The activity of intravesical hyaluronic acid and chondroitin sulfate administration on urothelial gene expression. Preliminary results on the epidermal growth factor receptor and fibronectin gene expression evaluated in bladder washings of patients affected by non muscle-invasive bladder cancer

Introduction & Objectives Hyaluronic acid (HA) and chondroitin sulfate (CS) are two major constituents of the bladder glycosaminoglycan layer. Recent data show that Fibronectin (FN) and Epidermal Growth Factor Receptor (EGFR) gene expression can be measured in bladder washings and could represent potential biomarkers of urothelial damage and tumor aggressiveness, respectively (1,2). The aim of our study was to investigate the interference of a single intravesical instillation of HA-CS solution on the expression of FN and EGFR genes in patients affected by non-muscle-invasive bladder cancer (NMIBC). Material & Methods A prospective double-blinded study included patients undergoing adjuvant intravesical therapy for NMIBC and age matched healthy controls. For EGFR evaluation, a single HA-CS solution was administered intravesically 14 days after transurethral resection of high risk NMIBC, before the start of the adjuvant therapy. For FN evaluation, a single HA-CS instillation was administered to patients showing local toxicity secondary to intravesical adjuvant therapy. Samples of bladder washings were collected before and one week after the HA-CS instillation, obtaining a cellular pellet stored at -80 °C. Cellular RNA was isolated by a miRNeasy Mini Kit (Qiagen®) and cDNA, obtained using a “High Capacity cDNA Reverse Transcription Kit” (Life Technologies®) was used to perform a gene expression analysis by a Real Time PCR. EGFR and FN gene expression values were expressed in FOLDs of change compared to healthy controls (FN and EGFR=1). Results Thirty-eight patients and 5 controls entered the study. Seventeen and 21 patients were evaluated for FN and EGFR respectively. In 21 patients with high risk NMIBC, the median EGFR expression decreased from 2.4 folds (range: 0.1-39.0) to 1.0 fold (range: 0.05-36.8) showing a statistically significant decrease of 58.3% (p<0.02). In patients showing clinically relevant toxicity secondary to intravesical adjuvant therapy (BCG in 9 and Epirubicin in 8 patients) the median FN expression value dropped from 1.8 folds (range: 0.07-8.1) to 0.9 fold (range: 0.1-7.5) after HA-CS administration with a statistically significant decrease of 50% (p<0.05). Conclusions FN gene expression in bladder washings appears related to the intensity of the urothelial damage, reaching higher expression levels in case of severe toxicity induced by intravesical adjuvant therapy (2). In our experience the FN gene expression significantly decreases a week after the administration of HA-CS solution with contemporary symptomatic relief. Moreover the urothelial EGFR gene expression resulted significantly lowered one week after the HA-CS intravesical administration. The reduced availability of its receptor could limit the proliferative activity of EGF on the urothelium promoting recurrence and progression. Acknowledgements: GSTU Foundation References: 1. Serretta V, et al. Feasibility of EGFR evaluation in bladder washings of patients affected by non muscle-invasive bladder cancer. J Urol, 2016. 195 (4S): e327. 2. Alonge V, et al. Correlation between Fibronectin gene expression and local toxicity induced by adjuvant intravesical therapy. J Urol, 2015. 193 (4S): e53

Intravesical chemotherapy for intermediate risk non-muscle invasive bladder cancer recurring after a first cycle of intravesical adjuvant therapy

Context: The therapeutic strategy in intermediate risk (IR) non-muscle invasive bladder cancer (NMIBC) recurring after intravesical therapy (IT) is not well defined. Most patients are usually retreated by Bacillus Calmette-Guerin (BCG). Aims: To evaluate the efficacy of intravesical chemotherapy (ICH) given at recurrence after the first cycle of ICH in IR-NMIBC recurring 6 months or later. Settings and Design: Retrospective analysis of the efficacy of ICH given after previous IT. Materials and Methods: The clinical files of IR-NMIBC patients recurring later than 6 months after transurethral resection (TUR) and IT and retreated by IT were reviewed. The patients should be at intermediate risk both initially and at the first recurrence. BCG should have been given at full dose. Cytology and cystoscopy were performed 3 monthly for 2 years and then 6 monthly. Statistical Analysis: The RFS was estimated by the Kaplan-Meier method and the differences between treatment groups were compared by log-rank test. Mann Whitney U-test was used to compare the parameters\u2032 distribution for median time to recurrence. Multivariate Cox proportional hazards models were used. Results: The study included 179 patients. The first IT was ICH in 146 (81.6%) and BCG in 33 (18.4%), re-IT was ICH in 112 (62.6%) and BCG in 67 (37.4%) patients. Median time to recurrence was 18 and 16 months after first and second IT (P = 0.32). At 3 years, 24 (35.8%) and 49 (43.8%) patients recurred after BCG and ICH, respectively (P = 0.90). No difference in RFS was found between BCG and ICH given after a first cycle of ICH (P = 0.23). Conclusions: Re-treatment with ICH could represent a legitimate option to BCG in patients harboring IR-NMIBC recurring after TUR and previous ICH. Prospective trials are needed

