Anti-Müllerian hormone: a novel biomarker for aggressive prostate cancer? Emerging evidence from a prospective study of radical prostatectomies

PURPOSE

Prostate cancer patients are a heterogeneous group as regards the aggressiveness of the disease. The relationship of steroid hormones with the aggressiveness of prostate cancer is unclear. It is known that the anti-Müllerian hormone (AMH) inhibits prostate cancer cell lines in vitro. The aim of this study is to investigate the relationship of AMH and steroid hormones with the aggressiveness of prostate cancer.

METHODS

This was a prospective study of consecutive radical prostatectomy patients. We measured the following hormones: total testosterone, sex hormone-binding globulin, albumin, luteinizing hormone, follicle-stimulating hormone, estradiol, dehydroepiandrosterone sulfate, androstenedione, and AMH. The minimum follow-up after radical prostatectomy was 5 years. For the aggressiveness of prostate cancer, we considered the following three variables: post-operative Gleason score (GS) ≥ 8, TNM pΤ3 disease, and prostate-specific antigen (PSA) biochemical recurrence (BCR).

RESULTS

In total, 91 patients were enrolled. The mean age and PSA were 64.8 years and 9.3 ng/dl, respectively. The median post-operative GS was 7. Low AMH blood levels were correlated with higher post-operative GS (p = 0.001), as well as with PSA BCR (p = 0.043). With pT3 disease, only albumin was (negatively) correlated (p = 0.008). ROC analysis showed that AMH is a good predictor of BCR (AUC 0.646, 95% CI 0.510-0.782, p = 0.043); a cutoff value of 3.06 ng/dl had a positive prognostic value of 71.4% and a negative prognostic value of 63.3% for BCR. Cox regression analysis showed that AMH is a statistically significant and independent prognostic marker for BCR (p = 0.013). More precisely, for every 1 ng/ml of AMH rise, the probability for PSA BCR decreases by 20.8% (HR = 0.792). Moreover, in Kaplan-Meier analysis, disease-free survival is more probable in patients with AMΗ ≥ 3.06 ng/ml (p = 0.004).

CONCLUSIONS

Low AMH blood levels were correlated with aggressive prostate cancer in this radical prostatectomy cohort of patients. Therefore, AMH could be a prognostic biomarker for the aggressiveness of the disease.

Epigenetics and prostate cancer: defining the timing of DNA methyltransferase deregulation during prostate cancer progression

DNA methyltransferases (DNMTs) regulate gene expression by methylating cytosine residues within CpG dinucleotides. Aberrant methylation patterns have been shown in a variety of human tumours including prostate cancer. However, the expression of DNMTs in clinical samples across the spectrum of prostate cancer progression has not been studied before. Tissue microarrays were constructed from the prostatectomy specimens of 309 patients across the spectrum of prostate cancer progression: hormone-naïve low-grade prostate cancer (n=49), hormone-naïve high-grade prostate cancer (n=151), hormonally treated high-grade prostate cancer (n=65), and castrate-resistant prostate cancer (CRPC) including neuroendocrine carcinoma (n=44). Adjacent non-neoplastic parenchyma was also available in 100 patients. In 71 patients with high-grade carcinoma and lymph node metastasis, tissue from the metastasis was also available for analysis. Immunohistochemical staining was performed with antibodies against DNMT1, DNMT2, DNMT3A, DNMT3B, and DNMT3L. Our results showed that DNMT1 and DNMT3L were upregulated early in prostate cancer progression, whereas DNMT2 was upregulated as a response to androgen ablation. DNMT1, DNMT3A, and DNMT3B were higher in the late stages of prostate cancer progression, i.e., the emergence of castrate resistance and androgen-independent growth. Lastly, DNMT1, DNMT2, and DNMT3L were upregulated in lymph node metastases compared to primary carcinomas. Our results highlight a cascade of epigenetic events in prostate cancer progression.

Deep sedation in GreenLight laser prostatectomy

Introduction:

Evaluation of ketamine and propofol combination for the performance of photoselective vaporization of prostate (PVP).

Patients and Methods:

Twenty-six patients undergoing PVP for benign prostatic hyperplasia were included in the study. Co-morbidities were present in 24 patients. Midazolam 2 mg intravenous was administered for the induction to anesthesia. Propofol (10 mg/ml) and ketamine (1 mg/ml) were administered with the use of two pumps. An initial bolus dose of 0.03 ml/kg of propofol and 5 mg of ketamine was administered intravenously. The anesthesia was maintained by continuous infusion of 0.01 ml/kg/min of propofol and 2 ml/min of ketamine. Fentanyl was administered when deemed necessary. The level of sedation, peri-operative parameters and side-effects were recorded.

