Pretreatment nomogram for prostate-specific antigen recurrence after radical prostatectomy or external-beam radiation therapy for clinically localized prostate cancer

PURPOSE

To present nomograms providing estimates of prostate-specific antigen (PSA) failure-free survival after radical prostatectomy (RP) or external-beam radiation therapy (RT) for men diagnosed during the PSA era with clinically localized disease.

PATIENTS AND METHODS

A Cox regression multivariable analysis was used to determine the prognostic significance of the pretreatment PSA level, 1992 American Joint Committee on Cancer (AJCC) clinical stage, and biopsy Gleason score in predicting the time to posttherapy PSA failure in 1,654 men with T1c,2 prostate cancer managed with either RP or RT.

RESULTS

Pretherapy PSA, AJCC clinical stage, and biopsy Gleason score were independent predictors (P < .0001) of time to posttherapy PSA failure in patients managed with either RP or RT. Two-year PSA failure rates derived from the Cox regression model and bootstrap estimates of the 95% confidence intervals are presented in the format of a nomogram stratified by the pretreatment PSA, AJCC clinical stage, biopsy Gleason score, and local treatment modality.

CONCLUSION

Men at high risk (> 50%) for early (< or = 2 years) PSA failure could be identified on the basis of the type of local therapy received and the clinical information obtained as part of the routine work-up for localized prostate cancer. Selection of these men for trials evaluating adjuvant systemic and improved local therapies may be justified.

The combination of preoperative prostate specific antigen and postoperative pathological findings to predict prostate specific antigen outcome in clinically localized prostate cancer

PURPOSE

The independent clinical and pathological predictors of time to postoperative prostate specific antigen (PSA) failure were used to identify prostate cancer patients at high risk for this end point.

MATERIALS AND METHODS

A Cox regression multivariate analysis was used to determine the prognostic significance of preoperative PSA, pathological stage, prostatectomy Gleason score and margin status in predicting the time to postoperative PSA failure in 862 men with palpable (T2) or PSA detected (T1c) prostate cancer. The 2-year PSA failure rates with 95% confidence intervals were calculated using the results of Cox regression analysis and a bootstrap procedure with 2,000 replications, respectively, and are presented in nomogram format stratified by preoperative PSA, pathological stage, prostatectomy Gleason score and margin status.

RESULTS

Preoperative PSA (p = 0.0001), pathological stage (p< or =0.002), margin status (p = 0.0001) and prostatectomy Gleason score (p = 0.034) were independent predictors of time to postoperative PSA failure.

CONCLUSIONS

Patients at high risk for early PSA failure could be identified postoperatively on the basis of preoperative PSA and prostatectomy pathology. Adjuvant therapy trials in these select patients may be justified.

The nephritogenic T cell response in murine chronic graft-versus-host disease

To investigate mechanisms of cell-mediated events in chronic glomerulonephritis, T cell clones were isolated from kidneys of animals with murine chronic graft-vs-host disease. This systemic disorder is induced in normal (C57BL/6 x DBA/2)F1 recipients (H-2b/d) following transfer of parental (DBA/2) T cells (H-2d). These studies demonstrate that mouse renal (MR) T cells isolated from nephritic kidneys of diseased recipients are host-derived CD4+ alpha/beta+ T cells. Adoptive transfer of a panel of MR clones to naive (C57BL/6 x DBA/2)F1 recipients reveals distinct functional subsets. One subset does not transfer renal disease, and one induces severe renal inflammation and damage. In vitro proliferative responses of nephritogenic MR clones reveal predominant reactivity toward autologous class II MHC (I-Ed/I-Ad) determinants, and selected nephritogenic MR clones preferentially recognize renal Ag preparations derived from normal (C57BL/6 x DBA/2)F1 kidneys. In addition, cytokine profile analysis of MR clones indicates a Th2 pattern with IL-4 and IL-10 expression, although nephritogenic T cell clones also express IFN-gamma. These data suggest that the nephritogenic T cell response in chronic graft-vs-host disease is autoreactive in nature and may be restricted by determinants shared by both graft and host (Iad).

