Antiadenovirus Antibodies Predict Response Durability to Nadofaragene Firadenovec Therapy in BCG-unresponsive Non-muscle-invasive Bladder Cancer: Secondary Analysis of a Phase 3 Clinical Trial

A recent phase 3 trial of intravesical nadofaragene firadenovec reported a promising complete response rate for patients with bacillus Calmette-Guérin-unresponsive non-muscle-invasive bladder cancer. This study examined the ability of antiadenovirus antibody levels to predict the durability of therapeutic response to nadofaragene firadenovec. A standardized and validated quantitative assay was used to prospectively assess baseline and post-treatment serum antibody levels among 91 patients from the phase 3 trial, of whom 47 (52%) were high-grade recurrence free at 12 mo (responders). While baseline titers did not predict treatment response, 3-mo titer >800 was associated with a higher likelihood of durable response (p = 0.026). Peak post-treatment titers >800 were noted in 42 (89%) responders versus 26 (59%) nonresponders (p = 0.001; assay sensitivity, 89%; negative predictive value, 78%). Moreover, 22 (47%) responders compared with eight (18%) nonresponders had a combination of peak post-treatment titers >800 and peak antibody fold change >8 (p = 0.004; assay specificity, 82%; positive predictive value, 73%). A majority of responders continued to have post-treatment antibody titers >800 after the first 6 mo of therapy. In conclusion, serum antiadenovirus antibody quantification may serve as a novel predictive marker for nadofaragene firadenovec response durability. Future studies will focus on large-scale validation and clinical utility of the assay. PATIENT SUMMARY: This study reports on a planned secondary analysis of a phase 3 multicenter clinical trial that established the benefit of nadofaragene firadenovec, a novel intravesical gene therapeutic, for the treatment of patients with bacillus Calmette-Guérin (BCG)-unresponsive high-risk non-muscle-invasive bladder cancer. Prospective assessment of serum anti-human adenovirus type-5 antibody levels of patients in this trial indicated that a combination of post-treatment titers and fold change from baseline can predict treatment efficacy. While this merits additional validation, our findings suggest that serum antiadenovirus antibody levels can serve as an important predictive marker for the durability of therapeutic response to nadofaragene firadenovec.

Can urinary PCA3 supplement PSA in the early detection of prostate cancer?

PURPOSE

Given the limited sensitivity and specificity of prostate-specific antigen (PSA), its widespread use as a screening tool has raised concerns for the overdiagnosis of low-risk and the underdiagnosis of high-grade prostate cancer. To improve early-detection biopsy decisions, the National Cancer Institute conducted a prospective validation trial to assess the diagnostic performance of the prostate cancer antigen 3 (PCA3) urinary assay for the detection of prostate cancer among men screened with PSA.

PATIENTS AND METHODS

In all, 859 men (mean age, 62 years) from 11 centers scheduled for a diagnostic prostate biopsy between December 2009 and June 2011 were enrolled. The primary outcomes were to assess whether PCA3 could improve the positive predictive value (PPV) for an initial biopsy (at a score > 60) and the negative predictive value (NPV) for a repeat biopsy (at a score < 20).

RESULTS

For the detection of any cancer, PPV was 80% (95% CI, 72% to 86%) in the initial biopsy group, and NPV was 88% (95% CI, 81% to 93%) in the repeat biopsy group. The addition of PCA3 to individual risk estimation models (which included age, race/ethnicity, prior biopsy, PSA, and digital rectal examination) improved the stratification of cancer and of high-grade cancer.

CONCLUSION

These data independently support the role of PCA3 in reducing the burden of prostate biopsies among men undergoing a repeat prostate biopsy. For biopsy-naive patients, a high PCA3 score (> 60) significantly increases the probability that an initial prostate biopsy will identify cancer.

