Retroviral transduction of intercellular adhesion molecule-1 enhances endothelial attachment of bladder cancer

An intercellular adhesion molecule-1 (ICAM-1)-negative RT4 transitional cell carcinoma (TCC) cell line was transduced with full-length ICAM-1 cDNA via a retroviral vector. Flow cytometry showed that a sense-oriented clone (S20) highly expressed ICAM-1 while an anti-sense clone (AS6) did not. Both S20 and AS6 bound with equal frequency (30 +/- 8.7% vs 30 +/- 9.4%) to unstimulated human umbilical vein endothelial cells (HUVECs) in cell attachment assays. However, when phorbol myristate acetate (PMA)-activated T lymphocytes, which express lymphocyte function-associated antigen-1 (LFA-1), were cocultured with tumor cells, attachment of S20 increased twofold (60 +/- 11.9%) but AS6 showed no change (32 +/- 11%). Blocking studies with anti-LFA-1 and anti-ICAM-1 monoclonal antibodies caused an inhibition of the attachment to baseline levels, demonstrating that the enhancement of S20 attachment was dependent upon the LFA-1/ICAM-1 interaction. Enhanced attachment of S20 was not inhibited by the addition of isotypic immunoglobulin G. These results suggest that LFA-1-expressing leukocytes may act as a bridge between the endothelium and tumor cells which express ICAM-1 and, thereby, enhance the potential for hematogenous metastasis.

Familial prostate cancer: a different disease?

PURPOSE

We analyzed the outcome after radical prostatectomy of patients with familial prostate cancer versus patients with sporadic prostate cancer.

MATERIALS AND METHODS

The study included 720 patients with prostate carcinoma who were treated with prostatectomy between 1987 and 1996. Patients were excluded from the study if they had received adjuvant or neoadjuvant treatment, or had no available pretreatment prostatic specific antigen (PSA) level, no available biopsy Gleason score, incomplete pathological information or no available followup PSA levels. The analysis was performed on 529 cases. Patients were considered to have a positive family history for prostate cancer when the index patient confirmed the diagnosis of prostate cancer in a first degree relative (brother or father). The outcomes of interest were biochemical relapse-free survival, local failure and distant metastases. Proportional hazards were used to analyze the effect of family history and confounding variables (that is age, stage, biopsy Gleason score, initial PSA levels, surgical specimen Gleason score, extracapsular extension, lymph node metastasis, seminal vesicle invasion and surgical margin involvement) on treatment outcome.

RESULTS

Median followup was 30 months. Of all cases 12% had a positive family history. Younger age was the only factor associated with positive family history, with 18% of patients younger than 65 years having a positive family history versus 6% of older patients (chi-square p <0.001). The 5-year biochemical relapse-free survival rate for the entire group was 64%. The 5-year biochemical relapse-free survival rates for patients with negative family history versus positive history were 66% and 46%, respectively (p = 0.001). A multivariate time-to-failure analysis using the proportional hazards model was performed based on family history, age (less than 65 versus 65 to 69 versus 70 or greater, initial PSA (10 or less versus greater than 10), biopsy Gleason score (6 or less versus 7 or greater), clinical T stage (T1-T2A versus T2B-C), prostatectomy specimen Gleason score (6 or less versus 7 or greater), extracapsular extension, seminal vesicle involvement, surgical margin involvement and lymph node involvement. After adjusting for the potential confounding factors, positive family history remained strongly associated with biochemical failure. The clinical failure rate for the entire group was 14%. The 5-year local failure rate was 7%, with positive surgical margins being the only independent predictor of local failure. The 5-year distant metastasis rate was 8%, with family history and initial PSA levels being independent predictors of distant relapse.

CONCLUSIONS

Our study suggests that patients with a familial prostate cancer have a higher likelihood of biochemical failure after radical prostatectomy than patients with sporadic cancer. This effect is independent of pretreatment or pathological factors. Our results suggest that the higher failure rates associated with familial prostate cancer are mainly secondary to higher distant relapse rates, and that familial prostate cancer may be more biologically aggressive than sporadic cancers.

Stage T1-2 prostate cancer with pretreatment prostate-specific antigen level < or = 10 ng/ml: radiation therapy or surgery?

