Combined modality staging of prostate carcinoma and its utility in predicting pathologic stage and postoperative prostate specific antigen failure

OBJECTIVES

This study was performed to predict the factors that can optimize preoperative staging for clinically localized prostate cancer patients.

METHODS

Logistic and Cox regression multivariable analyses were performed on 480 surgically-managed prostate cancer patients to evaluate the ability of clinical stage, prostate specific antigen (PSA), biopsy Gleason sum, percent positive biopsies, and endorectal coil magnetic resonance imaging (erMRI) results to predict for pathologic established extracapsular extension (ECE), seminal vesicle invasion (SVI), and time to postoperative PSA failure.

RESULTS

The characteristics of clinically organ-confined prostate cancer patients at high risk (> 67%) for postoperative PSA failure within 3 years include: (A) PSA > 20 ng/mL; (B) Biopsy Gleason sum > or = 8; or (C) erMRI positive for extraprostatic disease and intermediate risk disease. For patients at intermediate risk (ie, either a PSA < 4 and biopsy Gleason sum of 7; PSA > 4 to 10 ng/mL and biopsy Gleason sum 5 to 7; or a PSA > 10 to 20 ng/mL and biopsy Gleason sum 2 to 7), despite 100% positive biopsies, 50% of patients had pathologic organ-confined disease. However, in the subset of intermediate-risk patients with a positive erMRI for either ECE or SVI and at least 50% positive biopsies, all had extraprostatic disease and failed biochemically by 47 months postoperatively. Intermediate-risk patients with < 50% positive biopsies had pathologic organ-confined disease in at least 77% of the cases.

CONCLUSIONS

Combined modality staging using the PSA, biopsy Gleason sum, percent positive biopsies, and endorectal coil MRI findings in select patients can predict pathologic stage and postoperative PSA failure. Therefore, this combined modality staging may optimize patient selection for phase 3 trials examining the role of neoadjuvant androgen ablative therapy for patients with clinically localized disease.

Acute and chronic effects of dexfenfluramine on the porcine coronary artery

Experiments were designed to verify whether or not acute or chronic exposure to dexfenfluramine favors the occurrence of coronary vasospasm in vivo or in vitro. Rings of left anterior and left circumflex porcine coronary artery, with and without endothelium, were studied in conventional organ chambers for the measurement of isometric force. The donor pigs were divided into two groups: controls and animals fed for 4 weeks with dexfenfluramine. In each group, one-half of the animals underwent balloon denudation of the left anterior descending coronary artery at the beginning of the study. Coronary angiography was performed at the time of denudation and, in all animals, during the 3rd week of the study. Acutely, dexfenfluramine at concentrations higher than 10(-5) M caused contractions which were blunted by the presence of the endothelium and inhibited by indomethacin (an inhibitor of cyclooxygenase). Chronic treatment with dexfenfluramine did not affect coronary diameter and did not alter the response to intracoronary infusion of serotonin. Chronic treatment with dexfenfluramine reduced the contractions of rings without endothelium to serotonin, but not those to norepinephrine or endothelin. It did not affect endothelium-dependent relaxations in the absence or presence of pertussis toxin to serotonin, UK14304 (alpha-2 adrenergic agonist), adenosine diphosphate or aggregating platelets. Chronic treatment with dexfenfluramine did not modify relaxations of rings without endothelium to SIN-1 (nitric oxide donor; the active metabolite of molsidomine) or adenosine diphosphate. These findings do not support the hypothesis that acute or chronic exposure to dexfenfluramine favors the occurrence of coronary vasospasm.

Role of percent positive biopsies and endorectal coil MRI in predicting prognosis in intermediate-risk prostate cancer patients

PURPOSE

This study was performed to determine the clinical factors that can optimize preoperative staging for clinically localized intermediate-risk prostate cancer patients.

MATERIALS AND METHODS

Logistic and Cox regression multivariable analyses were performed on 480 prostate cancer patients whose disease was confined to the prostate to evaluate the ability of clinical stage, prostate-specific antigen (PSA), biopsy Gleason sum, percent positive biopsies, and endorectal coil magnetic resonance imaging (MRI) results to predict pathologic established extracapsular extension, seminal vesicle invasion, and time to postoperative PSA failure in patients with clinically localized prostate cancer. Intermediate risk was defined as PSA 4-10 ng/mL and Gleason sum 5-7; PSA 10-20 ng/mL and Gleason sum < or = 7.

