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β-Arrestins are classic attenuators of G-protein–coupled receptor signaling. However, they have multiple roles in cellular physiology, including carcinogenesis. This work shows for the first time that β-arrestins have prognostic significance for predicting metastasis and response to chemotherapy in bladder cancer. β-Arrestin-1 (ARRB1) and β-arrestin-2 (ARRB2) mRNA levels were measured by quantitative RT-PCR in two clinical specimen cohorts (n = 63 and 43). The role of ARRBs in regulating a stem cell-like phenotype and response to chemotherapy treatments was investigated. The consequence of forced expression of ARRBs on tumor growth and response to Gemcitabine in vivo were investigated using bladder tumor xenografts in nude mice. ARRB1 levels were significantly elevated and ARRB2 levels downregulated in cancer tissues compared with normal tissues. In multivariate analysis only ARRB2 was an independent predictor of metastasis, disease-specific-mortality, and failure to Gemcitabine + Cisplatin (G+C) chemotherapy; ∼80% sensitivity and specificity to predict clinical outcome. ARRBs were found to regulate stem cell characteristics in bladder cancer cells. Depletion of ARRB2 resulted in increased cancer stem cell markers but ARRB2 overexpression reduced expression of stem cell markers (CD44, ALDH2, and BMI-1), and increased sensitivity toward Gemcitabine. Overexpression of ARRB2 resulted in reduced tumor growth and increased response to Gemcitabine in tumor xenografts. CRISPR-Cas9–mediated gene-knockout of ARRB1 resulted in the reversal of this aggressive phenotype. ARRBs regulate cancer stem cell-like properties in bladder cancer and are potential prognostic indicators for tumor progression and chemotherapy response.

Supplementary Table S1: Specimen and patient characteristics; Supplementary Table S2: Determination of the association between adjuvant treatment failure and demographic/clinical parameters or marker levels; Supplementary Table S3: qPCR primers and ARRB1-specific CRISPR guide RNA sequences; Supplementary Table S4: Source of various antibodies used for immunofluorescence and Western blotting; Supplementary Figure S1: Kaplan Meier plot for stratification of patients into higher risk and lower risk for Disease-Specific Mortality (DSM) based on the ARRB2 arrestin level; Supplementary Figure S2: Expression of cytokeratins and Bmi-1 following modulation of ARRB2 levels in 5637 cells; Supplementary Figure S3: Expression of SOX2 following modulation of ARRB2 levels in bladder cancer cell lines; Supplementary Figure S4: Response of ARRB2 overexpressing transfectants to Cisplatin; Supplementary Figure S5: Expression ABC transporters in ARRB2-modulated bladder cancer cells; Supplementary Figure S6: Effect of ARRB2 overexpression on Cancer Stem Cell markers in vivo; Supplementary Figure S7: ARRB1 depletion affects clonogenic growth, spheroid formation and expression of CSC markers

Hasanali et al Supplementary Materials

Purpose:Gemcitabine-based chemotherapy regimens are first-line for several advanced cancers. Because of better tolerability, gemcitabine + cisplatin is a preferred neoadjuvant, adjuvant, and/or palliative chemotherapy regimen for advanced bladder cancer. Nevertheless, predicting treatment failure and overcoming resistance remain unmet clinical needs. We discovered that splice variant (V1) of HYAL-4 is a first-in-class eukaryotic chondroitinase (Chase), and CD44 is its major substrate. V1 is upregulated in bladder cancer and drives a malignant phenotype. In this study, we investigated whether V1 drives chemotherapy resistance.Experimental Design:V1 expression was measured in muscle-invasive bladder cancer (MIBC) specimens by qRT-PCR and IHC. HYAL-4 wild-type (Wt) and V1 were stably expressed or silenced in normal urothelial and three bladder cancer cell lines. Transfectants were analyzed for chemoresistance and associated mechanism in preclinical models.Results:V1 levels in MIBC specimens of patients who developed metastasis, predicted response to gemcitabine + cisplatin adjuvant/salvage treatment and disease-specific mortality. V1-expressing bladder cells were resistant to gemcitabine but not to cisplatin. V1 expression neither affected gemcitabine influx nor the drug-efflux transporters. Instead, V1 increased gemcitabine metabolism and subsequent efflux of difluorodeoxyuridine, by upregulating cytidine deaminase (CDA) expression through increased CD44–JAK2/STAT3 signaling. CDA inhibitor tetrahydrouridine resensitized V1-expressing cells to gemcitabine. While gemcitabine (25–50 mg/kg) inhibited bladder cancer xenograft growth, V1-expressing tumors were resistant. Low-dose combination of gemcitabine and tetrahydrouridine abrogated the growth of V1 tumors with minimal toxicity.Conclusions:V1/Chase drives gemcitabine resistance and potentially predicts gemcitabine + cisplatin failure. CDA inhibition resensitizes V1-expressing tumors to gemcitabine. Because several chemotherapy regimens include gemcitabine, our study could have broad significance.

To investigate the role of the peptide arginine-vasopressin (AVP) in controlling the function of penile erectile tissue, we determined the course of AVP through different stages of sexual arousal in both the systemic and cavernous blood of healthy males and patients presenting with ED. Twenty-five healthy males and 45 patients with ED were exposed to erotic stimulation to induce sexual arousal. Blood was withdrawn from the corpus cavernosum and a cubital vein during penile flaccidity, tumescence, rigid erection (attained only by the healthy individuals), and detumescence. AVP (ng/l plasma) was determined by means of a radioimmunoassay. Effects of AVP (0.1 to 100 nM) on isolated human CC were examined using a tissue bath system. AVP elicited contraction of isolated CC. In the healthy subjects, a decline in AVP levels (5.4 to 3 ng/l) was seen in the systemic blood when the flaccid penis became rigid. In the cavernous blood, no alterations were registered. In the group of ED patients, AVP in the systemic circulation did not display a transient decline. The drop in systemic AVP in healthy males during sexual stimulation might be a prerequisite to enable penile erection.

BACKGROUND: Lymphnode metastases (LMN) in metastatic renal cell carcinoma (mRCC) has been associated with an unfavourable prognosis. However, the prognostic impact of LNM in mRCC in context of other solid organ metastases and throughout subsequent therapeutic lines is not well-defined. OBJECTIVE: This retrospective single-center analysis was designed to elucidate the impact of LNM in the context of other solid organ metastases and throughout subsequent therapeutic lines. METHODS: mRCC patients (pts) at our center were analysed (observation period, 04/00-03/16). Primary endpoint was overall survival (OS) and the impact of line of therapy as a co-variate. Pts were grouped into: with LNM [LNM(+)], without LNM [LNN(–)]. Subgroup analyses of LNM(+) was performed including the subgroup LNM(+) and other solid organ metastases [LNM(+) other] and LNM(+) without other solid organ metastases [LMN(+) only]. RESULTS: 383/401 mRCC pts were eligible. 318 (83.2%), 230 (60.1%) and 154 (40.5%) pts received 1stL, 2ndL and 3rdL medical treatment, respectively. In the overall population OS was 40.1 months (95%CI: 32.7–47.4), with superior OS in LNM(–) compared to LNM(+) pts (log rank, HR 1.7, 95%-CI 1.3-2.2, p

