Per-operative frozen section examination of pelvic nodes is unnecessary for the majority of clinically localized prostate cancers in the prostate-specific antigen era

BACKGROUND

The incidence of unsuspected lymph node metastasis seems to be decreasing in the prostate-specific antigen (PSA) era. It remains controversial as to whether routine pelvic lymph node dissection and per-operative frozen section examination should be performed. In addition, it is still unclear whether an aggressive approach to local disease by surgery or irradiation confers survival benefits on stage D1 patients.

METHODS

Eighty-eight consecutive patients with clinically localized prostate cancer who underwent pelvic lymph node dissection prior to radical prostatectomy during the period between 1985 and 1998 were analyzed. The incidence of lymph node metastases after 1992 was compared with that before 1992. Sensitivity and specificity of frozen section examination was assessed. Progression-free survival and cause-specific survival curves of node-positive patients who underwent radical prostatectomy were estimated by the Kaplan-Meier method.

RESULTS

Six of 17 patients (35.3%) treated before 1992 and five of 71 patients (7.0%) treated after 1992 showed unsuspected lymph node metastasis (P = 0.0059). Eight of 11 node-positive patients underwent radical prostatectomy and two have so far demonstrated clinical progression and cancer death with a median follow-up period of 63 months. The 5 year progression-free rate and the cause-specific survival rate for these patients were 71.4 and 85.7%, respectively. Sensitivity of frozen section examination for micrometastasis and gross-metastasis cases, respectively, was 3/6 (50%) and 4/4 (100%), while specificity was 85/85 (100%).

CONCLUSIONS

The incidence of unsuspected lymph node metastases has been significantly decreased in the PSA era. Frozen section examination of pelvic nodes can be omitted and radical prostatectomy is an acceptable choice of treatment in patients without macroscopically apparent nodal metastases.

[National trend of management of benign prostatic hyperplasia in Japan during 1990s: analysis of national health statistics]

To review the contemporary management of benign prostatic hyperplasia (BPH) in Japan during 1990s, we analyzed several nationwide health statistics by the Ministry of Health and Welfare of Japan. The cross-sectional surveys revealed that the estimated total number of patients receiving treatment increased from 202,000 in 1987, to 335,000 and 590,000, respectively, in 1995 and 1998. Approximately 73-80% of patients were men aged 65 years or over and 94-98% 55 years or older. Urologists treated two thirds of the BPH patients. The incidence of prostatectomies remained relatively stable at 50,000/year (3.0-3.8 prostatectomies/1,000 men aged 55 or over). The average hospital stay in 1996 was 24.7 days. The total cost of BPH therapy nearly doubled between 1988 and 1998. The ratio of outpatient to inpatient costs ranged from 1.5 to 2.2 and 60% of the outpatient cost was spent for medical therapy. The total value of the market for medical therapy increased from 30-40 billion yen in 1989 to more than 80 billion yen in 1998. The application of alpha-blockers increased from 243,000 men (70% of all patients) in 1995 to 452,000 (77%) in 1998, whereas the number of patients taking antiandrogens, plant extracts and antispasmodic agents/Ca antagonists (for pollakisuria), respectively, remained relatively stable at 60,000-70,000, 180,000 and 300,000. Because Japan is a rapidly aging society and men aged 55 or older are expected to increase from 15 million in 1995 to 21 million in 2010, cost-effective treatment guidelines for the Japanese BPH patients are needed.

[Epididymal sperm aspiration for obstructive azoospermia]

Epididymal sperm aspiration technique combined with assisted reproductive technology (ART) including intracytoplasmic sperm injection (ICSI) has provided new frontiers for the treatment of unreconstructable obstructive azoospermia, including congenital bilateral absence of the vas deferens and failed surgical intervention. Epididymal sperm is obtained by several procedures, including microsurgical epididymal sperm aspiration (MESA), mini-MESA (Modified MESA), macroscopic epididymal sperm aspiration (MaESA) and percutaneous epididymal sperm aspiration (PESA). Since 1991 in our department, epididymal sperm aspiration combined with ART was performed by MESA (26 cases, 41 times) and PESA (3 cases, 4 times). Motile sperm retrieval using MESA and PESA was obtained in 34 out of 36 times (94.4%) and 2 out of 4 times (50%), respectively. MESA-ICSI resulted in a 47.3% 2PN (metaphase II) fertilization rate per eggs and a 28.8% pregnancy rate per transfer. With advancement of ICSI technique in which frozen sperm can be used, elective sperm retrieval can be planned at our convenience. PESA is a convenient, inexpensive and effective outpatient clinic procedure for retrieving sperm assisted with ICSI. In summary, infertile couples need to be given realistic options regarding treatment outcome. The fertility potential and age of the female partner need to be considered when addressing male treatment options.