The Nephritogenic T Cell Response in Murine Chronic Graft-Versus-Host Disease

To investigate mechanisms of cell-mediated events in chronic glomerulonephritis, T cell clones were isolated from kidneys of animals with murine chronic graft-vs-host disease. This systemic disorder is induced in normal (C57BL/6 × DBA/2)F1 recipients (H-2b/d) following transfer of parental (DBA/2) T cells (H-2d). These studies demonstrate that mouse renal (MR) T cells isolated from nephritic kidneys of diseased recipients are host-derived CD4+ α/β+ T cells. Adoptive transfer of a panel of MR clones to naive (C57BL/6 × DBA/2)F1 recipients reveals distinct functional subsets. One subset does not transfer renal disease, and one induces severe renal inflammation and damage. In vitro proliferative responses of nephritogenic MR clones reveal predominant reactivity toward autologous class II MHC (I-Ed/I-Ad) determinants, and selected nephritogenic MR clones preferentially recognize renal Ag preparations derived from normal (C57BL/6 × DBA/2)F1 kidneys. In addition, cytokine profile analysis of MR clones indicates a Th2 pattern with IL-4 and IL-10 expression, although nephritogenic T cell clones also express IFN-γ. These data suggest that the nephritogenic T cell response in chronic graft-vs-host disease is autoreactive in nature and may be restricted by determinants shared by both graft and host (Iad).

Use of endorectal MR imaging to predict prostate carcinoma recurrence after radical prostatectomy

PURPOSE

To determine the ability of endorectal magnetic resonance (MR) imaging to help predict postprostatectomy disease recurrence and, thereby, patient outcome.

MATERIALS AND METHODS

The authors evaluated 116 patients referred for prostate MR imaging during 1991 and 1992 who subsequently underwent radical prostatectomy and for whom follow-up data through 1996 could be obtained. The MR reports, clinic charts, and pathology reports were reviewed. Disease recurrence was established by means of detectable levels of serum prostate-specific antigen (PSA) after surgery.

RESULTS

Thirty-four patients (29%) had postoperative disease recurrence. Patients with recurrence had higher preoperative PSA values (P < .0001). These patients also more frequently had positive surgical margins (P = .0005), transcapsular tumor spread (P < .0001), seminal vesicle involvement (P = .0012), and tumors of advanced stage (P < .0001) and high grade (P = .0058). Of 13 patients whose MR examinations showed definite extracapsular disease, eight (62%) had disease recurrence. The recurrence rate when MR imaging indicated limited disease (24%) was similar to that when MR imaging showed possible microscopic extension (27%). An MR finding of definite extracapsular disease was 24% sensitive and 94% specific for the prediction of disease recurrence.

CONCLUSION

MR imaging findings of definite extracapsular spread of disease helped predict prostate tumor recurrence with high specificity, although with low sensitivity.

A prostate gland volume of more than 75 cm3 predicts for a favorable outcome after radical prostatectomy for localized prostate cancer

OBJECTIVES

Both the benign and malignant prostatic epithelial components of the prostate gland contribute to the serum prostate-specific antigen (PSA) level. Therefore, for a given PSA, the presence of benign hyperplastic prostate tissue (BHPT) may indicate a lower cancer burden. This study was performed to assess the impact of varying amounts of BHPT on PSA failure free (bNED) survival after radical prostatectomy for localized prostate cancer.

METHODS

Cox regression multivariable analyses were performed to assess the ability of the clinical stage, PSA, biopsy Gleason score, and prostate gland volume to predict time to postoperative PSA failure in 885 patients.

RESULTS

In addition to the PSA (P < 0.0001), biopsy Gleason score of 8 to 10 (P < 0.0001) and of 7 (P = 0.05), and clinical Stage T2c,3a (P < 0.0001) and T2b (P = 0.0016), the prostatectomy prostate gland volume (P < 0.0001) was a significant predictor of time to postoperative PSA failure. Patients with a prostatectomy prostate gland volume greater than 75 cm3 had a 100% 4-year bNED survival and favorable pathologic characteristics (pathologic Stage T2, 85%; prostatectomy Gleason score 6 or less, 78% and 7, 22%; and negative margins, 95%) despite a preoperative PSA of 10 to 20 ng/mL and more than 20 ng/mL in 28% and 13% of these men, respectively. In 75% of these cases, lead time bias because of PSA driven repeat biopsies provided an explanation.

