Martin J.P. Hennig

The Role of CD44 in Disease Pathophysiology and Targeted Treatment

The cell-surface glycoprotein CD44 is involved in a multitude of important physiological functions including cell proliferation, adhesion, migration, hematopoiesis, and lymphocyte activation. The diverse physiological activity of CD44 is manifested in the pathology of a number of diseases including cancer, arthritis, bacterial and viral infections, interstitial lung disease, vascular disease, and wound healing. This diversity in biological activity is conferred by both a variety of distinct CD44 isoforms generated through complex alternative splicing, posttranslational modifications (e.g., N- and O-glycosylation), interactions with a number of different ligands, and the abundance and spatial distribution of CD44 on the cell surface. The extracellular matrix glycosaminoglycan hyaluronic acid (HA) is the principle ligand of CD44. This review focuses both CD44-hyaluronan dependent and independent CD44 signaling and the role of CD44–HA interaction in various pathophysiologies. The review also discusses recent advances in novel treatment strategies that exploit the CD44–HA interaction either for direct targeting or for drug delivery.

Antitumor activity of sulfated hyaluronic acid fragments in pre-clinical models of bladder cancer

Tumor cell-derived hyaluronidase HYAL-1 degrades hyaluronic acid (HA) into angiogenic fragments (AGF: 10-12 disaccharides). AGF support tumor growth and progression. Urine and tissue HAase/HYAL-1 levels are sensitive markers for high-grade bladder cancer (BCa) and its metastasis. In preclinical models of BCa, we evaluated whether o-sulfated AGF (sHA-F) inhibits HAase activity and has antitumor activity. At IC50 for HAase activity inhibition (5-20 μg/ml [0.4-1.7 μM]), sHA-F significantly inhibited proliferation, motility and invasion of HYAL-1 expressing BCa cells (253J-Lung, HT1376, UMUC-3), P<0.001. sHA-F did not affect the growth of HYAL-1 non-expressing BCa (5637, RT4, T24, TCCSUP) and normal urothelial (Urotsa, SV-HUC1) cells. sHA-F treatment induced apoptosis by death receptor pathway. sHA-F downregulated transcript and/or protein levels of HA receptors (CD44, RHAMM), p-AKT, β-catenin, pβ-Catenin(S552), Snail and Twist but increased levels of pβ-Catenin(T41/S45), pGSK-3α/β(S21/S9) and E-cadherin. sHA-F also inhibited CD44/Phosphoinositide 3-kinase (PI-3K) complex formation and PI-3K activity. AGF addition or myristoylated-AKT overexpression attenuated sHA-F effects. Contrarily, HYAL-1 expression sensitized RT4 cells to sHA-F treatment. In the 253J-L and HT1376 xenograft models, sHA-F treatment significantly inhibited tumor growth (P<0.001), plausibly by inhibiting angiogenesis and HA receptor-PI-3K/AKT signaling. This study delineates that sHA-F targets tumor-associated HA-HAase system and could be potentially useful in BCa treatment.

Acceptance of Adjuvant and Neoadjuvant Chemotherapy in Muscle-Invasive Bladder Cancer in Germany: A Survey of Current Practice

Background: Guidelines support the use of neoadjuvant (NAC) and adjuvant (AC) chemotherapy in muscle-invasive bladder cancer. However, data from North America reported the underutilization of NAC in favor of AC despite the lower level of scientific evidence supporting AC. We aimed to assess current practice patterns of NAC and AC in Germany. Methods: A 15-question online survey was developed and sent via email newsletters to members of the German Association of Urology and of the German Society of Residents in Urology in October 2016 to analyze current practice patterns. Results: The survey yielded 141 individual responses from 61 different German urology departments. Eighty-nine (69.0%) and 119 (93.0%) participants were stated to regularly use NAC and AC respectively. The number of participants who were stated to use NAC and AC regularly was not associated with the type of institution (academic vs. nonacademic), number of hospital beds, and number of cystectomies performed annually. Gemcitabine/cisplatin combination chemotherapy was named as the primarily used NAC regimen by 80 (95%) respondents. The median number of administered cycles was 3 for NAC and 4 for AC. In the case of cisplatin ineligibility, combination chemotherapy with gemcitabine/carboplatin was the most common regimen. Respondents stated that chemotherapy was generally administered by urologists (81% for NAC and 85% for AC). Conclusions: Our survey of current practice shows a high acceptance rate of NAC in Germany, which was independent of the type of institution. Although the scientific level of evidence for AC is lower, it still seems to be more widely accepted than NAC. NAC and AC were generally administered by urologists.

