Local recurrence after radical prostatectomy: correlation of US features with prostatic fossa biopsy findings

PURPOSE

To evaluate the diagnostic accuracy of transrectal ultrasonography (US) in the detection of local recurrence following radical prostatectomy.

MATERIALS AND METHODS

Ninety-nine patients with biochemical recurrence after radical prostatectomy were evaluated at transrectal US and prostatic fossa biopsy. Location of suspected recurrence at transrectal US and clinical features, such as prostate-specific antigen levels and digital rectal examination findings, were correlated with biopsy results.

RESULTS

Forty-one (41%) of 99 cases of local recurrence were detected. The percentage of sites of lesions identified at transrectal US and corresponding positive biopsy rates were as follows: the urethrovesical anastomotic area, 56% and 61%; bladder neck, 26% and 54%; retrovesical space, 4% and 100%; and more than one site, 14% and 71%. By comparing transrectal US and digital rectal examination, the sensitivities were 76% and 44% (P =.007), while specificities were 67% and 91% (P =.004), respectively. An increased positive biopsy rate with increasing prostate-specific antigen levels was noted (P =.04).

CONCLUSION

Transrectal US is more sensitive but less specific than digital rectal examination in the detection of local recurrence. Biopsy findings in more than half of the suspected lesions at the urethrovesical anastomotic area and bladder neck were positive. Lesions in the retrovesical space, although less frequently encountered, had a high likelihood of representing cancer recurrence.

Adenovirus-mediated transfer of inducible caspases: a novel "death switch" gene therapeutic approach to prostate cancer

In patients with localized prostate cancer, radical prostatectomy and radiation therapy, although effective in controlling localized disease, are often associated with significant side effects attributable to injury of adjacent tissues. Moreover, patients with metastatic disease eventually fail systemic hormonal or chemotherapy because of the development of progressive, refractory disease. In this study, we evaluated the safety and efficacy of a novel suicide gene therapy that could potentially spare normal tissue while bypassing molecular mechanisms of apoptosis resistance by using chemically inducible effector caspases to trigger apoptosis in prostate cancer cells. Initially, we compared the ability of a panel of inducible Fas signaling intermediates to kill human and murine prostate cancer cell lines. On the basis of the superior killing by downstream caspase-1 and caspase-3, replication-deficient adenoviral vectors expressing conditional caspase-1 (Ad-G/iCasp1) or caspase-3 (Ad-G/iCasp3), regulated by nontoxic, lipid-permeable, chemical inducers of dimerization (CID), were constructed. Upon vector transduction followed by CID administration, aggregation and activation of these recombinant caspases occur, leading to rapid apoptosis. In vitro, both human (LNCaP and PC-3) and murine (TRAMP-C2 and TRAMP-C2G) prostate cancer cell lines were efficiently transduced and killed in a CID-dependent fashion. In vivo, direct injection of Ad-G/iCasp1 into s.c. TRAMP-C2 tumors caused focal but extensive apoptosis without evidence for a bystander effect at the maximal viral dose (i.e., 2.5 x 10(10) viral particles/25 microl) in host animals that also received CID compared with control animals. Treatment with Ad-G/iCasp1 plus CID resulted in a transient, yet significant, reduction both in tumor growth and volume compared with tumors treated with vector but not CID (P < 0.035) or vector-diluent plus CID (P < 0.022), both of which grew more rapidly. These results demonstrate that CID-regulated, caspase-based suicide gene therapy is safe and can inhibit the growth of experimental prostate cancer in vitro and in vivo through potent induction of apoptosis, providing a rationale for further development.

Characteristics of normal prostate vascular anatomy as displayed by power Doppler

BACKGROUND

To define the vascular anatomy of the normal prostate as depicted by power Doppler and to provide baseline data for evaluation of this modality in the diagnosis and management of prostatic disease.

METHODS

The vascular anatomy of 40 subjects was studied. Power Doppler images were correlated with corresponding gray-scale images. Doppler spectral waveform measurements were obtained for the vessels identified.

RESULTS

Separate branches of the capsular vessels were visualized clearly, distributed radially in the peripheral and central zones and converging toward the center of the gland. Urethral vessels were visualized in the transition zone coursing from bladder neck to verumontanum. The neurovascular bundles were identified posterolaterally along the length of the gland. No significant difference between the resistive indexes of the urethral and capsular vessels was identified (P = 0.595), although there was a significant difference between the resistive index of the neurovascular bundles and that the prostatic vessels (P < 0.001).

