Comparison of molecular profiles (Nectin-4 and TROP-2) in Upper Tract Urothelial Carcinoma with a positive history of urinary bladder cancer vs. UTUC only in the era of ADCs

Comparison of molecular profiles (Nectin-4 and TROP-2) in Upper Tract Urothelial Carcinoma with a positive history of urinary bladder cancer vs. UTUC only in the era of ADCs | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of molecular profiles (Nectin-4 and TROP-2) in Upper Tract Urothelial Carcinoma with a positive history of urinary bladder cancer vs. UTUC only in the era of ADCs Mohammed Rafea Kanaan, Jessica Schmitz, Jan Hinrich Braesen, Markus Antonius Kuczyk, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6725793/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Oct, 2025 Read the published version in BMC Cancer → Version 1 posted 11 You are reading this latest preprint version Abstract Upper tract urothelial carcinoma (UTUC) and urinary bladder cancer (UBC), though histologically similar, differ molecularly, prompting interest in their biomarker profiles for targeted therapies like antibody-drug conjugates (ADCs) enfortumab vedotin (targeting Nectin-4) and sacituzumab govitecan (targeting TROP-2). This study investigated Nectin-4 and TROP-2 expression in 87 UTUC patients, including 54 with a history of concurrent UBC (UTUC + UBC) and 33 with UTUC alone. Immunohistochemical analysis revealed widespread TROP-2 expression (98.8% of samples), with high levels linked to low-grade UTUC (p = 0.043) and intense staining (mean H-score 227 ± 63) across both cohorts. Nectin-4 was expressed in 70.1% of samples overall but was more frequent in the UTUC + UBC group (88.8% vs. 63.6% in UTUC-only patients), though this difference lacked statistical significance (p = 0.340). Notably, Nectin-4 staining intensity was weak in both groups (mean H-score 66 ± 65), suggesting biological distinctions between UTUC with and without UBC. The findings imply that ADCs targeting TROP-2 and Nectin-4 may hold therapeutic promise in UTUC without requiring prior biomarker testing. Additionally, the elevated Nectin-4 expression in UTUC + UBC patients hints at divergent molecular pathways that could influence treatment strategies, warranting further clinical exploration. TROP-2 (trophoblast cell surface antigen 2) Nectin-4 upper tract urothelial carcinoma (UTUC) Urinary bladder cancer (UBC) immunohistochemical analysis (IHC) Figures Figure 1 Figure 2 Introduction Upper tract urothelial carcinoma (UTUC) is a rare and aggressive subset of urothelial carcinoma, accounting for 5–10% of cases and often presenting with advanced or metastatic disease at diagnosis [ 1 , 2 ]. This contributes to a poorer prognosis compared to urothelial bladder cancer (UBC) [ 1 , 3 ]. The phenotypic and genetic differences between UTUC and UBC underline the importance of tailored treatment strategies, as UTUC often demonstrates distinct therapeutic responses [ 4 ]. Historically, treatment options for metastatic UTUC have been limited, with poor survival rates observed following platinum-based chemotherapy or immune checkpoint inhibitors. However, recent advances have reshaped the therapeutic landscape. Enfortumab vedotin (EV), an antibody-drug conjugate targeting Nectin-4, has demonstrated significant efficacy in advanced UC, including UTUC, particularly when combined with pembrolizumab, as shown in the pivotal EV-302 trial. This combination therapy improves progression-free survival (PFS) and overall survival (OS), establishing itself as a new standard of care for previously untreated, advanced UC cases [ 5 , 6 ]. Additionally, sacituzumab govitecan, targeting TROP-2, offers another effective option for patients resistant to earlier treatments [ 7 ]. Despite these advancements, the expression profiles of biomarkers like TROP-2 and Nectin-4 in UTUC, particularly in patients with a history of UBC, remain underexplored. Investigating these biomarkers can refine patient selection and support more precise therapeutic approaches. This study focuses on bridging this gap by examining the expression of TROP-2 and Nectin-4 in UTUC patients, contributing to the ongoing development of personalized treatment strategies in precision oncology. Materials and methods Population and tissue samples Eighty-seven patients with non-metastatic UTUC were included in the immunohistochemical analysis. The patients underwent radical nephroureterectomy or endoscopic therapy via laser for selected cases with UTUC between January 2010 and December 2023 at Hanover Medical School. Two patient cohorts were established in consideration of the history of urothelial bladder cancer (UBC). The initial group comprised 54 patients (62.1%) with a history of UTUC and UBC, while the second group consisted of 33 patients without a history of UBC. 87 UTUC tissue samples were subjected to immunohistochemical (IHC) analysis to assess the expression of TROP-2 and Nectin-4. This study was conducted in line with the ethical standards outlined in the Declaration of Helsinki and the research integrity policies of Hanover Medical School. Written informed consent was obtained from all patients before recruitment. IHC analysis of Trop-2 and Nectin‑4 expression IHC staining for NECTIN-4 protein was performed on a VENTANA BenchMark ULTRA autostainer (Ventana) following an accredited protocol in a facility certified to DIN EN ISO/IEC 17020 standards. Staining was evaluated using the H-score system, calculated as the product of intensity (0–3) and the percentage of stained cells (0–100), as described in the initial study on NECTIN-4 [ 8 ]. An H-score > 15 was considered positive and further classified into two categories: weak (15–149) or strong (150–300), based on staining intensity after powles et al. [ 9 ]. Statistical analysis In the first step, a descriptive evaluation was performed. The mean value ± standard deviation was selected for the quantitative parameters, and the absolute or percentage frequency was specified for the individual characteristics of the qualitative aspects. The frequencies for the descriptive illustration were determined with the help of bar charts. The Mann‒Whitney U test for continuous variables or the chi-square test for categorical variables were used to compare the groups. All the statistical calculations and graphical representations were made with the statistical software IBM-SPSS v. 29.0. All P values were obtained from two-sided statistical tests, with a probability of error of p < 0.05 considered to indicate statistical significance. Results 1.1 Patient Characteristics Between 2010 and 2023, 87 patients were evaluated and included in the final analysis of this study. The clinicopathological characteristics of the patients are summarized in Table 1 . The median age at diagnosis was 70 years, with a male-to-female ratio of 4:1. In most cases (70.1%), the UTUC was localized in the renal pelvis. Tissue samples were predominantly obtained following radical nephroureterectomy, performed in 85.1% of