The quality of biopsy is directly linked to survival in patients with bladder cancer

Oncology_Urology

UCLA researchers have shown for the first time that the quality of diagnostic staging using biopsy in patients with bladder cancer is directly linked with survival, meaning those that don’t get optimal biopsies are more likely to die from their disease.

The two-year study found that about half of bladder cancer patients who were biopsied had insufficient material – meaning there was no bladder wall muscle retrieved – to accurately stage the cancer. Additionally, the UCLA research team found that a suboptimal biopsy and incorrect tumor staging was associated with a significant increase in deaths from bladder cancer, said study first author Dr. Karim Chamie, an assistant professor of urology and surgical director of the bladder cancer program at UCLA.

“These findings are very important because while patients know about the stage of their cancer, they rarely question the quality of the biopsy,” said Chamie, who also is a researcher at UCLA’s Jonsson Comprehensive Cancer Center. “We hope these findings will help empower patients to ask about the quality of their biopsy and, if it is suboptimal, then urge their doctors to repeat the biopsy prior to deciding on what type of treatment to prescribe.”

The findings were published in the early, online edition of the peer-reviewed journal Cancer. The study was conducted at UCLA and the Cancer Surveillance Program at USC.

Chamie said that many times, biopsies only take tissue from the inner lining of the bladder itself, ignoring the underlying muscle wall. If the cancer has started to invade, tissue from the muscle wall needs to be examined to determine the next course of treatment.

For the study, the UCLA team reviewed the medical records of every patient diagnosed with “non-invasive” – meaning the cancer had yet not spread into the muscle – bladder cancer during the years 2004 and 2005 across medical institutes in Los Angeles County. Biopsy and surgery reports were reviewed.

The team found that about half the time, the surgeon either did not do an adequate biopsy or the pathologist did not clearly state the extent of the cancer invasion. When patients had aggressive tumors and their surgeons and pathologists appropriately staged them, the chance of dying of bladder cancer at five years was 8 percent.

If the surgeon did an inadequate job staging them, but the pathologist alerted the physician of inadequate staging, the five-year mortality rate was 12 percent.

However, if the pathologist did not comment on the extent of the cancer invasion, then the five-year mortality was 19 percent.

“Appropriately staging patients with bladder cancer is a skill set that every urologist and pathologist should have in his/her armamentarium,” Chamie said. “We believe the next step is to change the staging system for bladder cancer to incorporate the quality of staging. Not all stage I cancers are alike. Some patients may have stage II cancer, but because the biopsy was insufficient, these patients were inaccurately staged and may be undertreated. I really do believe that one reason why we have yet to see significant improvement in bladder cancer survival over the last two decades may, in part, be attributed to inadequate staging.”

The study sample included 1,865 patients, 335 urologists and 278 pathologists from medical institutes across Los Angeles County. Muscle was reported as present in 972, or 52.1 percent, absent in 564, or 30.2 percent, and was not mentioned at all in 329, or 17.7 percent of initial pathology reports.

Barbara James, 77, of Three Rivers in Central California was diagnosed bladder cancer a year ago by an urologist in her area, who also performed a biopsy and later removed the cancer. However, the urologist waited four months before going back in to check to ensure all the cancer was removed, James said.

More cancer was found and the urologist wanted to go in and remove more.

“It made me really nervous. I felt like he didn’t know what he was doing,” she said. “I decided I needed to go somewhere else.”

A friend, a neurosurgeon at UCLA, referred James to Chamie, who performed a more thorough biopsy, which found that James had invasive bladder cancer that was missed in the first biopsy. As a result, her bladder had to be removed and a new bladder built for her using a portion of her intestine. She’s recovering and advises anyone with bladder cancer to go to a major medical center for biopsy and staging.

Every year, nearly 75,000 Americans are diagnosed with bladder cancer, the vast majority with non-invasive disease. More than 15,500 will die.