CONCLUSIONS

The vascular anatomy of the normal prostate as displayed by power Doppler demonstrates a reproducible and symmetric flow pattern. Power Doppler is highly sensitive in depicting blood flow, the number, course, and continuity of vessels more readily than other imaging modalities, such as color Doppler. These data should allow comparison of the vascular anatomy of the normal prostate with that of the prostate with diseases such as prostate cancer and benign prostatic hyperplasia.

Prediction of response to salvage radiation therapy in patients with prostate cancer recurrence after radical prostatectomy

PURPOSE

To identify factors predictive of local recurrence as defined by a complete response to salvage radiation therapy in patients whose disease recurs after radical prostatectomy.

PATIENTS AND METHODS

Ninety-five patients with recurrence after radical prostatectomy who were evaluated by prostatic fossa biopsies, and a subset of 49 of these patients treated with radiation for control of presumed or biopsy-proven local recurrence, were studied.

RESULTS

Biopsies were positive in 40 (42%) of the 95 biopsied patients. Multivariate analysis revealed that prebiopsy prostate-specific antigen (PSA) level, postrecurrence PSA doubling time, and positive digital rectal examination (DRE) of the prostatic fossa were all statistically significant predictors of a positive biopsy. For the 49 patients subsequently treated with salvage radiation therapy, the overall actuarial 3- and 5-year PSA relapse-free probabilities were 43% and 24%, respectively. Univariate analysis showed no differences in the PSA relapse-free probabilities associated with any pathologic features of the radical prostatectomy specimen, biopsy confirmation of local recurrence, or DRE of the prostatic fossa. In multivariate analysis, controlling for all other variables, preradiation PSA and postrecurrence PSA doubling time measured before radiation were the only statistically significant predictors of outcome.

CONCLUSION

DRE of the prostatic fossa, prebiopsy PSA, and postrecurrence PSA doubling time predict which patients will have biopsy-proven local recurrence. However, response to salvage radiation therapy is associated with postrecurrence PSA doubling time and with preradiation PSA level only. DRE of the prostatic fossa and biopsy confirmation of local recurrence are not associated with salvage radiation outcome.

E-cadherin expression predicts clinical outcome in carcinoma in situ of the urinary bladder

OBJECTIVES

The clinical course of carcinoma in situ (CIS) of the bladder is highly variable. Our objective in this study was to describe E-cadherin expression patterns in CIS with and without papillary disease and to determine whether altered E-cadherin expression is associated with disease progression and survival in patients with CIS of the bladder.

METHODS

Tumor specimens from 53 patients who had CIS in the absence of muscle-invasive carcinoma on bladder biopsy were identified. Formalin-fixed paraffin sections were processed using a hot citric acid antigen retrieval method, followed by immunostaining with anti-E-cadherin monoclonal antibody. Expression patterns were evaluated in a blinded fashion and scored as normal and abnormal, which included absent and various degrees of heterogeneous immunostaining. Outcomes analyzed were recurrence, progression, and survival.

RESULTS

Loss of normal membrane E-cadherin immunoreactivity was found in 17 patients (32%). At a median follow-up of 131 months, abnormal E-cadherin expression was significantly associated with disease recurrence (P = 0.0087), disease progression (P = 0.0003), and bladder cancer-specific survival (P = 0.0285). In multivariate analyses, E-cadherin expression was independently associated with disease recurrence (P = 0.019, 95% confidence interval [CI] 1.342 to 5.940), disease progression (P = 0.002, 95% CI 2.049 to 17.989), and bladder cancer-specific survival (P = 0.025, 95% CI 1.179 to 10.432).

CONCLUSIONS

Loss of E-cadherin expression in patients CIS with and without papillary disease of the bladder predicts disease recurrence, disease progression, and bladder cancer-specific death. CIS with and without papillary disease associated with abnormal E-cadherin expression may represent a biologically more aggressive cancer, requiring early definitive therapy. This hypothesis should be evaluated in larger studies and prospective clinical trials.