A phase 2 cancer chemoprevention biomarker trial of isoflavone G-2535 (genistein) in presurgical bladder cancer patients

The soy compound genistein has been observed preclinically to inhibit bladder cancer growth with one potential mechanism being the inhibition of epidermal growth factor receptor phosphorylation (p-EGFR). A phase 2 randomized, placebo-controlled trial investigated whether daily, oral genistein (300 or 600 mg/d as the purified soy extract G-2535) for 14 to 21 days before surgery alters molecular pathways in bladder epithelial tissue in 59 subjects diagnosed with urothelial bladder cancer (median age, 71 years). G-2535 treatment was well tolerated; observed toxicities were primarily mild to moderate gastrointestinal or metabolic and usually not attributed to study drug. Genistein was detected in plasma and urine of subjects receiving G-2535 at concentrations greater than placebo subjects' but were not dose-dependent. Reduction in bladder cancer tissue p-EGFR staining between the placebo arm and the combined genistein arms was significant at the protocol-specified significance level of 0.10 (P = 0.07). This difference was most prominent when comparing the 300-mg group with placebo (P = 0.015), but there was no significant reduction in p-EGFR staining between the 600-mg group and placebo. No difference in normal bladder epithelium p-EGFR staining was observed between treatment groups. No significant differences in tumor tissue staining between treatment groups were observed for COX-2, Ki-67, activated caspase-3, Akt, p-Akt, mitogen-activated protein kinase (MAPK), or p-MAPK. No significant differences in urinary survivin or BLCA-4 levels between treatment groups were observed. Genistein displayed a possible bimodal effect (more effective at the lower dose) on bladder cancer tissue EGFR phosphorylation that should be evaluated further, possibly in combination with other agents.

Outcome of hand assisted laparoscopic bilateral native nephrectomy in transplant recipients

PURPOSE

We explored the safety and reproducibility of hand assisted laparoscopic bilateral native nephrectomy. We also present our improvements to the surgical technique.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 36 patients who underwent hand assisted laparoscopic bilateral nephrectomy at our institution between 2003 and 2010. In all cases the 2 kidneys were removed transperitoneally via a hand assisted laparoscopic technique.

RESULTS

Mean operative time was 222 minutes. Pathological kidney size was 20 to 34 cm. Mean hospital stay was 3 days (range 1 to 13). Average estimated blood loss was 175 cc (range 50 to 200). No patient required intraoperative blood transfusion. There were no intraoperative complications and no conversions to open surgery. Postoperatively complications developed in 8 patients (22%), including temporary adrenal insufficiency and pulmonary embolism in 1 each, and myocardial infarction, superficial wound infection and loss of arteriovenous fistula function in 2 each. According to the Clavien-Dindo classification complications were grades 1, 2, 3 and 4a in 2, 3, 1 and 2 patients, respectively. A total of 18 patients with kidney transplants continued to have normal graft function after surgery.

CONCLUSIONS

Simultaneous hand assisted bilateral nephrectomies are safe and reproducible. The complication rate is low and postoperative hospital stay is short compared to those in published open surgery series. Graft function was preserved in patients who underwent renal transplantation before native kidney removal.

Aberrant activation of androgen receptor in a new neuropeptide-autocrine model of androgen-insensitive prostate cancer

Treatment of advanced prostate cancer with androgen deprivation therapy inevitably renders the tumors castration-resistant and incurable. Under these conditions, neuroendocrine differentiation of prostate cancer (CaP) cells is often detected and neuropeptides released by these cells may facilitate the development of androgen independence. Exemplified by gastrin-releasing peptide (GRP), these neuropeptides transmit their signals through G protein-coupled receptors, which are often overexpressed in prostate cancer, and aberrantly activate androgen receptor (AR) in the absence of androgen. We developed an autocrine neuropeptide model by overexpressing GRP in LNCaP cells and the resultant cell line, LNCaP-GRP, exhibited androgen-independent growth with enhanced motility in vitro. When orthotopically implanted in castrated nude mice, LNCaP-GRP produced aggressive tumors, which express GRP, prostate-specific antigen, and nuclear-localized AR. Chromatin immunoprecipitation studies of LNCaP-GRP clones suggest that GRP activates and recruits AR to the cognate promoter in the absence of androgen. A Src family kinase (SFK) inhibitor, AZD0530, inhibits androgen-independent growth and migration of the GRP-expressing cell lines, and blocks the nuclear translocation of AR, indicating the involvement of SFK in the aberrant activation of AR and demonstrating the potential use of SFK inhibitor in the treatment of castration-resistant CaP. In vivo studies have shown that AZD0530 profoundly inhibits tumor metastasis in severe combined immunodeficient mice implanted with GRP-autocrine LNCaP cells. This xenograft model shows autocrine, neuropeptide- and Src kinase-mediated progression of androgen-independent CaP postcastration, and is potentially useful for testing novel therapeutic agents.

