Neda Sadeghi

Immediate radical cystectomy vs conservative management for high grade cT1 bladder cancer: is there a survival difference?

Study Type – Aetiology (individual cohort)

Urine Exosomes for Non-Invasive Assessment of Gene Expression and Mutations of Prostate Cancer.

Purpose The analysis of exosome/microvesicle (extracellular vesicles (EVs)) and the RNA packaged within them (exoRNA) has the potential to provide a non-invasive platform to detect and monitor disease related gene expression potentially in lieu of more invasive procedures such as biopsy. However, few studies have tested the diagnostic potential of EV analysis in humans. Experimental Design The ability of EV analysis to accurately reflect prostate tissue mRNA expression was examined by comparing urinary EV TMPRSS2:ERG exoRNA from pre-radical prostatectomy (RP) patients versus corresponding RP tissue in 21 patients. To examine the differential expression of TMPRSS2:ERG across patient groups a random urine sample was taken without prostate massage from a cohort of 207 men including prostate biopsy negative (Bx Neg, n = 39), prostate biopsy positive (Bx Pos, n = 47), post-radical prostatectomy (post-RP, n = 37), un-biopsied healthy age-matched men (No Bx, n = 44), and young male controls (Cont, n = 40). The use of EVs was also examined as a potential platform to non-invasively differentiate Bx Pos versus Bx Neg patients via the detection of known prostate cancer genes TMPRSS2:ERG, BIRC5, ERG, PCA3 and TMPRSS2. Results In this technical pilot study urinary EVs had a sensitivity: 81% (13/16), specificity: 80% (4/5) and an overall accuracy: 81% (17/21) for non-invasive detection of TMPRSS2:ERG versus RP tissue. The rate of TMPRSS2:ERG exoRNA detection was found to increase with age and the expression level correlated with Bx Pos status. Receiver operator characteristic analyses demonstrated that various cancer-related genes could differentiate Bx Pos from Bx Neg patients using exoRNA isolated from urinary EVs: BIRC5 (AUC 0.674 (CI:0.560–0.788), ERG (AUC 0.785 (CI:0.680–0.890), PCA3 (AUC 0.681 (CI:0.567–0.795), TMPRSS2:ERG (AUC 0.744 (CI:0.600–0.888), and TMPRSS2 (AUC 0.637 (CI:0.519–0.754). Conclusion This pilot study suggests that urinary EVs have the potential to be used as a platform to non-invasively differentiate patients with prostate cancer with very good accuracy. Larger studies are needed to confirm the potential for clinical utility.

Predictors of locally advanced and metastatic disease in patients with small renal masses

Study Type – Prognosis (case series)

Does absolute neutrophil count predict high tumor grade in African‐American men with prostate cancer?

African‐Americans (AA) are at risk for benign ethnic neutropenia (BEN), which has been implicated as a potential source of disparity in cancer outcomes among AAs. Since AAs with prostate cancer (PCa) are more likely to have aggressive pathological features, this investigation sought to determine if absolute neutrophil count (ANC) is associated with adverse pathologic findings at radical prostatectomy (RP) within a cohort of AA men.

Urinary exosomes as a stable source of mRNA for prostate cancer analysis.

174 Background: Exosomes are novel lipid bilayer vesicles that are released into biofluids such as urine and carry high integrity RNA from the parent cell which they were derived. Due to their unique stability and the fact that they contain prostate specific mRNA transcripts, we examined their potential as a non-invasive source of mRNA biomarkers for prostate cancer analysis. METHODS Following a Columbia University approved IRB protocol, random urine samples were collected from 163 men who were stratified into 4 groups: biopsy negative (Bx Neg, n=39), biopsy positive (Bx Pos, n=47), post-radical prostatectomy (RP, n=37) and controls (males <35 yrs, n=40). Urine samples were stored at 4°C and 0.8 μm filtration was used to remove whole cells and debris. Urinary exosomal RNA was isolated using our in-house technique. RT-qPCR was used to analyze PSA, PCA3, androgen receptor (AR), survivin, NCOA2, RAD21, transmembrane protease serine 2 (TMPRSS2), ERG and TMPRSS2:ERG fusion at the mRNA level. RESULTS Mean serum PSA protein level and age were similar in the Bx Neg and Bx Pos groups. Relative quantitation (RQ) of genes standardized to the PSA gene revealed that ERG (P<0.005), PCA3 (P<0.005), TMPRSS2:ERG fusion (P<0.05), TMPRSS2 (P<0.05) and survivin (P<0.005) were significantly increased in the Bx Pos vs. Bx Neg group. TMPRSS2:ERG fusion events occurred in 68% of Bx Pos vs. 44% of Bx Neg patients and were present in only 5% of controls. No patient in the RP group had positive TMPRSS2:ERG detection; this finding was further supported by the loss of TMPRSS2:ERG expression for 4 Bx Pos patients following prostatectomy suggesting specificity of the fusion event to the prostate. CONCLUSIONS This study confirms urinary exosomes as a source of high quality RNA and showed significant differences in the expression of ERG, PCA3, TMPRSS2:ERG genes between the Bx Pos and Bx Neg groups. Our findings are consistent with previous studies based on tissue and post-prostate massage urinary cell analyses. The unique stability and yield of urinary exosomal RNA collected without a prostatic massage will hopefully simplify sample handing, obviate sample variability and patient discomfort inherent to prostate massage, and broaden the role of exosomes in future diagnostic testing.