RESULTS

Intermediate-risk patients with at least 50%, 67%, 83%, or 100% positive biopsies have disease pathologically confined to the prostate at least 45% of the time; however, if an endorectal coil MRI is positive for either capsular penetration or seminal vesicle invasion, no more than 29% of patients have pathologically determined organ-confined disease. No intermediate-risk patient with both a positive MRI and at least 50% positive biopsies had pathologically determined organ-confined disease. Intermediate-risk patients with less than 50% positive biopsies had pathologically determined organ-confined disease in at least 77% of the cases.

CONCLUSIONS

Intermediate-risk patients with an endorectal coil MRI showing extracapsular extension or seminal vesticle invasion are at high risk for early postoperative PSA failure. The concomitant presence of at least 50% positive biopsies increases this risk to unity. Therefore, these patients are not good candidates for surgery alone because of their high risk of extraprostatic disease and should be considered for entry onto phase III trials examining the effect of adding androgen-deprivation therapy to definitive local therapy (external-beam radiation therapy or surgery) on overall survival. The subgroup of intermediate-risk patients likely to benefit from an endorectal coil MRI are those patients with PSA > 10-20 ng/mL; biopsy Gleason score < or = 7, and at least 50% positive biopsies representing approximately 7.5% of the total patient population.

The significance of subnormal serum vitamin B12 concentration in older people: a case control study

OBJECTIVES

To determine the clinical significance of subnormal serum vitamin B12 concentration in older people by comparing the hematological, neurological, and biochemical findings in patients with subnormal serum B12 with a control group with normal B12 levels.

DESIGN

Clinical and laboratory assessment of hospital patients selected to represent a wide range of serum B12 levels.

SETTING

Patients in the medical wards of two hospitals, one a general hospital and the other a geriatric hospital.

PARTICIPANTS

Ninety-four older patients, 43 with subnormal (< 150 pmol/L) and 51 with normal serum B12 concentrations.

MEASUREMENTS

Mini-Mental State Examination, neurological score, full blood examination, mean neutrophil lobe count; serum B12, holotranscobalamin II, total homocysteine, folate, creatinine and gastrin red folate; parietal cell antibodies, intrinsic factor antibodies.

RESULTS

Of all the measurements, only mean neutrophil lobe count and mean serum total homocysteine were significantly different in the low serum B12 compared with the control group. There was a significant correlation between serum B12 and homocysteine levels. Eighty-eight percent of patients in the test group compared with 76% in the control group showed at least one of the following; elevated serum total homocysteine, neutrophil hypersegmentation, or elevated MCV. This overlap was much reduced when patients with borderline values for serum B12 (150-250 pmol/L) were included in the low B12 group. Most of the older subjects had little or no B12 on transcobalamin II, irrespective of the serum B12 level.

CONCLUSION

Almost 90% of older patients with serum B12 < 150 pmol/L show evidence of tissue vitamin B12 deficiency. Deficiency becomes manifest in older patients at relatively higher concentrations of serum B12 than in younger subjects, possibly because of lower levels of holotranscobalamin II in the older patients.

Critical analysis of the ability of the endorectal coil magnetic resonance imaging scan to predict pathologic stage, margin status, and postoperative prostate-specific antigen failure in patients with clinically organ-confined prostate cancer

PURPOSE

To determine whether there is a role for endorectal coil magnetic resonance imaging (erMRI) in the prediction of pathologic stage, margin status, and/or postoperative prostate-specific antigen (PSA) failure in patients with clinically organ-confined prostate cancer.

PATIENTS AND METHODS

Using erMRI, the radiologic-pathologic correlation of extracapsular extension (ECE) and seminal vesicle invasion (SVI) was evaluated in 445 surgically managed patients. Logistic regression multivariable analysis was applied to the clinical stage, PSA, biopsy Gleason grade, and erMRI findings to assess the outcomes of ECE, SVI, positive surgical margins (PSM), and postoperative PSA failure.

RESULTS

The accuracy of erMRI to predict for ECE and SVI numerically decreased with both increasing PSA and biopsy Gleason score because of the increasing false-negative scans in cases of microscopic transcapsular or seminal vesicle disease. Of patients who could not be categorized into low or high risk for postoperative PSA failure on the basis of clinical stage, preoperative PSA, and biopsy Gleason score, a negative or positive erMRI for ECE or SVI stratified these patients into groups with a 78% versus 21% (P < .0001) 3-year rate of actuarial freedom from PSA failure. In this subgroup, the overall accuracy of the erMRI was 70% +/- 6% and 94% +/- 2% for ECE and SVI, respectively. The most significant predictor on multivariable analysis of PSM was the erMRI finding of ECE (P = .0001).

