Growth and major histocompatibility antigen expression regulation by IL-4, interferon-gamma (IFN-gamma) and tumour necrosis factor-alpha (TNF-alpha) on human renal cell carcinoma

We have recently shown that human renal cell carcinoma (RCC) tumour lines express high-affinity IL-4 receptors. Binding of IL-4 to RCC cells induced a growth inhibition in the range of 20-68%. To enhance the growth inhibitory effect of IL-4, we have tested the effects of two additional cytokines capable of directly affecting tumour cell growth. IFN-gamma caused a significant inhibition of RCC tumour cell growth (up to 70%) in a dose-dependent manner, whereas the effect of TNF-alpha was more limited (0-20% inhibition). The addition of IL-4 to IFN-gamma on RCC cells sensitive to IL-4 induced a greater inhibition of cell growth than that seen with each cytokine alone. IL-4 and IFN-gamma rendered RCC cells more responsive to the inhibitory effect mediated by TNF-alpha. The combination of TNF-alpha with IL-4 and IFN-gamma induced an optimal growth inhibition (up to 90-98%) of RCC cells. In addition to a direct anti-proliferative effect, we have demonstrated that these cytokines can also enhance the expression of MHC antigens on the surface of RCC tumour cell lines which may render the cells more immunogenic. All RCC lines tested expressed class I antigens, but not class II antigens. IFN-gamma induced class II expression and up-regulated the expression of class I antigens on RCC cells. Class II antigen expression was detectable following 48 h incubation, and greater after 72 h with IFN-gamma. IL-4 minimally affected class I expression, whereas TNF-alpha up-regulated class I antigen expression. IL-4 or TNF-alpha did not induce class II expression. The combination of the three cytokines slightly augmented the up-regulation of class I and class II antigens observed with IFN-gamma alone. These observations confirm the direct interaction of IL-4, IFN-gamma and TNF-alpha with RCC tumour cells, both at the level of growth regulation and MHC antigen expression, and suggest a therapeutic potential of the combination of the three cytokines for renal cell carcinoma.

Methods of early detection of prostate cancer: the role of prostatic specific antigen, transrectal ultrasound and digital rectal examination

PSA has significantly influenced the management of prostate cancer. Early detection of clinically significant cancer has been increased by combining PSA and digital rectal examination. PSA has been used as a prognostic factor for patients with local disease and as a monitoring test for patients undergoing curative therapy for localized prostate cancer.

W-stapled ileal neo-bladder formed entirely with absorbable staples

Orthotopic bladder replacement after total cystoprostatectomy for bladder cancer has gained broader use. Continent diversion has historically increased the complexity of the surgical procedure, often discouraging its adoption by many urologists. Absorbable staples on a GIA* instrument became available in 1992 and have been incorporated into reservoir formation in this preliminary study. A novel W-shaped ileal reservoir entirely fashioned from absorbable staples using the GIA and TA instruments has been developed and used in 15 patients undergoing cystoprostatectomy. The advantages of this technique are its simplicity and the speed with which the reservoir can be fashioned. In the first 15 patients operative time to construct the reservoir ranged from 12 to 21 minutes. Functional aspects of urodynamic studies and continence appear comparable to those of other ileal reservoirs. These preliminary data justify comparative trials on an expanded scale.

Influence of tumor site on the therapy of murine kidney cancer

OBJECTIVE

The purpose of this study was to evaluate the influence of tumor site on the therapy of an experimental murine kidney cancer model, Renca.

METHODS

Equal number of tumor cells were injected subcutaneously, intraperitoneally, sub-renal capsule, and intravenously to induce tumors. The animals were then assessed for growth of the primary tumor, metastases and survival. Immunohistochemistry and flow cytometry was performed to identify the phenotype of infiltrating lymphocytes. Tumor bearing animals were treated with high dose interleukin-2 or whole body radiation, and response of the primary tumors as well as the metastases was assessed.

RESULTS

Renca tumors grew well regardless of the methods of induction. Spontaneous metastasis could be best induced in the sub-renal capsule model. More consistent numbers of pulmonary metastases were obtained by intravenous injection of the tumor cells. Immunotherapy was able to reduce the size of the primary tumor as well as the number of metastasis. Whole body radiation caused some reduction in the primary tumor but did not have a major effect in reducing metastasis.

