Long-term assessment of renal function following nephrectomy for stage I renal carcinoma

OBJECTIVE

To evaluate the impact of nephrectomy on renal function in people who are potential candidates for nephron sparing surgery, i.e. partial nephrectomy.

PATIENTS AND METHODS

A retrospective analysis was carried out of 109 patients (35 women, 74 men) who had undergone a nephrectomy for stage I renal carcinoma at the University of Michigan between 1960 and 1979. All patients had a functioning contralateral kidney and had undergone at least one post-operative serum creatinine evaluation. Statistical analysis was by Pearson's correlation coefficient.

RESULTS

One individual developed a transitional cell carcinoma in the remaining renal pelvis and was treated with nephroureterectomy. No other patient progressed to dialysis. Five patients had post-operative serum creatinine levels from 221 to 354 mumol/l, one of whom had undergone both a nephrectomy and a partial nephrectomy for bilateral renal tumours. The remaining four had renal disease including diabetes, hypertension, pyelonephritis and renal artery stenosis. There was a strong association between pre-operative and post-operative serum creatinine values.

CONCLUSION

Patients with low stage renal tumours and a normal contralateral kidney are at low risk of progression to renal failure.

Decreased connexin expression and intercellular communication in human bladder cancer cells

Connexins make up a gene family encoding proteins that form intercellular channels known as gap junctions. Decreases in connexin expression and loss of intercellular communication have been associated with the malignant phenotype in some animal and human cells. The expression of connexin 26 and 43 mRNA was evaluated in cultured normal and malignant human urothelial cells. The normal urothelial cells were shown by Northern analysis to express both connexins. Increased confluence of the cultured normal human urothelial cells was associated with upregulation of connexin 26 mRNA. Connexin 26 mRNA expression was decreased in the bladder cancer cells. Using a human connexin 26 complementary DNA probe, nuclear run-on assays demonstrated that the decreased expression in the cancer cells was due to a failure of transcription. Southern blot analysis did not reveal any alterations in the genomic DNA. Assessment of gap junction function by scrape loading of lucifer yellow demonstrated dye transfer in normal urothelial cells but not in bladder cancer cells. Downregulation of connexin 26 mRNA was associated with functional loss of intercellular communication in the human bladder cancer cells. Connexin 43 expression varied considerably in the bladder cancer cell lines and did not correlate with dye transfer of lucifer yellow. These data suggest that alterations in the regulation of connexin 26 expression are associated with and may contribute to the malignant phenotype in bladder cancer.

Expression of the VLA beta 1 integrin family in bladder cancer

Integrins are a family of transmembrane heterodimers, many of which function as receptors for extracellular matrix molecules and play a role in adherence to and motility on matrix components. Because of these functions, integrins are suspected of participating in metastatic processes. We investigated the expression of beta 1 integrins in human bladder cancer cell lines and tissues. Expression of beta 1 integrins on cultured bladder cancer cell lines was evaluated by flow cytometry, of 8 cell lines tested, alpha 1 was found in 4, alpha 2 and alpha 3 in all 8, alpha 4 in 1, and alpha 5 in 3. These results were in sharp contrast to the expression detected by immunostaining tissues containing normal urothelium and low stage (noninvasive) and high stage (invasive) bladder cancers. All normal urothelial tissues tested expressed alpha 2 and alpha 3 and none expressed alpha 1, alpha 4, or alpha 5. Similarly, a majority (77%) of low stage (noninvasive) bladder cancers stained positively for alpha 3, whereas only 6 of 13 expressed alpha 2 and none expressed alpha 1, alpha 4, or alpha 5. Among invasive bladder cancers, alpha 1 was detected in 7%, alpha 2 in 24%, alpha 3 in 68%, alpha 5 in 10%, and alpha 4 was not found in any samples. These results indicate that integrin expression in cultured human bladder cancer cell lines does not represent expression observed in tissue samples and may reflect adaption to or selection during tissue culture conditions. A progressive loss of alpha 2 expression is seen from normal urothelial cells through invasive bladder cancers. This loss may contribute to an invasive phenotype by a loss of the cell-cell adherence function mediated by the alpha 2 beta 1 and alpha 3 beta 1 integrins.