patients. None of the patients received neoadjuvant chemotherapy before tissue collection. Regarding the pathological stage of UTUC, the majority of cases were classified as pTa (44.8%) and pNx (54.0%). Additionally, low-grade UTUC was identified in 54.0% of patients. A positive history of urothelial carcinoma of the bladder (UB-Ca) was observed in 62.1% of the patients. Table 1 Patient characteristics Age (years), mean ± SD 70 ± 10 sex (m / w), n (%) 64 (74%) / 23 (26%) Type of operation, n (%) open surgery 46 (52,9%) minimally invasive surgery 28 (32,2%) endoscopic laser therapy 13 (14,9%) Localization (pelvis/ureter), n (%) 61 (70,1%) / 26 (29,9%) UB-Ca, n (%) 54 (62%) Side (right/left), n (%) 50 (57,5%) / 37 (42,5%) Pathology: T-Staging Ta 39 (44,8%) T1 16 (18,4%) T2 7 (8,0%) T3 20 (23,0%) T4 3 (3,4%) (+) Tis 5 (5,7%) N-Staging Nx 62 (71,2%) N0 20 (23,0%) N1 1 (1,1%) N2 4 (4,6%) Grading Low grade 47 (54,0%) High grade 40 (46,0%) R-Staging Rx 13 (14,9%) R0 71 (81,6%) R1 3 (3,4%) 1.2 Nectin-4 Expression and Association with Clinicopathological Characteristics Positive Nectin-4 expression, as shown in Fig. 1 , was observed in 61 out of 87 UTUC samples (70.1%), with a mean H-Score of 66. The UTUC group with a positive history of UB-Ca exhibited higher expression rate (74.1%) compared to the UTUC-only group (63.6%), though this difference did not reach statistical significance (p > 0.05). The intensity of Nectin-4 expression was low in most cases, with 48 out of 61 positive samples (78.7%) showing low-intensity expression. No significant differences in intensity were found between the diagnostic groups, with 76.2% of UTUC-only cases and 80.0% of UTUC cases with a history of UB-Ca exhibiting low intensity (p > 0.05). Our analysis of the association between Nectin-4 expression (and its intensity) and clinicopathological features across the diagnostic groups (Table 2 ) revealed no significant correlations with patient sex, age, tumor location, tumor grade, lymphovascular invasion, or lymph node metastasis. Table 2 Immunohistochemical Analysis of Nectin-4 and TROP-2 in patients with UTUC Immunohistochemical Analysis: Nectin-4: Nectin-4 H-Score (Mean ± SD) 66 ± 65 Nectin-4 Expression (H-Score > 15), n (%) 61 (70,1%) Nectin-4 Intensity, n (%) weak (H-Score 15), n (%) 86 (98.8%) TROP-2 Intensity, n (%) weak (H-Score < 150) 10 (11,5%) strong (H-Score ≥ 150) 76 (87,4%) 1.3 Trop-2 Expression and Association with Clinicopathological Characteristics Positive TROP-2 expression was detected in 86 out of 87 UTUC samples (98.8%), with a higher mean H-Score of 227 compared to Nectin-4. No differences in TROP-2 expression were observed between the two diagnostic groups. The intensity of TROP-2 expression was vigorous in 76 of the 86 cases (87.4%). Among these, the UTUC group with a positive history of UB-Ca exhibited a higher intensity of expression (90.7%) than the UTUC-only group (84.4%). However, this difference did not reach statistical significance (p > 0.05). Figure 2 shows the differences in the intensity of TROP-2 expression. Our analysis of TROP-2 expression and its intensity across the 86 UTUC patients (Table 2 ) identified a significant association between tumor grade and TROP-2 expression intensity. Specifically, low-grade UTUC displayed stronger TROP-2 expression (95.6%) compared to high-grade UTUC (80.5%), with the difference achieving statistical significance (p = 0.04). However, no significant associations were found between TROP-2 expression and other clinicopathological factors, such as patient sex, age, tumor location, lymphovascular invasion, or lymph node metastasis. 1.4 Subgroup analysis of Nectin-4 and TROP-2 intensity after risk classification of U-BC Based on the European Association of Urology (EAU) classification of non-muscle-invasive bladder cancer (NMIBC), we categorized patients with a positive history of UB-Ca into risk groups. Two distinct groups were established: the first group included patients with low- and intermediate-risk UB-Ca (n = 28), while the second group comprised those with high- and very-high-risk UB-Ca (n = 26). Among patients in the higher-risk group of UB-Ca with positive Nectin-4 expression (n = 22), the intensity of Nectin-4 expression was more pronounced (27.3%) compared to the low- and intermediate-risk group (11.1%). However, this difference did not reach statistical significance (p > 0.05). Conversely, the intensity of TROP-2 expression did not differ significantly between the two subgroups, with expression rates of 89.3% and 92.3%, respectively (see Table 3 below). Table 3 Nectin-4 and TROP-2 intensity after risk classification of U-BC. Diagnosis Group UTUC UTUC + low/intermediate risk UB-Ca UTUC + high risk UB-Ca Nectin-4 Intensity, n (%) weak (H-Score < 150) 16 (33%) 16 (33%) 16 (33%) strong (H-Score ≥ 150) 5 (38%) 2 (15%) 6 (46%) TROP-2 Intensity, n (%) weak (H-Score < 150) 5 (50%) 3 (30%) 2 (20%) strong (H-Score ≥ 150) 27 (36%) 25 (33%) 24 (32%) Discussion This study aimed to compare the expression levels of TROP-2 and Nectin-4 in patients with upper tract urothelial carcinoma (UTUC) who had a prior history of urinary bladder carcinoma (UB-Ca) to those without such a history. While TROP-2 and Nectin-4 are well-studied therapeutic targets in UB-Ca, their comparative expression patterns in UTUC subgroups remain underexplored, particularly in patients with a history of UB-Ca. Our findings addressed this gap and highlighted critical differences with potential clinical implications. We demonstrated that Nectin-4, the target protein of enfortumab vedotin, was expressed in 70.1% of patients with UTUC. This finding is consistent with the results of Tomiyama et al., who reported an expression rate of 65.7% in their cohort [ 10 ]. In UB-Ca, however, Nectin-4 expression has been documented in approximately 83% of cases, suggesting a slightly higher expression rate than UTUC [ 11 ]. Intriguingly, UTUC patients with prior UB-Ca history showed a non-significantly higher Nectin-4 expression rate (74.1% vs. 63.6%, p > 0.05). This trend mirrors findings by Klümper et al., who observed reduced Nectin-4 expression in metastatic urothelial carcinoma, potentially linked to EV resistance mechanisms [ 8 ]. While statistical significance was not achieved, this trend underscores the need for larger cohort studies to clarify the role of UB-Ca history in UTUC biology. Powles et al. previously reported a median H-Score of 280 in patients with locally advanced or metastatic urothelial cancer, without distinguishing between UTUC and UB-Ca, in their exploratory analysis of Nectin-4 expression's impact on outcomes with enfortumab vedotin (EV) plus pembrolizumab (P) in the Phase 3 EV-302 study [ 9 ]. Our cohort, however, showed markedly lower H-scores (mean 66), with 78.7% of patients falling into low-expression categories. This discrepancy may reflect differences in tumor stage (our cohort included localized UTUC vs. EV-302’s metastatic cases) or assay variability. Despite the H-score widespread