CONCLUSIONS

The Renca model is a suitable animal model to study the response to different therapeutic interventions. The site of the tumor growth is not a significant variable in the response to treatment.

Value of preoperative PSA in predicting pathologic stage of patients undergoing salvage prostatectomy

OBJECTIVE

To evaluate the relationship of prostate-specific antigen (PSA) levels and pathologic stage in patients with prostate cancer treated with radiation therapy and undergoing salvage radical prostatectomy.

METHOD

Retrospective analysis of preoperative PSA levels and final pathology in 24 men undergoing salvage prostatectomy following prior radiation therapy.

RESULTS

Although preoperative PSA values were significantly higher in patients with positive surgical margins, preoperative PSA levels failed to predict the presence of absence of extracapsular extension, seminal vesicle involvement, or lymph node metastasis.

CONCLUSION

Our results suggest that PSA is not a reliable method of accurately predicting the pathologic stage of patients who are candidates for salvage radical prostatectomy.

Radiation therapy enhances the therapeutic effect of immunotherapy on pulmonary metastases in a murine renal adenocarcinoma model

In order to improve the efficacy of immunotherapy, we have evaluated the effects of radiation therapy combined with interleukin 2 (IL-2) treatment in a murine metastatic renal adenocarcinoma model (Renca). Pulmonary metastases were induced in Balb/c mice by intravenous injection of Renca and five days later a sublethal dose of radiation (300 rads) was administered either to the whole body or to the left lung only. One day following radiation, immunotherapy was given for 5 consecutive days of IL-2 at 5,000 Cetus units intraperitoneally, twice daily. The animals were either sacrificed on day 23 or 33 to assess tumor burden, or were followed for long term survival. We found that pretreatment with irradiation greatly enhanced the therapeutic efficacy of immunotherapy and was manifested by a significant reduction in pulmonary metastases and an increase in survival. When combined with immunotherapy, local tumor irradiation was not only as effective as whole body irradiation, but irradiation of one lung reduced the number of metastases similarly in both lungs. This suggests that local tumor irradiation may act through a systemic mechanism to increase the anti-tumor response mediated by IL-2 therapy.

Flow cytometric DNA analysis of fresh prostatic resections. Correlation with conventional prognostic parameters in patients with prostate cancer

BACKGROUND

DNA ploidy analysis has been investigated as a prognostic indicator in prostate cancer. Most of the data is derived from retrospective studies using paraffin-embedded tissue. This method has drawbacks related to the quality of DNA histograms and uncontrolled data collection.

METHODS

DNA ploidy analysis of freshly resected prostatic tissue was prospectively compared with conventional prognostic variables in 97 men treated with radical prostatectomy for localized prostate cancer.

RESULTS

Regarding the patients, 31.9% were African American and 66% had pathologic Stages C or D1 disease. Only 9.6% of patients with Stages A2 and B had a prostate-specific antigen (PSA) value greater than 10 ng/ml, whereas 97% of patients with PSA values greater than 20 ng/ml had pathologic Stages C and D1. PSA levels correlated with Gleason score (P = < 0.05); 51% and 100% of patients with Gleason score 5-7 and 8-10, respectively, had PSA values greater than 10 ng/ml. Twenty-two patients (23%) had DNA aneuploid tumors. Comparisons of mechanical to enzymatic cell suspensions indicated that DNA aneuploidy was better preserved in mechanical cell preparations. DNA ploidy correlated with pathologic stage (P = < 0.05) and Gleason score (P = < 0.05). Fifteen of 79 patients (18.9%) with Gleason score 5-7 had DNA aneuploid tumors versus 71.4% of patients with Gleason score 8-10. PSA groups correlated with ploidy status (P = 0.01). Although the majority of patients (19 of 22) with DNA aneuploid tumors had elevated preoperative PSA levels, none had a PSA value greater than 50 ng/ml.

CONCLUSIONS

DNA ploidy analysis correlated with established prognostic indicators in prostate cancer; however, its independent correlation with natural history and treatment outcome must be established for it to have an effect on therapeutic decisions.