CONCLUSION

This initial report suggests that a preoperative erMRI can identify clinically organ-confined prostate cancer patients at high risk for having ECE, SVI, and PSM that otherwise would be missed on the basis of the clinical stage, preoperative PSA, and biopsy Gleason score. Confirmatory studies are needed.

An analysis of the time course of postoperative prostate-specific antigen failure in patients with positive surgical margins: implications on the use of adjuvant therapy

OBJECTIVES

The role of adjuvant therapy in the postprostatectomy setting for positive margin patients is an unresolved issue. The purpose of this study is to provide the rationale for patient selection in Phase III trials that test the impact of adjuvant therapy on survival in positive margin prostate cancer patients.

METHODS

Early (12 months or less) and delayed (more than 12 months) postoperative prostate-specific antigen (PSA) failure have been correlated with distant and local failure, respectively, as the site of first failure. In this study, a Cox regression multivariate analysis was used to determine the significant independent clinical and pathologic predictors of early and delayed postoperative PSA failure in 143 margin-positive prostate cancer patients.

RESULTS

Margin-positive patients with positive pelvic lymph nodes, seminal vesicle invasion, or prostatectomy Gleason sum 8 or higher were excluded. For the remaining patients, a prostatectomy Gleason sum of 7, preoperative PSA more than 20 ng/mL, and an endorectal coil magnetic resonance imaging (erMRI) scan showing extensive disease were significant independent predictors of early postoperative PSA failure. Conversely, a prostatectomy Gleason sum of 6 or less, preoperative PSA 20 ng/mL or less, and an erMRI showing limited disease predicted delayed PSA failure.

CONCLUSIONS

Preliminary data suggest that the pattern of first failure can be predicted by the time course of rise in the postoperative PSA. The preliminary results of this study suggest that patient selection for clinical trials examining the efficacy of postoperative adjuvant therapy in the positive margin patient may be determined on the basis of the clinical and pathologic characteristics that predict early versus delayed postoperative PSA failure.

Localization of two potassium channel beta subunit genes, KCNA1B and KCNA2B

The gating properties and current amplitudes of mammalian voltage-activated Shaker potassium channels are modulated by at least two associated beta subunits (Kv beta 1.1 and Kv beta 1.2). The human Kv beta 1.1 gene (KCNA1B) resides on chromosome 3, as indicated by somatic cell hybrid mapping. More precise localization of KCNA1B to 3q26.1 was obtained with fluorescence in situ hybridization (FISH) and was corroborated by PCR screening of the CEPH YAC library. The human Kv beta 1.2 gene (KCNA2B) resides on chromosome 1, as indicated by somatic cell hybrid mapping, and has been localized by FISH to 1p36.3.

Development and Application of Assisted Reproductive Technologies in Marsupials: Their Value for Conservation of Rock-wallabies

Assisted reproductive technology is used routinely in management to treat infertility and in domestic species in basic husbandry. In eutherian mammals application of this technology is also well established in wildlife conservation programs. The development and application of this technology in marsupials, however, is a relatively new field. The reproductive techniques currently available for marsupial studies, their benefits and implications for conservation are discussed in order to remove any previous misconceptions and provide an insight into how these techniques might be applied. The potential of this technology for maintaining genetic variability and enhancing reproductive output of threatened marsupial species is highlighted, with particular reference to the conservation of rock wallabies.

Desmoplasia and neurotropism. Prognostic variables in patients with stage I melanoma

BACKGROUND

Desmoplastic melanomas with and without neurotropism are thought to be more clinically aggressive than other melanomas of comparable thickness. This study evaluates the prognostic significance of desmoplasia and neurotropism in Patients with Stage I cutaneous melanoma completely excised at the initial presentation of disease and prospectively studied for a minimum of 8 years.

METHODS

Desmoplasia and neurotropism were evaluated as single prognostic predictors in survival outcome of cutaneous Stage I melanomas and as variables in the University of Pennsylvania Pigmented Lesion Study Group 8-year survival model for Stage I melanoma. In addition, the clinical presentation and follow-up of melanomas with desmoplasia and/or neurotropism was compared with that of other types of cutaneous Stage I melanoma in patients also followed for a minimum of 8 years.