Detection of circulating cancer cells by reverse transcription-polymerase chain reaction for uroplakin II in peripheral blood of patients with urothelial cancer

Few attempts have been made at the molecular detection of urothelial cancer cells in the blood or lymph nodes mainly because of an absence of good candidate molecular or genetic changes specific to urothelial cancer or urothelium. In 1990, however, genes that encode urothelium-specific transmembrane proteins, uroplakins (UPs), were cloned. We have established a method of detecting circulating cancer cells in peripheral blood of patients with transitional cell carcinoma by nested reverse transcription-PCR assay for UP II. UP II mRNA-positive cells were detected in 3 (10.3%) of 29 patients with superficial cancers (pTa-1N0M0), 4 (28.6%) of 14 patients with muscularly invasive cancers (pT2-4N0M0), 2 (40.0%) of 5 loco-regional node-positive patients (pN1-2M0), and 6 (75.0%) of 8 patients with distant metastases. Positive rates, therefore, increased with tumor extension (P = 0.0033, Kruskal-Wallis test). Furthermore, sequential blood sampling was performed in three patients with metastases during and after systemic chemotherapy, and UP-II-positive cells were found to have disappeared in two patients who responded well to the systemic chemotherapy. These results suggest that our nested reverse transcription-PCR assay for UP II is highly specific and might be used as a tumor marker for molecular staging of urothelial cancers, although the sensitivity is not so optimal.

Telomerase activity in urine after transurethral resection of superficial bladder cancer and early recurrence

BACKGROUND

To explore the relationship between telomerase activity in urine after transurethral resection (TUR) of superficial bladder cancer and early intravesical recurrence.

METHODS

Urine samples were obtained from 42 patients with superficial bladder cancers prior to TUR and on the postoperative day 1 and day 6. These patients were followed-up prospectively by cystoscopy at 3 and 6 months after TUR in combination with urinary cytology and telomerase activity. Telomerase activity in the urine was assessed by the telomeric repeat amplification protocol assay.

RESULTS

Urinary telomerase activity prior to TUR was positive in 24 (57%) of the 42 patients. On the postoperative day 1 and day 6, positive urinary telomerase activity was seen in 13 (31%) and nine (21%) patients, respectively. Postoperative urinary telomerase activity on either day 1 or day 6 was significantly associated with pre-operative urinary telomerase activity status (P = 0.0024). Fifteen patients showed intravesical tumor recurrence at 3 months cystoscopic check-up and an additional nine had recurred at the 6 months check-up. Recurrence rate within 6 months in patients with pre-operative positive urinary telomerase activity was similar to that in those with negative activity (58.3 vs 58.8%). However, recurrence rate at 3 months for patients with positive activity was higher than that of those with negative activity (50 vs 17.7%), in 23 patients treated only by TUR.

CONCLUSIONS

Presence of cells positive for telomerase activity in urine after TUR of superficial bladder cancer indicates persistently existing cancer cells in the urine. It is, however, not a sole predictor of the early intravesical recurrence.

Enhancement of Fas-mediated apoptosis in renal cell carcinoma cells by adriamycin

Anti-Fas monoclonal antibody (mAb) kills Fas-expressing cells by apoptosis. Several anticancer agents also mediate apoptosis and may share common intracellular pathways leading to apoptosis with Fas. Thus, we reasoned that combination treatment of drug-resistant cells with anti-Fas mAb and drugs might overcome their resistance. We investigated whether anticancer agents enhance Fas-mediated apoptosis and cytotoxicity against renal cell carcinoma (RCC) cells. Treatment of ACHN RCC cells with anti-Fas mAb in combination with 5-fluorouracil, vinblastine, IFN-alpha, or IFN-gamma did not overcome resistance to these agents. However, combination treatment with anti-Fas mAb and Adriamycin (ADR) resulted in a synergistic cytotoxic effect. Furthermore, synergy was also obtained even when the exposure time was shortened from 24 h to 8 or 2 h. Synergy was also achieved in four other RCC cell lines and five freshly derived human RCC cells. Treatment with anti-Fas mAb in combination with epirubicin or pirarubicin also resulted in a synergistic cytotoxic effect on ACHN cells. Similar results were achieved with a combination of humanized anti-Fas mAb and ADR. Incubation of ACHN cells with ADR augmented the expression of Fas and p53, but not Bcl-2, Bax, or caspase-3. However, the activity of caspase-3 itself was apparently enhanced after treatment with ADR alone or combined treatment with anti-Fas mAb. The synergy obtained in cytotoxicity with anti-Fas mAb and ADR was also achieved in apoptosis. Exposure of ACHN cells and freshly derived RCC cells to ADR enhanced their susceptibility to lysis by peripheral blood lymphocytes and tumor-infiltrating lymphocytes. This study demonstrates that combination treatment of RCC cells with anti-Fas mAb and ADR might overcome their resistance. The sensitization required a low concentration of ADR and a short exposure time, thus supporting the potential in vivo application of a combination of ADR and anti-Fas mAb or immunotherapy in the treatment of ADR- and/or immunotherapy-resistant RCC.

