Michael Autenrieth

Intravesical α-Radioimmunotherapy with 213Bi-Anti-EGFR-mAb Defeats Human Bladder Carcinoma in Xenografted Nude Mice

Transurethral resection of urothelial carcinoma often results in tumor recurrence due to disseminated tumor cells. Therefore, new therapeutic strategies are urgently needed. The aim of this study was to establish an orthotopic human bladder carcinoma mouse model using the epidermal growth factor receptor (EGFR)–overexpressing bladder carcinoma cell line EJ28 and to compare therapeutic efficacy of intravesically instilled α-particle–emitting 213Bi-anti-EGFR-monoclonal antibody (mAb) with mitomycin C. Methods: Female Swiss nu/nu mice were intravesically inoculated with luciferase-transfected EJ28 human bladder carcinoma cells after the induction of urothelial lesions by electrocautery. At different time points after cell inoculation, mice were treated intravesically with 213Bi-anti-EGFR-mAb, mitomycin C, or unlabeled anti-EGFR-mAb. Tumor development and therapeutic response were evaluated via bioluminescence imaging. Results: Mice without therapy and those treated with unlabeled anti-EGFR-mAb reached a median survival of 41 d and 89 d, respectively. Mice that underwent therapy with 0.925 MBq of 213Bi-anti-EGFR-mAb 1 h, 7 d, or 14 d after cell instillation survived more than 300 d in 90%, 80%, and 40% of the cases, respectively. Therapy with 0.37 MBq 1 h or 7 d after tumor cell inoculation resulted in survival of more than 300 d in 90% and 50% of mice, respectively. Mitomycin C treatment after 1 h and 7 d prolonged survival to more than 300 d in 40% and 50%, respectively; however, treatment turned out to be nephrotoxic. In contrast, no signs of nephrotoxicity could be observed after 213Bi-anti-EGFR-mAb treatment. Conclusion: The study suggests that radioimmunotherapy using intravesically instilled 213Bi-anti-EGFR-mAb is a promising option for treatment of bladder cancer in patients.

Topography of Lymph Node Metastases in Prostate Cancer Patients Undergoing Radical Prostatectomy and Extended Lymphadenectomy: Results of a Combined Molecular and Histopathologic Mapping Study

BACKGROUND To determine the anatomic extent of pelvic lymph node dissection (PLND) in prostate cancer (PCa) patients at the time of radical prostatectomy (RP), knowledge about the topography of lymph node (LN) metastases is required. OBJECTIVE Because small-volume LN metastases may be missed by standard histopathologic examination, we performed an anatomic mapping study combining molecular and histopathologic LN examination in PCa patients treated with RP and extended PLND (ePLND). DESIGN, SETTING, AND PARTICIPANTS A total of 52 patients with intermediate- (n=15) and high-risk (n=37) PCa underwent RP and ePLND without neoadjuvant treatment. ePLND included dissection of the obturator fossa and the external, internal, and common iliac vessels. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS LNs ≥3 mm in diameter were analysed by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) for prostate-specific antigen (PSA) expression and by standard histopathology. Topography of positive LNs was determined descriptively. RESULTS AND LIMITATIONS Of 1469 dissected LNs (median: 27 LNs per patient), 1186 LNs were ≥3 mm. Molecular LN analysis was positive in 127 LNs of 27 patients (52%) including 32 LNs of 12 patients (23%) with histopathologic positive LNs. Molecular examination was negative in 3 of 35 histopathologic positive LNs (9%). Combining both molecular and histopathologic findings, positive LNs were located in the standard PLND field defined by obturator fossa and external iliac vessels in 71%, along the internal iliac vessels in 16%, and along the common iliac vessels in 13%. Of LN-positive patients, 63% had LN metastases outside the standard PLND field. The internal iliac field was involved in 48% and the common iliac field in 37% of node-positive patients. Notably, internal and common iliac vessels were the only positive regions in 7% and 11% of node-positive patients, respectively. A limitation is the small number of patients included. CONCLUSIONS These findings underline the enhanced sensitivity of qRT-PCR in comparison with standard histopathology for detection of small-volume LN metastases in PCa patients. Our results support an ePLND including the common iliac vessels, at least up to the ureteral crossing, to optimise nodal staging and to remove LNs potentially harbouring metastases.

