Uroepithelial carcinomasUroepithelial carcinomas

Imad Fadl-ElmulaImad Fadl-Elmula

Symposium on: Advances in Parasitology “Education and Research in Parasitology in the service of Mankind “

Genetic profile of post-bilharzial Genetic profile of post-bilharzial bladder SCCbladder SCC

The somatic mutation theory of cancer

Theodor Boveri (1862-1915)

Acquired genetic changes are

the main causes of malignant

transformation of target cells

Cancer cell characteristics

Histology The development of Carcinomas

MutatiMutationon

HyperplasiaHyperplasia DysplasiaDysplasiaIn situ CancerIn situ Cancer

Invasive CancerInvasive Cancer

Natural history of cancerNatural history of cancer

ProgressionProgression

Genetic

(Oncogenes/ tr suppressor genes)

Mitogenesis

Immune surveillance

Angiogenesis

Epigenetic

(clonal expansion)

Biology of Cancer!Biology of Cancer!

Promotion

Initiation

Ist Hit Normal Cell

Apoptosis

Rep

air

Mild Dysplasia

2nd Hit

Apopto

sis

Apopto

sis

Severe Dysplasia

Cancer

3rd Hit

Genetic alterations

Normal PIA PIN PCA

inflammation

30 year 80 year

Gene defects

Proliferation

GSTP expression

Oxidative stressOxidative stress

? ?

0

100

Well differentiated Moderately differentiated Moderately differentiated Undifferentiated Undifferentiated Poorly differentiated Poorly differentiated

Uroepithelial cancerUroepithelial cancer

54,000 new cases 12,500 deaths Three times more frequently in € than in

7th most common cancer in 4th most common cancer in €

In areas where Schistosoma haematobium is endemic

The most common cancer (25%) in €

Rarely occur before the age of 40 years

12.500 deaths

Sex€€€ :

7th most common cancer in

4th most common cancer in € in Europe and USA

The most common cancer (25%) in €in the

areas where Schistosoma haematobium is endemic

Age (rare before the age of 40 years)

54.000 new cases in USA 1.883 new cases in Sweden

Race €€:€

12th leading cause of cancer death

Uroepithelial carcinomas

Natural historyNatural history

High incidence of recurrence.

Heterogeneity of the clinical

course.

Multifocality.

EtiologyEtiology

(Rehan, 1895) Post-radiation

SCC

Bilharzia

(Ferguson, 1911)

Histopathology

Histology Transitional cell carcinoma (TCC) Squamous cell carcinoma (SCC) Adenocarcinoma (AC) Undifferentiated carcinoma (UC)

Grading (Koss, 1975) Well-differentiated carcinoma (G1) Moderately differentiated carcinoma (G2) Poorly differentiated carcinoma (G3)

DiagnosisDiagnosis

CystoscopyCystoscopy

Urine cytologyUrine cytology

AccidentallyAccidentally Excretory urographyExcretory urography

Signs and symptomsSigns and symptoms

Treatment

1. Superficial disease (Ta, T1) Transurethral resection of tumor (TUR-T)

TUR-T + Adjuvant intra-vesical immune- or chemotherapy

2. Invasive disease (T2)

Radical surgery + Pre- or post-operative radiation therapy

Palliative treatment in cases with systemic metastasis

THE PRESENT STUDY

AIMS1. Characterize the genetic alterations in tumors of

tumor

Bladder tumor

Renal pelvis

THE PRESENT STUDY

AIMS1. Characterize the genetic alterations in tumors of

Ureteral tumor

Bladder tumor

Renal pelvis

Aims were:

THE PRESENT STUDY

1. Different etiologies

To characterize the genetic alterations in tumors of:

THE PRESENT STUDY

AIMS1. Characterize the genetic alterations in tumors of

Ureteral tumor

Bladder tumor

Renal pelvis

3. Different histologic types

TCCTCC SCC

Clinical characteristics of TCC and SCC

1. Incidence Middle east, Africa USA, Europe 2. Age 45 years 65 years

3. Sex 4:1 3:1

4. Etiology Biological Chemicals

5. Clinical Invasive and solid Superficial, papillary, and multiple

6. Treatment Radical surgery T-TUR and others

7. Progression Fast Slow (15%)

8. Genetic

SCC TCC

Sole change?