Clinical significance of nonpalpable prostate cancer with favorable biopsy features in Japanese men

OBJECTIVE

To assess the clinical significance of nonpalpable localized prostate cancers with relatively favorable six sextant biopsy features in Japanese men.

PATIENTS AND METHODS

136 nonpalpable prostate cancers of which biopsy features confined to (1) a Gleason score of 6 or less, (2) one or two positive cores per six sextant cores, and (3) 50% or less involvement of any positive core were collected. The Gleason score, tumor extension, and cancer volume were compared with preoperative serum PSA and PSA density for the patients who underwent radical prostatectomy. PSA doubling time was measured for the patients who were treated expectantly.

RESULTS

Treatments chosen for 136 patients with favorable biopsy features were radical prostatectomy alone for 48 and with preoperative androgen deprivation for 30, radiation to the prostate for 12, androgen deprivation therapy for 21, and watchful waiting for 25. Of 48 patients who underwent radical prostatectomy without androgen deprivation therapy, 25% had nonorgan-confined cancers. Seven cancers (14.6%) were Gleason score of 7, but no cancers were 8 or greater. Among 42 prostatectomy specimens for which cancer volume was measured, 22 (52.4%) had cancer volume >0.5 cm(3). Pretreatment serum PSA levels were correlated neither with the Gleason score, tumor extension nor cancer volume. There was only one nonorgan-confined cancer in the 23 cancers for which PSA density was <0.2 ng/ml/g. The ability of PSA density to predict cancer volume <0. 5 cm(3) was 0.61 using a cut-off of 0.2 ng/ml/g. Of the 25 patients treated expectantly, the PSA doubling time was less than 2 years for 3 patients, while it was stable or fluctuated for 13.

CONCLUSIONS

Tumor extension can be predicted based on PSA density in nonpalpable prostate cancer with favorable biopsy features, but predictability of cancer volume based on PSA or PSA density is not satisfactorily high. New parameters or biomarkers that complement needle biopsy findings are needed to predict clinical significance of T1c prostate cancer with favorable biopsy features.

Allelic imbalances on chromosome 20 in human transitional cell carcinoma

One determinant of the survival time of cancer-bearing patients may be genetic factors. In chemically induced bladder cancers of mice, differences in survival time have been observed among several inbred strains. Genetic analyses of such differences in crosses between C57BL / 6 and NON mice revealed that the survival period is determined by two quantitative trait loci on mouse chromosomes 6 and 2, respectively. We explored the possibility that genetic alterations may be observed in the syntenic conserved chromosomal regions of human transitional cell carcinoma corresponding to mouse chromosomes 6 and 2. Human chromosome 7, containing a region syntenic to mouse chromosome 6, is reported to harbor frequent genetic alterations in bladder cancers. In this study, we investigated 70 human urothelial cancers for possible genetic alterations on human chromosome 20p and 20q containing regions syntenic to mouse chromosome 2. Allelic imbalances were observed in 22 cases (31.4%) on 20p and 18 cases (25.7%) on 20q. Those allelic imbalances, however, did not show a direct correlation with the prognosis of the patients. Higher grade tumors tended to show more frequent imbalances on chromosome 20; however, this tendency was not significant.