Loss of co-localization of alpha 6 beta 4 integrin and collagen VII in bladder cancer

In normal epithelial cells, the alpha 6 beta 4 integrin co-localizes with the hemidesmosomal anchoring complex on the basolateral surface of basal cells. We studied the co-expression of alpha 6 beta 4 integrin with collagen VII, a component of the hemidesmosomal anchoring complex, in normal bladder tissues and in bladder cancers. In normal bladder, the alpha 6 beta 4 integrin co-localized with collagen VII at the junction of the basolateral surface of the basal urothelial cells and the lamina propria. In five of six noninvasive bladder cancers, the localization of collagen VII remained unchanged, found at the junction of the basal cells and the papillary connective tissue. However, in these tumors the alpha 6 beta 4 expression was not polarized and was expressed on suprabasal as well as basal cells. In invasive bladder cancers, the majority (25 of 30) showed either loss of alpha 6 beta 4 and/or collagen VII expression or showed a lack of co-localization of alpha 6 beta 4 and collagen VII. Our results show derangement of the co-localization of these two components of the hemidesmosomal anchoring complex is a consistent event in bladder cancer. Furthermore, the degree of derangement increases in invasive cancers. Loss of co-expression and co-localization of alpha 6 beta 4 and collagen VII may predispose cancer cells to local invasion and may facilitate metastasis as well.

Acquired crossed renal ectopia secondary to a giant renal cyst

We report a case of contralateral renal displacement due to a giant ipsilateral renal cyst. Drainage and partial excision of the cyst was followed by return of the kidney and liver to their normal positions. Incidentally, a small focus of renal cell carcinoma was found after pathologic examination of the cyst wall. The relevant literature is reviewed.

Expression of multidrug resistance gene product (P-glycoprotein) in transitional cell carcinomas of the upper urinary tract

We assessed the expression of P-glycoprotein, the product of the multidrug resistance gene, in 107 specimens from patients with transitional cell carcinoma of the upper urinary tract, using an immunohistochemical method with a polyclonal antibody. P-glycoprotein was expressed in 28 of 107 (26%) specimens. While P-glycoprotein expression was not related to the grade or stage of these tumors, the incidence of P-glycoprotein in specimens with tumors which coexisted in renal pelvic and ureter is significantly higher than those with either renal pelvic or ureter tumor alone. In the patients with advanced upper urinary tract tumor who had adjuvant chemotherapy including at least one P-glycoprotein-transported drug (mdr regimen), overall survival of patients with P-glycoprotein-positive tumor was significantly shorter than that of patients with negative tumor. This pilot study demonstrates that P-glycoprotein can be expressed in one fourth of transitional cell carcinomas of the upper urinary tract and that P-glycoprotein expression serves as a prognostic indicator in patients with these tumors who are treated with mdr regimens.

P-glycoprotein expression in bladder cancer

Multi-drug resistance is a phenomenon by which tumor cells express resistance to a variety of chemically unrelated chemotherapeutic drugs. The classical form of multi-drug resistance is mediated through the expression of P-glycoprotein, which acts as an energy dependent drug efflux pump. P-glycoprotein expression was evaluated in 29 cystectomy specimens from patients with bladder cancer with no prior exposure to chemotherapeutic drugs, and in bladder biopsies from 9 subjects before treatment with intravesical doxorubicin. Furthermore, the strategy of circumvention of P-glycoprotein-mediated resistance using the combination of doxorubicin and verapamil intravesically was tested in 5 patients. P-glycoprotein was expressed in 75% of the cystectomy specimens. In the doxorubicin treated patients no correlation was noted between P-glycoprotein expression on the initial tumors and subsequent response to doxorubicin. The pilot trial of verapamil and doxorubicin was well tolerated but did not suggest increased efficacy of this combination. P-glycoprotein can be expressed on bladder cancer cells without prior chemotherapy. The role of P-glycoprotein mediated multi-drug resistance in bladder cancer treatment failure remains to be defined.