Diarrhea and flatulence are major bowel disorders after radical cystectomy: Results from a cross-sectional study in bladder cancer patients

OBJECTIVES We had previously demonstrated changes in defecation after radical cystectomy (RC). Reports addressing long-term bowel disorders following RC are rare. This cross-sectional study evaluates long-term bowel issues in a large cohort. MATERIAL AND METHODS A questionnaire assessing changes in bowel function (diarrhea, constipation, urge to defecate, sensation of incomplete defecation, and flatulence) and its effect on quality of life was developed based on the gastrointestinal quality of life index and distributed in collaboration with the German bladder cancer support group. There were 431 evaluable questionnaires. For the analyses, we focused on patients that had the RC>1 year ago (n = 324). RESULTS Current bowel problems were reported by 42.6% of patients. The most frequent bowel problems were flatulence (48.8%), diarrhea (29.6%), and sensation of incomplete defecation (22.5%). In cases of bowel problems, 39.7% and 59.8% of the patients indicated life restriction and dissatisfaction, respectively. Prevalence of diarrhea and flatulence were significantly higher>12 (vs. ≤12) months following RC. Both symptoms significantly correlated with younger age at RC, life restriction, lower quality of life, lower health state, and lower energy level. Additionally, diarrhea significantly correlated with pouches as urinary diversion (vs. ileal conduit or ureterocutaneostomy) and higher dissatisfaction level. CONCLUSIONS To our knowledge this is the largest cohort evaluating long-term bowel symptoms after RC. Diarrhea is a prominent symptom after RC with a high impact on daily life that leads to dissatisfaction. A better understanding of long-term bowel symptoms could be translated into optimized surgical procedures, postoperative medication/nutrition, and patient education.

Molecular Characterization of Renal Cell Carcinoma: A Potential three microRNA Prognostic Signature

Background: Aberrantly expressed miRNAs promote renal cell carcinoma (RCC) growth and metastasis and are potentially useful biomarkers for metastatic disease. However, a consensus clinically significant miRNA signature has not been identified. To identify an miRNA signature for predicting clinical outcome in RCC patients, we used a four-pronged interconnected approach. Methods: Differentially expressed miRNAs were identified and analyzed in 113 specimens (normal kidney: 59; tumor: 54). miRNA profiling was performed in matched normal and tumor specimens from 8 patients and extended to 32 specimens. Seven aberrantly expressed miRNAs were analyzed by qPCR, and their levels were correlated with RCC subtypes and clinical outcome. miRNA signature was confirmed in The Cancer Genome Atlas RCC dataset (n = 241). Results: Discovery phase identified miR-21, miR-142-3p, miR-142-5p, miR-150, and miR-155 as significantly upregulated (2–4-fold) and miR-192 and miR-194 as downregulated (3–60-fold) in RCC; miR-155 distinguished small tumors (<4 cm) from benign oncocytomas. In univariate and multivariate analyses, miRNA combinations (miR-21+194; miR-21+142-5p+194) significantly predicted metastasis and/or disease-specific mortality; miR-21+142-5p+194 (for metastasis): P = 0.0017; OR, 0.53; 95% confidence interval (CI), 0.75–0.33; 86.7% sensitivity; 82% specificity. In the TCGA dataset, combined biomarkers associated with metastasis and overall survival (miR-21+142-5p+194: P < 0.0001; OR, 0.37; 95% CI, 0.58–0.23). Conclusions: The interconnected discovery–validation approach identified a three-miRNA signature as a potential predictor of disease outcome in RCC patients. Impact: With 10% survival at 5 years, metastatic disease presents poor prognosis for RCC patients. The three-miRNA signature discovered and validated may potentially at an early stage detect and predict metastasis, to allow early intervention for improving patient prognosis. Cancer Epidemiol Biomarkers Prev; 27(4); 464–72. ©2018 AACR.

MP39-15 SDCT2 AS A FUNCTIONAL BIOMARKER OF RENAL CELL CARCINOMA

patients were stained for iron and TfR1 protein using Prussian Blue and immunohistochemistry, respectively. 178 tissue cores from 14 different body sites of non-cancer patients were included as controls. Staining was scored by a clinically blinded genitourinary pathologist based on the product of intensity and tissue percentage (Z-score), and tested for association with clinicopathologic features and survival using a MannWhitney U test, Kruskal Wallis test and Cox regression model. RESULTS: Renal epithelium from non-cancer patients had low iron content (mean Z-score,MZS1⁄4 0.1), but by far the highest TfR1 levels of any tissue site in the body (MZS1⁄4 153). Compared to non-cancer patients, iron content in RCC patients increased mildly (4-fold) in benign renal epithelium (MZS1⁄4 0.6) and dramatically (>100 fold) in primary tumors (MZS1⁄4 21, p< 0.001). Higher tumor iron content was accompanied by moderate TfR1 downregulation (MZS1⁄4 21, p< 0.001) and associated with clear cell and papillary histologies, male gender and tobacco usage (p< 0.05 each). Opposite to changes observed with tumorigenesis, iron and TfR1 levels decreased and increased, respectively, with progression in tumor size, grade, pT stage andmetastatic stage (all p< 0.05). Iron loss andTfR1upregulationweremost apparent inmetastatic lesions (MZS1⁄45 and 111, respectively) and each associated with patient anemia and worse RCC-specific survival (all p< 0.05). CONCLUSIONS: Benign renal epithelium has uniquely high levels of the iron import protein, TfR1, potentially priming these cells for dysregulated iron uptake and large intracellular iron increases (>100 fold) during tumorigenesis. Reduction in iron content during RCC progression to metastasis, despite TfR1 increases, may reflect lower systemically available iron in advanced RCC patients and raises the possibility that these cancers might have increased susceptibility to iron deprivation as a novel therapeutic strategy.