application, establishing standardized H-score thresholds for clinical responses remains a subject of debate, primarily due to variability in scoring systems across different institutions. Recent studies have shown that TROP-2, the target protein of sacituzumab govitecan, is widely expressed in UTUC, with 94% of UTUC cases demonstrating positivity. High TROP-2 expression has also been associated with favorable prognosis in UTUC [ 12 ]. In our study, TROP-2 expression was detected in 98.8% (86 out of 87 patients), confirming the high expression rate of TROP-2 in UTUC, which is higher than that of Nectin-4. Notably, our findings were consistent with Tomiyama et al., who observed stronger TROP-2 expression (95.6%) in low-grade UTUC compared to high-grade variants, which was associated with a favorable prognosis [ 12 ]. This contrasts with findings in other cancers, such as non-muscle-invasive UB-Ca, breast cancer, and metastatic prostate cancer, where high TROP-2 expression has been linked to increased tumor aggressiveness and poor prognosis [ 12 – 17 ]. in our cohort, no significant associations were found between TROP-2 expression and clinicopathological factors such as lymphovascular invasion or lymph node or distant metastasis. Additionally, subgroup analysis based on UB-Ca classification did not reveal significant differences in Nectin-4 or TROP-2 expression. Although patients with a positive history of UB-Ca exhibited higher intensity of TROP-2 expression, the difference was not statistically significant. This suggests that a history of UB-Ca does not directly influence the expression levels of TROP-2 or Nectin-4 in UTUC. Our study has few limitations. First, its retrospective design limits causal inference, making it difficult to establish definitive relationships between TROP-2 and Nectin-4 expression and clinical outcomes. Second, survival data were unavailable, preventing validation of prognostic role. In general H-scores are assessed by a single pathologist, introducing potential observer bias. To overcome these limitations, future research should incorporate prospective, multi-institutional cohorts with centralized pathology review to ensure greater reliability and generalizability of findings. Conclusion This study confirms that TROP-2 and Nectin-4 are widely expressed in UTUC, making them potential therapeutic targets. TROP-2 was more strongly expressed in low-grade UTUC, suggesting its role as a favorable prognostic marker, while Nectin-4 showed no significant correlation with tumor characteristics. Although patients with a history of UB-Ca had slightly higher expression levels of both proteins, the difference was not statistically significant. These findings emphasize the therapeutic importance of TROP-2 and Nectin-4 and highlight the need for further research to clarify their prognostic and predictive value in clinical practice. Declarations Declaration of conflicting interests The author(s) declared no potential conflicts of interest concerning this article's research, authorship, and/or publication. Funding The author(s) received no financial support for this article's research, authorship, and/or publication Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions Conceptualization, M.K. and H.T.; methodology, M.K. and H.T.; software, M.K.; validation, M.K.; formal analysis, M.K.; investigation, M.K., J.S., J.B. and H.T.; resources, J.S. and J.B., data curation, M.K.; writing—original draft preparation, M.K. and H.T.; writing—review and editing, M.K., H.T., J.S., J.B. and M.A.K.; visualization, M.K.; supervision, H.T.; project administration, H.T. All authors have read and agreed to the published version of the manuscript. Data Availability The datasets generated and analysed during the current study are available from the corresponding author on reasonable request. Ethics approval This study was conducted in line with the ethical standards outlined in the Declaration of Helsinki and the research integrity policies of Hanover Medical School, Approval was granted by the Ethics Committee of Hanover Medical School. Consent to participate Informed consent was obtained from all individual participants included in the study. References Rouprê t M, et al.: European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2023 Update. European urology. 84. pp. 49–64 (2023). W u J, et al.: Trends of incidence and prognosis of upper tract urothelial carcinoma. Bosnian journal of basic medical sciences. 21. pp. 607–619 (2021). Flai g TW, et al.: NCCN Guidelines® Insights: Bladder Cancer, Version 2.2022. Journal of the National Comprehensive Cancer Network : JNCCN. 20. pp. 866–878 (2022). Colema n JA, et al.: Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma: AUA/SUO Guideline. The Journal of urology. 209. pp. 1071–1081 (2023). Powle s T, et al.: Enfortumab Vedotin and Pembrolizumab in Untreated Advanced Urothelial Cancer. The New England journal of medicine. 390. pp. 875–888 (2024). Thomas B. Powles: ESMO 2024: EV-302: Exploratory Analysis of Nectin-4 Expression and Response to 1L Enfortumab Vedotin (EV) + Pembrolizumab (P) in Previously Untreated Locally Advanced or Metastatic Urothelial Cancer (la/mUC) (2024). Bardi a A, et al.: Sacituzumab Govitecan in Metastatic Triple-Negative Breast Cancer. The New England journal of medicine. 384. pp. 1529–1541 (2021). Klümpe r N, et al.: Membranous NECTIN-4 Expression Frequently Decreases during Metastatic Spread of Urothelial Carcinoma and Is Associated with Enfortumab Vedotin Resistance. Clinical cancer research : an official journal of the American Association for Cancer Research. 29. pp. 1496–1505 (2023). Powle s TB, et al.: 1966MO EV-302: Exploratory analysis of nectin-4 expression and response to 1L enfortumab vedotin (EV) + pembrolizumab (P) in previously untreated locally advanced or metastatic urothelial cancer (la/mUC). Annals of Oncology. 35. pp. S1137-S1138 (2024). Tomiyam a E, et al.: Expression of Nectin-4 and PD-L1 in Upper Tract Urothelial Carcinoma. International journal of molecular sciences. 21 (2020). Tomiyam a E, et al.: Comparison of molecular profiles of upper tract urothelial carcinoma vs. urinary bladder cancer in the era of targeted therapy: a narrative review. Translational andrology and urology. 11. pp. 1747–1761 (2022). Tomiyam a E, et al.: Trop-2 in Upper Tract Urothelial Carcinoma. Current oncology (Toronto, Ont.). 29. pp. 3911–3921 (2022). Siege l RL; Miller, Kimberly D.; Fuchs, Hannah E.; Jemal, Ahmedin: Cancer statistics, 2022. CA: a cancer journal for clinicians. 72. pp. 7–33 (2022). Asla n M, et al.: Oncogene-mediated metabolic gene signature predicts breast cancer outcome. NPJ breast cancer. 7. pp. 141 (2021). Avellin i C, et al.: The trophoblast cell surface antigen 2 and miR-125b axis in urothelial bladder cancer. Oncotarget. 8. pp. 58642–58653 (2017). Zhan g L; Yang, G.; Jiang, H.; Liu, M.: TROP2 is associated with the recurrence of patients with non-muscle invasive bladder cancer. Int. J. Clin. Exp. Med. Hs u E-C, et al.: Trop2 is a driver of metastatic prostate cancer with neuroendocrine phenotype via PARP1. Proceedings of the National Academy of Sciences of the United States of America. 