Expression of the repressor element-1 silencing transcription factor (REST) is regulated by IGF-I and PKC in human neuroblastoma cells

The repressor element 1-silencing transcription factor (REST) was first identified as a protein that binds to a 21-bp DNA sequence element (known as repressor element 1 (RE1)) resulting in transcriptional repression of the neural-specific genes [Chong et al., 1995; Schoenherr and Anderson, 1995]. The original proposed role for REST was that of a factor responsible for restricting neuronal gene expression to the nervous system by silencing expression of these genes in non-neuronal cells. Although it was initially thought to repress neuronal genes in non-neuronal cells, the role of REST is complex and tissue dependent. In this study I investigated any role played by REST in the induction and patterning of differentiation of SH-SY5Y human neuroblastoma cells exposed to IGF-I. and phorbol 12- myristate 13-acetate (PMA) To down-regulate REST expression we developed an antisense (AS) strategy based on the use of phosphorothioate oligonucleotides (ODNs). In order to evaluate REST mRNA levels, we developed a real-time PCR technique and REST protein levels were evaluated by western blotting. Results showed that nuclear REST is increased in SH-SY5Y neuroblastoma cells cultured in SFM and exposed to IGF-I for 2-days and it then declines in 5-day-treated cells concomitant with a progressive neurite extension. Also the phorbol ester PMA was able to increase nuclear REST levels after 3-days treatment concomitant to neuronal differentiation of neuroblastoma cells, whereas, at later stages, it is down-regulated. Supporting these data, the exposure to PKC inhibitors (GF10923X and Gö6976) and PMA (16nM) reverted the effects observed with PMA alone. REST levels were related to morphological differentiation, expression of growth coneassociated protein 43 (GAP-43; a gene not regulated by REST) and of synapsin I and βIII tubulin (genes regulated by REST), proteins involved in the early stage of neuronal development. We observed that differentiation of SH-SY5Y cells by IGF-I and PMA was accompanied by a significant increase of these neuronal markers, an effect that was concomitant with REST decrease. In order to relate the decreased REST expression with a progressive neurite extension, I investigated any possible involvement of the ubiquitin–proteasome system (UPS), a multienzymatic pathway which degrades polyubiquinated soluble cytoplasmic proteins [Pickart and Cohen, 2004]. For this purpose, SH-SY5Y cells are concomitantly exposed to PMA and the proteasome inhibitor MG132. In SH-SY5Y exposed to PMA and MG 132, we observed an inverse pattern of expression of synapsin I and β- tubulin III, two neuronal differentiation markers regulated by REST. Their cytoplasmic levels are reduced when compared to cells exposed to PMA alone, as a consequence of the increase of REST expression by proteasome inhibitor. The majority of proteasome substrates identified to date are marked for degradation by polyubiquitinylation; however, exceptions to this principle, are well documented [Hoyt and Coffino, 2004]. Interestingly, REST degradation seems to be completely ubiquitin-independent. The expression pattern of REST could be consistent with the theory that, during early neuronal differentiation induced by IGF-I and PKC, it may help to repress the expression of several genes not yet required by the differentiation program and then it declines later. Interestingly, the observation that REST expression is progressively reduced in parallel with cell proliferation seems to indicate that the role of this transcription factor could also be related to cell survival or to counteract apotosis events [Lawinger et al., 2000] although, as shown by AS-ODN experiments, it does not seem to be directly involved in cell proliferation. Therefore, the decline of REST expression is a comparatively later event during maturation of neuroroblasts in vitro. Thus, we propose that REST is regulated by growth factors, like IGF-I, and PKC activators in a time-dependent manner: it is elevated during early steps of neural induction and could contribute to down-regulate genes not yet required by the differentiation program while it declines later for the acquisition of neural phenotypes, concomitantly with a progressive neurite extension. This later decline is regulated by the proteasome system activation in an ubiquitin-indipendent way and adds more evidences to the hypothesis that REST down-regulation contributes to differentiation and arrest of proliferation of neuroblastoma cells. Finally, the glycosylation pattern of the REST protein was analysed, moving from the observation that the molecular weight calculated on REST sequence is about 116 kDa but using western blotting this transcription factor appears to have distinct apparent molecular weight (see Table 1.1): this difference could be explained by post-translational modifications of the proteins, like glycosylation. In fact recently, several studies underlined the importance of O-glycosylation in modulating transcriptional silencing, protein phosphorylation, protein degradation by proteasome and protein–protein interactions [Julenius et al., 2005; Zachara and Hart, 2006]. Deglycosilating analysis showed that REST protein in SH-SY5Y and HEK293 cells is Oglycosylated and not N-glycosylated. Moreover, using several combination of deglycosilating enzymes it is possible to hypothesize the presence of Gal-β(1-3)-GalNAc residues on the endogenous REST, while β(1-4)-linked galactose residues may be present on recombinant REST protein expressed in HEK293 cells. However, the O-glycosylation process produces an immense multiplicity of chemical structures and monosaccharides must be sequentially hydrolyzed by a series of exoglycosidase. Further experiments are needed to characterize all the post-translational modification of the transcription factor REST.