CONCLUSIONS

Lead time bias because of PSA driven repeat biopsy accounted for the high 4-year bNED survival and favorable pathologic findings for most patients who had prostate cancer coexisting in a prostate gland comprised of BHPT and a total gland volume in excess of 75 cm3. An additional explanation is needed, however, for the remaining patients.

Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer

CONTEXT

Interstitial radiation (implant) therapy is used to treat clinically localized adenocarcinoma of the prostate, but how it compares with other treatments is not known.

OBJECTIVE

To estimate control of prostate-specific antigen (PSA) after radical prostatectomy (RP), external beam radiation (RT), or implant with or without neoadjuvant androgen deprivation therapy in patients with clinically localized prostate cancer.

DESIGN

Retrospective cohort study of outcome data compared using Cox regression multivariable analyses.

SETTING AND PATIENTS

A total of 1872 men treated between January 1989 and October 1997 with an RP (n = 888) or implant with or without neoadjuvant androgen deprivation therapy (n = 218) at the Hospital of the University of Pennsylvania, Philadelphia, or RT (n = 766) at the Joint Center for Radiation Therapy, Boston, Mass, were enrolled.

MAIN OUTCOME MEASURE

Actuarial freedom from PSA failure (defined as PSA outcome).

RESULTS

The relative risk (RR) of PSA failure in low-risk patients (stage T1c, T2a and PSA level < or =10 ng/mL and Gleason score < or =6) treated using RT, implant plus androgen deprivation therapy, or implant therapy was 1.1 (95% confidence interval [CI], 0.5-2.7), 0.5 (95% CI, 0.1-1.9), and 1.1 (95% CI, 0.3-3.6), respectively, compared with those patients treated with RP. The RRs of PSA failure in the intermediate-risk patients (stage T2b or Gleason score of 7 or PSA level >10 and < or =20 ng/mL) and high-risk patients (stage T2c or PSA level >20 ng/mL or Gleason score > or =8) treated with implant compared with RP were 3.1 (95% CI, 1.5-6.1) and 3.0 (95% CI, 1.8-5.0), respectively. The addition of androgen deprivation to implant therapy did not improve PSA outcome in high-risk patients but resulted in a PSA outcome that was not statistically different compared with the results obtained using RP or RT in intermediate-risk patients. These results were unchanged when patients were stratified using the traditional rankings of biopsy Gleason scores of 2 through 4 vs 5 through 6 vs 7 vs 8 through 10.

CONCLUSIONS

Low-risk patients had estimates of 5-year PSA outcome after treatment with RP, RT, or implant with or without neoadjuvant androgen deprivation that were not statistically different, whereas intermediate- and high-risk patients treated with RP or RT did better then those treated by implant. Prospective randomized trials are needed to verify these findings.

PTCH gene mutations in invasive transitional cell carcinoma of the bladder

LOH analysis suggests that multiple tumor suppressor genes play a role in the development of human TCC. The human homolog of the Drosophila PTCH was recently cloned and mapped to the BCNS locus on 9q22.3, a chromosomal region commonly deleted in TCCs. We first examined the steady state mRNA transcription of the PTCH, SMOH and GLI3 genes of the HH signal transduction pathway in TCC cell lines and normal urothelium. Normal urothelium and TCC cell lines express these three genes within the PTCH signal transduction pathway. We then screened for PTCH mutations in 'hot spot' exons 6, 8, 13 and 16 by PCR/SSCP analysis of genomic DNAs from 54 TCC tumor samples and control autologous peripheral blood lymphocytes. DNA sequence analysis confirmed TCC-specific mutations in two of 54 patients (3.7%). These mutations resulted a single amino acid substitution and two frame shifts. One tumor had PTCH mutations in exon 16 as well as exon 13 and one tumor had a mutation in exon 13 alone. Both TCC tumors that contained PTCH mutations had a loss of heterozygosity at 9q. Although the PTCH protein has an unknown function in urothelial cells, the detection of the PTCH, SMOH and GLI3 transcripts in normal urothelium and TCC cell lines and rare PTCH mutations in tumor samples suggest that the HH pathway may have a role in controlling the proliferation of urothelial cells and that PTCH mutations may contribute to the development of a subset of TCCs.