Background and AimsThe transient receptor potential cationic channel ankyrin 1 (TRPA1), a channel protein permeable to most divalent cations, has been suggested to play a role in mechano-afferent/efferent signaling (including the release of neurotransmitters) in the human urinary tract (bladder, prostate, and urethra). To date, only a few studies have addressed the expression of this receptor in male and female reproductive tissues. The present study aimed to evaluate human seminal vesicles (SVs) for the expression and localization of TRPA1. MethodsSV tissue was obtained from 5 males who had undergone pelvic surgery due to malignancies of the prostate or urinary bladder. The expression of messenger ribonucleic acid (mRNA) specifically encoding for the TRPA1 protein was elucidated by means of reverse transcriptase polymerase chain reaction (RT-PCR). Using immunohistochemical methods, the distribution of TRPA1 was examined in relation to the endothelial and neuronal nitric oxide synthases (eNOS, nNOS) and the neuropeptides calcitonin gene-related peptide (CGRP) and vasoactive intestinal polypeptide (VIP). ResultsRT-PCR revealed signals related to the expected molecular size of 656 bp. Immunohistochemistry demonstrated that TRPA1 is located in nerves running through the smooth muscle portion of the SV. Here, the protein is in part co-localized with nNOS and CGRP, whereas no co-localization with VIP was registered. Dot-like signals specific for TRPA1 were observed in the cytoplasm of epithelial cells lining the lumen of glandular spaces. The epithelial layer also presented staining for eNOS. The smooth musculature appeared free of immunosignals for TRPA1. ConclusionThe results convincingly show the expression of TRPA1 in nerve endings as well as in epithelial cells of the SV. Based on its location in epithelial cells, TRPA1 might be involved in the mechanism of the NO/cyclic guanosine monophosphate (GMP)-mediated signaling and also the control of secretory function (mediated by cyclic GMP) in the human SV.

The efficacy of the transurethral convective interstitial radiofrequency water vapor thermal ablation of the prostate with the Rezūm system for the treatment of male lower urinary tract symptom due to benign prostatic hyperplasia is well proven. The improvement of urodynamic parameters obtained from a simple uroflowmetry cannot measure the effect of water vapor injection on the bladder outlet obstruction.This monocentric retrospective pilot study analyzes the data of pressure-flow studies performed before and after 17 Rezūm procedures to answer the question whether thus obtained ablation of prostate tissue has a disobstructive effect on the bladder outlet.All the functional outcomes were consistently improved after the procedure, with a median flowrate increase of 5.1 ml/s (p = 0.0022) and a median postvoid residual urine (PVR) reduction of 100 ml (p = 0.0042). The prostate volume was reduced by 40% (p 0.0001) and the median Bladder Outlet Obstruction Index (BOOI) reduction was 53.8 (p 0.0001).These data show that the possibility to significantly reduce the obstruction grade with even a single Rezūm procedure is concrete and seems to be independent from the degree of the obstruction grade.

Background DNA methylation is frequently observed in the development and progression of many human tumors as well as renal cell cancer (RCC). Tumor Associated Calcium Signal Transducer 2 (TACSTD2) participates in cell cycle progression through MAPK signalling pathway activation. Moreover, tumor-specific hypermethylation and association with aggressive cancer characteristics has been found for lung adenocarcinoma, hepatocellular carcinoma and cholangiocarcinoma. Whether TACSTD2 is tumor specifically hypermethylated in RCC or shows association of methylation with adverse clinicopathological parameters and survival of patients has not been investigated at yet. Methods Quantitative methylation-specific PCR (qMSP) analysis of a locus in the intron 1 region of TACSTD2 gene was carried out in a cross-sectional study of 127 paired RCC and normal samples. In silico analysis of TACSTD2 methylation in the TCGA Kidney Renal Clear Cell Carcinoma (KIRC) dataset of 280 patients served as validation cohort. Statistical analyses were carried out using the two-sided paired t-test for matched tumor and normal sample comparisons, logistic regression for subgroup comparisons, Cox regression for analysis of recurrence free survival (RFS) and Pearson correlation analysis for correlation of TACSTD2 methylation and TACSTD2 mRNA in KIRC data. Results Higher methylation levels in RCC were significantly associated with advanced disease (p p = 0.003), tumor differentiation (p = 0.033) and presence of lymph node (p = 0.021) or distant metastases (p = 0.008). TACSTD2 hypermethylation was associated with a shorter RFS of patients and demonstrate statistical independency from clinical parameters as state of metastasis, tumor stage, grade and state of advanced disease. In silico validation using TCGA KIRC data also demonstrated association of TACSTD2 loci with adverse clinicopathology and shortened RFS of patients. In addition, in silico analyses of TCGA KIRC data showed an inverse correlation between DNA methylation levels of TACSTD2 and mRNA expression. Conclusions Our results suggest an association between TACSTD2 methylation and disease progression and clinical course of RCC.

Harrina E Rahardjo,1,2 Stefan Ückert,2 Andreas Bannowsky,3 Markus A Kuczyk,2 George T Kedia2,4 1Department of Urology, Universitas Indonesia School of Medicine, Cipto Mangunkusumo Hospital, Jakarta, Indonesia; 2Hannover Medical School, Division of Surgery, Department of Urology & Urological Oncology, Hannover, Germany; 3Imland Hospital GmbH, Department of Urology, Rendsburg, Germany; 4DIAKOVERE GmbH, Friederikenstift Lutheran Hospital, Department of Urology, Hannover, GermanyCorrespondence: Stefan ÜckertHannover Medical School, Department of Urology & Urological Oncology, Hannover, 30623, GermanyTel +49 511 5 32 34 37Fax +49 511 5 32 34 81Email sue_de_99@yahoo.dePurpose: Although it has been supposed that the NO/cyclic GMP system produces inhibitory signals to reduce the resistance of the bladder outlet and urethra during the micturition phase, little is known on the mechanisms controlling the function of urethral smooth muscle. The aim of the present study was to examine in the male and female urethra the expression of phosphodiesterase (PDE) isoenzymes, known as key proteins of the cyclic GMP/AMP signaling.Methods: Urethral tissue was obtained from 4 female cadavers and 7 male patients (who had undergone gender reassignment surgery). The expression of mRNA encoding for PDE1A, 1B, 1C, 2A, 4B, 4D, 5A, 10A and 11A was investigated by means of real-time polymerase chain reaction. Western blot (WB) analysis was conducted to detect PDE isoenzymes.Results: RT-PCR revealed relevant amounts of mRNA encoding for PDE1A, 2A, 4B, 5A, 10A and 11A in male and female urethral tissue. The expression of PDE1A, 2A, 4B and 10A was 2-fold higher in the female than in the male urethra, whereas the expression of PDE11A mRNA was 7-fold higher in the male tissue. In the WB experiments, immunosignals specific for PDE1A, PDE4A and 4B and PDE11A were of higher degree in the female than the male tissue specimens, while an almost equivocal expression of PDE2A, PDE5A and PDE10A was registered.Conclusion: On the level of mRNA and function proteins, different patterns of expression of PDE isoenzymes were registered in human male and female urethra. Future studies may clarify whether inhibition of PDE isoenzymes is likely to facilitate the relaxation of the outflow region in both sexes.Keywords: urethral smooth muscle, phosphodiesterase isoenzymes, cyclic adenosine monophosphate, nitric oxide/cyclic guanosine monophosphate