Development of analytical methodologies for iodine species in gaseous and particulate phases of the coastal atmosphere

It has been demonstrated that iodine does have an important influence on atmospheric chemistry, especially the formation of new particles and the enrichment of iodine in marine aerosols. It was pointed out that the most probable chemical species involved in the production or growth of these particles are iodine oxides, produced photochemically from biogenic halocarbon emissions and/or iodine emission from the sea surface. However, the iodine chemistry from gaseous to particulate phase in the coastal atmosphere and the chemical nature of the condensing iodine species are still not understood. A Tenax / Carbotrap adsorption sampling technique and a thermo-desorption / cryo-trap / GC-MS system has been further developed and improved for the volatile organic iodine species in the gas phase. Several iodo-hydrocarbons such as CH3I, C2H5I, CH2ICl, CH2IBr and CH2I2 etc., have been measured in samples from a calibration test gas source (standards), real air samples and samples from seaweeds / macro-algae emission experiments. A denuder sampling technique has been developed to characterise potential precursor compounds of coastal particle formation processes, such as molecular iodine in the gas phase. Starch, TMAH (TetraMethylAmmonium Hydroxide) and TBAH (TetraButylAmmonium Hydroxide) coated denuders were tested for their efficiencies to collect I2 at the inner surface, followed by a TMAH extraction and ICP/MS determination, adding tellurium as an internal standard. The developed method has been proved to be an effective, accurate and suitable process for I2 measurement in the field, with the estimated detection limit of ~0.10 ng∙L-1 for a sampling volume of 15 L. An H2O/TMAH-Extraction-ICP/MS method has been developed for the accurate and sensitive determination of iodine species in tropospheric aerosol particles. The particle samples were collected on cellulose-nitrate filters using conventional filter holders or on cellulose nitrate/tedlar-foils using a 5-stage Berner impactor for size-segregated particle analysis. The water soluble species as IO3- and I- were separated by anion exchanging process after water extraction. Non-water soluble species including iodine oxide and organic iodine were digested and extracted by TMAH. Afterwards the triple samples were analysed by ICP/MS. The detection limit for particulate iodine was determined to be 0.10~0.20 ng•m-3 for sampling volumes of 40~100 m3. The developed methods have been used in two field measurements in May 2002 and September 2003, at and around the Mace Head Atmospheric Research Station (MHARS) located at the west coast of Ireland. Elemental iodine as a precursor of the iodine chemistry in the coastal atmosphere, was determined in the gas phase at a seaweed hot-spot around the MHARS, showing I2 concentrations were in the range of 0~1.6 ng∙L-1 and indicating a positive correlation with the ozone concentration. A seaweed-chamber experiment performed at the field measurement station showed that the I2 emission rate from macro-algae was in the range of 0.019~0.022 ng•min-1•kg-1. During these experiments, nanometer-particle concentrations were obtained from the Scanning Mobility Particle Sizer (SMPS) measurements. Particle number concentrations were found to have a linear correlation with elemental iodine in the gas phase of the seaweeds chamber, showing that gaseous I2 is one of the important precursors of the new particle formation in the coastal atmosphere. Iodine contents in the particle phase were measured in both field campaigns at and around the field measurement station. Total iodine concentrations were found to be in the range of 1.0 ~ 21.0 ng∙m-3 in the PM2.5 samples. A significant correlation between the total iodine concentrations and the nanometer-particle number concentrations was observed. The particulate iodine species analysis indicated that iodide contents are usually higher than those of iodate in all samples, with ratios in the range of 2~5:1. It is possible that those water soluble iodine species are transferred through the sea-air interface into the particle phase. The ratio of water soluble (iodate + iodide) and non-water soluble species (probably iodine oxide and organic iodine compounds) was observed to be in the range of 1:1 to 1:2. It appears that higher concentrated non-water soluble species, as the products of the photolysis from the gas phase into the particle phase, can be obtained in those samples while the nucleation events occur. That supports the idea that iodine chemistry in the coastal boundary layer is linked with new particle formation events. Furthermore, artificial aerosol particles were formed from gaseous iodine sources (e.g. CH2I2) using a laboratory reaction-chamber experiment, in which the reaction constant of the CH2I2 photolysis was calculated to be based upon the first order reaction kinetic. The end products of iodine chemistry in the particle phase were identified and quantified.