Results:

The average periods from the induction of anesthesia and intraoperative infusion were 12.38 ± 5.84 min and 59.5 ± 22.15 min, respectively. Average propofol and total ketamine dose were 85.5 ± 10.62 μg/kg/min and 144.9 ± 45.62 mg, respectively. The average dose of fentanyl administered was 29.81 ± 27.40 μcg. An average period between the end of the infusion and the discharge to the urology clinic was 34.62 ± 22.89 min. Ten patients experienced nausea and five eventually vomited. Hallucinations were observed in five cases while visual disturbances in two patients.

Conclusion:

The combined use of ketamine and propofol for the performance of PVP proved to be an efficient method for anesthesia. The “deep sedation” provided by these drugs was not associated with significant side-effects. Moreover, the use of the above method is indicated in patients with significant co-morbidities that should undergo PVP.

Solitary Fibrous Tumor of the Kidney with Massive Retroperitoneal Recurrence. A Case Presentation

Solitary fibrous tumor is an unusual spindle cell neoplasm that usually occurs in the pleura but has also been described in other sites. Renal presentation is rare and only 38 cases of SFT of the kidney have been described until now. Up to 90% of the tumors have benign characteristics. Local retroperitoneal recurrence is extremely rare. We report a case of a large malignant solitary fibrous tumor recurrence after the surgical excision of the primary tumor. Histological examination of the specimen confirmed the diagnosis by revealing highly positive reaction of the neoplasmatic cells for vimentin, CD34, bcl-2 and moderately positive for actin. The rate of Ki67 lied between 2–7%. No adjuvant therapy was given to the patient and he is disease-free with no imaging findings of recurrence or metastasis 9 months after the re-operation.

Contemporary pharmacotherapy for the prevention of skeletal complications in patients with prostate cancer

INTRODUCTION

Bones represent the most common metastatic sites in prostate cancer (PCa) patients, and in addition with androgen deprivation therapy, they represent the causative reasons of bone mineral density loss and the onset of skeletal-related events.

AREAS COVERED

An extensive search of PubMed/Medline was performed to identify randomized, Phase II/III controlled trials reporting results regarding the prevention of skeletal morbidity in patients with PCa.

EXPERT OPINION

Preventing bone health is an imperative issue for preserving quality of life and elongate survival and, thus, a concerted effort should be made to monitor skeletal changes and to apply treatment for preventing bone loss. Although several agents have received approval for routine use, it is of paramount importance to identify the appropriate patients who would mostly be benefited by the use of these agents with attention to documenting the toxicity and economic implications. Additionally, it remains to be justified the frequency of administration in order to balance the efficacy and the potential complications.

Early hospital admission and treatment onset may positively affect spontaneous passage of ureteral stones in patients with renal colic

OBJECTIVE

To evaluate the impact of early hospital admission and onset of medical expulsive therapy (MET) in spontaneous passage of ureteral stones causing renal colic.

METHODS

We recruited 392 patients referred to the emergency room with symptoms of renal colic. All patients received standard MET of oral tamsulosin 0.4 mg at the time of diagnosis. In group A, patients who received MET in <2 hours from the symptom onset were included, whereas group B consisted of patients treated in >2 hours. The association of MET onset and stone-free rates after 6 weeks of follow-up was evaluated. Early MET onset predictive impact on spontaneous stone passage was evaluated as well.

RESULTS

The stone-free rate in group A and B patients was 71.2% and 59.7% (P=.018), respectively. A significant association was observed between spontaneous calculus elimination and stone size (P≤.001), location within the ureter (P=.007), and the interval between pain onset and pharmaceutical management (P=.018). Patients who received a late-onset MET had an increased risk to develop febrile upper urinary tract infection during the follow-up period (P=.040). In the multivariate analysis, size (P≤.001) and early therapy onset (P=.019) were statistically important predictors for stone-free status after the surveillance period.

CONCLUSION

Patients with renal colic who admitted to the emergency department earlier since symptom onset may have increased potential to be stone free during the surveillance period.

The role of PSA density to predict a pathological tumour upgrade between needle biopsy and radical prostatectomy for low risk clinical prostate cancer in the modified Gleason system era

OBJECTIVES

We evaluate the role of prostate-specific antigen (PSA) density to predict Gleason score upgrade between prostate biopsy material and radical prostatectomy specimen examination in patients with low-risk prostate cancer.

METHODS

Between January 2007 and November 2011, 133 low-risk patients underwent a radical prostatectomy. Using the modified Gleason criteria, tumour grade of the surgical specimens was examined and compared to the biopsy results.