Comparing lymphadenectomy during radical nephroureterectomy: open versus laparoscopic

OBJECTIVES

Laparoscopic nephroureterectomy (LNU) is an accepted treatment for tumors of the ureter and renal pelvis, although the ability to perform a regional lymphadenectomy has been criticized. We compared the quality of lymphadenectomy with LNU with that involving open nephroureterectomy (ONU) to determine whether oncologic principles are maintained.

METHODS

We searched our institutional database for patients who had undergone ONU from 1990 to 2005. These were compared with a series of patients from January 2003 to April 2007 who underwent LNU. From each patient's medical records, we assessed the number of lymph nodes removed, the number of positive nodes removed, and the density of positive nodes. The differences between groups were analyzed using the Wilcoxon rank sum statistical test.

RESULTS

We identified 106 patients who underwent ONU with lymphadenectomy and 28 who underwent LNU with lymphadenectomy. The median number of nodes removed, median number of positive nodes, and median density of positive nodes were, respectively, 3, 0, and 0 for the ONU group; and 6, 0, and 0, for the LNU group. There was a statistically significant difference between groups with respect to the number of nodes removed (P = 0.01) but not with respect to the number of positive nodes removed (P = 0.61) or the lymph node density (P = 0.42).

CONCLUSIONS

Offsetting the benefits of laparoscopy could be a flawed oncologic technique. We have demonstrated that lymphadenectomy, which is a potentially important component of nephroureterectomy, can be performed as well during LNU as it is with ONU when a dedicated effort is made.

Ability of clinical grade to predict final pathologic stage in upper urinary tract transitional cell carcinoma: implications for therapy

OBJECTIVES

To evaluate whether the clinical grade predicts the final pathologic stage in upper urinary tract transitional cell carcinoma.

METHODS

We retrospectively reviewed the records of 184 consecutive patients undergoing nephroureterectomy for upper urinary tract transitional cell carcinoma at our institution from 1986 to 2004. Their clinical, surgical, and pathologic data were reviewed to determine the positive and negative predictive values of the clinical biopsy grade with respect to the final pathologic disease stage.

RESULTS

Of the 184 patients, 119 (64.7%) had information available regarding the clinical grade of disease from the preoperative endoscopic biopsy. The distribution was grade 1 in 2 (1.6%), grade 2 in 46 (38.7%), and grade 3 in 71 (59.7%) patients. Of the 71 patients with grade 3 disease, 47 had Stage pT2 disease or higher (66% positive predictive value). Of the 48 patients with less than grade 3 disease, 35 had less than pT2 disease (72% negative predictive value). Of the 71 patients with grade 3 disease, 30 had pT3 disease or greater (42% positive predictive value), and of the 48 patients with less than grade 3 disease, 44 had less than pT3 disease (92% negative predictive value).

CONCLUSIONS

The histologic grade obtained from the diagnostic biopsy for upper urinary tract transitional cell carcinoma can be used to predict the pathologic disease stage. This information can be used to counsel patients before surgery and to identify patients for whom neoadjuvant chemotherapy would be most beneficial.

Neoadjuvant chemotherapy followed by aggressive surgical consolidation for metastatic penile squamous cell carcinoma

PURPOSE

Combination chemotherapy for advanced penile cancer can produce partial response rates of up to 64%. Complete responses are rare, suggesting a need for adjunct therapies to facilitate cure. We evaluated patients with metastases who underwent surgical consolidation after responding to chemotherapy.

MATERIALS AND METHODS

We reviewed the records of 59 patients with advanced penile carcinoma treated from 1985 to 2000 and identified 10 treated with surgical consolidation after demonstrating a stable, partial or complete response to chemotherapy. Presenting tumor burden included pelvic and inguinal metastases. Surgical outcomes and survival were assessed.

