Nephron-sparing Management of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) is a relatively rare tumor, but is characterized by high rates of recurrence, morbidity, and mortality. Choice of treatment modality is generally influenced by lesion size, grade, and focality. Radical nephroureterectomy with bladder cuff excision is the gold-standard management of UTUC, although an organ-sparing approach may be beneficial in selected patients. Conservative endoscopic management of UTUC in appropriate patients has a favorable impact on quality of life and health care costs when compared with patients who progress to dialysis-dependent renal failure. Careful ureteroscopic surveillance following endoscopic management of UTUC is essential.Key words: Upper tract urothelial carcinoma, Tumor grade, Nephron-sparing endoscopic treatment, Topical adjuvant chemo-immunotherapy, Oncologic outcomesUpper tract urothelial carcinoma (UTUC) accounts for < 5% of all cases of urothelial neoplasia, but is a very morbid disease, with recurrence rates up to 90%^1–9 and 5-year survival rates ranging from 30% to 60%.¹⁰ Radical nephroureterectomy (NU) with bladder-cuff excision has been the traditional treatment for UTUC because of its high rate of recurrence. However, given the morbidity of nephrectomy and the risk of developing chronic kidney disease (CKD) or dialysis-dependent renal failure, as well as the risk of contralateral tumors,^11–14 a nephron-sparing approach may be preferable in selected patients.     

The TRPV4 Cation Channel Mediates Stretch-evoked Ca2+ Influx and ATP Release in Primary Urothelial Cell Cultures