RESULTS

A tumour upgrade was noticed in 57 (42.9%) patients. Organ-confined disease was found in 110 (82.7%) patients, while extracapsular disease and seminal vesicles invasion was found in 19 (14.3%) and 4 (3.0%) patients, respectively. Positive surgical margins were reported in 23 (17.3%) patients. A statistical significant correlation between the preoperative PSA density value and postoperative upgrade was found (p = 0.001) and this observation had a predictive value (p = 0.002); this is in contrast to the other studied parameters which failed to reach significance, including PSA, percentage of cancer in biopsy and number of biopsy cores. Tumour upgrade was also highly associated with extracapsular cancer extension (p = 0.017) and the presence of positive surgical margins (p = 0.017).

CONCLUSIONS

PSA density represents a strong predictor for Gleason score upgrade after radical prostatectomy in patients with clinical low-risk disease. Since tumour upgrade increases the potential for postoperative pathological adverse findings and prognosis, PSA density should be considered when treating and consulting patients with low-risk prostate cancer.

Bilateral cancer in prostate biopsy associates with the presence of extracapsular disease and positive surgical margins in low risk patients: a consideration for bilateral nerve sparing radical prostatectomy decision

PURPOSE

To evaluate the epidemiological, clinical and pathological parameters that may predict the presence of positive surgical margins and extraprostatic disease in patients with low risk [prostate specific antigen (PSA) < 10, and Gleason score ≤ 6, stage T1c)] prostate cancer.

MATERIALS AND METHODS

We retrospectively analyzed the medical records of patients who had undergone radical prostatectomy from January 2005 until January 2011. The analysis comprised patients age, preoperative serum prostate specific antigen (PSA) level, prostate volume, PSA density, biopsy Gleason score, the presence of bilateral disease according to the results of biopsy cores analysis, the percentage of cancer in biopsy material and the presence of high grade prostatic intraepithelial neoplasia.

RESULTS

A total of 117 patients were included in the study. Positive surgical margins were found in 37 (31.6%) patients and 23 (19.7%) had advanced disease. The results of the multivariate analysis showed that bilateral disease was the single significant predictor for advanced disease prediction (P = .04). Same results was obtained by the univariate analysis of the variables for prediction of positive surgical margins, where bilateral disease after biopsy cores analysis was the only factor to be statistical significant (P = .018).

CONCLUSION

Bilateral prostate cancer in prostate biopsy is significantly associated with positive surgical margins and advanced disease in patients that are operated for prostate cancer of low risk.This observation may assist the selection of patients in whom a bilateral nerve sparing radical prostatectomy is planned to be performed.

Evaluating PSA Density as a Predictor of Biochemical Failure after Radical Prostatectomy: Results of a Prospective Study after a Median Follow-Up of 36 Months

Purpose. To evaluate the predictive ability of PSA density for biochemical relapse after radical prostatectomy in patients operated for clinically localized disease and to compare its predictive strength with preoperative PSA and Gleason score. Patients and Methods. The study evaluated 244 patients with localized disease who underwent an open retropubic radical prostatectomy between February 2007 and April 2011. PSA was measured every 3 months after surgery with a mean follow-up period of 36 months. Two consecutive rises >0.2 ng/mL were considered as biochemical relapse. Results. Biochemical recurrence was observed in 71 (29.1%). A great correlation was found between relapse and PSA (P = 0.005), PSA density (P = 0.002), Gleason score (P = 0.015), pathological stage (P = 0.001), positive surgical margins (P = 0.021), and invasion of seminal vesicles (P < 0.001) and lymph nodes (P < 0.001). We also found that PSA density was associated with adverse pathological findings. In univariate and multivariate analysis both PSA (P = 0.006) and PSA density (P = 0.009) were found to be significant predictors for relapse in contrast to tumor grade. Conclusion. PSA density is a valuable parameter in estimating the danger of biochemical failure and it may increase predictive potential through the incorporation in preoperative nomograms.

Parameters predicting postoperative unilateral disease in patients with unilateral prostate cancer in diagnostic biopsy: a rationale for selecting hemiablative focal therapy candidates

BACKGROUND

Focal hemiablative therapy for prostate cancer is a new treatment alternative. Unilateral and unifocal disease are its main limitations. The aim of this study was to identify the epidemiological, clinical and pathological parameters that may predict unilateral disease in patients diagnosed with prostate cancer.

METHODS

We performed a retrospective analysis of patients at our institution between January 2005 and January 2011. Only patients with unilateral disease in prostate biopsy were part of the study. The analysis included age, preoperative prostate-specific antigen (PSA) and its density, prostate volume, biopsy first and second Gleason pattern and Gleason summary, number of biopsy cores, percentage of cancer in biopsy material and the presence of high-grade prostatic intraepithelial neoplasia. Their role as potential predictors was evaluated by univariate and multivariate analysis.

RESULTS

A total of 161 patients had unilateral disease after prostate biopsy. A significant correlation was found between prostate volume, PSA density and percentage of cancer in biopsy material and the presence of unilateral disease in the surgical specimen. These are the same factors significant in the univariate analysis. The results of the multivariate analysis demonstrated that PSA density (p = 0.015) and percentage of cancer in biopsy material (p = 0.028) are the most significant predictors.