Multivariate analysis of prognostic determinants after surgery for renal cell carcinoma at Himeji National Hospital

A clinico-pathological study was performed retrospectively on 62 patients who underwent surgery for renal cell carcinoma between January 1992 and October 1998 at Himeji National Hospital to clarify the prognostic determinants for survival. The median follow-up period was 32 months and the cause-specific survival rates at 1, 3 and 5 years were 86.7, 81.3, 81.3%, respectively. Of the 62 patients, 11 (17.7%) patients died of renal cell carcinoma and 2 (3.2%) patients died of unrelated causes. Of the variables related to survival, presenting symptoms, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), alkaline phosphatase (ALP), tumor size, pathological tumor grade, infiltration pattern, pathological tumor stage, N classification and M classification were significant risk factors for survival by univariate analysis. However, ALP, N classification and M classification were significant for survival as determined by the step-wise procedure and M classification was the most significant factor according to Cox's proportional hazard model analysis.

Radical retropubic prostatectomy: time trends, morbidity and mortality in Japan

OBJECTIVES

To assess the time trends, morbidity and mortality of contemporary anatomical radical retropubic prostatectomy (RRP) in a multi-institutional study in Japan, where RRP has become more popular in the last decade.

PATIENTS AND METHODS

Between January 1991 and August 1998, 638 patients underwent RRP at seven urological centres in Japan. Major complications (within 30 days of surgery) and the 30-day mortality were reviewed retrospectively. Of the patients, 12.9% were < 60 years old, 56.3% were 60-69 years old and 30.9% were >/= 70 years old (median age 67). Results The number of RRPs increased markedly, by more than sevenfold, from 1991-92 to 1996-97, mainly because there were more patients undergoing RRP in their sixth decade. The contribution of T1c disease increased in absolute and relative terms, from 13.9% in 1991-92 to 37.9% in 1997-98. Over time, the mean blood loss and the allogeneic transfusion rate decreased steadily. There was a trend toward more favourable outcomes for pathological variables (an increased percentage of organ-confined disease, decreased margin positivity and a decreased incidence of positive lymph node metastasis). The most common complications were wound-related (7.5%), or anastomotic leakage (4.1%). Major cardiopulmonary complications occurred in only two patients (0.31%, both pulmonary embolisms). One patient died from cerebral haemorrhage within 30 days of surgery, giving a mortality rate of 0.16%.

CONCLUSION

s This study indicates a trend towards selecting patients most likely to benefit from RRP. Although the procedure is technically demanding, it can have an acceptably low rate of early complications, little mortality and need for allogeneic transfusion. The assessment of morbidity suggests a lower incidence of catastrophic thrombo-embolic and cardiac complications in Japanese patients than in Western men. The present data may be useful in decision-analysis models evaluating the role of therapy for Asian men with early-stage prostate cancer.

CROP/Luc7A, a novel serine/arginine-rich nuclear protein, isolated from cisplatin-resistant cell line

A novel putative SR protein, designated cisplatin resistance-associated overexpressed protein (CROP), has been cloned from cisplatin-resistant cell lines by differential display. The N-half of the deduced amino acid sequence of 432 amino acids of CROP contains cysteine/histidine motifs and leucine zipper-like repeats. The C-half consists mostly of charged and polar amino acids: arginine (58 residues or 25%), glutamate (36 residues or 16%), serine (35 residues or 15%), lysine (30 residues, 13%), and aspartate (20 residues or 9%). The C-half is extremely hydrophilic and comprises domains rich in lysine and glutamate residues, rich in alternating arginine and glutamate residues, and rich in arginine and serine residues. The arginine/serine-rich domain is dominated by a series of 8 amino acid imperfect repetitive motif (consensus sequence, Ser-Arg-Ser-Arg-Asp/Glu-Arg-Arg-Arg), which has been found in RNA splicing factors. The RNase protection assay and Western blotting analysis indicate that the expression of CROP is about 2-3-fold higher in mRNA and protein levels in cisplatin-resistant ACHN/CDDP cells than in host ACHN cells. CROP is the human homologue of yeast Luc7p, which is supposed to be involved in 5'-splice site recognition and is essential for vegetative growth.

Genetic alterations of the p16 gene in urothelial carcinoma in Taiwanese patients

OBJECTIVE

To measure changes in the p16 gene (MTS1, a negative regulator of cell-cycle progression at the G1 checkpoint, and a tumour suppressor gene) in urothelial carcinomas (including upper tract urothelial and bladder tumours), and to correlate these measurements with the clinical status of such patients in Taiwan, where renal pelvic tumours comprise 47% of all kidney tumours and are more common than the average worldwide.

MATERIALS AND METHODS

Thirty-five upper tract urothelial and 61 bladder tumours were examined for changes in p16. Deletion of the gene was assessed by Southern blot analysis and mutation analysed using polymerase chain reaction-single strand conformation polymorphism, followed by direct sequencing.