“The omission of muscle in the specimen or its mention in the pathology report in nearly half of all diagnostic resections is associated with increased mortality, particularly in patients with aggressive disease,” the study states. “Because urologists cannot reliably discern between aggressive and indolent disease, we recommend that patients with bladder cancer should undergo adequate muscle sampling at the time of biopsy.”

The study was funded by the National Cancer Institute, UCLA’s Jonsson Comprehensive Cancer Center, the Surveillance, Epidemiology, and End Results Program and the STOP Cancer Foundation.

http://www.medicalnewstoday.com/releases/284232.php

 

 

New evaluation system leads to incontinence relief

Urology

After living with overactive bladder and urinary retention symptoms for 11 years, Jennifer LaForest, a 26-year-old woman from Auburn Hills, Michigan, recently became one of the first in the U.S. to receive a test evaluation with the new Verify(TM) Evaluation System from Medtronic, and subsequently received Medtronic Bladder Control Therapy.

The Verify System, which was recently approved by the U.S. Food and Drug Administration (FDA), is used temporarily to determine if Medtronic Bladder Control or Bowel Control Therapies, delivered by the InterStim® System, may provide long-term relief for a patient suffering from chronic symptoms of overactive bladder, non-obstructive urinary retention or bowel incontinence who failed, could not tolerate or were not candidates for more conservative therapies. More than 37 million adults in the United States – one in six – suffer from overactive bladder,i,ii and nearly 18 million Americans – about one in 12 – have bowel incontinence.iii

Both the Verify System and the long-term InterStim System provide mild electrical stimulation to the sacral nerves, which are located near the tailbone and help bladder and bowel function. The therapy is thought to help normalize communication between the bladder or bowel and the brain. The implantable components of the InterStim System consist of a pacemaker-like device called a neurostimulator and a lead (thin wire). These are implanted under the skin during a minimally invasive procedure following a successful trial stimulation period with Verify, which typically lasts up to 14 days.

While an evaluation system has been available to patients previously, the new, easy-to-use Verify Evaluation System offers a more discreet and unobtrusive experience to patients during the evaluation period. The system uses two advanced components: a small, external neurostimulator weighing less than two ounces and concealed securely in a soft belt worn at the waist under clothing; and a mobile phone-sized wireless controller with a touch-screen for easy stimulation adjustments. The Verify Evaluation System is used following a minimally invasive outpatient procedure to place the lead.

“In the short time that I’ve received this therapy, my overactive bladder and retention issues have dramatically improved. Previously, I rarely left my house feeling comfortable, and my self-esteem was very low. Now I have more confidence, and my worries about hygiene and odor have been reduced,” said LaForest, who received Medtronic Bladder Control Therapy after a 14-day trial stimulation period with the Verify System. “Not only did the evaluation system confirm that the therapy works for me, but it was easy to use, was concealed easily beneath my clothes, and didn’t get in the way of my normal daily activities.”

The Verify System includes a usage log that allows physicians to effectively manage patient evaluations by reviewing the operation of the system and matching it against a patient’s diary of daily bladder or bowel episodes. Ken Peters, M.D., chief of urology at Beaumont Hospital in Royal Oak, Michigan was the first in the U.S. to use the Verify System.

“Mild stimulation of the sacral nerves can have a significant impact on patients suffering from overactive bladder, urinary retention or bowel control issues. The trial stimulation period allows them to try the therapy before having a neurostimulator implanted,” said Dr. Peters. “This new trial system provides me with vital information so I can determine if the long-term therapy is right for individual patients.”

“More than 150,000 patients worldwide have received Medtronic Bladder Control or Bowel Control Therapies, and we are excited to bring the latest advancement in evaluation technology to physicians and patients,” said Linnea Burman, vice president and general manager, gastro/urology therapies at Medtronic. “The Verify System reinforces Medtronic’s commitment to innovative solutions for the treatment of overactive bladder, urinary retention and bowel incontinence.”

Results of the therapy vary, and not every patient’s response is the same. People should consult their physicians to decide whether InterStim therapy is appropriate. In addition to risks related to a medical procedure, complications from this therapy can include pain, infection, sensation of electrical shock, device problems, undesirable change in voiding function, and lead migration, among others. Additional safety information can be found athttp://www.everyday-freedom.com/.