Transient receptor potential channels have recently been implicated in physiological functions in a urogenital system. In this study, we investigated the role of transient receptor potential vanilloid 4 (TRPV4) channels in a stretch sensing mechanism in mouse primary urothelial cell cultures. The selective TRPV4 agonist, 4α-phorbol 12,13-didecanoate (4α-PDD) evoked Ca²⁺ influx in wild-type (WT) urothelial cells, but not in TRPV4-deficient (TRPV4KO) cells. We established a cell-stretch system to investigate stretch-evoked changes in intracellular Ca²⁺ concentration and ATP release. Stretch stimulation evoked intracellular Ca²⁺ increases in a stretch speed- and distance-dependent manner in WT and TRPV4KO cells. In TRPV4KO urothelial cells, however, the intracellular Ca²⁺ increase in response to stretch stimulation was significantly attenuated compared with that in WT cells. Stretch-evoked Ca²⁺ increases in WT urothelium were partially reduced in the presence of ruthenium red, a broad TRP channel blocker, whereas that in TRPV4KO cells did not show such reduction. Potent ATP release occurred following stretch stimulation or 4α-PDD administration in WT urothelial cells, which was dramatically suppressed in TRPV4KO cells. Stretch-dependent ATP release was almost completely eliminated in the presence of ruthenium red or in the absence of extracellular Ca²⁺. These results suggest that TRPV4 senses distension of the bladder urothelium, which is converted to an ATP signal in the micturition reflex pathway during urine storage.Transient receptor potential vanilloid 4 (TRPV4),³ a member of the TRP superfamily of cation channels, is a Ca²⁺-permeable channel activated by a wide variety of physical and chemical stimuli (1, 2). TRPV4 was originally viewed as an osmo- or mechano-sensor, because the channel opens in response to hypotonicity-induced cell swelling (3–5) and shear stress (6). Alternatively, TRPV4 can be activated by diverse chemical stimuli such as synthetic phorbol ester 4α-phorbol 12,13-didecanoate (4α-PDD) (7), a botanical agent (bisandrographolide A), anandamide metabolites such as arachidonic acid and epoxyeicosatrienoic acids, as well as moderate warmth (>27 °C) (8–10). TRPV4 is widely expressed throughout the body, including renal epithelium, auditory hair cells, skin keratinocytes, hippocampus neurons, endothelial cells, and urinary bladder epithelium, thereby contributing to numerous physiological processes such as osmoregulation (11, 12), hearing (13), thermal and mechanical hyperalgesia (14, 15), neural activity in the brain (16), skin barrier recovery (17), and cell volume regulation (18). Therefore, the TRPV4 channel is now considered a multimodal transducer in various tissues and cells.Non-neuronal cells within the urinary bladder wall (notably the transitional epithelial cells (urothelial cells)) function as a barrier against ions, solutes, and infection and also participate in the detection of physical and chemical stimuli (19–21). The urothelium expresses various sensory receptors and channels (bradykinin receptors, adrenergic/cholinergic receptors, nerve growth factor receptors, purinergic receptors, amiloride-sensitive Na⁺ channels, and TRP channels), all of which are substantially implicated in modulating bladder functions (22).Recently, the potential roles of TRP channels have been explored in the bladder. Thus far, expression of TRPV1, TRPV2, TRPV4, TRPA1, and TRPM8 has been reported in different regions of urogenital tracts (21). TRPV1 is reportedly expressed in the epithelial cells lining the urothelium, in interstitial cells, and in sensory nerve terminals. TRPV1-deficient mice displayed a higher frequency of low amplitude non-voiding bladder contractions in comparison with wild-type (WT) mice (22), suggesting that TRPV1 is required for detection of bladder stretch, which involves stretch-evoked release of ATP and nitric oxide. The release of both mediators was reduced in the bladders of TRPV1-deficient mice. In a clinical setting, capsaicin or resiniferatoxin reduces bladder overactivity through desensitization of bladder afferents by acting on TRPV1 (23). Expression of other TRP channels, e.g. TRPM8 and TRPA1, was found in sensory C fibers in the bladder (24–27). The diagnostic ice water test is utilized to determine whether disturbance of bladder function involves neurogenic components, one of which could be related to TRPM8 function, in patients with spinal cord lesion (28). TRPA1 in sensory afferents is activated by several known ligands (allyl isothiocyanate and cinnamaldehyde), thereby inducing bladder overactivity (26). TRPV2 is expressed by several cell types in the rat bladder (29); however, its physiological function has not yet been investigated. TRPV4 is expressed in the urothelium and in smooth muscle cells of the urinary bladder (30, 31). Activation of the channel by specific ligands leads to augmentation of bladder contraction amplitude in cystometry and induction of bladder overactivity in vivo. In a separate cystometry analysis in conjunction with behavioral experiments, the intermicturitional interval was elongated and storage urine volume was increased in TRPV4-deficient mice compared with WT mice (32). Thus, TRPV4 may contribute to bladder function, especially to mediating bladder distention signals to primary afferent nerves during urine storage. However, whether urothelial TRPV4 is required for sensing mechanical stretch, or to what extent urothelial TRPV4 contributes to stretch-evoked ATP release, has not been precisely determined.In the present study, we examined the functional contribution of TRPV4 to stretch-dependent urothelial cell responses and stretch-evoked ATP release in vitro. We first established a primary cell culture for mouse urothelium and retention of TRPV4 expression was confirmed. Because urothelial cells are physically extended during urine storage in vivo, we reproduced this phenomenon in an in vitro experiment using the uni-axial cell stretch system. All the experiments were performed by comparing urothelial cells obtained from WT mice and TRPV4-deficient mice to evaluate the correlation between TRPV4 expression and stretch responses. We demonstrated that urothelial cells sense mechanical stretch stimuli via TRPV4 channels, which induces robust Ca²⁺ influx and contributes to ATP release upon extension.     