RESULTS

Of the 61 bladder carcinomas, homozygous deletion of p16 was detected in 12 (20%). However, a homozygous deletion was detected in 11 of 35 (31%) upper tract urothelial carcinomas, a higher frequency than that reported for transitional cell bladder carcinomas. Deletion was detected as frequently in stage I tumours as in late-stage tumours, suggesting that p16 deletion is a relatively early event in urothelial tumorigenesis. No point mutations were noted for p16 in any of the primary urothelial tumours. Most multiple and recurrent tumours and metastatic nodules in individual patients contained identical p16 genetic lesions, confirming that the tumours were probably monoclonal. In addition, there was a high gene dose of p16 in bladder carcinomas from patients with lymph node metastasis.

CONCLUSION

Deletion of p16 appears to be a common event in urothelial carcinomas, especially in upper tract urothelial tumours. High levels of p16 were detected in tumours with lymph node metastasis. It seems likely that a high p16 level is associated with carcinomas of advanced stage and grade, and with poor prognosis in patients with such cancers.

[The prognostic value of adjuvant and neoadjuvant chemotherapy in total cystectomy for locally advanced bladder cancer]

PURPOSE

Adjuvant chemotherapy and neoadjuvant chemotherapy have been widely used as adjuvant treatment in patients requiring total cystectomy for locally advanced transitional cell carcinoma of the bladder. However, there has been no conclusive evidence that the adjunctive chemotherapy improves survival and no agreement exists concerning what subsets of such patients receive significant benefits from the adjunctive chemotherapy. The study retrospectively sought to clarify these points.

PATIENTS AND METHODS

We retrospectively analyzed clinical and pathological records of the 229 patients with transitional cell carcinoma of the bladder who underwent total cystectomy with or without lymph node dissection in our University Hospital from January 1975 to December 1997. Forty-two patients received 1-4 cycles (mean = 1.7) of adjuvant chemotherapy with VPMisCF (n = 19), CisCA (n = 4), MVAC (n = 8), or MEC (Methotrexate, Epirubicin and Cisplatin) (n = 11). Twenty-three patients received 1-4 cycles (mean = 2.1) of neoadjuvant chemotherapy with CisCA (n = 2), MVAC (n = 5), or MEC (n = 16). Using the Kaplan-Meier method, disease-specific survival rate was assessed according to various clinical and pathological factors as well as the administration of adjuvant or neoadjuvant chemotherapy. The generalized-Wilcoxon test was used to evaluate statistical significance (p < 0.05) of survival curves for two or more groups. In addition, a multivariate analysis using the Cox proportional hazards model was performed with respect to multiple clinical and pathological parameters, and treatment modalities.

RESULTS

In patients who received neither adjuvant chemotherapy nor radiotherapy, the disease-specific survival rate was significantly lower in those with pT3a and/or more advanced tumors compared with those with pT2 or less advanced tumors. The survival rate in patients with positive lymph node metastasis was significantly lower than that in patients without lymph node metastasis. No apparent survival benefit was noted for those patients who received adjuvant chemotherapy when compared with patients who had pT3a or more advanced tumor and were followed without any adjunctive therapy. In patients with pN2 or more advanced lymph node metastasis, the survival rate of those who received adjuvant CisCA/MVAC/MEC chemotherapy was significantly higher than that those without any adjunctive therapy. Although no apparent survival benefit was observed in patients who received neoadjuvant chemotherapy, the survival rate in patients whose tumor was considered to be down-staged to pT1 or lower was significantly higher than patients who did not receive neoadjuvant chemotherapy and had pT3a or higher pT-stage tumor. The survival rate in patients whose tumor showed clinical partial or complete response by neoadjuvant chemotherapy was also significantly higher than the same control patients. However, the multivariate analysis revealed no significant survival benefit after adjuvant chemotherapy or after neoadjuvant chemotherapy.

CONCLUSIONS

Adjuvant chemotherapy after total cystectomy is an acceptable approach in patients with pN2 or higher pN-stage bladder cancer. The significant survival benefit may be obtained who acquired pathological downstaging or partial to complete clinical response after neoadjuvant chemotherapy. To get maximum survival benefit from the present chemotherapeutic regimens and exclude administration of toxic chemotherapeutic agents to unresponsive patients, there should be more reliable markers that give clear information to differentiate tumors that will respond fairly to present chemotherapeutic regimens from tumors that will respond poorly.