Management of residual non-retroperitoneal disease following chemotherapy for germ cell tumor

Over the past 20 years, it is estimated that approximately 195,969 patients were diagnosed with testicular cancer in the United States and that 22,144 of those patients had non-retroperitoneal (non-RP) metastases at the time of diagnosis. Although most patients with testicular cancer can be cured with platinum-based systemic chemotherapy, 35% of patients with Stage III/IV disease will have residual non-RP masses after treatment. The management paradigms for residual, non-RP disease following chemotherapy for nonseminomatous germ cell tumor are influenced by the site of metastases as well as whether there is concordant histology between the testicle and the metastatic site. Although retroperitoneal lymph node dissection findings such as the presence of fibrosis only are helpful indicators of concordant histology, no set of criteria provides a perfect prediction such that the risk of residual teratoma or viable GCT outside the retroperitoneum is eliminated. This acknowledgement, in conjunction with the long-term survival data favoring resection, establishes that surgical resection remains an important part of the management of patients with non-RP residual masses.

Renal Cortical Neoplasms and Associated Renal Functional Outcomes

In 2010 alone there were an estimated 54,000 new diagnoses and 12,000 deaths attributable to renal cell carcinoma (RCC), with the vast majority of these tumors consituting small renal masses incidentially detected on cross-sectional imaging.(2010; Chow, Dong, and Devesa, 2010) Renal cortical tumors include a complex family of neoplasms with unique histology, cytogenetic effects, and metastatic potential; the differential presentation of symptomatic, locally advanced disease as opposed to small renal tumors (median tumor size <4cm, T1a) evokes different management paradigms.(Lee et al., 2010; McKiernan et al., 2002b; Mitchell et al., 2006; Russo et al., 2002) This large subcategory of patients with localized RCC have historically been treated with radical nephrectomy, and this management has continued in many regions of the United Stes and the world.(Hollenbeck et al., 2006) Nevertheless, a paradigm shift has occured in the surgical management of renal cortical tumors over the last 10 years, favoring nephron-sparing surgery or partial nephrecotmy whenever this approach is feasible from a technical and oncologic standpoint. The rationale underpinning this shift has involved the observed non-inferiority in terms of cancer control and operative morbidity as well as the superior renal functional outcomes. Within the neprhology and urology communities, the last decade has also witnessed a increased understanding of how renal volume effects renal function, and how this in turn affects cardiovascular competence. It now is evident that having less renal parenchyma does not only worsen renal function, but it also is a poor prognosticator of cardiac function and overall survival. It is within this context that a review of renal functional outcomes following surgery for renal coritcal tumors can be undertaken.

1996 AGE AND GENDER PREDICTS RISK OF NON-LOCALIZED DISEASE IN SMALL RENAL TUMORS ≤3CM IN SIZE IN THE UNITED STATES FROM 1988–2007

INTRODUCTION AND OBJECTIVES: It is thought that patients with small renal masses (SRMs) have a negligible risk of metastases. However, recent publications have shown there to be a significant burden of metastatic RCC (mRCC) even in masses 3cm. The aim of this study was to assess the prevalence and characteristics of mRCC in the US population with SRMs to help identify patients at risk for non-localized disease. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) registry we identified 14,962 patients diagnosed between 1988-2007 with renal cell carcinoma (RCC) 3cm in size. Patients were separated by stage into metastatic, locally advanced, and localized disease. Differences in baseline characteristics amongst patients in these 3 groups were assessed. After controlling for age, sex, grade, tumor size, and year of surgery, a logistic regression analysis was performed to determine likelihood of having non-localized disease. RESULTS: In the SEER cohort, 13,574 (90.7%) patients with RCC 3cm were diagnosed with localized disease, 938 (6.3%) patients had invasion beyond the kidney into regional lymph nodes or nearby organs, and 450 (3.0%) patients had distant metastasis. Patients with metastasis were older (65.9 years) compared to those with localized disease (59.5 years) (p .001). The rate of metastatic disease was higher in patients with tumors 2.5–3.0cm (4.3%) compared with tumors 2.5cm (2.4%). Independent preoperative predictors of having more aggressive disease at diagnosis (locally advanced/metastatic) included older age, particularly age 70 (OR: 2.46; 95% CI: 2.06–2.92), male sex(OR: 1.50; 95% CI: 1.33–1.70), and tumor size 2.5 (OR: 1.41; 95% CI: 1.25–1.58). CONCLUSIONS: A small subset (3%) of patients in the US with RCC 3cm have distant metastasis. Older patients, men, and those with tumors 2.5-3cm are more likely to present with regionally advanced and metastatic disease despite having a mass 3cm. As the incidence of SRMs is increasing and active surveillance protocols are becoming more commonplace, clinician’s should be aware of characteristics associated with advanced disease.

