Pablo Gomez

Radionuclide bone scintigraphy in patients with biochemical recurrence after radical prostatectomy: when is it indicated?

To evaluate the use of radionuclide bone scintigraphy following biochemical recurrence after radical retropubic prostatectomy (RRP) for localized prostate cancer.

Comparison of the prognostic potential of hyaluronic acid, hyaluronidase (HYAL‐1), CD44v6 and microvessel density for prostate cancer

Despite the development of nomograms designed to evaluate a prostate cancer (PCa) patients prognosis, the information has been limited to PSA, clinical stage, Gleason score and tumor volume estimates. We compared the prognostic potential of 4 histologic markers, hyaluronic acid (HA), HYAL‐1‐type hyaluronidase (HAase), CD44v6 and microvessel density (MVD) using immunohistochemistry. HA is a glycosaminoglycan that promotes tumor metastasis. CD44 glycoproteins serve as cell surface receptors for HA, and the CD44v6 isoform is associated with tumor metastasis. HYAL‐1‐type HAase is expressed in tumor cells and, like other HAases, degrades HA into angiogenic fragments. Archival PCa specimens (n = 66) were obtained from patients who underwent radical prostatectomy for clinically localized PCa and had a minimum follow‐up of 72 months (range 72–131 months, mean 103 months). For HA, HYAL‐1 and CD44v6 staining and MVD determination, a biotinylated HA‐binding protein, an anti‐HYAL‐1 IgG, an anti‐CD44v6 IgG and an anti‐CD34 IgG were used, respectively. HA and HYAL‐1 staining was classified as either low‐ or high‐grade. CD44v6 staining and MVD were evaluated quantitatively and then grouped as either low‐ or high‐grade. Using 72 months as the cut‐off limit for evaluating biochemical recurrence, HA, HYAL‐1, combined HA–HYAL‐1, CD44v6 and MVD staining predicted progression with 96%, 84%, 84%, 68% and 76% sensitivity, respectively. Specificity was, 61% (HA), 80.5% (HYAL‐1), 87.8% (HA–HYAL‐1), 56.1% (CD44v6) and 61% (MVD). Sensitivity and specificity values for each marker did not change significantly in a subset of 45 patients for whom follow‐up of longer than 112 months was available. In univariate analysis using the Cox proportional hazards model, preoperative PSA, Gleason sum, margin status, seminal vesicle, extraprostatic extension (EPE), HA, HYAL‐1, HA–HYAL‐1 and MVD, but not CD44v6, age and clinical stage, were significant in predicting biochemical recurrence (p < 0.05). In multivariate analysis using stepwise selection, only preoperative PSA (hazard ratio/unit PSA change = 1.086, p < 0.0001), EPE (hazard ratio = 6.22, p = 0.0016) and HYAL‐1 (hazard ratio = 8.196, p = 0.0009)/HA–HYAL‐1 (hazard ratio = 5.191, p = 0.0021) were independent predictors of biochemical recurrence. HA was an independent predictor of prognosis if HYAL‐1 staining inference was not included in the multivariate model. In our retrospective study with 72‐ to 131‐month follow‐up, EPE, preoperative PSA and HYAL‐1 either alone or together with HA (i.e., combined HA–HYAL‐1) were independent prognostic indicators for PCa.

Small cell carcinoma of the bladder.

(a) Derivation from the amine precursor uptake and decarboxylation (APUD) system. APUD cells are ubiquitous neuroendocrine cells next to the basal lamina of epithelial surfaces including the bladder [6]. These cells contain dense cytoplasmic granules thought to be the origin of peptide-hormone secretion. Such neurosecretory granules may also be identified in SCC. The prevalence of neurosecretory granules as well as neuroendocrine markers in SCC prompted many authors to believe that extrapulmonary SCC derives from APUD cells [3–6]. APUD cells are known to give rise to adenomas, carcinomas and carcinoid-like tumours. Despite the morphological similarity between APUD cells and some SCCs, this theory fails to explain the finding that a high proportion of extrapulmonary SCC coexist with malignancies of epithelial origin such as TCC [2].