PURPOSE

To detect differences in biochemical failure rates by treatment modality (radiation therapy or radical prostatectomy) in patients with early-stage prostate cancer presenting with pretreatment prostatic-specific antigen (PSA) levels < or = 10.0 ng/ml.

METHODS AND MATERIALS

A total of 1467 consecutive patients with prostate carcinoma were treated with either radiotherapy (RT) or radical prostatectomy (RP) between January 1987 and June 1996. Patients with the following were excluded from the present study: initial PSA (iPSA) level > 10 ng/ml (n = 444), clinical Stage T3 disease (n = 73), adjuvant or neoadjuvant treatment (n = 173), no available iPSA level (n = 31), no available biopsy Gleason score (GS) (n = 33), incomplete pathologic information (n = 16), and no available follow-up PSA levels (n = 90). The analysis was performed on 607 cases: 354 treated with RP and 253 with RT (median dose 68.4 Gy). The outcome of interest was biochemical relapse-free survival (bRFS), with biochemical relapse being defined as either a detectable PSA level after RP or elevation in PSA levels of > or = 1.0 ng/ml above the nadir after RT. Proportional hazards were used to analyze the effect of treatment modality and confounding variables (i.e., age, stage, biopsy GS, iPSA levels) on treatment outcome.

RESULTS

Seventy-nine percent of patients (n = 478) had clinical Stage T1 or T2A disease at presentation (RP vs. RT: 84% vs. 71%, p < 0.001). Twenty-one percent of patients (n = 127) had iPSA levels < or = 4 ng/ml (RP vs. RT: 24% vs. 17%, p = 0.027). Seventy-six percent of patients (n = 460) had biopsy GS < or = 6 (RP vs. RT: 79% vs. 71%, p = 0.014). The median follow-up time was 24 months (range 3-110). For the 607 patients, the 5-year bRFS rate was 76%. The 5-year RFS rates for RP versus RT were 76% versus 75%, respectively (p = 0.09). After adjustment for all confounding variables, iPSA levels (p < 0.001) and biopsy GS (p = 0.001) were the only independent predictors of relapse, whereas age, clinical stage, and treatment modality were not (p = 0.20; p = 0.09; and p = 0.10, respectively).

CONCLUSION

In patients with clinical Stage T1-2 prostate cancer and pretreatment PSA < or = 10 ng/ml, there is no difference in biochemical failure rates between those treated with radiation and those treated with surgery.

Combined nested reverse transcription-PCR assay for prostate-specific antigen and prostate-specific membrane antigen in detecting circulating prostatic cells

Accurate staging is an important issue in managing patients with prostate cancer. Current staging modalities are poor predictors for locally advanced disease. In the present study, we investigated the role of a peripheral blood-based, nested reverse transcription-PCR (RT-PCR) for prostate-specific antigen (PSA) and prostate-specific membrane antigen (PSM) in prostate cancer staging. Our nested RT-PCR could detect both PSA and PSM mRNA in one LNCaP cell diluted in 10(6) mononuclear cells. None of the controls, including patients with benign prostate hyperplasia, normal male subjects, and female subjects, were positive for either marker, confirming the assay's specificity for prostate cancer. In patients with bony metastases, 100% were positive by combined PSA/PSM assays (64% by PSA and 91% by PSM). In patients with clinically localized prostate cancer, 29% were positive by combined PSA/PSM assays (13% by PSA and 23% by PSM). The combined PSA/PSM assay is more sensitive than the PSA assay alone in detecting circulating prostatic cells (P = 0.0071). PSM is a more sensitive marker than PSA (P = 0.042). We also correlated preoperative nested RT-PCR results with pathological findings in prostatectomy patients. Nested RT-PCR for PSA/PSM has an odds ratio of 20 in predicting tumor extracapsular penetration (P = 0.017). These results indicate that a nested RT-PCR result may provide the staging information unavailable from other modalities, including the clinical stage, initial serum PSA, and Gleason score. Additional investigation is needed to determine the ultimate role of this assay in the management of patients with prostate cancer.