RESULTS

Neurotropism was associated with a statistically significant decrease in survival in patients with melanomas with desmoplasia. A decrease in survival also was observed in other types of melanoma with neurotropism, but the difference was not statistically significant. Melanomas with neurotropism had a statistically significant increase in local recurrence. Desmoplasia was not associated with a statistically significant decrease in survival.

CONCLUSION

Desmoplasia is not associated with a statistically significant decrease in the prognosis of patients with primary cutaneous Stage I melanoma. The more clinically aggressive behavior of desmoplastic melanomas observed in previous studies may be secondary to initial misdiagnosis and/or inadequate margin assessment of these lesions. Neurotropism, however, is associated with a statistically significant decrease in survival in patients with desmoplastic melanomas and is most likely associated with decreased reduces patient survival in other melanoma types. Neurotropism is also related to an increase in the frequency of local recurrence of melanoma.

Factors associated with a positive reexcision after excisional biopsy for invasive breast cancer

BACKGROUND

Breast-conserving therapy followed by adjuvant radiotherapy represents an alternative to mastectomy as a treatment for invasive breast cancer. When excisional biopsy has been performed outside the parent institution, reexcision is often performed, with tumor being identified in 32% to 62% of the subsequent specimens. We analyzed not only the factors associated with a positive reexcision but also those factors associated with final surgical margins that are positive for tumor.

METHODS

Between 1978 and 1991, 956 female patients with American Joint Committee on Cancer clinical stage I or II breast cancer were treated with breast-conserving therapy where a total of 420 patients underwent reexcision after an initial excisional biopsy. Several factors were analyzed to determine their association with a positive reexcision, the status of the final surgical margin, and the nature of the disease present within the reexcision specimen.

RESULTS

Factors that correlated with a positive reexcision in both univariate and multivariate analysis were clinical tumor size, method of detection, the pathologic status of the axillary lymph nodes, and the histologic appearance. Those factors associated with finding invasive disease at the time of reexcision were clinical tumor size, clinical presentation, and nodal status. The single factor associated with finding residual in situ disease at the time of reexcision was histologic appearance of the primary tumor. A final positive margin was associated with method of tumor detection, age of the patient, and the presence of axillary lymph node metastases.

CONCLUSIONS

The most significant factors associated with a positive reexcision are clinical tumor size, method of tumor detection, pathologic nodal status, and histologic appearance. Patients with larger tumors or those that are detected by physical examination, as well as invasive lobular carcinomas, may require a more generous initial resection to achieve negative surgical margins and avoid the likelihood of reexcision.

The inhibition of foam cell formation by sodium diethyldithiocarbamate

A prominent feature of human atherosclerosis is the lipid-laden foamy macrophage, which often also contains the insoluble pigment, ceroid. The culture of macrophage-like cells, P388D1s, with artificial lipoproteins composed of cholesteryl linoleate (CL) and bovine serum albumin (BSA) results in foam cell formation with lipoprotein uptake and the intracellular accumulation of ceroid. Ceroid accumulation is accompanied by the oxidation of the cholesterol ester as monitored by gas chromatography. The sodium salt of diethyldithiocarbamic acid (DDC) at 1-5 microM effectively inhibited lipoprotein uptake, cholesteryl linoleate oxidation and ceroid accumulation in cultures of P388D1. Further studies showed that intracellular ceroid accumulation appeared to require the presence of cystine in the medium. Lipoprotein oxidation by this macrophage-like cell therefore appears to involve a mechanism dependent on cystine metabolism which is consistent with previous reports of macrophage-mediated lipoprotein oxidation. Studies on CL/BSA-induced ceroid accumulation in human monocytes also showed that DDC behaved in much the same manner. This inhibitory effect of DDC on foam cell formation, often considered a primary event of atherosclerosis, at concentrations as low as 1 microM, suggests the need for further, more comprehensive, studies on this compound's activities.

