[High dosage brachytherapy and external irradiation of localized prostate carcinoma--results at the Kiel University Clinic]

To evaluate a new therapy protocol for local dose escalation by high dose rate (HDR) brachytherapy for survival, morbidity and prognostic variables in men with localized prostate cancer. The prospectively recorded files of 189 men aged in median 69 years with a mean follow-up of 6 years (12-143 months) receiving curatively intended combined high dose rate (HDR) 192-iridium-brachytherapy (BT) and external beam radiation (EBR) for locally confined prostate cancer were analyzed. Mean age was 68.2 (range 44-84 years). Hundred and twenty-seven patients had T1-2 tumors, and 62 patients had T3-tumors. The total planned dose applied by external beam radiation was 50 Gy in the pelvis, and 40 Gy in the prostate by in-field-dose modification. The HDR-brachytherapy was delivered in two fractions. The dose per fraction amounted 15 Gy. Mean survival was 6 years (range 12-143 months), 76.7% of the patients survived and 86.3% were disease-free. The biochemical non-evidence of disease rate (BNED) was 78%. Univariate survival analysis revealed that low stage (T1-2), low grade (G1-2), normal PSA status after radiation therapy, and no adjuvant hormonal treatment were associated with long survival. However, the stratification for adjuvant hormonal treatment was not according to random. In multivariate analyses PSA status was an independent prognostic factor. The six year results confirm that local dose escalation by HDR-brachytherapy and external beam radiation is curative in men with locally confined prostate cancer. The results are especially in high risk patients encouraging.

[Vascular endothelial growth factor (VEGF) and its role in neoplastic processes]

This review concerns structural and functional properties of human vascular endothelial growth factor as well as the process of alternative splicing of its transcript. Regulation of VEGF gene transcription and participation of the protein in the angiogenesis of tumours are also broadly discussed.

Cytokeratin-20 reverse-transcriptase polymerase chain reaction as a new tool for the detection of circulating tumor cells in peripheral blood and bone marrow of bladder cancer patients

OBJECTIVES

Systemic progression is the prevalent form of bladder tumor recurrence after radical cystectomy. The ability to detect circulating tumor cells in peripheral blood or bone marrow could be of prognostic value for the disease with the consequence of early adjuvant chemotherapy. We established a sensitive and specific method using a double cytokeratin-20 (CK-20) reverse-transcriptase polymerase chain reaction (RT-PCR) to detect circulating bladder cancer cells in venous blood and bone marrow

MATERIAL AND METHODS

The sensitivity of the detection method was determined by a serial dilution of bladder cancer cells from the cell line HT1376 in whole blood. Bone marrow from 20 bladder cancer patients was drawn prior to radical cystectomy and CK-20 cDNA was amplified by RT-PCR. Additionally, pre- and postoperative venous blood samples from 11 of these patients with bone marrow aspirates and 9 patients undergoing only transurethral resection of the bladder as well as blood samples of 25 healthy volunteers were investigated by CK-20 RT-PCR.

RESULTS

The detection limit of the method was 2 bladder cancer cells/ml whole blood containing one million peripheral blood mononuclear cells. The positive detection rate in bone marrow was 7 of 20 (35%) for bladder cancer patients of all stages. However, investigation of the preoperatively collected venous blood samples from 20 patients revealed onyl 2 positive findings, belonging to advanced tumor stages pT4pN0M0 and pT3pN2M0. In contrast, CK-20 was detected in 3 of 20 postoperatively collected venous blood samples from patients with low tumor stages (pTaNXM0 and pT1NXM0) as well as from 1 patient with pelvic lymph node metastases (pT3apN2M0). All venous blood samples of the control group (n = 25) were negative for CK-20.

CONCLUSION

The detection of circulating bladder tumor cells in venous blood and bone marrow by the CK-20 RT-PCR is a promising approach that could improve risk assessment and the identification of bladder cancer patients who would benefit from adjuvant chemotherapy.

Prostate-specific antigen in female urine: a prospective study involving 217 women

OBJECTIVES

Histomorphologic studies have provided evidence of prostate-specific antigen (PSA)-producing tissue in the female urethra. Some urine samples from women in a small series were positive for PSA, but no systematic investigation of this subject has been done to date.

METHODS

In a prospective study, we analyzed whether PSA occurs in the urine of women and what factors induce detectable PSA levels. The urine samples of 217 women were analyzed (Hybritech-Tandem E-PSA) under standardized conditions. The impact of urine pH and volume was investigated, and the results were correlated with clinical data (age, residual urine, urinary tract infection and prior sexual intercourse within 48 hours).