Localization of the prostatic apex for radiation therapy using implanted markers

PURPOSE

This report concentrates on the localization of the prostatic apex using implantable markers, and a comparison to localization defined by computed tomography (CT) and retrograde urethrography.

METHODS AND MATERIALS

Fifteen patients were entered into a prospective trial and scheduled to undergo (a) pelvic CT, (b) retrograde urethrogram, and (c) transrectal ultrasound with placement of radiodense markers. Three markers were implanted: one was placed at the trapezoid area (prostatic apex), and the others placed lateral to the base of each seminal vesicle. The retrograde urethrogram was performed using standard technique. The superior-inferior distance between the apex identified by the marker placed at the prostatic apex and the other studies was measured.

RESULTS

CT and urethrogram overestimated the inferior extent of the prostatic apex when compared to the location as defined by the implanted marker. With CT, the average distance from the marker to the CT-defined apex was 0.6 cm (95% C.I.--0.4-0.8 cm). With urethrogram, the average distance from the marker to the urethrogram-defined apex was 1.3 cm (95% C.I.--0.7-1.9 cm). When CT and urethrogram were compared, CT was more accurate in identifying the prostatic apex.

CONCLUSION

Under ultrasound guidance, radiodense markers have been implanted into the prostate. This has revealed that the apex is localized superior to the apical margin as defined by retrograde urethrogram and CT, and that CT may be more accurate than retrograde urethrogram. In addition, the placement of multiple markers yields spatial information on prostatic position that can be extracted from megavoltage portal images.

Pelvic CT findings after radical prostatectomy

OBJECTIVE AND METHODS

To evaluate the spectrum of pelvic CT findings in patients who have had radical prostatectomy, we retrospectively evaluated the pelvic CT of 17 patients after surgery for prostate cancer. All patients were thought to be clinically free of local recurrence of carcinoma.

RESULTS

The bladder base was retropubic in 100%, the levator sling was well delineated in its entirety in only 88%, and fat was clearly demonstrated between the rectum and bladder base in only 44%. Unsuspected findings in this group included soft tissue density structures in the resected bed of the seminal vesicles (88%) and a transversely oriented, soft tissue density bar between the bladder base and rectum (53%). A variety of symmetric abnormalities are commonly seen on postprostatectomy pelvic CT.

CONCLUSION

Seminal vesical-like soft tissue structures are routinely visualized, and a horizontal bar of soft tissue in the rectovesical space is commonly demonstrated. These structures should not be confused with local tumor recurrence.

Evaluation of multiple drug resistance in human bladder cancer cell lines

We evaluated multidrug resistance (MDR) in human bladder cancer cell lines UM-UC-2, UM-UC-6, UM-UC-9 and the UM-UC-6dox subline induced to doxorubicin resistance by in vitro doxorubicin exposure. We compared the profile of multidrug resistance in these cell lines with that of the UM-UC-3 human renal cancer cell line. Of these cell lines, UM-UC-2 was most sensitive to both doxorubicin and etoposide, while UM-UC-6, UM-UC-9 and UM-UC-3 showed 1.5-, 2.1-, and 5.4-fold more resistance to doxorubicin than UM-UC-2 cells. These cell lines were also more resistant to etoposide than UM-UC-2. Addition of verapamil at 10 microM. reduced the doxorubicin resistance in UM-UC-6 and UM-UC-6dox cells, but UM-UC-9 cells showed little change in doxorubicin sensitivity in the presence of verapamil. In a model of intravesical (short-term) treatment verapamil increased the doxorubicin sensitivity of UM-UC-6dox but not that of UM-UC-6 cells. This effect in UM-UC-6dox cells was enhanced by continuously treating with verapamil after doxorubicin had been removed. Western blot analysis with rabbit anti-human P-glycoprotein polyclonal antibody demonstrated a distinct increase in P-glycoprotein in the resistant cell lines as compared with UM-UC-2. P-glycoprotein expression was roughly proportional to the degree of resistance to both doxorubicin and etoposide, but did not always correlate with the effect of verapamil on decreasing doxorubicin resistance. These results suggest that multidrug resistance is an important phenomenon in bladder cancer and that more than one pathway of multidrug resistance may be present in human bladder cancer cell lines.