RESULTS

After chemotherapy 4 patients had a complete response, 1 had a partial response and 5 had stable disease. Three major perioperative complications, including postoperative bleeding, an episode of acute renal failure and deep venous thrombosis in 1 patient each, and 4 minor complications, including skin breakdowns in 3 and wound seroma in 1, occurred. Three cases were rendered pN0. All 3 patients received ifosfamide, paclitaxel and cisplatin chemotherapy. Seven patients had 3 or fewer metastatic lymph nodes following surgery, of whom 4 showed no disease and 3 died. All 3 patients with greater than 3 metastatic lymph nodes died. For all patients the 5-year actuarial survival rate was 40% with a median survival of 26 months. Patients with 3 or fewer and greater than 3 positive nodes had a median survival of 48 and 23 months, respectively (p = 0.116).

CONCLUSIONS

Select patients with metastatic penile cancer that shows disease stabilization or a response to chemotherapy should be considered for surgical consolidation to extend survival.

Laparoscopic radical nephroureterectomy for transitional cell carcinoma: where are we in 2007?

PURPOSE OF REVIEW

Nephroureterectomy has undergone critical changes during the past 15 years with the advent of the laparoscopic approach. New data supporting laparoscopic nephroureterectomy (LNU) continue to emerge as new techniques are developed and current approaches refined. The purpose of this study was to investigate the findings within LNU from the past 2 years as an evolving although proven modality for treatment of upper-tract transitional cell carcinoma (TCC).

RECENT FINDINGS

Intermediate outcomes continue to be published equating the oncologic efficacy and perioperative parameters (i.e. blood loss and pain medication requirements) of LNU to those of open nephroureterectomy, allaying previous arguments against the minimally invasive approach. Newer approaches to the nephrectomy segment of LNU have been described, including robot assistance in retroperitoneoscopic cases and hand-assisted laparoscopic nephrectomy without the use of a hand-port. Data supporting specific approaches to the distal ureter have been published, including implementing robotics and flexible cystoscopy.

SUMMARY

Findings over the past 2 years show both the continued progress of LNU and the need for further evolution to optimize patient morbidity and oncologic outcomes. As laparoscopic training is integrated into urologic residency programs, standardizing the variables within LNU will be paramount.

Nephroureterectomy for treating upper urinary tract transitional cell carcinoma: Time to change the treatment paradigm?

OBJECTIVE

To evaluate factors associated with disease recurrence and survival in patients undergoing nephroureterectomy for upper urinary tract transitional cell carcinoma (UUT-TCC) in one centre over an 18-year period.

PATIENTS AND METHODS

The records of patients who had a nephroureterectomy for UUT-TCC at our institution from 1986 to 2004 were reviewed for clinical, pathological and treatment period data. Cox's proportional hazards regression model was used to test the statistical significance of several potential prognostic factors for recurrence and survival. RESULTS The median overall duration of follow-up was 2.5 years for 184 patients. Significant prognosticators for disease-specific survival (DSS) by univariate analysis were tumour stage (P < 0.01), tumour grade (P < 0.01), node-positive disease (P < 0.01), multifocality (P = 0.03), previous cystectomy (P < 0.01) and synchronous bilateral UUT-TCC (P = 0.02). On multivariate analysis, only tumour stage (P = 0.03) and grade (P = 0.01) correlated with DSS. The median recurrence-free survival duration was 2.4 years. In 44 patients, the disease recurred outside the bladder; 15 (8.2%) had local recurrence, 20 (10.9%) distant metastasis, and nine (4.9%) both local and distant recurrence. Bladder tumours occurred in 40 (26.1%) patients with no previous cystectomy. The evaluation of treatment outcome during three periods of the study showed no significant effect on DSS.

CONCLUSION

Tumour stage and grade correlated with DSS in this cohort, with no improvement in outcome over the 18-year period assessed. Patients with high-stage and high-grade disease continue to fare poorly, suggesting a need for changing the treatment protocol. Judiciously applying a multimodal approach to the management of high-risk patients by incorporating neoadjuvant chemotherapy and surgical resection might provide, for the first time, the opportunity to improve patient outcome.