Metodiche di preservazione del polmone isolato per lo studio ecografico: Studio sperimentale

Oggetto della tesi e' l'approfondimento su tecniche e metodiche di preservazione del polmone isolato per lo studio ecografico. E' discussa l'appropriatezza sull'uso degli ultrasuoni in corso di chirurgia mini invasiva polmonare, obiettivo di una ricerca sperimentale. Il razionale dello studio si fonda sull'indicazione all'exeresi chirurgica di noduli polmonari di diametro inferiore al centometro, ovvero di diametro superiore ma localizzati in aree centrali del polmone. Queste lesioni sono sempre piu' frequentente diagnosticate per mezzo di avanzate tecniche di imaging. L'atto chirurgico ha scopo terapeutico quando sia stata posta la diagnosi di neoplasia maligna, diagnostico-terapeutico quando non sia ancora ottenuta la tipizzazione istologica della lesione. La tecnica toracoscopica offre numerosi vantaggi rispetto alle tecniche chirurgiche tradizionali ma presenta il grave limite di non permettere la palpazione diretta del tessuto polmonare e la localizzazione della formazione tumorale quando essa non sia visibile macroscopicamente. Gli ultrasuoni sono stati utilizzati con successo per indirizzare la localizzazione del nodulo polmonare. Scopo dello studio sperimentale e' quello di confrontare tecniche diverse di preservazione del polmone isolato in un modello animale, comparando catatteristiche e prestazioni di sonde ecografiche differenti per tipologia. Del tutto recentemente, in ambito trapiantologico, sono state proposte tecniche di preservazione organica utili ai fini di uno studio anatomico sperimentale particolareggiato (EVLP) e moderna e' da considerarsi la concezione di mezzi tecnici specifici per la localizzazione di bersagli intrapolmonari. La tecnica clinica applicata allo studio del particolare ecografico, nel modello animale, ha reso comprensibile e meglio definito il ruolo delle sonde ecografiche nell'individuazione di forme tumorali suscettibili di exeresi definitiva.

