Marcus Horstmann

Comprehensive Transcriptional Analysis of Early-Stage Urothelial Carcinoma

Non-muscle-invasive bladder cancer (NMIBC) is a heterogeneous disease with widely different outcomes. We performed a comprehensive transcriptional analysis of 460 early-stage urothelial carcinomas and showed that NMIBC can be subgrouped into three major classes with basal- and luminal-like characteristics and different clinical outcomes. Large differences in biological processes such as the cell cycle, epithelial-mesenchymal transition, and differentiation were observed. Analysis of transcript variants revealed frequent mutations in genes encoding proteins involved in chromatin organization and cytoskeletal functions. Furthermore, mutations in well-known cancer driver genes (e.g., TP53 and ERBB2) were primarily found in high-risk tumors, together with APOBEC-related mutational signatures. The identification of subclasses in NMIBC may offer better prognostication and treatment selection based on subclass assignment.

FISH analysis of washing urine from the upper urinary tract for the detection of urothelial cancers

IntroductionTo evaluate FISH analysis of washing urine from the upper urinary tract (UUT) in comparison with cytology (Cyt) for the detection of urothelial cancers.Patients and methodsIn 82 patients with symptoms or abnormalities of the UUT sampling of washing urine for FISH and Cyt and a stepwise diagnostic work-up (e.g. retrograde ureteropyelography, ureterorenoscopy and endoscopic biopsy) were performed. In case of endoscopically and/or histologically proven malignancy patients either underwent nephroureterectomy, partial ureterectomy or local treatment. Sensitivity and specificity for FISH and Cyt as well as its combination were determined.ResultsUrothelial cancer of the UUT was detected in 20 patients. Eleven patients underwent nephroureterectomy, six partial ureterectomy and three endoscopic tumour treatment. This revealed nine pTa, three pT1 and seven muscle-invasive tumours. Twelve tumours were classified as low and seven as high-grade tumours. In one patient with a macroscopic unequivocal finding of tumour, endoscopic laser ablation without histologic confirmation was performed. FISH was evaluable in 76 patients and detected 16 tumours with a sensitivity and specificity of 84.2 and 91.1xa0%, respectively. Cyt was performed in 79 and was evaluable in 78 patients. It detected ten tumours with a sensitivity and specificity of 52.6 and 91.4xa0%, respectively. Cyt and FISH together detected 19 tumours with (sensitivity 100xa0% and specificity 83.6xa0%).ConclusionFISH was more sensitive than and equally specific to Cyt in the detection of urothelial cancers of the UUT. Both markers in combination revealed the best sensitivity, making it a possible approach in future settings.

Prognostic Impact of a 12-gene Progression Score in Non–muscle-invasive Bladder Cancer: A Prospective Multicentre Validation Study

BACKGROUNDnProgression of non-muscle-invasive bladder cancer (NMIBC) to muscle-invasive bladder cancer (MIBC) is life-threatening and cannot be accurately predicted using clinical and pathological risk factors. Biomarkers for stratifying patients to treatment and surveillance are greatly needed.nnnOBJECTIVEnTo validate a previously developed 12-gene progression score to predict progression to MIBC in a large, multicentre, prospective study.nnnDESIGN, SETTING, AND PARTICIPANTSnWe enrolled 1224 patients in ten European centres between 2008 and 2012. A total of 750 patients (851 tumours) fulfilled the inclusion and sample quality criteria for testing. Patients were followed for an average of 28 mo (range 0-76). A 12-gene real-time qualitative polymerase chain reaction assay was performed for all tumours and progression scores were calculated using a predefined formula and cut-off values.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnWe measured progression to MIBC using Cox regression analysis and log-rank tests for comparing survival distributions.nnnRESULTS AND LIMITATIONSnThe progression score was significantly (p<0.001) associated with age, stage, grade, carcinoma in situ, bacillus Calmette-Guérin treatment, European Organisation for Research and Treatment of Cancer risk score, and disease progression. Univariate Cox regression analysis showed that patients molecularly classified as high risk experienced more frequent disease progression (hazard ratio 5.08, 95% confidence interval 2.2-11.6; p<0.001). Multivariable Cox regression models showed that the progression score added independent prognostic information beyond clinical and histopathological risk factors (p<0.001), with an increase in concordance statistic from 0.82 to 0.86. The progression score showed high correlation (R2=0.85) between paired fresh-frozen and formalin-fixed paraffin-embedded tumour specimens, supporting translation potential in the standard clinical setting. A limitation was the relatively low progression rate (5%, 37/750 patients).nnnCONCLUSIONSnThe 12-gene progression score had independent prognostic power beyond clinical and histopathological risk factors, and may help in stratifying NMIBC patients to optimise treatment and follow-up regimens.nnnPATIENT SUMMARYnClinical use of a 12-gene molecular test for disease aggressiveness may help in stratifying patients with non-muscle-invasive bladder cancer to optimal treatment regimens.