Nephroureterectomy for treating upper urinary tract transitional cell carcinoma: Time to change the treatment paradigm?

OBJECTIVE

To evaluate factors associated with disease recurrence and survival in patients undergoing nephroureterectomy for upper urinary tract transitional cell carcinoma (UUT-TCC) in one centre over an 18-year period.

PATIENTS AND METHODS

The records of patients who had a nephroureterectomy for UUT-TCC at our institution from 1986 to 2004 were reviewed for clinical, pathological and treatment period data. Cox's proportional hazards regression model was used to test the statistical significance of several potential prognostic factors for recurrence and survival. RESULTS The median overall duration of follow-up was 2.5 years for 184 patients. Significant prognosticators for disease-specific survival (DSS) by univariate analysis were tumour stage (P < 0.01), tumour grade (P < 0.01), node-positive disease (P < 0.01), multifocality (P = 0.03), previous cystectomy (P < 0.01) and synchronous bilateral UUT-TCC (P = 0.02). On multivariate analysis, only tumour stage (P = 0.03) and grade (P = 0.01) correlated with DSS. The median recurrence-free survival duration was 2.4 years. In 44 patients, the disease recurred outside the bladder; 15 (8.2%) had local recurrence, 20 (10.9%) distant metastasis, and nine (4.9%) both local and distant recurrence. Bladder tumours occurred in 40 (26.1%) patients with no previous cystectomy. The evaluation of treatment outcome during three periods of the study showed no significant effect on DSS.

CONCLUSION

Tumour stage and grade correlated with DSS in this cohort, with no improvement in outcome over the 18-year period assessed. Patients with high-stage and high-grade disease continue to fare poorly, suggesting a need for changing the treatment protocol. Judiciously applying a multimodal approach to the management of high-risk patients by incorporating neoadjuvant chemotherapy and surgical resection might provide, for the first time, the opportunity to improve patient outcome.

Therapy of multidrug resistant human prostate tumors in the prostate of nude mice by simultaneous targeting of the epidermal growth factor receptor and vascular endothelial growth factor receptor on tumor-associated endothelial cells

BACKGROUND

Inhibiting epidermal growth factor receptor (EGF-R) and vascular endothelial growth factor receptor (VEGF-R) activation with AEE788 can decrease prostate cancer (CaP) growth/progression. We determined whether tumor cells or tumor-associated endothelial cells were the primary target by treating multidrug-resistant (MDR) CaP growing in the prostate of nude mice.

METHODS

MDR human CaP cells with 30-fold increased taxane-resistance were implanted into nude mouse prostates. After 2 weeks, mice were randomized to control, paclitaxel, AEE788, and AEE788/paclitaxel for 10 weeks. Mice were necropsied and tumors stained.

RESULTS

AEE788 or AEE788 plus paclitaxel significantly reduced tumor incidence and tumor weight, and eradicated lymph node metastasis. Inhibiting VEGF-R and EGF-R phosphorylation induced apoptosis of tumor-associated endothelial cells causing a second apoptotic wave of surrounding tumor cells.

CONCLUSION

Inhibiting VEGF-R and EGF-R activation on tumor-associated endothelial cells with AEE788 combined with paclitaxel can bypass CaP cell resistance and prevent lymph node metastasis.

Chemoprevention for Bladder Cancer

PURPOSE

Bladder cancer is the most expensive cancer to treat and follow in the United States due to often extended courses of treatment coupled with the necessity for frequent surveillance examinations. Because direct exposure to carcinogens is implicated in bladder cancer development and many potentially protective compounds are concentrated in urine, bladder cancer is a logical target for chemoprevention.

MATERIALS AND METHODS

We performed a MEDLINE search of the English language literature to identify reports of chemoprevention of bladder cancer. Study outcomes were evaluated and mechanisms of action were identified when possible. In cases of multiple reports of the same compound critical comparisons were performed.

RESULTS

For most putative chemopreventive agents against bladder cancer the results of different studies are conflicting. Megadose vitamins, certain vitamin A analogues and pyridoxines have been associated with promising findings. For vitamins C and E and selenium, studies showing benefit are balanced by studies showing no benefit. Other compounds, such as soy, green tea and isothiocyanates, have been suggested by some studies to be protective and by others to be tumor promoting.

