Trudy N. Jonges

In vivo bladder cancer diagnosis by high-volume Raman spectroscopy.

We studied the feasibility of Raman spectroscopy for the diagnosis of bladder cancer in vivo. Since the invasion stage is crucial for the treatment choice, a high-volume based Raman probe was used to investigate the potential of determining the invasiveness of bladder cancer. High quality spectra were obtained from suspicious and nonsuspicious bladder locations during the procedure of transurethral resection of bladder tumors (TURBT) with collection times of 1-5 s. Multivariate analysis was used to generate the classification models. The algorithm was able to distinguish bladder cancer from normal bladder locations with a sensitivity of 85% and a specificity of 79%. The Raman spectra of bladder cancer stages showed a gradual increase in the intensity of specific amino acid peaks and, most likely, an increase in the intensity of DNA peaks.

Testicular microlithiasis, a premalignant condition: prevalence, histopathologic findings, and relation to testicular tumor

OBJECTIVES To perform a retrospective analysis concerning the prevalence of testicular microlithiasis (TM). In patients with TM, the association of TM with testicular tumor, histopathologic findings, and follow-up were studied. METHODS During a 6-year period at the Central Military Hospital or the University Medical Center in Utrecht, The Netherlands, ultrasonography of the testis was performed in 1535 patients. Patient records, ultrasound images, and histopathologic specimens were reviewed. Follow-up was performed in patients with TM. RESULTS In 63 patients (4.1%), with a mean age of 35.4 years (range 19 to 74), TM was diagnosed at ultrasonography. In 29 of these patients (46%), a concomitant testicular tumor was diagnosed. A statistically significant correlation was found between TM and the presence of a testicular tumor (P <0.001; chi-square test). No significant correlation was found concerning the respective positions of the TM and the tumor in the testis, type of calcification, and histologic type of the tumor. In 34 patients, TM was found without a malignancy at diagnosis (mean age 39.2 years; range 19 to 69). Follow-up was possible in 31 patients. During the follow-up period (median 61.8 months), 1 patient developed a testicular tumor. CONCLUSIONS A correlation was found between TM and testicular tumor. Because an increasing number of studies have reported patients with TM who developed a testicular tumor, TM should be regarded as a premalignant condition, which necessitates follow-up. Urologists should consider testis biopsy in patients with TM.

Photodynamic Diagnosis (5-Aminolevulinic Acid) of Transitional Cell Carcinoma After Bacillus Calmette-Guérin Immunotherapy and Mitomycin C Intravesical Therapy

BACKGROUND Photodynamic diagnosis (PDD) is a technique that enhances the detection of occult bladder tumors during cystoscopy using a fluorescent dye. OBJECTIVE To study the differential effects of bacillus Calmette-Guérin (BCG) and mitomycin C (MMC) intravesical therapy on the false-positive rate of PDD of bladder cancer. DESIGN, SETTING, AND PARTICIPANTS This study included 552 procedures and 1874 biopsies. INTERVENTION Tumors were resected and biopsies were taken from suspicious areas, under guidance of white-light endoscopy and 5-ALA (5-aminolevulinic acid)-induced fluorescence cystoscopy. MEASUREMENTS The influence of intravesical BCG immunotherapy and intravesical MMC chemotherapy on pyuria, inflammation, and PDD specificity was examined in univariate analyses. RESULTS AND LIMITATIONS BCG significantly results in inflammation (odds ratio [OR]: 1.53, p=0.002), leukocyturia (OR: 1.84, p=0.034), and false positives in PDD (OR: 1.49, p=0.001). However, a single BCG instillation within 3 mo before PDD is most likely not associated with increased false-positive rates (OR: 0.35, p=0.26). Leukocyturia normalizes within 6 wk after the last BCG instillation, but PDD specificity is reduced up to 3 mo. CONCLUSIONS BCG is an important predictor for false positives in PDD (5-ALA). More than one BCG instillation within 3 mo before fluorescence cystoscopy decreases the specificity of PDD.

Expression and Localization of Hypoxia Proteins in Prostate Cancer: Prognostic Implications After Radical Prostatectomy

OBJECTIVES To uncover novel biomarkers that will help predict which patients are at risk and may guide future treatment decisions. A significant proportion of prostate cancer patients treated with radical prostatectomy will experience a recurrence of the disease. Given the substantial role of hypoxia in prostate cancer development and treatment, this investigation focuses on the Hypoxia Inducible Factor (HIF-1alpha) pathway. METHODS A tissue microarray was constructed of prostate cancer tissue collected from 71 patients undergoing radical prostatectomy. The expression of proteins involved in the HIF-1alpha pathway was investigated by an immunohistochemical approach and correlated to clinical features including the time to biochemical recurrence. RESULTS Expression of GLUT1 correlated significantly (P <.05) with a shorter time to biochemical recurrence after radical prostatectomy and was independent from the Gleason grade and stage of cancer. Furthermore, our studies revealed for the first time that accumulation of prolyl-4-hydroxylases 1 especially in the nucleus, is a significant indicator for a worse prognosis (P <.001). CONCLUSIONS This study confirms the upregulation of proteins involved in the HIF-1alpha hypoxia pathway in prostate cancer cells, indicative of a hypoxic tumor state. Importantly, we report the identification of 2 novel markers, GLUT1 and prolyl-4-hydroxylases 1, with prognostic significance for patients undergoing radical prostatectomy.