A multivariate analysis of clinical and pathological factors that predict for prostate specific antigen failure after radical prostatectomy for prostate cancer

A Cox regression multivariate analysis was done to determine the clinical and pathological indicators that predict for prostate specific antigen (PSA) failure in 347 patients who underwent radical prostatectomy for clinically localized prostate cancer between 1989 and 1993. In the patient subgroups (PSA less than 20 ng./ml. and biopsy Gleason sum 5 to 7 or PSA more than 10 to 20 ng./ml. and biopsy Gleason sum 2 to 4) not classifiable into those at high and low risk for postoperative PSA failure using PSA and biopsy Gleason sum, the status of the seminal vesicles and prostatic capsule on endo-rectal coil magnetic resonance imaging (MRI) allowed for this categorization. Specifically, 2-year actuarial PSA failure rates were 84% versus 23% in patients with and without seminal vesicle invasion, respectively, on MRI (p < 0.0001) and 58% versus 21% in those with and without extracapsular extension, respectively (p = 0.0001). In patients with extracapsular extension but without pathological involvement of the seminal vesicle(s) or poorly differentiated tumors (pathological Gleason sum 8 to 10), the 2-year actuarial PSA failure rates were 50% (margin positive), 28% (margin negative with established extracapsular disease) and 9% (margin negative with focal microscopic extracapsular disease). Therefore, endo-rectal coil MRI showing seminal vesicle invasion or extracapsular extension when the PSA level is less than 20 ng./ml. and the biopsy Gleason sum is 5 to 7 or the PSA level is more than 10 but less than 20 ng./ml. and the biopsy Gleason sum is 2 to 4 predicted for PSA failure. In patients with extracapsular extension who had pathological Gleason sum less than 8 disease with uninvolved seminal vesicles, the margin status and extent of extracapsular disease predicted for PSA failure.

A method for determining a prostate-specific antigen cure after radiation therapy for clinically localized prostate cancer

PURPOSE

A method that allows the determination of a prostate-specific antigen (PSA) cure after definitive management for prostate carcinoma with radiation therapy is presented and tested.

METHODS AND MATERIALS

The method involves a calculation of the patient's theoretical baseline PSA prior to the development of prostate cancer by using three serial rising PSA determinations obtained prior to the institution of therapy. The rate of rise of the PSA prior to therapy and the rate of decline of the PSA posttherapy are calculated, using an exponential model. Two criteria must be satisfied to define a PSA cure. First, the PSA nadir after treatment should be less than the calculated theoretical baseline PSA. Second, the rate of decline of PSA posttreatment should be greater than the rate of rise of the PSA prior to treatment.

RESULTS

Applying these two criteria to the patient data base (n = 16) at a median follow-up of 19 months enabled the accurate prediction of 6 out of 6 (100%) of patients with documented PSA failure and 7 out of 10 (70%) of patients without PSA failure. Therefore, despite short follow-up, all six patients with PSA failure were predicted. Further follow-up is needed to ascertain if the seven patients predicted to be cured will remain PSA failure free and if the three patients currently without PSA failure in whom the model predicts failure, will subsequently fail.

CONCLUSION

Therefore, using each patient's PSA history as the natural control may eliminate the error that is introduced with defining a PSA cure by using a single value for the PSA nadir at a specified time after radiation therapy.

The impact of the inclusion of endorectal coil magnetic resonance imaging in a multivariate analysis to predict clinically unsuspected extraprostatic cancer

BACKGROUND

The introduction of the endorectal coil magnetic resonance imaging (MRI) technique has improved the accuracy of preoperative staging for prostate cancer. This study quantifies the improvement in the ability to identify clinically unsuspected extraprostatic disease with the use of the endorectal coil MRI.

METHODS

A retrospective review of the pathologic findings of 347 patients with prostate cancer treated with a radical retropubic prostatectomy was performed. The preoperative clinical indicators including prostate specific antigen (PSA), clinical stage, Gleason score, and endorectal coil MRI data were employed in a multivariate analysis to identify patients who were at high risk for seminal vesicle invasion (SVI) or extracapsular extension (ECE). The sensitivity, specificity, and positive and negative predictive values for predicting SVI and ECE were calculated using the significant clinical indicators found on the multivariate analysis.

RESULTS

The clinical factors identified on multivariate analysis as significant predictors of SVI include the endorectal coil MRI data (P < 0.0001), PSA (P = 0.0096), and the Gleason score (P = 0.012). Endorectal coil MRI data (P < 0.0001), PSA (P = .0001), and Gleason score (P < .0001) were significant predictors of ECE. In the patient subgroup with PSA (> 10-20 ng/ml) and Gleason score of 5 to 7, the addition of the endorectal coil MRI data enabled an additional 71 and 27% of patients with SVI and ECE, respectively, to be correctly identified. These patients would have been missed based on the prediction obtained from the PSA and Gleason score alone.

CONCLUSIONS

The use of the endorectal coil magnetic resonance imaging data, in addition to prostate specific antigen and Gleason score, provides a more accurate prediction of the pathologic outcome of seminal vesicle invasion and extracapsular extension than the PSA and Gleason score alone for the patient subgroup with a PSA of greater than 10 to 20 ng/ml and Gleason score of 5 to 7.