CRP-based scoring systems were found to correlate with survival in patients with urooncologic diseases. Our retrospective single-centre study aimed to confirm CRP as a prognostic parameter in patients with bladder cancer (BCa) undergoing radical cystectomy (RC) and, based on the findings, to develop our own outcome score for muscle-invasive bladder cancer (MIBC) patients undergoing RC in order to identify patients with a high risk of mortality.A total of 254 patients who underwent RC at Hanover Medical School between 1996 and 2007 were reviewed with a follow-up until autumn 2013. The clinicopathologic parameters assessed included age, co-morbidities, pre-/postoperative serum levels of CRP, leukocytes, haemoglobin, creatinine, urinary diversion, tumour grading, staging, lymph node status, lymph node density (LND), lymphovascular invasion (LVI), metastases, and resection margin status. The Chi-square test was used for univariate analyses. Kaplan-Meier estimates and the log-rank test were used for survival analyses. Regarding outcome, overall survival (OS) was assessed.The multivariate analysis excluding lymph node (LN)-positive and metastatic patients at time of RC showed a significant association of R status (R; p 0.001), LVI (L; p = 0.021) and preoperative CRP level 5 mg/l (C; p = 0.008) with OS. Based on these parameters, the RLC score was developed. The median OS in the intermediate, high-risk and very high-risk groups according to the RLC score was 62, 22, and 6.5 months, respectively. The score had a high predictive accuracy of 0.752.The RLC score identifies BCa patients at a higher risk of overall mortality after RC. Overall, our study supports the role of CRP in prognostic score models for BCa.In der Vergangenheit konnte für CRP basierte Klassifizierungssysteme bereits eine Korrelation mit dem Überleben bei Patienten mit uroonkologischer Erkrankung nachgewiesen werden. Unsere retrospektive, unizentrische Studie zielte darauf ab, CRP als prognostischen Parameter für Patienten mit Harnblasenkarzinom (BCa), die sich einer radikalen Zystektomie (RC) unterziehen, zu bestätigen und basierend auf diesen Beobachtungen ein eigenes Klassifizierungssystem für muskelinvasive Harnbasenkarzinome zu entwickeln, welches Patienten mit einem hohen Mortalitätsrisiko sicher identifizieren kann.Insgesamt wurden Daten von 254 Patienten der Medizinischen Hochschule Hannover, die sich zwischen 1996 und 2007 einer RC unterzogen und bis Herbst 2013 nachbeobachtet wurden, ausgewertet. Die ausgewerteten klinisch-pathologischen Parameter umfassten u. a. das Alter, Komorbiditäten, prä- und postoperative CRP-Spiegel, Tumorgrading und -staging, Lymphknotenstatus, die lymphovaskuläre Infiltration (LVI) sowie Metastasenstatus und Resektionsränder (R-Status). Univariate Analysen wurden mittels Chi-Quadrat-Test durchgeführt. Ausgewertet wurde das Gesamtüberleben (OS).Die multivariate Analyse unter Ausschluss Lymphknoten positiver und metastasierter Patienten ergab eine signifikante Korrelation von R-Status (R; p 0,001), LVI (L; p = 0.021) und präoperativ eleviertem CRP-Spiegel 5 mg/l (C; p = 0,008) mit dem OS. Das mediane OS in den RLC-Risikogruppen betrug 62 Monate in der mittleren Risikogruppe, 22 Monate in der Hochrisikogruppe und 6,5 Monate in der Gruppe mit sehr hohem Risiko. Der Score hatte eine hohe Vorhersagegenauigkeit von 0,752.Der RLC-Score identifiziert BCa-Patienten nach RC mit einem höheren Risiko für eine erhöhte Mortalität. Insgesamt stützen unsere Daten die Rolle von CRP in prognostischen Vorhersagemodellen beim BCa.

The European Association of Urology (EAU) Renal Cell Carcinoma (RCC) Guideline Panel performed a protocol-driven systematic review (SR) on thermal ablation (TA) compared with partial nephrectomy (PN) for T1N0M0 renal masses, in order to provide evidence to support its recommendations. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed, and only comparative studies published between 2000 and 2019 were included. Twenty-six nonrandomised comparative studies were included, recruiting a total of 167 80 patients. Risk of bias (RoB) assessment revealed high or uncertain RoB across all studies, with the vast majority being retrospective, observational studies with poorly matched controls and short follow-up. Limited data showed TA to be safe, but its long-term oncological effectiveness compared with PN remains uncertain. A quality assessment of pre-existing SRs (n=11) on the topic, using AMSTAR, revealed that all SRs had low confidence rating, with all but two SRs being rated critically low. In conclusion, the current data are inadequate to make any strong and clear conclusions regarding the clinical effectiveness of TA for treating T1N0M0 renal masses compared with PN. Therefore, TA may be cautiously considered an alternative to PN for T1N0M0 renal masses, but patients must be counselled carefully regarding the prevailing uncertainties. We recommend specific steps to improve the evidence base based on robust primary and secondary studies. PATIENT SUMMARY: In this report, we looked at the literature to determine the effectiveness of thermoablation (TA) in the treatment of small kidney tumours compared with surgical removal. We found that TA could cautiously be offered as an option due to many remaining uncertainties regarding its effectiveness.

Purpose To assess the outcome of prostate cancer (PCa) patients diagnosed with oligorecurrent disease and treated with a first and a second PSMA (prostate-specific membrane antigen ligand) PET(positron-emission tomography)-directed radiotherapy (RT). Patients and methods Thirty-two patients with oligorecurrent relapse after curative therapy received a first PSMA PET-directed RT of all metastases. After biochemical progression, all patients received a second PSMA PET-directed RT of all metastases. The main outcome parameters were biochemical progression-free survival (bPFS) and androgen deprivation therapy-free survival (ADT-FS). The intervals of BPFS were analyzed separately as follows: the interval from the last day of PSMA PET-directed RT to the first biochemical progression was defined as bPFS_1 and the interval from second PSMA PET-directed RT to further biochemical progression was defined as bPFS_2. Results The median follow-up duration was 39.5 months (18–60). One out of 32 (3.1%) patients died after 47 months of progressive metastatic prostate cancer (mPCa). All patients showed biochemical responses after the first PSMA PET-directed RT and the median prostate-specific antigen (PSA) level before RT was 1.70 ng/mL (0.2–3.8), which decreased significantly to a median PSA nadir level of 0.39 ng/mL (range p = 0.004). The median PSA level at biochemical progression after the first PSMA PET-directed RT was 2.9 ng/mL (range 0.12–12.80; p = 0.24). Furthermore, the PSA level after the second PSMA PET-directed RT at the last follow-up (0.52 ng/mL, range p = 0.36) from the median PSA level (1.70 ng/mL, range 0.2–3.8) before the first PSMA PET-directed RT. The median bPFS_1 was 16.0 months after the first PSMA PET-directed RT (95% CI 11.9–19.2) and the median bPFS_2 was significantly shorter at 8.0 months (95% CI 6.3–17.7) after the second PSMA PET-directed RT (p = 0.03; 95% CI 1.9–8.3). Multivariate analysis revealed no significant parameter for bPFS_1, whereas extrapelvic disease was the only significant parameter (p = 0.02, OR 2.3; 95% CI 0.81-4.19) in multivariate analysis for bPFS_2. The median ADT-FS was 31.0 months (95% CI 20.1–41.8) and multivariate analysis showed that patients with bone metastases, compared to patients with only lymph node metastases at first PSMA PET-directed RT, had a significantly higher chance (p = 0.007, OR 4.51; 95% CI 1.8–13.47) of needing ADT at the last follow-up visit. Conclusion If patients are followed up closely, including PSMA PET scans, a second PSMA PET-directed RT represents a viable treatment option for well-informed and well-selected patients.

