Does the extent of carcinoma in prostatic biopsies predict prostate-specific antigen recurrence? A systematic review.

CONTEXT: The biologic potential of prostate cancer (pCA) is variable, and the ability to identify tumours that might cause morbidity and mortality is limited. OBJECTIVE: This systematic review sought to establish whether measurement of tumour extent in biopsies provides additional prognostic information on the risk of disease progression. EVIDENCE ACQUISITION: A comprehensive 31-step search strategy was run in MEDLINE, EMBASE, and the Web of Knowledge (January 1990-July 2007) and supplemented by the hand-searching of references in retrieved articles and relevant journals to identify publications related to the measurement of the length of cancer in biopsies and biochemical or clinical recurrence or pCA death. Thirteen papers reporting on at least 100 patients were identified and included patients treated by watchful waiting or hormonal therapy (n=1), radical prostatectomy (n=11), or radiotherapy (n=1). Only two studies reported on clinical progression or mortality. Sources of bias included patient selection and missing data resulting from the retrospective nature of the studies. Confounding factors included differences in biopsy strategies and measurement methods. EVIDENCE SYNTHESIS: The percentage of cancer in biopsies (overall percentage or the greatest percentage in the most involved core) was an independent predictor of prostate-specific antigen (PSA) and clinical outcomes regardless of the form of treatment and was generally superior to simply counting the number of positive cores. The marked variability in study design, conduct, and reporting precluded meta-analysis of the data and precise risk estimation. CONCLUSIONS: Tumour quantitation is a promising prognostic tool in the assessment of risk of pCA progression. However, well-designed, population-based studies, controlling for confounding factors, are required to provide more accurate risk estimation and develop management strategies. This review highlights the need for new approaches in the assessment of pathologic prognostic factors to reach the level of evidence achieved in other areas of medical practice.

The clinical management of patients with a small volume of prostatic cancer on biopsy: what are the risks of progression? A systematic review and meta-analysis.

Clinically localized prostate cancer is associated with a wide variation in biologic behavior, and men with the less aggressive form of the disease may never develop symptoms. There has been a rise in prostate cancer incidence in countries in which the blood test for prostatic-specific antigen (PSA) is common, and concerns have been expressed that this may be because of the increased detection of indolent disease, subjecting these men to unnecessary treatment and associated side effects. For the current review, the authors conducted a systematic evaluation of the literature regarding the outcomes of men who were diagnosed on the basis of a small volume of cancer in prostatic biopsies. The results indicated that, despite differences in study design and reporting, a significant proportion of patients with microfocal cancer, regardless of how it was defined, had adverse pathologic findings and a significant risk of PSA recurrence after undergoing radical prostatectomy. Biochemical and clinical recurrences also were observed after radiotherapy or watchful waiting. The authors concluded that patients with microfocal carcinoma on biopsy should be advised that their disease is not necessarily "insignificant" and should be counseled accordingly.

The prognostic significance of perineural invasion in prostatic cancer biopsies: a systematic review.

Men with clinically localized prostate cancer are faced with a wide range of treatment options, and only Gleason grading is universally used as a histopathological prognostic factor for this disease. The significance of perineural invasion in diagnostic biopsies is controversial. Opinion about whether or not it should influence treatment decisions is currently almost equally divided. To address this, the authors performed a systematic review of studies that examine the association between perineural invasion and prostate cancer recurrence. MEDLINE, Embase, and the Web of Knowledge were searched from January 1990 to December 2005. Outcomes analyzed were the development of biochemical or clinical recurrence. Twenty-one articles on the association of perineural invasion in biopsies and prostate cancer recurrence after radical prostatectomy (n = 10) or radiotherapy (n = 11) were found but none on its significance in the context of watchful waiting. Structured data extraction was performed to allow comparisons between articles and to identify sources of heterogeneity to explain discrepancies in results. The considerable variation in study design, execution, and reporting precluded meta-analysis and quantitative risk estimation, but the weight of evidence suggested that perineural invasion in biopsies was a significant prognostic indicator, particularly in specific patient groups defined by presenting serum prostate-specific antigen levels and biopsy Gleason scores. Immediate treatment rather than watchful waiting may be more appropriate for patients with localized prostatic cancer and perineural invasion. However, the data are limited, and well-designed studies that use predefined stringent protocols are required to provide robust estimates of risk to aid in treatment planning.

Expression of matrix metalloproteinase-10 in human bladder transitional cell carcinoma.

OBJECTIVES: To analyze matrix metalloproteinase-10 (MMP-10) expression in transitional cell carcinoma (TCC) of the bladder, evaluate the correlations between MMP-10 protein expression and clinicopathologic parameters, and address the viability of MMP-10 as a therapeutic target for TCC. MMP-mediated degradation of the extracellular matrix is an important factor in the pathogenesis of tumorigenesis and metastasis. METHODS: Using immunohistochemistry, the expression of MMP-10 was assessed using both tissue microarrays and whole sections of archival tissue specimens representative of all grades and stages of human bladder TCC (n = 60). MMP-10 expression was also assessed in histologically normal human bladder tissue (n = 10). The immunostaining results for MMP-10 expression were examined for correlations with tumor grade and stage. RESULTS: Unlike most MMPs, MMP-10 was localized primarily in the tumor mass as opposed to the tumor stroma and was detectable in all grades and stages of TCC. Significantly greater levels of MMP-10 protein were observed in superficial (pTa, pT1; n = 38) tumors than in normal bladder tissue (P = 0.01). In contrast to the proposed role of MMPs in tumor invasion, no significant difference was observed between muscle-invasive tumors (pT2 or worse; n = 22) and histologically normal bladder tissue (P = 0.50). MMP-10 expression showed no significant correlation with tumor grade. CONCLUSIONS: The data from our study showed that, unlike most MMPs, MMP-10 was not associated with tumor aggression or invasion. Our results suggest that MMP-10 protein levels are significantly greater in the earlier stages of TCC development.