Ultrastructure and motility of spermatozoa in macropodid and potoroidid marsupials

In order to gain some understanding of the significance of the morphological features of spermatozoa within the Macropodoidea, the motility of spermatozoa from two macropodids (Petrogale xanthopus and Dendrolagus matschiei) and the motility, number and distribution of spermatozoa from three potoroidids (Aepyprymnus rufescens, Bettongia penicillata and Potorous tridactylus) were examined. Sperm were collected by electro-ejaculation or from the cauda epididymides. Epididymides from the potoroidids were divided into 12 regions. One epididymidis per animal was fixed for light and transmission electron microscopy and, on the contralateral side, the number of sperm, their distribution and motility were determined. In general, spermatozoa of all five species differed markedly from one another in head and flagella dimensions. Spermatozoa from B. penicillata and P. tridactylus were significantly longer and broader and had a smaller acrosome relative to head length, and there was a radial displacement of dense fibres. They also progressed more rapidly in standard culture media. Spermatozoa from at least three species were able to alter their motility pattern in vitro as media viscosity increased. Sperm movement in all species appeared to be restricted to one plane and showed no evidence of rotation, whereas lateral head displacement was often pronounced; there was no evidence of a sinusoidal mode of progressive motility. Testicular and epididymal sperm numbers in A. rufescens and P. tridactylus were relatively high (approximately 17.5-50 x 10(6)). In A. rufescens, approximately 69% of all epididymal sperm were located in the cauda epididymidis compared with approximately 40% in P. tridactylus. This study demonstrated that marked radial displacement of the dense fibres is probably closely associated with the ability to develop a sinusoidal mode of progressive movement, and that this feature of the sperm tail structure is not just linked with sperm size. Sperm size, however, is associated with sperm velocity.

Dysplastic nevi as a melanoma risk factor in patients with familial melanoma

BACKGROUND

Familial melanoma has been associated with "clinically atypical moles" or "dysplastic nevi," (DN) which are markers for increased melanoma risk. In addition, melanomas in these kindreds present at a younger age, and tend to be multiple.

METHODS

Melanoma incidence rates were determined for 710 members of 311 melanoma families, defined as kindreds in which melanoma had occurred in two or more blood relatives. Patients were classified either clinically or histologically as expressing DN. Melanomas that occurred before the first examination were recorded, and patients were followed prospectively for new melanomas.

RESULTS

In prospective follow-up, the age-adjusted melanoma incidence rate was 1710/100,000 patient-years in family members with DN. In contrast, the rate was zero (no melanomas occurred) in family members without DN. For family members with DN, but without a history of melanoma, the age-adjusted incidence rate of melanoma was 413/100,000 patient-years, whereas the rate was 2779/100,000 patient-years in family members with DN and a history of melanoma.

CONCLUSIONS

Dysplastic nevi and a history of melanoma are strong risk factors for subsequent melanoma. Prognostic factors are greatly improved for patients with melanomas diagnosed in follow-up compared with the first two melanomas in each kindred. These findings warrant surveillance of individuals with DN who are members of familial melanoma kindreds.

A multivariable analysis of clinical factors predicting for pathological features associated with local failure after radical prostatectomy for prostate cancer

PURPOSE

A multivariate analysis is used to determine the predictive value of pretreatment clinical indicators on pathologic features associated with local failure after radical prostatectomy in patients with prostate cancer.

METHODS AND MATERIALS

A retrospective review of the pathologic findings of 235 patients with adenocarcinoma of the prostate treated between 1990 and 1993 with a radical retropubic prostatectomy was performed. The preoperative clinical data including the serum prostate specific antigen, clinical stage, Gleason sum, and endorectal magnetic resonance scan findings are used to identify patients prior to definitive treatment who would be at high risk for having pathologic features associated with local failure at radical prostatectomy. Outcome prediction curves are constructed from a logistic regression multivariate analysis displaying the probability of pathologic involvement of the seminal vesicle, extracapsular disease, or positive surgical margins as a function of the preoperative prostate specific antigen and Gleason sum for the cases when the endorectal magnetic resonance scan is positive, negative, or not included in the multivariate analysis.