The Use of Botulinum Neurotoxin Type A in a Patient With Refractory Urge Incontinence to Facilitate the Intravesical Treatment of Bladder Carcinoma

Intravesical Bacillus Calmette-Guérin (BCG) has become the preferred initial treatment after resection of high-grade T1 urothelial carcinoma and carcinoma in situ (CIS). We report the case of a patient with high-grade T1 urothelial carcinoma and CIS who was treated with intravesical BCG. Due to the patient’s severe urge incontinence, however, the BCG solution leaked from the bladder immediately upon instillation. We describe our experience of using botulinum neurotoxin A intradetrusor injections to facilitate successful intravesical therapy by increasing bladder capacity to enable the BCG to remain in the patient’s bladder for the appropriate treatment duration.Key words: Bacillus Calmette-Guérin, Bladder carcinoma, Botulinum neurotoxin, Gemcitabine, Urge incontinenceThe role of intravesical Bacillus Calmette-Guérin (BCG) in treating residual papillary lesions, decreasing recurrence, and reducing the risk of progression has been shown in several studies.^1–3 After BCG therapy, the initial tumor-free response rate has been reported as high as 84%.⁴ Approximately half of patients receiving BCG treatment achieve a long-term response for a median of 4 years. As such, BCG is the preferred first-line treatment for carcinoma in situ (CIS) by the American Urological Association Guidelines Panel.⁵Botulinum toxin is a neurotoxin formed by the bacterium Clostridium botulinum that inhibits the release of acetylcholine at the neuromuscular junction to cause muscle paralysis.⁶ Dykstra and Sidi⁷ first described the use of botulinum neurotoxin type A (BoNT/A) in the lower urinary tract with the treatment of detrusor-sphincter dyssynergia with injection into the urethral sphincter.⁷ A decade later, Schurch and colleagues⁸ used BoNT/A in the treatment of urinary incontinence in patients with spinal cord injuries. Since its US Food and Drug Administration approval, BoNT/A has become a second-line therapy for neurogenic detrusor overactivity with urinary incontinence and overactive bladder in patients who are refractory to or intolerant of antimuscarinic therapy. We describe the use of BoNT/A intradetrusor injections to facilitate the use of intravesical BCG in a patient with severe urge incontinence refractory to first-line therapy.     

Effectiveness of Antegrade Access in Bladder Tumors With Inaccessible Urethra

Inaccessible urethra with no retrograde endoscopic access due to multiple/diffuse strictures or multiple urethrocutaneous fistulas with acute urinary retention due to posturethral instrumentation (transurethral resection of bladder tumor [TURBT], or TURBT with transurethral resection of the prostate [TURP]), is a rare entity. Management of such a case with a bladder tumor for TURBT/surveillance cystoscopy poses a great challenge. The authors present 12 cases of bladder tumor with inaccessible urethra, 10 cases due to multiple strictures (post-TURBT and/or TURP), and 2 cases due to urethrocutaneous fistulas (post-TURBT), who presented to our emergency department with acute urinary retention. Emergent suprapubic catheterization was used as a temporary treatment method.Key words: Suprapubic cystostomy, Inaccessible urethra, Bladder tumors, Tract seedlingBladder tumors are the most common neoplasm of the lower urinary tract, comprising 6% of all malignancies in men and 2% of those in women.¹ A majority of patients present with gross painless hematuria, usually as the sole presenting symptom.² Bladder carcinoma is unique among human neoplasms in that many of its etiologic factors are known; the urologist should be aware of the possible occupational exposures to urothelial carcinogens.³ Initial symptoms of urothelial carcinoma of the bladder (UCB) include microhematuria, painless macrohematuria, and/or irritative voiding symptoms, and require further investigation. Carcinoma in situ of the bladder causes irritative lower urinary tract symptoms (LUTS) more often than does papillary UCB. Histopathologic evaluation is necessary to assess stage and grade with sufficient certainty after the appearance of bladder tumors.⁴ Bladder tumors spread by implantation in abdominal wounds, denuded epithelium, resected prostatic fossa, or traumatized urethra⁵; implantation occurs most often with high-grade tumors.     