 

Accurate test for aggressive prostate cancer steps closer with genetic study

Urology

Rsearchers behind a new genetic study led by the University of Pittsburgh School of Medicine, PA, suggest their findings will lead to a more accurate test for aggressive prostate cancer and new ways to treat it.

Writing about their work in the American Journal of Pathology, the team explains how they found prostate cancerpatients with certain genetic mutations have a 91% chance of their cancer coming back.

Senior author Jian-Hua Luo, a professor of pathology at Pitt School of Medicine who specializes in researching the genome and gene expression of cancers, and particularly how prostate cancers become invasive, says:

“Being able to say, with such certainty, that a patient is nearly guaranteed to see a recurrence of his prostate cancer means that doctors and patients can elect to be more aggressive in treating the cancer, knowing that the benefits likely outweigh the risks.”

He suggests eventually such a finding could lead to a genetic therapy that cures prostate cancer, and adds:

“With this discovery, we’re at the tip of the iceberg in terms of possibilities for improving patient outcomes.”

Prostate cancer treatment can be worse than the disease

Prostate cancer is the second most common cancer in men (after skin cancer) and the second leading cause of cancer death in American men, behind only lung cancer.

According to the American Cancer Society, about 1 man in 7 will be diagnosed with prostate cancer during his lifetime.

However, despite this high rate of disease, few men diagnosed with it develop the aggressive type that spreads, which poses a problem for treatment, as Prof. Luo explains:

“In some cases, this can make the treatment more dangerous than the disease, so doctors need more accurate tests to tell them which patients would most benefit from aggressive therapies, such as surgery, radiation andchemotherapy.”

Study found 8 ‘hybrid genes’ or ‘fusion transcripts’ strongly linked to prostate cancer

For the study, the team sequenced the genomes of tissue samples taken from the prostates of five men whose prostate cancer recurred, and compared them with the genomes of tissue samples from men without cancer.

In the tissue of the men with prostate cancer recurrence, they found 76 hybrid genes that are often linked to cancer. After further tests, 8 of these hybrid genes were found to be strongly linked to prostate cancer.

The hybrid genes are known as “fusion transcripts” that are formed from previously separate genes. These are often linked to cancer.

The team then looked for the 8 hybrid genes in 289 prostate tissue samples from men treated at three centers, with clinical follow-up ranging from 1 to 15 years after surgery.

The analysis showed that 91% of the patients (69 out of 76) who tested positive for any of the hybrid genes experienced prostate cancer recurrence, metastases, and/or died of prostate cancer after surgery. Also, three of the hybrid genes were only found in tissue samples from patients who experienced recurrence or died from prostate cancer.

However, of the prostate cancer patients who did not carry any of the genes, only 37% (58 out of 157) experienced recurrence, metastases or died of prostate cancer.

The researchers say the findings suggest formation of the hybrid genes may underlie the aggressive behavior of prostate cancer.

Subject to successful clinical trials, Prof. Luo expects the test to be available to patients in a few years. He says there are also plans to further investigate the hybrid genes most strongly linked to prostate cancer. This could one day lead to treatments that stop the cancer by changing or stopping the mutations.

Funds for the study came from the National Institutes of Health, the American Cancer Society and the University of Pittsburgh Cancer Institute.

Meanwhile, in May 2014, Medical News Today learned about research from the University of Tampere in Finland that established the feasibility of diagnosing prostate cancer using an eNose. The team found the eNose results were comparable to those obtained from prostate specific antigen tests.

Written by Catharine Paddock PhD

 

After spinal cord injury, transplanted stem cells help prevent bladder fibrosis

Urology

A team of researchers from Korea and Canada have found that transplantation of B10 cells (a stable immortalized human bone marrow derived mesenchymal stem cell line; B10 hMSC) directly into the bladder wall of mice modeled with spinal cord injury (SCI) helped inhibit the development of bladder fibrosis and improved bladder function by promoting the growth of smooth muscle cells in the bladder.