ZusammenfassungIn den letzten zwei Jahren sind Anti-VEGFR-Tyrosinkinase-Inhibitoren (TKI) in der Erstlinientherapie des fortgeschrittenen Nierenzellkarzinom nahezu komplett durch Immuntherapie-Kombinationen mit Checkpoint-Inhibitoren ersetzt worden. Die Prognose der Patienten konnte damit nochmals deutlich verbessert werden. In den entsprechenden Zulassungsstudien wurden mediane Überlebenszeiten von drei bis vier Jahren erreicht. Die TKI-Monotherapie hat bei günstigem Progressionsrisiko, bei Kontraindikationen gegen eine Immuntherapie und im Kontext der SARS-CoV-2-Pandemie aber weiterhin einen Stellenwert.Die Frage, welche Therapie für welche Patient/-innen geeignet ist, stellt sich vor dem Hintergrund von zwei CPI-TKI-Kombinationen und einer reinen CPI-Kombination als neuem Erstlinien-Standard auf einer neuen Basis. Temsirolimus und die Kombination Bevacizumab + Interferon-alpha spielen nahezu keine Rolle mehr. In der Zweitlinientherapie wurde für Nivolumab und Cabozantinib nach TKI-Vortherapie ein signifikanter Überlebensvorteil gegenüber Everolimus gezeigt. Die Kombination Lenvatinib + Everolimus sowie Axitinib sind weitere zugelassene Substanzen. Auch für TKI liegen Daten vor, allerdings mit begrenzter Aussagekraft. Everolimus als Monotherapie ist durch die neuen Optionen in der Zweitlinie abgelöst worden. Insgesamt fehlt es an Biomarkern, die bei der Therapiewahl unterstützen könnten. Die kürzlich erfolgte Aktualisierung der S3-Leitlinie war daher ein wichtiger Schritt, um evidenzbasiert in der klinischen Praxis Orientierung zu geben.Bei potenziell komplexeren Therapiealgorithmen und gleichzeitig nur wenig Evidenz muss auch die Frage nach der optimalen Sequenztherapie neu diskutiert werden. Die meisten Zweitlinien-Optionen wurden nach Versagen einer gegen VEGF-gerichteten TKI-Therapie geprüft, die nur noch für eine Minderheit der Patient/-innen infrage kommt.Im Rahmen eines interdisziplinären Expertengesprächs wurden im November 2020 die aktuelle Datenlage einschließlich neuerer Studienergebnisse sowie relevante Kriterien für die individuelle Therapieentscheidung diskutiert. Auch die SARS-CoV-2-Pandemie fand dabei Berücksichtigung. Ziel war es, gemeinsame Empfehlungen auf Basis der aktuell publizierten Daten und der eigenen klinischen Erfahrung für den Praxisalltag abzuleiten. Die Ergebnisse werden in dieser Publikation vorgestellt.

Objective Rezum is a minimal invasive surgical treatment for patients with lower urinary tract symptoms (LUTS) related to benign prostatic enlargement (BPE). The aim of our study was to assess safety and efficacy of the Rezum procedure in a consecutive series of patients. Material and methods A retrospective study was performed in a single tertiary care hospital in patients undergoing Rezum procedure between 2018 and 2020. All patients that underwent intervention because of drug-refractory moderate to severe LUTS were assessed. Descriptive outcomes such as symptoms scores (IPSS, IPSS-QoL), peak flow in uroflowmetry (Qmax), post-micturition residual urine volume (PVR) and prostate volume (PVol) were analysed. Results In total, 92 Rezum procedures were performed in the observational period. All interventions were competed without device- or procedure relates adverse events. Patients achieved a significant symptom relief as measured in IPSS (50% reduction, p Conclusion Rezum therapy is safe and effective and can be considered a viable treatment option for BPH related LUTS.

In the treatment of advanced renal cell carcinoma, anti-VEGFR tyrosine kinase inhibitors (TKI) have been replaced mostly by immunotherapy combinations with checkpoint inhibitors (CPI), especially in first line therapy. Due to these novel therapies, the prognosis of patients has been improved further. In pivotal studies a median overall survival of 3-4 years has been achieved. TKI monotherapy remains important for patients with low risk, a contraindication against immunotherapy and with regard to the SARS-CoV-2 pandemic.Selection of the correct first line therapy is difficult to answer because there are two CPI-TKI combinations and one CPI-combination. Temsirolimus and the combination bevacizumab + interferon alfa have become less important. In second line therapy, nivolumab and cabozantinib have demonstrated superior overall survival compared to everolimus. Furthermore, the combination of lenvatinib + everolimus and axitinib are approved treatment options in the second line and further settings. TKI are an option as well, but they have lower supporting evidence. Everolimus has been replaced in the second line setting by these new options. Biomarkers are not available. The German S3 guideline has been updated recently to give better orientation in clinical practice.The question of the optimal sequence is still unanswered. Most second line options were evaluated after failure of anti-VEGF-TKI, but these are only applicable for a minority of patients.The purpose of an interdisciplinary expert meeting in november 2020 was to debate which criteria should influence the therapy. The members discussed several aspects of treating patients with advanced or metastatic RCC, including the SARS-CoV-2 pandemic. As in previous years, the experts intended to provide recommendations for clinical practice. The results are presented in this publication.In den letzten zwei Jahren sind Anti-VEGFR-Tyrosinkinase-Inhibitoren (TKI) in der Erstlinientherapie des fortgeschrittenen Nierenzellkarzinom nahezu komplett durch Immuntherapie-Kombinationen mit Checkpoint-Inhibitoren ersetzt worden. Die Prognose der Patienten konnte damit nochmals deutlich verbessert werden. In den entsprechenden Zulassungsstudien wurden mediane Überlebenszeiten von drei bis vier Jahren erreicht. Die TKI-Monotherapie hat bei günstigem Progressionsrisiko, bei Kontraindikationen gegen eine Immuntherapie und im Kontext der SARS-CoV-2-Pandemie aber weiterhin einen Stellenwert.Die Frage, welche Therapie für welche Patient/-innen geeignet ist, stellt sich vor dem Hintergrund von zwei CPI-TKI-Kombinationen und einer reinen CPI-Kombination als neuem Erstlinien-Standard auf einer neuen Basis. Temsirolimus und die Kombination Bevacizumab + Interferon-alpha spielen nahezu keine Rolle mehr. In der Zweitlinientherapie wurde für Nivolumab und Cabozantinib nach TKI-Vortherapie ein signifikanter Überlebensvorteil gegenüber Everolimus gezeigt. Die Kombination Lenvatinib + Everolimus sowie Axitinib sind weitere zugelassene Substanzen. Auch für TKI liegen Daten vor, allerdings mit begrenzter Aussagekraft. Everolimus als Monotherapie ist durch die neuen Optionen in der Zweitlinie abgelöst worden. Insgesamt fehlt es an Biomarkern, die bei der Therapiewahl unterstützen könnten. Die kürzlich erfolgte Aktualisierung der S3-Leitlinie war daher ein wichtiger Schritt, um evidenzbasiert in der klinischen Praxis Orientierung zu geben.Bei potenziell komplexeren Therapiealgorithmen und gleichzeitig nur wenig Evidenz muss auch die Frage nach der optimalen Sequenztherapie neu diskutiert werden. Die meisten Zweitlinien-Optionen wurden nach Versagen einer gegen VEGF-gerichteten TKI-Therapie geprüft, die nur noch für eine Minderheit der Patient/-innen infrage kommt.Im Rahmen eines interdisziplinären Expertengesprächs wurden im November 2020 die aktuelle Datenlage einschließlich neuerer Studienergebnisse sowie relevante Kriterien für die individuelle Therapieentscheidung diskutiert. Auch die SARS-CoV-2-Pandemie fand dabei Berücksichtigung. Ziel war es, gemeinsame Empfehlungen auf Basis der aktuell publizierten Daten und der eigenen klinischen Erfahrung für den Praxisalltag abzuleiten. Die Ergebnisse werden in dieser Publikation vorgestellt.

Simple Summary Early prediction of aggressive cancer using biomarkers is thought to be important for future improvements in the personalized treatment of renal cell carcinoma (RCC). Epigenetic alterations, such as DNA methylation, are promising candidates because they are frequently associated with distant metastasis of tumors and combinations of them offer greater informativity. Here, we describe the indication of the metastatic disease state of renal cell tumors by the methylation of three new candidate genes, INA, NHLH2, and THBS4. The inclusion of the methylation status of these genes could improve the early detection of metastatic tendency in renal tumors and help identify patients who will benefit from adjuvant treatments. Abstract The detection of DNA methylation in primary tumor tissues could be relevant for early stratification of aggressive renal cell carcinomas (RCCs) as a basis for future personalized adjuvant therapy. Methylated TCGA KIRC based candidate CpG loci in INA, NHLH2, and THBS4 that are possibly associated with RCC metastasis were evaluated by pyrosequencing in 154 paired normal adjacent and primary tumor tissues, as well as in 202 metastatic tissues. Statistical analysis was carried out by bivariate logistic regression for group comparisons, log rank survival analysis, and unsupervised and supervised analysis for the classification of tumors. Increased methylation of INA, NHLH2, and THBS4 loci were significantly associated with distant metastasis in primary tumors (p < 0.05), tissue-specific hypermethylation in metastatic (p = 7.88 × 10−8, 5.57 × 10−10, 2.06 × 10−7) and tumor tissues (p = 3.72 × 10−24, 3.17 × 10−13, 1.58 × 10−19), and shortened progression free survival in patients (p = 0.03). Combined use of CpG site-specific methylation permits the discrimination of tissues with metastatic disease and reveals a significant contribution of CpG sites in all genes to the statistical classification model. Thus, metastasis in RCC is significantly associated with methylation alterations in INA, NHLH2, and THBS4 loci, providing independent information for the potential early detection of aggressive renal cancers as a rationale for stratifying patients to adjuvant therapies.