En Bloc Robot-assisted Laparoscopic Partial Cystectomy,Urachal Resection,and Pelvic Lymphadenectomy for Urachal Adenocarcinoma

Primary adenocarcinomas of the bladder and urachus are extremely rare, accounting for 0.5% to 2.0% of all bladder malignancies. During fetal development, the urachus develops into the median umbilical ligament that stretches from the umbilicus to the bladder. Adenocarcinoma accounts for 90% of all cases of urachal carcinoma. There is no consensus regarding the management of urachal carcinoma. Although the preferred treatment is wide local excision with partial or radical cystectomy, bladder-sparing management is increasing. We report a case of robot-assisted laparoscopic partial cystectomy with en bloc resection of the urachus and bilateral pelvic lymphadenectomy for urachal carcinoma. The robot-assisted laparoscopic approach allowed us to minimize surgical morbidity, postoperative pain, and convalescent time while maintaining the oncologic principle of wide local excision.Key words: Urachal adenocarcinoma, Robotic partial cystectomy, Pelvic lymphadenectomyPrimary adenocarcinomas of the bladder and urachus are extremely rare, accounting for 0.5% to 2.0% of all bladder malignancies.¹ The urachus is a musculofibrous band that extends from the dome of the bladder to the umbilicus. During fetal development, the urachus develops into the median umbilical ligament that stretches from the umbilicus to the bladder. Urachal carcinoma stems from the epithelium of the remnant of this structure, and adenocarcinoma accounts for 90% of all cases.² Historically, patients tend to have a poor prognosis, with 5-year survival rates of 11% to 61%.³ Patients with urachal carcinoma most commonly present with dysuria, hematuria, abdominal pain, or umbilical discharge.There is no consensus regarding the management of urachal carcinoma. Although the preferred treatment is wide local excision with partial or radical cystectomy, ^4–6 bladder-sparing management is increasing because the published reports do not clearly support a survival advantage with more radical extirpation.^7,8We report a case of robot-assisted laparoscopic partial cystectomy with en bloc resection of the urachus and bilateral pelvic lymphadenectomy for urachal carcinoma. The robot-assisted laparoscopic approach allowed us to minimize surgical morbidity, postoperative pain, and convalescent time while maintaining the oncologic principle of wide local excision.     

Occult Renal Cell Carcinoma Manifesting as Nasal Mass and Epistaxis

Metastasis of renal cell carcinoma (RCC) to the nasal cavity and paranasal sinuses is rare, with fewer than 50 cases described in the literature. Nasal metastasis as the initial presentation of RCC is even rarer. Metastases to the nasal cavity usually represent advanced disease with poor outcome. The authors report a case of metastatic RCC presenting with right nasal cavity mass and epistaxis, followed by a brief review of the relevant literature.Key words: Renal cell carcinoma, Nasal metastasis, EpistaxisRenal cell carcinoma (RCC) accounts for approximately 85% of primary renal tumors, and represents approximately 3% of all adult malignancies.¹ Usual sites of metastasis include lungs (75%), regional lymph nodes (65%), bone (40%), liver (40%), and brain (5%).² Metastasis to the nasal cavity is an extremely rare occurrence, with fewer than 50 cases reported,^3,4 although RCC is the most common infraclavicular primary tumor that metastasizes to the nasal cavity and paranasal sinuses.⁵ We describe a case of occult clear-cell RCC that presented with epistaxis due to nasal cavity metastasis.     

Chemokine (C-C Motif) Ligand 2 Engages CCR2+ Stromal Cells of Monocytic Origin to Promote Breast Cancer Metastasis to Lung and Bone