RESULTS

Factors identified on multivariate analysis as significant predictors of seminal vesicle invasion include endorectal magnetic resonance scan findings (p < 0.0001), and preoperative prostate specific antigen (p = 0.017). Endorectal magnetic resonance scan findings (p = 0.0016), preoperative prostate specific antigen (p = 0.0002), and Gleason sum (p < 0.0001) were significant predictors of extracapsular extension and preoperative prostate specific antigen (p < 0.0001) and Gleason sum (p = 0.03) were significant predictors of disease extending to the margins of resection. Clinical stage was not a significant predictor (p > 0.05) of pathologic features associated with local failure on multivariate analysis. As a single modality, endorectal surface coil magnetic resonance imaging was accurate 93%, 69%, and 72% of the time for predicting seminal vesicle invasion, transcapsular disease, and final pathologic stage, respectively. Failure to recognize microscopic penetration of the capsule found at the time of pathologic evaluation in a prostate gland with a grossly intact capsule accounts for the majority (70%) of the staging inaccuracies.

CONCLUSIONS

The use of the endorectal surface coil magnetic resonance scan findings in conjunction with both the serum prostate specific antigen and Gleason sum improves the clinical accuracy of predicting those patients at high risk for clinically unsuspected extraprostatic disease. In particular, for the subgroup of patients with moderately elevated prostate specific antigen (> 10-20 ng/mL) and intermediate grade clinically organ confined prostate cancer [Gleason sum: 5-7] where the specificity of these tests to predict for occult extraprostatic disease is suboptimal, the additional information obtained from the endorectal coil magnetic resonance scan allows the physician to definitively subgroup these patients into low and high risk for seminal vesicle invasion or transcapsular disease.

Hypoxia-selective antitumor agents. 9. Structure-activity relationships for hypoxia-selective cytotoxicity among analogues of 5-[N,N-bis(2-chloroethyl)amino]-2,4-dinitrobenzamide

A series of analogues of the novel hypoxia-selective cytotoxin 5-[N,N-bis(2-chloroethyl)amino]-2,4-dinitrobenzamide (6) have been prepared and evaluated, in a search for compounds which retain high hypoxic selectivity but have increased potency and/or aqueous solubility. Several analogues with ionizable or dipolar carboxamide side chains showed improved solubility but generally had reduced cytotoxic potency and hypoxic selectivity. Modification of the mustard leaving groups or replacement of the carboxamide moiety provided some compounds with superior potency, but only the mixed chloro/mesylate mustard 20 provided a gain in potency relative to solubility while retaining the hypoxic selectivity of 6. These nitrogen mustards did not show the remarkable activity demonstrated by the related aziridine 7 [CB 1954, 5-(N-aziridinyl)- 2,4-dinitrobenzamide] in Walker 256 adenocarcinoma cells and are not efficient substrates for the DT-diaphorase which activates the latter compound by aerobic nitroreduction in Walker cells. Variations in hypoxic selectivity within the dinitrobenzamide mustards appear not to be due to differences in sensitivity to activation by this enzyme. Walker cells showed intermediate sensitivity to the mono(2-chloroethyl) analogue 26 but not to the related half-mustard 27, suggesting that the inhibition of DT-diaphorase activity is due to steric effects in the 5-position. The preferred compound overall with respect to solubility, potency, and in vitro hypoxic cell selectivity was the (dimethylamino)-ethyl derivative 11. DNA elution studies and comparison of the sensitivity of AA8 and UV4 cells to this compound indicated reductive activation to form a DNA cross-linking agent under hypoxia. Radiobiological studies indicated 11 to be equally active against both aerobic and hypoxic cells in KHT tumors. It is not clear whether this reflects efficient killing of aerobic cells as a result of diffusion of reduced metabolites from hypoxic regions or whether cytotoxicity in tumors is independent of hypoxia.

Two-color multiparametric method for flow cytometric DNA analysis. Standardization of spectral compensation