Bladder contracture following intravesical BCG immunotherapy

Intravesical BCG immunotherapy is commonly associated with irritative bladder symptoms. Bladder contracture as a result of this treatment is rare. Two cases of persistent small-capacity bladders occurring more than one year after intravesical BCG therapy are reported.

Treatment of T3a bladder cancer with iridium implantation

A total of 7 patients with high grade, T3a (Stage B2) bladder cancer were treated with external radiation therapy and interstitial iridium implantation from May 1986 through March 1988. Follow-up has ranged from nineteen to sixty-one months with a median of forty months. One patient has required a cystectomy and is currently free of disease, and 1 patient has had recurrence of his cancer and metastatic carcinoma has developed; 5 are free of disease and have maintained their usual state of bladder function. Iridium implantation maintains bladder function and is effective therapy for selected individuals with localized, muscle-invading bladder cancer.

Evidence for urothelial cell activation in interstitial cystitis

Bladder biopsy samples from 17 interstitial cystitis patients and 20 controls were evaluated for urothelial cell activation using a panel of monoclonal antibodies to HLA-DR, intercellular adhesion molecule 1, interleukin 1 alpha and tumor necrosis factor alpha. Urothelial cells in the majority (13 of 16, 81%) of the biopsies from patients with interstitial cystitis showed increased expression of HLA-DR, while fewer samples were positive for intercellular adhesion molecule 1 (3 of 16, 19%), interleukin 1 alpha (2 of 17, 12%) or tumor necrosis factor alpha (1 of 15, 7%). No urothelial cell expression of intercellular adhesion molecule 1, interleukin 1 alpha or tumor necrosis factor alpha was detected in the controls, and only 1 of 20 control samples contained HLA-DR positive urothelial cells. These results suggest that an unusual type of cellular activation is present in interstitial cystitis. In vitro studies with cultured normal urothelial cells indicated that cells activated with gamma interferon and tumor necrosis factor alpha expressed intercellular adhesion molecule 1 and HLA-DR, although increases in intercellular adhesion molecule 1 expression occurred earlier. Urothelial cells in interstitial cystitis patients may be defective in ability to express intercellular adhesion molecule 1. Alternatively, the differential expression of HLA-DR and intercellular adhesion molecule 1 in interstitial cystitis specimens may represent a functional subset of interstitial cystitis or reflect different stages of the disease. Urothelial cell activation in interstitial cystitis may result in aberrant immune responses and immune activation within the bladder. Because HLA-DR can be detected in paraffin-embedded tissues, evaluation of urothelial cell HLA-DR expression, although not specific for interstitial cystitis, may become a useful tool in the pathological evaluation of biopsy tissues from patients with this disease.

The monoclonal antibody BQ16 identifies the alpha 6 beta 4 integrin on bladder cancer