RESULTS

A positive PSA level greater than the detection limit of 0.1 ng/mL was found in 11% of the analyzed samples; their mean value was 0.29 ng/mL. pH correction did not result in a significant difference. The voiding volume had no influence on the PSA level. Among the cases of detectable PSA, women younger than 50 years of age (n = 14) had a mean PSA of 0.34 ng/mL and those older than 50 years (n = 9) a mean of 0.23 ng/mL. One of 9 women with and 22 of 208 women without residual urine volume had a detectable PSA level, as did 0 of 20 with and 23 of 197 women without urinary tract infection, and 3 of 7 with and 20 of 210 women without prior sexual intercourse within the previous 48 hours. None of the differences were significant.

CONCLUSIONS

A urine PSA level was detected in 11% of all women studied, with PSA values apparently age dependent. Any urine portion is suitable for analysis. No influence was determined for residual urine volume or urinary tract infection. Sexual intercourse may cause detectable PSA values, but the data of this study did not provide sufficient evidence for this hypothesis.

Retroperitoneal mature teratoma 15 years after initial treatment of testicular mixed germ cell tumor

We present a patient with a retroperitoneal tumor noted 15 years after treatment of a testicular mixed germ cell cancer. The patient initially underwent right-sided orchiectomy and retroperitoneal lymph node dissection for clinical stage I disease. An early relapse indicated by increasing tumor markers shortly after retroperitoneal lymph node dissection was successfully treated with five cycles of combined chemotherapy. However, 187 months after completion of chemotherapy, a symptomatic right-sided iliac mass was diagnosed. Radical surgical excision of the mass was performed and histologic examination revealed differentiated mature teratoma. This represents the longest time interval reported in the literature for a mature teratoma following treatment of a testicular germ cell tumor.

Urinary leakage of tubular enzymes after shock wave lithotripsy

OBJECTIVES

Urinary loss of tubular marker enzymes following shock wave lithotripsy (SWL) suggests corresponding morphological changes in the kidney. To date, the morphological correlate of enzymuria and its dependence on the energy applied remains unclear.

METHODS

In an animal study, the acute morphological changes occurring in the tubulus cells as the basis of enzymuria were investigated. It was evaluated whether SWL-induced enzymuria correlates with the extent of renal damage.

RESULTS

Acute morphological changes in the tubulus cells were demonstrated beneath isolated tubulus necrosis. The mechanically induced lesions of the cell organelles included fragmentation of the lysosomes and severe alterations of the cell membrane. The tubulus damage can be quantified. With the help of histochemical N-acetyl-beta-D-glucosaminidase (NAG) staining and electron microscopic observations, a significant correlation was found between the shock wave parameters number of impulses and intensity and the tubular damage. The intensity of NAG enzymuria reflected the severity of the tubular damage.

CONCLUSIONS

In this animal model, NAG proved to be a suitable marker enzyme for estimation of the degree of SWL-induced tubular damage.

Long term follow-up of combined radiochemotherapy for locally advanced bladder carcinoma

BACKGROUND

The 5- and 10-year survival rates and the toxicity of combined radiochemotherapy for 53 consecutive patients with locally advanced bladder carcinoma were studied in a noncomparative trial.

METHODS

Between November 1986 and October 1987, 53 consecutive patients (mean age, 68 years) with muscle invasive and/or locally advanced bladder carcinoma were treated by simultaneous chemotherapy and hyperfractionated irradiation. Radiation was administered during the first to fourth week and during the ninth to tenth week as an interrupted treatment protocol. Cisplatin and epirubicin were used as radiosensitizers before radiation. The maximum dose of irradiation was 57.6 grays.

RESULTS

Of 53 patients, 45 completed the planned treatment course. Causes for discontinuing therapy in 8 patients were pronounced myelosuppression (n = 2), severe gastrointestinal symptoms (n = 2), nephrotoxicity (n = 1), and severe radioproctitis (n = 1). Two additional patients stopped therapy due to vascular diseases independent of treatment-related toxicity. The overall survival for all 53 patients was 23% after 5 years and 8% after 10 years. Cause specific survival was 36% after 5 years and 29% after 10 years. Four patients are still alive after 10 years without disease progression. One of them received incomplete therapy due to toxicity. All four patients underwent transurethral resections for superficial, local tumor recurrences.

CONCLUSIONS

The poor prognosis group of patients with invasive and/or locally advanced bladder carcinoma was found to have a limited disease specific survival after combined radiochemotherapy.