[Muscle-invasive urothelial carcinoma of the bladder. Detection and topography of micrometastases in lymph nodes].

Detection of metastases in lymph nodes is an important prognostic factor for progression-free survival in bladder cancer patients. Patients undergoing radical cystectomy with pelvic lymphadenectomy are randomized in the LEA study (AUO AB 25/02) into two groups receiving standard (obturator and external nodes) or extended lymphadenectomy (complete pelvic nodes up to the inferior mesenteric artery).The aim of this study is the detection of lymph node metastases that are not identified with classic pathological methods using RT-PCR as a highly sensitive and specific method. For detection of occult disseminated tumor cells we analyze the expression of the tumor markers cytokeratin 20 (CK-20), uroplakin II (UP II), mucin 2 (MUC2), and mucin 7 (MUC7).We examined 315 lymph nodes from 19 cystectomy patients for the expression of CK-20. In 93 lymph nodes CK-20 expression was detected whereas only 18 lymph nodes were histopathologically positive. More than one third of CK-20-positive lymph node metastases were located outside the standard lymphadenectomy field. We did not detect any skip lesions. Follow-up data will validate if there is a correlation between detection of occult disseminated tumor cells and progression-free survival.

Muskelinvasives Urothelkarzinom der Harnblase

Detection of metastases in lymph nodes is an important prognostic factor for progression-free survival in bladder cancer patients. Patients undergoing radical cystectomy with pelvic lymphadenectomy are randomized in the LEA study (AUO AB 25/02) into two groups receiving standard (obturator and external nodes) or extended lymphadenectomy (complete pelvic nodes up to the inferior mesenteric artery).The aim of this study is the detection of lymph node metastases that are not identified with classic pathological methods using RT-PCR as a highly sensitive and specific method. For detection of occult disseminated tumor cells we analyze the expression of the tumor markers cytokeratin 20 (CK-20), uroplakin II (UP II), mucin 2 (MUC2), and mucin 7 (MUC7).We examined 315 lymph nodes from 19 cystectomy patients for the expression of CK-20. In 93 lymph nodes CK-20 expression was detected whereas only 18 lymph nodes were histopathologically positive. More than one third of CK-20-positive lymph node metastases were located outside the standard lymphadenectomy field. We did not detect any skip lesions. Follow-up data will validate if there is a correlation between detection of occult disseminated tumor cells and progression-free survival.

Fractionated intravesical radioimmunotherapy with 213Bi-anti-EGFR-MAb is effective without toxic side-effects in a nude mouse model of advanced human bladder carcinoma

Gold standard in therapy of superficial, non-muscle invasive urothelial tumors is transurethral resection followed by intravesical instillation therapies. However, relapse is commonly observed and therefore new therapeutic approaches are needed. Application of 213Bi-immunoconjugates targeting EGFR had shown promising results in early tumor stages. The aim of this study was the evaluation of fractionated application of 213Bi-anti-EGFR-MAb in advanced tumor stages in a nude mouse model. Luciferase-transfected EJ28 human bladder carcinoma cells were instilled intravesically into nude mice following electrocautery. Tumor development was monitored via bioluminescence imaging. One day after tumor detection mice were treated intravesically either 2 times with 0.93 MBq or 3 times with 0.46 MBq of 213Bi-anti-EGFR-MAb. Therapeutic efficacy was evaluated via overall survival and toxicity toward normal urothelium by histopathological analysis. Mice without treatment and those treated with the native anti-EGFR-MAb showed mean survivals of 65.4 and 57.6 d, respectively. After fractionated treatment with 0.93 MBq of 213Bi-anti-EGFR-MAb animals reached a mean survival of 141.5 d and 33% of the animals survived at least 268 d. Fractionated treatment with 0.46 MBq 213Bi-anti-EGFR-MAb resulted in a mean survival of 131.8 d and 30% of the animals survived longer than 300 d. Significant differences were only observed between the control groups and the group treated twice with 0.93 MBq of 213Bi-anti-EGFR-MAb. No toxic side-effects on the normal urothelium were observed even after treatment with 3.7 MBq of 213Bi-anti-EGFR-MAb. The study demonstrates that the fractionated intravesical radioimmunotherapy with 213Bi-anti-EGFR-MAb is a promising approach in advanced bladder carcinoma.