Family history of prostate cancer in patients with localized prostate cancer: an independent predictor of treatment outcome

PURPOSE

To determine if familial prostate cancer patients have a less favorable prognosis than patients with sporadic prostate cancer after treatment for localized disease with either radiotherapy (RT) or radical prostatectomy (RP).

PATIENTS AND METHODS

One thousand thirty-eight patients treated with either RT (n = 583) or RP (n = 455) were included in this analysis. These patients were noted as having a positive family history if they confirmed the diagnosis of prostate cancer in a first-degree relative. The outcome of interest was biochemical relapse-free survival (bRFS). We used proportional hazards to analyze the effect of the presence of family history and other potential confounding variables (ie, age, treatment modality, stage, biopsy Gleason sum [GS], and initial prostate-specific antigen [iPSA] levels) on treatment outcome.

RESULTS

Eleven percent of all patients had a positive family history. The 5-year bRFS rates for patients with negative and positive family histories were 52% and 29%, respectively (P < .001). The potential confounders with bRFS rates were iPSA levels, biopsy GS, and clinical tumor stage; treatment modality and age did not appear to be associated with outcome. After adjusting for potential confounders, family history of prostate cancer remained strongly associated with biochemical failure.

CONCLUSION

This is the first study to demonstrate that the presence of a family history of prostate cancer correlates with treatment outcome in a large unselected series of patients. Our findings suggest that familial prostate cancer may have a more aggressive course than nonfamilial prostate cancer, and that clinical and/or pathologic parameters may not adequately predict this course.

Stage T1-2 prostate cancer: a multivariate analysis of factors affecting biochemical and clinical failures after radical prostatectomy

PURPOSE

Prostate-specific antigen (PSA) is extensively used in case selection and outcome evaluation after treatment of clinically localized prostate cancer. Careful case selection can have a profound impact on pathologic findings and ultimate outcome. In addition, salvage treatment is frequently initiated at the time of biochemical relapse rather than clinical recurrence. Consequently, patterns of failure can be significantly altered compared to previous times when PSA was not available. To better understand the impact of PSA on pathologic findings, outcome, and salvage treatment, we reviewed our experience in the PSA era with clinical Stage T1-2 prostate cancer treated with radical prostatectomy.

METHODS AND MATERIALS

Between 1987 and 1993, 423 cases could be identified with clinical Stage T1-2 prostate cancer treated with radical prostatectomy. The distribution of cases by pretreatment PSA levels was as follows: < or = 4 ng/ml (18%), 4-10 ng/ml (42%), 10-20 ng/ml (21%), > 20 ng/ml (14%), and unknown (5%). The median pretreatment PSA level for the entire group was 8.0 ng/ml. Sixteen patients received adjuvant or neoadjuvant androgen suppression and 13 received postoperative radiotherapy. Only 31 patients (7%) had pathologically positive pelvic lymph nodes. The overall margin involvement rate was 46%. Fifty-three percent of patients had surgical Gleason scores > or = 7, and 65% had extracapsular extension. The median follow-up time was 41 months.

RESULTS

The projected overall survival at 7 years after surgery was 90%. The 5-year clinical relapse-free survival rate was 84%. At 5 years, the local control and distant failure rates were 92% and 91%, respectively. Biochemical relapse was defined as a detectable or rising PSA level after prostatectomy. The 5-year biochemical relapse-free survival (bRFS) rate was 59%. The 5-year RFS was 88% in patients with preoperative PSA levels < or = 4, 62% for 4-10, 48% for 10-20, and 31% for > 20. Combining the two independent preoperative variables, iPSA and biopsy GS (bGS), two risks groups were defined: low risk [initial PSA (iPSA) levels < or = 10.0 and bGS < or = 6] and high risk (iPSA levels > 10.0 ng/ml or bGS > or = 7). The 5-year bRFS rate for the low-risk cases was 81% vs. 40% for high-risk cases (p < 0.001). On multivariate analysis, three factors independently predicted biochemical relapse: iPSA levels (p = 0.005), Gleason score from the surgical specimen (sGS) (p = 0.002), and positive surgical margins (p < or = 0.001). The 5-year bRFS rates for margin positive vs. margin negative patients were 37% vs. 78%, respectively. The 5-year bRFS rates for GS > or = 7 vs. GS > or = 6 were 42% vs. 80%, respectively. All clinical relapses were accompanied by a rise in PSA. In patients who manifested biochemical failure followed by a clinical failure, the median interval between the PSA rise and clinical failure was 19 months (range 7-71). Margin involvement was the only independent predictor of local failure (p = 0.019). The 5-year local failure-free survival for negative margin cases was 96% vs. 87% for positive margin cases (p = 0.012). Lymph node (LN) involvement and high-risk group were the two independent predictors of distant failure. The 5-year distant failure-free survival for negative LN cases was 94% vs. 67% for positive LN cases (p < 0.001). The 5-year distant failure-free survival for low-risk cases was 97% vs. 85% for high-risk cases (p = 0.005). For the 124 patients failing biochemically, 85 were observed and 39 were treated either with radiation or androgen deprivation. With a median follow-up of 32 months, the clinical disease relapse-free survival was 79% for the treated patients vs. only 32% for the patients observed (p < 0.001).