INTRODUCTION: The corticotropin-releasing hormone (CRH) system, its receptors corticotropin-releasing hormone receptor 1 (CRHR1) and 2 (CRHR2), and its corresponding binding protein corticotropin-releasing hormone-binding protein (CRHBP) as well as the urocortin proteins-structural homologues to CRH, which are included in this peptide family-have become interesting oncological targets recently. Carcinogenesis of various human tumors has been reported with an altered presence of members of this system. The aim of the present study was to examine the role of urocortin 3 (UCN3) in renal cell carcinoma (RCC). METHODS: Therefore, tumoral tissues of 106 patients with RCC and available corresponding normal tissues were analyzed using qPCR for quantitative mRNA expression analysis. Tissue localization and protein signals of UCN3 in normal and tumoral renal specimens were evaluated using western blot and immunohistochemistry. In addition, correlation studies of UCN3 mRNA expression with clinicopathological parameters of patients with RCC and different histological subtypes were evaluated. RESULTS: UCN3 mRNA was significantly downregulated in nearly all tumoral tissues (p = 7.92 × 10-13). The same effect was observed at protein level using immunohistochemistry. Level of UCN3 mRNA expression was not directly correlated with clinicopathological parameters. CONCLUSION: We report for the first time the significant downregulation of UCN3 in RCC. These results demonstrate a possible involvement of the CRH system and its significance in carcinogenesis of RCC. peerReviewed

To systematically assessed the diagnostic performance of contrast-enhanced computed tomography (CT) compared to other imaging modalities for diagnosing and staging renal-cell carcinoma in adults.A comprehensive literature search was conducted through various electronic databases. Data from the selected studies were extracted and pooled, and median sensitivity and specificity were calculated wherever possible. Forty studies analyzing data of 4354 patients were included. They examined CT, magnetic resonance imaging (MRI), positron emission tomography-CT, and ultrasound (US).For CT, median sensitivity and specificity were 88% (interquartile range [IQR] 81%-94%) and 75% (IQR 51%-90%), and for MRI they were 87.5% (IQR 75.25%-100%) and 89% (IQR 75%-96%). Staging sensitivity and specificity for CT were 87% and 74.5%, while MRI showed a median sensitivity of 90% and specificity of 75%. For US, the results varied greatly depending on the corresponding technique. Contrast-enhanced US had a median diagnostic sensitivity of 93% (IQR 88.75%-98.25%) combined with mediocre specificity. The diagnostic performance of unenhanced US was poor. For positron emission tomography-CT, diagnostic accuracy values were good but were based on only a small amount of data. Limitations include the strong heterogeneity of data due to the large variety in imaging techniques and tumor histotypes. Contrast-enhanced CT and MRI remain the diagnostic mainstay for renal-cell carcinoma, with almost equally high diagnostic and staging accuracy.For specific questions, a combination of different imaging techniques such as CT or MRI and contrast-enhanced US may be useful. There is a need for future large prospective studies to further increase the quality of evidence.

To assess the differences in the target volume (TV) delineation of metachronous lymph node metastases between 68 Ga-PSMA ligand PET/CT and conventional imaging in a comparative retrospective contouring study. Twenty-five patients with biochemical prostate cancer recurrence after primary prostatectomy underwent 68 Ga-PSMA ligand PET/CT in addition to conventional imaging techniques such as CT and/or MR imaging for restaging. All patients were diagnosed with at least one lymph node metastasis. TVs were manually delineated in two different ways: (a) based on conventional imaging (CT/MRI) and (b) based on conventional imaging (CT/MRI) plus 68 Ga-PSMA ligand PET/CT. The size of TVs, overlap rates, and subjective assessment of the difficulty of TV delineation reported by the radiation oncologist (easy/moderate/difficult) were compared. With the additional information from PSMA ligand PET, 47 lymph node metastases were identified and included in the gross tumor volume (GTV). The median clinical target volume (CTV) of non-PET-based TV delineation was statistically larger than the CTV based on PET imaging (134.8 ml [range 6.9–565.2] versus 44.9 ml [range 4.9–481.3; p = 0.001]). The CTV based on CT/MRI enclosed only 81.3% (39/48) of PET-positive lymph nodes. The CT/MRI-based CTV did not enclose all PET-positive lymph nodes in 24% (6/25) of patients. In 12% (3/25) of patients, all PET-positive lymph nodes were outside of the CT/MRI-based CTV. The median overlap rates (TVPET/TVCT/MRI × 100) were 45.7% (range 0–96.9) for the GTV and 71.7% (range 9.8–98.2) for the CTV. The assessment of difficulty of contouring revealed that contouring with the additional imaging information of the PET was categorized as easy/moderate in 92% (23/25) and as difficult in 8% (2/25) of the cases, whereas contouring based on CT/MRI without PET was categorized as difficult in 56% (14/25) and as easy/moderate in 44% of the cases (11/25; p = 0.003). 68 Ga-PSMA ligand PET/CT is superior to conventional cross-sectional imaging for the delineation of lymph node metastases from prostate cancer. PET-based TV delineation allows for smaller target volumes and should be considered the standard for irradiation of metachronous lymph node metastases in recurrent prostate cancer. Conventional imaging is not sufficiently sensitive for radio-oncological treatment concepts in oligometastatic prostate cancer.

Purpose To determine the patterns of progression after 68Ga prostate-specific membrane antigen (PSMA)-ligand positron emission tomography (PET)/computed tomography (CT)-guided radiation therapy (RT) for recurrent oligometastatic prostate cancer (PCa). Methods and Materials One hundred and eight patients with increased prostate-specific antigen levels, who received 68Ga-PSMA-ligand PET/CT-guided RT for recurrent oligometastatic disease after primary therapy for PCa were included. The biochemical progression-free survival and distant disease-free survival after PSMA-ligand PET/CT-guided RT were determined. The patterns of progression were determined using renewed 68Ga-PSMA-ligand PET/CT in patients with biochemical progression and compared with the clinical target volume of the 68Ga-PSMA-ligand PET/CT-guided RT. The frequency of infield and outfield relapses was recorded. Results A total of 97.2% (105 of 108) of patients showed a decrease in prostate-specific antigen levels after RT and were classified as biochemical responders. After the median follow-up of 18 months, 43.5% (47 of 108) of the patients experienced biochemical progression, resulting in an estimated biochemical progression-free survival of 16 months. Renewed 68Ga-PSMA-ligand PET/CT allowed localization of recurrent disease in 91.7% (33 of 36) of patients. Analysis of the patterns of progression resulted in a cumulative infield relapse rate of 12.1% (4 of 33) and a cumulative outfield relapse rate of 87.9% (29 of 33). The resultant median disease-free survival was 11 months. In terms of the pattern of progression, we observed a shift in the pattern of metastases toward skeletal involvement and distant lymph node metastases. Of these patients, 45.5% (15 of 33) were treated with further RT to delay initiation or escalation of systemic therapies. Conclusion PSMA-ligand PET/CT-guided RT for relapsed PCa with limited tumor burden allowed individualization of treatment approaches, provided effective local control, and resulted in considerably prolonged biochemical progression-free survival. As indicated by the PSMA-ligand PET/CT-based patterns of progression, repeated PET/CT-guided RT may represent a treatment option in well-selected patients with relapse after RT for oligometastatic disease.