[Improvement of transrectal ultrasound. Artificial neural network analysis (ANNA) in detection and staging of prostatic carcinoma]

As a result of the enhanced clinical application of prostate specific antigen (PSA), an increasing number of men are becoming candidates for prostate cancer work-up. A high PSA value over 20 ng/ml is a good indicator of the presence of prostate cancer, but within the range of 4-10 ng/ml, it is rather unreliable. Even more alarming is the fact that prostate cancer has been found in 12-37% of patients with a "normal" PSA value of under 4 ng/ml (Hybritech). While PSA is capable of indicating a statistical risk of prostate cancer in a defined patient population, it is not able to localize cancer within the prostate gland or guide a biopsy needle to a suspicious area. This necessitates an additional effective diagnostic technique that is able to localize or rule out a malignant growth within the prostate. The methods available for the detection of these prostate cancers are digital rectal examination (DRE) and Transrectal ultrasound (TRUS). DRE is not suitable for early detection, as about 70% of the palpable malignancies have already spread beyond the prostate. The classic problem of visual interpretation of TRUS images is that hypoechoic areas suspicious for cancer may be either normal or cancerous histologically. Moreover, about 25% of all cancers have been found to be isoechoic and therefore not distinguishable from normal-appearing areas. None of the current biopsy or imaging techniques are able to cope with this dilemma. Artificial neural networks (ANN) are complex nonlinear computational models, designed much like the neuronal organization of a brain. These networks are able to model complicated biologic relationships without making assumptions based on conventional statistical distributions. Applications in Medicine and Urology have been promising. One example of such an application will be discussed in detail: A new method of Artificial Neural Network Analysis (ANNA) was employed in an attempt to obtain existing subvisual information, other than the gray scale, from conventional TRUS and to improve the accuracy of prostate cancer identification.

Anti-HCV RIBA/LiaTek reactivity and HCV genotype in EIA-negative patients with viremia

Individuals infected with hepatitis C virus (HCV) usually produce anti-HCV antibodies detectable by enzyme immunoassay (EIA); however, in certain viremic cases this antibody does not appear. To investigate whether anti-HCV in these cases is detectable by Western blot (WB), 38 HCV RNA positive/anti-HCV EIA-negative sera were tested by RIBA 3.0 or LiaTek III. The HCV genotypes (INNO-LiPA) were analyzed to determine whether the variance in these genotypes can be the reason for the late, weak antibody production or its absence. As the control group, 282 EIA-positive/HCV RNA-positive patients were examined. A single band reactivity of various intensities by RIBA or LiaTek was observed in 16/38 EIA negative sera. Positive results with NS3 were detected in 4 sera and weak positive (+/-) with core, NS3, and NS5 in 5, 6, and 1 sera, respectively. In 3 cases with anti-NS3, the seroreversion was observed in follow-up. The distribution of genotypes in anti-HCV-negative versus anti-HCV-positive groups was: 1b alone, 50.0% vs. 78.0%; 3a alone, 13.2% vs. 15.6%; and mixed (1b+3a), 36.8% vs. 5.0%, respectively. The follow-up studies showed that viremia was lost spontaneously in 12/35 patients. In some patients infected with two genotypes, the spontaneous loss of the 3a genotype was observed. The study showed that WB tests are useful for serological confirmation of HCV infection in some EIA negative/HCV RNA-positive patients but, because seroreversion may occur, sequential sera samples should be tested. No unusual HCV genotype was detected in anti-HCV-negative/HCV RNA-positive cases, but the frequency of mixed infection with the 1b+3a genotypes in this group was found to be higher than that in anti-HCV-positive hepatitis patients.

Incidence and treatment of hepatitis C virus infection in children with haemophilia in Poland

In 80% of children with haemophilia treated in our department, screening tests showed the presence of antibodies against the hepatitis C virus (HCV). HCV RNA was detected in serum in 41% of cases. In 20% of cases there were periodic increases in the level of alanine aminotransferase (ALT) activity, and in these cases liver biopsy was performed after factor concentrate replacement. No haemorrhagic complications or pain complaints were reported either during the biopsy or immediately afterwards. In all cases histopathological examination revealed chronic hepatitis type C - chronic mild hepatitis and chronic minimal hepatitis. Eight boys were treated with interferon (INF) alpha. In two cases this therapy was successful. No HCV RNA was detected in serum and transaminase activity was normal during the year following interferon treatment.