CONCLUSIONS

For most bladder cancer chemopreventive agents studied to date results regarding efficacy vary, precluding the possibility of universal support by health care providers for this specific role. Megadose multivitamin supplements have demonstrated the ability to prevent bladder cancer recurrences in a single smaller study. Some analogues of vitamins A, B6, C and E have been shown to be beneficial in other disease processes, suggesting that these compounds may be advocated with the caveat that they do not have a specific protective role in bladder cancer. Data from randomized, prospective trials show a benefit in bladder cancer only after eliminating early or initial recurrences, suggesting the need for long-term administration of a chosen agent. Additional prospective trials with long-term followup, likely involving multiple institutions, are required before definitive recommendations can be made about chemoprevention for bladder cancer. In 2006 no oral agent can be recommended and to our knowledge the best chemopreventive strategy remains to be determined.

Histological changes in prostate biopsies after salvage cryotherapy: effect of chronology and the method of biopsy

OBJECTIVES

To examine changes in prostate biopsies at different intervals after salvage cryotherapy and the effect of biopsy type (transrectal ultrasonography-guided vs transurethral resection, TUR), as the sequence and extent of histological changes occurring in the prostate after salvage cryotherapy for local failure of prostate cancer treatment are unknown.

PATIENTS AND METHODS

In all, 158 prostate biopsies from 150 patients were examined histologically after salvage cryotherapy for prostate cancer after radiotherapy had failed. Specimens were grouped by time from cryotherapy and biopsy technique.

RESULTS

Biopsies showed hyalinization, necrosis, inflammation and residual cancer. Hyalinization became predominant over time, most notably in biopsies with no residual cancer. Core biopsies showed more hyalinization and regenerating glands, while TUR biopsies showed more necrosis and inflammation.

CONCLUSIONS

Tissue cryo-injury and reactive changes last for >1 year; more extensive cryo-injury suggests more effective cancer ablation. A long-term follow-up is necessary, as prostate cancer might remain indolent for >1 year.

Upper urinary tract tumors with nontransitional histology: A single-center experience

OBJECTIVES

To review our experience with patients with upper urinary tract tumors of nonurothelial origin. Upper urinary tract tumors of nonurothelial origin are uncommon entities. To our knowledge, no series of patients with these neoplasms has been published in the past decade.

METHODS

We reviewed the records at the University of Texas M. D. Anderson Cancer Center from 1990 to 2004 to identify patients with primary nonurothelial tumors of the upper urinary tract. We reviewed the patient records to collect data on tumor subtype, treatment, recurrence, and survival.

RESULTS

Sixteen patients (1.9% of our database of patients with upper urinary tract tumors) were identified; 12 had squamous cell carcinoma, 2 had adenocarcinoma, 1 had sarcomatoid carcinoma, and 1 had small cell carcinoma. The tumors were located in the renal pelvis in 10 and the ureter in 6. Of the 16 patients, 15 had been treated with nephrectomy or nephrouterectomy and 1 with chemotherapy and radiotherapy. Fifteen of the tumors were pathologic Stage T3 or worse. Ten patients received adjuvant chemotherapy. Of the 16 patients, 9 died (1 of unknown causes), 4 were alive without disease, 2 were alive with disease, and 1 was alive at last follow-up with the disease status unknown. The median follow-up was 30.1 months, the median overall survival time was 11.3 months, and 1-year survival rate was 46%. The median recurrence-free survival time and 1-year recurrence-free survival rate were 5.8 months and 38%, respectively.

CONCLUSIONS

Primary nonurothelial carcinomas of the renal pelvis and ureter are rare. Our analysis suggests a poor prognosis for most patients with these pathologic types, probably resulting from the advanced stage at diagnosis and poor responses to systemic therapy.