PD57-11 CROSS-SECTIONAL STUDY EVALUATING LONG-TERM BOWEL ISSUES IN BLADDER CANCER PATIENTS: DIARRHEA AS A LIMITING FACTOR OF QUALITY OF LIFE AFTER RADICAL CYSTECTOMY

INTRODUCTION AND OBJECTIVES: Patient reports of health related quality of life (HRQoL) are being used to facilitate understanding of the physical and psychological impacts of surgery in patients with bladder cancer. Presently, the true effect of radical cystectomy (RC) on female sexual function is poorly described. The aim of this study is to prospectively report baseline and post-operative sexual function in a group of females undergoing RC. METHODS: Seventy-four females undergoing RC for bladder cancer were enrolled from 2008-2014 in a prospective HRQoL study. The Female Sexual Function Index (FSFI) was administered 1 month prior to RC, 6and 12-months post-operatively. Latent Transition Analysis (LTA) was conducted at all 3 points in time to assign patients to homogeneous groups based on their survey responses (i.e., patients with similar responses were grouped together). Group membership was modeled by marital status, type of urinary diversion, vaginal reconstruction, and administration of neoadjuvant chemotherapy. LTA was also used to estimate transitions between groups over time. RESULTS: Sixty patients completed baseline surveys and 47 (64%) one year following cystectomy. Median age of the cohort was 66 (IQR 59,72) and 62 patients (84%) underwent vaginal reconstruction with RC. LTA revealed that at baseline, 65% of patients provided responses that were characterized as having 0no sexual activity0 (group 1), 17% 0 limited sexual function0 (group 2), and 18% 0adequate sexual function0 (group 3). The distributions were stable one year after RC (65%, 21%, and 14% for the 3 groups, respectively). Analyzing transitions between preop grouping and at 1 year revealed that 44% of patients with adequate sexual function (group 3) remained unchanged. In group 2, 33% remained in the same category, while 21% transitioned to group 3. For patients reporting no sexual activity pre-op, 87% remained in the same category at 1 year, but 8% and 5% transitioned to groups 2 & 3 respectively. Being married was significantly associated with sexual function after surgery (p<0.001). No significant association was found based on the type of urinary diversion, vaginal reconstruction, or neoadjuvant chemotherapy. CONCLUSIONS: Although a large proportion of females are not sexually active either before or after RC, one third of patients in this study maintained sexual function, with a small proportion demonstrating improvement at 1 year. Enhanced understanding of pre-op and post-op sexual function can lead to improved peri-operative counseling & surgical planning for sexually active females undergoing RC.

Sarcopenia as a marker for prediction of long-term survival following radical cystectomy.

435 Background: Patients undergoing radical cystectomy (RC) face a relevant risk of tumor relapse and mortality based on variable factors. Risk stratification may be enhanced by objective measures such as sarcopenia (loss of skeletal muscle mass) which has been described as a potential biomarker associated with survival after radical cystectomy. However, data on this highly interesting biomarker in conjunction with urothelial carcinoma of the bladder are sparse. Methods: A retrospective study including patients that were treated with RC at Hannover Medical School between 2005 and 2011 were included. The lumbar skeletal muscle index (SMI) was measured on preoperative computed tomography (CT) which was performed within 60 days prior to surgery. MeVisLab 2.7 was used to perform calculations. The fat mass index (FMI) was calculated based on the same CT slides. The body mass index (BMI) was used as a comparative value. Cut off points were developed for men and women separately. Results: Indices were measured o...

Correlation of the clinical frailty scale with long-term survival after radical cystectomy.

314 Background: Demographic changes account for an increasingly large proportion of elderly patients with urothelial carcinoma of the bladder. It remains under debate to which extent a patient might benefit from major surgery such as the radical cystectomy. Current tools for preoperative assessment of biological age might be of limited significance. The frailty concept, which refers to a biological syndrome of decreased reserve to stressors and resistance to stressors, has gained recent recognition for measuring patient’s physiological reserve and has been linked to adverse outcomes after surgery. Methods: Clinical, surgical and pathological data of patients undergoing radical cystectomy and lymph node dissection at Hannover Medical School with a minimum age of 60 years were retrospectively collected from 2000 to 2010. Frailty was assessed using the clinical frailty scale by Rockwood et al. derived from the Canadian Study of Health and Aging (CSHA). The relationship between frailty and various risk assess...