Direct amifostine effect on renal tubule cells in rats

Clinical trials indicate that amifostine offers protection against cisplatin-induced nephrotoxicity. It is unclear whether a direct pharmacological t on renal tubular cells is involved. We investigated the effect of amifostine pretreatment on the tubular apparatus and evaluated its nephroprotective potential. A total of 32 rats were treated by i.p. administration of 0.9% saline solution (group 1), 5 mg/kg cisplatin (group 2), 25 mg/kg amifostine (group 3), and 25 mg/kg amifostine followed by 5 mg/kg cisplatin (group 4) after 30 min. We recorded elevation of N-acetyl-beta-D-glucosaminidase (NAG) in 24 h pooled urine as a specific marker for tubular lesions, renal leakage of magnesium as an unspecific nephrotoxicity marker, and survival over a 10-day observation period. A significant (P < 0.002) increase in urinary NAG after treatment was documented only in cisplatin-treated group 2 [day 2 (mean+/-SE), 93+/-2.1 units/gram creatinine; day 4, 70.6+/-16 units/gram creatinine; normalization at day 8]. Treatment with amifostine before cisplatin administration resulted in a slight urinary NAG leakage (day 2, 2.8+/-1.8 units/gram creatinine; day 4, 13.8+/-13 units/gram creatinine; normalization at day 6). No increase in urinary enzyme levels was seen in the other groups, and there were no significant differences in urinary magnesium between all groups. Four of eight rats in the cisplatin-treated group and one of eight rats in the amifostine plus cisplatin-treated group died.

Prostate preservation by combined external beam and HDR brachytherapy in nodal negative prostate cancer

PURPOSE

The combined external beam- and high-dose rate brachytherapy (HDR-BT) of localized prostate cancer was introduced at Kiel University in 1986. The aim of this intermediate analysis was to judge the Kiel method of localized prostate cancer radiation treatment after ten years experience.

PATIENTS AND METHODS

In the past ten years 174 patients with histological proven localized prostate cancer were subjected to combined tele-/HDR-brachytherapy. Local staging in all of the cases by transrectal ultrasound, nodal staging in the majority of the cases by CT or MRI. Average age of the patients was 68.2 years (44-84). According to AJCC/UICC staging T1B, T2, T3 was found in 2, 113 and 59 cases, respectively. Highly differentiated tumors (G1) were found in 27, moderately differentiated (G2) in 87, poorly differentiated (G3) in 60 cases. The mean follow-up was 47.1 months with the median of 51.7 months. Total prescribed dose 50 Gy on the small pelvis and 70 Gy on the prostate capsule due to the integration of two, 15 Gy each, HDR-brachytherapy fractions in 6 weeks.

RESULTS

Ten patients died of prostate cancer and 18 of intercurrent diseases resulting in a 5 years overall survival rate of 83% and tumor specific survival rate of 94%. Twenty-one patients showed a clinical progression, of these 14 systemic, 5 local and 2 both systemic and local. Additional 16 patients had PSA elevation only. The 5-years biochemical and/or clinical progression-free survival in the cohort was 79% and 73% for the T3 tumors. Side effects were 27 cases of proctitis/colitis and 20 cases of dysuria/cystitis.

CONCLUSION

The integrated HDR-BT combined with external beam radiation treatment is a method with excellent tumor control rates at five years superior to those of external beam treatment alone or external beam combined with iodine-125 implants. This form of radiotherapy would appear to be particularly well-suited to treatment of advanced localized (T3) tumors.

Artificial neural network analysis (ANNA) of prostatic transrectal ultrasound

BACKGROUND

Our purpose was to determine the diagnostic potential of a new, computerized method of interpreting transrectal ultrasound (TRUS) information by artificial neural network analysis (ANNA). This method was developed to resolve the current dilemma of visual differentiation between benign and malignant tissue on TRUS. To train and objectively evaluate ANNA, a new precise method of computerized virtual correlation of preoperative ultrasound findings and radical prostatectomy histopathology was devised. After training with this pathologically confirmed digitized TRUS information, ANNA was tested in a blinded study.

METHODS

Following radical prostatectomy, 289 pathology whole-mount sections of 61 patients were correlated digitally with the corresponding TRUS slices. Specific selection of TRUS areas unequivocally identified on the correlated digitized pathohistology resulted in 553 pathology-confirmed representations (samples). Of these, 53 were used for training and 500 were subjected to blind analysis by ANNA.

