Zoladex with or without flutamide in the treatment of locally advanced or metastatic prostate cancer: interim analysis of an ongoing PONCAP study. Italian Prostatic Cancer Project (PONCAP)

Since March 1987, 304 evaluable patients with stage C and D prostate cancer have been entered into a prospective trial comparing Zoladex and Zoladex plus flutamide. To date, there has been no significant difference in over-all and progression-free survival between the 2 treatment groups. However, combined treatment produced a higher response rate (particularly in stage D patients) and a more rapid normalization of abnormal prostatic acid phosphatase levels. In addition, more prompt relief of bone pain was evident in the Zoladex plus flutamide group. However, significantly more side-effects were associated with combined treatment. These findings should be considered with caution because they form an interim analysis, and follow-up time is short. The results do suggest, however, that there is no particular advantage in using a combination of Zoladex plus flutamide compared to adding flutamide on failure of treatment with Zoladex alone.

Flexible antegrade and retrograde nephroscopy: review of 50 cases

50 cases of flexible instrumentation of the intrarenal collecting system are reviewed. 28 were performed by retrograde flexible ureterorenoscopy. The introduction was carried out by combining hydraulic dilation, rigid ureterorenoscopy and a working sheath. 22 cases were performed through a percutaneous route. The indications were both diagnostic (filling defects and/or hematuria) and therapeutic (caliceal stone and/or fragments). The success rate was high in the diagnostic cases (20 of 24), but lower in the therapeutic cases (13 of 26). The complication rate was extremely low and the postoperative course was always uneventful. Flexible instruments offer a very good chance to explore the intrarenal collecting system. Both transureteral and percutaneous flexible nephroscopies are feasible and effective procedures. A laser can be used well in this area.

In situ or retrograde manipulation of ureteral stones: still a controversy?

A series of 365 patients with ureteral stones is reviewed. ESWL, ureterorenoscopy, basket extraction and open surgery were alternatively used according to the stone and to the increasing experience in minimally invasive techniques. The overall success rate of in situ ESWL varied between 79 and 90% according to the localization of the stone and no difference was noted between patients treated with the original HM III Dornier lithotriptor and patients treated with the upgraded HM III with low pressure and large ellipsoid for painfree ESWL. Also the retreatment rate did not differ significantly (38 vs 42%). Ureterorenoscopy, carried out as first approach or after ESWL failure, was successful in 80.4% of the cases. Basket extraction was successful only in 32.3% of the cases. In situ ESWL, in one or two sessions, without anaesthesia and without hospital stay, is a good solution for roughly 80% of ureteral stones. Retrograde manipulation with or without ureterorenoscopy, requiring anaesthesia and hospitalization, should be reserved to failures of in situ ESWL.

A rational postoperative follow-up with carcinoembryonic antigen, tissue polypeptide antigen, and urinary hydroxyproline in breast cancer patients

Breast cancer patients (n = 224) aged 28 to 81 were postoperatively followed up with serial determinations of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA), and urinary hydroxyproline (OHP). The clinical usefulness of these tumor markers to diagnose and monitor distant metastases was compared with that of the imaging techniques commonly used to monitor breast cancer patients (bone scanning [BS], liver echography [LE], chest radiograph, and skeletal radiograph). So far, 23 patients withdrew from the study, and distant metastases occurred in 33 patients. In 91% of the metastatic patients, constant elevation or progressive increase in serum CEA and/or TPA levels were the first pathologic findings of the relapse. Of the remaining 168 nonrelapsed patients, 122 were followed up longer than 24 months (43 +/- 17 months; mean +/- SD). In these 122 patients the false-positive results of CEA, TPA, and OHP were 0.8%, 2.4%, and 0%, respectively, when used simultaneously with clinical examination and the common laboratory examinations. BS and LE are the only imaging techniques that showed such a high sensitivity to be suitable in the postoperative follow-up of breast cancer patients. Nevertheless, because BS has a low specificity and is not harmless, it should be performed at longer intervals than tumor markers. Eventually, in the relapsed patients, TPA and OHP well reflected the response to treatment better than CEA and prevented useless radiologic examinations.

[Monodose aztreonam in the prevention of infection after extracorporeal shockwave lithotripsy. Theoretical premises]

A series of 905 patients suffering from renal calculosis and treated with ESWL is considered and the indications for antibiotic treatment with prophylactic or prolonged aztreonam reviewed: 1) for calculi with sterile urine or occasionally infected with I.S.T. less than 200, monodose prophylaxis is certainly advantageous; 2) for calculi with sterile urine or occasionally infected with I.S.T. between 200 and 500, prolonged antibiotic cover is useful; 3) for calculi with chronic infection or with I.S.T. greater than 500, prolonged target antibiotic therapy is necessary; 4) aztreonam is an effective drug for both monodose prophylaxis and for cover treatment. In more complex cases, an antibiogram indication is necessary.

