Faculty Bibliography

PURPOSE: The GR gene produces GRalpha and GRbeta isoforms by alternative splicing of a C-terminal exon. GRalpha binds glucocorticoids, modulates transcription in a glucocorticoid dependent manner and has a growth inhibitory role in prostate cells. Due to this role glucocorticoids are often used to treat androgen independent prostate cancer. In contrast, GRbeta has intrinsic transcriptional activity and binds mifepristone (RU486) but not glucocorticoids to control gene expression. To our knowledge the role of GRbeta in prostate cell proliferation is unknown. MATERIALS AND METHODS: We determined GRbeta levels in various prostate cancer cell lines by reverse transcriptase-polymerase chain reaction and Western blot. The effect of GRbeta on the kinetics of prostate cancer cell growth was determined by cell counting and flow cytometry upon mifepristone and dexamethasone treatment. Cell proliferation was also examined after siRNA mediated knockdown and over expression of GRbeta. RESULTS: GRbeta mRNA and protein were up-regulated in LNCaP cells that over expressed the androgen receptor co-factor ARA70beta. Treatment of LNCaP-ARA70beta with mifepristone or siRNA targeting GRbeta inhibited proliferation compared to that of parental LNCaP cells. The immortal but nontumorigenic RC165 prostate cell line and the tumorigenic DU145 prostate cell line with endogenous GRbeta also showed partial growth reduction upon GRbeta depletion but to a lesser extent than LNCaP-ARA70beta cells. The growth stimulatory effect of ARA70beta on LNCaP cells was partly GRbeta dependent, as was the proliferation of RC165 cells and to a lesser extent of DU145 cells. CONCLUSIONS: Results suggest that patients with a primary tumor that expresses GRbeta and ARA70beta may benefit from mifepristone.

What's known on the subject? and What does the study add? Androgen stimulation of prostate cancer (PCa) cells has been the basis for extensive studies evaluating the role of androgen in PCa but the diagnostic measurement of androgen as well as androgen values that potentially influence prognosis are unclear in patients with PCa. The 50 ng/dL threshold has been questioned as a result of reports indicating worse outcomes for levels between 20 and 50 ng/dL. Instead, a 20 ng/dL threshold for serum testosterone after androgren deprivation therapy in patients with advanced PCa was recommended. OBJECTIVE: * Androgen stimulation of prostate cancer (PCa) cells has been extensively studied. The increasing trend of using serum testosterone as an absolute surrogate for castration state means that the diagnostic measurement of testosterone and the values potentially influencing prognosis must be better understood. This is especially important when PCa progresses from an endocrine to an intracrine status. PATIENTS AND METHODS: * We performed a literature review using the MEDLINE database for publications on: (i) hormonal changes with androgen deprivation therapy (ADT); (ii) monitoring hormonal therapy with testosterone measurement; (iii) the efficacy of intermittent androgen deprivation (IAD) compared with continuous androgen deprivation; (iv) the underlying mechanisms of castration-resistance; and (v) novel treatments for castration-resistant PCa (CRPCa). RESULTS: * The optimum serum castration levels to be achieved with ADT are still debated. Recently, the 50 ng/dL threshold has been questioned because of reports indicating worse outcomes when levels between 20 and 50 ng/dL were studied. Instead, a 20 ng/dL threshold for serum testosterone after ADT in patients with advanced prostate cancer was recommended. CONCLUSION: * Understanding the mechanisms of androgen biosynthesis relating to PCa as well as prognostic implications might achieve a consensus regarding the role of ADT for both the androgen-sensitive and -insensitive disease state.

