A 61-year-old man presented with hematuria and intermittent right pelvic pain. Intravenous urography showed a tubular filling defect and ureteroscopy a tumor in the right mid ureter. Urine cytology and tumor biopsy showed nonmalignant results. Open surgery was performed, and an intraoperative frozen section revealed a fibroepithelial polyp of the right mid ureter. A fibroepithelial polyp is a rare benign lesion that can occur in childhood but is an important differential diagnosis of an upper urinary tract urothelial cell carcinoma in adults.
Urine cytology coupled with cystoscopic examination has been and remains the standard in the initial evaluation of lower urinary tract lesions to rule out bladder cancer. However, cystoscopy is invasive and may miss some flat lesions, whereas cytology has low sensitivity in low-grade papillary disease. Additional lab-based or office-based markers are needed to aid in the evaluation of these lesions. Recently, many such markers have been developed for the purpose of improving the cytologic diagnosis of bladder malignancies. In this review, we will first discuss conventional cytomorphologic analysis of urine cytology followed by a discussion of markers that have been developed in the past for detection and surveillance of urothelial carcinoma. We will focus on how these markers can be used in conjunction with urine cytology in daily practice.
Bladder cancer; urine cytology; tumor markers
Renal cell carcinoma (RCC) and urothelial carcinoma of the upper urinary tract are not uncommon urological malignancies. Their simultaneous occurrence in a patient is, however, extraordinarily rare. We report the case of a patient who underwent unilateral nephrectomy for suspected RCC and diagnosed transitional cell carcinoma of the superior pelvis. Preoperative imaging was suspicious for renal pelvic involvement, which was confirmed upon performing cystoscopy and biopsy of the suspected lesion preoperatively. This preoperative approach was especially appropriate as a nephron saving procedure was being considered prior to the discovery of the synchronous lesion. We discuss this rare simultaneous occurrence of synchronous malignancies in the same kidney.
In the last 4 years many studies have been published on the topic of upper urinary tract urothelial carcinoma (UTUC). This is a recent review of the available literature of the last 3 years. A systematic Medline/PubMed search on UTUC including limits for clinical trials and randomized, controlled trials was performed for English-language articles using the keywords ‘upper urinary tract carcinoma’, ‘nephroureterectomy’, ‘laparoscopic’, ‘ureteroscopy’, ‘percutaneous’, ‘renal pelvis’, ‘ureter’ and their combinations from January 2008 to December 2010. Additional selected reports from 2007 were included. Case reports and non-English literature were excluded. Publications were mostly retrospective, including some large, multicentre studies from the Upper Tract Urothelial Carcinoma Collaboration (UTUCC). The authors of this article are members of the UTUCC. Altogether, 92 original articles dealing with UTUC were identified and summarized. The vast majority of the available literature has a low level of evidence (level IV), although many multicentre studies tried to overcome the problem of low numbers by pooling data. It was concluded that in the last 3 years our knowledge regarding UTUC has increased dramatically, although new study concepts allowing us to increase the level of evidence are needed.
upper tract urothelial carcinoma; nephroureterectomy; laparoscopic; endoscopic; ureter; renal pelvis
Exfoliative urinary cytology was performed on 260 new cases of histologically proven urothelial cancer. The site, size, shape and histological grade of the tumours were documented, and they were classified by the TNM system. Overall, urine cytology was positive in 135 (52%), suspicious in 28 (11%) and negative in 97 (38%) cases. Malignant cells were found most often when the urothelial tumours were large, papillary and solid, moderately or poorly differentiated and invasive (T2-4). Most upper tract tumours and those situated in bladder diverticula had positive urinary cytology. This study confirms that exfoliative urinary cytology is useful in detecting the more malignant bladder tumours including in-situ carcinoma, and other tumours in less accessible parts of the urinary tract.
We report an unusual case of a urothelial tumor on a ureteral polyp without hydronephrosis. The patient was a 50-year-old male. He had experienced several episodes of gross hematuria. Cystoscopy revealed a tumor that periodically prolapsed into the bladder. The tumor had a smooth-surfaced stalk with an erythematous, edematous lesion at the end. Tomography showed a mass and filling defect at the left ureterovesical junction. The results of urine cytology tests were negative. After the tumor was identified as a urothelial carcinoma by frozen biopsy analysis, a ureteroscopic resection was performed. The final pathological diagnosis was urothelial carcinoma arising in a ureteral polyp. No recurrence of the tumor or polyp was observed at the 3-month follow-up. To our knowledge, this is the first report in the Korean population of a urothelial tumor arising from a ureteral polyp.