The significance of extended pelvic lymphadenectomy in bladder cancer

ZusammenfassungTrotz radikaler Zystektomie besteht beim invasiven Urothelkarzinom der Harnblase ein hohes systemisches Progressionsrisiko. Wahrscheinlichster Grund dafür ist eine zum Zeitpunkt der Operation bereits vorliegende lymphogene oder hämatogene Mikrometastasierung. Die ausgedehnte Lymphadenektomie zeigt in allen retrospektiven und hier zusammengefassten Studien einen deutlichen Überlebensvorteil sowohl für pN0- als auch pN +-Patienten. Auch scheinen die Lymphknoten-Density und Gesamtzahl der Lymphknotenmetastasen für das Überleben relevant zu sein. Prospektiv erhobene Daten aus einer randomisierte Studie werden allerdings erstmals mit Auswertung der inzwischen abgeschlossenen LEA-Studie vorliegen.AbstractDespite radical surgery, invasive urothelial carcinoma has a high risk of systemic progression. This might be due to the presence of occult but already disseminated tumor cells in lymph nodes, blood, or bone marrow. In all retrospective series presented here, extended pelvic lymphadenectomy seems to provide a clear benefit for survival in pN0 and pN+ patients. Lymph node density and absolute number of positive lymph nodes appear to affect patient outcome and survival. However, only the randomized, prospective German LEA study will hopefully provide conclusive new data.Despite radical surgery, invasive urothelial carcinoma has a high risk of systemic progression. This might be due to the presence of occult but already disseminated tumor cells in lymph nodes, blood, or bone marrow. In all retrospective series presented here, extended pelvic lymphadenectomy seems to provide a clear benefit for survival in pN0 and pN+ patients. Lymph node density and absolute number of positive lymph nodes appear to affect patient outcome and survival. However, only the randomized, prospective German LEA study will hopefully provide conclusive new data.

Stellenwert der extendierten pelvinen Lymphadenektomie beim Harnblasenkarzinom

ZusammenfassungTrotz radikaler Zystektomie besteht beim invasiven Urothelkarzinom der Harnblase ein hohes systemisches Progressionsrisiko. Wahrscheinlichster Grund dafür ist eine zum Zeitpunkt der Operation bereits vorliegende lymphogene oder hämatogene Mikrometastasierung. Die ausgedehnte Lymphadenektomie zeigt in allen retrospektiven und hier zusammengefassten Studien einen deutlichen Überlebensvorteil sowohl für pN0- als auch pN +-Patienten. Auch scheinen die Lymphknoten-Density und Gesamtzahl der Lymphknotenmetastasen für das Überleben relevant zu sein. Prospektiv erhobene Daten aus einer randomisierte Studie werden allerdings erstmals mit Auswertung der inzwischen abgeschlossenen LEA-Studie vorliegen.AbstractDespite radical surgery, invasive urothelial carcinoma has a high risk of systemic progression. This might be due to the presence of occult but already disseminated tumor cells in lymph nodes, blood, or bone marrow. In all retrospective series presented here, extended pelvic lymphadenectomy seems to provide a clear benefit for survival in pN0 and pN+ patients. Lymph node density and absolute number of positive lymph nodes appear to affect patient outcome and survival. However, only the randomized, prospective German LEA study will hopefully provide conclusive new data.Despite radical surgery, invasive urothelial carcinoma has a high risk of systemic progression. This might be due to the presence of occult but already disseminated tumor cells in lymph nodes, blood, or bone marrow. In all retrospective series presented here, extended pelvic lymphadenectomy seems to provide a clear benefit for survival in pN0 and pN+ patients. Lymph node density and absolute number of positive lymph nodes appear to affect patient outcome and survival. However, only the randomized, prospective German LEA study will hopefully provide conclusive new data.

Prognostic impact of PD-1 and its ligands in renal cell carcinoma

Programmed death-1 receptor (PD-1) and programmed death-1 receptor-ligand (PD-L1) have been suggested to play a role as prognostic markers in clear cell renal cell carcinoma (ccRCC). The association between PD-L1 and prognosis seems to be more robust than for PD-1. Further, preliminary analyses suggest that neither PD-1 nor its ligands play a role as prognostic markers in non-clear cell RCC, while the prognostic role of PD-L2 in ccRCC as well as in non-clear cell RCC remains unclear.