51Cr-release assay adapted to a 96-well format sample reading

The application of the Matrix 96, a direct beta counter, to monitor cell-mediated lympholysis assays (CML) was investigated. Until now, the gamma rays emitted from 51Cr, released in the supernatant of the sample following lysis of targets by effector cells, were read in gamma counters using individual tubes for each sample. The Matrix 96 has been designed to count 96 wells simultaneously for assays performed in 96-well microplates. Aliquots of supernatants were spotted on a 96-well disposable metal spotting plate and dried prior to reading in the Matrix 96. A tight correlation was observed between the counts obtained in the Matrix 96 and a gamma counter, which indicates that the detection of electron capture beta particles emitted from 51Cr was as accurate as reading gamma rays from the same isotope. Both methods confirmed the minimal level of cytotoxicity mediated by unstimulated lymphocytes and the high levels of nonspecific cytolytic activity mediated by lymphokine-activated killer (LAK) cells against several tumor cell lines.

The frequency of carcinoma and intraepithelial neoplasia of the prostate in young male patients

The incidence of clinically detected prostate cancer is increasing with more frequent diagnosis in younger male patients. Whether this represents a genuine increase in incidence or earlier detection is not clear. To understand better the evolution and early changes of prostate cancer we evaluated 152 prostate glands from young male patients 10 to 49 years old. Of the prostates 98 were from African-Americans and 54 were from white patients. Prostatic intraepithelial neoplasia was identified in 0%, 9%, 20 and 44%, and small foci of histological cancer in 0%, 0%, 27% and 34% of the male patients in the second, third, fourth and fifth decades of age, respectively. The majority of the cases of prostatic intraepithelial neoplasia were of low grade. High grade prostatic intraepithelial neoplasia, found in 5 prostates, was first identified in the fifth decade. All 5 cases occurred in prostates containing histological carcinoma. Incidental carcinoma was detected with a similar frequency in white and black patients. The cancerous foci were of similar size with a tendency for cancer in black patients to be multifocal, particularly in those in the fifth decade. We conclude that prostatic intraepithelial neoplasia and histological cancers are surprisingly common in young male patients of both races. The evolution of prostatic intraepithelial neoplasia and focal histological cancers is not clear but it appears to present several decades earlier than clinically detected carcinoma. The natural history of prostate cancer must encompass many more years (decades) than has been previously realized. In addition, the initiating events leading to clinically relevant prostate cancers likely occur at a remarkably young age.

Combined radical retropubic prostatectomy and proctosigmoidectomy for en bloc removal of locally invasive carcinoma of the rectum

A novel technique of combined radical retropubic prostatectomy and restorative proctosigmoidectomy is described, and indications and expected complications are discussed. It is offered as an alternative to total pelvic exenteration for patients with carcinoma of the rectum exhibiting isolated extension to the prostate gland or seminal vesicles. This procedure obviates the need for urinary and fecal diversion and provides excellent exposure for optimal rectal dissection. Thus, it offers the opportunity for improved functional results without compromising the principles important for local tumor control.

Application of the direct beta counter Matrix 96 for cytotoxic assays: simultaneous processing and reading of 96 wells using a 51Cr-retention assay

To assess the cytotoxic activity of immune cells, we have developed a 51Cr-retention assay in which the radioactivity retained by 51Cr-labeled target cells, following coincubation with cytotoxic cells, is monitored using the automated Matrix 96 beta counter. The Matrix 96 is designed for simultaneously counting 96 samples isolated from a 96-well microplate. It uses 96 uniform and independent detectors operating on the principle of avalanche gas ionization in the Geiger-Muller mode. Samples must be dry because the detectors are of the open-window type. Therefore, samples from the 96 wells of the microplate are simultaneously harvested onto a filter using the MicroMate 196, a 96-well cell harvester, dried and quantified in the Matrix 96. Usually the 51Cr isotope is measured by the detection of gamma radiation in gamma counters. The Matrix 96, however, monitors Auger electrons, which are also emitted by 51Cr. We have shown that the retention assay can be used to monitor the cytotoxic activity of activated lymphocytes including lymphokine-activated killer cells and tumor-infiltrating lymphocytes against various tumor cell lines. This assay is most suitable for experiments in which low E/T ratios are sufficient to detect highly cytotoxic cells, such as clone screening in cloning assays or in limiting-dilution analysis assays. These assays involve processing and reading large numbers of microplates. In this case, the retention assay monitored in the Matrix 96 will improve the work flow and decrease the amount of radioactive waste.