Dual inhibition of the epidermal growth factor and vascular endothelial growth factor phosphorylation for antivascular therapy of human prostate cancer in the prostate of nude mice

BACKGROUND

Androgen-independent prostate cancer (PCa) may be susceptible to modulation of the tumor microenvironment. We determined whether a dual tyrosine kinase inhibitor (AEE788) of the epidermal growth factor receptor (EGF-R) and vascular endothelial growth factor receptor (VEGF-R) combined with chemotherapy can produce therapy of human PCa in nude mice.

METHODS

PC-3MM2 human PCa cells were injected into the prostate of nude mice. Three days later, the mice were randomized into four groups: saline control, paclitaxel, AEE788, and AEE788 and paclitaxel. The mice were treated for 5 weeks and necropsied. Tumor incidence, weight, and incidence of lymph node metastasis were recorded. Tumor tissue was analyzed immunohistochemically.

RESULTS

Treatment of mice with AEE788 or AEE788 plus paclitaxel significantly decreased tumor incidence, total tumor weight, and incidence of lymph node metastasis. AEE788 treatment alone or in combination with paclitaxel inhibited the phosphorylation of EGF-R and VEGF-R on tumor cells and tumor-associated endothelial cells. Therapeutic efficacy correlated with an increase in apoptosis of tumor cells and tumor-associated endothelial cells.

CONCLUSION

Blockade of EGF-R and VEGF-R signaling pathways coupled with chemotherapy suppressed the progressive growth and metastasis of human PCa cells growing orthotopically in nude mice.

What's new in the management of penile cancer?

PURPOSE OF REVIEW

Penile cancer is a rare disease. This has led to little in the way of therapeutic advances in the last two decades. Efforts have been made to minimize the use of disfiguring or morbid procedures in treating the primary tumor or managing the inguinal region. In addition, new insights have been gained into multimodal therapy for treating metastatic disease. We reviewed the literature published during the past two years to define the recent insights into the diagnosis and management of penile cancer.

RECENT FINDINGS

Surveillance, Epidemiology and End Results Program data revealed poor outcome among African-American patients compared with Caucasians with penile cancer. Risk factors, including human papilloma virus, HIV, and the practice of circumcision have been reassessed. To improve diagnosis and staging, new modifications in imaging have been developed including magnetic resonance imaging with artificial erection. In addition, the technique of dynamic sentinel node biopsy has been refined. Pathologic features of the primary tumor (i.e., stage, grade, vascular invasion) assist in identifying patients who would benefit from lymphadenectomy. Organ-sparing treatments using laser ablation and reconstructive procedures to preserve glans or phallus length have also been developed. Systemic chemotherapy regimens, including consolidative approaches with surgery or radiotherapy, are discussed for advanced penile cancer.

SUMMARY

Penile cancer remains a rare disease. Epidemiologic insights reveal provocative findings with respect to risk factors and racial differences in the outcome. Recent literature provides information that will aid urologists in (1) minimizing the need for disfiguring treatment of penile tumors in some patients and (2) reducing the number of unnecessary inguinal staging procedures in others. Novel systemic therapies that generate durable responses tested in multi-institutional treatment trials are needed.

Old friends, new ways: revisiting extended lymphadenectomy and neoadjuvant chemotherapy to improve outcomes

PURPOSE OF REVIEW

Standard therapy for muscle-invasive bladder cancer is radical cystectomy and pelvic-lymph-node dissection. Because 50% of patients will die at 5 years as a result of micrometastases, improvements have been sought to increase the survival rates. Two specific approaches include administration of neoadjuvant chemotherapy or extending the boundaries of the lymph-node dissection. We reviewed the current literature to define present trends and studies that involve these adjunct treatments.

RECENT FINDINGS

The benefits of extended lymphadenectomy have been demonstrated by several groups. These include mapping nodal metastatic sites and defining the requisite number of nodes removed to optimize survival. Though not universal, it is frequently concluded that increasing the number of nodes removed improves survival without worse morbidity. Neoadjuvant chemotherapy has been proposed to eliminate occult cancer cells outside the margins of resection. Results have been variable and modest, though emerging data from the Southwest Oncology Group may further support such an approach and improve organ preservation.

SUMMARY

Extended lymphadenectomy has consistently shown benefit with minimal morbidity and should be considered--especially in cystectomy patients that are T3. The results from neoadjuvant chemotherapy are more modest. Further studies await further elucidation to confirm this.