Homozygous deletion at the 9q32-33 candidate tumor suppressor locus in primary human bladder cancer

Loss of heterozygosity (LOH) on chromosome arm 9q is the most frequent genetic alteration found in superficial and invasive transitional cell carcinoma (TCC) in a previous microsatellite-based deletion mapping study of the bladder and upper urinary tract, indicating the presence of one or more important tumor suppressor genes (TSGs). One of the putative tumor suppressor loci on 9q (DBC1) was mapped to 9q32-33 and the candidate region was localized within a single YAC. We report here a case of superficial papillary TCC, which showed a homozygous deletion encompassing this candidate tumor suppressor region. The region of homozygous deletion spanned the interval between D9S275 and AFMA239XA9 at 9q32-33, and was estimated to be </=6 cM. Although homozygous deletion mapping did not narrow down the candidate tumor suppressor region, this case provides further support for the presence of a TSG for TCC in this chromosomal region. To our knowledge, this is the first report to show homozygous deletion at 9q32-33 in TCC or any other type of human tumor. Genes Chromosomes Cancer 26:171-175, 1999.

[Molecular biological testing for diagnosis and treatment of urothelial cancer]

Detection of urinary telomerase activity is superior to the conventional urine cytological examination in terms of sensitivity for diagnosis of low grade urothelial cancers. Several causative factors including pyuria and hematuria which might have affected falsely positive and negative rates of urinary telomerase activity were investigated but their influence seemed negligible. As for progression from superficial to invasive urothelial cancers, destruction of the basement membrane underlying tumor is considered as an important event in the initial step of invasion. Our immunohistochemical analyses revealed that expression of type IV collagen in the basement membrane was reduced or disappeared in more than half of grade 2 to 3, pTa urothelial cancers. Overexpression of p53 tumor suppressor and/or mdm2 oncoprotein was strongly correlated with this basement membrane destruction. Urothelial cancers harboring p53 aberration may be resistant to cisplatin-based chemotherapy because of impairment of apoptosis induction. The relationship between chemosensitivity and p53 status in urothelial cancers was investigated, and a favorable response to neoadjuvant chemotherapy was found in tumors without p53 aberration.

Orthotopic ileal neobladder in male patients: functional outcomes of 66 cases

BACKGROUND

Orthotopic urinary diversion has become the preferred form of bladder reconstruction after cystectomy. We report on our experience with 66 male patients undergoing this procedure from November 1990 to February 1998.

METHODS

A neobladder was constructed using an ileal segment with a Hautmann type bladder. Complications were assessed and subdivided into early and late types. Voiding function was evaluated in terms of voiding pattern and continence. Median follow up was 19.5 (range 3.5-87.7) months.

RESULTS

There was one (1.5%) perioperative death. The most frequent pouch-related and unrelated early complications were persistent urine leak (7.6%) and prolonged ileus (16.7%), respectively, the majority of cases of which were managed conservatively. Analysis of late complications revealed 6.2% ureteroileal stenosis and 1.5% urethrointestinal stenosis rates, but no case of bladder stone formation. Of the 61 patients in whom voiding function was evaluable, 95.1% achieved excellent daytime continence, while only 67.2% had night-time continence. With regard to posture at voiding, 23 (37.7%) voided in a sitting position. Three of the patients (4.9%) were unable to void and required regular intermittent catheterization.

CONCLUSIONS

An orthotopic neobladder can be constructed with acceptable morbidity and excellent functional results. We believe that orthotopic urinary diversion offers an attractive alternative to a bladder substitute when cystectomy is required.

Role of matrix metalloproteinase-9 in the basement membrane destruction of superficial urothelial carcinomas

PURPOSE

This study was conducted to clarify which matrix metalloproteinases (MMPs) play a key role in destruction of the underlying basement membrane (BM) of superficial urothelial carcinomas. Urine concentrations of MMP-9 and tissue inhibitors of matrix metalloproteinase-1 (TIMP-1) were also measured.

MATERIALS AND METHODS

Overexpression of MMP-1, MMP-2 and MMP-9 was analyzed immunohistochemically in 60 patients with transitional cell carcinomas of the urothelium (41 were pTa or pis, 19 were pT1-4), and compared them with type IV collagen expression in tumor BM. In 33 of them, urine concentrations of MMP-9 and TIMP-1 were measured by one-step sandwich enzyme immunoassay.