INTERPRETATION

Our results demonstrate that PSA density and the percentage of cancer in biopsy cores are significant predictors for prostate cancer unilaterality and should be considered for the selection of hemiablative focal therapy candidates.

Clinical and pathological variables that predict changes in tumour grade after radical prostatectomy in patients with prostate cancer

INTRODUCTION

Preoperative Gleason score is crucial, in combination with other preoperative parameters, in selecting the appropriate treatment for patients with clinically localized prostate cancer. The aim of the present study is to determine the clinical and pathological variables that can predict differences in Gleason score between biopsy and radical prostatectomy.

METHODS

We retrospectively analyzed the medical records of 302 patients who had a radical prostatectomy between January 2005 and September 2010. The association between grade changes and preoperative Gleason score, age, prostate volume, prostate-specific antigen (PSA), PSA density, number of biopsy cores, presence of prostatitis and high-grade prostatic intraepithelial neoplasia was analyzed. We also conducted a secondary analysis of the factors that influence upgrading in patients with preoperative Gleason score ≤6 (group 1) and downgrading in patients with Gleason score ≤7 (group 2).

RESULTS

No difference in Gleason score was noted in 44.3% of patients, while a downgrade was noted in 13.7% and upgrade in 42.1%. About 2/3 of patients with a Gleason score of ≤6 upgraded after radical prostatectomy. PSA density (p = 0.008) and prostate volume (p = 0.032) were significantly correlated with upgrade. No significant predictors were found for patients with Gleason score ≤7 who downgraded postoperatively.

CONCLUSION

Smaller prostate volume and higher values of PSA density are predictors for upgrade in patients with biopsy Gleason score ≤6 and this should be considered when deferred treatment modalities are planned.

PSA density is superior than PSA and Gleason score for adverse

Introduction: Prostate-specific antigen (PSA) and its kinetics have changed prostate cancer screening and diagnosis. The aim of the present study was to evaluate their value in prostate cancer prognosis by determining the predictive potential of PSA density for adverse pathologic features after radical prostatectomy, in terms of positive surgical margins (PSM), extracapsular disease (ECD), seminal vesicle invasion (SVI) and/or lymph node invasion (LNI), and to compare their predictive ability with preoperative PSA and biopsy Gleason score.Methods: We retrospectively analysed 285 patients diagnosed with prostate cancer and underwent a retropubic radical prostatectomy for clinically localized disease. Data concerning preoperative PSA, biopsy Gleason score and PSA density were collected and analyzed. PSA density was calculated by dividing preoperative PSA and the pathological volume of the prostate.Results: There was a significant difference in PSA density valuesbetween patients with PSM, ECD, SVI and LNI. Areas under thecurve for PSA density were higher than those of PSA and Gleason score for all parameters of adverse pathology. In multivariate analyses, it was shown that PSA density and Gleason score were the only statistically significant predictors for PSM and ECD, PSA density and PSA for SVI and only PSA density for LNI.Conclusion: PSA density is an accurate predictor for adverse pathology prediction in patients undergoing radical prostatectomy. Theseresults demonstrate that this parameter is useful to determine the aggressiveness of prostate cancer and can be used as an adjunct in predicting outcomes after surgery.

PSA density is superior than PSA and Gleason score for adverse pathologic features prediction in patients with clinically localized prostate cancer

INTRODUCTION

Prostate-specific antigen (PSA) and its kinetics have changed prostate cancer screening and diagnosis. The aim of the present study was to evaluate their value in prostate cancer prognosis by determining the predictive potential of PSA density for adverse pathologic features after radical prostatectomy, in terms of positive surgical margins (PSM), extracapsular disease (ECD), seminal vesicle invasion (SVI) and/or lymph node invasion (LNI), and to compare their predictive ability with preoperative PSA and biopsy Gleason score.

METHODS

We retrospectively analysed 285 patients diagnosed with prostate cancer and underwent a retropubic radical prostatectomy for clinically localized disease. Data concerning preoperative PSA, biopsy Gleason score and PSA density were collected and analyzed. PSA density was calculated by dividing preoperative PSA and the pathological volume of the prostate.

RESULTS

There was a significant difference in PSA density values between patients with PSM, ECD, SVI and LNI. Areas under the curve for PSA density were higher than those of PSA and Gleason score for all parameters of adverse pathology. In multivariate analyses, it was shown that PSA density and Gleason score were the only statistically significant predictors for PSM and ECD, PSA density and PSA for SVI and only PSA density for LNI.

CONCLUSION

PSA density is an accurate predictor for adverse pathology prediction in patients undergoing radical prostatectomy. These results demonstrate that this parameter is useful to determine the aggressiveness of prostate cancer and can be used as an adjunct in predicting outcomes after surgery.