Calculated prostate cancer volume greater than 4.0 cm3 identifies patients with localized prostate cancer who have a poor prognosis following radical prostatectomy or external-beam radiation therapy

PURPOSE

Patients with palpable extraprostatic disease (T3) have a poor prostate-specific antigen (PSA) failure-free (bNED) survival rate after radical prostatectomy (RP) or external-beam radiation therapy (RT). This study was performed to validate or refute the prognostic value of the previously defined calculated prostate cancer volume (cV(Ca)).

PATIENTS AND METHODS

For patients with clinically localized disease (T1c,2), a Cox regression multivariable analysis was used to assess the ability of the cV(Ca) value to predict time to posttherapy PSA failure following RP or RT.

RESULTS

The cV(Ca) value was a significant predictor (P < or = .0005) of time to posttherapy PSA failure in both an RP and RT data set independent of the one used to derive the cV(Ca)-based clinical staging system. In both RP- and RT-managed patients, estimates of 3-year bNED survival were not statistically different for patients with either T1c,2 disease and a cV(Ca) greater than 4.0 cm3 (RP, 27%; RT, 18%) or T3 disease (RP, 37%; RT, 34%). Despite pathologic T2 disease, the 3-year estimate of bNED survival was at most 51% in RP-managed patients with T1c,2 disease and cV(Ca) greater than 4.0 cm3.

CONCLUSION

A cV(Ca) greater than 4.0 cm3 identified patients with T1c.2 disease whose bNED survival was poor after RT or RP despite pathologic T2 disease that suggests the presence of occult micrometastatic disease in many of these patients. Prospective randomized trials to evaluate the impact on survival of adjuvant systemic therapy in these high-risk patients are justified.

bcl-2 expression in normal adrenal glands and in adrenal neoplasms

Archival paraffin-embedded tissue from 5 normal adrenal glands (including 1 from a fetus of 28 weeks' gestation), 6 cases of adrenal cortical hyperplasia, 9 cortical adenomas, 14 cortical carcinomas, and 11 pheochromocytomas were immunostained with monoclonal antibody against bcl-2. Ultrastructural localization of bcl-2 protein was also performed on selected cases. Positive immunostaining for bcl-2 was seen in all of the layers of the normal adrenal cortex, with different staining characteristics. bcl-2 expression was never observed in the normal adrenal medulla. Electron microscopic studies revealed bcl-2 to be localized predominantly to mitochondria, with a small number of labels along the nuclear envelope. Analysis of adrenal neoplasms showed expression of bcl-2 in cortical tumors, but only one positive case in pheochromocytomas. Restriction of bcl-2 expression to adrenal cortex-derived tissue versus adrenal medulla-derived tissue might prove to be helpful for the differential diagnosis between cortical and medullary tumors.

Desmin myopathy involving cardiac, skeletal, and vascular smooth muscle: report of a case with immunoelectron microscopy

Desmin myopathy is a rare idiopathic disorder characterized by abnormal aggregates of desmin-type intermediate filaments, which affects cardiac and skeletal muscle, and rarely the intestinal smooth muscle. We report a 42-year-old woman with atrial fibrillation and progressive restrictive cardiomyopathy. Left ventricular biopsy, cardiac explant, and subsequent autopsy study of skeletal muscle revealed cytoplasmic granulo-filamentous inclusions that were continuous with Z-lines and were immunoreactive for desmin filaments both at the light immunohistochemical and electron microscopic level. In addition, we report the presence of characteristic inclusions within the smooth muscle of intramural coronary blood vessels. This is the first description of desmin inclusions within vascular smooth muscle, and underscores the systemic nature of this rare myopathy.