Detection of metastatic prostate cancer using a splice variant-specific reverse transcriptase-polymerase chain reaction assay for human glandular kallikrein

We developed a highly sensitive splice variant-specific reverse transcriptase-PCR (RT-PCR) assay for human glandular kallikrein (hK2) mRNA and tested its ability to detect metastatic disease in men with clinically localized prostate cancer. An RT-PCR assay using primers spanning intron IV and including a significant portion of the 3' untranslated region of the hKLK2 gene, with maximum nonhomology to both hK1 and hK3, was developed. The limit of detection of the assay was five copies of hK2 cDNA and one LNCaP cell in 10(9) lymphoblasts. RT-PCR-hK2 was performed on preoperative peripheral blood specimens from 228 consecutive radical prostatectomy patients as well as 7 metastatic prostate cancer patients and 14 healthy men without prostate cancer. This new RT-PCR-hK2 assay amplifies two distinct fragments. The larger fragment (hK2-U) is approximately 680 bp in length and corresponds to the amplified product of a previously reported splice variant in the splice donor site of intron IV in the hKLK2 gene. The smaller fragment (hK2-L) is approximately 643 bp in length and corresponds to the amplified product of the native hK2 mRNA. Whereas the RT-PCR-hK2-L assay was positive in 71% of our patients with metastatic prostate cancer, 14% of healthy control men also tested positive. By univariate (P = 0.028) and multivariate (P = 0.0269) analysis, which controlled for preoperative PSA, clinical stage, and biopsy Gleason score, RT-PCR-hK2-L status added prognostic information to the prediction of lymph node-positive disease. We have developed a new RT-PCR assay which demonstrates a high sensitivity for detecting hK2 mRNA. Preoperative RT-PCR-hK2-L status helps predict pathological lymph node positivity in patients with clinically localized prostate cancer.

Prognostic value of P53 nuclear accumulation and histopathologic features in T1 transitional cell carcinoma of the urinary bladder

OBJECTIVES

To determine whether molecular and histopathologic tumor features can predict disease progression in Stage T1 transitional cell carcinoma of the bladder.

METHODS

Tumor specimens from 43 patients were analyzed with respect to grade, presence of carcinoma in situ, invasion deep or superficial to the lamina propria's muscularis mucosa, p53 expression using DO-7 and PAb1801 antibodies, age, and sex. Flow cytometry was performed on 30 patients from whom there was adequate paraffin-embedded tissue to assess DNA ploidy. Seven patients underwent immediate cystectomy as primary treatment and 36 patients retained their bladders and were at risk of recurrence and progression.

RESULTS

The median follow-up was 79 months. Disease recurred in 17 patients (47.2%) and progressed in 6 (16.7%). Only 3 patients (7.0%) died of bladder cancer. None of the parameters investigated was statistically significant in predicting recurrence, progression, or survival. Only carcinoma in situ approached statistical significance (P = 0.0593) as a predictor of progression. Early cystectomy did not have a significant effect on cancer-specific survival (P = 0.3603). The concordance rate between the two p53 antibodies was 88% (P <0.0001).

CONCLUSIONS

Deep invasion of the lamina propria, p53 positive immunohistochemistry, high grade, and aneuploidy were not significant adverse prognostic factors for either disease progression or survival. Carcinoma in situ associated with Stage T1 transitional cell carcinoma may represent a biologically more aggressive cancer requiring early definitive therapy, but this hypothesis should be evaluated in prospective clinical studies.

Correlation of preoperative plasma IGF-I levels with pathologic parameters and progression in patients undergoing radical prostatectomy

OBJECTIVES

To test whether preoperative insulin-like growth factor (IGF)-I levels could predict pathologic stage and prognosis of prostate cancer in patients undergoing radical prostatectomy.

METHODS

The study group consisted of 120 consecutive patients who underwent radical prostatectomy for clinically localized prostate cancer. Preoperative plasma IGF-I levels were measured using the DSL-IGF-I Elisa assay. Surgically removed prostate specimens were analyzed pathologically, using a whole-mount step-section technique. Preoperative plasma IGF-I levels were compared with final pathologic parameters and with prostate-specific antigen (PSA) progression-free survival. Preoperative IGF-I levels in this cohort were also compared with IGF-I levels measured in 20 healthy men without any cancer and in 10 men with untreated, metastatic prostate cancer.

RESULTS

Plasma IGF-I levels predicted neither organ-confined disease (P = 0.5611) nor the risk of PSA progression (P = 0.8125) at a median follow-up of 48.6 months after prostatectomy. Furthermore, IGF-I levels did not correlate with preoperative PSA level (P = 0. 2811) or final Gleason score (P = 0.4906). IGF-I levels in radical prostatectomy patients were not significantly higher than those in healthy subjects or in patients with metastatic disease (mean 156.7 +/- 66 ng/mL, 148.6 +/- 49 ng/mL, and 148.6 +/- 93 ng/mL, respectively; P = 0.8442).

CONCLUSIONS

Circulating IGF-I levels may predict the future risk of developing prostate cancer, but our study found no association with other established markers of biologically aggressive disease or with disease progression in patients with clinically localized prostate cancer.