CONCLUSION

Pretreatment PSA is the most potent clinical factor independently predicting biochemical relapse, thereby allowing markedly better case selection. Achieving negative margins, even in relatively advanced disease, provides excellent lon

Indications for excluding the seminal vesicles when treating clinically localized prostatic adenocarcinoma with radiotherapy alone

PURPOSE

The indications for treating the seminal vesicles (SV) in patients with clinically localized carcinoma of the prostate are controversial. We sought to define subgroups of patients in whom coverage could be avoided, using pretreatment prostate specific antigen (PSA) values and the Gleason score. Because the rectum is the major dose-limiting structure, we also measured the extent of rectal sparing achieved by excluding the SV from external beam treatment fields.

METHODS AND MATERIALS

We retrospectively studied lateral x-ray simulation films of 43 patients treated with standard four-field radiotherapy and dose-volume histograms of eight patients treated with conformal radiotherapy. The rectal surface areas were measured and the volumes were calculated including and excluding the SV. The pathology reports of patients treated with radical prostatectomy alone between 1987 and 1993 were reviewed. Patients without preoperative PSA levels or biopsy Gleason scores, or who received neoadjuvant hormonal therapy were excluded. Of the 368 remaining patients, 66 (18%) had preoperative PSA levels < or = 4, 172 (47%) had PSA levels 4-10, and 130 (35%) had PSA levels > 10. The Gleason score was < or = 6 in 269 (73%), and 99 (27%) had a score > or = 7.

RESULTS

The reduction in the total irradiated rectal areas to full doses when the SV were excluded ranged from 5 to 67% in individual patients (median, 44%). The median reduction in the irradiated rectal volumes to 50% of the prescribed dose, as determined by dose-volume histograms, was 51% (range: 37-76%). The median reduction in bladder volumes was 9% (range: 6%-15%). The incidence of SV involvement was 19% (70 out of 368). Patients with normal PSA levels (< or = 4 ng/mL) had a 3% (2 out of 66) rate of SV involvement. Patients with PSA levels between 4-10 ng/mL had a 8% (10 out of 126) rate of SV involvement. All other cases had at least 20% rate of SV involvement, with a combined rate of 33%. Using a cutoff of 15%, two low risk groups were identified: all patients with PSA levels < or = 4, and patients with PSA 4-10 and Gleason score < or = 6. These constituted 52% (192 out of 368) of all patients. Overall, the low-risk patients had a 6% (12 out of 192) incidence of SV involvement vs. 33% (58 out of 176) for the high risk patients (p < or = .001).

CONCLUSIONS

Excluding the SV from the treatment field can significantly reduce (40%-50%) the volume of irradiated rectum. Our data confirm that pretreatment PSA levels and Gleason scores can be effectively used to define subgroups of patients in whom SV irradiation can be avoided. We propose excluding the SV in all patients with PSA levels < or = 4, and patients with PSA levels 4-10 and a Gleason score < or = 6.