The study will be published in a future issue of Cell Transplantation and is currently freely available on-line as an unedited early e-pub.

Spinal cord injury (SCI) can cause severe lower urinary tract dysfunction and conditions such as overactive bladder, urinary retention and increased bladder thickness and fibrosis. HMSCs, multipotent cells that can differentiate into a variety of cell types, including bone cells, cartilage cells, and fat cells, have been transplanted into injured spinal cords to help patients regain motor function.

In this study, mice receiving the B10 hMSCs injected directly into the bladder wall experienced improved bladder function while an untreated control group did not.

“Human MSCs can secrete growth factors,” said study co-author Seung U. Kim of the Division of Neurology at the University of British Columbia Hospital, Vancouver, Canada. “In a previous study, we showed that B 10 cells secrete various growth factors including hepatocyte growth factor (HGF) and that HGF inhibits collagen deposits in bladder outlet obstructions in rats more than hMSCs alone. In this study, the SCI control group that did not receive B10 cells showed degenerated spinal neurons and did not recover. The B10-injected group appeared to have regenerated bladder smooth muscle cells.”

Four weeks after the onset of SCI, the treatment group received the B10 cells transplanted directly into the bladder wall. To track the transplanted B10 cells via magnetic resonance imaging (MRI), the researchers labeled them with fluorescent magnetic particles.

“HGF plays an essential role in tissue regeneration and angiogenesis and acts as a potent antifibrotic agent,” explained Kim.

The researchers concluded that local injection, rather than systemic intravenous injection, was preferred because systemic injection caused the hMSCs to be localized in the pulmonary capillary bed.

Voiding function was assessed at four weeks post-transplantation and MRI “showed clear hypointense signal induced by the labeled cells”. When the bladders of the transplanted group were harvested they were found to have improved smooth muscle cells and reduced collagen deposition.

The researchers concluded that MSC-based cell transplantation may be a novel therapeutic strategy for bladder dysfunction in patients with SCI.

“This study provides potential evidence that an human stable immortalized MSC line could be useful in the treatment of spinal cord injury-related problems such as bladder dysfunction.” said Dr. David Eve, associate editor of Cell Transplantation and Instructor at the Center of Excellence for Aging & Brain Repair at the University of South Florida. “Further studies to elucidate the mechanisms of action and the long term effects of the cells, as well as confirm the optimal route of administration, will help to illuminate what the true benefit of these cells could be.”

http://www.medicalnewstoday.com/releases/282059.php

Picture courtesy of https://twitter.com/BioheartInc

 

 

Catheter-associated urinary tract infections significantly reduced by electronic alerts

Urology_Nephrology

A Penn Medicine team has found that targeted automated alerts in electronic health records significantly reduce urinary tract infections in hospital patients with urinary catheters. In addition, when the design of the alert was simplified, the rate of improvement dramatically increased.

The alerts help physicians decide whether their patients need urinary catheters in the first place and then alert them to reassess the need for catheters that have not been removed within a recommended time period. The electronic alert, developed by medical researchers and technology experts at the Perelman School of Medicine at the University of Pennsylvania, is the subject of a study published in the September issue of Infection Control and Hospital Epidemiology.

Approximately 75 percent of urinary tract infections acquired in the hospital are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. According to the Centers for Disease Control and Prevention, 15 to 25 percent of hospitalized patients receive urinary catheters during their hospital stay. As many as 70 percent of urinary tract infections in these patients may be preventable using infection control measures such as removing no longer needed catheters resulting in up to 380,000 fewer infections and 9,000 fewer deaths each year.

“Our study has two crucial, applicable findings,” said the Penn study’s lead author Charles A. Baillie, MD, an internal medicine specialist and fellow in the Center for Clinical Epidemiology and Biostatistics at Penn Medicine. “First, electronic alerts do result in fewer catheter-associated urinary tract infections. Second, the design of the alerts is very important. By making the alert quicker and easier to use, we saw a dramatic increase in the number of catheters removed in patients who no longer needed them. Fewer catheters means fewer infections, fewer days in the hospital, and even, fewer deaths. Not to mention the dollars saved by the health system in general.”