Correlation of ultrasound-estimated bladder weight to urodynamic diagnoses in women with lower urinary tract symptoms

OBJECTIVE

To test the hypothesis that the ultrasound-estimated bladder weight (UEBW) will correlate with the urodynamic diagnoses in women with lower urinary tract symptoms, in particular, detrusor underactivity and bladder outflow obstruction. Ultrasonography has been increasingly used in the assessment of lower urinary tract conditions.

METHODS

Adult women referred to the urodynamics suite for investigation of lower urinary tract symptoms were enrolled. After urodynamic evaluation, the portable BladderScan BVM 6500 device was used to calculate the bladder wall thickness and UEBW according to a standardized protocol. The patients were categorized according to the urodynamic findings. Women with normal findings, despite the symptoms for which they were referred, were used as the control group. The UEBW and bladder wall thickness measurements were compared between the groups and controls, using the Mann-Whitney and Kolmogorov-Smirnov tests. P <.05 was considered statistically significant.

RESULTS

A total of 187 women were enrolled. The UEBW was significantly lower in the patients with detrusor underactivity than in the controls (39.3 ± 3.0 g vs 45.7 ± 3.1 g, P <.001). Significant differences were also noted between the controls and patients with bladder outflow obstruction, with or without detrusor overactivity (45.7 ± 3.1 g vs 52.1 ± 3.9 g and 52.3 ± 6.2 g, respectively; P <.001 for both). The difference, in terms of the UEBW, between controls and patients with detrusor overactivity was not statistically significant (45.7 ± 3.1 g vs 45.3 ± 3.0, P > .05).

CONCLUSION

A significantly reduced UEBW in female patients with detrusor underactivity and a significantly increased UEBW in patients with bladder outflow obstruction were found. However, the finding of a significantly increased bladder weight in patients with detrusor overactivity was not confirmed in the present study.

Implication of high grade intraepithelial neoplasia in adverse pathology after radical prostatectomy

The implication of high grade prostatic intraepithelial neoplasia (HGPIN) to prostate cancer aggressiveness and prognosis is conflicted. The aim of the present study was to evaluate the role of HGPIN in prediction of adverse pathology in patients undergoing a radical prostatectomy. We retrospectively analysed patients who underwent a radical prostatectomy between January 2005 and December 2010. The relationship between HGPIN and the presence of upgrade, positive surgical margins (PSM), extracapsular disease (ECD), seminal vesicle invasion (SVI) and lymph node invasion (LNI) was analysed. HGPIN predictive ability was estimated by using receiver operating characteristic curves. HGPIN was found in 160 (53.3%) specimens. A statistically significant correlation was found between HGPIN and preoperative prostate specific antigen (p=0.020) and patients' age (p=0.025). No significant differences were found, regarding the presence of adverse pathological findings, between the patients with or without HGPIN, irrespective of the preoperative risk stratification. HGPIN did not reach significance for the prediction of upgrade, PSM, ECD, SVI and LNI. The presence of concomitant HGPIN and prostate cancer found not to be related with tumor aggressiveness in patients undergoing a radical prostatectomy and should not be considered as a parameter for the operative outcome prediction.

A systematic review of the role of adjuvant and neoadjuvant pharmacotherapy in patients undergoing radical prostatectomy

INTRODUCTION

Between 25 and 30% of patients with newly diagnosed prostate cancer are classified as high risk for an adverse prognosis. A significant number of these will progress to biochemical or clinical relapse. As there is no consensus regarding the optimal treatment of these cases, a multimodal therapeutic approach, including radical prostatectomy, remains an option.

AREAS COVERED

The Pubmed/Medline database was searched to identify trials that have evaluated adjuvant and neoadjuvant pharmaceutical protocols combined with radical prostatectomy and provided information regarding efficacy and safety.

EXPERT OPINION

Improvements in adverse pathological findings, following operations in patients who received neoadjuvant treatment, have been reported in the majority of the reviewed studies. Furthermore, the addition of pharmacotherapy to radical prostatectomy has produced beneficial results in survival surrogates. However, no benefits in overall survival were observed with adjuvant or neoadjuvant protocols and toxicity was a concern, especially in combination regimens. New studies on the effects of current pharmacotherapy and of new agents on overall survival and quality of life, after defining well-established criteria for patient stratification and inclusion, are required urgently.