Molecular markers increase precision of the European Association of Urology non-muscle invasive bladder cancer progression risk groups

Purpose: The European Association of Urology (EAU) guidelines for non–muscle-invasive bladder cancer (NMIBC) recommend risk stratification based on clinicopathologic parameters. Our aim was to investigate the added value of biomarkers to improve risk stratification of NMIBC. Experimental Design: We prospectively included 1,239 patients in follow-up for NMIBC in six European countries. Fresh-frozen tumor samples were analyzed for GATA2, TBX2, TBX3, and ZIC4 methylation and FGFR3, TERT, PIK3CA, and RAS mutation status. Cox regression analyses identified markers that were significantly associated with progression to muscle-invasive disease. The progression incidence rate (PIR = rate of progression per 100 patient-years) was calculated for subgroups. Results: In our cohort, 276 patients had a low, 273 an intermediate, and 555 a high risk of tumor progression based on the EAU NMIBC guideline. Fifty-seven patients (4.6%) progressed to muscle-invasive disease. The limited number of progressors in this large cohort compared with older studies is likely due to improved treatment in the past two decades. Overall, wild-type FGFR3 and methylation of GATA2 and TBX3 were significantly associated with progression (HR = 0.34, 2.53, and 2.64, respectively). The PIR for EAU high-risk patients was 4.25. On the basis of FGFR3 mutation status and methylation of GATA2, this cohort could be reclassified into a good class (PIR = 0.86, 26.2% of patients), a moderate class (PIR = 4.32, 49.7%), and a poor class (PIR = 7.66, 24.0%). Conclusions: We conclude that the addition of selected biomarkers to the EAU risk stratification increases its accuracy and identifies a subset of NMIBC patients with a very high risk of progression. Clin Cancer Res; 24(7); 1586–93. ©2018 AACR.

Urinary transcript quantitation of CK20 and IGF2 for the non-invasive bladder cancer detection

PurposeCytokeratin 20 (CK20) and insulin-like growth factor 2 (IGF2) were previously proposed to be elevated in clinical samples from patients with bladder cancer (BCa). A two cohort design validation study was used to assess the relevance for BCa detection by transcript quantitation of both markers in urine samples. Their diagnostic value was assessed in comparison with voided urine cytology (VUC).MethodsRNA isolation was carried out using cellular sediments of urine samples from 196/103 histologically positive BCa patients, as well as 97/50 control subjects for the test (TC) and validation cohort (VC), respectively. Urinary transcript levels of CK20 and IGF2 were determined by qPCR.ResultsRelative transcript levels were significantly elevated 3.4/11-fold for CK20 and 188/64-fold for IGF2 (pxa0<xa00.001) in urine sediments of BCa patients compared to controls in the TC and VC, respectively. In a combined analysis, the resulting sensitivity (SN) (SNTC: 77.9; SNVC: 90.3%) and specificity (SP) (SPTC: 88.0; SPVC: 84.0%) were similar to that of VUC. The sensitivity of VUC in combination with CK20 and IGF2 was considerably increased (SNTC: 94.6; SNVC: 93.2%) while specificity was reduced (SPTC: 72.0; SPVC: 82.0%) compared to VUC alone in the test and validation cohort.ConclusionsTranscript levels of IGF2 and CK20 enabled the detection of BCa with a diagnostic performance similar to VUC. Combined analysis of voided urine cytology together with altered transcript levels of CK20 and IGF2 enhanced sensitivity, but did not improve overall test performance.

Differenzialdiagnose der Hämaturie

ZusammenfassungHämaturie ist das Leitsymptom etlicher urologischer und nephrologischer Erkrankungen. Bei der Differenzialdiagnose wird zwischen schmerzhafter und schmerzloser und zwischen der mit bloßem Auge sichtbaren Makro- und der nicht sichtbaren Mikrohämaturie unterschieden. Als Grund für eine Hämaturie kommen prinzipiell renale (glomeruläre) und nicht renale (nicht glomeruläre) Ursachen in Frage. Um einerseits Frühsymptome maligner und relevanter gutartiger Erkrankungen nicht zu verpassen und um andererseits eine übermäßige Diagnostik zu vermeiden, ist ein differenziertes Vorgehen wichtig.AbstractHematuria is the main symptom of many urological and nephrological diseases. In the differential diagnostics a distinction is made between painful and pain-free and between macrohematuria which is visible to the naked eye and microhematuria which is not visible. The reasons for hematuria are basically renal (glomerular) and non-renal (non-glomerular) causes. In order not to overlook early symptoms of malignant and relevant benign diseases and also to avoid excessive diagnostic tests, a differentiated approach is necessary.

Differential diagnosis of hematuria

ZusammenfassungHämaturie ist das Leitsymptom etlicher urologischer und nephrologischer Erkrankungen. Bei der Differenzialdiagnose wird zwischen schmerzhafter und schmerzloser und zwischen der mit bloßem Auge sichtbaren Makro- und der nicht sichtbaren Mikrohämaturie unterschieden. Als Grund für eine Hämaturie kommen prinzipiell renale (glomeruläre) und nicht renale (nicht glomeruläre) Ursachen in Frage. Um einerseits Frühsymptome maligner und relevanter gutartiger Erkrankungen nicht zu verpassen und um andererseits eine übermäßige Diagnostik zu vermeiden, ist ein differenziertes Vorgehen wichtig.AbstractHematuria is the main symptom of many urological and nephrological diseases. In the differential diagnostics a distinction is made between painful and pain-free and between macrohematuria which is visible to the naked eye and microhematuria which is not visible. The reasons for hematuria are basically renal (glomerular) and non-renal (non-glomerular) causes. In order not to overlook early symptoms of malignant and relevant benign diseases and also to avoid excessive diagnostic tests, a differentiated approach is necessary.