Structural characterization of intermediate and metastable phases by electron microscopy

Structure characterization of nanocrystalline intermediates and metastable phases is of primary importance for a deep understanding of synthetic processes undergoing solid-to-solid state phase transitions. Understanding the evolution from the first nucleation stage to the final synthetic product supports not only the optimization of existing processes, but might assist in tailoring new synthetic paths. A systematic investigation of intermediates and metastable phases is hampered because it is impossible to produce large crystals and only in few cases a pure synthetic product can be obtained. Structure investigation by X-ray powder diffraction methods is still challenging on nanoscale, especially when the sample is polyphasic. Electron diffraction has the advantage to collect data from single nanoscopic crystals, but is limited by data incompleteness, dynamical effects and fast deterioration of the sample under the electron beam. Automated diffraction tomography (ADT), a recently developed technique, making possible to collect more complete three-dimensional electron diffraction data and to reduce at the same time dynamical scattering and beam damage, thus allowing to investigate even beam sensitive materials (f.e. hydrated phases and organics). At present, ADT is the only technique able to deliver complete three-dimensional structural information from single nanoscopic grains, independently from other surrounding phases. Thus, ADT is an ideal technique for the study of on-going processes where different phases exist at the same time and undergo several structural transitions. In this study ADT was used as the main technique for structural characterization for three different systems and combined subsequently with other techniques, among which high-resolution transmission electron microscopy (HRTEM), cryo-TEM imaging, X-ray powder diffraction (XRPD) and energy disperse X-ray spectroscopy (EDX).rnAs possible laser host materials, i.e. materials with a broad band emission in the near-infrared region, two unknown phases were investigated in the ternary oxide system M2O-Al2O3-WO3 (M = K, Na). Both phases exhibit low purity as well as non-homogeneous size distribution and particle morphology. The structures solved by ADT are also affected by pseudo-symmetry. rnSodium titanate nanotubes and nanowires are both intermediate products in the synthesis of TiO2 nanorods which are used as additives to colloidal TiO2 film for improving efficiency of dye-sensitized solar cells (DSSC). The structural transition from nantubes to nanowires was investigated in a step by step time-resolved study. Nanowires were discovered to consist of a hitherto unknown phase of sodium titanate. This new phase, typically affected by pervasive defects like mutual layer shift, was structurally determined ab-initio on the basis of ADT data. rnThe third system is related with calcium carbonate nucleation and early crystallization. The first part of this study is dedicated to the extensive investigations of calcium carbonate formation in a step by step analysis, up to the appearance of crystalline individua. The second part is dedicated to the structure determination by ADT of the first-to-form anhydrated phase of CaCO3: vaterite. An exhaustive structure analysis of vaterite had previously been hampered by diffuse scattering, extra periodicities and fast deterioration of the material under electron irradiation. rn

Human melanocytes can be isolated, propagated and expanded from plucked anagen hair follicles

Herein, we report a technically simple method for isolation and culture of human follicular melanocytes based on explant cultures of epilated hair follicles. This technique does not require any surgical intervention and allows the isolation and cultivation of follicular melanocytes from a comparatively small amount of raw material. Generally, 30-60 human anagen hair follicles have been plucked from the scalp of healthy donors and cultivated under low oxygen pressure (5%). After a short period of time cells of various types were growing out from the outer root sheath (ORS) of the hair follicles. Under the selected culture conditions, most of the cells other than melanocytes have been eliminated and a nearly 100% pure population of melanocytes has been achieved, as confirmed by immunohistochemical analyses for melanocyte-specific markers, for example, Tyrosinase-1, S-100 and premelanosomal antigens. These melanocytes derived from the ORS were proliferating for up to 2 months.