Monoclonal antibody BQ16, raised against UM-UC-9, a human bladder cancer cell line, exhibited strong reactivity with most bladder carcinoma tissue samples and cell lines. In normal urothelium, BQ16 stained only the basal surface of urothelial cells at the junction with the lamina propria. BQ16 immunoprecipitated two protein bands of approximately 140 and 180 kDa (under non-reducing conditions), while on Western blots, BQ16 identified only the 140 kDa protein indicating that BQ16 binds to one chain of a dimeric protein complex. The dimeric structure, molecular size, and basal orientation of the BQ16 antigen prompted a comparison with the alpha 6 beta 4 integrin identified by monoclonal antibody UM-A9. In most tissues BQ16 and UM-A9 produced identical staining patterns. However, normal lymphocytes and certain bladder cancer cell lines were BQ16 positive but failed to react with UM-A9, indicating that the BQ16 and UM-A9 epitopes can be expressed independently. Pulse-chase immunoprecipitation experiments showed that the alpha 6 subunit was more prominent in early BQ16 precipitates and the beta 4 subunit was more prominent in early UM-A9 precipitates. Furthermore, preclearing cell extracts with the anti-alpha 6 antibody GoH3 removed all BQ16 reactivity and in UM-A9-negative, BQ16-positive cells, BQ16 precipitated the alpha 6 beta 1 complex. We conclude that BQ16 identifies the alpha 6 integrin subunit and that alpha 6 beta 4 integrin is strongly expressed in most bladder cancers.

Blood group antigens and integrins as biomarkers in head and neck cancer: is aberrant tyrosine phosphorylation the cause of altered alpha 6 beta 4 integrin expression?

Head and neck cancer is a capricious disease that varies greatly in its clinical behavior. The development of biomarkers that can distinguish between biologically aggressive and indolent tumors has been a long term goal of our laboratories. Predictive markers applicable to biopsy specimens should facilitate clinical management through early identification of patients at greatest risk for early relapse or metastatic spread. Two prominent cell surface markers that we identified by raising monoclonal antibodies to squamous cell carcinomas are blood group antigens and the A9 antigen/alpha 6 beta 4 integrin. Both of these markers are abnormally displayed in squamous cancers of the head and neck and serve as indicators of early relapse. Loss of blood group antigen expression is a stronger single indicator than is overexpression of the alpha 6 beta 4 integrin. However, use of both markers together is a stronger predictive indicator than is either alone. We know little about the function of the blood group antigens in squamous cells except that the mature antigens are associated with differentiation. Similarly, the function of the alpha 6 beta 4 integrin is also not fully understood. Integrin alpha 6 beta 4 is thought to serve as an extracellular matrix receptor, but its ligand has not been confirmed. In resting epithelium, the alpha 6 beta 4 integrin is polarized to the basal aspect of the basal cell as a component of the hemidesmosome, the anchoring structures of the epithelia. This basal polarization is lost in migrating normal squamous cells and squamous carcinomas. Tyrosine phosphorylation of the beta 4 subunit is absent or greatly reduced in malignant cells and this may be a critical signal for subcellular localization of alpha 6 beta 4 and cell anchoring. On the basis of our current experimental results, we postulate that tyrosine phosphorylation of the beta 4 subunit is a reversible signal that regulates cell migration in normal and malignant cells, and may therefore be an important initial event in the metastatic cascade.

Objective treatment response to endocrine therapy in metastatic prostate cancer

A ten-year review of 198 patients with Stage D2 prostate cancer identified 13 patients (6.6%) who exhibited objective responses to hormonal treatment, as indicated by regression of a positive bone scan, CT scan, or chest x-ray film. Four patients had complete responses and 9 patients achieved partial responses as judged by the National Prostatic Cancer Project criteria. Median survival for those with objective treatment response has not yet been reached (> 44 months) compared with twenty-four months for the nonresponders (p = 0.00006). Although relatively uncommon, objective treatment response in Stage D2 prostate cancer is correlated with an improved prognosis.

Ureteroscopic treatment of urothelial carcinoma of the ureter and renal pelvis

From June 1987 to September 1990, 12 patients were evaluated for ureteroscopic treatment of upper urinary tract neoplasms. Four patients were not considered candidates because of technical reasons. Each of these patients was treated by nephroureterectomy. A total of 8 patients underwent ureteroscopic therapy with a neodymium:YAG laser 1 to 11 times (median 2) for the treatment of 3 proximal ureteral or pelvic lesions and 7 distal ureteral lesions. One patient had local progression and 1 failed subsequent laser treatment for technical reasons. Both of these individuals were salvaged with an operation. Three patients were without recurrence for 15, 21 and 36 months. Two patients had multiple superficial local recurrences and continue to be managed endoscopically without local progression for 12 and 32 months. One patient was asymptomatic 16 months after treatment but he has refused followup evaluation. Of 7 patients with ureteral tumors who were believed to be candidates for endoscopic therapy 5 have had the tumors controlled by this method of treatment. Only 1 renal pelvic tumor has been successfully treated. Most patients with tumors in the renal pelvis are not candidates for rigid endoscopic therapy because of the tumor size and location. In selected individuals ureteroscopic laser treatment of upper urinary tract transitional cell carcinoma can achieve local control with renal preservation.