Cyclooxygenase-2 (cox-2) expression is an independent predictor of prostate cancer recurrence

Lack of reliable prognostic markers hinders accurate prediction of disease progression in prostate cancer. The inducible proinflammatory enzyme cyclooxygenase‐2 (COX‐2) is implicated in prostate carcinogenesis, but its role in cancer progression is less clear. We examined whether COX‐2 expression evaluated by immunohistochemistry (IHC) in radical prostatectomy (RP) specimens can predict biochemical recurrence. Archival prostate cancer specimens (n = 60) were obtained from patients who underwent RP, but had not received neoadjuvant hormonal therapy. Twenty‐three patients had biochemical or clinical recurrence (mean time of recurrence: 38.2 months), and 37 patients were recurrence free (mean follow‐up: 95 months). COX‐2 expression was determined by IHC, using an anti‐COX‐2 antibody. Three individuals scored the staining independently, as high‐ or low‐expression. COX‐2 was expressed in prostate cancer cells, in adjacent normal glands and in specimens from patients who later progressed. At 62‐months follow‐up, COX‐2 staining predicted progression with 82.4% sensitivity and 81.3% specificity. Sensitivity (86.4%) and specificity (86.7%) improved at ≥ 100‐months follow‐up. In univariate analysis, Gleason score, preoperative PSA, extraprostatic extension, margin, seminal vesicle invasion, and high COX‐2 expression were significant predictors of biochemical recurrence (p < 0.05). In multivariate analysis, preoperative PSA (hazard ratio/unit PSA change 1.080; p = 0.0036) and COX‐2 expression (hazard ratio 16.442; p < 0.0001) were independent prognostic indicators. Patients with PSA > 7 ng/ml and high COX‐2 expression had the highest probability of recurrence (Kaplan‐Meier analysis). COX‐2 expression is an independent predictor of prostate cancer progression following RP and underscores the significance of inflammatory factors in this process.

Urethral recurrence after cystoprostatectomy: Implications for urinary diversion and monitoring

OBJECTIVES To review our cystoprostatectomy (CP) database to determine the urethral recurrence rate. Urethral recurrence after CP has been reported to occur in up to 10% of patients. Recent data have suggested a much lower incidence. This has important implications when considering the type of urinary diversion and postoperative monitoring. METHODS We retrospectively analyzed our single-surgeon, consecutive CP series and determined the urethral recurrence rate and prognostic factors for recurrence. Urethrectomy was performed at CP if the prostatic apical margin was positive for carcinoma. All patients were followed up quarterly for 2 years and then semiannually. Urethral wash cytology was obtained if the patient had an ileal conduit. Cytology and cystoscopy were performed if they had an orthotopic neobladder. RESULTS A total of 226 men had undergone radical CP. The mean age for all patients was 69 years. Eight (3.5%) had undergone urethrectomy at CP. The mean follow-up was 42 months for the remaining 218 patients, of whom 108 had an orthotopic neobladder and 110 had supravesical diversion. Of the 218 patients, 8 (3.7%) developed urethral recurrence, 7 (6.4%) in the 110 who had undergone supravesical diversion and 1 in the 108 (0.9%) who had an orthotopic neobladder. Seven patients underwent urethrectomy for the recurrence and had no evidence of disease at last follow-up. One patient died of metastatic transitional cell carcinoma at 61 months. CONCLUSIONS In our series, the risk of urethral recurrence after radical CP was low. The risk was substantially lower for patients who had an orthotopic neobladder. Our results show that urethrectomy at CP is rarely necessary because the proximal urethral margin is usually free of cancer. An orthotopic neobladder can therefore be safely considered in most patients. Delayed urethrectomy can be safely performed in those few patients with isolated urethral recurrence without compromising their survival.

Upper tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: incidence and risk factors.

The considerable experience of the University of Miami in treating TCC is reviewed in the first article in this section. The authors found that the incidence of upper tract tumour after radical cystectomy for TCC is low, but that patients with prostatic urethral involvement at cystectomy have a greater risk of developing upper tract tumours.

HYAL1-v1, an alternatively spliced variant of HYAL1 hyaluronidase: a negative regulator of bladder cancer.

Tumor cells express HYAL1 hyaluronidase, which degrades hyaluronic acid. HYAL1 expression in bladder cancer cells promotes tumor growth, invasion, and angiogenesis. We previously described five alternatively spliced variants of HYAL1 that encode enzymatically inactive proteins. The HYAL1-v1 variant lacks a 30-amino acid sequence that is present in HYAL1. In this study, we examined whether HYAL1-v1 expression affects bladder cancer growth and invasion by stably transfecting HT1376 bladder cancer cells with a HYAL1-v1 cDNA construct. Although HYAL1-v1 transfectants expressed equivalent levels of enzymatically active HYAL1 protein when compared with vector transfectants, their conditioned medium had 4-fold less hyaluronidase activity due to a noncovalent complex formed between HYAL1 and HYAL1-v1 proteins. HYAL1-v1 transfectants grew 3- to 4-fold slower due to cell cycle arrest in the G(2)-M phase and increased apoptosis. In HYAL1-v1 transfectants, cyclin B1, cdc2/p34, and cdc25c levels were > or =2-fold lower than those in vector transfectants. The increased apoptosis in HYAL1-v1 transfectants was due to the extrinsic pathway involving Fas and Fas-associated death domain up-regulation, caspase-8 activation, and BID cleavage, leading to caspase-9 and caspase-3 activation and poly(ADP-ribose) polymerase cleavage. When implanted in athymic mice, HYAL1-v1-expressing tumors grew 3- to 4-fold slower and tumor weights at day 35 were 3- to 6-fold less than the vector tumors (P < 0.001). Whereas vector tumors were infiltrating and had high mitoses and microvessel density, HYAL1-v1 tumors were necrotic, infiltrated with neutrophils, and showed low mitoses and microvessel density. Therefore, HYAL-v1 expression may negatively regulate bladder tumor growth, infiltration, and angiogenesis.