RESULTS

Positive expression of MMP-1, MMP-2 and MMP-9 was found in 53%, 17%, and 65% of tumors, respectively. Only MMP-9 expression rates were increased with grades and stages (p = 0.03). In pTa and pis tumors, type IV collagen expression was reduced in 17 of 26 (65.4%), and it was associated with positive MMP-9 expression (p = 0.0283). MMP-9 was detected in all urine samples of urothelial cancer patients, while urine TIMP-1 was detectable in 18 of 33 patients. In 16 healthy volunteers, both of them were below detectable levels. Balance between urinary MMP-9 and TIMP-1 were particularly kept in superficial urothelial carcinomas with intact tumor BM. Tumor BM status, however, was not associated with urinary MMP-9 or TIMP-1 levels.

CONCLUSIONS

These results suggest that MMP-9 plays a key role in the invasion step of superficial urothelial carcinomas. Detection of urinary MMP-9 may become a new, non-invasive mean for the diagnosis of urothelial carcinomas.

Clonal and chronological genetic analysis of multifocal cancers of the bladder and upper urinary tract

Recent molecular genetic studies have suggested that multifocal urothelial cancers are derived from an identical progenitor cell. However, the clonal origin of multifocal urothelial cancers of a low-grade superficial type has not been fully defined. Using microsatellite markers, we examined genetic alterations at 20 loci on eight chromosomal arms (2q, 4p, 4q, 8p, 9p, 9q, 11p, and 17p) in 87 metachronous and/or synchronous multifocal urothelial cancers, which included 84 low-grade superficial papillary tumors from 29 patients. Judging from the patterns of loss of heterozygosity, microsatellite shifts, and the subchromosomal partial deletion, multifocal tumors in at least 20 (80%) of the 25 evaluable patients were considered to be derived from a single progenitor cell, although the possibility remained that multifocal tumors in a small subset of patients might develop from distinct progenitor cells due to field cancerization. In 13 of the 20 patients, a chronological genetic analysis was available: genetic heterogeneity was detected in 3 (23%) patients, and an apparent accumulated pattern of genetic alterations was detected in only 1 (8%) patient. In the 20 patients with multifocal tumors of an identical clonal origin, discordant microsatellite alterations were observed, with significantly lower frequencies on chromosome 9 compared to those on the other chromosomes tested. The results indicate that most multifocal low-grade superficial urothelial cancers are genetically stable despite their incidence of frequent recurrence, and genetic divergence occurs in a subset of patients. This heterotopic spread and genetic divergence may occur long before the clinical manifestation of multiplicity from a single transformed cell. These data support the previous view that heterotopic spread of transformed progenitor cells and genetic divergence occur after chromosome 9 alterations in most of low-grade superficial urothelial cancers.

[Synchronous multifocal development of invasive transitional cell carcinoma of the urinary tract in a patient with renal failure receiving long-term hemodialysis: a case report]

We report a case of transitional cell carcinoma in a patient with chronic renal failure receiving hemodialysis for 22 years. A 55-year-old man was admitted to our hospital. Under diagnosis of invasive bladder cancer and left renal pelvic tumor, removal of the whole urinary tract, e.g., bilateral nephroureterectomy and total cystourethrectomy was performed. Transitional cell carcinoma was found in bilateral renal pelvis, left ureter, bladder and prostate in the resected specimen. Thirteen months after the operation, multiple lung metastases and pathologic bone fracture of the 4th lumber vertebra were found. Chemotherapy (3 courses of modified CISCA, consisting of cisplatin, adriamycin and cyclophosphamide) was performed, but the died of systemic metastases of cancer and bleeding due to perforation of multiple gastric ulcers.

[Three cases of the nephrogenic adenoma of the bladder]

Nephrogenic adenoma is a rare, benign tumor of the urinary tract. The origin of this tumor is supposed to be a metaplastic transformation of urothelium in response to stimulation such as recurrent urinary tract infections or surgical trauma. We experienced three cases of nephrogenic adenoma originating in the bladder. The first patient was a 29-year-old man with right vesicoureteral reflux (VUR). When Teflon injection for VUR was performed, a papillary tumor was found on the right wall of the bladder. Transurethral resection of the bladder tumor (TUR-Bt) was performed. The second patient was a 72-year-old woman who was suffering from chronic cystitis. Although she was treated with antibiotics for one year, the symptoms were not improved. Cystoscopy showed multiple papillary tumors at the retrotrigonum of the bladder and TUR-Bt was performed. The third patient was a 75-year-old man who had a history of the left pelvic and bilateral ureteral tumors. Left radical nephroureterectomy and right radical ureterectomy with an ileal graft replacement was performed. Three years later, cystoscopy demonstrated a papillary tumor at the retrotrigonum, which was resected transurethrally. Our cases are the 20th to 22nd cases of the nephrogenic adenoma of the bladder reported in the Japanese literature.