NAD(P)H:Quinone oxidoreductase-1 C609T polymorphism analysis in human superficial bladder cancers: relationship of genotype status to NQO1 phenotype and clinical response to Mitomycin C.

NAD(P)H:Quinone oxidoreductase-1 (NQO1) has been implicated in the bioreductive activation of the clinically active anticancer drug Mitomycin C (MMC) and a polymorphic variant of NQO1 which lacks functional enzyme activity (NQO1*2) has been linked with poor survival in patients treated with MMC. The relationship between NQO1 activity and cellular response to MMC is however controversial and the aim of this study was to determine whether the response of bladder cancer patients to MMC can be forecast on the basis of NQO1*2 genotype status. Genomic DNA was extracted from formalin-fixed, paraffin-embedded tissue from 148 patients with low to intermediate grade (G1/G2) superficial (Ta/T1) bladder cancers and NQO1*2 genotype status determined by PCR-RFLP. NQO1*2 genotype status was retrospectively compared with clinical response to intravesical administered MMC with the primary end-point being time to first recurrence. NQO1 phenotype was determined by immunohistochemistry. Of the 148 patients genotyped, 85 (57.4%) were NQO1*1 (wild-type), 59 (39.8%) were NQO1*1/*2 (heterozygotes) and 4 (2.7%) were NQO1*2/*2. No NQO1 protein expression was detected in NQO1*2/*2 tumours. A broad spectrum of NQO1 protein expression existed in tumours genotyped as NQO1*1 and NQO1*1/*2 although tumours with NQO1*1 typically expressed higher NQO1 protein. A poor correlation existed between NQO1*2 genotype status and clinical response to MMC. The results of this retrospective study suggest that tailoring MMC therapy to individual patients with superficial bladder cancer on the basis of NQO1 genotype status is unlikely to be of clinical benefit.

Immunohistochemical analysis of NAD(P)H:quinone oxidoreductase and NADPH cytochrome P450 reductase in human superficial bladder tumours: relationship between tumour enzymology and clinical outcome following intravesical mitomycin C therapy.

A central theme within the concept of enzyme-directed bioreductive drug development is the potential to predict tumour response based on the profiling of enzymes involved in the bioreductive activation process. Mitomycin C (MMC) is the prototypical bioreductive drug that is reduced to active intermediates by several reductases including NAD(P)H:quinone oxidoreductase (NQO1) and NADPH cytochrome P450 reductase (P450R). The purpose of our study was to determine whether NQO1 and P450R protein expression in a panel of low-grade, human superficial bladder tumours correlates with clinical response to MMC. A retrospective clinical study was conducted in which the response to MMC of 92 bladder cancer patients was compared to the immunohistochemical expression of NQO1 and P450R protein in archived paraffin-embedded bladder tumour specimens. A broad spectrum of NQO1 protein levels exists in bladder tumours between individual patients, ranging from intense to no immunohistochemical staining. In contrast, levels of P450R were similar with most tumours having moderate to high levels. All patients were chemotherapy naïve prior to receiving MMC and clinical response was defined as the time to first recurrence. A poor correlation exists between clinical response and NQO1, P450R or the expression patterns of various combinations of the 2 proteins. The results of our study demonstrate that the clinical response of superficial bladder cancers to MMC cannot be predicted on the basis of NQO1 and/or P450R protein expression and suggest that other factors (other reductases or post DNA damage events) have a significant bearing on tumour response.

Detection of (NAD(P)H:Quinone oxidoreductase-1, EC 1.6.99.2) 609C-->T and 465C-->T polymorphisms in formalin-fixed, paraffin-embedded human tumour tissue using PCR-RFLP.

NQO1 is a cytosolic flavoprotein that plays a dual role in the detoxification of potentially carcinogenic compounds and the bioreductive activation of quinone based anticancer drugs. Two polymorphic variants of NQO1 exist (NQO1*2 and NQO1*3) which cause significant phenotypic reductions in NQO1 protein content and activity. Current methods for detecting NQO1 polymorphisms commonly use PCR-RFLP techniques and have exclusively used DNA isolated from fresh tissues. This study describes a method that is suitable for analysing NQO1 polymorphisms in genomic DNA isolated from formalin-fixed paraffin-embedded tissue. The method utilises two rounds of PCR amplification using a nested primer strategy that generates specific PCR products followed by RFLP analysis using either Hinf1 (for NQO1*2) or Msp1 (for NQO1*3). Whilst existing methods proved unsatisfactory (low product yield and poor specificity), the nested primer strategy produced good quality PCR products suitable for RFLP analysis and genotyping of NQO1*2 and NQO1*3 in archival tissue samples. The ability to utilise the vast archives of human tissue held by pathology laboratories would be of considerable benefit as retrospective studies comparing NQO1 genotype status, patient history and treatment outcomes could be conducted.