Spectral overlap of green fluorescence signals into the red detector (red-minus-green compensation) is one potential source of variation in two-color flow cytometric DNA analysis. Suboptimal compensation in a two-color propidium iodide (PI)/fluorescein isothiocyanate (FITC) system may be observed if compensation is adjusted using an inappropriate standard, or if changes to fluorescence detector high-voltage settings are made without corresponding readjustment of fluorescence compensation. To quantitate the influence of red-minus-green compensation on the quality of DNA histograms, data from 60 dual PI/cytokeratin (CK)-FITC stained carcinomas were acquired in parallel using two compensation standards: a PI/CK-FITC-stained T24 cell line calibrator overstained to achieve a high-intensity green fluorescence standard (HIGFS) with manually set compensation and automated compensation settings derived from commercial phycoerythrin/low intensity FITC beads (LIGF). Both compensation standards gave similar DNA hyperdiploidy results (DNA index, 1.1-2.8). However, LIGF standard yielded two falsely hypodiploid peaks (DNA index, .7 and .9). Eight left-skewed peaks became DNA diploid and symmetric, respectively, with the HIGFS. Use of HIGFS lowered the coefficient of variation percentage in 95% of cases, the greatest differences (maximum, 3.4%; mean, 1.81%) in tumors of highest intensity CK-FITC. The authors concluded that use of cell-based compensation standards (HIGFS) with intense green signals that mimic clinical tumor samples will avoid spurious aneuploidy and maximize resolution of near-diploid abnormalities.

Impact of improved irradiation technique, age, and lymph node sampling on the severe complication rate of surgically staged endometrial cancer patients: a multivariate analysis

PURPOSE

Limited information is available regarding factors that predispose to complications following postoperative pelvic radiotherapy (RT) for endometrial cancer. To address this issue, patients with clinically staged I/II endometrial cancer who received postoperative RT following total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH/BSO) with or without lymph node sampling (LNS) were studied.

PATIENTS AND METHODS

From 1960 through 1990, 235 patients with adenocarcinoma of the endometrium received postoperative RT after surgical staging. Multiple factors were evaluated to determine associations with severe complications. Pretreatment factors included age, stage, comorbidities. Treatment-related factors consisted of LNS, total RT dose, volume of RT fields, dose per fraction, total number of RT fields, number of RT fields treated per day, machine energy, and addition of vaginal implant.

RESULTS

The 5-year actuarial risk of a severe complication was 5.5%. Factors associated with an increased risk of complications in univariate analysis included age more than 65 years (11% v 2%), use of only one portal per day (40% v 3%), use of anteroposterior/posteroanterior fields (23% v 4%), total dose > or = 50 Gy (8% v 2%), and LNS (11% v 3%). In a multivariate analysis, only older age, LNS, and the use of one field per day were significant. Increased risks associated with a total dose > or 50 Gy and the anteroposterior/posteroanterior technique were entirely attributable to the use of one field per day. A subanalysis among patients who had adequate RT techniques (eg, multiple fields treated per day) showed a significant increase in complications (7% v 1%) for those with and without LNS, respectively.

CONCLUSIONS

Severe complications associated with adjuvant RT for endometrial cancer were increased among patients who were older or underwent LNS or received suboptimal RT technique. Pelvic RT using proper methods can be delivered with acceptable risks.

Determinants of subsequent home health care nursing service use by hospitalized patients with cancer

BACKGROUND

The authors examined the extent to which specific patient characteristics and length of hospital stay were capable of independently explaining the use of home health care nursing services by hospitalized patients with cancer after discharge.

METHODS

The current study represents a secondary analysis of a data set originally gathered to identify the home health care needs of patients with cancer. The sample involved 87 patients with cancer who received home health care after hospitalization and 43 patients who did not receive such services.

RESULTS

A logistic regression analysis indicated that home health care use was related to patient age, length of hospital stay, and level of symptom distress. Specifically, the likelihood of home health care use was found to increase among subjects older than 50 years of age, subjects with hospital stays of more than 7 days (apparently related to surgery), and those who experienced moderate to high levels of symptom distress.

CONCLUSIONS

The results indicate a need for home health care nurses to be skilled in the management of cancer symptoms and in the complex problems commonly experienced by the postsurgical patient with cancer.

Cloning, chromosomal localization, and functional expression of the alpha 1 subunit of the L-type voltage-dependent calcium channel from normal human heart

A unique structural variant of the cardiac L-type voltage-dependent calcium channel alpha 1 subunit cDNA was isolated from libraries derived from normal human heart mRNA. The deduced amino acid sequence shows significant homology to other calcium channel alpha 1 subunits. However, differences from the rabbit heart alpha 1 include a shortened N-terminus, a unique C-terminal insertion, and both forms of an alternatively spliced motif IV S3 region. The shortened N-terminus provides optimal access to consensus sequences thought to facilitate translation. Northern blot analysis revealed a single hybridizing mRNA species of 9.4 kb. The gene for the human heart alpha 1 subunit was localized specifically to the distal region of chromosome 12p13. The cloned alpha 1 subunit was expressed in Xenopus oocytes and single-channel analyses revealed native-like pharmacology and channel properties.