Immunotherapy of renal cell carcinoma

Immunologic approaches to the therapy of metastatic renal cell carcinoma have provided moderate improvement in response rates for a disease that is extremely resistant to all forms of treatment. This article reviews recent clinical efforts using immunotherapy for renal cell carcinoma, including the adoptive transfer of cytotoxic killer cells and/or the use of biologic response modifiers, such as interferon and interleukin-2.

Immunotherapy for metastatic renal cell cancer: effect on the primary tumor

The traditional approach to immunotherapy for metastatic renal cell cancer, to first reduce the tumor burden by nephrectomy and then offer systemic therapy, has been challenged recently. There is mounting evidence that objective responses in the metastatic disease can be achieved without prior nephrectomy, although responses in the primary tumor are much less frequent. We describe our experience that some patients may, in fact, have significant responses in extensive local disease and become surgical candidates after systemic immunotherapy. A 46-year-old patient who presented with a large renal primary tumor and pulmonary metastases was treated with high-dose interleukin 2 therapy. A complete response in the lung and partial response in the primary tumor was achieved. The patient then underwent resection of his primary tumor, and on histological evaluation only minimal residual cancer was present. He has no evidence of disease at 14 months. This case demonstrates that immunotherapy can achieve not only objective responses at metastatic sites but also in the primary tumor.

Salvage surgery for radiation failure in prostate cancer

METHODS

Salvage surgery was done in 43 patients who did not respond to radiation therapy of prostate cancer between 1982-1991. Thirty-five patients underwent salvage prostatectomy and 8, cystoprostatectomy.

RESULTS

The complications were significant; four patients had rectal injuries (all closed primarily), one had a ureteral injury, and there was one perioperative death. Urinary incontinence occurred in 10 of 35 patients (30%). Pathologic step sections of the prostate showed that only 13 of 43 patients (30%) had negative surgical margins. Follow-up (range, 1-10 years) revealed that 34 patients were alive, and 9 had died. Eleven of 20 patients were alive who were followed more than 5 years. Ten patients were considered to have no evidence of disease (undetectable prostate specific antigen levels).

CONCLUSION

In selected patients, salvage surgery has a place in the treatment of prostate cancer after radiation therapy failure.

DNA quantitation of intraepithelial neoplasia and invasive carcinoma of the prostate

The relation of prostatic intraepithelial neoplasia (PIN) or ductal dysplasia and the development of invasive prostate cancer is not clear. PIN, especially high grade, is usually associated with coexisting invasive cancer. Although some investigators have identified micro foci of invasive cancer evolving from PIN, the two are usually anatomically separated. Because of these distinct anatomic patterns, many investigators have concluded that PIN represents a "field effect" or marker of potential cancer progression, and is not directly involved in or leads to the development of invasive prostate cancer. We measured the DNA content in 49 foci of invasive cancer and 87 foci of PIN identified in 34 radical prostatectomies containing both PIN and invasive cancer. In addition, we examined 13 prostatectomies and 5 TUR specimens containing only PIN. We found that the majority of low grade PIN had normal or diploid range DNA and that approximately half of the high grade PIN were abnormal or aneuploid. Prostates with coexisting diploid range PIN and invasive cancer had an approximately equal number of diploid range and aneuploid invasive cancers. Conversely, almost all of the aneuploid PIN (usually high grade) had coexisting aneuploid invasive cancers. This would support the hypothesis that events in the progression of prostate cancer may be operative in both the development of PIN and invasive cancer.

Translocation (X;1) in papillary renal cell carcinoma. A new cytogenetic subtype

We report a consistent t(X;1)(p11.2;q21) that was observed in four cases of papillary renal tumors. In one of the cases, two cells showed the cytogenetic abnormality as the only change, whereas the other cases showed additional chromosomal anomalies particularly involving chromosomes 7 and 17. One identical t(X;1) has been reported previously in a papillary renal cell carcinoma. To date, all of the patients carrying this translocation have been males.

Accuracy of frozen section examination of testicular tumors

Benign testicular masses are recognized with increasing frequency and testis-sparing surgery, based on benign frozen section diagnosis, is practiced more often. However, there is a paucity of information in the medical literature regarding the accuracy of frozen section diagnoses of testicular tumors, and misdiagnoses could have dire consequences. We reviewed thirty frozen section examinations that were performed between 1962 and 1991, a period in which five hundred inguinal orchiectomies were performed. The entire testicle was available for histologic evaluation in 26 cases. Frozen sections correctly identified all of twenty-four malignant and two benign testicular masses. This study demonstrates that frozen section examinations can accurately diagnose testicular cancer.