117. pp. 2032–2042 (2020). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Oct, 2025 Read the published version in BMC Cancer → Version 1 posted Editorial decision: Revision requested 21 Jul, 2025 Reviews received at journal 19 Jul, 2025 Reviewers agreed at journal 19 Jul, 2025 Reviews received at journal 22 Jun, 2025 Reviewers agreed at journal 09 Jun, 2025 Reviewers agreed at journal 31 May, 2025 Reviewers invited by journal 30 May, 2025 Editor invited by journal 23 May, 2025 Editor assigned by journal 23 May, 2025 Submission checks completed at journal 23 May, 2025 First submitted to journal 22 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6725793","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464592600,"identity":"fe4f9e4d-9368-4cae-8789-eec5956f5a87","order_by":0,"name":"Mohammed Rafea Kanaan","email":"data:image/png;base64,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","orcid":"","institution":"Hanover Medical School (MHH)","correspondingAuthor":true,"prefix":"","firstName":"Mohammed","middleName":"Rafea","lastName":"Kanaan","suffix":""},{"id":464592601,"identity":"156a3178-97f9-4e80-8e16-8121aba2f1a8","order_by":1,"name":"Jessica Schmitz","email":"","orcid":"","institution":"Hanover Medical School (MHH)","correspondingAuthor":false,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Schmitz","suffix":""},{"id":464592602,"identity":"bfad5734-5b9c-408e-b5fa-fa77cac4ad83","order_by":2,"name":"Jan Hinrich Braesen","email":"","orcid":"","institution":"Hanover Medical School (MHH)","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"Hinrich","lastName":"Braesen","suffix":""},{"id":464592603,"identity":"60b3e7d3-0a65-48af-a666-0bfc1ed678f9","order_by":3,"name":"Markus Antonius Kuczyk","email":"","orcid":"","institution":"Hanover Medical School (MHH)","correspondingAuthor":false,"prefix":"","firstName":"Markus","middleName":"Antonius","lastName":"Kuczyk","suffix":""},{"id":464592604,"identity":"9bed6873-779a-4c01-ab36-b96c12ff3c96","order_by":4,"name":"Hossein Tezval","email":"","orcid":"","institution":"Hanover Medical School (MHH)","correspondingAuthor":false,"prefix":"","firstName":"Hossein","middleName":"","lastName":"Tezval","suffix":""}],"badges":[],"createdAt":"2025-05-22 14:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6725793/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6725793/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12885-025-15042-7","type":"published","date":"2025-10-06T15:57:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":83816554,"identity":"f9921b06-f97b-4e82-be91-03f120fd4c03","added_by":"auto","created_at":"2025-06-03 07:52:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4096689,"visible":true,"origin":"","legend":"\u003cp\u003eImmunohistochemical analysis of Nectin-4 expression in upper tract urothelial carcinoma (UTUC). Representative IHC-stained sections demonstrating variable Nectin-4 expression in UTUC tissue samples.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6725793/v1/8068b93586810ad9cb4f32ca.png"},{"id":83816555,"identity":"13cbac29-7d76-4dd6-be96-fe56046c39b3","added_by":"auto","created_at":"2025-06-03 07:52:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":4433512,"visible":true,"origin":"","legend":"\u003cp\u003eImmunohistochemical analysis of TROP-2 expression in upper tract urothelial carcinoma (UTUC). Representative IHC-stained sections demonstrating variable TROP-2 expression in UTUC tissue samples.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6725793/v1/97e934957384eb21b8ae3938.png"},{"id":93419628,"identity":"2dbb9a97-1359-4016-b83d-e4aa2517dcab","added_by":"auto","created_at":"2025-10-13 16:04:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":14435924,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6725793/v1/481940e7-b934-45d5-9c0c-ea529f14463b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of molecular profiles (Nectin-4 and TROP-2) in Upper Tract Urothelial Carcinoma with a positive history of urinary bladder cancer vs. UTUC only in the era of ADCs","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUpper tract urothelial carcinoma (UTUC) is a rare and aggressive subset of urothelial carcinoma, accounting for 5\u0026ndash;10% of cases and often presenting with advanced or metastatic disease at diagnosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This contributes to a poorer prognosis compared to urothelial bladder cancer (UBC) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The phenotypic and genetic differences between UTUC and UBC underline the importance of tailored treatment strategies, as UTUC often demonstrates distinct therapeutic responses [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHistorically, treatment options for metastatic UTUC have been limited, with poor survival rates observed following platinum-based chemotherapy or immune checkpoint inhibitors. However, recent advances have reshaped the therapeutic landscape. Enfortumab vedotin (EV), an antibody-drug conjugate targeting Nectin-4, has demonstrated significant efficacy in advanced UC, including UTUC, particularly when combined with pembrolizumab, as shown in the pivotal EV-302 trial. This combination therapy improves progression-free survival (PFS) and overall survival (OS), establishing itself as a new standard of care for previously untreated, advanced UC cases [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Additionally, sacituzumab govitecan, targeting TROP-2, offers another effective option for patients resistant to earlier treatments [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these advancements, the expression profiles of biomarkers like TROP-2 and Nectin-4 in UTUC, particularly in patients with a history of UBC, remain underexplored. Investigating these biomarkers can refine patient selection and support more precise therapeutic approaches. This study focuses on bridging this gap by examining the expression of TROP-2 and Nectin-4 in UTUC patients, contributing to the ongoing development of personalized treatment strategies in precision oncology.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePopulation and tissue samples\u003c/h2\u003e \u003cp\u003eEighty-seven patients with non-metastatic UTUC were included in the immunohistochemical analysis. The patients underwent radical nephroureterectomy or endoscopic therapy via laser for selected cases with UTUC between January 2010 and December 2023 at Hanover Medical School. Two patient cohorts were established in consideration of the history of urothelial bladder cancer (UBC). The initial group comprised 54 patients (62.1%) with a history of UTUC and UBC, while the second group consisted of 33 patients without a history of UBC. 87 UTUC tissue samples were subjected to immunohistochemical (IHC) analysis to assess the expression of TROP-2 and Nectin-4. This study was conducted in line with the ethical standards outlined in the Declaration of Helsinki and the research integrity policies of Hanover Medical School. Written informed consent was obtained from all patients before recruitment.