Surgical dislocation of the hip for a locked traumatic posterior dislocation with associated femoral neck and acetabular fractures

Traumatic posterior dislocation of the hip associated with a fracture of the posterior acetabular wall and of the neck of the femur is a rare injury. A 29-year-old man presented at a level 1 trauma centre with a locked posterior dislocation of the right hip, with fractures of the femoral neck and the posterior wall of the acetabulum after a bicycle accident. An attempted closed reduction had failed. This case report describes in detail the surgical management and the clinical and radiological outcome. Open reduction and fixation with preservation of the intact retinaculum was undertaken within five hours of injury with surgical dislocation of the hip and a trochanteric osteotomy. Two years after operation the function of the injured hip was good. Plain radiographs and MR scans showed early signs of osteoarthritis with some loss of joint space but no evidence of avascular necrosis. The patient had begun skiing and hiking again. The combination of fractures of the neck of the femur and of the posterior wall of the acetabulum hampers closed reduction of a posterior dislocation of the hip. Surgical dislocation of the hip with trochanteric flip osteotomy allows controlled open reduction of the fractures, with inspection of the hip joint and preservation of the vascular supply.

Clinical radiology and postmortem imaging (Virtopsy) are not the same: Specific and unspecific postmortem signs

The aim of this article is to disclose the characteristics of postmortem forensic imaging; give an overview of the several possible findings in postmortem imaging, which are uncommon or new to clinical radiologists; and discuss the possible pitfalls. Unspecific postmortem signs are enlisted and specific signs shall be presented, which are typical for one cause of death. Unspecific signs. Livor mortis may not only be seen from the outside, but also inside the body in the lungs: in chest CT internal livor mortis appear as ground glass opacity in the dependent lower lobes. The aortic wall is often hyperdense in postmortem CT due to wall contraction and loss of luminal pressure. Gas bubbles are very common postmortem due to systemic gas embolism after major open trauma, artificial respiration or initial decomposition; in particular putrefaction produces gas bubbles globally. Specific signs. Intracranial bleeding is hyperattenuating both in radiology and in postmortem imaging. Signs of strangulation are hemorrhage in the soft tissue of the neck like skin, subcutaneous tissue, platysma muscle and lymph nodes. The "vanishing" aorta is indicative for exsanguination. Fluid in the airways with mosaic lung densities and emphysema (aquosum) is typical for fresh-water drowning.

Percutaneous endoscopic gastrostomy in head and neck cancer patients: indications, techniques, complications and results

The aim of this study was to review our experience in percutaneous endoscopic gastrostomy (PEG) performed in patients with cancer of the upper aerodigestive tract. Descriptive retrospective study of 142 patients (115 males, 27 females), mean age 62.4 years (25-84 years), with head and neck or esophageal cancer, who underwent PEG tube insertion between January 2006 and December 2008. The studied parameters were indications, success rate, rate and type of complications, and their management. Percutaneous endoscopic gastrostomy was inserted before chemoradiation therapy in 80% and during or after cancer treatment in 20% of the patients. PEG placement was possible in 137 patients (96%). Major complications were observed in 9 (7%) and minor complications in 22 (17%) of the 137 patients. Seven of the 9 patients with a major complication needed revision surgery. The mortality directly related to the procedure was 0.7%. Percutaneous endoscopic gastrostomy tube insertion has a high success rate. In patients with upper aerodigestive tract cancer, PEG should be the first choice for enteral nutrition when sufficient oral intake is not possible. Although apparently easy, the procedure may occasionally lead to severe complications. Therefore, a strict technique and knowledge of clinical signs of possible complications are mandatory.

Operation time and body mass index are significant risk factors for surgical site infection in laparoscopic sigmoid resection: a multicenter study

Surgical site infection (SSI) in patients who underwent colorectal surgery is a common complication associated with increased morbidity and costs. The aim of this study was to assess risk factors for SSI in laparoscopic sigmoid resection for benign disease.

Evaluation of a portable image overlay projector for the visualisation of surgical navigation data: phantom studies

Presenting visual feedback for image-guided surgery on a monitor requires the surgeon to perform time-consuming comparisons and diversion of sight and attention away from the patient. Deficiencies in previously developed augmented reality systems for image-guided surgery have, however, prevented the general acceptance of any one technique as a viable alternative to monitor displays. This work presents an evaluation of the feasibility and versatility of a novel augmented reality approach for the visualisation of surgical planning and navigation data. The approach, which utilises a portable image overlay device, was evaluated during integration into existing surgical navigation systems and during application within simulated navigated surgery scenarios.

