Clinical decisions for treatment of different staged bladder cancer based on multitarget fluorescence in situ hybridization assays?

Non-invasive methods for detecting genetic alterations of bladder cancer are increasingly becoming the focus of attention as diagnostic tools. The fluorescence in situ hybridization we performed to detect genetic alterations of chromosomes 3, 7, 9p21, and 17 (UroVysion Test) showed very high sensitivity, higher even than cytology, in detecting bladder tumors of varying differentiation (pTa-pT4). The use of this test in everyday clinical urology can be a very useful decision aid in treating problem cases. A pT1G3 bladder carcinoma in the presence of multichromosomal alterations should be treated as a muscle-invasive pT2 tumor. Other superficial bladder tumors (pTaGI-III, pT1GI-II) with negative histopathology in follow-up and positive FISH analysis with the UroVysion Test should have bladder mapping performed again. Although FISH analysis is currently the most sensitive marker for bladder tumors, the elaborate handling, the cost of the DNA probes and the laboratory equipment required, limit the use of this method in the urologist's everyday routine.

Polymorphisms of human androgen receptor (hAR) gene in prostate cancer cell lines PC-EW and PC-OR.

BACKGROUND: Prostate cancer is the leading tumor of the male in Western societies. Genetic alterations of the androgen receptor gene are known in the advanced metastatic disease. In this study, the androgen receptor gene was tested in two human prostate cancer cell lines, the androgen-sensitive PC-EW and the androgen-independent PC-OR. MATERIALS AND METHODS: Genomic DNA was isolated from two cell lines from metastatic prostate adenocarcinoma in heterotransplanted male athymic nude (nu/nu) Balb/c mice. Mutation screening was performed by sequencing of exons 1-8 of the human androgen receptor gene. RESULTS: Despite two polymorphisms found in the transactivation domain of hAR exon 1, no point mutations were detected in the hAR gene of both cell lines. CONCLUSION: Point mutations of hAR are not necessary for metastatic prostate cancer, while alterations in the solyglutamine and polyglycine repeat region in exon 1 of the MR gene are more often found. These repeats are two of many genetic influences that contribute to the overall risk of developing prostate cancer.

Polymorphisms in the human progesterone receptor (PGR) gene of two human prostate adenocarcinoma cell lines.

BACKGROUND: The incidence and mortality rate of prostate cancer has been steadily increasing in most countries worldwide. A potential implication of the progesterone receptor has been reported in prostatic carcinogenesis. In this study, an allele of human progesterone receptor gene (PROGINS), which was demonstrated to be associated with an increased risk of sporadic ovarian cancer, was tested in two human prostate cancer cell lines, PC-EW and PC-OR. MATERIALS AND METHODS: Genomic DNA was isolated from the cell lines in athymic nude mice. The polymorphisms in exon 4 and exon 5 and the insertion in intron G (PROGINS) were identified by sequencing and gel electrophoresis. RESULTS: The PROGINS allele and the polymorphisms in exon 4 and exon 5 were found heterozygous in the PC-OR cell line but not in the PC-EW cell line. CONCLUSION: We described the polymorphisms of exon 4, exon 5 and PROGINS in prostate cancer. Mutation screening of the PGR gene may provide information for risk assessment of developing prostate cancer.

Heterogeneity in prostate cancer: prostate specific antigen (PSA) and DNA cytophotometry.

BACKGROUND: The heterogeneity in prostate cancer is the reason for the difficult diagnosis and prognosis of this tumor. In this study, we looked for a correlation between prostate specific antigen (PSA), tumor staging and DNA cytophotometry. MATERIALS AND METHODS: Twenty-two prostates (pT1-T4) from patients with prostate cancer, who underwent radical prostatectomy, were examined. Preoperative PSA and postoperative DNA image cytometry, after 2-8 needle biopsies out of each organ, were evaluated. RESULTS: The prostate cancer tissues showed, in DNA stemline-interpretation according to Fu, in homogenous diploid tumors an average PSA level of 3.8 ng/ml, and, in homogenous aneuploid tumors, a level of 14.0 ng/ml. Tumors with heterogeneous DNA patterns with a majority of aneuploidy had an average PSA level of 85.6 ng/ml, and heterogeneous tissues with a majority of diploidy a level of 10.9 ng/ml. CONCLUSION: Only the stemline-interpretation of Fu after DNA cytophotometry is efficient for diagnosis of prostate cancer, and allows prognostic statements of the disease.