Molecular regulation of intercellular adhesion molecule 1 (ICAM-1) expression in renal cell carcinoma

Intercellular adhesion molecule-1 (ICAM-1) mediates two important functional aspects of tumor biology, namely enhancement of tumor metastasis and mediation of host defense mechanisms such as lymphocyte-mediated tumor cytotoxicity. Since ICAM-1 is expressed by most renal cell carcinomas (RCC), the regulation of ICAM-1 expression is important in understanding the biological behavior of RCC. We report an investigation on ICAM-1 expression and molecular regulation by cytokines and protein kinase C activator on RCC cell lines. Of the various cytokines, tumor necrosis factor alpha (TNF alpha), interferon-gamma (IFN gamma), and phorbol myristate acetate (PMA) strongly upregulated ICAM-1 protein expression on RCC. The kinetics of ICAM-1 message induction was studied by Northern analysis of total RNA extracted from RCC and normal kidney proximal tubular (NKPT) cells. Time course studies showed that ICAM-1 mRNA was upregulated by INF gamma, TNF alpha, and PMA, plateaued after 2 h, and remained increased for up to 24 h. Although ICAM-1 mRNA in NKPT cells was upregulated by these cytokines, their messages returned to basal levels after 24 h. ICAM-1 mRNA stability assays showed that both unstimulated and stimulated RCC cells had very stable ICAM-1 mRNA up to 24 h. In order to investigate whether increased gene transcription contributes to ICAM-1 upregulation, RCC cells were treated with TNF alpha, IFN gamma, or PMA with or without simultaneous addition of actinomycin D. ICAM-1 message induction-blocking studies suggested that primary upregulation of ICAM-1 mRNA may be caused by transcriptional upregulation. These results suggest that long-lasting ICAM-1 message upregulation in response to cytokines or PMA may be due to transcriptional upregulation in the early phase and stabilization of ICAM-1 message in the later phase (after 4 h). These observations suggest that RCC may lack the normal downregulatory mechanisms which control ICAM-1 expression and may explain the high frequency of ICAM-1 expression observed on primary human RCC.

The Le Bag orthotopic urinary diversion

PURPOSE

We reviewed our experience with Le Bag orthotopic urinary diversion in 38 cases.

MATERIALS AND METHODS

Between April 1990 and January 1995, 38 men underwent radical cystectomy and Le Bag urinary diversion for treatment of bladder cancer. Approximately 20 cm. each of detubularized ileum and cecum were used to construct the pouch. A total of 22 pouches was fashioned with absorbable staples. In 21 cases freely refluxing Bricker ureterointestinal anastomoses were used.

RESULTS

There was no significant difference in major complication rates in the hand sewn versus stapled anastomosis groups, and there were no complications specifically related to the use of staples. There were 3 episodes of febrile urinary tract infection: 2 in the Bricker group and 1 in the tunneled anastomosis group. There was no significant difference between the 2 groups with respect to ureteral obstruction. The daytime continence rate was 91%, and 80% of the patients are completely dry or have only mild incontinence at night. Most patients had mild hyperchloremic metabolic acidosis postoperatively as evidenced by a decrease in median serum bicarbonate level (28 versus 24 mmol./l.). This difference appears to be related to pouch length (r = 0.58, p = 0.0002).

CONCLUSIONS

We conclude that the Le Bag technique is a technically feasible form of urinary diversion with functional results similar to other forms of orthotopic diversion. Use of absorbable staples simplifies pouch construction without increasing complications. This form of urinary diversion is associated with hyperchloremic metabolic acidosis, which is related to pouch length.

Maintaining quality of care and patient satisfaction with radical prostatectomy in the era of cost containment

OBJECTIVES

To determine the effect of shortened hospital stay after radical retropubic prostatectomy on costs, adverse surgical outcomes, and patient satisfaction.

METHODS

The effect of changes in preoperative counseling, perioperative care, and analgesic management on hospital length of stay; mean cost per case and cost per hospital day; and 30-day complication, hospital readmission, and mortality rates were analyzed for a consecutive sample of 374 patients undergoing radical prostatectomy between July 1989 and November 1995. Satisfaction with length of stay, analgesic regimen, and surgical outcome was assessed in a random subset of 150 patients by anonymous questionnaire.

