الفهرس 
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Abstract
Bladder cancer is the most common malignancy of the urinary tract with non-muscle invasive urothelial carcinoma [NMIUC] being the most frequent type of urothelial carcinoma.
Based on the high recurrence, much effort has been devoted to predict recurrence or progression in NMIUC.
Despite recent advances in therapeutic modalities which allowed better management of bladder cancer, yet, the high recurrence rate and the potential to progress marks bladder carcinoma as a health problem.
Tumor infiltration by dendritic cells and macrophages has been suggested to be an evidence of host immune response against tumors. TIDCs have been generally associated with a favorable prognosis in many human malignancies; however the biological significance of tumor infiltration by macrophages which have well defined functions in inflammation remains unclear.
BCG immunotherapy represents the gold standard treatment for superficial intermediate and high risk bladder cancer, yet, 30-50% of patients fail BCG therapy, and identifying this subset of patients is of utmost importance.
The present study aimed at detecting the degree and localization of infiltration of CD68+TAM and CD1a+TIDC in non-muscle invasive papillary urothelial carcinoma using immunohistochemistry and correlating them with BCG treatment response.
To achieve this aim, formalin-fixed paraffin-embedded (FFPE) tumor tissue blocks of 63 patients who underwent transurethral resection (TUR) for non-muscle invasive papillary urothelial carcinoma in the period between January 2013 and December 2014 were retrieved retrospectively from the archives of the Pathology department. The sections were cut and stained with CD68, and CD1a antibodies.
All patients received induction BCG therapy at least 3 weeks following transurethral resection (TUR). Patients were subsequently scheduled to receive three weekly maintenance treatments at months 3, 6, 12, 18, 24, 30, and 36 after inclusion. Compliance was variable, with some patients receiving only the induction dose of BCG.
Follow up data of all studied patients as regards recurrence /progression and as regards maintenance BCG therapy were collected from the archives of the Department of Urosurgery, Faculty of Medicine, Alexandria University.
In the present study, the age of the patients ranged between 40 years and 84 years with mean age of 58.68 years. Fifty five cases (87.3%) were males while eight were females (12.7%). Out of the 63 studied cases, 31 cases (49.2%) were classified as low grade NMIUC and 32 cases (50.8%) were classified as high grade tumors. Fifty nine cases
Only 13 cases (20.6%) revealed the presence of lymphovascular invasion. Fifty nine cases (93.7%) were high risk tumors while, only four cases (6.4%) were considered of low risk. Out of the 63 cases, only 2 cases (3.2%) revealed urothelial hyperplasia and 4 cases (6.4%) revealed carcinoma in situ (CIS). Associated bilharzial infection was detected in only 10 cases.
Among the studied cases, the mean count of CD68 +TAMs in the tumor stroma was higher than that within the tumor epithelium (26.20 ± 16.088) and (9.88± 16.434), respectively. Conversely, the mean stromal CD1a+TIDC infiltration score was lower than the mean epithelial infiltration score (4.65± 5.553) and (6.85± 6.878), respectively.
Four cases (6.3 %) revealed low CD68+TAM infiltration score while, 93.7 % of cases (n=59) revealed high infiltration score. In opposition, thirty two cases (50.8 %) revealed low CD1a +TIDC infiltration scores while, 49.2% of cases (n=31) revealed high infiltration scores. Neither a correlation nor an agreement was detected between the degree of infiltration of both immune cells.
CD68 positive cytoplasmic staining was noted in tumor epithelial cells in 51 cases (81%). In these cases the percentage of positive cells ranged from 10% to 100% while, CD1a did not stain the tumor epithelium in any of the 63 studied cases.
The CD68+TAM infiltration score correlated only with patients’ age and tumor grade. Otherwise, no significant correlation was noted with all other studied clinicopathologic parameters.
Regarding CD1a+TIDC score, it failed to correlate significantly with all studied clinicopathologic parameters.
Out of the 63 studied cases, 46 % of the patients (n=29) had not received BCG maintenance thereby, 22.2 % of the patients (n= 14) received only one dose of maintenance therapy and only 31.8% of the patients (n=20) received more than one maintenance therapy.
About sixty percent of our studied cases (n=38) experienced tumor recurrence. Out of those 38 cases, only 7 cases progressed to muscle invasive urothelial carcinoma. The median recurrence time was 5 months (range: 2-36 months), while the median recurrence free survival (RFS) was 10 months. No significant differences were noted between recurrent and non-recurrent cases as regards clinicopathological characteristics.
Both CD68+TAM and CD1a+TIDC were evaluated in the context of BCG treatment outcome. Significant differences were noted between recurrent and non-recurrent cases regarding the immune cell infiltration after stratifying the cases into low and high infiltration scores. Moreover, high macrophage and high dendritic cell infiltration scores correlated with shorter RFS.
Receiver-operator characteristics (ROC) curve analysis was performed to test the ability of TAM and TIDC infiltration scores to discriminate recurrent from non-recurrent cases. Only CD1a was able to discriminate recurrent from non-recurrent cases and using the Youden index, the value of >7 was determined as the optimal cut off point of the CD1a +TIDC to predict the liability of tumor recurrence with a positive predictive value of 84.6% , a negative predictive value of 56.8%, Sensitivity of 57.89 and Specificity of 84%.
Univariate Cox regression analysis was done and revealed that patients with high overall or high stromal CD68+TAM infiltration scores exhibited a statistically significant higher risk of recurrence after BCG treatment while, only high stromal TIDC score increased the risk of recurrence.
Multivariate analysis was done after adjusting the results for age, sex, and tumor stage. A significant increase in the risk of recurrence was maintained in patients with high overall CD68+TAM infiltration scores and for patients with high stromal CD1a+TIDC infiltration scores.
from the current study, it can be concluded that both the level of infiltration and the localization of TAMs and TIDCs in pretreatment biopsy specimen of NMIUC affect the BCG treatment outcome. Thereby, they represent valuable predictor biomarkers for BCG treatment outcome.
Confirmation of these results via prospective mega studies is strongly recommended together with development of standardized cut offs and automated counting soft wares before being validated for clinical use.