Native atherosclerosis and vein graft arterialization: association with increased urokinase receptor expression in vitro and in vivo

Interaction of proteases with cell surface receptors may modulate cell adhesion, migration, invasion, and matrix degradation. Since the plasminogen activator system has been hypothesized to play a role in intimal thickening after various types of vascular injury, we first studied the expression of urokinase receptor (u-PAR) protein and mRNA by smooth muscle cells (SMC) grown in explant cultures from normal and diseased vessels. Using equilibrium binding studies with radiolabeled 125I-labeled single chain urokinase-type plasminogen activator (scu-PA), we determined that SMC cultured from atherosclerotic arteries expressed a higher maximal number of binding sites/cell (3.6 +/- 0.4 x 10(5) sites/cell vs. 2.1 +/- 0.3 x 10(5), +/- SEM, p < 0.05) with a similar affinity (Kd = 1.5 +/- 0.1 vs. 1.2 +/- 0.2 nM, p = ns). However, SMC subcultured from diseased saphenous vein grafts expressed the highest levels of u-PAR compared to SMC from normal saphenous vein (4.8 +/- 0.6 x 10(5) sites/cell vs. 1.6 +/- 0.9 x 10(5), +/- SEM, p < 0.05). Using binding studies and Northern analysis, we demonstrated a dose and time dependent upregulation of u-PAR protein and mRNA expression respectively in human SMC in response to serum stimulation. Using a rabbit specific u-PAR cDNA probe, we demonstrated a similar upregulation of u-PAR mRNA both in rabbit aortic SMC in culture in response to serum stimulation and up to a 20 fold increase in u-PAR mRNA in rabbit jugular veins in response to implantation as arterial grafts in vivo. Finally, to confirm that u-PAR mRNA is upregulated in human vessels after injury, we performed immunohistochemistry and in situ hybridization studies on coronary arteries, normal saphenous veins and saphenous veins from 10 weeks to 13 years after implantation as grafts. u-PAR mRNA was found mainly in the periadventitial microcirculation in normal veins, but was found to be upregulated in the neointima and media of thickened veins in both macrophages and smooth muscle cells. SMC near the internal elastic laminae in diseased coronary arteries appeared to express increased u-PAR mRNA. These data suggest that this increased expression of u-PAR may contribute to early lesion development.

Assessment of outcome prediction models for patients with localized prostate carcinoma managed with radical prostatectomy or external beam radiation therapy

BACKGROUND

A clinical staging system for localized prostate carcinoma that provides reliable information on which management decisions regarding an individual patient can be based is lacking. This study compared the abilities of all published proposed clinical staging systems to predict time to prostate specific antigen (PSA) failure after radical prostatectomy or external beam radiation therapy for clinically localized prostate carcinoma.

METHODS

A total of 1441 clinically localized prostate carcinoma patients who were managed with radical prostatectomy at the University of Pennsylvania in Philadelphia (n = 688) or the Brigham and Women's Hospital in Boston (n = 288) or with external beam radiation therapy at the Joint Center for Radiation Therapy in Boston (n = 465) were entered into this study. Patients who received adjuvant or neoadjuvant hormonal or radiation therapy were excluded. Akaike's Information Criterion (AIC) and Schwartz Bayesian Criterion (SBC) estimates, which are comparative measures, were calculated for each clinical staging system. Pairwise comparisons of the AIC and SBC estimates for the most predictive clinical staging systems were performed using a formal bootstrap technique with 2000 replications.

RESULTS

Both the staging system based on the risk score and the staging system based on the calculated volume of prostate carcinoma and PSA (cVCa-PSA) optimized the prediction of time to posttreatment PSA failure. The cVCa-PSA system, however, provided a more clinically useful stratification of outcome.

CONCLUSIONS

Improved clinical staging for patients with localized prostate carcinoma may be possible with parameters obtained during routine evaluation. Validation by other investigators is underway.