Combination cisplatin and dichloromethotrexate in patients with advanced bladder cancer. Phase 2. A Southwest Oncology Group study

The combination of cisplatin and dichloromethotrexate is a pharmacologically rational strategy designed to avoid the nephrotoxicity associated with the systemic chemotherapy of bladder cancer. Of 97 patients with metastatic bladder cancer entered into this study 73 with good renal function received cisplatin and dichloromethotrexate, while 24 with impaired renal function received dichloromethotrexate alone. No responses were noted in the latter group. A 42% response rate (95% exact confidence interval 30.0 to 55.2%), including 9 patients (14%) who achieved a complete response, was observed in the combination group. The toxicity patterns in both groups of patients were consistent with the hypothesis that renal toxicity would be ameliorated with the use of the methotrexate analogue. However, the failure to achieve a higher overall response rate despite near maximum tolerated doses of dichloromethotrexate discourages future studies with this agent. New agents for metastatic bladder cancer should be tested as first line therapy.

Premalignant and early carcinomas of the penis and scrotum

Premalignant penile lesions are a spectrum of diseases ranging from those that are almost always benign to neoplasms that are carcinoma in situ. Balanitis xerotica obliterans is a localized variant of lichen sclerosus et atrophicus. The Buschke-Löwenstein tumor is a low-grade malignancy, whereas erythroplasia of Queyrat is a carcinoma in situ. Obtaining the correct diagnosis may challenge even the skilled clinician. It is increasingly likely that papillomaviruses play a role in the development of some cases of penile carcinoma. Scrotal cancer has both historical and current significance as an indicator of occupational health. Occasionally, extramammary Paget's disease presents as a primary scrotal neoplasm.

Cytokine-induced gene expression of interleukin-8 in human transitional cell carcinomas and renal cell carcinomas

Chemotactic cytokines play a critical role in recruiting leukocytes to sites of tissue injury. Interleukin-8 (IL-8) is a chemotactic cytokine secreted by a variety of cells (eg, monocytes, endothelial cells, fibroblasts) during the inflammatory response. In this report, the authors demonstrate that human transitional cell carcinomas and renal cell carcinomas have the capacity to elaborate IL-8 in response to the inflammatory mediators IL-1 beta and tumor necrosis factor (TNF)-alpha. All cell lines expressed high levels of IL-8 mRNA on stimulation with either IL-1 beta or TNF-alpha, but not lipopolysaccharide; one expressed the gene constitutively. The authors selected one transitional cell carcinoma cell line (UM-UC-9) and one renal cell carcinoma cell line (UM-RC-5) for further study. Both displayed a time- and dose-dependent increase in steady-state levels of IL-8 mRNA in response to IL-1 beta and TNF-alpha. Specific mRNA was detectable by 1 hour after stimulation. Secretion of antigenic IL-8 measured by enzyme-linked immunosorbent assay into culture supernatants reflected the kinetics of mRNA expression. Because heat-inactivated TNF-alpha failed to induce synthesis of IL-8 mRNA, and cycloheximide augmented TNF-alpha-induced synthesis, IL-8 expression appears to be a stimulus-specific primary induction phenomenon. As with other inflammatory mediators whose mRNA contains a 3' AU-rich sequence (eg, IL-2, TNF-alpha), the half-life of IL-8 mRNA was short, less than 1 hour. Our data suggest that secretion of IL-8 by malignant cells may partly account for the inflammatory infiltrates associated with some malignant neoplasms.