Metastatic spread of cancer to distant vital organs, including lung and bone, is the overwhelming cause of breast cancer mortality and morbidity. Effective treatment of systemic metastasis relies on the identification and functional characterization of metastasis mediators to multiple organs. Overexpression of the chemokine (C-C motif) ligand 2 (CCL2) is frequently associated with advanced tumor stage and metastatic relapse in breast cancer. However, the functional mechanism of CCL2 in promoting organ-specific metastasis of breast cancer has not been rigorously investigated. Here, we used organ-specific metastatic sublines of the MDA-MB-231 human breast cancer cell line to demonstrate that overexpression of CCL2 promotes breast cancer metastasis to both lung and bone. Conversely, blocking CCL2 function with a neutralizing antibody reduced lung and bone metastases. The enhancement of lung and bone metastases by CCL2 was associated with increased macrophage infiltration and osteoclast differentiation, respectively. By performing functional assays with primary cells isolated from the wild type, CCL2 and CCR2 knock-out mice, we showed that tumor cell-derived CCL2 depends on its receptor CCR2 (chemokine, CC motif, receptor 2) expressed on stromal cells to exert its function in promoting macrophage recruitment and osteoclast differentiation. Overall, these data demonstrated that CCL2-expressing breast tumor cells engage CCR2⁺ stromal cells of monocytic origin, including macrophages and preosteoclasts, to facilitate colonization in lung and bone. Therefore, CCL2 and CCR2 are promising therapeutic targets for simultaneously inhibiting lung and bone metastasis of breast cancer.Breast cancer is the most common malignancy in women in the United States, with an estimated 182,000 new cases and 40,000 deaths in 2008 (1). Late stage breast cancer patients develop metastases in bone, lung, liver, brain, and other organs, which are responsible for most breast cancer-related mortality and morbidity (2). Severe complications from bone metastasis include debilitating bone fractures, nerve compression and bone pain, and hypercalcemia (3–5), whereas lung metastasis is accompanied by cough, bloody sputum, rib cage pain, and, eventually, failure of the respiratory functions (6). Colonization of different secondary organs by breast cancer is believed to be a complex, multigenic process that depends on productive interactions between tumor cells and stromal microenvironments through concerted actions of organ-specific metastasis genes (7, 8). Functional genomic analysis of preclinical models of breast cancer to bone, lung, and brain have identified distinct sets of organ-specific metastasis genes (9–11), providing novel mechanistic insights into key rate-limiting steps of metastasis to different organs. However, as advanced breast cancer patients often suffer from metastases at several secondary organs, identifying genes that are capable of instigating metastasis to multiple sites may provide the ideal targets for therapeutic intervention of systemic metastasis.Chemokines are small (8–14 kDa) proteins classified into four conserved groups (CXC, CC, C, and CX3C) based on the position of the first two cysteines that are adjacent to the amino terminus (12). They are chemotactic cytokines that stimulate directed migration of leukocytes in response to inflammatory signals. Chemokines are also involved in the maintenance of hematopoietic homeostasis, regulation of cell proliferation, tissue morphogenesis, and angiogenesis (13). Chemokines bind to the seven-transmembrane domain receptors to elicit downstream molecular events that coordinate cell movement. Even though chemokines are unlikely to be a contributing factor for tumor initiation, they can have pleiotropic effects on tumor progression (13, 14). Among more than 50 human chemokines, CCL2 is of particular importance. CCL2, also called monocyte chemoattractant protein-1 (MCP-1), is a potent chemoattractant for monocytes, memory T lymphocytes, and natural killer cells (15). It is involved in a number of inflammatory conditions associated with monocyte recruitment, including delayed hypersensitivity reactions, bacterial infection, arthritis, and renal disease (15). The importance of CCL2 in cancer was manifested by its overexpression in a variety of tumor types, including glioma, ovarian, esophagus, lung, breast, and prostate cancers (15–17). In prostate cancer, CCL2 expression levels was associated with advanced pathological stage (16). Importantly, CCL2-neutralizing antibodies inhibit bone resorption in vitro and bone metastasis in vivo (18–20). In lung cancer, serum CCL2 levels were elevated in lung cancer patients with bone metastasis compared with localized diseases. Neutralizing antibodies against CCL2 also inhibited the tumor conditioned media-induced osteoclast formation in vitro and bone metastasis in vivo (17). Taken together, these findings suggested a role of CCL2 in bone metastasis.A potential role of CCL2 in breast cancer progression and metastasis has been indicated by the analysis of CCL2 expression of tumor and serum samples from breast cancer patients. Serum CCL2 levels were significantly higher in postmenopausal breast cancer patients than in age-matched controls (21). Over 50% of breast cancer tumor samples had intense staining of CCL2 in tumor cells (22). Prognostic analysis further revealed that high expression of CCL2 was correlated with advanced tumor stage, lymph node metastasis (23), and early relapse (24). CCL2 up-regulation in breast tumors was also associated with the infiltration of tissue-associated macrophages (TAMs)³ and with increased microvessel density (22, 24). TAMs have been known to contribute to primary tumor progression and metastasis of breast cancer (25), which is supported by epidemiological evidence showing that TAM infiltration portended a poor clinical outcome (26, 27). However, whether the function of CCL2 in modulating activity of macrophages and possibly other cell types is important for breast tumor organotropic metastasis has not been rigorously investigated. CCL2 may engage organ-specific cell types derived from the same bone marrow myelomonocytic progenitors. These progenitors differentiate into osteoclast precursors in bone or into blood monocytes that eventually become mature macrophages in different tissues, like alveolar macrophages in lung (28). These stromal cell types of myelomonocytic origin may contribute to different functions in different organ-specific metastases. Another unresolved question regarding the function of CCL2 in tumor-stroma interaction is the functional involvement of CCL2 receptors. CCL2 can bind to both CCR2 and CCR4 (29, 30). Loss of function studies in mice showed CCL2 and CCR2 knock-out mice displayed similar impairments in monocyte migration (31, 32), suggesting that CCR2 is the major functional receptor for CCL2. Understanding whether CCR2 deficiency in stromal cells leads to compromised monocyte engagement by CCL2-expressing tumor cells may have important implications in designing targeting therapeutics against the CCL2/CCR2 axis.In this study, we used the recently developed organ-specific metastatic sublines of the human breast cancer cell MDA-MB-231 (9, 10, 33) and showed that overexpression of CCL2 promotes both lung and bone metastases. This function was associated with increased TAM infiltration in lung metastasis and increased osteoclast differentiation in bone metastasis, respectively. Furthermore, by using macrophages and bone marrow cells isolated from wild type, CCL2-deficient, and CCR2-deficient mice, we showed that CCR2 expression in stromal cells is essential for tumor-derived CCL2 to recruit macrophages and promote osteoclastogenesis. Targeting tumor-derived CCL2 by a neutralizing antibody significantly reduced metastasis formation in both bone and lung.     