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIHC analysis of Trop-2 and Nectin‑4 expression\u003c/h3\u003e\n\u003cp\u003eIHC staining for NECTIN-4 protein was performed on a VENTANA BenchMark ULTRA autostainer (Ventana) following an accredited protocol in a facility certified to DIN EN ISO/IEC 17020 standards. Staining was evaluated using the H-score system, calculated as the product of intensity (0\u0026ndash;3) and the percentage of stained cells (0\u0026ndash;100), as described in the initial study on NECTIN-4 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. An H-score\u0026thinsp;\u0026gt;\u0026thinsp;15 was considered positive and further classified into two categories: weak (15\u0026ndash;149) or strong (150\u0026ndash;300), based on staining intensity after powles et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eIn the first step, a descriptive evaluation was performed. The mean value\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation was selected for the quantitative parameters, and the absolute or percentage frequency was specified for the individual characteristics of the qualitative aspects. The frequencies for the descriptive illustration were determined with the help of bar charts. The Mann‒Whitney U test for continuous variables or the chi-square test for categorical variables were used to compare the groups.\u003c/p\u003e \u003cp\u003eAll the statistical calculations and graphical representations were made with the statistical software IBM-SPSS v. 29.0. All P values were obtained from two-sided statistical tests, with a probability of error of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered to indicate statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Patient Characteristics\u003c/h2\u003e \u003cp\u003eBetween 2010 and 2023, 87 patients were evaluated and included in the final analysis of this study. The clinicopathological characteristics of the patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The median age at diagnosis was 70 years, with a male-to-female ratio of 4:1.\u003c/p\u003e \u003cp\u003eIn most cases (70.1%), the UTUC was localized in the renal pelvis. Tissue samples were predominantly obtained following radical nephroureterectomy, performed in 85.1% of patients. None of the patients received neoadjuvant chemotherapy before tissue collection.\u003c/p\u003e \u003cp\u003eRegarding the pathological stage of UTUC, the majority of cases were classified as pTa (44.8%) and pNx (54.0%). Additionally, low-grade UTUC was identified in 54.0% of patients. A positive history of urothelial carcinoma of the bladder (UB-Ca) was observed in 62.1% of the patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (years), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e70\u0026thinsp;\u0026plusmn;\u0026thinsp;10\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003esex (m / w), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e64 (74%) / 23 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eType of operation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eopen surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e46 (52,9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eminimally invasive surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e28 (32,2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eendoscopic laser therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e13 (14,9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLocalization (pelvis/ureter), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e61 (70,1%) / 26 (29,9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eUB-Ca, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e54 (62%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSide (right/left), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e50 (57,5%) / 37 (42,5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003ePathology:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eT-Staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (44,8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eT1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (18,4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eT2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (8,0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eT3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (23,0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eT4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3,4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e(+) Tis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (5,7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eN-Staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62 (71,2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eN0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (23,0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eN1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1,1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eN2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (4,6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGrading\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eLow grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47 (54,0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eHigh grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (46,0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eR-Staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (14,9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71 (81,6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eR1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3,4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Nectin-4 Expression and Association with Clinicopathological Characteristics\u003c/h2\u003e \u003cp\u003ePositive Nectin-4 expression, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, was observed in 61 out of 87 UTUC samples (70.1%), with a mean H-Score of 66. The UTUC group with a positive history of UB-Ca exhibited higher expression rate (74.1%) compared to the UTUC-only group (63.6%), though this difference did not reach statistical significance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe intensity of Nectin-4 expression was low in most cases, with 48 out of 61 positive samples (78.7%) showing low-intensity expression. No significant differences in intensity were found between the diagnostic groups, with 76.2% of UTUC-only cases and 80.0% of UTUC cases with a history of UB-Ca exhibiting low intensity (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOur analysis of the association between Nectin-4 expression (and its intensity) and clinicopathological features across the diagnostic groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) revealed