Genomic and transcriptomic plasticity in treatment-naïve ovarian cancer

Intra-tumor heterogeneity is a hallmark of many cancers and may lead to therapy resistance or interfere with personalized treatment strategies. Here, we combined topographic mapping of somatic breakpoints and transcriptional profiling to probe intra-tumor heterogeneity of treatment-naïve stage IIIC/IV epithelial ovarian cancer. We observed that most substantial differences in genomic rearrangement landscapes occurred between metastases in the omentum and peritoneum versus tumor sites in the ovaries. Several cancer genes such as NF1, CDKN2A, and FANCD2 were affected by lesion-specific breakpoints. Furthermore, the intra-tumor variability involved different mutational hallmarks including lesion-specific kataegis (local mutation shower coinciding with genomic breakpoints), rearrangement classes, and coding mutations. In one extreme case, we identified two independent TP53 mutations in ovary tumors and omentum/peritoneum metastases, respectively. Examination of gene expression dynamics revealed up-regulation of key cancer pathways including WNT, integrin, chemokine, and Hedgehog signaling in only subsets of tumor samples from the same patient. Finally, we took advantage of the multilevel tumor analysis to understand the effects of genomic breakpoints on qualitative and quantitative gene expression changes. We show that intra-tumor gene expression differences are caused by site-specific genomic alterations, including formation of in-frame fusion genes. These data highlight the plasticity of ovarian cancer genomes, which may contribute to their strong capacity to adapt to changing environmental conditions and give rise to the high rate of recurrent disease following standard treatment regimes.

Expression of nuclear FIH independently predicts overall survival of clear cell renal cell carcinoma patients.

AIM The hypoxia inducible factor (HIF) pathway plays an important role in sporadic clear cell renal cell carcinoma (ccRCC) by stimulating processes of angiogenesis, cell proliferation, cell survival and metastases formation. Herein, we evaluate the significance of upstream proteins directly regulating the HIF pathway; the prolyl hydroxylases domain proteins (PHD)1, 2 and 3 and factor-inhibiting HIF (FIH), as prognostic markers for ccRCC. METHODS Immunohistochemical marker expression was examined on a tissue microarray containing tumour tissue derived from 100 patients who underwent nephrectomy for ccRCC. Expression levels of HIF, FIH and PHD1, 2 and 3 were correlated with overall survival (OS) and clinicopathological prognostic factors. RESULTS HIF-1α was positively correlated with HIF-2α (p<0.0001), PHD1 (p = 0.024), PHD2 (p<0.0001), PHD3 (p = 0.004), FIH (p<0.0001) and VHL (p = 0.031). HIF-2α levels were significantly associated with FIH (p<0.0001) and PHD2 (p = 0.0155). Mutations in the VHL gene, expression variations of HIF-1α, HIF-2α and PHD1, 2, 3 did not show a correlation to OS or clinicopathological prognostic factors. Tumour stage, grade, diameter, metastastic disease and intensity of nuclear FIH were significantly correlated to OS in univariable analysis (p = 0.023). Low nuclear FIH levels remained a strong independent prognostic factor in multivariable analysis (p = 0.009). CONCLUSION These results show that low nuclear expression of FIH is a strong independent prognostic factor for a poor overall survival in ccRCC.

Mutations in LRRC50 Predispose Zebrafish and Humans to Seminomas

Seminoma is a subclass of human testicular germ cell tumors (TGCT), the most frequently observed cancer in young men with a rising incidence. Here we describe the identification of a novel gene predisposing specifically to seminoma formation in a vertebrate model organism. Zebrafish carrying a heterozygous nonsense mutation in Leucine-Rich Repeat Containing protein 50 (lrrc50 also called dnaaf1), associated previously with ciliary function, are found to be highly susceptible to the formation of seminomas. Genotyping of these zebrafish tumors shows loss of heterozygosity (LOH) of the wild-type lrrc50 allele in 44.4% of tumor samples, correlating with tumor progression. In humans we identified heterozygous germline LRRC50 mutations in two different pedigrees with a family history of seminomas, resulting in a nonsense Arg488* change and a missense Thr590Met change, which show reduced expression of the wild-type allele in seminomas. Zebrafish in vivo complementation studies indicate the Thr590Met to be a loss-of-function mutation. Moreover, we show that a pathogenic Gln307Glu change is significantly enriched in individuals with seminoma tumors (13% of our cohort). Together, our study introduces an animal model for seminoma and suggests LRRC50 to be a novel tumor suppressor implicated in human seminoma pathogenesis.