In the first phase of the study, two percent of urinary catheters were removed after an initial “off-the-shelf” electronic alert was triggered (the stock alert was part of the standard software package for the electronic health record). Hoping to improve on this result in a second phase of the study, Penn experts developed and used a simplified alert based on national guidelines for removing urinary catheters they had previously published with the CDC. Following introduction of the simplified alert, the proportion of catheter removals increased more than seven-fold to 15 percent.

The study also found that catheter associated urinary tract infections decreased from an initial rate of .84 per 1,000 patient days to .70 per 1,000 patient-days following implementation of the first alert and .50 per 1,000 patient days following implementation of the simplified alert. Among other improvements, the simplified alert required two mouse clicks to submit a remove-urinary-catheter order compared to seven mouse clicks required by the original alert.

The study was conducted among 222,475 inpatient admissions in the three hospitals of the University of Pennsylvania Health System between March 2009 and May 2012. In patients’ electronic health records, physicians were prompted to specify the reason (among ten options) for inserting a urinary catheter. On the basis of the reason selected, they were subsequently alerted to reassess the need for the catheter if it had not been removed within the recommended time period based on the reason chosen.

Women’s health units had the highest proportion of alerts that led to a remove-urinary-catheter order and critical care units saw the lowest proportion of alerts leading to a remove order.

“As more hospitals adopt electronic health records, studies such as ours can help point the way toward improved patient care,” said senior author Craig Umscheid, MD, MSCE, assistant professor of Medicine and Epidemiology and director of Penn’s Center for Evidence-based Practice. “Thoughtful development and deployment of technology solutions really can make a difference. In this study, we learned that no two alerts are alike, and that changes to an alert’s usability can dramatically increase its impact.”

Several studies have already shown that reminder systems to limit the use and duration of urinary catheters can lower catheter infection rates. However, the majority of these have used non-computerized reminders, such as written reminders or stickers. The current Penn study is one of the largest to examine the impact of electronically generated alerts. In addition to the size of the study, a second strength is its multi-year duration. Most prior studies relied on a brief study period, and several studies observed an increase in catheter use when the relatively brief intervention had ended.

http://www.medicalnewstoday.com/releases/281479.php

 

 

 

Atypical antipsychotic drug use increases risk for acute kidney injury

Nephrology_Urology

Atypical antipsychotic drug use is associated with an increased risk for acute kidney injury (AKI) and other adverse outcomes, according to a study being published in Annals of Internal Medicine.

Each year, millions of older adults are prescribed atypical antipsychotic drugs (quetiapine, risperidone, and olanzapine) to manage behavioral symptoms of dementia, which is not an approved indication. This type of off-label use has raised safety concerns, as these atypical antipsychotics are known to cause AKI. Researchers compared medical records for 97,777 adults aged 65 or older who received a new outpatient prescription for an oral atypical antipsychotic drug against a matched cohort of patients who had not received such a prescription to determine the risk for AKI and other adverse outcomes.

Persons who had received a prescription for any three atypical antipsychotic drugs in the previous 90 days had an elevated risk for hospitalization with AKI. The drugs were also associated with increased risk for hypotension, acute urinary retention, and death. The findings support current safety concerns regarding the use of these drugs in older adults.