Compliance to therapy with Dapoxetine in patients affected by Premature Ejaculation

Introduction: Premature ejaculation (PE) is a sexual dysfunction with high prevalence. According to some reports, it is present in about 20-30% of the male population.
Since 2009 PE has been treated with a novel inhibitor of serotonin re-uptake, Dapoxetine, which has been reported to be specifically active for PE.
Materials and methods: 59 patients have been selected among the patients affected by PE observed at the outpatient department of Urology and Andrology of the "Paolo Giaccone" University Policlinic Hospital of Palermo.
Diagnosis was confirmed unequivocally in all patients, who were suitable for drug treatment and accepted to participate in the study. They were divided in 2 groups: one receiving Dapoxetine (41 patients), another (18 patients) receiving Citalopram. Patients were followed up by telephone at monthly intervals, in order to compare compliance, efficacy and side effects.
Results: Compliance to treatment was obtained in 56% of patients treated with Dapoxetine and in 61% of those treated with Citalopram.
In the Dapoxetine group side effects were reported in 14.6% versus 38.4% in the Citalopram group. Benefit from the treatment was reported in 82% and 69.2%, respectively

PRELIMINARY DATA ON PSA CHANGES DURING INTRAVESICAL THERAPY FOR NON-MUSCLE INVASIVE BLADDER CANCER

Introduction/Aim: Many factors can cause an increase of PSA independently from the presence of prostate cancer . The objective was to evaluate the fluctuation of the serum levels of PSA during adjuvant intravesical chemotherapy or immunotherapy. An increase of PSA due to intravesical BCG and up to 3 months later has been reported (1). Patients and Methods: Patients treated with intravesical chemotherapy or immunotherapy for non- muscle invasive bladder cancer (NMIBC) were entered in the study. Serum samples were collected before starting intravesical therapy, during therapy (within 3rd and 6th instillation) and 30 days after the end of the 6-week induction regimen and during maintenance regimen when given. Patients with urinary tract infections, history of chronic prostatitis, elevated PSA before starting intravesical therapy, palpable prostate nodule or prostate cancer were not included. Results: Forty-five patients were studied, 34 receiving chemotherapy and 11 BCG. Thirty-three patients completed the induction regimen and in 12 more patients the research is ongoing. Out of the 33 evaluable patients, 23 received chemotherapy (mitomycin or epirubicin), while 10 immunotherapy (BCG Connaught). The pre-induction PSA mean level was 2.9 ng/ml.We observed a median PSA increase of 33,5% (p<0.0001) during therapy, in 18 (54.5%) patients. Twelve patients (36.3%) showed a median PSA decrease of 31.4% (p=0.3638). In two patients only (6%) PSA remained unchanged.We also observed a median increase of serum PSA levels of 87.4% at one month after the end of induction regimen. No significant difference between serum PSA level fluctuations induced by chemotherapy or BCG was detected: median increases during therapy and 30 days after the end were 91.7% and 149, 7% and 91.7% and 133% respectively (p<0.001). Discussion and Conclusion: Our preliminary study shows a clinically relevant increase of serum PSA levels in men undergoing both adjuvant intravesical BCG or chemotherapy. We confirm the results of the few studies reporting the increase of PSA during intravesical therapy with BCG or chemotherapy (2). The above mentioned variations should be considered when selecting patients undergoing prostate biopsy

PATIENT\u2019S COMPLIANCE TO INTRAVESCICAL BCG IN ROUTINE CLINICAL PRACTICE, RETROSPECTIVE ANALYSIS OF 411 CONSECUTIVE PATIENTS.

