent 5‐aza‐2′‐deoxycytidine. The present study showed that CpG hypermethylation was an important mechanism of E‐cadherin gene inactivation in bladder cancer and also that specific CpG sites consistently presented higher methylation levels than others. These findings may provide a better strategy for the diagnosis and management of bladder cancer.

Promoter CpG hypomethylation and transcription factor EGR1 hyperactivate heparanase expression in bladder cancer

Heparanase plays a critical role in the degradation of extracellular matrix and cell membrane and is frequently upregulated in malignant tumors. Transcription factor, early growth response 1 (EGR1), is closely associated with inducible transcription of the heparanase gene. We hypothesized that promoter CpG hypomethylation with increased EGR1 expression could determine heparanase expression during the pathogenesis of bladder cancer. Bladder cancer cell lines (J82, T24 and transitional cell carcinoma) significantly restored heparanase expression after 5-Aza-dC treatment. Transfection of EGR1 siRNA with T24 bladder cancer cell line significantly downregulated heparanase expression compared to the control siRNA transfection. In 54 bladder cancer and paired normal bladder samples, heparanase expression was significantly higher in bladder cancer than in normal bladder (P<0.01). We performed methylation-specific PCR targeting the CpG sites within the core-binding consensus motifs of EGR1 (GGCG) and Sp1 (GGGCGG). Methylation prevalence was significantly higher in normal bladder than in bladder cancer (P<0.05) and inversely correlated with heparanase expression (P=0.055). In the total series of bladder cancer and normal bladder samples, the combination of promoter CpG methylation and EGR1 expression regulated heparanase expression in a stepwise manner, where heparanase expression was the lowest in methylation-positive and EGR1-negative samples and the highest in methylation-negative and EGR1-positive samples. To our knowledge, this is the first study demonstrating that increased heparanase expression during the pathogenesis of bladder cancer is due to promoter hypomethylation and transcription factor EGR1.

E-cadherin and β-catenin Loss of Expression Related to Bone Metastasis in Prostate Cancer

ObjectivesE-cadherin and β-catenin are adhesion molecules responsible for the maintenance of normal epithelial cell phenotype. A disturbance in epithelial cell adhesion, which leads to a more invasive and metastatic phenotype, is a hallmark of tumor progression. Several immunohistochemical studies have reported a strong correlation between loss of their expression to higher stage and grade in prostate carcinoma, but their influence in metastatic process is not yet known. The aim of this study is to verify the role of adhesion molecules in the progression of prostate cancer (PC), assessing the expression of E-cadherin and β-catenin in bone metastasis. Materials and MethodsTwenty-eight bone metastases of prostate carcinoma were submitted to immunohistochemistry analysis for E-cadherin and β-catenin expression. In 6 patients, we were able to assess the expression of the adhesion molecules in the primary tumors and their respective metastases. The definition of normal expression for both antibodies was strong and diffuse expression in more than 70% of tumor cells. ResultsIn bone metastases, there was loss of expression of E-cadherin and β-catenin in 86% and 82%, respectively. Among the primary tumors, E-cadherin and β-catenin expression was normal in 83% and 50% cases, respectively. Considering the 6 patients with paired primary and bone metastasis, we found loss of expression for both E-cadherin and β-catenin in most of the cases. ConclusionsComparing primary PC and its metastasis, we showed persistent loss of E-cadherin and β-catenin expression. This phenomenon may be related to metastatic potential in PC, because we have shown underexpression for E-cadherin and β-catenin in 86% and 82% of bone metastases.

Association between integrin expression and prognosis in localized prostate cancer

Integrins and other adhesion molecules are essential for maintaining the epithelial phenotype. Some studies have reported correlations between abnormalities in their expression and carcinogenesis, but their role in prostate cancer is unclear. Our aim was to study the expression profile of integrins in surgical specimens of prostate cancer and associate their expression patterns with patient outcomes.

Tgf-β1 expression as a biomarker of poor prognosis in prostate cancer

OBJECTIVE: To evaluate the correlation between transforming growth factor beta (TGF-β1) expression and prognosis in prostate cancer. PATIENTS AND METHODS: TGF-β1 expression levels were analyzed using the quantitative real-time polymerase chain reaction to amplify RNA that had been isolated from fresh-frozen malignant and benign tissue specimens collected from 89 patients who had clinically localized prostate cancer and had been treated with radical prostatectomy. The control group consisted of 11 patients with benign prostate hyperplasia. The expression levels of TGF-β1 were compared between the groups in terms of Gleason scores, pathological staging, and prostate-specific antigen serum levels. RESULTS: In the majority of the tumor samples, TGF-β1 was underexpressed 67.0% of PCa patients. The same expression pattern was identified in benign tissues of patients with prostate cancer. Although most cases exhibited underexpression of TGF-β1, a higher expression level was found in patients with Gleason scores ≥7 when compared to patients with Gleason scores <7 (p = 0.002). Among the 26 cases of TGF-β1 overexpression, 92.3% had poor prognostic features. CONCLUSIONS: TGF-β1 was underexpressed in prostate cancers; however, higher expression was observed in tumors with higher Gleason scores, which suggests that TGF-β1 expression may be a useful prognostic marker for prostate cancer. Further studies of clinical specimens are needed to clarify the role of TGF-β1 in prostate carcinogenesis.