2. Chromosomal abnormalities2. Chromosomal abnormalities involved in initiation processinvolved in initiation process

3. Chromosomal abnormalities involved in progression

Secondary changes

THE PRESENT STUDY

AIMS1. Characterize the genetic alterations in tumors of

Ureteral tumor

Bladder tumor

Renal pelvis

THE PRESENT STUDY

AIMS1. Characterize the genetic alterations in tumors of

Ureteral tumor

Bladder tumor

Renal pelvis

These goals were approached by analyzing samples from

Sweden Sudan

Sampling-

Collagenase II

Mechanical and enzymatic disaggregation

3-10 Days

Short-term culture

T3-2

T2-1

T2-2

Harvest and preparation of the slides

Hypotonic treatment Fixation

G-Banding

1 T1-T1-2

Analysis

47,X,-Y,del(2)(q21q31),t(3;5)(q27q31),del(5)(q11q13),+7,-9,+r[50]

Karyotyping (ISCN)

Cytogenetic analysis

2. Cytogenetic analyses Complex karyotypes in both tumors

Muscle invasive tumors Squamous differentiation

1. Histopathology

Results

Conclusions

The putative genetic changes that steer The putative genetic changes that steer the differentiation of the neoplastic the differentiation of the neoplastic epithelium in the direction of squamous epithelium in the direction of squamous cells thus remain unknowncells thus remain unknown

Secondary SCCs of the bladder are Secondary SCCs of the bladder are karyotypically indistinguishable from karyotypically indistinguishable from advanced TCCs of the same organadvanced TCCs of the same organ

Clinical conclusions

1. Beside endoscopic removal of superficial

tumors, additional measures against the

intraluminal seeding of cancer cells and

their ability to divide should take place.

2. Surgeons should avoid unnecessary

epithelium trauma during the endoscopic

removal of bladder tumor(s).

Chromosome 9

Rearranged in 92% of the informative

cases

As a single anomaly in two cases, del(9)(p11)

and del(9)(q12q22)

Loss of one copy in 15 cases

Structural rearrangement in 8 cases

Chromosomes 1 and 11

Chromosomes 1 and 11 were rearranged in 10 (33%) and 11 (37%) cases each.

The most common consequences of the changes in chromosome 1 were gain of 1q material and loss of 1p.

The most common consequences of the changes in chromosome 11 were losses of material from 11p

Often found in simple karyotypes in low-grade tumors

Never seen as the sole change but often accompanied chromosome 9

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The karyotypic profileThe karyotypic profile of bladder TCC of bladder TCC

is cis characterizedharacterized by: by:

1. Nonrandom chromosomal aberrations

2. Few changes in low-grade and early stage tumors and

massively rearranged karyotypes in muscle invasive ones

2. Losses of chromosomal material

3. Little intratumor cytogenetic heterogeneity

4. Monoclonal origin

Study 7Study 7

Chromosomal aberrations in benign and Chromosomal aberrations in benign and

malignant bilharzia-associated bladder malignant bilharzia-associated bladder

lesions analyzed by comparativelesions analyzed by comparative

genomic hybridizationgenomic hybridization

BBilharzia-associated bladderilharzia-associated bladder cancer cancer

Most common cancer among men (25%)

80% of patients present with muscle infiltrating disease

Long-term survival is obtained in 27–39% of the cases

Low mean age at diagnosis (45 years)

Earlier diagnosis is important for treatment outcome

87% of the cases are SCC type

Distribution of urinary schistosomiasis in Africa (WHO/TDR)

600 million run the risk of becoming infected

Endemic in 74 countries

Preventable disease !!!!!

200 million are infected

250.000 annual deaths

1. To determine the genetic imbalances involved in BAC

2. To find out if preneoplastic bilharzia lesions carry chromosomal

aberrations resembling those seen in carcinomas

3. To see whether the unique etiology yields a distinct cytogenetic

profile compared to chemically induced bladder tumors

Objectives Objectives

MaterialsMaterials

20

Post-bilharzial bladder lesions

6 benign 14 malignant

12 € ƒ 8

Sudan

The National Health Laboratory Khartoum, Sudan

Pathology archives of Ibn Sina hospital, Khartoum, Sudan

MethodsMethods

20-30 paraffin sections20-30 Paraffin sections Control DNA

Normal DNA

Isolation and labelling-

Tumor DNAIsolation and labelling FITC-dUTP

Hybridization to normal metaphase

Cot-1 DNA

Loss (green-to-red ratios < 0.80)

Gain (green-to-red ratios >1.2)

CGH analysis

Fluorescence in situ hybridization (FISH)

Xylene

Absolute ethanol Proteinase K

2xSSC

air-drying

Pericentromeric probes

17

X

9

pBAMX7

pHuR98

p17H8

Analysis

MethodsMethods

ResultsResults

Of the 20 lesions only 7 showed abnormality

6 carcinomas (4 SCC and 2 TCC)

1 granuloma

Chromosomal imbalances varying from 1 to 6 changes

The most common changes (seen in three cases each):

Loss of 1p21-31, 8p21-pter, and 9p

Gain of 19p material

ConclusionsConclusions

1. The cytogenetic profiles of chemical- and bilharzia

induced carcinomas are largely similar.

2. Loss of material from 9p seems to be the initiating event

and gain of material from 19p a later progressional event.

3. Preneoplastic bilharzia lesions carry chromosomal

aberrations resembling those seen in carcinomas.