Squamous cell carcinoma of the bladder in a patient on intermittent self-catheterization

Squamous cell carcinoma of the bladder has been associated with exstrophy, defunctionalized bladders, chronic infection, cystolithiasis, and chronic indwelling catheters. We report a case of squamous cell carcinoma of the bladder in a woman performing intermittent self-catheterization for the previous 14 years.

Synergy of radiation therapy and immunotherapy in murine renal cell carcinoma

The treatment of metastatic renal cell carcinoma with immunotherapy has resulted in objective anti-tumor responses in 15-30% of patients. To enhance the therapeutic effects of immunotherapy, it is becoming evident that this approach should be combined with other treatment modalities. In this study, a spontaneously metastasizing murine renal adenocarcinoma (Renca), transplanted under the renal capsule, was treated with either radiation therapy, immunotherapy or a combination of both. In order to distinguish between the local and systemic effects of radiation therapy, total body irradiation was compared to irradiation of the tumor-bearing kidney only, or irradiation of the whole mouse with the tumor-bearing kidney shielded. Immunotherapy was administered with interleukin-2 (IL-2) alone or with IL-2 and lymphokine activated killer (LAK) cells. Combined radiation and immunotherapy induced a better anti-tumor response than either modality alone. The best response was obtained by local tumor irradiation and IL-2 therapy and resulted in a significant reduction in primary tumor size, elimination of lung metastases and a significant increase in survival.

Renal cell carcinoma with inferior vena cava tumor thrombi

Renal cell carcinoma is a unique neoplasm because of its common propensity to propagate into the renal vein and inferior vena cava (IVC) as tumor thrombus. Historically, the surgical difficulties encountered in removal of these cancers limited the ability of a single institution to obtain experience with large numbers of instances. Between January 1956 and July 1987, 68 patients with renal cell carcinoma extending into the IVC or right atrium underwent radical nephrectomy with vena cava thrombus extraction at the Cleveland Clinic. Twenty-five patients had partial resection of the IVC with reconstruction. Fifteen patients had partial resection and reconstruction of the IVC; however, because of narrowing of the infrarenal IVC, persisting bland thrombus in the proximal IVC or iliac veins or concern regarding postoperative pulmonary emboli, the infrarenal IVC was either ligated or clipped. Seven patients underwent cavectomy with division of the IVC. A right atriotomy was performed upon 14 patients and cardiopulmonary bypass was used in 20 patients, with 17 also having deep hypothermic circulatory arrest. The tumor thrombus was removed intact in 64 per cent of the patients and in multiple small fragments ("piecemeal") in 36 per cent of the patients. The mortality rate was 7 per cent. Survival was examined relative to extent of vena caval thrombus. Patients with extension into the atrium had a significantly worse prognosis than those with other levels of vena caval involvement. Other factors, such as lymph node status, perinephric fat involvement, resection of IVC and intact or "piecemeal" extraction, did not influence the survival rate. Patients with pre-existing metastases preoperatively had an extremely poor survival rate. The techniques now available for surgical resection of all levels of tumor thrombus of the IVC make resection feasible in most patients. In our opinion, the addition of deep hypothermic circulatory arrest has been a significant advance.

Coexistence of autologous antibodies and decay-accelerating factor, an inhibitor of complement, on human renal tumor cells

Autologous immunoglobulin was detected on the cell surface of tumor cells freshly isolated from cancerous kidneys of patients with renal cell carcinoma by flow cytometry after staining with murine anti-human IgG monoclonal antibodies. Cells isolated in parallel from macroscopically normal regions of the tumorous kidneys were not specifically stained with the anti-human IgG reagents. In further studies, tumor cells were stained with an antibody to decay-accelerating factor (DAF), a known inhibitor of complement. Flow cytometry of these cells revealed that nearly all tumor cells expressed DAF, and that the intensity of staining with the anti-DAF monoclonal antibody correlated with the staining of cells with anti-IgG. The results suggest that tumor cells coated with autologous antibody may be resistant to complement-mediated cytotoxicity in vivo through the expression of high levels of DAF.