Printor, a Novel TorsinA-interacting Protein Implicated in Dystonia Pathogenesis

Early onset generalized dystonia (DYT1) is an autosomal dominant neurological disorder caused by deletion of a single glutamate residue (torsinA ΔE) in the C-terminal region of the AAA⁺ (ATPases associated with a variety of cellular activities) protein torsinA. The pathogenic mechanism by which torsinA ΔE mutation leads to dystonia remains unknown. Here we report the identification and characterization of a 628-amino acid novel protein, printor, that interacts with torsinA. Printor co-distributes with torsinA in multiple brain regions and co-localizes with torsinA in the endoplasmic reticulum. Interestingly, printor selectively binds to the ATP-free form but not to the ATP-bound form of torsinA, supporting a role for printor as a cofactor rather than a substrate of torsinA. The interaction of printor with torsinA is completely abolished by the dystonia-associated torsinA ΔE mutation. Our findings suggest that printor is a new component of the DYT1 pathogenic pathway and provide a potential molecular target for therapeutic intervention in dystonia.Early onset generalized torsion dystonia (DYT1) is the most common and severe form of hereditary dystonia, a movement disorder characterized by involuntary movements and sustained muscle spasms (1). This autosomal dominant disease has childhood onset and its dystonic symptoms are thought to result from neuronal dysfunction rather than neurodegeneration (2, 3). Most DYT1 cases are caused by deletion of a single glutamate residue at positions 302 or 303 (torsinA ΔE) of the 332-amino acid protein torsinA (4). In addition, a different torsinA mutation that deletes amino acids Phe³²³–Tyr³²⁸ (torsinA Δ323–328) was identified in a single family with dystonia (5), although the pathogenic significance of this torsinA mutation is unclear because these patients contain a concomitant mutation in another dystonia-related protein, ϵ-sarcoglycan (6). Recently, genetic association studies have implicated polymorphisms in the torsinA gene as a genetic risk factor in the development of adult-onset idiopathic dystonia (7, 8).TorsinA contains an N-terminal endoplasmic reticulum (ER)³ signal sequence and a 20-amino acid hydrophobic region followed by a conserved AAA⁺ (ATPases associated with a variety of cellular activities) domain (9, 10). Because members of the AAA⁺ family are known to facilitate conformational changes in target proteins (11, 12), it has been proposed that torsinA may function as a molecular chaperone (13, 14). TorsinA is widely expressed in brain and multiple other tissues (15) and is primarily associated with the ER and nuclear envelope (NE) compartments in cells (16–20). TorsinA is believed to mainly reside in the lumen of the ER and NE (17–19) and has been shown to bind lamina-associated polypeptide 1 (LAP1) (21), lumenal domain-like LAP1 (LULL1) (21), and nesprins (22). In addition, recent evidence indicates that a significant pool of torsinA exhibits a topology in which the AAA⁺ domain faces the cytoplasm (20). In support of this topology, torsinA is found in the cytoplasm, neuronal processes, and synaptic terminals (2, 3, 15, 23–26) and has been shown to bind cytosolic proteins snapin (27) and kinesin light chain 1 (20). TorsinA has been proposed to play a role in several cellular processes, including dopaminergic neurotransmission (28–31), NE organization and dynamics (17, 22, 32), and protein trafficking (27, 33). However, the precise biological function of torsinA and its regulation remain unknown.To gain insights into torsinA function, we performed yeast two-hybrid screens to search for torsinA-interacting proteins in the brain. We report here the isolation and characterization of a novel protein named printor (protein interactor of torsinA) that interacts selectively with wild-type (WT) torsinA but not the dystonia-associated torsinA ΔE mutant. Our data suggest that printor may serve as a cofactor of torsinA and provide a new molecular target for understanding and treating dystonia.     

Ureteral Metastasis as the Presenting Manifestation of Pancreatic Carcinoma

We recently cared for a patient with adenocarcinoma of the pancreas who presented with ureteral metastasis followed by hydroureteronephrosis long before the appearance of any symptoms related to the primary lesion. The entity is extremely rare; only seven similar cases are on record in the scientific literature. No recent review exists on this topic. This encouraged us to present our case along with the previous cases of adenocarcinoma of the pancreas with ureteral metastasis that have been reported.Key words: Ureter, Metastasis, Ureteral metastasis, Pancreatic adenocarcinoma, HydronephrosisAlthough, ureteral obstruction is relatively common in patients with locally invasive pelvic malignancies, it is extremely rare to find ureteral obstruction due to metastases to the ureter from distant primary tumors.^1–4 Only approximately 400 such cases have been reported.^1,2 Most reported cases were diagnosed postmortem. Ureteral metastases from pancreatic adenocarcinoma have been reported in only seven published cases until now. In the case of the tumors in sites other than the pancreas with ureteral metastases, the primary lesions usually become evident before the ureteral lesions are found.⁵ Three of the seven (43%) reported cases of pancreatic adenocarcinoma presented with initial urologic complaints, and not with complaints related to the primary lesion. We report on a case of pancreatic adenocarcinoma that presented with ureteral metastasis and hydronephrosis. This case also had metastatic invasion of all layers of the ureter which is another infrequent and unique finding.³ We also review the seven previously reported cases here, along with the relevant literature.     