Alterations in antigen expression in superficial bladder cancer

Bladder cancer can be viewed as a prototype for carcinogen-induced neoplasia. This has been demonstrated experimentally in a variety of systems and in man through epidemiological studies of occupational exposure to putative carcinogens. The natural history of this neoplasm demonstrates recurrence in time and space, i.e., multifocal disease. This clinical scenario is precisely what would be expected if a target tissue, e.g., urothelium, was continuously exposed to a weak carcinogen. The detection of gross disease is clinically easy. However, the ability to intervene at early stages and monitor the success of this treatment requires the definition of early markers for bladder cancer. Integrins are a family of cell surface proteins, many of which function as receptors for extracellular matrix components. Normal epithelial cells express the integrin alpha 6 beta 4 in association with an anchoring structure known as the hemidesmosome. Urothelium expresses alpha 6 beta 4 on the basal layer of cells similar to the distribution seen on other epithelial surfaces. Even early stages of bladder cancer demonstrate an alteration in the expression of this integrin. Low-stage bladder tumors express alpha 6 beta 4 diffusely throughout the tumor as well as at the invading margin. Altered expression of alpha 6 beta 4 may be an early marker for bladder cancer which may contribute to an invasive phenotype. A second potential marker is detected by DD23, an IgG1 murine monoclonal antibody triggered by the immunization of a BALB/c mouse with a fresh human bladder tumor specimen. The antigen detected by DD23 is not present on normal urothelial specimens.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of 15 monoclonal antibodies against tumor-associated antigens of transitional cell carcinoma of the human bladder

Quantitative urinary immunocytology with our monoclonal antibody (mab) 486p 3/12 proved to be valuable for diagnostic use in bladder-cancer patients' urine, especially in the followup of patients with superficial bladder carcinoma. To evaluate the use of other monoclonal antibodies in bladder cancer, we compared 15 mabs directed against bladder-tumor-associated antigens from seven research groups in a broad panel of cellular and tissue specimens (bladder tumor, prostatic adenoma, and kidney stone). Quantitative evaluation was done in cytocentrifuged preparations and tissue specimens. None of the 15 mabs was bladder-tumor-specific. All 15 stained normal urothelium to some extent and six stained granulocytes. Each of the 15 seemed to identify a different cellular antigen, as can be clearly demonstrated by the staining pattern of different regions in the normal kidney. The sensitivity of quantitative urinary immunocytology in bladder-tumor patients can be improved by using a panel, rather than one mab in bladder-tumor patients, but specificity decreases simultaneously. A main reason for the poor specificity of quantitative urinary immunocytology with all 15 mabs is that false-positive results are obtained with all mabs in kidney-stone patients. Our quantitative urinary immunocytology method is a general tool for the diagnostic use of all mabs in bladder-tumor patients. Mabs that have a high sensitivity might be useful in the followup of patients with superficial bladder carcinoma. None of the 15 mabs (because of their poor specificity) seems to be helpful in quantitative urinary immunocytology for screening a population for bladder carcinoma.

Imaging of renal cancer using positron emission tomography with 2-deoxy-2-(18F)-fluoro-D-glucose: pilot animal and human studies

The feasibility of imaging renal cancers with 2-deoxy-2-[18F]-fluoro-D-glucose (FDG) and whole-body positron emission tomographic scanning was assessed in nude mice with human renal adenocarcinoma xenografts and then in 5 patients with primary renal cancer (4 adenocarcinomas and 1 transitional cell carcinoma). In nude mouse biodistribution studies tumor FDG uptake was maximal at 0.33 to 2 hours but tumor-to-blood ratios increased continuously to 7.8/l. by 4 hours after intravenous FDG injection. In all 5 patients primary and metastatic tumors were imaged within 1 hour by FDG positron emission tomography following intravenous injection of the FDG. By contrast, an hepatic hemangioma did not accumulate FDG. In summary, FDG metabolic and anatomical imaging of primary and metastatic renal cancer is feasible and in these pilot studies appears to be a promising imaging methodology that may be further enhanced by delayed imaging times. Additional study in a larger number of patients is essential to define better the accuracy and potential clinical use of this method.