RESULTS

ANNA classified 378 (99%) of the 381 benign pathology-confirmed samples correctly as benign. The false-positive rate was 1% (n = 3). Of the 119 pathology-confirmed malignant samples, 94 (79%) were classified correctly; 25 (21%) were falsely classified as normal. Out of all 119 cancers, ANNA classified 60 (71%) of the hypoechoic cancers as malignant and 24 (29%) as benign. Surprisingly, 34 (97%) of the isoechoic cancers were correctly classified by ANNA, missing only one sample.

CONCLUSIONS

The introduction of ANNA enhanced the accuracy of TRUS prostate cancer identification. Although not all malignant areas were detected, cancer was detected in each patient. The ability to detect isoechoic cancerous lesions appears to be the essential innovation over conventional TRUS interpretation.

Pneumocystis carinii pneumonia in the Federal Republic of Germany in the era of changing antiretroviral therapy - IDKF 13 -. German AIDS Study Group (GASG/IdKF)

BACKGROUND

Pneumocystis carinii pneumonia (PCP) is one of the most common AIDS defining diagnoses.

METHODS

In a prospective observational trial all cases of Pneumocystis carinii pneumonia (PCP) were evaluated. Patients with and without PCP-prophylaxis were compared for symptoms, efficacy, side effects and mortality at week 4 and 26.

RESULTS

293 patients developed a PCP episode. Patients with no prophylaxis had a significant lower CD4 cell count and a more severe clinical status at time of diagnosis. This was pronounced in the group with first positive HIV test at time of diagnosis. There was no difference in the rate of successful treatment between both groups. At week four a tendency to a better survival in the group with prophylaxis was observed, however this changed to a trend to a better survival at week 26 for the group without prophylaxis.

CONCLUSION

Even in the era of highly active antiretroviral treatment many patients present with PCP. Nearly 60% of patients presented without antiretroviral treatment or PCP-prophylaxis. Nearly 25% of all patients had their first HIV-test at time of PCP diagnosis.

Hepatitis G virus coinfection in chronic hepatitis B and C patients in Poland

This study evaluated the epidemiology and impact of hepatitis G virus (HGV) infection in patients with chronic hepatitis B and C. Serum samples were obtained from 128 consecutive untreated patients with chronic hepatitis B (72 cases) or C (56 cases). The presence of HGV RNA was determined by PCR amplification of the 5'untranslated region; the sensitivity of the assays was ten template copy equivalents. The prevalence of HGV RNA in hepatitis B and C was found to be 25% and 34%, respectively. HGV-positive and HGV-negative patients did not differ with respect to risk factors for infection, age, sex, or alanine aminotransferase activity. Similarly, there was no difference in the severity of liver disease, as assessed with HAI score. In conclusion, we found a very high prevalence of HGV infection in chronic hepatitis B and C patients in Poland. Nevertheless, no evidence was found that HGV coinfection has any impact on the severity of the underlying disease.

[Results of treatment with interferon for chronic hepatitis B in children]

8 children with chronic hepatitis B were treated with interferon, 3 M.U. subcutaneously three times a week for 4-5 months. Seroconversion from HBe antigen to anti HBe antibodies was observed in 3 of them and in 1 also seroconversion from HBs antigen to anti HBs antibodies. In remaining 5 cases the therapy was ineffective which could be caused by: more advanced inflammatory lesions in liver, infection with HB in infancy and low activity of aminotransferases before the treatment. Side effects of interferon were only transitory and in no case caused cessation of the therapy.

Identification of a microsatellite region composed of a long homopurine/homopyrimidine tract surrounded by AT-rich sequences upstream of the rat stress-inducible hsp 70.1 gene

A DNA region containing several repetitive motifs has been detected about 1.9 kbp upstream of the transcription unit of the rat stress-inducible hsp 70.1 gene. The most interesting element of this area is a microsatellite sequence (GA)6CAG(TC)24 that consists of an inverted repeat partially overlapping with the long homopurine/homopyrimidine tract (Pu/Py). DNA molecule within the described sequence can theoretically adopt alternate, non-B structures (H-DNA or cruciform) containing single-stranded regions. This microsatellite region is flanked by AT-rich sequences containing several poly(A) tracts. The longest of them with a possible potential to destabilized a double-stranded DNA helix is localized around 160 bp downstream the (GA)6CAG(TC)24. The DNA fragment containing sequences described above was subcloned into the pUC19 vector and the resulting plasmid was subjected to the standard S1 susceptibility assay. Preliminary mapping of the S1 cleavage site indicates for the formation of the non-B-DNA structure within the Pu/Py tract. This is to our knowledge a first report on the existence of a complex microsatellite region on upstream the 5'-end of the hsp 70 gene in mammals.