[Expression of major histocompatibility complex antigens and adhesion molecules on renal cell carcinoma cells, and effect of interferon-alpha and/or cimetidine on the expression]

Recently the combined therapy with interferon-alpha (IFN-alpha) and cimetidine has been reported to be effective against advanced renal cell carcinoma (RCC). IFN-alpha and cimetidine have an antitumor effect partly due to enhancement of cytotoxic activity of lymphocytes against cancer cells. We examined the expression of major histocompatibility complex (MHC) antigens and adhesion molecules on 4 fresh RCC cells and 5 RCC cultured cell lines, which have an important role in recognition and killing of cytotoxic lymphocytes against cancer cells. The effect of treatment with IFN-alpha and/or cimetidine on the expression of MHC antigens and adhesion molecules on RCC cells was also investigated. MHC class I and leukocyte function-associated antigen-3 (LFA-3) were expressed on all RCC cells, but not MHC class II. Intercellular adhesion molecule-1 (ICAM-1) and B7 were expressed on 6 and 5 of 8 RCC cells, respectively. IFN-alpha significantly augmented the expression of MHC class I in 6 of 9 RCC cells, ICAM-1 in 1 and LFA-3 in 2 of 8 RCC cells. However, IFN-alpha did not affect the expression of MHC class II and B7. On the other hand, cimetidine enhanced the expression of LFA-3 in 2 of 8 RCC cells, but not MHC antigens, ICAM-1 or B7. The combination of IFN-alpha and cimetidine did not show a synergistic enhancing effect on the expression of MHC antigens, ICAM-1, LFA-3 or B7. These results suggest that IFN-alpha augments the sensitivity of RCC cells to lysis by cytotoxic lymphocytes partly due to the enhancement of expression of MHC class I, ICAM-1 and LFA-3 on RCC cells, and that cimetidine also augments the susceptibility of RCC cells to lymphocytes by the enhanced expression of LFA-3 on RCC cells.

[Epidemiology and clinical features of prostate cancer in Japan]

The incidence rate of clinically manifest prostate cancer in 1992 was estimated 15.7 per 100,000 men, although it is increasing exponentially. Accordingly, 5399 deaths from prostate cancer in 1995 will be increased to 13,494 deaths in 2015. Change in dietary habit (more Western-style diet) is considered to be a major cause of the increase. Escalating number of elderly people in the Japanese population is another major reason of elevated incidence. On the other, public awareness of prostate cancer and introduction of serum PSA measurement to health check-up undoubtedly have raised the detection rate of early stage disease. The way of androgen ablation do not seem to have influenced on survival of the advanced disease so far. It remains to be clarified whether the combined androgen blockade using pure anti-androgens with castration provide better patients' survival than castration alone.

Decision analysis for treatment of early stage prostate cancer

We performed a decision analysis to evaluate the usefulness of pretreatment prediction of clinically significant or insignificant tumor in patients with prostate-specific antigen (PSA)-detected stage T1c prostate cancer nonpalpable on rectal examination. Analysis was done for otherwise healthy subjects with 20 years of life expectancy. The prevalence of insignificant tumor among those with T1c prostate cancer was initially assumed to be 0.2. Quality-adjusted life expectancy was calculated and compared between 2 strategies; one with prediction-based selection of either radical prostatectomy or watchful waiting and the other with unselective assignment of one of the treatments. The selection strategy was superior when the sensitivity and specificity for detecting clinically significant tumor were 0.92 and 0.73, respectively, as reported by Epstein et al. (1994) using criteria of PSA density and Gleason score in a needle biopsy specimen. Sensitivity analysis revealed that the prediction-based selection strategy is preferred, with sensitivity and specificity constant, when the prevalence of insignificant tumor exceeds 0.16. On the other hand, when the prevalence of insignificant tumor is kept constant at 0.2, sensitivity should be 0.85 or higher for the prediction strategy to be preferred. As the prevalence of insignificant tumor among those with T1c prostate cancer increased, the prediction-based selection strategy is preferred with lower values of sensitivity and specificity for detecting significant tumor. These results suggest that a selective treatment strategy of either radical or conservative treatment based on pretreatment prediction for significant tumor is a beneficial alternative to radical prostatectomy unselectively assigned to all patients at the T1c stage, if a reasonable accuracy in prediction is attained.