Combined-modality treatment and organ preservation in bladder cancer. Do molecular markers predict outcome?

PURPOSE: In invasive bladder cancer, several groups have reported the value of organ preservation by a combined-treatment approach, including transurethral resection (TUR-BT) and radiochemotherapy (RCT). As more experience is acquired with this organ- sparing treatment, patient selection needs to be optimized. Clinical factors are limited in their potential to identify patients most likely to respond to RCT, thus, additional molecular markers for predicting treatment response of individual lesions are sorely needed. PATIENTS AND METHODS: The apoptotic index (AI) and Ki-67 index were evaluated by immunohistochemistry on pretreatment biopsies of 134 patients treated for bladder cancer by TUR-BT and RCT. Expression of each marker as well as clinicopathologic factors were then correlated with initial response, local control and cancer-specific survival with preserved bladder in univariate and multivariate analysis. RESULTS: The median AI for all patients was 1.5% (range 0.2-7.4%). The percentage of Ki-67-positive cells in the tumors ranged from 0.2% to 85% with a median of 14.2%. A significant correlation was found for AI and tumor differentiation (G1/2: AI = 1.3% vs. G3/4: AI = 1.6%; p = 0.01). A complete response at restaging TUR-BT was achieved in 76% of patients. Factors predictive of complete response included T-category (p < 0.0001), resection status (p = 0.02), lymphovascular invasion (p = 0.01), and Ki-67 index (p = 0.02). For local control, AI (p = 0.04) and Ki-67 index (p = 0.05) as well as T-category (p = 0.005), R-status (p = 0.05), and lymphatic vessel invasion (p = 0.05) reached statistical significance. Out of the molecular markers only high Ki-67 levels were associated to cause-specific survival with preserved bladder. On multivariate analysis, T-category was the strongest independent factor for initial response, local control and cancer-specific survival with preserved bladder. CONCLUSION: The indices of pretreatment apoptosis and Ki-67 predict a favorable outcome in bladder cancer patients treated with TUR-BT and RCT. Molecular markers may help to select patients for an organ-sparing approach.

Examination of tumorigenesis of precursor lesions in bladder cancer by in situ hybridization.

Through examinations using fluorescence in situ hybridization (FISH) of chromosomes 1 and 9, we tried to obtain more information on dysplasia and carcinoma in situ (Cis) in relation to the oncogenesis of bladder cancer. 63 paraffin sections (dysplasia grades I-III and Cis) were evaluated, and 8 negative sections functioned as a control group. For FISH, DNA samples of CEP 1 and 9 (alpha satellites) were chosen. Gains (aneuploidy) or losses (monosomy) of chromosomal material were determined microscopically. Dysplasia grades I-III showed a 5-18% aberration in chromosome 1 aneuploidy and a 19-29% aberration in monosomy 9. Cis revealed 27% aneuploidy of chromosomes 1 and 9. Although at present dysplasia grade III and Cis of the bladder are viewed as histopathologically identical, we examined both molecular genetic differences in chromosome 9. As referred to in the literature we found the same genetic aberrations for dysplasias (grades I-III) and noninvasive papillary bladder tumors as well as for Cis and solid invasive bladder cancer.

Clinical aspects for the use of DNA image cytometry in detection of bladder cancer: a valuable tool?

The employment of DNA flow or image cytometry for oncological diagnostic procedures is favored because of its high correlation to tumor biological behavior. Prognostic statements and therapeutic strategies therefore are based on the high validity of DNA cytometric measurements. Using 151 bladder washings from patients suspected of bladder cancer for this study, we examined the clinical value of various common methods of DNA single cell (SCI) and stemline interpretations (SLI). Comparing the specificity and sensitivity of DNA image cytometry in detection of bladder tumors, we found 81 and 52%, respectively, for SCI of Boecking, 84 and 45% for SLI of Boecking, 61 and 58% for SLI of Fu, and 82 and 40% for conventional stemline interpretation. To improve diagnostic and prognostic validity of DNA image cytometry, we designed our own method of interpretation. In consequence, we identified six single DNA parameters out of all recorded measurements that correlated most to histopathological grading (G1-G3). Creating reference values at random and rating by points, we used a cytometric grading system for ranking. In detection of bladder cancer specificity and sensitivity ultimately arrived at almost 70% in application of our method. Thus, by this study, we were able to show that sensitivity of DNA examination can be increased by combining various DNA parameters. Apart from our own scheme, the discrepancy in interpretation of DNA image cytometry does not allow us to recommend this procedure as the only diagnostic in detection of bladder cancer. However, in regard to prognostic statements, particularly tumor biological behavior, DNA image cytometry appears to be useful.