Hyaluronic Acid and HYAL-1 in Prostate Biopsy Specimens: Predictors of Biochemical Recurrence

PURPOSE Molecular markers could aid prostate specific antigen, biopsy Gleason sum and clinical stage to provide accurate information on prostate cancer progression. HYAL-1 hyaluronidase and hyaluronic acid staining in prostatectomy specimens predicts biochemical recurrence. We examined whether hyaluronic acid and HYAL-1 staining in biopsy specimens predicts biochemical recurrence and correlates with staining in matched prostatectomy specimens. MATERIALS AND METHODS Biopsy and prostatectomy specimens were obtained from 61 patients with clinically localized prostate cancer from multiple centers, including 23 with (group 1) and 38 without (group 2) biochemical recurrence. Mean followup was 103.1 months. Biotinylated hyaluronic acid binding protein and anti-HYAL-1 antibody were used for hyaluronic acid and HYAL-1 staining, respectively. Staining was graded between 0 and 300 depending on staining intensity and area. RESULTS HYAL-1 and hyaluronic acid were expressed in tumor cells and stroma, respectively. In biopsy specimens HYAL-1 and hyaluronic acid expression was higher in group 1 than in group 2 (203.9 and 182.1 vs 48.8 and 87.0, respectively, p <0.0001). On univariate analysis hyaluronic acid, HYAL-1, biopsy Gleason and prostate specific antigen significantly predicted biochemical recurrence (p <0.001). On multivariate analysis only HYAL-1 staining independently predicted recurrence with an accuracy of 81.8% (p <0.001). In prostatectomy specimens only HYAL-1 staining correlated with staining in biopsy specimens (Spearman rho = 0.72, p = 0.0002) and predicted biochemical recurrence. CONCLUSIONS To our knowledge this is the first report that HYAL-1 staining in biopsy specimens is an independent predictor of biochemical recurrence. This may be useful when selecting treatment.

Prostatic involvement by urothelial carcinoma of the bladder: Clinicopathological features and outcome after radical cystectomy

To review the long‐term outcome of prostatic involvement in patients with bladder cancer (BC) treated with radical cystectomy (RC), as urothelial carcinoma (UC) involving the prostate occurs in such patients, and prostatic invasion by UC is by transmural invasion (contiguous), or when UC develops from the epithelium of the prostatic urethra (not contiguous).

Epigenetic Regulation of HYAL-1 Hyaluronidase Expression IDENTIFICATION OF HYAL-1 PROMOTER

HYAL-1 (hyaluronoglucosaminidase-1) belongs to the hyaluronidase family of enzymes that degrade hyaluronic acid. HYAL-1 is a marker for cancer diagnosis and a molecular determinant of tumor growth, invasion, and angiogenesis. The regulation of HYAL-1 expression is unknown. Real time reverse transcription-PCR using 11 bladder and prostate cancer cells and 69 bladder tissues showed that HYAL-1 mRNA levels are elevated 10–30-fold in cells/tissues that express high hyaluronidase activity. Although multiple transcription start sites (TSS) for HYAL-1 mRNA were detected in various tissues, the major TSS in many tissues, including bladder and prostate, was at nucleotide 27274 in the cosmid clone LUCA13 (AC002455). By analyzing the 1532 base sequence 5′ to this TSS, using cloning and luciferase reporter assays, we identified a TACAAA sequence at position -31 and the minimal promoter region between nucleotides -93 and -38. Mutational analysis identified that nucleotides -73 to -50 (which include overlapping binding consensus sites for SP1, Egr-1, and AP-2), bases C-71 and C-59, and an NFκB-binding site (at position -15) are necessary for promoter activity. The chromatin immunoprecipitation assay identified that Egr-1, AP-2, and NFκB bind to the promoter in HYAL-1-expressing cells, whereas SP1 binds to the promoter in non-HYAL-1-expressing cells. 5-Aza-2′-deoxycytidine treatment, bisulfite DNA sequencing, and methylation-specific PCR revealed that HYAL-1 expression is regulated by methylation at C-71 and C-59; both Cs are part of the SP1/Egr-1-binding sites. Thus, HYAL-1 expression is epigenetically regulated by the binding of different transcription factors to the methylated and unmethylated HYAL-1 promoter.