Tissue factor regulates plasminogen binding and activation

Tissue factor (TF) has been implicated in several important biologic processes, including fibrin formation, atherogenesis, angiogenesis, and tumor cell migration. In that plasminogen activators have been implicated in the same processes, the potential for interactions between TF and the plasminogen activator system was examined. Plasminogen was found to bind directly to the extracellular domain of TF apoprotein (amino acids 1-219) as determined by optical biosensor interaction analysis. A fragment of plasminogen containing kringles 1 through 3 also bound to TF apoprotein, whereas isolated kringle 4 and miniplasminogen did not. Expression of TF on the surface of a stably transfected Chinese hamster ovary (CHO) cell line stimulated plasminogen binding to the cells by 70% more than to control cells. Plasminogen bound to a site on the TF apoprotein that appears to be distinct from the binding site for factors VII and VIIa as judged by a combination of biosensor and cell assays. TF enhanced two-chain urokinase (tcuPA) activation of Glu-plasminogen, but not of miniplasminogen, in a dose-dependent, saturable manner (half maximal stimulation at 59 pmol/L). TF apoprotein induced an effect similar to that of relipidated TF, but a relatively higher concentration of the apoprotein was required (half maximal stimulation at 3.8 nmol/L). The stimulatory effect of TF on plasminogen activation was confirmed when plasmin formation was examined directly on sodium dodecyl sulfate-polyacrylamide gel electrophoresis. In accord with this, TF inhibited fibrinolysis by approximately 74% at a concentration of 14 nmol/L and almost totally inhibited the binding of equimolar concentrations of plasminogen to human umbilical vein endothelial cells and human trophoblasts. Further, CHO cells expressing TF inhibited uPA-mediated fibrinolysis relative to a wild-type control. TF apoprotein and plasminogen were found to colocalize in atherosclerotic plaque. These data suggest that plasminogen localization and activation may be modulated at extravascular sites through a high-affinity interaction between kringles 1 through 3 of plasminogen and the extracellular domain of TF.

Endorectal coil magnetic resonance imaging identifies locally advanced prostate cancer in select patients with clinically localized disease

OBJECTIVES

Endorectal coil magnetic resonance imaging (erMRI) has been reported to improve the prediction of pathologic Stage T3 disease in patients with clinical Stage T1,2 disease, prostate-specific antigen (PSA) of 10 to 20 ng/mL, biopsy Gleason score of 7 or less, and at least 50% of the biopsy specimens positive from a sextant sampling. This study examines the performance characteristics of the erMRI to predict established extracapsular extension (ECE), seminal vesicle invasion (SVI), and PSA failure-free survival (bNED) in this subgroup.

METHODS

The sensitivity, specificity, positive and negative predictive value, and accuracy of the erMRI to predict established ECE and SVI were calculated in the proposed subgroup. PSA failure-free survival stratified by the erMRI-defined stage was estimated by using the method of Kaplan and Meier.

RESULTS

The sensitivity, specificity, positive and negative predictive value, and accuracy to predict established ECE and SVI in clinical Stage T1,2 patients was 65%, 100%, 100%, 79%, and 84%, respectively. No patient would have been excluded from surgery on the basis of a false-positive study. Moreover, the percent of patients with pathologic organ-confined disease would have increased from 32% to 61%, and the 3-year bNED rate would have increased from 12% to 45% (P = 0.07) if only patients with erMRI Stage T2 disease were selected for surgery.

CONCLUSIONS

The erMRI may significantly improve the identification of established ECE and SVI in select patients with prostate cancer preoperatively. Further study of the erMRI in these select patients is warranted and ongoing.