no significant correlations with patient sex, age, tumor location, tumor grade, lymphovascular invasion, or lymph node metastasis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eImmunohistochemical Analysis of Nectin-4 and TROP-2 in patients with UTUC\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eImmunohistochemical Analysis:\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNectin-4:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNectin-4 H-Score (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66\u0026thinsp;\u0026plusmn;\u0026thinsp;65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNectin-4 Expression (H-Score\u0026thinsp;\u0026gt;\u0026thinsp;15), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (70,1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNectin-4 Intensity, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eweak (H-Score\u0026thinsp;\u0026lt;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (78,7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003estrong (H-Score\u0026thinsp;\u0026ge;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (21,3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eTROP-2:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTROP-2 H-Score (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e227\u0026thinsp;\u0026plusmn;\u0026thinsp;63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTROP-2 Expression (H-Score\u0026thinsp;\u0026gt;\u0026thinsp;15), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (98.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTROP-2 Intensity, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eweak (H-Score\u0026thinsp;\u0026lt;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (11,5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003estrong (H-Score\u0026thinsp;\u0026ge;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (87,4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1.3 Trop-2 Expression and Association with Clinicopathological Characteristics\u003c/h3\u003e\n\u003cp\u003ePositive TROP-2 expression was detected in 86 out of 87 UTUC samples (98.8%), with a higher mean H-Score of 227 compared to Nectin-4. No differences in TROP-2 expression were observed between the two diagnostic groups.\u003c/p\u003e \u003cp\u003eThe intensity of TROP-2 expression was vigorous in 76 of the 86 cases (87.4%). Among these, the UTUC group with a positive history of UB-Ca exhibited a higher intensity of expression (90.7%) than the UTUC-only group (84.4%). However, this difference did not reach statistical significance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the differences in the intensity of TROP-2 expression.\u003c/p\u003e \u003cp\u003eOur analysis of TROP-2 expression and its intensity across the 86 UTUC patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) identified a significant association between tumor grade and TROP-2 expression intensity. Specifically, low-grade UTUC displayed stronger TROP-2 expression (95.6%) compared to high-grade UTUC (80.5%), with the difference achieving statistical significance (p\u0026thinsp;=\u0026thinsp;0.04). However, no significant associations were found between TROP-2 expression and other clinicopathological factors, such as patient sex, age, tumor location, lymphovascular invasion, or lymph node metastasis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003e1.4 Subgroup analysis of Nectin-4 and TROP-2 intensity after risk classification of U-BC\u003c/h3\u003e\n\u003cp\u003eBased on the European Association of Urology (EAU) classification of non-muscle-invasive bladder cancer (NMIBC), we categorized patients with a positive history of UB-Ca into risk groups. Two distinct groups were established: the first group included patients with low- and intermediate-risk UB-Ca (n\u0026thinsp;=\u0026thinsp;28), while the second group comprised those with high- and very-high-risk UB-Ca (n\u0026thinsp;=\u0026thinsp;26).\u003c/p\u003e \u003cp\u003eAmong patients in the higher-risk group of UB-Ca with positive Nectin-4 expression (n\u0026thinsp;=\u0026thinsp;22), the intensity of Nectin-4 expression was more pronounced (27.3%) compared to the low- and intermediate-risk group (11.1%). However, this difference did not reach statistical significance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Conversely, the intensity of TROP-2 expression did not differ significantly between the two subgroups, with expression rates of 89.3% and 92.3%, respectively (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNectin-4 and TROP-2 intensity after risk classification of U-BC.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDiagnosis Group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUTUC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUTUC\u0026thinsp;+\u0026thinsp;low/intermediate risk UB-Ca\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUTUC\u0026thinsp;+\u0026thinsp;high risk UB-Ca\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNectin-4 Intensity,\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eweak\u003c/p\u003e \u003cp\u003e(H-Score\u0026thinsp;\u0026lt;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003estrong\u003c/p\u003e \u003cp\u003e(H-Score\u0026thinsp;\u0026ge;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTROP-2 Intensity,\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eweak\u003c/p\u003e \u003cp\u003e(H-Score\u0026thinsp;\u0026lt;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (20%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003estrong\u003c/p\u003e \u003cp\u003e(H-Score\u0026thinsp;\u0026ge;\u0026thinsp;150)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (32%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to compare the expression levels of TROP-2 and Nectin-4 in patients with upper tract urothelial carcinoma (UTUC) who had a prior history of urinary bladder carcinoma (UB-Ca) to those without such a history. While TROP-2 and Nectin-4 are well-studied therapeutic targets in UB-Ca, their comparative expression patterns in UTUC subgroups remain underexplored, particularly in patients with a history of UB-Ca. Our findings addressed this gap and highlighted critical differences with potential clinical implications.\u003c/p\u003e \u003cp\u003eWe demonstrated that Nectin-4, the target protein of enfortumab vedotin, was expressed in 70.1% of patients with UTUC. This finding is consistent with the results of Tomiyama et al., who reported an expression rate of 65.7% in their cohort [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In UB-Ca, however, Nectin-4 expression has been documented in approximately 83% of cases, suggesting a slightly higher expression rate than UTUC [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Intriguingly, UTUC patients with prior UB-Ca history showed a non-significantly higher Nectin-4 expression rate (74.1% vs. 63.6%, p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This trend mirrors findings by Kl\u0026uuml;mper et al., who observed reduced Nectin-4 expression in metastatic urothelial carcinoma, potentially linked to EV resistance mechanisms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. While statistical significance was not achieved, this trend underscores the need for larger cohort studies to clarify the role of UB-Ca history in UTUC biology.