Study Type - Outcomes (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? It is generally accepted in the medical community that total and intra-operative blood loss after RALP is significantly lower in comparison with ORRP. This has led to speculation that less bleeding results in better visualization of the operative field resulting in superior potency and continence. Blood loss (BL) during ORRP does not adversely impact clinical and functional outcomes irrespective of how BL is defined. Thus, the lower BL associated with RALP would not be expected to improve functional or oncological outcomes. OBJECTIVE: * To determine the short- and long-term impact of blood loss (BL) on clinical, oncological and functional outcomes as well as complication rates after an open radical retropubic prostatectomy (ORRP). PATIENTS AND METHODS: * Between 2000 and 2008, 1567 men who underwent an ORRP participated in our prospective longitudinal outcomes study. * Haematocrit (Hct) levels, transfusion rates, BL and complications were recorded prospectively. * Validated, self-administered quality-of-life (QoL) questionnaires were completed at baseline, 3, 6 and 12 months and yearly thereafter. * Urinary function and erectile dysfunction were assessed using AUA Symptom Score and the UCLA Prostate Cancer Index and analysis of variance (anova)/chi-square tests were used to compare clinical, BL, biochemical recurrence (BCR) and QoL outcomes amongst the three groups for continuous/categorical variables. RESULTS: * The mean estimated BL was 742.7 (45 to 3500) mL and 5.4% and 3.8% received an autologous (AU) or allogeneic (AL) blood transfusions, respectively. * The average baseline, induction, postoperative and discharge Hct was 43.8%, 48.3%, 35.7% and 34.1%, respectively. * The estimated BL and the rate of change of Hct correlated moderately (r = 0.41, P < 0.0001). * Tertiles of BL were based on the difference between induction and discharge Hct (Delta 1) and the average Delta 1 for Groups 1, 2 and 3 were 7.9%, 12.7% and 17.2%, respectively. * Intra-operative, early/delayed complications, length of hospital stay (LoS), SM surgical margins status, anastomotic stricture and BCR were not statistically different (P < 0.001) and the mean AUASS, UCLA Prostate Cancer urinary bother scores, urinary function scores, sexual bother/function scores at 24 months were similar amongst all tertiles (P > 0.05). CONCLUSIONS: * BL during ORRP does not adversely impact clinical and functional outcomes irrespective of how BL is defined. * Thus, the lower BL associated with robotic-assisted laparoscopic prostatectomy (RALP) in and of itself would not be expected to improve functional or oncological outcomes.

Study Type - Diagnostic (validating cohort) Level of Evidence 1b What's known on the subject? and What does the study add? Nadir Ultrasensitive PSA levels has some value for predicting BCR following RD. AccuPSA assays lower limit of PSA quantification of <0.01 pg/ml greatly enhances sensitivity and specificity of nadir PSA to predict BCR following RP. Our pilot study shows an AccuPSA of 3 pg/ml has a sensitory and specificity of 100% and 75% respectively for predicting 5 year BCR following RP. OBJECTIVES * To conduct a proof of concept study to evaluate a novel digital single molecule immunoassay (AccuPSA(TM) ) that detects prostate-specific antigen (PSA) a thousandfold more sensitively than current PSA detection methods. * To determine the ability of the AccuPSA(TM) assay to predict 5-year biochemical recurrence (BCR)-free survival after radical prostatectomy (RP). PATIENTS AND METHODS * A total of 31 frozen serum specimens were obtained from specimen logs maintained at New York University Langone Medical Center and the Johns Hopkins University School of Medicine on men who had undergone RP. Those men without evidence of BCR had a minimum of 5 years' PSA follow-up. * In all cases, preoperative and pathological information were available, as was a serum specimen 3-6 months after RP, with a PSA level of <0.1 ng/mL measured by conventional PSA methods at the time of serum collection. * Specimens were tested using the AccuPSA(TM) method. * A Cox proportional hazard model and Kaplan-Meier analysis were used to determine whether AccuPSA(TM) predicted the risk of BCR. RESULTS * Overall, 11/31 (35.5%) men developed BCR. * Mean AccuPSA(TM) nadir levels were significantly different (P < 0.001) between the non-BCR group (2.27 pg/mL) and the BCR group (46.99 pg/mL). * Using a multivariate Cox proportional hazard model, AccuPSA(TM) nadir level was a significant predictor of BCR-free survival (P < 0.01). * Kaplan-Meier analysis of up to 5 years follow-up showed that 100% of men with AccuPSA(TM) nadir values <3 pg/mL did not develop BCR, whereas 62.5% of men with values >3 pg/mL developed BCR (P= 0.00024). * The sensitivity, specificity, positive predictive value and negative predictive value of the AccuPSA(TM) method was 100%, 75%, 69% and 100%, respectively. CONCLUSIONS * AccuPSA(TM) assay predicts 5-year BCR- free survival after RP. * Identifying a reliable predictor of BCR soon after RP has important implications for frequency of PSA testing, selection of candidates for adjuvant therapy, and reassuring a large subset of men that they are not at risk of recurrence. * Larger studies are needed to validate these findings

