1. Pathology 430/827 Bladder cancer Etiology, classification, and diversity David M. Berman, MD, PhD Pathology and Molecular Medicine Queen’s Cancer Research Institute bermand@queensu.ca bermanlab.org

2. Objectives 1.Recognize who gets bladder cancer and why

3. Objectives 1.Recognize who gets bladder cancer and why 2.Recognize different types of bladder cancers A.Two genomic pathways cause bladder cancer B.Bladder cancers can change (“progress”) over time I.Grade II.Stage

4. Objectives 1.Recognize who gets bladder cancer and why 2.Recognize different types of bladder cancers A.Two genomic pathways cause bladder cancer B.Bladder cancers can change (“progress”) over time I.Grade II.Stage 3.Understand concept of epithelial differentiation and how it produces different types of bladder cancer cells

5. Epidemiology 4 th most common cancer in men, – Affecting ~3% of men in Western countries – 3x less frequent in women – Peak age 75yrs

6. Epidemiology In 2013 in US & Canada, – ~80,000 new cases – ~16,000 deaths

7. RISK Smoking Strong (~50%) Occupation Strong (~25%)

8. IatrogenicSchistosomes RISK

9. Family History Muir Torre Syndrome Arsenic

10. Symptoms > Hematuria (>75%)Dysuria (~10%)

11. Urinary bladder: A urine storage system Lumen (optional)

12. Common (75%) Recur (50%) Local treatment

13. Uncommon (25%) Usually progress

14. Radical treatment Local treatment

15. Progression and classification of urothelial carcinoma Grade Low or High High Grade High High 85%

16. Bladder Cancer Staging STAGEPrimary tumour (T)Regional Lymph Nodes (N)Distant Metastasis (M) 0Ta or Tis00 IT100 IIT200 IIIT3 or T4a00 IVT4bAND/OR N1-N3AND/OR M1

17. Survival rates by stage StageRelative 5- year Survival Rate 098% I88% II63% III46% IV15%

18. Non-invasive papillary urothelial carcinoma

19. Papillary urothelial neoplasia Fibrovascular cores Urothelium

20. Low grade non-invasive papillary urothelial carcinoma

21. High grade non-invasive papillary urothelial carcinoma

22. Invasive urothelial carcinoma

23. Flat/invasive urothelial carcinoma Benign Carcinoma in situ (CIS)

24. Invasive urothelial carcinoma

25. Sweden (Lund) North Carolina (UNC) Texas (MD Anderson TCGA (U.S.) Studies describing molecular subtypes

26. Non-invasiveInvasive Urobasal A (Lund) ~ Luminal (Texas, NC) ~ Group B (TCGA) Urobasal B (Sweden) Squamous-like (Sweden), Basal (Texas, NC) Molecular Subtypes

27. Different cell types within a bladder cancer

28. (niche?) Epithelial architecture (basal) Intermediate Cell

29. Differentiation in urothelial carcinoma Three cell layers of benign urothelium He X et al., 2009 Stem Cells, 27:1487 Uroplakins Basal cells repopulate Superficial cells protect Intermediate cells mature

30. Differentiation programs in cancer REYA ET AL. NATURE (2001) 414:105 Stem cells Intermediate cells Fully differentiated cells

31. Cancer Stem Cells Minority tumor cell subpopulation Resistant to standard “killing” therapies –Chemotherapy –Radiation  Responsible for recurrence and therapy resistance

32. Stem cells Intermediate cells Fully differentiated cells Growth rate Slow Fast N/A

33. Targeting Cancer Stem Cells

34. Epithelial differentiation in cancer Epigenetic changes (Basal cell) Intermediate Cell

35. Urothelial differentiation in Urothelial Carcinoma Benign Urothelium Bladder Cancer

36. 67 Kd Laminin Receptor: Surface marker of tumor “basal cells” But not in vitro He X et al., 2009 Stem Cells, 27:1487

37. SW780 Human Bladder cancer xenograft Single cell digest FACS Inject 10 sites, 2-20k cells each 67LR + (13%) 67LR + 67LR _ CK17 67LR - (87%) 67LR expression in vivo identifies basal-like bladder cancer cells He X et al., 2009 Stem Cells, 27:1487

38. “Basal” cells form tumors. More differentiated cells do not 67 LR bright (Basal) Unfractionated 67 LR dim (Differentiated) He X et al., 2009 Stem Cells, 27:1487

39. Gene Expression Programs in Basal-like Urothelial Cancer Cells Migration Angiogenesis Apoptosis Proliferation Poor prognosis 67LR + 67LR _ CK17 He X et al., 2009 Stem Cells, 27:1487

40. Sweden (Lund) Texas (MD Anderson TCGA (U.S.) Studies describing molecular subtypes

41. Basal differentiation = shorter survival

42. Tailored therapy?

43. Conclusions Two pathways of bladder cancer – Genomic differences between cancers Bladder cancers differentiate in a manner similar to benign urothelium Genomic subtypes correspond to different cell types in benign urothelium Treatment strategies need to be adapted to new subtypes