Study: Atypical Antipsychotic Drugs and the Risk for Acute Kidney Injury and Other Adverse Outcomes in Older Adults: A Population-Based Cohort Study, Y.J. Hwang, S.N. Dixon, J.P. Reiss, R. Wald, C.R. Parikh, S. Gandhi, S.Z. Shariff, N. Pannu, D.M. Nash, F. Rehman, and A.X. Garg, Annals of Internal Medicine, doi: 10.7326/M13-2796, published 18 August 2014.

http://www.medicalnewstoday.com/releases/281206.php

 

 

Enzyme lost in 100 percent of kidney tumors analyzed

Urology_Nephrology

In an analysis of small molecules called metabolites used by the body to make fuel in normal and cancerous cells in human kidney tissue, a research team from the Perelman School of Medicine at the University of Pennsylvania identified an enzyme key to applying the brakes on tumor growth. The team found that an enzyme called FBP1 – essential for regulating metabolism – binds to a transcription factor in the nucleus of certain kidney cells and restrains energy production in the cell body. What’s more, they determined that this enzyme is missing from all kidney tumor tissue analyzed. These tumor cells without FBP1 produce energy at a much faster rate than their non-cancer cell counterparts. When FBP1 is working properly, out-of-control cell growth is kept in check.

The new study, published online this week in Nature, was led by Celeste Simon, PhD, a professor of Cell and Developmental Biology and the scientific director for the Abramson Family Cancer Research Institute at Penn.

Clear cell renal cell carcinoma (ccRCC), the most frequent form of kidney cancer, is characterized by elevated glycogen (a form of carbohydrate) and fat deposits in affected kidney cells. This over-storage of lipids causes large clear droplets to accumulate, hence the cancer’s name.

In the last decade, ccRCCs have been on the rise worldwide. However, if tumors are removed early, a patient’s prognosis for five-year survival is relatively good. If expression of the FBP1 gene is lost, patients have a worse prognosis.

“This study is the first stop in this line of research for coming up with a personalized approach for people with clear cell renal cell carcinoma-related mutations,” says Simon, also an investigator with the Howard Hughes Medical Institute.

A Series of Faulty Reactions

The aberrant storage of lipid in ccRCC results from a faulty series of biochemical reactions. These reactions, called the Kreb’s cycle, generate energy from carbohydrates, fats, and proteins in the form of ATP. However, the Kreb’s cycle is hyperactive in ccRCC, resulting in enhanced lipid production. Renal cancer cells are associated with changes in two important intracellular proteins: elevated expression of hypoxia inducible factors (HIFs) and mutations in the von Hippel-Lindau (VHL) encoded protein, pVHL. In fact, mutations in pVHL occur in 90 percent of ccRCC tumors. pVHL regulates HIFs, which in turn affect activity of the Kreb’s cycle.

Although much is already known about metabolic pathways and their role in cancer, there are still important questions to be answered. For example, kidney-specific VHL deletion in mice does not elicit clear cell-specific tumor formation, suggesting that additional mechanisms are at play. Toward answering that hunch, recent large-scale sequencing analyses have revealed the loss of several epigenetic enzymes in certain types of ccRCCs, suggesting that changes within the nucleus also account for kidney tumor progression.

To complement genetic studies revealing a role for epigenetic enzymes, the team evaluated metabolic enzymes in the 600-plus tumors they analyzed. The expression of FBP1 was lost in all kidney cancer tissue samples examined. They found FBP1 protein in the cytoplasm of normal cells, where it would be expected to be active in glucose metabolism. But, they also found FBP1 in the nucleus of these normal cells, where it binds to HIF to modulate its effects on tumor growth. In cells without FBPI, the team observed the Warburg effect – a phenomenon in which malignant, rapidly growing tumor cells go into overdrive, producing energy up to 200 times faster than their non-cancer-cell counterparts.

This unique dual function of FBP1 explains its ubiquitous loss in ccRCC, distinguishing FBP1 from previously identified tumor suppressors that are not consistently inhibited in all tumors. “And since FBP1 activity is also lost in liver cancer, which is quite prevalent, FBP1 depletion may be generally applicable to a number of human cancers,” notes Simon.

Next steps, according to the researchers, will be to identify other metabolic pathways to target, measure the abundance of metabolites in kidney and liver cancer cells to determine FBP1’s role in each, and develop a better mouse model for preclinical studies.

Picture Credit: Credit: Bo Li and Brian Keith, Perelman School of Medicine, University of Pennsylvania.

http://www.medicalnewstoday.com/releases/279893.php