RESULTS

Length of stay (LOS) was shortened from a median 7 to 2 nights after surgery during the study (P < 0.0001), whereas the acute complication, 30-day readmission, and 30-day mortality rates remained constant. Reducing LOS resulted in a 43% decrease in mean cost per case while mean cost per day increased by 22% to 35%. Overall patient satisfaction was high, with 83.5% of patients rating LOS as "just right" and 89.2% reporting they were "satisfied" or "very satisfied" with their pain control after surgery.

CONCLUSIONS

Shortened LOS after radical retropubic prostatectomy can be accomplished safely and can meet with high levels of patient satisfaction while significantly reducing hospital-related costs. The potential for further incremental reductions in cost with reductions in LOS to less than 2 nights appears to be small, and future efforts at cost reduction for this procedure should center on decreasing the intensity of care during hospitalization.

Creation of the LeBag orthotopic bladder using absorbable staples

Absorbable stapling devices have been described by several groups for the creation of continent urinary diversions. Experience with these devices in the creation of the LeBag ileocecal orthotopic pouch is described. Use of the staplers simplifies pouch construction and yields functional results similar to hand-sewn reservoirs.

Biology of metastasis and its clinical implications: renal-cell cancer

The ability of malignant cells to metastasize from a primary tumor and from secondary lesions is the most life-threatening aspect of cancer. Reported factors enabling this metastatic cascade to occur include reduced levels or an absence of cell-adhesion molecules, proteolytic enzymes, and angiogenic factors. The metastatic cell must also escape immune destruction. Defects in lymphocytes from renal-cell carcinoma patients with abnormalities in their proliferation, receptor structure, and signal transduction are present. The pathologic stage has been the most consistent single prognostic factor to influence survival. Other factors include the performance status, age, and histology grade and may include serum interleukin 6 (IL-6) levels and ploidy. Current and future therapeutic approaches that interfere with this metastatic cascade include applications of cytokines, antiadhesion-molecule strategies, and antisense nucleotides. An improvement in our understanding of the biology of metastases is essential before a significant increase in the cure rate can be realized.

Intraoperative evaluation of renal cell carcinoma: a prospective study of the role of ultrasonography and histopathological frozen sections

PURPOSE

Nephron sparing surgery is being performed increasingly for treatment of renal cell carcinoma, including in select patients with a normal contralateral kidney. The number of tumors in the involved kidney (single versus multiple) and presence or absence of perinephric fat involvement (pathological stage T1 to 2 versus T3A) are important prognostic factors. In a prospective study we evaluated the accuracy of intraoperative histopathological frozen section analysis of renal capsular biopsies for assessing local tumor stage, and the accuracy of intraoperative ultrasonography for assessing tumor focality.

MATERIALS AND METHODS

Intraoperative frozen section biopsies and ultrasonography were compared with information obtained from preoperative computerized tomography (CT), intraoperative inspection of the kidney by the surgeon and permanent histopathological specimens.

RESULTS

We evaluated 99 patients (102 kidneys) with localized sold renal masses undergoing either radical nephrectomy (48) or nephron sparing surgery (54). Final pathological analysis revealed 95 renal cell carcinomas (stage T3A in 24), 6 oncocytomas and 1 angiomyolipoma. Multiple tumors were detected in 18 of 102 kidneys overall. Frozen section analysis identified 87% of the stage T3A lesions with no false-positive results, compared to CT, which only identified 67%. Ultrasonography identified 14 of 18 multifocal tumors (78%) and was not more accurate than the combination of CT and intraoperative inspection. However, during nephron sparing surgery ultrasonography was useful to localize the intrarenal extent of tumors (17 cases).

CONCLUSIONS

Our results clarify the role of intraoperative ultrasonography and frozen section analysis in patients undergoing nephron sparing surgery for renal cell carcinoma. Frozen section analysis may be useful in select patients with small peripheral tumors who are under consideration for elective nephron sparing surgery.

The influence of cytokines on the adhesion of renal cancer cells to endothelium

PURPOSE

The development of tumor metastasis requires direct adhesive interactions between tumor cells and vascular endothelium. We examined the adherence of renal cell carcinoma (RCC) lines to endothelium after stimulation with different cytokines that induce expression of the vascular adhesion molecules endothelial leukocyte adhesion molecule (ELAM)-1, vascular cell adhesion molecule (VCAM)-1 and intercellular adhesion molecule (ICAM)-1,

MATERIALS AND METHODS

Human umbilical vein endothelial cells (HUVEC) were used to determine the adhesion of the RCC lines CCF-RC1, 2 and 7 to endothelium. Expression of cell adhesion molecules (CAM) on HUVEC and RCC lines was measured with immunoflowcytometry.