Approximately 21% of patients with renal cell cancer (RCC) present with synchronous metastatic disease at the time of diagnosis, and metachronous metastatic disease occurs in 20–50% of cases within 5 years. Recent advances in adjuvant treatment of aggressive RCC following surgery suggest that biomarker-based prediction of risk for distant metastasis could improve patient selection. Biometrical analysis of TCGA-KIRC data identified candidate loci in the NK6 homeobox 2 gene (NKX6-2) that are hypermethylated in primary metastatic RCC. Analyses of NKX6-2 DNA methylation in three gene regions including a total of 16 CpG sites in 154 tumor-adjacent normal tissue, 189 RCC, and 194 metastatic tissue samples from 95 metastasized RCC patients revealed highly significant tumor-specific, primary metastatic-specific, and metastatic tissue-specific hypermethylation of NKX6-2. Combined CpG site methylation data for NKX6-2 and metastasis-associated genes (INA, NHLH2, and THBS4) demonstrated similarity between metastatic tissues and metastatic primary RCC tissues. The random forest method and evaluation of an unknown test cohort of tissues using receiver operator characteristic curve analysis revealed that metastatic tissues can be differentiated by a median area under the curve of 0.86 (p = 1.7 × 10−8–7.5 × 10−3) in 1000 random runs. Analysis of variable importance demonstrated an above median contribution for decision-making of at least one CpG site in each of the genes, suggesting superior informativity for sites annotated to NHLH2 and NKX6-2. Thus, DNA methylation of NKX6-2 is associated with the metastatic state of RCC tissues and contributes to a four-gene-based statistical predictor of tumoral and metastatic renal tissues.

Available tests to detect clinically significant prostate cancer frequently lead to overdiagnosis and overtreatment. Our study assessed the feasibility of combining a urinary biomarker-based risk score (SelectMDx®) and multiparametric MRI outcomes in order to identify patients with prostate cancer on prostate biopsy with increased accuracy and reliability. Samples of 74 men with suspicion of prostate cancer and available multiparametric MRI were analysed in a prospective cross-sectional study design. First-voided urine for determination of HOXC6 and DLX1 mRNA levels was collected after digital rectal examination and prior to MRI/ultrasound fusion-guided prostate biopsy. All multiparametric MRI images were centrally reviewed by two experienced radiologists blinded for urine test results and biopsy outcome. The PI-RADS v2 was used. SelectMDx® score, PI-RADS and Gleason Sore were obtained. Associations between Gleason Score, PI-RADS scores and SelectMDx® were assessed using ANOVA and t-test. Sensitivity and specificity were assessed and evaluated as area-under-the-curve of the receiver operating characteristic. Upon biopsy, 59.5% of patients were diagnosed with prostate cancer, whereby 40.6% had high-grade prostate cancer (GS ≥ 7a). SelectMDx® scores were significantly higher for patients with positive biopsy findings (49.07 ± 25.99% vs. 22.00 ± 26.43%; p < 0.001). SelectMDx® scores increased with higher PI-RADS scores. Combining SelectMDx®, history of prior biopsy with benign histology and PI-RADS scores into a novel scoring system led to significant prostate cancer detection rates with tiered detection rate of 39%, 58%, 81% and 100% for Gleason grade group II, III, IV, and V, respectively. The area-under-the-curve for our novel sum score in receiver operating characteristic analysis was 0.84. The synergistic combination of two non-invasive tests into a sum score with increased sensitivity may help avoiding unnecessary biopsies for initial prostate cancer diagnosis. For confirmation, further prospective studies with larger sample sizes and univariate and multivariate regression analyses and decision curve analyses are required.

Up until today, there are still uncertainties regarding the occurrence of isoforms of the nitric oxide synthase (eNOS, nNOS) in the human prostate. While nNOS was exclusively seen in slender nerve fibres branching within the transition zone, eNOS was reported in glandular structures and also in small vessels interspersing the tissue. This study aimed to re-evaluate by means of light and electron microscopy (LM, EM), the distribution of eNOS and nNOS in the transition zone of the human prostate. Tissue specimens were obtained from 16 patients who underwent surgery for pelvic malignancies. Using specific antibodies in conjunction with advanced fixation and staining procedures, the occurrence of eNOS and nNOS was investigated. nNOS was detected in nerve fibres interspersing the tissue and was also seen in glandular structures. EM revealed that in glandular epithelial cells immunoreaction for nNOS was limited to the cytoplasmic compartment. Vascular endothelial cells of small vessels transversing glandular structures significantly stained for eNOS, while epithelial layers of prostatic glandules appeared free of eNOS. The results implicate that, in the prostate, nNOS is a mediator of stromal and glandular tissue function, and counteract the assumption of eNOS activity in glandular epithelial cells as a source of NO synthesis.

PurposeTo assess the outcome of radiotherapy (RT) to all PSMA ligand positive metastases for patients with castrate-resistant prostate cancer (mCRPC).Patients and methodsA total of 42 patients developed oligometastatic mCRPC and received PSMA PET-guided RT of all metastases. The main outcome parameters were biochemical progression-free survival (bPFS), and second-line systemic treatment free survival (SST-FS).ResultsA total of 141 PSMA ligand-positive metastases were irradiated. The median follow-up time was 39.0 months (12-58 months). During the follow-up five out of 42 (11.9%) patients died of progressive mPCa. Five out of 42 (11.9%) patients showed no biochemical responses and presented with a PSA level ≥10% of the baseline PSA at first PSA level measurement after RT and were classified as non-responders. The median PSA level before RT was 4.79 ng/mL (range, 0.4-46.1), which decreased significantly to a median PSA nadir level of 0.39 ng/mL (range, ConclusionIn well-informed and closely followed-up patients, PSMA PET-guided RT represents a viable treatment option for patients with oligometastatic mCRPC to delay further systemic therapies.

Introduction: Renal cell carcinoma (RCC), an immunogenic tumor, is the most common form of kidney cancer worldwide. Immune checkpoint inhibitors (ICIs) play an important role in the treatment of metastatic RCC. Programmed death-ligand (PD-L1) has already been proposed as a possible prognosticator for ICIs effectiveness. To elucidate the feasible role of ICIs in neoadjuvant settings, we have assessed the most common PD-L1 expression modalities [tumor proportion score (TPS), combined positivity score (CPS) and inflammatory cell (IC) score] in primary tumors (PTs) and venous tumor thrombi (VTT) in first diagnosed, previously untreated RCC patients with accompanying VTT. Methods: Between January 1999 and December 2016, 71 patients with a first diagnosed, untreated, locally advanced RCC (aRCC) (≥ pT3a) underwent surgery in Hanover Medical School (MHH). PD-L1 expression was examined separately in PTs and VTT using the CPS, IC score and TPS. We also considered the age at the time of the initial surgery and gender as probable influencing factors. By using a cutoff value of 1 (1%), PD-L1 expression levels in PTs and VTT were assessed to enable the determination of any frequency differences. Results: Positive scores for PTs were shown by 54 (CPS), 53 (IC score) and 34 (TPS) patients, whereas in VTT, positive scores were evaluated for a total of 50 (CPS), 47 (IC-score) and 36 (TPS) patients. No statistically significant differences were obtained between the PD-L1 expression immunoscores for PTs and VTT. The covariates age at the time of the initial surgery and gender could not be statistically proven to influence the differences in PD-L1 expression between the VTT and PTs. Conclusion: To the best of our knowledge, this research is the largest study to investigate PD-L1 expression in PTs and VTT in 71 cases. It could have relevance for the future development of neoadjuvant immunotherapy options, particularly in aRCC with VTT.