\u003c/p\u003e \u003cp\u003ePowles et al. previously reported a median H-Score of 280 in patients with locally advanced or metastatic urothelial cancer, without distinguishing between UTUC and UB-Ca, in their exploratory analysis of Nectin-4 expression's impact on outcomes with enfortumab vedotin (EV) plus pembrolizumab (P) in the Phase 3 EV-302 study [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Our cohort, however, showed markedly lower H-scores (mean 66), with 78.7% of patients falling into low-expression categories. This discrepancy may reflect differences in tumor stage (our cohort included localized UTUC vs. EV-302\u0026rsquo;s metastatic cases) or assay variability. Despite the H-score widespread application, establishing standardized H-score thresholds for clinical responses remains a subject of debate, primarily due to variability in scoring systems across different institutions.\u003c/p\u003e \u003cp\u003eRecent studies have shown that TROP-2, the target protein of sacituzumab govitecan, is widely expressed in UTUC, with 94% of UTUC cases demonstrating positivity. High TROP-2 expression has also been associated with favorable prognosis in UTUC [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In our study, TROP-2 expression was detected in 98.8% (86 out of 87 patients), confirming the high expression rate of TROP-2 in UTUC, which is higher than that of Nectin-4. Notably, our findings were consistent with Tomiyama et al., who observed stronger TROP-2 expression (95.6%) in low-grade UTUC compared to high-grade variants, which was associated with a favorable prognosis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This contrasts with findings in other cancers, such as non-muscle-invasive UB-Ca, breast cancer, and metastatic prostate cancer, where high TROP-2 expression has been linked to increased tumor aggressiveness and poor prognosis [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. in our cohort, no significant associations were found between TROP-2 expression and clinicopathological factors such as lymphovascular invasion or lymph node or distant metastasis.\u003c/p\u003e \u003cp\u003eAdditionally, subgroup analysis based on UB-Ca classification did not reveal significant differences in Nectin-4 or TROP-2 expression. Although patients with a positive history of UB-Ca exhibited higher intensity of TROP-2 expression, the difference was not statistically significant. This suggests that a history of UB-Ca does not directly influence the expression levels of TROP-2 or Nectin-4 in UTUC.\u003c/p\u003e \u003cp\u003eOur study has few limitations. First, its retrospective design limits causal inference, making it difficult to establish definitive relationships between TROP-2 and Nectin-4 expression and clinical outcomes. Second, survival data were unavailable, preventing validation of prognostic role.\u003c/p\u003e \u003cp\u003eIn general H-scores are assessed by a single pathologist, introducing potential observer bias. To overcome these limitations, future research should incorporate prospective, multi-institutional cohorts with centralized pathology review to ensure greater reliability and generalizability of findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study confirms that TROP-2 and Nectin-4 are widely expressed in UTUC, making them potential therapeutic targets. TROP-2 was more strongly expressed in low-grade UTUC, suggesting its role as a favorable prognostic marker, while Nectin-4 showed no significant correlation with tumor characteristics. Although patients with a history of UB-Ca had slightly higher expression levels of both proteins, the difference was not statistically significant. These findings emphasize the therapeutic importance of TROP-2 and Nectin-4 and highlight the need for further research to clarify their prognostic and predictive value in clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest concerning this article's research, authorship, and/or publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) received no financial support for this article's research, authorship, and/or publication\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, M.K. and H.T.; methodology, M.K. and H.T.; software, M.K.; validation, M.K.; formal analysis, M.K.; investigation, M.K., J.S., J.B. and H.T.; resources, J.S. and J.B., data curation, M.K.; writing—original draft preparation, M.K. and H.T.; writing—review and editing, M.K., H.T., J.S., J.B. and M.A.K.; visualization, M.K.; supervision, H.T.; project administration, H.T. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in line with the ethical standards outlined in the Declaration of Helsinki and the research integrity policies of Hanover Medical School, Approval was granted by the Ethics Committee of Hanover Medical School.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u003cstrong\u003eRoupr\u0026ecirc;\u003c/strong\u003e\u003cstrong\u003et\u003c/strong\u003e M, et al.: European Association of Urology Guidelines on Upper Urinary Tract Urothelial Carcinoma: 2023 Update. European urology. 84. pp. 49\u0026ndash;64 (2023).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eW\u003c/strong\u003e\u003cstrong\u003eu\u003c/strong\u003e J, et al.: Trends of incidence and prognosis of upper tract urothelial carcinoma. Bosnian journal of basic medical sciences. 21. pp. 607\u0026ndash;619 (2021).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eFlai\u003c/strong\u003e\u003cstrong\u003eg\u003c/strong\u003e TW, et al.: NCCN Guidelines\u0026reg; Insights: Bladder Cancer, Version 2.2022. Journal of the National Comprehensive Cancer Network : JNCCN. 20. pp. 866\u0026ndash;878 (2022).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eColema\u003c/strong\u003e\u003cstrong\u003en\u003c/strong\u003e JA, et al.: Diagnosis and Management of Non-Metastatic Upper Tract Urothelial Carcinoma: AUA/SUO Guideline. The Journal of urology. 209. pp. 1071\u0026ndash;1081 (2023).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003ePowle\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e T, et al.: Enfortumab Vedotin and Pembrolizumab in Untreated Advanced Urothelial Cancer. The New England journal of medicine. 390. pp. 875\u0026ndash;888 (2024).\u003c/li\u003e\n\u003cli\u003eThomas B. Powles: ESMO 2024: EV-302: Exploratory Analysis of Nectin-4 Expression and Response to 1L Enfortumab Vedotin (EV) + Pembrolizumab (P) in Previously Untreated Locally Advanced or Metastatic Urothelial Cancer (la/mUC) (2024).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eBardi\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e A, et al.: Sacituzumab Govitecan in Metastatic Triple-Negative Breast Cancer. The New England journal of medicine. 