Correspondence

Caspase 3 and p27 as Predictors of Invasive Bladder Cancer

N Engl J Med 2000; 343:1418-1420November 9, 2000

Article

To the Editor:

In the United States and the United Kingdom, about 57,000 patients are given a diagnosis of bladder cancer each year. Invasive bladder cancer usually arises from a precursor lesion of either flat carcinoma in situ or noninvasive papillary transitional carcinoma. Flat carcinoma in situ is typified by the increased proliferation of transitional epithelial cells. In approximately 50 percent of patients, bladder carcinoma in situ will evolve into full-blown, invasive bladder cancer. Increased understanding of the molecular mechanisms driving the transition from carcinoma in situ to invasive cancer would have major implications for the treatment of this condition. Furthermore, it could lead to tests that would identify patients in whom carcinoma in situ will evolve into invasive bladder cancer.

The presence of p27, a cyclin-dependent kinase inhibitor that powerfully blocks progression of the cell cycle,1 in the nucleus of a variety of tumor cells has been correlated with improved survival.2 Activated caspase 3 is a downstream effector of the apoptotic pathway that can cleave p27 into two fragments that leave the nucleus, resulting in a dramatic up-regulation in the activity of cyclin-dependent kinase 2, a requirement for cell proliferation.3

We hypothesized that the loss of the expression of p27 in nuclei coupled with increased expression of activated caspase 3 in bladder carcinoma-in-situ cells correlates with the subsequent development of invasive bladder cancer. To test this hypothesis, we performed immunocytochemical analysis, using standard techniques,4 on tissue sections from 34 patients with a diagnosis of bladder carcinoma in situ and then determined whether or not invasive bladder cancer developed.

The mean length of follow-up was 3.6 years. Among the 34 patients, invasive bladder cancer developed in 14 (41 percent). Loss of immunostaining for p27 in the nucleus was associated with the subsequent development of invasive disease (sensitivity, 76 percent; specificity, 66 percent; P<0.05). The presence of high levels of activated caspase 3 was also associated with progression to invasive disease (sensitivity, 60 percent; specificity, 68 percent; P<0.05). However, the presence of both factors was associated even more strongly with invasiveness. Of the 14 patients in whom invasive bladder cancer developed, 11 had high levels of expression of activated caspase 3 (Figure 1AFigure 1Immunocytochemical Analysis of Activated Caspase 3 Levels (Panels A and B) and Nuclear p27 Levels (Panels C and D) in Two Patients with Bladder Carcinoma in Situ (Immunostaining, with Hematoxylin Counterstaining).) and a total or near-total loss of nuclear immunostaining for p27 (Figure 1C). In contrast, 17 of the 20 patients in whom invasive bladder cancer did not develop had low levels of activated caspase 3 on immunostaining (Figure 1B) and high levels of nuclear p27 (Figure 1D) (sensitivity, 78 percent; specificity, 85 percent; P<0.001). Furthermore, among six patients with recurrent carcinoma in situ who received intravesicular bacille Calmette–Guérin as immunotherapy, the three patients in whom invasive bladder cancer subsequently developed had low levels of expression of p27 in the nuclei and high levels of expression of activated caspase 3. The three patients without disease recurrence after treatment with bacille Calmette–Guérin had high levels of expression of p27 in nuclei and low levels of expression of activated caspase 3.

These data suggest that the measurement of both nuclear p27 levels and activated caspase 3 levels may be useful in monitoring patients with bladder carcinoma in situ, to identify both those at increased risk for invasive bladder cancer and those who are more likely to have a response to intravesicular immunotherapy.

(This work was supported by the Medical Research Council of the United Kingdom.)

Paul B.J. Burton, M.B., B.S., Ph.D.
National Heart and Lung Institute at Imperial College School of Medicine, London SW3 6LY, United Kingdom

Christopher J. Anderson, F.R.C.S.
Cathy M. Corbishly, F.R.C.Path.
St. George's Hospital National Health Service Trust, London SW17 0QT, United Kingdom

4 References

1. 1

   Nakayama K, Nakayama K. Cip/Kip cyclin-dependent kinase inhibitors: brakes of the cell cycle engine during development. Bioessays 1998;20:1020-1029
   CrossRef | Web of Science | Medline

2. 2

   Tsihlias J, Kapusta L, Slingerland J. The prognostic significance of altered cyclin-dependent kinase inhibitors in human cancer. Annu Rev Med 1999;50:401-423
   CrossRef | Web of Science | Medline

3. 3

   Levkau B, Koyama H, Raines EW, et al. Cleavage of p21Cip1/Waf1 and p27Kip1 mediates apoptosis in endothelial cells through activation of Cdk2: role of a caspase cascade. Mol Cell 1998;1:553-563
   CrossRef | Web of Science | Medline

4. 4

   Burton PBJ, Raff MC, Kerr P, Yacoub MH, Barton PJ. An intrinsic timer that controls cell-cycle withdrawal in cultured cardiac monocytes. Dev Biol 1999;216:659-670
   CrossRef | Web of Science | Medline

Citing Articles (6)

Citing Articles

1. 1

   Kazuhito Matsushita, Eugene K Cha, Kazumasa Matsumoto, Shiro Baba, Thomas F Chromecki, Harun Fajkovic, Maxine Sun, Pierre I Karakiewicz, Douglas S Scherr, Shahrokh F Shariat. (2011) Immunohistochemical biomarkers for bladder cancer prognosis. International Journal of Urologyno-no
   CrossRef

2. 2

   Qiang Lu, Chao Lu, Guo-Ping Zhou, Wei Zhang, Hang Xiao, Xin-Ru Wang. (2010) MicroRNA-221 silencing predisposed human bladder cancer cells to undergo apoptosis induced by TRAIL. Urologic Oncology: Seminars and Original Investigations 28:6, 635-641
   CrossRef

3. 3

   Eva Karamitopoulou, Cyrill A. Rentsch, Regula Markwalder, Claudio Vallan, George N. Thalmann, Thomas Brunner. (2010) Prognostic significance of apoptotic cell death in bladder cancer. Pathology 42:1, 37-42
   CrossRef

4. 4

   In Gab Jeong, Sung Han Kim, Hwang Gyun Jeon, Baek Hee Kim, Kyung Chul Moon, Sang Eun Lee, Eunsik Lee. (2009) Prognostic value of apoptosis-related markers in urothelial cancer of the upper urinary tract. Human Pathology 40:5, 668-677
   CrossRef

5. 5

   Shahrokh F Shariat, Jose A Karam, Seth P Lerner. (2008) Molecular markers in bladder cancer. Current Opinion in Urology 18:1, 1-8
   CrossRef

6. 6

   Jose A Karam, Yair Lotan, Pierre I Karakiewicz, Raheela Ashfaq, Arthur I Sagalowsky, Claus G Roehrborn, Shahrokh F Shariat. (2007) Use of combined apoptosis biomarkers for prediction of bladder cancer recurrence and mortality after radical cystectomy. The Lancet Oncology 8:2, 128-136
   CrossRef