The ZOTECT study: Effect of zoledronic acid on bone metabolism in patients with bone metastases from prostate or breast cancer

Purpose The ZOTECT study assesses the effect of zoledronic acid (ZOL) on bone-marker levels and potential correlations with disease outcomes in bisphosphonate-naive patients. Methods This prospective, single-arm, open-label study in bisphosphonate-naive (≥6 months) patients with bone metastases from prostate cancer (PC; n=301) or breast cancer (BC; n=99) enrolled at 98 German sites (May 2006 to July 2008) investigated the effect of ZOL (4 mg intravenously every 4 weeks×4 months, with a final follow-up at 12 months) on bone-marker levels. Secondary assessments: skeletal-related event (SRE) rate, pain, quality of life (QoL), and prostate-specific antigen levels. Endpoints were assessed using summary statistics by visit/tumor type and Kaplan–Meier analyses. Results ZOL treatment significantly decreased bone-marker levels (amino-terminal propeptide of type I collagen [P1NP], C-terminal cross-linking telopeptide of type I collagen [CTX]; P<0.0001), and this decrease was maintained through the final 1-year follow-up visit. Baseline P1NP and CTX levels correlated with extent of bone disease (P<0.0001, each) and on-treatment decreases in marker levels. Skeletal disease burden and bone-marker levels were similar between PC and BC patients, and ZOL did not significantly influence osteoprotegerin/receptor activator of nuclear factor-κB ligand levels. Only 13 SREs occurred in 11 patients, supporting the known ZOL-mediated reduction in SREs. On-treatment bone-marker level changes did not correlate with SRE rate, pain scores, or QoL. Generally, ZOL was well tolerated and adverse events were consistent with its known safety profile. Conclusions This study confirms that ZOL therapy significantly reduces bone turnover (measured as P1NP and CTX levels) in patients with bone metastases from PC or BC.

Molecular Lymph Node Status for Prognostic Stratification of Prostate Cancer Patients Undergoing Radical Prostatectomy with Extended Pelvic Lymph Node Dissection

Purpose: Molecular lymph node (LN) analysis using quantitative polymerase chain reaction (qPCR) detects LN metastases with higher sensitivity than histopathology. However, the prognostic role of molecular LN status in prostate cancer patients treated with radical prostatectomy (RP) and extended pelvic LN dissection (ePLND) is unclear. To investigate the association of molecular compared with histopathologic LN status with biochemical recurrence. Experimental Design: Patients with intermediate and high-risk prostate cancer were prospectively enrolled and underwent RP with ePLND, including the obturator, internal, external, and the common iliac region. LNs ≥3 mm were bisected and examined by standard histopathology and qPCR for Kallikrein3 (KLK3) expression. Biochemical recurrence was defined by confirmed postoperative PSA > 0.2 ng/mL. Results: In 111 patients, 2,411 of 3,173 removed LNs were examined by both methods. Histopathology detected 68 LN metastases in 28 (25%) patients. Molecular analysis confirmed elevated KLK3 expression in 65 histopathologic LN metastases of all 28 pN1 patients (pN1/molN1) and additionally reclassified 224 histopathologic negative LNs and 32 (29%) pN0 patients as LN-positive (pN0/molN1). At a median follow-up of 48 months, 52 (47%) patients developed biochemical recurrence. Median biochemical recurrence-free survival was 9 months [95% confidence interval (CI), 0.0–20.1] in pN1/molN1 patients, 24 months (95% CI, 1.7–46.3) in pN0/molN1 patients and was not reached in pN0/molN0 patients (P < 0.001). On multivariable Cox regression analysis, molecular LN status [HR 4.1 (95% CI, 1.9–8.8), P < 0.001] but not histopathologic LN status [HR 1.5 (95% CI, 0.8–3.0), P = 0.198] was confirmed as independent predictor of biochemical recurrence. Conclusions: Molecular LN analysis identified pN0 patients with a high risk of biochemical recurrence and provided superior prognostic information in comparison with histopathology alone. Clin Cancer Res; 24(10); 2342–9. ©2018 AACR.