Clinical and pathological parameters predicting extracapsular disease in patients undergoing a radical prostatectomy for clinically localized prostate cancer

To determine the epidemiological, clinical and pathological factors that can potentially predict extracapsular extension of prostate cancer in patients undergoing radical prostatectomy for clinically localized disease. We retrospectively analyzed the medical records of patients who undergone radical prostatectomy from January 2001 until November 2010. Patients age, prostate volume, PSA, PSA density, percent of cancer in prostate biopsy material, presence of cancer in biopsy cores of the right lobe or the left lobe or both lobes, Gleason summary, 1st Gleason pattern and 2nd Gleason pattern were analyzed for their predictive ability. From 187 studied patients, 44 of them (23.5%) had extracapsular disease. Multivariate analyses revealed that smaller prostate volumes and the presence of malignancy in both lobes after prostate biopsy were significant predictors for non-organ confined disease in the total population and in patients with Gleason score ≥ 7. Presence of malignancy in both lobes was the only significant predictive factor in patients with PSA ≤ 10 and in those with Gleason score ≤ 6. Prostate volume and positive cores for malignancy from both lobes after prostate biopsy are preoperative data that can be used for prediction of extracapsular disease. This information can be valuable in cases a nerve sparing radical prostatectomy is planned.

Role of white blood cell and neutrophil counts in predicting spontaneous stone passage in patients with renal colic

OBJECTIVE

To determine the clinical, imaging and laboratory variables that can predict spontaneous passage of ureteral stones causing renal colic and the role of white blood cell (WBC) and neutrophil counts for the prediction of spontaneous calculi passage.

PATIENTS AND METHODS

A total of 156 patients who were referred to the emergency department complaining of renal colic due to a ureteral stone entered the analysis. Several clinical, laboratory and imaging parameters were evaluated for their potential ability to predict stone passage in a time interval of 1 month. The study design had two objectives. Primarily we analyzed all patients irrespective of stone size and secondly we analyzed patients with calculi of 10 mm maximum length.

RESULTS

Spontaneous stone passage was observed in 96 (61.5%) patients in the overall population and in 84 (65.1%) of 129 patients with calculi <10 mm. Increased concentrations of serum WBCs and neutrophils at the time of the acute phase of a renal colic were associated with increased likelihood of spontaneous passage. In the multivariate analyses we found that WBC and neutrophil counts were the most important predictors of stone elimination.

CONCLUSIONS

Active surveillance of patients suffering from ureteral lithiasis is an acceptable option. Identifying the parameters which can predict those patients who will mostly benefit from this is of great importance. Based on our results, WBC and neutrophil counts should be considered when patients with renal colic secondary to ureteral calculi are evaluated since they can significantly add to spontaneous elimination prediction. Their consideration in addition to other important factors, like stone size and location, would maximize their predictive ability.

Stenting or not prior to extracorporeal shockwave lithotripsy for ureteral stones? Results of a prospective randomized study

PURPOSE

To determine the need for pre-treatment stenting in patients undergoing extracorporeal shockwave lithotripsy (ESWL) for ureteral stones sized 4-10 mm.

METHODS

A prospective randomized study was conducted between September 2009 and March 2011. Included 156 patients randomized in stented and non-stented groups and underwent a maximum of 3 ESWL sessions. Radiographic follow-up was used to assess the stone fragmentation and clearance. Results were compared in terms of stone-free rates, post-treatment morbidity and complications.

RESULTS

Overall efficacy was 76.9%. Stone-free rates were statistically significantly lower (P = 0.026) in the stented group (68.6%) compared to the non-stented ones (83.7%). Furthermore, stenting was significantly correlated with post-treatment lower urinary tract symptoms (P ≤ 0.001), need for more ESWL sessions (P = 0.019) and possibility for operation due to ESWL failure (P = 0.026). A multivariate analysis was conducted to identify the parameters which may predict complete stone removal after ESWL. Stone size (P = 0.026), stone location (P = 0.011) and stenting (P = 0.007) were the most significant factors.

CONCLUSIONS

ESWL is an efficient and safe treatment for 4- to 10-mm ureteral stones. Pre-treatment stenting is limiting stone-free rates and is significantly influencing post-ESWL morbidity and quality of life in a negative manner, while it contributes minimally to the prophylaxis of complications.

The angiogenic switch for vascular endothelial growth factor-A and cyclooxygenase-2 in prostate carcinoma: correlation with microvessel density, androgen receptor content and Gleason grade

OBJECTIVE

Angiogenesis is essential for tumor growth and metastasis; however, angiogenic factors are not uniformly expressed in prostate carcinoma. Our aim was to determine the expression of vascular endothelial growth factor-A (VEGF-A) and cyclooxygenase-2 (COX-2) in prostate carcinomas in relation to intratumoral microvessel density (MVD), tumor grade and androgen receptor (AR) status.

MATERIALS AND METHODS

The expression of AR, VEGF-A and COX-2 was immunohistochemically evaluated in 24 benign prostatic hyperplasia (BPH) and 139 prostate carcinoma cases. MVD was evaluated by CD34 immunostaining.