Polyps; Ureteral neoplasms; Ureteroscopy
FGFR3 mutations are common in low grade urothelial carcinoma and represent a potential therapeutic target in this disease. Their incidence and functional role in high grade urothelial carcinoma (HGUC), which displays an increased propensity for recurrence and muscularis propria invasion, is less well defined. We developed a mass spectrometry based genotyping assay to define the incidence of FGFR3 mutations in a large clinically annotated set of urothelial carcinomas. FGFR3 mutations were found in 17% of HGUC versus 84% of low-grade lesions. Retrospective pathologic review of the class of FGFR3 mutant HGUC revealed unique histologic features characterized by a bulky, exophytic component with branching papillary architecture as well as irregular nuclei with a koilocytoid appearance. The predictive value of this histologic appearance was confirmed using a prospective set of 49 additional HGUC. Prospective histologic review was able to correctly predict for the presence of an FGFR3 mutation in 13 of 24 HGUC specimens that exhibited the distinct morphology (54%). All 25 specimens lacking the defined histologic features were FGFR3 wild-type for a negative predictive value of 100%. Macrodissection of individual tumors confirmed the presence of the FGFR3 mutant allele in non-invasive and invasive, low and high-grade regions of individual tumors and in the lymph node metastases of patients whose tumors possessed the characteristic morphologic signature, suggesting that FGFR3 mutations are not restricted to the more clinically indolent regions of HGUCs. These data suggest that histologic screening of HGUC followed by confirmatory genotyping can be used to enrich for the population of HGUC most likely to harbor activating mutations in the FGFR3 receptor tyrosine kinase. Histologic review could thus aid in the development of targeted inhibitors of FGFR3 by facilitating the identification of the subset of patients most likely to harbor activating mutations in the FGFR3 gene.
fibroblast growth factor receptor-3; FGFR3; urothelial carcinoma; morphology
A total of 190 patients being treated or followed up for urothelial carcinoma have been studied by the serial estimation of their urinary and plasma CEA levels. Only 46% of patients with a urothelial neoplasm present have a raised urinary CEA level. Infection or ileal conduit urine vitiate the result as they produce high CEA levels in the urine in the absence of any neoplastic disease. The accuracy of urinary CEA estimations is compared with that of cytology. Plasma CEA levels do not serve as a useful guide to the presence of extra-urinary tract tumour spread if taken as isolated readings. However, serial plasma CEA estimations may indicate that metastatic disease is present several months before its detection by the more usual clinical methods in a minority of patients.
Nephroureterectomy is currently the gold standard for management
of upper urinary tract urothelial carcinoma despite it results. This review article
in the loss of a renal unit. The ultimate aim of endoscopic
management of this condition is cancer control whilst preserving
renal function and the integrity of the urinary tract. Endoscopic
treatments of upper tract TCC include the antegrade percutaneous
and retrograde ureteroscopic approaches. This review article
summarizes the endoscopic management of upper tract urothelial
carcinoma, surveillance of the disease after endoscopic management
and adjuvant therapy. The main message regarding endoscopic
management of upper tract urothelial cancer is that patients must
be carefully selected. Patient selection is based on tumour size,
grade, and multifocality. Single low-grade tumours, less than 1.5
cm in size, generally have a good outcome with endoscopic treatment
provided that they have regular ureteroscopic surveillance.
Ureteroscopic treatment of high-grade tumours is essentially
palliative. It is essential that patients are motivated and
compliant as lifetime follow-up is necessary. However, until
large randomized trials with long-term follow-up are performed,
endoscopic management cannot be considered a standard treatment
and should be limited to poor performance status patients.