How reliable is Ki-67 immunohistochemistry in grade 2 breast carcinomas? A QA study of the Swiss Working Group of Breast- and Gynecopathologists

Adjuvant chemotherapy decisions in breast cancer are increasingly based on the pathologist's assessment of tumor proliferation. The Swiss Working Group of Gyneco- and Breast Pathologists has surveyed inter- and intraobserver consistency of Ki-67-based proliferative fraction in breast carcinomas. Methods Five pathologists evaluated MIB-1-labeling index (LI) in ten breast carcinomas (G1, G2, G3) by counting and eyeballing. In the same way, 15 pathologists all over Switzerland then assessed MIB-1-LI on three G2 carcinomas, in self-selected or pre-defined areas of the tumors, comparing centrally immunostained slides with slides immunostained in the different laboratoires. To study intra-observer variability, the same tumors were re-examined 4 months later. Results The Kappa values for the first series of ten carcinomas of various degrees of differentiation showed good to very good agreement for MIB-1-LI (Kappa 0.56–0.72). However, we found very high inter-observer variabilities (Kappa 0.04–0.14) in the read-outs of the G2 carcinomas. It was not possible to explain the inconsistencies exclusively by any of the following factors: (i) pathologists' divergent definitions of what counts as a positive nucleus (ii) the mode of assessment (counting vs. eyeballing), (iii) immunostaining technique, and (iv) the selection of the tumor area in which to count. Despite intensive confrontation of all participating pathologists with the problem, inter-observer agreement did not improve when the same slides were re-examined 4 months later (Kappa 0.01–0.04) and intra-observer agreement was likewise poor (Kappa 0.00–0.35). Conclusion Assessment of mid-range Ki-67-LI suffers from high inter- and intra-observer variability. Oncologists should be aware of this caveat when using Ki-67-LI as a basis for treatment decisions in moderately differentiated breast carcinomas.

The location of paravertebral catheters placed using the landmark technique

The aim of this prospective clinical study was to evaluate the location of paravertebral catheters that were placed using the classical landmark puncture technique and to correlate the distribution of contrast dye injected through the catheters with the extent of somatic block. Paravertebral catheter placement was attempted in 31 patients after video-assisted thoracic surgery. In one patient, an ultrasound-guided approach was chosen after failed catheter placement using the landmark method. A fluoroscopic examination in two planes using contrast dye was followed by injection of local anaesthetic and subsequent clinical testing of the extent of the anaesthetised area. In nine patients (29%), spread of contrast dye was not seen within the paravertebral space as intended. Misplaced catheters were in the epidural space (three patients), in the erector spinae musculature (five patients), and in the pleural space (one patient). There was also a discrepancy between the radiological findings and the observed distribution of loss of sensation. We have demonstrated an unacceptably high misplacement rate of paravertebral catheters using the landmark method. Additional research is required to compare the efficacy and safety of continuous paravertebral block using ultrasound-guided techniques or surgical inserted catheters.