RESULTS

Nuclear AR expression was inversely related to tumor grade (p < 0.001). MVD was strongly related to tumor grade, VEGF-A and COX-2 (p < 0.001 in all comparisons). VEGF-A expression increased with tumor grade (p < 0.01) and was inversely related to stromal AR expression. COX-2 was present in both BPH and prostate carcinoma, but its expression increased with tumor grade (p < 0.01). High-grade neoplasms presented low-to-moderate VEGF staining intensity compared to strong COX-2 expression.

CONCLUSIONS

Both VEGF-A and COX-2 expression is positively correlated with tumor grade and MVD. However, in Gleason 8-10 tumors, VEGF expression is moderate while COX-2 immunostaining is intense, suggesting a possible switch in the role of these two angiogenic factors in poorly differentiated neoplasms.

Predictors for spontaneous stone passage in patients with renal colic secondary to ureteral calculi

OBJECTIVES

To determine the clinical, laboratory, and imaging variables that can predict spontaneous stone passage in patients with renal colic secondary to ureteral calculi.

METHODS

We prospectively analyzed the medical records of 114 patients who admitted to the emergency department for renal colic from June until November of 2010. Forty-six of them were excluded. The presence of ureteral calculi was confirmed by either a kidney-ureter-bladder plain film or an ultrasound or a computer tomography. In all patients, a second visit after 1 month was planned and the stone status was checked by the same imaging techniques.

RESULTS

From the 68 patients, 16 had a calculus in the upper ureter, 10 in the mid ureter, and 42 in lower part. Stone size was ranged from 2.3 to 15 mm, 52.9% of them were located in the left ureter and 51.5% were radiopaque. Stones passed spontaneously in 36 patients. In multivariate analysis, serum white blood cell count found to be the most significant predictor (P = 0.028) for spontaneous passage followed by stone size (P = 0.037). In analysis of patients with stone size <10 mm, left side (P = 0.017) and serum white blood cell count (P= 0.032) found to be significant predictors.

CONCLUSIONS

Serum white blood cell count is an easy to assay variable in everyday practice. This study showed that its value, at the acute phase of a renal colic, is a significant predictor for stone spontaneous passage and should be considered. Stone size remains a valuable predictor. Stones <10 mm on the left ureter have a higher likelihood to pass spontaneously.

A comparative analysis of primary and secondary Gleason pattern predictive ability for positive surgical margins after radical prostatectomy

To compare the predictive ability of primary and secondary Gleason pattern for positive surgical margins in patients with clinically localized prostate cancer and a preoperative Gleason score ≤ 6. A retrospective analysis of the medical records of patients undergone a radical prostatectomy between January 2005 and October 2010 was conducted. Patients' age, prostate volume, preoperative PSA, biopsy Gleason score, the 1st and 2nd Gleason pattern were entered a univariate and multivariate analysis. The 1st and 2nd pattern were tested for their ability to predict positive surgical margins using receiver operating characteristic curves. Positive surgical margins were noticed in 56 cases (38.1%) out of 147 studied patients. The 2nd pattern was significantly greater in those with positive surgical margins while the 1st pattern was not significantly different between the 2 groups of patients. ROC analysis revealed that area under the curve was 0.53 (p=0.538) for the 1st pattern and 0.60 (p=0.048) for the 2nd pattern. Concerning the cases with PSA <10 ng/ml, it was also found that only the 2nd pattern had a predictive ability (p=0.050). When multiple logistic regression analysis was conducted it was found that the 2nd pattern was the only independent predictor. The second Gleason pattern was found to be of higher value than the 1st one for the prediction of positive surgical margins in patients with preoperative Gleason score ≤ 6 and this should be considered especially when a neurovascular bundle sparing radical prostatectomy is planned, in order not to harm the oncological outcome.

Schwannoma of the kidney with magnetic resonance images of non-homogenous renal mass--a case presentation

Schwannomas are rare tumours that originate from the neural sheath and are usually located in the head and neck, extremities, and posterior mediastinum. Although 3% of schwannomas occur in the retroperitoneum, involvement of visceral organs is extremely uncommon. Schwannomas of the kidney are rare, with only a few reported cases. A 55-year-old woman was referred to our hospital with an abdominal sonography showing a spherical lesion in the upper pole of the left kidney that did not have the characteristics of a cortical cyst. The ultrasound had been recommended from her family doctor, due to a non specific pain in the hypogastrium in the previous 10 days. The final pathologic diagnosis was intrarenal benign schwannoma. Schwannomas are rare renal tumours with usually benign behaviour. Due to nonspecific symptoms and limited radiologic features for the diagnosis and assessment of the benign or malignant character of the tumour, the therapeutic approach is similar to other renal tumours. The definitive diagnosis is achieved with the help of immunohistochemistry.