Upper urinary tract transitional cell carcinoma (TCC) accounts for up to 10% of cases of neoplasm of the upper urinary tract. The “gold standard” management of upper tract TCC is nephroureterectomy. Technological innovations, miniaturisations and increased availability of energy sources such as Holmium laser fibers have improved the armamentarium of endoscopic management of upper tract TCC. Endoscopic management of upper tract TCC includes the percutaneous (antegrade) and retrograde approaches. Modern flexible ureterorenoscopy allows retrograde approach to small (<1.5cm), low grade and noninvasive tumors, which is inaccessible to standard rigid ureteroscopes without breaching the urothelial barrier. In patients with large tumors or in whom retrograde access is difficult, the percutaneous approach to the renal pelvis, although more invasive, provides an alternative access and control. Both retrograde and percutaneous approaches allow instillation of various chemotherapeutic agents. Careful selection of patients is the key point in the successful endoscopic management of upper tract TCC. Patient selection is based on tumor size, grade and multifocality and other patient factors such as comorbidities, single kidney, post kidney transplant and patient choice. Both motivation and compliance of patients are needed for long-term successes. However, until large randomized trials with long term follow-up are available, endoscopic management of upper tract TCC should be reserved for only selected group of patients. This review summarizes the current techniques, indications, contraindications and outcomes of endoscopic management of UTTCC and the key published data.
Endoscopy; minimally invasive therapy; transitional cell carcinoma
Upper tract urothelial cell carcinoma accounts for 5% of all urothelial tumors. Compared to lower urinary tract tumors, upper tract urothelial carcinoma is diagnosed more frequently at advanced stages. Open radical nephroureterectomy remains the gold standard treatment option for upper tract tumors. However, with the advancement of minimally invasive techniques and the benefits of these procedures regarding perioperative morbidity, cosmesis, and earlier convalescence, these options have shown promise in managing the patients with upper tract urothelial carcinoma. Despite the perioperative advantages, concerns exist on the oncological safety after minimally invasive surgery. In this article, we provide a comprehensive overview of the surgical management of upper tract urothelial carcinoma.
Upper tract urothelial cell carcinoma; ureteroscopy; endoscopic surgery; ureteropyeloscopy
Urine cytology test is a useful diagnostic tool in detection of urinary tract cancer. However, the presence of cancer cells in urine cytology sediment in patients with relapsed lung cancer and renal metastases could be used widely in order to avoid interventional procedures of the urothelial tract in a false positive diagnosis of a primary renal cancer.
Patients and methods
A 52 year-old smoker woman of 40 p/y was presented for examination of intermittent episodes of haematuria over a 2 months period. The patient had right lower lobectomy (3 years ago) due to well differentiated squamous cell lung cancer, treated with neo-adjuvant chemotherapy and local relapse at the coloboma, 19 months after the surgery. The patient received chemotherapy of 4500 Gy. Eleven months later because of the history of haematuria, the patient proceeded in Contrast enhanced computed tomography (CT) examination of the abdomen revealed a heterogeneous mass of the right kidney. Before of a prospective FNA right renal biopsy, the patient proceeded in an everyday urine cytology test and chest CT examination in order to exclude a new relapse of lung cancer.
The urine cytology test with Thin Prep technique was positive and detected squamous cell lung cancer well differentiated. Bronchoscopy followed chest CT defined and showed clear evidence of new lesions and tracheal invasion. We would like to notice that there is no histological existence of primary squamous renal cancer.
Every renal lesion detected in patients with lung cancer history must alert metastatic disease, especially if computed tomography of the mass demonstrates relative homogeneity and minimal enhancement. Recent studies strongly showed that renal metastases count maximum 19% and usually have occult radiological findings. Urine cytology could be valuable to patients with lung cancer and urinary tract signs, especially if there are radiological lesions from lower abdomen CT scan. The above mentioned may be used in order of detection of renal metastases and especially to differentiate metastatic lung disease from primary renal cancer.
Urothelial carcinoma (UC) can arise at any location along the urothelial tract, including the urethra, bladder, ureter, or renal pelvis. Although tumors arising in these various locations have similar morphology, it is unclear whether the gene expression profiles are similar between the upper-tract (ureter and renal pelvis) and lower-tract (bladder and urethra) carcinomas. Because differences may facilitate different screening and treatment modalities, we sought to examine the relationship between urothelial carcinoma of the renal pelvis (rUC) and urothelial carcinoma of the bladder (bUC).