Valpromide is a poor inhibitor of the cytosolic epoxide hydrolase

The effect of the antiepileptics valpromide and sodium valproate on the cytosolic epoxide hydrolase was studied in human fetal liver, kidneys and adrenals and from human adult liver and kidneys. Trans-stilbene oxide was used as substrate. Valpromide (10 mM) lowered the activity of the epoxide hydrolase to one half of the control in all organs studied. Sodium valproate (10 mM) was less powerful as an inhibitor than valpromide; however, it exerted a significant inhibition in all tissues studied.

[Antibiotic prevention with aztreonam in urologic surgery in children]

In a group of 51 children aged 3 days-17 years old, 40 were given operative 8 endoscopic and 3 percutaneous surgery, while all received antibiotic prophylaxis with Aztreonam (Squibb Azactam) for the prevention of surgical infections. Preoperative uroculture revealed sterile urine in all 51 but 49 needed excretory catheters at various levels: urethral, pyelic. Drug treatment was started preoperatively at the time of narcosis and continued until catheter removal. Aztreonam was chosen for its anti-Gram negative action and absence of toxicity as reported in the literature. Urine cultures at the end of treatment and 7 days later revealed sterile urine in 49 (96%) of the children, while 2 presented asymptomatic infection by Gram positive bacteria. No significant side effects definitely attributable to the drug were encountered.

Neoadjuvant or definitive alternating chemotherapy and radiotherapy for infiltrating bladder cancer

Thirty-two patients with infiltrating bladder cancer were treated with transurethral resection followed by one course of alternating chemoradiotherapy before radical cystectomy (group A, 20 patients) or two courses as definitive procedure (group B, 12 patients). One course consisted of: cisplatin 20 mg/m2 i.v. and 5-fluorouracil 200 mg/m2 i.v. for 5 consecutive days, the first and the fourth weeks; radiotherapy 20 Gy in 10 fractions in the second and third weeks. At the seventh week the same integrated therapy was restarted in group B. All 32 patients were evaluable for toxicity after the first course: no grade IV toxicity was observed. Significant increase in hematological toxicity was observed in 12 patients who received the second course of chemoradiotherapy: two patients had grade IV toxicity, and five patients had grade III. Fifteen patients of group A underwent radical cystectomy: 40% had a pathological (p) complete response (CR) and 13.3% a partial response Five patients in group A did not receive either the second course of therapy or cystectomy because of age (three patients), vascular obliteration (one patient) and enteritis (one patient). Actuarial disease-free survival in group A is 78% at 21 months. All patients of group B obtained clinical (c) CR and all but one have no evidence of disease at a median follow-up of 10 months (range 6-13). The high pCR and cCR obtained in patients of group A and group B, respectively, appears promising. A longer follow-up and a larger number of patients is required to determine the role of this integrated treatment.

Distribution of 2-naphthol sulphotransferase and its endogenous substrate adenosine 3'-phosphate 5'-phosphosulphate in human tissues

The activity of sulphotransferase towards 2-naphthol and the concentration of its endogenous substrate, adenosine 3'-phosphate 5'-phosphosulphate (PAPS), have been measured in five specimens of human liver, lung, and kidney, and the mucosa from the ileum and the ascending, descending and sigmoid colon. The activity of 2-naphthol sulphotransferase (mean nmol.min-1.mg-1 protein) was 1.82 (liver); 0.034 (kidney); 0.19 (lung); 0.64 (ileum); 0.47 (ascending colon); 0.50 (descending colon); 0.40 (sigmoid colon). The concentration of PAPS (mean nmol.g-1 wet tissue) was 22.6 (liver); 4.8 (kidney); 4.3 (lung); 12.8 (ileum); 8.1 (ascending colon); 7.5 (descending colon); 6.2 (sigmoid colon). The concentration of PAPS and the activity of 2-naphthol sulphotransferase were higher in the liver than in the extrahepatic tissues. There was significant difference between ileum and ascending colon, both the activity of sulphotransferase and the concentration of PAPS being higher in the former. 2-Naphthol sulphotransferase activity and the concentration of PAPS have consistent distribution patterns. Differences between the tissues studied were more marked for sulphotransferase than for its endogenous substrate.