Epidemiologic and experimental data suggest that soy consumption may prevent prostate cancer and be beneficial for men with prostate cancer. Soy intake and risk of prostate cancer are inversely correlated; soy isoflavones inhibit growth of prostate cancer cells and reduce prostate carcinogenesis in animal models. We tested the hypothesis that soy consumption reduces biochemical recurrence after radical prostatectomy in a randomized controlled clinical trial with a soy protein supplement versus a casein-based placebo in men at increased risk for PSA failure in the first 2 years after radical prostatectomy. PSA was tested at 2-month intervals in year 1 and every 3 months in year 2. Eligibility criteria were: Gleason sum of >8, extra-capsular extension, seminal vesicle invasion, positive surgical margins, positive lymph nodes, and/or a preoperative PSA of >20 ng/ml. Biochemical recurrence was defined a priori as reaching a PSA value of alpha0.07 ng/ml, confirmed twice. A two-year PSA failure rate in eligible subjects of approximately 30% was expected, based on data from NYU and previous literature. With a planned sample size of 128 evaluable subjects per arm, the study had 80% power to detect a 50% reduction in PSA failure rate at a 2-sided significance level of 0.05. The soy protein isolate and placebo (generously provided by Solae LCC, St Louis, MO) were identical in composition, except for the protein source (19.2-19.8 g protein/day); the soy product provided daily 23.5 mg genistein and 40.9 mg total isoflavones (aglycone equivalents); the placebo was devoid of any soy-specific constituents. Accrual did not reach the intended level and 172 subjects were randomized and enrolled, of whom 142 were evaluable (completed two years on study or developed confirmed recurrence within two years). Soy protein consumption did not alter recurrence rate or time-to-recurrence (TTR). Of the 74 evaluable subjects in the soy arm 22 (30%) recurred as did 22 (32%) of the 68 subjects in the placebo arm recurred. The!

Although formation of urothelial carcinoma of the bladder (UCB) requires multiple steps and proceeds along divergent pathways, the underlying genetic and molecular determinants for each step and pathway remain undefined. By developing transgenic mice expressing single or combinatorial genetic alterations in urothelium, we demonstrated here that overcoming oncogene-induced compensatory tumor barriers was critical for urothelial tumor initiation. Constitutively active Ha-ras (Ras*) elicited urothelial hyperplasia that was persistent and did not progress to tumors over a 10 months period. This resistance to tumorigenesis coincided with increased expression of p53 and all pRb family proteins. Expression of a Simian virus 40 T antigen (SV40T), which disables p53 and pRb family proteins, in urothelial cells expressing Ras* triggered early-onset, rapidly-growing and high-grade papillary UCB that strongly resembled the human counterpart (pTaG3). Urothelial cells expressing both Ras* and SV40T had defective G(1)/S checkpoint, elevated Ras-GTPase and hyperactivated AKT-mTOR signaling. Inhibition of the AKT-mTOR pathway with rapamycin significantly reduced the size of high-grade papillary UCB but hyperactivated mitogen-activated protein kinase (MAPK). Inhibition of AKT-mTOR, MAPK and STAT3 altogether resulted in much greater tumor reduction and longer survival than did inhibition of AKT-mTOR pathway alone. Our studies provide the first experimental evidence delineating the combinatorial genetic events required for initiating high-grade papillary UCB, a poorly defined and highly challenging clinical entity. Furthermore, they suggest that targeted therapy using a single agent such as rapamycin may not be highly effective in controlling high-grade UCB and that combination therapy employing inhibitors against multiple targets are more likely to achieve desirable therapeutic outcomes.

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? It is well recognized that RP is associated with short- and long-term SUI and erectile dysfunction. The incidence, clinical significance and treatment of UI during sexual activity is less well understood. The present study demonstrates the effectiveness of both an AUS and male sling to improve sexual QOL in men presenting with both SUI and UI during sexual activity. OBJECTIVE: * To determine the impact of anti-incontinence surgical procedures (artificial urinary sphincter [AUS] or male sling) on bother due to urinary incontinence (UI) during sexual activity after radical prostatectomy (RP). PATIENTS AND METHODS: * Between October 2000 and December 2007, 27 men in a large single-surgeon RP series underwent anti-incontinence surgery with an AUS or male sling. * In all, 16 of these 27 men completed a questionnaire retrospectively capturing bother attributable to UI during arousal and orgasm and the impact of the AUS/male sling on UI and sexual quality of life (QoL). RESULTS: * In all, 15 men were evaluable. Of these, 11 were sexually active; four and seven men underwent AUS and sling placement, respectively. * All 11 men had a marked improvement in stress UI symptoms, which was the primary indication for surgery. * All men undergoing AUS had an improvement in their sexual QoL, and most (three of four men) indicated marked improvement. * Slightly more than half of men undergoing the sling procedure reported marked improvement in sexual QoL. CONCLUSIONS: * Our study shows a beneficial effect of anti-incontinence surgery on UI during sexual activity. * Whether these surgical approaches would benefit men with significant bother due to UI limited to sexual activity warrants further investigation.