RESULTS

Stimulation of HUVEC with rIl-1 beta, rTNF-alpha, or PMA resulted in a time-dependent 1.4- to 2.9-fold increase of RCC adhesion to HUVEC. Significant increased tumor cell binding was observed after 4 hours and paralleled the time-dependent induction of ELAM-1 and VCAM-1. Immunocytometry demonstrated the presence of the ligands sialyl Lewis X and VLA-4 on RCC, and blocking studies with monoclonal antibodies directed against tumor cell-endothelial interactions mediated by VCAM-1/VLA-4 and ELAM-1/sialyl Lewis X demonstrated marked inhibition of tumor cell adherence to cytokine-stimulated HUVEC.

CONCLUSIONS

This study demonstrates that cytokine-induced increases in RCC adherence to HUVEC are mediated in part by VCAM-1/VLA-4 and ELAM-1/sialyl Lewis X interactions and suggest that these molecules may play an important role in the ability of RCC to metastasize.

Testicular cancer in association with developmental renal anomalies and hypospadias

OBJECTIVES

To characterize the clinical, pathologic, and genetic aspects of patients with a previously undescribed phenotype of testicular germ cell tumors associated with renal hypoplasia or agenesis and urethral hypospadias.

METHODS

Review of clinical and pathologic findings and genetic analysis of constitutional and tumor DNA for mutations of the Wilms' tumor suppressor gene (WT1).

RESULTS

Clinical findings suggest that this phenotype is distinct from other syndromes associated with renal anomalies and that the associated testicular tumors are histologically and clinically similar to those that occur sporadically. No karyotypic abnormalities, loss of heterozygosity, or mutations in the zinc finger domains (exons 7-10) of WT1 were observed in 5 patients with this phenotype.

CONCLUSIONS

The phenotype of testicular germ cell tumor, developmental renal anomalies, and urethral hypospadias constitutes a discrete syndrome caused by a gene distinct from WT1.

Hormone therapy for prostate cancer: a topical perspective

Evolution of the roles proposed for antiandrogenic agents in prostatic disease has been rapid. Since the early suggestions by Labrie and his colleagues that the nonsteroidal antiandrogen flutamide could be used in combination with medical or surgical castration to provide superior care for patients with metastatic prostate cancer, and subsequent substantiation of the theory in a number of clinical trials, we have observed an increasing tendency to test the use of antiandrogens (alone or in combination with other interventions) earlier in the disease process. At least in part, this tendency is a consequence of our increased ability to detect prostate cancer earlier in the disease process. At the present time, flutamide is the only nonsteroidal antiandrogen available for the treatment of prostate cancer in general clinical practice in the United States. However, two other nonsteroidal antiandrogens currently await decisions on their efficacy and safety by the Food and Drug Administration: nilutamide and bicalutamide. Will either of these agents offer clinical benefits beyond those offered by flutamide? Will the safety, activity, and dosing profiles of the nonsteroidal antiandrogens allow us to use them to treat even earlier stages of prostate cancer and perhaps even prostatic intraepithelial dysplasia in patients at high risk of prostate cancer? What are the potential future roles for bicalutamide and other nonsteroidal antiandrogens in the management of prostatic disorders? This article will attempt to lay out the key questions that await definitive answers as we expand our understanding of the possible future roles for antiandrogens in the management of prostate cancer and related conditions.

Bilateral Krukenberg tumors due to appendiceal mucinous carcinoid

A case of mucinous carcinoid of the appendix presenting as bilateral Krukenberg tumors is reported. The patient, a 66-year-old woman, presented with vaginal spotting and lower abdominal pain of 2 months' duration. Sonography revealed a 5-cm ovarian mass. At operation a frozen section revealed metastatic mucinous carcinoid of the left ovary. Twenty months after radical surgery the patient died from abdominal carcinomatosis despite 4,500 cGy of abdominal radiation and multiagent chemotherapy. Primary ovarian carcinoid is invariably unilateral, whereas metastatic carcinoid to the ovary is almost always bilateral. The mucinous subtype appears to be more aggressive whether primary or metastatic.