Acellular matrix in urethral reconstruction

The treatment of severe urethral stenosis has always been a challenge even for skilled urologists. Classic urethroplasty, skin flaps and buccal mucosa grafting may not be used for long and complex strictures. In the quest for an ideal urethral substitute, acellular scaffolds have demonstrated the ability to induce tissue regeneration layer by layer. After several experimental studies, the use of acellular matrices for urethral reconstruction has become a clinical reality over the last decade. In this review we analyze advantages and limitations of both biological and polymeric scaffolds that have been reported in experimental and human studies. Important aspects such as graft extension, surgical technique and cell-seeding versus cell-free grafts will be discussed.

Tumor banks: the cornerstone of basic research in urology

PURPOSE Tumor banks have the primary responsibility for collecting, cataloging, storing and disseminating samples of tissues, cells and fluids, which are used by researchers to identify diagnostic molecular markers, prognostic indicators and therapeutic targets. The objective of this review was to describe a simple, reliable and reproducible protocol for obtaining and storing samples of urological tumors. MATERIALS AND METHODS Urogenital tumor tissues were collected by the surgeons from the Urology Division of University of Sao Paulo Medical School. The obtained surgical specimens were immediately placed in liquid nitrogen, dry ice or in a tube containing RNAlater, and then stored by cryopreservation (-80 degrees C). A mirror fragment was fixed in 10% formalin processed routinely and embedded in Paraplast. RESULTS We developed a protocol for the collection, cataloging, storage, conservation and use of tumor samples. During a period of one year the Urological Tumor Bank of the Urology Division stored 274 samples of prostate, bladder, kidney, penis and testicle tumors of different histological types, 74 urine and 271 serum samples. CONCLUSIONS Having biological materials characterized and available along with the clinical patient information provides an integrated portrait of the patients and their diseases facilitating advances in molecular biology. It also promotes the development of translational research improving methods of diagnosis and cancer treatment.

The Moreau Strain of Bacillus Calmette-Guerin (BCG) for High-Risk Non-Muscle Invasive Bladder Cancer: An Alternative during Worldwide BCG Shortage?

Background: Bacillus Calmette-Guerin (BCG) is the standard of care for adjuvant intravesical instillation therapy for intermediate- and high-risk non-muscle invasive bladder cancer (NMIBC) after complete transurethral resection. Increasing evidence suggests that there are marked differences in outcomes according to BCG substrains. BCG-Moreau was recently introduced to the European market to cover the issue of BCG shortage, but there are little data regarding the oncologic efficacy. Methods: We retrospectively analyzed 295 consecutive patients, who received adjuvant intravesical instillation therapy with BCG-Moreau for intermediate- and high-risk NMIBC between October 2007 and April 2013 at a single institution. The end points of this study were time to first recurrence and progression to muscle-invasive disease. Results: Median age was 66 years (interquartile range 59-74, mean 65.9 years). According to the EAU risk group, 76 patients presented with intermediate-risk and 219 patients with high-risk NMIBC. The 5-year recurrence-free survival and progression-free survival rate was 64.8% (95% CI 52.8-74.4) and 81.4% (95% CI 65.2-90.2), respectively. Conclusions: BCG-Moreau is an effective substrain for adjuvant instillation therapies of NMIBC, and outcomes appear to be comparable to series using other substrains. During worldwide shortage of BCG-TICE, Connaught and RIVM, BCG-Moreau may serve as an equally effective alternative.

Correlation between Beta1 integrin expression and prognosis in clinically localized prostate cancer

UNLABELLED Integrins are transmembrane glycoprotein receptors that regulate cell-matrix interactions, thus functioning as sensors from the environment. They also act as cell adhesion molecules that are responsible for the maintenance of the normal epithelial phenotype. Some studies have reported a correlation between carcinogenesis and changes in integrin expression, especially β1 integrin, however its role in prostate cancer (PC) is unclear. The aim of our study was to evaluate the expression of β1 integrin in localized PC and to correlate the pattern of expression with recurrence after surgical treatment. Methods For this case-control study, we retrospectively selected surgical specimens from 111 patients with localized PC who underwent radical prostatectomy. Recurrence was defined as a PSA level exceeding 0.2 ng/mL after surgery, and the median follow-up was 123 months. Integrin expression was evaluated by immunohistochemistry in a tissue microarray containing two samples from each tumor. We employed a semiquantitative analysis and considered a case as positive when the expression was strong and diffusely present. RESULTS There was a loss of 11 cases during the tissue micro array assembling. β1 expression was positive in 79 of the 100 evaluated cases (79%). The univariate and multivariate analyses showed that the negative expression of β1 integrin was associated with biochemical recurrence (p = 0.047) and time to recurrence after radical prostatectomy (p = 0.023). When β1 was negative, the odds ratio for recurrence was 2.78 times higher than that observed in the positive cases [OR = 2.78, p = 0.047, IC 95% (1.01-7.66)]. CONCLUSIONS The loss of β1 integrin immune expression was correlated with biochemical recurrence in patients treated with radical prostatectomy for localized PC.