Transitional cell carcinoma of the bladder: patterns of recurrence after cystectomy as determined by CT

CT scans have been recommended for examination of patients at risk for recurrent transitional cell carcinoma after cystectomy. For CT to be useful in this regard, the location and type of recurrences must be known, so that appropriate scans can be made. Therefore, we retrospectively studied CT scans in 27 postcystectomy patients with recurrent transitional cell carcinoma of the bladder to identify the type and location of the recurrent disease. Recurrence was documented by biopsy in 18 patients and by progression of disease shown on serial CT scans in nine patients. All 27 patients had pelvic CT, and 23 had concomitant abdominal CT. Tumor recurred at the cystectomy site in 10 (37%) of 27 patients, pelvic adenopathy was present in 18 (67%) of 27 patients, and retroperitoneal adenopathy was present in 13 (57%) of 23 patients. Tumor recurrence at the cystectomy site was associated with pelvic adenopathy in seven of 10 patients, and the cystectomy site was the solitary site of disease in the remaining three patients. Conversely, in 11 of 18 patients with pelvic adenopathy no recurrence was seen at the cystectomy site. Combined retroperitoneal and pelvic adenopathy was identified in 11 of 23 patients, but two patients had retroperitoneal lymphadenopathy as their only site of recurrence. Hepatic metastases were seen in seven (30%) of 23 patients; six of these seven patients had metastases elsewhere. In four of five patients in whom underestimation of recurrent disease occurred, the deep pelvis and/or deep perineal space were involved. Our results show that the pelvis is the most common site for recurrence. Cystectomy site or retroperitoneal nodal recurrences are usually accompanied by pelvic adenopathy, but the converse is not as common. Our findings of deep perineal and isolated abdominal recurrences indicate that proper protocol for CT follow-up of the postcystectomy patient should include abdominal scans and scans through the perineum.

A randomized trial of intravesical doxorubicin and immunotherapy with bacille Calmette-Guérin for transitional-cell carcinoma of the bladder

BACKGROUND

In carcinoma of the bladder, both intravesical chemotherapy and immunotherapy can induce tumor regression and reduce the rate of recurrence, but the relative merits of these two therapies are unclear. We conducted a multi-institutional study to address this question.

METHODS

Patients with rapidly recurrent (stage Ta and T1) or in situ transitional-cell carcinoma of the bladder were randomly assigned to receive either doxorubicin administered intravesically or bacille Calmette-Guérin (BCG) administered both intravesically and percutaneously. The 262 eligible patients were followed for a median of 65 months. Complete responses to treatment of carcinoma in situ were confirmed by biopsy and cytologic analysis of the urine.

RESULTS

For patients with Ta and T1 tumors without carcinoma in situ, the estimated probability of being disease free at five years was 17 percent after doxorubicin, as compared with 37 percent after immunotherapy with BCG (P = 0.015). The median times to treatment failure (termination of treatment, due to persistence, recurrence, or progression of disease) were 10.4 and 22.5 months, respectively. For patients with carcinoma in situ the complete-response probability estimates (i.e., the estimated probability of documented disappearance of disease) were 34 percent for doxorubicin (23 of 67 patients) and 70 percent for BCG (45 of 64 patients) (P less than 0.001); the median times to treatment failure were 5.1 and 39 months, respectively. The probability of being disease-free at five years survival among the patients with carcinoma in situ was 18 percent after treatment with doxorubicin and 45 percent after BCG therapy. Patients treated with BCG had a higher incidence of toxic systemic effects and a larger number of local irritative symptoms than patients treated with doxorubicin, but few of these adverse reactions were severe.

CONCLUSIONS

As compared with intravesical doxorubicin, immunotherapy with BCG provides improved protection against the recurrence of superficial bladder cancer.