384. pp. 1529\u0026ndash;1541 (2021).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eKl\u0026uuml;mpe\u003c/strong\u003e\u003cstrong\u003er\u003c/strong\u003e N, et al.: Membranous NECTIN-4 Expression Frequently Decreases during Metastatic Spread of Urothelial Carcinoma and Is Associated with Enfortumab Vedotin Resistance. Clinical cancer research : an official journal of the American Association for Cancer Research. 29. pp. 1496\u0026ndash;1505 (2023).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003ePowle\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e TB, et al.: 1966MO EV-302: Exploratory analysis of nectin-4 expression and response to 1L enfortumab vedotin (EV) + pembrolizumab (P) in previously untreated locally advanced or metastatic urothelial cancer (la/mUC). Annals of Oncology. 35. pp. S1137-S1138 (2024).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eTomiyam\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e E, et al.: Expression of Nectin-4 and PD-L1 in Upper Tract Urothelial Carcinoma. International journal of molecular sciences. 21 (2020).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eTomiyam\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e E, et al.: Comparison of molecular profiles of upper tract urothelial carcinoma vs. urinary bladder cancer in the era of targeted therapy: a narrative review. Translational andrology and urology. 11. pp. 1747\u0026ndash;1761 (2022).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eTomiyam\u003c/strong\u003e\u003cstrong\u003ea\u003c/strong\u003e E, et al.: Trop-2 in Upper Tract Urothelial Carcinoma. Current oncology (Toronto, Ont.). 29. pp. 3911\u0026ndash;3921 (2022).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eSiege\u003c/strong\u003e\u003cstrong\u003el\u003c/strong\u003e RL; Miller, Kimberly D.; Fuchs, Hannah E.; Jemal, Ahmedin: Cancer statistics, 2022. CA: a cancer journal for clinicians. 72. pp. 7\u0026ndash;33 (2022).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAsla\u003c/strong\u003e\u003cstrong\u003en\u003c/strong\u003e M, et al.: Oncogene-mediated metabolic gene signature predicts breast cancer outcome. NPJ breast cancer. 7. pp. 141 (2021).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eAvellin\u003c/strong\u003e\u003cstrong\u003ei\u003c/strong\u003e C, et al.: The trophoblast cell surface antigen 2 and miR-125b axis in urothelial bladder cancer. Oncotarget. 8. pp. 58642\u0026ndash;58653 (2017).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eZhan\u003c/strong\u003e\u003cstrong\u003eg\u003c/strong\u003e L; Yang, G.; Jiang, H.; Liu, M.: TROP2 is associated with the recurrence of patients with non-muscle invasive bladder cancer. Int. J. Clin. Exp. Med.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eHs\u003c/strong\u003e\u003cstrong\u003eu\u003c/strong\u003e E-C, et al.: Trop2 is a driver of metastatic prostate cancer with neuroendocrine phenotype via PARP1. Proceedings of the National Academy of Sciences of the United States of America. 117. pp. 2032\u0026ndash;2042 (2020).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"TROP-2 (trophoblast cell surface antigen 2), Nectin-4, upper tract urothelial carcinoma (UTUC), Urinary bladder cancer (UBC), immunohistochemical analysis (IHC)","lastPublishedDoi":"10.21203/rs.3.rs-6725793/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6725793/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eUpper tract urothelial carcinoma (UTUC) and urinary bladder cancer (UBC), though histologically similar, differ molecularly, prompting interest in their biomarker profiles for targeted therapies like antibody-drug conjugates (ADCs) enfortumab vedotin (targeting Nectin-4) and sacituzumab govitecan (targeting TROP-2). This study investigated Nectin-4 and TROP-2 expression in 87 UTUC patients, including 54 with a history of concurrent UBC (UTUC\u0026thinsp;+\u0026thinsp;UBC) and 33 with UTUC alone. Immunohistochemical analysis revealed widespread TROP-2 expression (98.8% of samples), with high levels linked to low-grade UTUC (p\u0026thinsp;=\u0026thinsp;0.043) and intense staining (mean H-score 227\u0026thinsp;\u0026plusmn;\u0026thinsp;63) across both cohorts. Nectin-4 was expressed in 70.1% of samples overall but was more frequent in the UTUC\u0026thinsp;+\u0026thinsp;UBC group (88.8% vs. 63.6% in UTUC-only patients), though this difference lacked statistical significance (p\u0026thinsp;=\u0026thinsp;0.340). Notably, Nectin-4 staining intensity was weak in both groups (mean H-score 66\u0026thinsp;\u0026plusmn;\u0026thinsp;65), suggesting biological distinctions between UTUC with and without UBC. The findings imply that ADCs targeting TROP-2 and Nectin-4 may hold therapeutic promise in UTUC without requiring prior biomarker testing. Additionally, the elevated Nectin-4 expression in UTUC\u0026thinsp;+\u0026thinsp;UBC patients hints at divergent molecular pathways that could influence treatment strategies, warranting further clinical exploration.\u003c/p\u003e","manuscriptTitle":"Comparison of molecular profiles (Nectin-4 and TROP-2) in Upper Tract Urothelial Carcinoma with a positive history of urinary bladder cancer vs. UTUC only in the era of ADCs","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 07:52:32","doi":"10.21203/rs.3.rs-6725793/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-21T10:07:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-19T14:37:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10196775854481898149405386310195868347","date":"2025-07-19T09:47:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-22T09:09:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"321549976477229805262279637366314950938","date":"2025-06-09T14:26:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12778746142490549354724942472747338485","date":"2025-05-31T15:01:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-30T11:14:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-23T17:47:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-23T11:16:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-23T11:14:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2025-05-22T13:59:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fad8a436-c179-4cc8-930b-fd46043f4e30","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T15:59:31+00:00","versionOfRecord":{"articleIdentity":"rs-6725793","link":"https://doi.org/10.1186/s12885-025-15042-7","journal":{"identity":"bmc-cancer","isVorOnly":false,"title":"BMC Cancer"},"publishedOn":"2025-10-06 15:57:07","publishedOnDateReadable":"October 6th, 2025"},"versionCreatedAt":"2025-06-03 07:52:32","video":"","vorDoi":"10.1186/s12885-025-15042-7","vorDoiUrl":"https://doi.org/10.1186/s12885-025-15042-7","workflowStages":[]},"version":"v1","identity":"rs-6725793","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6725793","identity":"rs-6725793","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}