Microsurgical management of large intra-and extracranial calvarial meningiomas

Objective: Based on the largest series reported of giant intra- and extracranial calvarial meningiomas (GIECM) the purpose of the present study was to characterize the treatment and outcome data associated with patients operated on GIECM and to describe our experience in the management of this rare and therapeutically demanding tumour entity. Methods: The data of 12 patients (7/12 males, 5/12 females) with surgically treated GIECM at the University Hospitals Aachen and Bern between 1994 and 2011 were retrospectively analyzed. The mean patient age was 58 years (range, 22 to 78 years). Symptom distribution included extracranial swelling (12/12), seizures (5/12), headache (4/12), gait disturbance (3/12), dizziness (2/12), and impaired vision (1/12). GIECM were located frontal (6/12), temporal (3/12), parietal, fronto-parietal, and parieto-occipital (1/12 each). Microsurgical resection with acrylic-augmented cranioplasty was performed in all patients and 11/12 patients received dural repair with synthetic (7/11) or autologous (4/11) patch grafts. Surgical excision in two stages with primary removal of the extracranial meningioma component was undertaken in 2/12 patients, whereas preoperative embolization and postoperative radiotherapy were applied in 1/12 patient each. Results: In contrast to intradural meningiomas GIECM mainly affect male patients at a comparatively younger age. GIECM could be completely (9/12) or subtotally (3/12) resected. Surgical-associated complications included minor CSF leak (6/12), wound healing disturbance (3/12), venous engorgement, and haemorrhage (2/12 each), requiring reoperation in 3/12 cases. Histopathological examination revealed meningothelial (6/12), atypical (4/12), and transitional (1/12) GIECM. 10/12 patients exhibited excellent postoperative clinical outcome, 1/12 patient each deteriorated or died of pulmonary embolism. Conclusions: The operative management of GIECM is challenging, carries a substantial risk, and demands special strategies because of the large tumour size, anatomical involvement of scalp, calvaria, meninges, brain or vascular structures, and more frequent atypical histology. Although microsurgical resection with cranioplasty and mostly dural grafting usually results in a good clinical outcome, the potential complication rate is markedly higher when compared to smaller meningiomas without extracranial component. Preoperative embolization and staging of surgical resection are possible additional therapeutic options.

[Lymphadenectomy for bladder cancer: current status and controversies]

Pelvic lymph node dissection is an integral part of the radical cystectomy procedure for patients with muscle-invasive bladder cancer. The optimal extent of the lymphadenectomy (LND) and mainly the proximal template boundary remain controversial issues. In view of the existing mapping studies and retrospective analyses, extended LND up to the mid-upper third of the common iliac vessels appears to provide further prognostic and therapeutic benefit and therefore should be defined as standard LND. This applies for all procedures irrespective of the choice of surgical approach (open surgery, minimally invasive approach). In this context total lymph node count is not a quality criterion because nodal yield is overly influenced by the individual patient's anatomy, surgical technique, template applied and pathological work-up. Consecutively, considerable inter-institutional differences result, which render any comparison impossible. Lymph node density is thought to be a superior prognostic factor, but it is similarly influenced by the above-mentioned factors. Concerning molecular techniques to improve the sensitivity of postoperative nodal staging further research is necessary. The two ongoing prospective randomized trials will potentially help to further define the optimal LND template.

Role and extent of lymphadenectomy during radical cystectomy for invasive bladder cancer

There is substantial variability in the extent of the node dissection performed during radical cystectomy for bladder cancer. Here, we review the diagnostic assessment of lymph node metastasis and the prognostic and therapeutic benefit for pelvic node dissection for bladder cancer. A review of the applicable urologic literature regarding the topics of lymphadenectomy for bladder cancer was conducted. Nodal metastasis above a limited or standard template is not uncommon, with up to 16% of all nodal metastasis detected proximal to the aortic bifurcation. However, skip metastasis is extremely rare. Proteins associated purely with epithelial tissue such as cytokeratin (CK)-19, CK-20, and uroplakin II have been observed in reportedly negative nodal specimens, which indicates that routine microscopic analysis of nodal tissue may miss small foci of metastatic cancer. In addition to the surgical technique, the total number of lymph nodes removed is influenced by patient anatomy and pathologic processing and therefore may be unsuitable as a procedural quality statement. Consecutively, meticulous removal of tissue within a defined and uniformly applied template may be more relevant than absolute nodal count. Observational cohort series indicate an improved oncologic outcome for patients undergoing extensive nodal dissection. The results of two randomized controlled trials addressing the extent of nodal dissection for bladder cancer are forthcoming.