Fresh tumor tissue was collected from patients with bUC (n = 10) and benign mucosa from the bladder of individuals undergoing resection for non-UC conditions (n = 7). Gene expression profiles from these samples were determined using high-throughput Affymetrix gene expression microarray chips. Bioinformatic approaches were used to compare the gene expression profiles of these samples with those of rUC samples and normal kidney samples that had been described previously.
Using unsupervised analytic approaches, rUC and bUC were indistinguishable. Yet when a supervised analytic approach was used, a small number of differentially expressed genes were identified; these differences were most likely limited to a single pathway--the chloride ion binding activity pathway--which was more frequently activated in rUC than in bUC.
We found that the gene expression profiles of UCs from the upper and lower tract were extremely similar, suggesting that similar pathogenic mechanisms likely function in the development of these tumors. The differential expression of genes in the identified pathway may represent a new avenue for detection of upper-tract tumors.
We compared renal function and oncologic outcomes of parenchymal sparing ureteral resection with radical nephroureterectomy for the treatment of upper tract urothelial carcinoma confined to the ureter.
Materials and Methods
Review of a large institutional database identified 367 patients treated for primary upper tract urothelial carcinoma with radical nephroureterectomy or parenchymal sparing ureteral resection from 1994 to 2009. Patients with known renal pelvis tumors, muscle invasive urothelial carcinoma, prior cystectomy, contralateral upper tract urothelial carcinoma, metastatic disease or chemotherapy were excluded, leaving 120 patients for analysis. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Recurrence-free, cancer specific and overall survival were estimated using Kaplan-Meier analysis.
Radical nephroureterectomy was performed in 87 patients and parenchymal sparing ureteral resection in 33. Median age at surgery was 73 years in the radical nephroureterectomy group (IQR 64 –76) vs 70 years (IQR 59 –77) in the parenchymal sparing ureteral resection group (p = 0.5). The radical nephroureterectomy and parenchymal sparing ureteral resection cohorts had several disparate clinicopathological variables including preoperative hydronephrosis (80% vs 45%, p = 0.0006), stage (pT3 or greater 26% vs 9%, p = 0.01) and baseline estimated glomerular filtration rate (51 vs 63 ml/minute/1.73 m2, p = 0.009). Patients who underwent radical nephroureterectomy experienced a significantly greater decrease in estimated glomerular filtration rate after surgery (median −7 vs 0 ml/minute/1.73 m2, p <0.001). Median followup was 4.2 years. Of the patients 79 experienced cancer recurrence and 44 died (28 of upper tract urothelial carcinoma). There were no obvious differences in the rates of recurrence, cancer specific death or overall death by procedure type. However, due to the limited number of events we cannot exclude the possibility that there are large differences in oncologic outcomes by procedure type.
Parenchymal sparing ureteral resection is associated with superior postoperative renal function. However, the impact on cancer control cannot be determined conclusively due to the small sample size and putative selection bias.
carcinoma; transitional cell; kidney failure; chronic; ureter
Balkan endemic nephropathy is a chronic tubulointerstitial disease frequently accompanied by urothelial cell carcinomas of the upper urinary tract. This disorder has recently been linked to exposure to aristolochic acid, a powerful nephrotoxin and human carcinogen. Following metabolic activation, aristolochic acid reacts with genomic DNA to form aristolactam-DNA adducts that generate a unique TP53 mutational spectrum in urothelium. The aristolactam-DNA adducts are concentrated in the renal cortex, thus serving as biomarkers of internal exposure to aristolochic acid. Here, we present molecular epidemiologic evidence relating carcinomas of the upper urinary tract to dietary exposure to aristolochic acid. DNA was extracted from the renal cortex and urothelial tumor tissue of 67 patients that underwent nephroureterectomy for carcinomas of the upper urinary tract and resided in regions of known endemic nephropathy. Ten patients from non-endemic regions with carcinomas of the upper urinary tract served as controls. Aristolactam-DNA adducts were quantified by 32P-post-labeling, the adduct was confirmed by mass spectroscopy, and TP53 mutations in tumor tissues were identified by chip-sequencing. Adducts were present in 70% of the endemic cohort and in 94% of patients with specific A:T to T:A mutations in TP53. In contrast, neither aristolactam-DNA adducts nor specific mutations were detected in tissues of patients residing in non-endemic regions. Thus, in genetically susceptible individuals, dietary exposure to aristolochic acid is causally related to endemic nephropathy and carcinomas of the upper urinary tract.