Both age-dependent and age-independent alteration of DNA methylation in human tissues are functionally associated with the development of many malignant and non-malignant human diseases. TCGA-KIRC data were biometrically analyzed to identify new loci with age-dependent DNA methylation that may contribute to tumor risk in normal kidney tissue. ANKRD34B and ZIC1 were evaluated as candidate genes by pyrosequencing of 539 tissues, including 239 normal autopsy, 157 histopathologically tumor-adjacent normal, and 143 paired tumor kidney samples. All candidate CpG loci demonstrated a strong correlation between relative methylation levels and age (R = 0.70–0.88, p < 2 × 10−16) and seven out of 10 loci were capable of predicting chronological age in normal kidney tissues, explaining 84% of the variance (R = 0.92). Moreover, significantly increased age-independent methylation was found for 9 out of 10 CpG loci in tumor-adjacent tissues, compared to normal autopsy tissues (p = 0.001–0.028). Comparing tumor and paired tumor-adjacent tissues revealed two patient clusters showing hypermethylation, one cluster without significant changes in methylation, and a smaller cluster demonstrating hypomethylation in the tumors (p < 1 × 10−10). Taken together, our results show the presence of additional methylation risk factors besides age for renal cancer in normal kidney tissue. Concurrent tumor-specific hypermethylation suggests a subset of these loci are candidates for epigenetic renal cancer susceptibility.

Context The epidemiological signature of renal cell carcinoma (RCC) during the past decades is explained by overdetection and overtreatment of indolent cancers; furthermore, a non-negligible proportion of patients undergoing surgery for suspected RCC harbour benign renal tumours. As the gold standard for RCC diagnosis remains histopathological analysis of surgical or biopsy specimens, implementation of noninvasive diagnostic strategies to discriminate between benign and malignant renal masses is an urgent unmet need. Objective To systematically review novel liquid biomarkers and imaging modalities for RCC diagnosis. Evidence acquisition A systematic review of the recent English-language literature was conducted according to the European Association of Urology guidelines and the PRISMA statement recommendations (PROSPERO ID: CRD42020190773) using the MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, and ClinicalTrials.gov databases. Risk-of-bias assessment was performed according to the QUADAS 2 tool. Evidence synthesis Overall, 15 studies (six on biomarkers and nine on imaging) and eight clinical trials were included. None of the biomarkers or imaging modalities has been validated or shown to have a distinct clinical value for RCC. Specific combinations of urinary cell-free and exosomal miRNAs, urinary miR-15a, and specific panels of urinary metabolites assessed by metabolomics appear promising. In addition, machine/deep learning algorithms and radiomics applied to cross-sectional images may have potential to improve RCC diagnosis. Most studies are limited by the retrospective design, size, and lack of external validation. Conclusions Liquid biomarkers or imaging modalities are not ready for integration in the clinic and further well-designed studies must validate preliminary findings and explore utility in clinical decision-making. Patient summary We provide a comprehensive overview of the currently available biomarkers (measured in blood or urine) and novel imaging tests (other than conventional imaging) to discriminate kidney cancer from benign renal masses in a noninvasive fashion. None of the biomarkers or imaging modalities studied was validated or added clinical value; therefore, none of them can be implemented in the clinic. However, these approaches appear to be promising for improving the diagnosis of kidney cancer in the future.

Due to novel therapies, the prognosis of patients with metastatic renal cell carcinoma (mRCC) has improved. A median overall survival of more than two years is a realistic goal. Immunotherapy combinations with checkpoint inhibitors or checkpoint inhibitors and the tyrosine kinase inhibitor axitinib are new first-line options.Sunitinib, pazopanib, tivozanib and the combination of bevacizumab + interferon alpha are approved for first-line therapy regardless of the progression risk score. The use of both the combination of nivolumab + ipilimumab and cabozantinib is restricted to intermediate and high-risk patients. In this subgroup, the immunotherapy combination was more effective in terms of overall survival compared with sunitinib. Temsirolimus is only approved for high-risk patients.Sunitinib and pazopanib can also be applied as second-line options - for pazopanib the use is restricted to the event of cytokine failure. Nivolumab and cabozantinib demonstrated superior overall survival compared with everolimus. Furthermore, the combination of lenvatinib + everolimus and axitinib are approved treatment options in the second-line and further settings. Everolimus has been replaced in the second-line setting by these new options.The question regarding the optimal sequence is still unanswered.The purpose of an interdisciplinary expert meeting was to debate which criteria should influence treatment. The members discussed several aspects of treating patients with advanced or metastatic RCC. As in previous years, the experts intended to provide recommendations for clinical practice. The results are presented in this publication.Die Prognose von Patienten mit metastasiertem Nierenzellkarzinom (mRCC) hat sich dank neuer Therapien deutlich verbessert. Überlebenszeiten von mehr als zweieinhalb Jahren sind realistisch. Immuntherapiekombinationen mit Checkpoint-Inhibitoren (CPI) oder dem Tyrosinkinaseinhibitor Axitinib sind neue Standards in der Erstlinientherapie und haben die Monotherapie mit Tyrosinkinase-Inhibitoren weitgehend verdrängt.Für die Erstlinientherapie des mRCC sind Ipilimumab + Nivolumab (intermediäres und hoges Risiko) und Pembrolizumab + Axitinib sowie Avelumab + Axitinib für alle Risikogruppen zugelassen. Darüber hinaus stehen Sunitinib, Pazopanib, Tivozanib, Cabozantinib (intermediäres und hohes Risiko), die Kombination Bevacizumab + Interferon-alpha sowie Temsirolimus (hohes Risiko) zur Verfügung.Sunitinib und Pazopanib haben eine Zulassung auch für die Zweitlinientherapie – bei Pazopanib gilt diese für den Einsatz nach Zytokinen. Für Nivolumab und Cabozantinib wurde in der Zweitlinientherapie ein signifikanter Überlebensvorteil gegenüber Everolimus gezeigt. Die Kombination Lenvatinib + Everolimus sowie Axitinib sind weitere für die Zweitlinie zugelassene Substanzen. Everolimus als Monotherapie ist durch die neuen Optionen in der Zweitlinie abgelöst worden.Die Frage nach der optimalen Sequenztherapie muss aufgrund des Einzugs von CPI in die Erstlinie neu diskutiert werden, da die meisten Optionen nach Versagen einer VEGF-gerichteten TKI-Therapie geprüft wurden. Solange hierzu keine validen Studien oder Biomarker vorliegen, müssen andere Kriterien für die Therapieentscheidung herangezogen werden.Ziel eines interdisziplinären RCC-Expertengesprächs war es, gemeinsame Therapieempfehlungen auf Basis der aktuell publizierten Daten und der eigenen klinischen Erfahrung für den Praxisalltag abzuleiten. Die Ergebnisse werden in dieser Publikation vorgestellt.