Profile of drug-metabolizing enzymes in human ileum and colon

Six patients (4 women and 2 men, age between 60 and 90 years), subjected to right hemicolectomy, were gut donors. The mucosa was isolated from the last portion of the ileum and the first portion of the colon. Tissue specimens were free from pathological changes. The activities of the enzymes of phase I (NADPH cytochrome c reductase, ethoxycoumarin O-deethylase, aminopyrine N-demethylase, microsomal epoxide hydrolase, cytosolic epoxide hydrolase, glutathione reductase and glutathione peroxidase) and the enzymes of phase II (glutathionetransferase, glucuronyltransferase, acetyltransferase, thioltransferase, sulphotransferase and glyoxalase) were measured in the microsomal or cytosolic fractions obtained from ileum and colon mucosa. The activity in the ileum was higher than in the colon for NADPH cytochrome c reductase (p less than 0.05) and cytosolic epoxide hydrolase (p less than 0.001) (phase I enzymes), and glutathionetransferase (p less than 0.02), sulphotransferase (p less than 0.05) and glyoxalase (p less than 0.02) (phase II enzymes). The other enzymes had similar activities in two mucosa. The distribution pattern of drug metabolizing enzymes cannot be considered as a single pattern in human ileum and colon because of the observed enzyme-dependent differences.

Characterization of sulphotransferase in human ileum and colon

The kinetics of sulphotransferase (ST) were studied at varying concentrations of 2-naphthol or adenosine 3'-phosphate-5'-phosphosulphate (PAPS) in specimens of ileum and colon mucosa obtained from 6 subjects. When 2-naphthol was the variable substrate the enzyme obeyed non-Michaelis-Menten kinetics. The enzyme kinetic profile consists of two phases: one at higher and the other at lower activity for 2-naphthol. The maximum velocity of reaction (Vmax, mean +/- SD; pmol/min.mg protein) of the high-affinity phase was 403 +/- 82 (ileum) and 216 +/- 42 (colon) (p less than 0.01). Vmax for the low-affinity phase was 669 +/- 105 (ileum) and 415 +/- 84 (colon) (p less than 0.01). Km (mean +/- SD) of the high affinity phase was 0.034 +/- 0.004 (ileum) and 0.025 +/- 0.001 mmol/l (colon) (NS) and that of the low-affinity phase was 0.101 +/- 0.013 (ileum) and 0.095 +/- 0.014 mmol/l (colon) (NS). At varying concentrations of PAPS the enzyme obeyed Michaelis-Menten kinetics. Vmax (mean +/- SD) was 995 +/- 163 (ileum) and 520 +/- 114 (colon) pmol/min.mg protein (p less than 0.02). Km was 0.096 +/- 0.008 (ileum) and 0.079 +/- 0.012 mmol/l (colon) (NS). The ST of ileum differs from that of colon for Vmax only.

Painless extracorporeal shock wave lithotripsy for outpatients: a new option

Extracorporeal shock wave lithotripsy is becoming the most common procedure for the treatment of renal and ureteral stones. The introduction of a new generator and a new hemi-ellipsoid for the Dornier HM-III lithotripter improves patient comfort and requires no general or peridural anesthesia, thus making it easier to perform this procedure on an outpatient basis.

Cytosolic epoxide hydrolase in humans: development and tissue distribution

Cytosolic epoxide hydrolase activity was measured towards trans-stilbene oxide in 41 human adult livers, in 40 fetal livers, in 17 placentas and in fetal and adult lungs, kidneys and gut. The cytosolic epoxide hydrolase activity was measurable in all specimens investigated. The rate of formation of trans-stilbene glycol (pmol/min per mg protein, mean +/- SD) was 55.2 +/- 89.6 (fetal liver). 303.2 +/- 73.2 (adult liver) and 18.8 +/- 13.1 (placenta) In the fetal extrahepatic tissues, the cytosolic epoxide hydrolase activity was 70.0 +/- 9.4 (adrenals), 47.6 +/- 7.2 (gut), 69.4 +/- 22.5 (kidneys) and 43.2 +/- 19.2 (lungs) pmol/min per mg protein, whereas in the adult tissues it was 131.2 +/- 63.1 (kidneys), 27.8 +/- 20.3 (intestine), 8.5 +/- 2.8 (lungs) and 7.2 +/- 4.2 (urinary bladder) pmol/min per mg protein.

Glutathione S-transferase in humans: development and tissue distribution

Glutathione S-transferase (GST) was investigated with benzo(a)pyrene-4,5-oxide (BPO) as substrate in tissue specimens from 26 fetal and 27 adult livers and 27 placentas. The average (+/- SEM) of GST activity in the cytosol was 1.80 +/- 0.18 (fetal liver), 3.05 +/- 0.30 (adult liver) and 1.18 +/- 0.07 (placenta) nmol/min/mg. GST was also investigated in human fetal and adult lungs, kidneys and gut. In these tissues the average (+/- SEM) GST activity ranged between 0.71 +/- 0.12 (adult intestine) and 2.11 +/- 0.18 (fetal lungs) nmol/min/mg. Whereas in the fetal liver the conjugation of BPO was catalyzed at a rate of about two-thirds of the adult rate, similar or higher GST activities were found in the fetal non-hepatic tissues as compared to the adult organs. No correlation was found between the activity of the GST in fetal liver and placenta and the gestational age (11-25 weeks). GST develops before the 11th week of gestation and it does not undergo changes during the mid-gestation. No correlation was found between GST activity in adult liver and age (32-70 years).