To evaluate the ability of fluorescence in situ hybridization (FISH) in detecting bladder urothelial carcinoma (BUC), FISH and cytology were compared for the evaluation of 308 consecutive urine samples from patients suspected of having BUC. All patients underwent cystoscopy for identification of bladder lesions. The FISH results were compared with the cytology assessment. In all, 122 patients had confirmed BUC. Among them, 68 (55.7%) were FISH-positive, while only 33 (27%) were positive on cytology. According to disease stage (superficial vs. invasive) and grade (low vs. high), the sensitivities of FISH were also significantly higher than those of cytology in all categories. Moreover, in 36 patients who had no visible tumor with flat, erythematous mucosa (suspicious lesion), FISH was more sensitive than cytology for the detection of BUC (83.3% vs. 33.3%, P=0.002). The FISH was negative in 168 (90.3%) of 186 patients with no histological evidence of BUC or negative cystoscopy findings. The sensitivity of FISH for detecting BUC was superior to that of cytology, regardless of tumor stage and grade. FISH is a significant additional and complementary method for detection of BUC in patients who have suspicious lesions on cystoscopy.
Bladder Urothelial Carcinoma; Cytology; In Situ Hybridization, Fluorescence
Introduction. In cases of anatomic or functional single kidney with urothelial tumours of the upper urinary tract, the endoscopic laser ablation has proven efficacious. Based on the knowledge that low-grade, low-stage upper tract transitional cell carcinomas rarely progress to invasive lesions, indications for endoscopic laser ablation have expanded to include patients with bilateral functioning kidneys and low-grade tumours. The question that remains to be answered is whether endoscopic laser ablation has the ability to completely eradicate upper urinary tract tumours. Methods. We performed in 25 patients in a period of 11 years 288 ureteroscopies and, if needed, laser ablation of upper urinary tract tumours in imperative indication. Results. In 32% of the patients the cancer remained even after several laser sessions. 64% of patients were tumour free after one or more laser sessions but remained clear only for the next 3 months. Only 1 patient was tumour free for a period of 68 months after 1 session of laser treatment. The procedure had low complication rates. Conclusion. The laser technology and the introduction of small diameter semirigid and flexible ureteroscopes made ablation of upper urinary tract tumours possible and safe. Nevertheless a complete resection of the carcinomas is rarely possible.
The micropapillary variant of urothelial carcinoma (uPC) is a rare variant of urothelial carcinoma that carries a poor prognosis. Definitive surgery may represent optimal management of low stage tumors. Urine cytology is indispensable in the screening and follow-up of urinary tract cancer. However, cytopathological criteria for diagnosis of uPC and its differentiation from conventional urothelial carcinoma (CUC) are not well-defined.
Materials and Methods:
Twenty-five cases of histologically confirmed micropapillary uPC from 21 patients were compared to 25 cases of histologically confirmed high-grade CUC.
In uPC cases, cell clusters were identified in 13 of 25 specimens from 10 patients. Six of the 13 specimens containing cell clusters corresponded to surgical pathology specimens in which micropapillary carcinoma accounted for at least 50% of total carcinoma. In contrast, only 1 of the 12 urine specimens devoid of cell clusters corresponded to surgical specimens in which micropapillary carcinoma accounted for at least 50% of total carcinoma. Cytomorphologic features of urinary specimens from patients with histologically confirmed micropapillary carcinoma were generally similar to those from patients with high-grade CUC, making it difficult to distinguish these entities in exfoliative urine specimens.
Conclusions and Summary:
Further investigation of the core cytopathological characteristics of uPC is warranted to refine its diagnostic criteria by exfoliative urine cytology.
Cytology; carcinoma; exfoliative; micropapillary; urothelial
The objective of this study was to determine the value of routine urine cytology in the initial evaluation of patients presenting to a one-stop haematuria clinic.