Combined-modality treatment and selective organ preservation in invasive bladder cancer: long-term results.

PURPOSE: To evaluate our long-term experience with combined modality treatment and selective bladder preservation and to identify factors that may predict treatment response, risk of relapse, and survival. PATIENTS AND METHODS: Between 1982 and 2000, 415 patients with bladder cancer (high-risk T1, n = 89; T2 to T4, n = 326) were treated with radiotherapy (RT; n = 126) or radiochemotherapy (RCT; n = 289) after transurethral resection (TUR) of the tumor. Six weeks after RT/RCT, response was evaluated by restaging-TUR. In case of complete response (CR), patients were observed at regular intervals. In case of persistent or recurrent invasive tumor, salvage-cystectomy was recommended. Median follow-up was 60 months (range, 6 to 199 months). RESULTS: CR was achieved in 72% of patients. Local control after CR without muscle-invasive relapse was maintained in 64% of patients at 10 years. Distant metastases were diagnosed in 98 patients with an actuarial rate of 35% at 10 years. Ten-year disease-specific survival was 42%, and more than 80% of survivors preserved their bladder. Early tumor stage and a complete TUR were the most important factors predicting CR and survival. RCT was more effective than RT alone in terms of CR and survival. Salvage cystectomy for local failure was associated with a 45% disease-specific survival rate at 10 years. Cystectomy because of a contracted bladder was restricted to 2% of patients. CONCLUSION: TUR with RCT is a reasonable option for patients seeking an alternative to radical cystectomy. Ideal candidates are those with early-stage and unifocal tumors, in whom a complete TUR is accomplished.

Organ preservation in patients with invasive bladder cancer: initial results of an intensified protocol of transurethral surgery and radiation therapy plus concurrent cisplatin and 5-fluorouracil.

PURPOSE: To assess safety, tolerance, and disease control of transurethral resection of the bladder tumor (TURB) plus concurrent cisplatin, 5-fluorouracil (5-FU), and radiation therapy (RT) with selective organ preservation in patients with bladder cancer. PATIENTS AND METHODS: Forty-five patients with muscle-invading or high-risk T1 (G3, associated carcinoma in situ, multifocality, >5 cm) bladder cancer were entered into a protocol of TURB followed by concurrent cisplatin (20 mg/m(2)/day, 20-min infusion) and 5-FU (600 mg/m(2)/day, 120-hour continuous infusion), administered on Day 1-5 and 29-33 of RT (single dose 1.8 Gy, total dose to the bladder 54-59.4 Gy). Response was evaluated by restaging TURB 6 weeks later. In case of invasive residual or recurrent tumor, salvage cystectomy was recommended. Median follow-up was 35 months (range: 8-80 months). RESULTS: Thirty-nine patients (87%) had no detectable tumor at restaging TURB; 29 patients (64%) have been continuously free of tumor in their bladders. A superficial relapse occurred in 4 patients, a muscle-invasive relapse in 6 patients. Overall survival and survival with preserved bladder was 67% and 54%, respectively, at 5 years. Hematologic Grade 3/4 toxicity occurred in 10%/4%; Grade 3 diarrhea occurred in 9%. Thirty-four patients (76%) completed the protocol as scheduled or with only minor deviations. One patient required salvage cystectomy because of a shrinking bladder. CONCLUSION: This protocol of concurrent cisplatin/5-FU and RT has been associated with acceptable toxicity. The complete response rate of 87% and the 5-year survival with intact bladder of 54% are encouraging and compare favorably with our historical control series using RT with carboplatin and cisplatin alone.