Urodynamic effects of transrectal intraprostatic Ona botulinum toxin A injections for symptomatic benign prostatic hyperplasia.

OBJECTIVE To investigate urodynamic, symptomatic, and histologic effects of intraprostatic injection with Ona botulinum toxin A for benign prostatic hyperplasia. METHODS Patients >55 years with symptomatic benign prostatic hyperplasia failing medical therapy were treated. Inclusion criteria were International Prostate Symptom Score >7, prostate volume 30-50 cm(3), and urodynamic bladder outlet obstruction >Schäfer grade 2. A transrectal intraprostatic injection of 200 IU Ona botulinum toxin A was given. Filling cystometry and pressure flow studies were performed at 3, 6, and 12 months post injection. International Prostate Symptom Score, International Prostate Symptom Score quality of life, prostate-specific antigen, and prostate volume were measured up until 12 months; prostate biopsies before and after Ona botulinum toxin A injection were done for histology and cell proliferation. RESULTS Fifteen men (mean age 64.9 years) were included. Ona botulinum toxin A injection was well tolerated with few complications. Postvoid residual improved (170 to 80 mL), but maximum flow rate and bladder outlet resistance parameters did not change during follow-up. International Prostate Symptom Score and International Prostate Symptom Score quality of life improved (22 to 13 and 5 to 2, respectively), whereas prostate-specific antigen and prostate volume remained unaltered. Cell proliferation did not decrease and in 37% and 64% of pre- and posttreatment biopsies, respectively, some degree of prostatitis was found. Ten of 15 patients eventually underwent transurethral prostate resection because of persisting symptoms. CONCLUSION Intraprostatic Ona botulinum toxin A for symptomatic benign prostatic hyperplasia did not affect urodynamic outcomes, except for postvoid residual. Although symptom scores improved, we were not able to show change in prostate volume, prostate-specific antigen, or histologic outcomes. A placebo effect of intraprostatic Ona botulinum toxin A could not be ruled out.

Predictors of false positives in 5-aminolevulinic acid-induced photodynamic diagnosis of bladder carcinoma: identification of patient groups that may benefit most from highly specific optical diagnostics.

OBJECTIVES To identify patient groups associated with a high probability of false positives in photodynamic diagnosis (PDD) of bladder cancer for which the use of highly specific optical instruments could be beneficial. METHODS This study includes the data of 306 patients. Under white light and 5-aminolevulinic acid-induced fluorescence light guidance, tumor locations were recorded, cold-cup biopsies were taken and tumors resected. Age, gender, recent transurethral resection of bladder tumor (TURBT), previous intravesical therapy, and urinary tract infections were examined for association with the false-positive rates in fluorescence cystoscopy by performing a multivariate analysis. RESULTS Significant univariate associations were found between false positives and gender (P = .009, odds ratio [OR] = 0.51), previous intravesical therapy (P = .03, OR = 1.78), previous BCG instillations (P = .03, OR = 2.05), and TURBT in the past 90 days (P = .01, OR = 2.37). In the multivariate regression model, female gender (male; P = .005, OR = 0.41) and TURBT within 90 days before PDD (P = .01, OR = 2.38) are significant independent predictors of false-positive findings in PDD. CONCLUSIONS Recent TURBTs and female gender are significant independent predictors of false positives in fluorescence cystoscopy.

The quality of 5-aminolevulinic acid-induced photodynamic diagnosis and transurethral resection of bladder tumors: does the urologist play a role?.

Introduction: The aim of this study is to evaluate the quality of photodynamic diagnosis (PDD) and transurethral resection of bladder tumors (TURBT) among different urologists. Patients and Methods: The selected data consists of 194 patients, 268 5-aminolevulinic acid (5-ALA)-induced PDD procedures and 934 biopsies. Tumors were resected and biopsies were taken from suspicious areas under guidance of white light endoscopy and 5-ALA-induced fluorescence cystoscopy. The quality of PDD was determined by evaluating the mean number of tumors resected by 5 urologists and, thereafter, assessing the time to recurrence between groups. Results: Urologist 1 took 37% more biopsies (p < 0.001) and diagnosed 42% more tumors (p = 0.005) and 46% more false positives (p < 0.001) from bladders compared to urologists 2, 3, 4 and 5 together. The mean time to bladder cancer recurrence for all recurrences within 0–18 months was 11.0 months for operator 1 and 8.3 months for the other urologists (p = 0.01). Conclusions: The resecting urologist appears to be an important factor for the quality of standard and PDD-assisted TURBT. Learning curve programs may be required with experienced surgeons accompanying those with less experience.