PATIENTS AND METHODS
A total of 1000 consecutive patients who attended the haematuria clinic between June 2003 and November 2004 were studied prospectively. A standard protocol was used to investigate these patients. This included urine cytology, upper tract imaging and flexible cystoscopy.
Overall, 986 samples of urine were sent for cytology. In 126 patients, the report was abnormal; of these, 71 patients were found to have bladder transitional cell carcinoma by flexible cystoscopy and a further 3 had upper tract transitional cell carcinoma diagnosed radiologically. The remaining 52 patients with abnormal cytology were not found to have cancer on further investigations. The total cost for urine cytology and additional investigations was £50,535.
In this study of the initial evaluation of patients with haematuria, no case of urothelial malignancy was diagnosed on the basis of urine cytology alone. Therefore, urine cytology need not be used routinely in the initial diagnostic workup for haematuria.
Haematuria; Urine cytology; Urothelial malignancy; Diagnosis
Lymphoepithelioma-like carcinoma (LELC) in the bladder is uncommon with a reported incidence of 0.4%–1.3% of all bladder carcinomas. In Japan, some occurrences of LELC have been reported in the renal pelvis and ureter but only two in the bladder. A bladder tumor was identified in a 70-year-old man suffering from macroscopic hematuria for 2 months. Sections of the transurethral tumor resection showed invasive high-grade urothelial carcinoma. The patient was diagnosed with local invasive bladder tumor, and cystectomy with ileal conduit formation was performed. The final pathological evaluation was predominant LELC with urothelial carcinoma. We present a new case of LELC in the bladder and performed a review of all published cases of LELC in the urinary tract to obtain its characteristics and prognostic guide.
Squamous differentiation (SqD) is variably present in urinary tract tumours, but its significance remains unclear. In this study, SqD was assessed by immunohistochemistry using the monoclonal antibody Mac387 in 145 urothelial tumours (bladder, n = 115; renal pelvis, n = 30). Mac387 detects the myelomonocytic L1 antigen; a member of the calgranulin family shared by epithelial cells and keratinocytes. L1 antigen was shown in SqD in urothelial carcinomas of the bladder or the renal pelvis, including 11 cases with focal SqD unrecognised by conventional analysis. SqD is more frequent in renal pelvic tumours (p = 0.027) and increases with grade/stage mainly in bladder carcinoma (grade, p = 0.05; stage, p = 0.005). Stage Ta/T1 bladder carcinomas with SqD recurred more (p = 0.021). In conclusion, Mac387 efficiently shows SqD in urothelial tumours.
Light microscopic evaluation of cell morphology in preparations from urine or bladder washing containing exfoliated cells is a standard and primary method for the detection of bladder cancer and also malignancy from other parts of the urinary tract. The cytopathologic examination is a valuable method to detect an early recurrence of malignancy or new primary carcinoma during the follow-up of patients after the treatment of bladder cancer.
Characteristic cellular and nuclear signs of malignancy indicate invasive or in situ urothelial carcinoma or high-grade papillary urothelial carcinoma. However, low sensitivity of the method reflects the unreliable cytopathologic diagnosis of low-grade urothelial neoplasms as cellular and nuclear signs of malignancy in these neoplasms are poorly manifested. Many different markers were developed to improve the diagnosis of bladder carcinoma on urinary samples. UroVysion™ test is among the newest and most promising tests. By the method of in situ hybridization one can detect specific cytogenetic changes of urothelial carcinoma.
cytology; urine; bladder washing; urothelial carcinoma
Objective. We here report a patient with upper urinary tract urothelial carcinoma with hypercalcemia likely due to elevated 1,25-dihydroxyvitamin D. Methods. We present a clinical case and a summary of literature search. Results. A 57-year-old man, recently diagnosed with a left renal mass, for which a core biopsy showed renal cell carcinoma, was admitted for hypercalcemia of 11.0 mg/mL He also had five small right lung nodules with a negative bone scan. Both intact parathyroid hormone and parathyroid hormone-related peptide were appropriately low, and 1,25-dihydroxyvitamin D was elevated at 118 pg/dL. The patient's calcium was normalized after hydration, and he underwent radical nephrectomy. On the postoperative day 6, a repeat 1,25-dihydroxyvitamin D was 24 pg/mL with a calcium of 8.1 mg/dL. Pathology showed a 6 cm high-grade urothelial carcinoma with divergent differentiation. We identified a total of 27 previously reported cases with hypercalcemia and upper tract urothelial carcinoma in English. No cases have a documented elevated 1,25-dihydroxyvitamin D level. Conclusion. This clinical course suggests that hypercalcemia in this case is from the patient's tumor, which was likely producing 1,25-dihydroxyvitamin D. Considering the therapeutic implications, hypercalcemia in patients with upper urinary tract urothelial carcinoma should be evaluated with 1,25-dihydroxyvitamin D.