Introduction For risk stratification of non-muscle invasive bladder cancer (NMIBC), the depth of stromal invasion can be further classified, where the lamina muscularis mucosae (MM) serves as a reference structure. While the overall identifiability of MM in standard transurethral specimens is low, en bloc resection may help in identification and overall orientation. The aims of this study were to report the detection rate of MM in en bloc resected bladder tumors (ERBT) and to provide real-world information on tissue stability and preservation of en bloc architecture during recovery and processing for histopathologic evaluation. Methods Thirty-four ERBT specimens were histologically re-evaluated with regard to MM detectability and structure as well as the presence of en bloc architecture and further histologic features. Associations with tumor size and energy source and within histologic parameters were assessed by standard Pearson's chi-squared analyses and Cramér’s V effect size testing (V). Results The first parameter assessed was MM detection rate. In 19 out of 34 samples (56%) MM was detectable: scattered in 9 cases (26%), interrupted in 8 cases (24%) and continuous in 2 cases (6%). The second parameter assessed was preservation of en bloc architecture. In 11 out of 34 samples (32%), en bloc architecture could not be confirmed, and these samples served as a reference group for the detection of MM. Preservation of en bloc architecture was associated with an increased MM detection rate (MM in en bloc preserved 16/23, 70% vs. non-preserved 3/11, 27%; p = 0.020; V = 0.398) and with tumor size (p = 0.005; V = 0.595). Medium-sized tumors (1.1–2 cm) were best preserved. The choice of energy source did not show relevant association with en bloc architecture (p = n.s.). Conclusions In line with recent publications, ERBT increases the MM detection rate considerably. However, a third of the ERBT specimens lost en bloc architecture during sample recovery and processing. Tumor size is a relevant factor, with optimal architecture preservation between 1 and 2 cm. Optimizing resection techniques, recovery, transport, and diagnostic processing of ERBT samples is warranted to verify the diagnostic value of MM-based substaging.

Background: The introduction of checkpoint inhibitors is a long-awaited new option for a urothelial cancer with a poor prognosis. Apart from clinical studies, the data on real world experience is scarce. Methods: Patients for monotherapy with either Atezolizumab, Nivolumab or Pembrolizumab after chemotherapy were included. Adverse events and immune related adverse events as well as survival data and imaging analyses were recorded in a prospectively designed multi-center data base. Duration of response, progression free survival (PFS), and overall survival (OS) were estimated with the Kaplan-Meier method. Results: A total of 28 patients were included. The median follow-up was 8.0 (range, 0.7-41.7) months. Median PFS was 5.8 (95% CI, 2.3-NA) months. Median OS for all patients was 10.0 (95% CI, 8.0-NA) months. The overall response rate (ORR) was 21.4% (6 out of 28 patients). Adverse events were recorded in 20 (71.4%) of patients. Higher grade adverse events (≥Grade 3) were present in 11 (39.3%) patients. No therapy related deaths occurred during the observation period. A total of 13 (46.4%) patients had adverse events that were considered to be immune related. The most commonly affected organ was the thyroid gland with 21.4% of events. Conclusion: Our real-world clinical series confirms an objective response for about every fifth patient, promising OS and a low incidence for severe adverse events (≥Grade 3).

Background:The TNR-C score (tumor stage, lymph node density, resection margin status, and serum CRP) correlates with cancer specific survival (CSS) in patients with bladder cancer (BCa) undergoing radical cystectomy (RC). Our retrospective single center study aimed to evaluate CRP as a prognostic parameter in patients with BCa undergoing RC, to externally validate the TNR-C score, and based on the findings, to develop our own outcome score for muscle-invasive bladder cancer (MIBC) patients undergoing RC that can identify patients with a high risk of progression. Material and methods:In total, 254 patients who underwent RC at Hanover Medical School between 1996 and 2007 were reviewed. The clinicopathologic parameters assessed included age; co-morbidities; pre-/postoperative serum levels of CRP; leucocytes; hemoglobin; creatinine; urinary diversion; tumor grading, staging, and lymph node status; lymph node density (LND); lymphovascular invasion (LVI); metastases; and resection margin status. Regarding outcome, overall survival (OS) was assessed. Results:Single parameters of the TNR-C-score, such as T-stage (p=0.012) and R-status (p=0.002), were independent prognostic parameters for overall survival (OS). Univariate analysis showed a significant association of OS with the T-stage (pT2, p=0.001), R-status (p5 mg/L (C; p=0.008) with OS. Based on these parameters, the RLC-score was developed. The median OS in the low, intermediate, and high-risk groups according to the RLC score was 62, 22, and 6.5 months, respectively. The score had a high predictive accuracy of 0.752.Conclusion:The RLC-score identifies BCa patients at a higher risk of disease progression and overall mortality after RC. Regarding the TNR-C score, only T-stage and R-status were independent prognostic factors for OS. Nevertheless, the survival curves showed a significantly lower OS for TNR-C high risk group members than low and intermediate risk group members. Overall, our study supports the role of CRP in prognostic score models for BCa.

Background While a considerable number of tumor-specific hypermethylated loci have been identified in renal cell cancer (RCC), DNA methylation of loci showing successive increases in normal, tumoral, and metastatic tissues could point to genes with high relevance both for the process of tumor development and progression. Here, we report that DNA methylation of a locus in a genomic region corresponding to the 3′UTR of the transcription factor T-box brain 1 (TBR1) mRNA accumulates in normal renal tissues with age and possibly increased body mass index. Moreover, a further tissue-specific increase of methylation was observed for tumor and metastatic tissue samples. Results Biometric analyses of the TCGA KIRC methylation data revealed candidate loci for age-dependent and tumor-specific DNA methylation within the last exon and in a genomic region corresponding to the 3′UTR TBR1 mRNA. To evaluate whether methylation of TBR1 shows association with RCC carcinogenesis, we measured 15 tumor cell lines and 907 renal tissue samples including 355 normal tissues, 175 tissue pairs of normal tumor adjacent and corresponding tumor tissue as well 202 metastatic tissues samples of lung, bone, and brain metastases by the use of pyrosequencing. Statistical evaluation demonstrated age-dependent methylation in normal tissue (R = 0.72, p < 2 × 10−16), association with adiposity (P = 0.019) and tumor-specific hypermethylation (P = 6.1 × 10−19) for RCC tissues. Comparison of tumor and metastatic tissues revealed higher methylation in renal cancer metastases (P = 2.65 × 10−6). Conclusions Our analyses provide statistical evidence of association between methylation of TBR1 and RCC development and disease progression.

ZusammenfassungDie Prognose von Patienten mit metastasiertem Nierenzellkarzinom (mRCC) hat sich dank neuer Therapien deutlich verbessert. Überlebenszeiten von mehr als zweieinhalb Jahren sind realistisch. Immuntherapiekombinationen mit Checkpoint-Inhibitoren (CPI) oder dem Tyrosinkinaseinhibitor Axitinib sind neue Standards in der Erstlinientherapie und haben die Monotherapie mit Tyrosinkinase-Inhibitoren weitgehend verdrängt.Für die Erstlinientherapie des mRCC sind Ipilimumab + Nivolumab (intermediäres und hoges Risiko) und Pembrolizumab + Axitinib sowie Avelumab + Axitinib für alle Risikogruppen zugelassen. Darüber hinaus stehen Sunitinib, Pazopanib, Tivozanib, Cabozantinib (intermediäres und hohes Risiko), die Kombination Bevacizumab + Interferon-alpha sowie Temsirolimus (hohes Risiko) zur Verfügung.Sunitinib und Pazopanib haben eine Zulassung auch für die Zweitlinientherapie – bei Pazopanib gilt diese für den Einsatz nach Zytokinen. Für Nivolumab und Cabozantinib wurde in der Zweitlinientherapie ein signifikanter Überlebensvorteil gegenüber Everolimus gezeigt. Die Kombination Lenvatinib + Everolimus sowie Axitinib sind weitere für die Zweitlinie zugelassene Substanzen. Everolimus als Monotherapie ist durch die neuen Optionen in der Zweitlinie abgelöst worden.Die Frage nach der optimalen Sequenztherapie muss aufgrund des Einzugs von CPI in die Erstlinie neu diskutiert werden, da die meisten Optionen nach Versagen einer VEGF-gerichteten TKI-Therapie geprüft wurden. Solange hierzu keine validen Studien oder Biomarker vorliegen, müssen andere Kriterien für die Therapieentscheidung herangezogen werden.Ziel eines interdisziplinären RCC-Expertengesprächs war es, gemeinsame Therapieempfehlungen auf Basis der aktuell publizierten Daten und der eigenen klinischen Erfahrung für den Praxisalltag abzuleiten. Die Ergebnisse werden in dieser Publikation vorgestellt.