Aim of the study BCG maintenance for at least one year is advocated by urological guidelines as the best intravesical regimen in high-risk non muscle invasive bladder cancer (NMIBC), conservatively treated. Noteworthy, a relevant percentage of patients does not complete the planned treatment even if toxicity accounted for less that 10% of drop outs in recent multi-institutional trials. The aim of this study was to analyze the reasons for treatment interruption in everyday clinical practice. Materials and methods Consecutive patients affected by T1HG NMIBC undergoing conservative management with adjuvant BCG entered the study. The Connaught BCG strain was administered intravesically, at the dose of 81mg diluted in 50 ml of saline solution, according to the South West Oncology Group schedule for one year, starting 21-30 days after TUR. Toxicity and causes of treatment interruption were recorded. Results Between 2000 and 2012, intravesical BCG with 1-year maintenance regimen was proposed to 411 patients. Out of them, 380 (92,5%) completed the induction cycle and 308 (81%) started the maintenance. A total of 215 (52.3%) completed one year of treatment. Patients\u2019 compliance decreased from 81% at 3 months to 56.6% at 12 months. Toxicity requiring treatment interruption was recorded in 25 (6.1%) patients only. In 60 patients (14.6%) a delay of one or more instillations was necessary. Noteworthy, grade-I toxicity, not requiring therapy interruption or delay on urologists\u2019 judgment, was recorded in 193 (46.9%) cases. The retrospective nature of the study represents its major limit. Discussion Although one year BCG maintenance is recommended by both European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN), and indicated as the elective intravesical adjuvant regimen in intermediate- and high- risk NMIBC, conservatively treated, patients who complete the planned schedule doesn\u2019t exceed 50%. According to recent literature BCG-related toxicity shouldn\u2019t represent the major limiting fact. In the present experience, the high drop-out rate from treatment could be meanly attributable to grade-I toxicity underestimated by the urologists and to inadequate counselling. Conclusions Severe toxicity caused BCG interruption in a limited amount of cases. Almost 60% of treatment interruptions could be attributable to lack of patient\u2019s counseling and low grade toxicity

FEASIBILITY OF EGFR EVALUATION IN BLADDER WASHINGS OF PATIENTS AFFECTED BY NON MUSCLE-INVASIVE BLADDER CANCER.

INTRODUCTION AND OBJECTIVES: Epidermal Growth Factor Receptor (EGFR) overexpression has been recognized as a marker of biological aggressiveness in several malignant neoplasms. EGFR studies on non-muscle invasive bladder cancer (NMIBC) are lacking. Urothelial EGFR status after TUR could provide useful information about the risk of recurrence and progression. The aim of our study was to investigate the feasibility of EGFR evaluation in bladder washings of patients affected by NMIBC correlating its expression to European Association of Urology (EAU) risk classes. METHODS: A prospective double-blinded study included patients undergoing adjuvant intravesical therapy for NMIBC and age-matched healthy controls. Acellular pelletwas obtained and stored at -80C. Isolation of cellular RNA was performed using a miRNeasy Mini Kit (Qiagen) and DNA derived from reverse transcription was used to perform gene expression analysis by a Real Time PCR according to ??Ct method. RESULTS: Fifty-eight patients and 21 controls entered the study. One hundred fifty-three samples were collected. A useful pellet was obtained in 50 patients (86.2%) and 18 controls (85.7%). The mean EGFR expression in 50 NMIBC was 1.94 folds (range: 0.10-8.00). Compared with healthy controls (EGFR¼1), 40 patients (80%) were positive for EGFR. Particularly, in 18 patients (36%) EGFR was overexpressed (EGFR>1.94) with a mean value of 3.61 folds (range: 2.00- 8.00). According to EAU risk groups, EGFR expression was evaluated in low, intermediate and high risk patients respectively. In 20 high risk NMIBC the mean EGFR expression resulted 2.45 folds and 10 of them (50%) presented significant up-regulation with a mean value of 4.10 folds (range: 2.30-8.00). CONCLUSIONS: Our preliminary study demonstrates the feasibility of EGFR determination in bladder washings of patients affected by NMIBC after TUR, during adjuvant treatment and subsequent follow-up. A useful pellet was available in more than 85% of patients, with evidence of up-regulation in 36% of them. Within the high risk category, a significant overexpression of EGFR, mean value of 4.16 folds, was detected. EGFR overexpression might identify a subgroup of high risk tumors inclined to progression despite of intravesical therapy and could represent an additional prognostic factor to select candidates for early radical cystectomy

Fibronectin (FN), epidermal growth factor-receptor (EGF-R) and heparin-binding epidermal growth factor-like (HB-EGF) urinary expressions and topical toxicity of adjuvant intravesical therapy for non muscle invasive bladder cancer (NMI-BC)

NMI bladder cancer, EGF-R, intravesical therapy. fibronecti