Ureteroscopic treatment of renal calculi

Although ureteroscopic treatment of renal calculi is safe and effective. it is relatively inefficient compared with ESWL and PCNL. It should be considered primary therapy for patients with lower pole stones who have adverse ESWL characteristics and patients who are not suitable candidates for PCNL. There are also numerous clinical situations, as outlined previously, where the ureteroscopic approach is favored over other treatment modalities.

Determining variables for repeat prostate biopsy

During the evaluation of prostate cancer, men who have undergone transrectal ultrasound-guided biopsy with negative results present a dilemma as to what further follow-up is required. Multiple variables have been proposed throughout the literature to improve cancer detection rates not only in initial biopsy results, but also on repeat evaluation. These variables include prostate-specific antigen (PSA) velocity, PSA density, free-percent PSA, and histological findings, each of which may singly or collectively dictate the need for further biopsy. After performing a Medline literature search using specific Medical Subject Headings (prostate biopsy, repeat prostate biopsy, PSA velocity, PSA density, free-percent PSA, prostate inflammation), we critically evaluated pertinent articles. Using this accumulated data and information, we composed an algorithm to assist in the decision process for repeat biopsy.

Paratesticular rhabdomyoma

A case of rhabdomyoma of the spermatic cord in an infant with cryptorchidism is reported. This extremely rare tumor has not been described in an extrascrotal position or at such a young age. Differential diagnosis includes malignant rhabdomyosarcoma. Although fetal-type rhabdomyoma of the head and neck generally is a benign tumor, the prognosis of paratesticular fetal-type rhabdomyoma is unknown. Long-term follow-up is recommended.

Angiogenesis is not Mediated by Prostate Cancer Neuropeptides

Once metastatic, prostate cancer (CaP) treatment options are limited to androgen withdrawal. In this environment, the cells often develop an androgen independent state resulting in patient demise. It has been shown that during this transition, CaP cells transdifferentiate to neuroendocrine cells, which produce neuropeptides. These neuropeptides have a mitogenic effect on surrounding CaP cells. Previous observations suggest that endothelial cells may show a similar mitogenic response to neuropeptides, implicating angiogenesis in the progression of CaP. We stimulated human umbilical endothelial cells (HUVECs) with the neuropeptides bombesin and neurotensin and measured proliferation, migration, cell tube formation, and tyrosine kinase activation. In our studies, neurotensin and bombesin did not stimulate HUVEC proliferation, migration, nor tube formation. Although HUVECs express the non-receptor tyrosine kinases Fak, Src, and Etk which mediate neuropeptide signaling in CaP, they are not activated by neuropeptides in HUVECs.

The effect of nicotine on in vitro sperm motion characteristics

PURPOSE AND STUDY PLAN: Men who are habitual smokers tend to have poor semen quality. We studied the effect of nicotine on sperm motility in vitro. Spermatozoa from 13 normal fertile nonsmoking donors, washed free of seminal plasma, were treated with medium alone (control); and, 10 mM, 5 mM, 1 mM and 0.1 mM nicotine (concentrations estimated to approximate residual concentrations of nicotine in the testes of heavy smokers). Computerized sperm motion analysis (CASA) was done at 2, 4, 6 and 24 h after incubation.

RESULTS

Sperm motility, beat/cross frequency, linearity and maximum anterior lateral head displacement (ALH max.) were significantly decreased across nominal dosages (P < 0.001 by repeated measures analysis of variance). Of the concentrations tested, 0.1 mM had no effect; 1 mM significantly decreased sperm motility (P = 0.003) and linearity (P = 0.02); 5 mM decreased the beat frequency (P = 0.001) and linearity (0.02); and 10 mM markedly decreased motility (P = 0.0001), beat frequency (P = 0.0002), linearity (P = 0.02) and ALH max. (P = 0.02). The interactions between dose and time were insignificant.

CONCLUSION

Nicotine at concentrations of > or = 1 mM significantly decreased sperm motion characteristics after different periods of incubation, whereas 0.1 mM concentration had the least effect.