1746 IMMEDIATE RADICAL CYSTECTOMY VERSUS CONSERVATIVE MANAGEMENT OF HIGH GRADE CT1N0M0 BLADDER CANCER: IS THERE A SURVIVAL DIFFERENCE?

INTRODUCTION AND OBJECTIVES: Intravesical therapy (IVT) and advancements in endoscopic techniques have made bladder preservation a viable option for patients with high grade (HG) T1 bladder cancer. This study sought to examine whether a survival difference exists between patients receiving an immediate radical cystectomy (IRC) as opposed to those choosing bladder preservation. METHODS: Between 1/1986 and 8/2010, 331 patients were identified with HG cT1N0M0 transition cell carcinoma (TCC) according to the 2004 WHO classification. Patients were divided into two groups: those who underwent IRC, and those who opted for bladder preservation. IRC was defined as surgery within 90 days of HG T1 diagnosis with no intervening IVT. Patients within the non-operative group may have gone on to have a RC. Conservative management (CM) patients were evaluated by the number of IVT cycles received, whereby each “cycle” was defined as a trial with a different agent or a period of induction, maintenance, or salvage therapy with any given agent. Kaplan-Meier and log-rank analysis were used to compare the diseasespecific survival (DSS) between groups. RESULTS: In a cohort of 331 patients with HG cT1N0M0 bladder cancer, a total of 94 patients underwent IRC, and 237 opted for CM. The mean follow-up was 48.9 / 45.5 mo, and there was a larger proportion of men in the IRC cohort as compared to the CM group (83 vs 71%; p 0.028). No statistical differences in known pathological risk factors for progression were observed between the groups. 62 patients who originally had CM ultimately underwent radical surgery because of BCG failure or clinical progression. In the nonoperative group 74 patients had TURBT alone; a total of 91 received combined TURBT and IVT, with a median of 1 cycle (1-7) received. A significant trend toward bladder preservation was noted in a subset analysis of patterns in treatment over time (p 0.001). In a multivariable model controlling for the aforementioned clinical and pathologic variables, the CM cohort had a 2.25 fold increase in the risk of death from bladder cancer (HR 2.25, CI 1.10–4.57, p 0.025) compared to the IRC group. Further delineation of factors predicting mortality among conservatively managed patients are in abstract #1103034. CONCLUSIONS: Bladder-preservation for patients with HG T1 TCC is becoming more common in the current era. However, after controlling for differences between the two subsets of patients, conservative management is independently associated which a higher risk of cancer-related death compared to IRC.

Abstract C133: The use of exosomal mRNA for noninvasive transcriptional analysis of the prostate.

Background: Prostate cancer studies have used urine as a non-invasive source of nucleic acids for biomarker analysis. These studies have been limited by the need for a digital rectal exam (DRE) or prostate massage prior to urine collection to enable enough cellular material for RNA analysis. Such manipulations can potentially lead to variability in assay performance depending on DRE intensity and may also reduce compliance. Here we investigate the novel use of RNA in urinary exosomes, small lipid bilayer vesicles released from cells into bodily fluids, to analyze previously identified prostate cancer mRNA biomarkers without a prostate massage. Methods: Random urine samples (>20ml) were collected from 207 consecutive patients under a Columbia University IRB approved prospective protocol. Patients were stratified into 5 groups: TRUS biopsy negative (Bx Neg, n=39), TRUS biopsy positive (Bx Pos, n=47), post-radical prostatectomy (RP, n=37), no TRUS biopsy (No Bx, n=44) and control (healthy males Results: All groups were age matched except for control males ( Conclusion: This study confirms that urinary exosomes are a novel source of high quality RNA to examine prostate gene expression. We demonstrate that expression levels of ERG, PCA3, TMPRSS2:ERG, TMPRSS2 and survivin are significantly higher in cases of confirmed prostate cancer, consistent with previous studies using prostate biopsies and/or urinary cells collected after DRE/prostate massage. The unique stability and yield of urinary exoRNA collected without the need for a prostatic massage will hopefully simplify sample handing, obviate sample variability and patient discomfort inherent to prostate massage, and broaden the role of exosomes in future diagnostic testing. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr C133.