Human saphenous vein allograft bypass grafts: immune response

Although it has been claimed that allografts of blood vessels might be successful because of minimal immunogenicity, they are subject to frequent and early failure, the cause of which has not been thoroughly investigated. We sought to define the immune response to allograft bypass. In a prospective trial, 40 patients underwent cryopreserved venous allograft bypass. Allograft biopsies were performed at implantation and at allograft explantation in instances of graft failure. Tissues were evaluated in a blinded manner by means of standard histologic examination and paraffin immunohistochemical analysis with monoclonal antibodies against a variety of immune markers. During the 31-month follow-up period, 22 allografts were removed, and 19 were suitable for immunohistochemical study. Of these 19, 6 (32%) had moderate or severe infiltrates, which were evenly distributed throughout the intima, media, and adventitia. Immunohistochemical study of the explants demonstrated all of these infiltrates to be leukocytes (+LCA), which were predominantly activated T lymphocytes (+CD3, CD8, CR3) containing cytotoxic granules (+TIA-1). Macrophages were uncommon (+CD68); B cells (+L26, CD79) and natural killer cells (+CD56) were rare. Immunosuppression was associated with decreased presence of cytotoxic granules (TIA-1). Human venous allografts are immunogenic and prompt a T cell-mediated response. Allografts also fail without strong evidence of rejection, presumably because of local injury, hypercoagulability, or stasis. It may be possible to modify the contribution of rejection to venous allograft failure by means of immunosuppression and to modify the contribution of local hypercoagulability by means of anticoagulation.

Calculated prostate carcinoma volume: The optimal predictor of 3-year prostate specific antigen (PSA) failure free survival after surgery or radiation therapy of patients with pretreatment PSA levels of 4-20 nanograms per milliliter

BACKGROUND

In this study, the authors evaluated whether a clinically relevant stratification of prostate specific antigen (PSA) failure free survival (bNED) after definitive local therapy could be made for patients with prostate carcinoma clinically classified as T1 or T2 and pretreatment PSA levels of 4-20 ng/mL.

METHODS

Multivariate Cox regression analysis and Kaplan-Meier analysis were performed for clinically localized prostate carcinoma patients who presented with PSA levels of 4-20 ng/mL. Three hundred forty-eight of the patients were managed definitively with conventional external beam radiation therapy (median dose, 67 gray), whereas 547 of the patients were managed definitively with a radical retropubic prostatectomy. The outcome tested was time to posttreatment PSA failure. The clinical predictors evaluated included the standard paradigm (PSA, biopsy Gleason score, and clinical stage); type of local therapy; and a newly defined factor, the calculated prostate cancer volume (cV[Ca]).

RESULTS

Time to posttreatment PSA failure was equivalent (P = 0.52) independent of the type of local therapy. The cV(Ca) (P < 0.0001), pretreatment PSA (P = 0.003), and clinical classification of T2c (P = 0.04) remained significant predictors of time to posttreatment PSA failure in multivariate analysis.

CONCLUSIONS

The staging system described herein, which is based on cV(Ca) and PSA, may optimize patient selection for definitive local therapy and entry onto randomized clinical trials examining the use of adjuvant hormonal or chemotherapy in patients with clinically localized disease who present with PSA levels of 4-20 ng/mL. Validation of this staging system by other investigators is currently underway.

Ethylene glycol poisoning: toxicokinetic and analytical factors affecting laboratory diagnosis

Ethylene glycol poisoning is an important toxicological problem in medical practice because early diagnosis and treatment can prevent considerable morbidity and mortality. When ingested in the form of antifreeze or other automotive products, ethylene glycol results in central nervous system depression, cardiopulmonary compromise, and renal insufficiency. Metabolism of ethylene glycol to organic acids is required for metabolic derangement and organ damage. Laboratory features of ethylene glycol poisoning include increased anion gap metabolic acidosis, increased osmolal gap, calcium oxalate crystalluria, and detectable ethylene glycol in serum. This Case Conference integrates discussion of the toxicokinetic and analytical variables that affect the laboratory diagnosis of ethylene glycol intoxication.