Evaluation of Plasmatic Kisspetin-10 as a Biomarker for Malignancy and Subtype Differentiation in Small Renal Tumours.

Objective: To evaluate Kisspeptin-10 (Kiss-10) in patients with small renal tumours (SRTs) and controls. Material and Methods: Kiss-10 was measured in preoperative plasma samples in a cohort of 143 patients with unilateral renal tumours smaller than or equal to 4 cm and 40 age-matched controls by a competitive ELISA test kit. The cohort of patients included 56 patients with clear cell renal cell carcinoma (ccRCC), 43 with papillary RCC (pRCC), 12 with chromophobe RCC (chRCC) and 32 with oncocytomas. Results: Kiss-10 was detected in all patients and controls. SRT patients revealed significantly higher Kiss-10 levels than controls (mean value 10.04 vs. 6.37 pmol/l, p < 0.001). In SRT patients, Kiss-10 was detected at significantly different concentrations between the subgroups (p = 0.021). The highest concentration was observed in those with oncocytomas (11.50 pmol/) followed by chRCC, pRCC and ccRCC patients (9.89, 10.01 and 9.25 pmol/l, respectively). Receiver operating characteristic curve analyses revealed an area under the curve (AUC) of 0.82 for the comparison of all tumours vs. controls (p < 0.001) and an AUC of 0.671 for all malignant tumours vs. oncoytomas (p = 0.003). Conclusion: This study shows that Kiss-10 levels are significantly altered by malignancy and tumour subtypes even in patients with SRTs. Kiss-10 therefore deserves further attention as a plasmatic biomarker for renal tumours.

PD61-12 IMPACT OF SURGICAL TECHNIQUE ON THE PERFORMANCE OF PELVIC LYMPH NODE DISSECTION AT RADICAL PROSTATECTOMY: RESULTS FROM A GERMAN MULTICENTER DATABASE

INTRODUCTION AND OBJECTIVES: Aim of our study was to evaluate differences between the old and the new classification systems in upgrading and downgrading rates in a cohort of patients undergoing radical prostatectomy (RP) for PCa. METHODS: Between 2012 and 2016, 636 patients with clinically localized PCa were treated with RP at two tertiary referral centers. Blood samples were collected and tested for total PSA. All the patients included in the study presented a biopsy performed in the same center where the RP was performed. Biopsy specimens as well as RP specimens were graded according to both 2005 Gleason and 2015 Epstein Gleason grading systems. Upgrading and downgrading rates on RP were recorded for both classifications and then compared. Clinically significant upgrading was defined as: Epstein score raising from 2 to 3 or from 3 to 5 and Gleason (2005) raising from 6 to 7 or from 7 to 9. As well clinically significant downgrading was defined as: Epstein score decreasing from 3 to 2 or from 5 to 3 and Gleason (2005) decreasing from 7 to 6 or from 9 to 7. The accuracy of the biopsy for each Gleason score classification was determined using the kappa coefficient of agreement: <0.4 poor agreement, 0.4-0.75 good agreement and > 0.75 excellent agreement. RESULTS: Median age and preoperative PSA levels were 66 years (IQR: 61-69) and 7.1 ng/ml (IQR: 5.2-10.0), respectively. Overall 247/636 (39 %) had advanced disease (pT 3a). Pathological grading of biopsies and RP specimens according to both classifications are described in table 1. The Epstein Gleason score presented a lower upgrading rate (93/636:15% vs 150/636:24%; p1⁄40.000) and a similar downgrading rate (36/636:6 % vs 28/636:4% p1⁄40.194) when compared to the 2005 one. The kappa-statistics measures of agreement between needle biopsy and RP specimens was better for the Epstein score when compared to the 2005 Gleason score (k1⁄4 0.569 0.034 vs k1⁄4 0.481 0.033). CONCLUSIONS: The new Epstein Gleason score classification significantly reduces upgrading events in patients with PCa treated with RP. The implementation of this new classification could better define prostate cancer aggressiveness with important clinical implications particularly in PCa management. Further studies with a pathological review and reclassification of the specimens are needed to confirm our data.

Gigantic Suprapubic Lymphedema: A Case Study

We present the first case study of idiopathic gigantic suprapubic lymphedema and buried penis treated with puboscrotal reconstruction in a patient with initial extreme obesity after an extensive weight reduction (120 kg). Massive localized lymphedema of the suprapubic region should be differentiated from the scrotal type. Severe lymphedema could not resolve on its own and weight reduction does not seem to be helpful in such cases.