NDRG4 Is Required for Cell Cycle Progression and Survival in Glioblastoma Cells

NDRG4 is a largely unstudied member of the predominantly tumor suppressive N-Myc downstream-regulated gene (NDRG) family. Unlike its family members NDRG1–3, which are ubiquitously expressed, NDRG4 is expressed almost exclusively in the heart and brain. Given this tissue-specific expression pattern and the established tumor suppressive roles of the NDRG family in regulating cellular proliferation, we investigated the cellular and biochemical functions of NDRG4 in the context of astrocytes and glioblastoma multiforme (GBM) cells. We show that, in contrast to NDRG2, NDRG4 expression is elevated in GBM and NDRG4 is required for the viability of primary astrocytes, established GBM cell lines, and both CD133⁺ (cancer stem cell (CSC)-enriched) and CD133⁻ primary GBM xenograft cells. While NDRG4 overexpression has no effect on cell viability, NDRG4 knockdown causes G₁ cell cycle arrest followed by apoptosis. The initial G₁ arrest is associated with a decrease in cyclin D1 expression and an increase in p27^Kip1 expression, and the subsequent apoptosis is associated with a decrease in the expression of XIAP and survivin. As a result of these effects on cell cycle progression and survival, NDRG4 knockdown decreases the tumorigenic capacity of established GBM cell lines and GBM CSC-enriched cells that have been implanted intracranially into immunocompromised mice. Collectively, these data indicate that NDRG4 is required for cell cycle progression and survival, thereby diverging in function from its tumor suppressive family member NDRG2 in astrocytes and GBM cells.The N-Myc downstream-regulated gene (NDRG)⁵ family consists of four genes (NDRG1–4) that can be divided into two subfamilies based on sequence homology: NDRG1 and NDRG3 are in the first subfamily, and NDRG2 and NDRG4 make up the second subfamily. Although the four NDRG family members show distinct spatiotemporal expression patterns during embryonic development and in adult tissues (1–10), all four are highly expressed in the brain (4). To date, however, NDRG2 is the only NDRG family member that has been studied in the context of GBM cells and astrocytes. NDRG2 mRNA and protein levels are lower in GBM than in normal brain tissue, normal glial cells, and low grade astrocytomas (11–14), suggesting a tumor suppressive function. Data from experimental and clinical studies support this hypothesis: NDRG2 overexpression inhibits GBM cell proliferation (15), and decreased NDRG2 expression correlates with decreased GBM patient survival (13).In contrast to its subfamily member NDRG2, NDRG4 has not been studied in GBM cells or astrocytes. Nevertheless, available evidence supports the hypothesis that NDRG4 has an important role in this context that is similar to the role of NDRG2. First, unlike the relatively ubiquitous expression patterns of NDRG1–3, NDRG4 expression is restricted to a small number of tissues including the brain, where it is expressed at particularly high levels (7, 10). This restricted expression pattern suggests that NDRG4 plays an important role within the central nervous system. Second, NDRG4 is more than 60% identical in amino acid sequence to NDRG2. This sequence similarity is likely behind the overlapping functions of these two proteins in certain cell types within the brain. For example, in PC12 neuronal cells, both NDRG4 and NDRG2 promote neurite extension (16–18). In combination with the brain-specific expression pattern of NDRG4, these functional and sequence similarities suggest that NDRG4 may recapitulate the tumor suppressive function of NDRG2 in primary brain neoplasms.To determine if the similarities between NDRG2 and NDRG4 extend to the context of GBM, we investigated the role of NDRG4 in GBM cell lines and primary human astrocytes. In contrast to the established roles of NDRG2 and other NDRG family members, we found that the role of NDRG4 in GBM is not tumor suppressive. On the contrary, both astrocytes and GBM cells require the presence of NDRG4 for cell cycle progression and survival.