Thermal preconditioning before rat arterial balloon injury: limitation of injury and sustained reduction of intimal thickening

Heat shock proteins (HSPs) are a family of highly conserved proteins, essential to cell survival, that are induced during times of physiological stress. These proteins, when induced, can provide tolerance to subsequent injury. Several studies have documented that HSPs play an important role in the response of vascular cells to injury or stress. Whether the vasculature itself can be effectively preconditioned before arterial injury is unknown. Vascular HSP induction by whole-body hyperthermia (WBH) was evaluated with regard to its effects on the vascular response to balloon injury. WBH treatment of Sprague-Dawley rats (colonic temperatures of 41 to 42 degrees C for 15 minutes) resulted in maximal arterial HSP expression within 8 to 12 hours. Rats (male, 300 g, n=59) were randomly assigned to undergo either WBH or no treatment 8 hours before standard carotid balloon injury. At 14 (n=26) and 90 (n=21) days after balloon injury, histomorphometric analysis revealed a significant limitation of intimal accumulation in preconditioned arteries as compared to controls (intimal/medial area ratios+/-SEM: 14 days, 0.57+/-0.07 versus 0.86+/-0.08, P=0.01; 90 days, 0.78+/-0.12 versus 1.19+/-0.14, P<0.05). The medial cell proliferation index at 4 days (n=12) was significantly reduced in the treated group as well (3.6+/-0.9% versus 7.2+/-1.3%, P<0.05). Conversely, the mean total cell number in the media of heated arteries was higher (393+/-20 versus 328+/-17, P<0.05). Vascular preconditioning with brief WBH induces a heat shock response in the arterial wall that is associated with a significant and sustained reduction in intimal accumulation. This effect appears to be due in part to preservation of medial cell integrity and limitation of the proliferative response. These results suggest that thermal preconditioning of vascular tissue may be an effective strategy to improve long-term results after revascularization procedures.

Ethylene glycol poisoning: toxicokinetic and analytical factors affecting laboratory diagnosis

Ethylene glycol poisoning is an important toxicological problem in medical practice because early diagnosis and treatment can prevent considerable morbidity and mortality. When ingested in the form of antifreeze or other automotive products, ethylene glycol results in central nervous system depression, cardiopulmonary compromise, and renal insufficiency. Metabolism of ethylene glycol to organic acids is required for metabolic derangement and organ damage. Laboratory features of ethylene glycol poisoning include increased anion gap metabolic acidosis, increased osmolal gap, calcium oxalate crystalluria, and detectable ethylene glycol in serum. This Case Conference integrates discussion of the toxicokinetic and analytical variables that affect the laboratory diagnosis of ethylene glycol intoxication.

Expression of prolactin and its receptor in human breast carcinoma

The growth regulatory effects of PRL on the human breast are mediated by its receptor (PRLr), a member of the cytokine receptor family. Recent reverse transcriptase-PCR studies by our laboratory and others have shown PRL expression within breast tissues at the RNA level. To confirm the role of this growth factor-receptor complex in normal and malignant breast tissues, the expression of PRL and PRLr was examined in parallel with the estrogen receptor (ER) and progesterone receptor (PR). Sixty-nine cases of primary invasive breast carcinoma were examined for PRL and PRLr expression by in situ hybridization and immunohistochemical technique, respectively. These data revealed widespread expression of PRL and its receptor in the breast cancers studied (>95%) and in the normal breast tissues (>93%), with no association between the expression of PRL-PRLr and ER or PR. These findings stand in contrast to prior RIA-based studies that detected the PRLr in only 20-60% of breast carcinomas, most commonly in ER-PR-positive cells. These results confirm prior data indicating the presence of an autocrine/paracrine loop for the PRL-PRLr complex within human breast tissues. Given the widespread expression of PRL-PRLr in breast cancer, pharmacological interventions aimed at the inhibition of function of this growth regulatory receptor complex may be of considerable utility in the therapy of this disease.

Progressive angiomyolipoma with inferior vena cava tumor thrombus

A 45-year-old man presented with an incidentally discovered benign renal angiomyolipoma. This lesion initially demonstrated renal vein involvement. On referral to our institution 3 years later, there was interval progression of tumor thrombus to the intrahepatic inferior vena cava. Intravascular extension of benign angiomyolipoma, though rare, has been reported. We present a new example and review the literature concerning this unusual complication of a common renal neoplasm.