Reactive oxygen species (ROS) production via NADPH oxidase (NOX) contributes to various types of cancer progression. In the present research, we examined the pathobiological role of NADPH oxidase (NOX)4-mediated generation of reactive oxygen species (ROS) in urothelial carcinoma (UC) of the urinary bladder, and demonstrated the utility of ROS labeling in urine cytology.
NOX4 gene was silenced in vivo and in vitro by NOX4 siRNA transfection with or without atlocollagen. Cell cycle and measurement of ROS were analyzed by flowcytometry. Orthotopic implantation animal model was used in vivo experiment. NOX4 expression in urothelial carcinoma cells was observed by immunohistochemical analysis using surgical specimens of human bladder cancer. Urine cytology was performed after treatment with ROS detection reagents in addition to Papanicolaou staining.
NOX4 was overexpressed in several UC cell lines and the NOX inhibitor, diphenylene iodonium reduced intracellular ROS and induced p16-dependent cell cycle arrest at the G1 phase. Moreover, silencing of NOX4 by siRNA significantly reduced cancer cell growth in vivo as assessed in an orthotopic mouse model. Immunohistochemistry demonstrated high expression of NOX4 in low grade/non-invasive and high grade/invasive UC including precancerous lesions such as dysplasia but not in normal urothelium. Then, we assessed the usefulness of cytological analysis of ROS producing cells in urine (ROS-C). Urine samples obtained from UC cases and normal controls were treated with fluorescent reagents labeling the hydrogen peroxide/superoxide anion and cytological atypia of ROS positive cells were analyzed. As a result, the sensitivity for detection of low grade, non-invasive UC was greatly increased (35% in conventional cytology (C-C) vs. 75% in ROS-C), and the specificity was 95%. Through ROS-C, we observed robust improvement in the accuracy of follow-up urine cytology for cases with previously diagnosed UC, especially in those with low grade/non-invasive cancer recurrence (0% in C-C vs. 64% in ROS-C).
This is the first report demonstrating that ROS generation through NOX4 contributes to an early step of urothelial carcinogenesis and cancer cell survival. In addition, cytology using ROS labeling could be a useful diagnostic tool in human bladder cancer.
Activating mutations of FGFR3 are frequently identified in superficial urothelial carcinoma (UC) and increased expression of FGFR1 and FGFR3 are common in both superficial and invasive UC.
The effects of inhibition of receptor activity by three small molecule inhibitors (PD173074, TKI-258 and SU5402) were investigated in a panel of bladder tumour cell lines with known FGFR expression levels and FGFR3 mutation status.
All inhibitors prevented activation of FGFR3, and inhibited downstream MAPK pathway signalling. Response was related to FGFR3 and/or FGFR1 expression levels. Cell lines with the highest levels of FGFR expression showed the greatest response and little or no effect was measured in normal human urothelial cells or in UC cell lines with activating RAS gene mutations. In sensitive cell lines, the drugs induced cell cycle arrest and/or apoptosis. IC50 values for PD173074 and TKI-258 were in the nanomolar concentration range compared with micromolar concentrations for SU5402. PD173074 showed the greatest effects in vitro and in vivo significantly delayed the growth of subcutaneous bladder tumour xenografts.
These results indicate that inhibition of FGFR1 and wild-type or mutant FGFR3 may represent a useful therapeutic approach in patients with both non-muscle invasive and muscle invasive UC.
FGFR3; FGFR1; tyrosine kinase inhibitor; urothelial carcinoma; PD173074; TKI-258