Diagnosis of male impotence after intracavernous papaverine test

The diagnosis and treatment of male impotence have been radically modified by the introduction of intracavernous injections of papaverine. Papaverine treatment can solve more than 70% of male impotence cases, so that the real clue to the diagnosis of impotence is to discriminate between patients who can be treated by papaverine alone and patients deserving thorough investigation. The association of papaverine injection plus video sexual stimulation for this purpose was adopted in our last 250 unselected patients and represents a valuable tool. 115 of 250 achieved successful treatment for their impotence according the following percentages: intracavernous papaverine injections at the practice or at home 75.8%; prosthesis, 19.1%; venous surgery, 3.4%, and arterial surgery, 1.7%.

Hormonal pattern and testicular histology in patients with prostatic cancer after long-term treatment with a gonadotropin-releasing hormone agonist analogue

Seven patients suffering from prostatic cancer were treated with a depot form of D-Trp-6-luteinizing hormone-releasing hormone (LH-RH), a LH-RH agonist analogue (3 mg i.m. every 28 days) for a period of 24-32 months. The peptide induced a sharp and long-lasting inhibition of both gonadotropin and testosterone secretion. A sustained suppression of pituitary and testicular function was observed 40 days after the treatment was suspended. Testicular biopsies performed in all patients showed a marked impairment of Leydig cell mass and a complete spermatogenic arrest with a tubular derangement and fibrosis. Results indicate that the long-term continued gonadotropin-releasing hormone agonist analogue therapy induces not only a functional inhibition of testicular androgenesis but also anatomical testicular damage whose reversibility does not seem to be probable.

Sulfotransferase in humans: development and tissue distribution

Sulfotransferase with 2-naphthol as substrate was investigated in the cytosolic fraction of human fetal liver, lungs, kidneys, adrenal glands, intestine and placenta and also in liver, lungs, kidneys, intestinal and urinary bladder mucosa from human adult subjects. All tissue specimens assayed catalyzed the sulfation of 2-naphthol at a significant rate. The activity (expressed as pmole per minute per milligram protein; mean +/- SD) was 211 +/- 197 (n = 46) fetal liver; 22 +/- 12 (n = 29) placenta; 625 +/- 205 (n = 42) human adult liver. In fetal kidneys (576 +/- 177; n = 6) and gut (558 +/- 293; n = 6) the activity was twice as high as in liver. In the lungs (273 +/- 125; n = 6) and in the adrenals (174 +/- 119; n = 19) the sulfotransferase activity was comparable with the hepatic one. In human adult extrahepatic tissues the highest activity was found in the intestinal mucosa (153 +/- 49; n = 4) and the lowest one in the urinary bladder mucosa (16 +/- 4; n = 4). This paper shows that the sulfotransferase has a wide distribution in the human fetus and the distribution pattern of this enzyme is different in the human fetus and adult subject.

Percutaneous debulking of staghorn stones combined with extracorporeal shockwave lithotripsy: results and complications

The results and complications of 122 percutaneous debulking of staghorn stones are carefully reviewed, discriminating between dilated and not dilated kidneys. Percutaneous debulking can be defined as satisfactory in about 70% of the cases. In the remaining 30% of the cases (mostly not dilated kidneys) it has got little or no results. The overall complication rate is quite low and most of the common complications can be prevented. Percutaneous procedures in nondilated kidneys have an overall complication rate highly superior to that in dilated kidneys. It should be preferable to treat as many staghorn stones as possible in nondilated kidneys with staged extracorporeal shockwave lithotripsy (ESWL) monotherapy, stenting the ureter and monitoring the urinary infection. Struvite stones are best suitable for stented ESWL because of their fragility. In case of cystine or oxalate monohydrate staghorn stone open surgery might be preferable in virgin patients, but it is often refused by the patients.

Penile-brachial pressure index as a guide for the dosage of intracavernous injection of papaverine

From October 1985 to June 1986 we have treated 82 impotent patients. We related their penis-brachial pressure index (PBPI) with the dosage of papaverine necessary to obtain a full erection as measured by tumistore. We describe the technique and the relationship between the PBPI and the dose of papaverine necessary for the erection; in this way PBPI should be used as guide for the dosage of intracavernous papaverine injection.