An update on prostate cancer

As screening for prostate cancer has become more common, the issues surrounding its diagnosis and treatment have grown more complex. This review surveys recent advances and controversies, including definition of risk factors, the role of screening, and current treatment strategies.

Open pelvic lymph node dissection for prostate cancer: a reassessment

OBJECTIVES

To provide a risk-to-benefit analysis of open staging pelvic lymph node dissection (PLND) for prostate cancer.

METHODS

The medical records of all patients presenting with prostate cancer from July 1989 to April 1994 were reviewed. A total of 245 patients with clinically localized disease were selected to undergo radical retropubic prostatectomy (RRP) preceded by open PLND. Univariate and multivariate analyses were performed to evaluate the predictive value of the preoperative serum prostate-specific antigen (PSA) concentration, clinical stage, and Gleason score with regard to final nodal status. The cost and morbidity associated with PLND in the setting of RRP was also defined.

RESULTS

Overall, only 16 patients (6.5%) had lymph node metastases. Lymph node involvement correlated significantly with elevated serum PSA values (P = 0.0001), high Gleason score (P = 0.0022), and advanced clinical stage (P = 0.0001). Lymph node metastases were particularly uncommon in patients with nonpalpable tumors (1 of 67 [1.5%]), PSA values less than 10 (2 of 154 [1.3%]), and Gleason score less than 6 (1 of 26 [3.8%]). Overall, 179 patients (73.1%) presented with at least one or more of these favorable characteristics, and only 4 (2.2%) had lymph node involvement. Complications related to the lymphadenectomy occurred in 10 patients (4.1%). The cost per metastasis diagnosed in patients with low-risk characteristics was approximatley $43,600.

CONCLUSIONS

An open staging PLND may no longer be justified on a routine basis in patients undergoing radical retropubic prostatectomy.

Expression of cell adhesion molecules in an established and characterized new human renal cell cancer line, CCF-RC7

In order to investigate the importance of cell adhesion molecules (CAMs) in renal cell carcinoma (RCC), a cell line, designated as CCF-RC7, was established from a human RCC of the clear cell type. CCF-RC7 was passaged over 50 times in vitro for 3 1/2 years. The cell line has an epithelial morphology and a doubling time of 30 h, forming colonies in soft agar with an average efficiency of 10.4% and producing clear cell tumors in athymic nude mice. CCF-RC7 cells have an aneuploid-hypotetraploid karyotype with a modal chromosome number of 82 and rearrangements in chromosomes 9, 12 and 14. Immunohistochemical and flow immunocytometric analyses revealed high expression of ICAM-1 (CD54), and Hermes antigen (CD44), which was significantly upregulated by cytokine and PMA treatment. VLA-4 was expressed on approximately 20% of tumor cells and could not be altered by cytokine or PMA stimulation. High expression of sialyl Lewis X was also demonstrated by immunohistological examination. This newly characterized cell line will serve as a useful model for the study of CAMs during hematogenous metastasis and host defense mechanisms in human RCC.

Opportunistic infections of the central nervous system in children with HIV infection: report of 9 autopsy cases and review of literature

Central nervous system (CNS) abnormalities attributed to direct effects of HIV infection are seen in most of children with acquired immunodeficiency syndrome (AIDS). Secondary CNS infections with opportunistic and common pathogens are infrequent in this age group. We report 9 cases of opportunistic infection of the CNS found among 65 autopsy cases of pediatric AIDS. These included 4 cases of cytomegalovirus (CMV) infection, 1 of which was associated with aspergillosis, and 2 cases of candidiasis, 1 of which coexisted with Mycobacterium avium intracellulare (MAI) infection. There were also 2 cases of leptomeningitis, 1 due to Mycobacterium tuberculosis (MTB) and the other to Cryptococcus neoformans. In 1 child progressive multifocal leukoencephalopathy (PML) coexisted with mycotic encephalitis caused by an Aspergillus sp.