Preoperative prostate specific antigen and prostate volume are significant predictors of seminal vesicle invasion in patients with prostate cancer

To evaluate the potential role of several clinical and pathological parameters in prediction of seminal vesicle invasion in patients with clinically localized prostate cancer undergoing radical prostatectomy. We retrospectively analyzed the medical records of patients who undergone radical prostatectomy from January 2005 until November 2010. Patients age, prostate volume, PSA, PSA density, percent of cancer in prostate biopsy material, Gleason summary, 1st Gleason pattern, 2nd Gleason pattern and the presence of high grade prostatic intraepithelial neoplasia were studied for their predictive ability. Two hundred and seventeen patients analyzed and 13.8% of them had seminal vesicle invasion in the final histopathological examination of the surgical specimen. A significant difference in PSA values, PSA density, percentage of cancer in biopsy material, biopsy Gleason score and 1st Gleason pattern was noticed between patients with and without seminal vesicle invasion. In univariate analysis, PSA, PSA density, prostate volume, percentage of cancer in biopsy material, biopsy Gleason score and 1st Gleason pattern found significant. However, in multivariate analysis, only PSA (p=0.008) and prostate volume (p=0.027) were found to be significant predictors. PSA ≥ 10 ng/ml and prostate volume ≤ 41 ml was shown to be the optimal cut-off values for seminal vesicle invasion in receiver operating curve analysis. PSA and prostate volume should be considered significant predictors for adverse pathology of the seminal vesicles in patients planned for surgical treatment of prostate cancer. This is of great concern especially in cases that a seminal vesicle sparing technique is planned.

Implications of PSA kinetics for an adverse pathology after radical prostatectomy

OBJECTIVE

To determine and compare the prognostic value of PSA density, PSA velocity and free/total PSA ratio in predicting adverse pathological findings after radical prostatectomy.

MATERIALS

We analyzed the medical records of 142 patients who underwent a radical prostatectomy from May 2009 until February of 2011. After exclusion of of them for defined criteria, preoperative PSA and its derivatives were analysed for their ability to predict unfavorable pathology after radical prostatectomy.

RESULTS

From the 105 patients included in the analysis, 23.8% had extraprostatic cancer extension, 8.6% had seminal vesicle involvement and positive surgical margins found in 38.1% of them. PSA density value >0.2 ng/ml2 was the solitary and most significant predictor for surgical margin status (p=0.015) and for extracapsular disease (p=0.050) as well, in multivariate analysis. Preoperative PSA was the only significant parameter for seminal vesicle invasion prediction (p=0.033). Both PSA velocity and ratio failed to reach predictive significance in all analyses.

CONCLUSION

The present results demonstrate a significance of PSA density in preoperative estimation of adverse pathological findings in patients who undergo radical prostatectomy for clinically localized prostate cancer. A value of 0.2 ng/ml2 seems to be a reliable cutoff. PSA density is a bettgerer predictor than PSA velocity and the PSA ratio.

Percutaneous minimally invasive management of iatrogenic ureteral injuries

PURPOSE

To present experience with the percutaneous management of iatrogenic ureteral injuries.

PATIENTS AND METHODS

Eighteen women and six men with a mean age of 59.3 years (range 33-80 years) received a diagnosis of ureteral injury sustained during gynecologic, urologic, and general surgical procedures. In a total of 25 injured ureters, 12 had interruption of continuity of their lumen, 10 were associated with contrast extravasation, and 3 were related to both. A standard percutaneous nephrostomy tract was established on the side of the afflicted kidney. Combined use of hydrophilic guidewires and balloon dilations were performed to achieve antegrade recanalization of the ureteral lesion. Then, a ureteral stent was inserted to assure patency.

RESULTS

Average stricture length was 1.21 (range 0.5-1.9 cm). Success of the aforementioned technique was possible in 18 ureters. Successful management in one session took place in 14 ureters. Average hospitalization time was 1.8 days (range 0-5 d). The follow-up period ranged between 12 and 18 months, with mean follow-up time of 12.9 months. Ureteral patency was evident at 1 week follow-up in six patients with obstructed ureters. In the remaining patients, balloon dilation of the stricture was repeated, and another stent was placed. Extravasation of contrast was observed in two patients with extravasating ureters in the same period. Nephrostomy tubes were removed after a mean indwelling period of 5.9 weeks (range 1-12 wks). Two patients treated by the described method died during their hospitalization in the intensive care unit because of sepsis from peritonitis that was related to colon injury and multiple concomitant injuries. Major complications were not observed in the remaining 22 patients during the follow-up period.

CONCLUSION

The minimally invasive management of ureteral injuries is a safe and efficient method for both ureteral obstruction and/or laceration in a wide range of iatrogenic ureteral injuries.

Thyroid hormone receptor alpha1 downregulation in postischemic heart failure progression: the potential role of tissue hypothyroidism

Thyroid hormone (TH) signaling is altered in response to various stresses including myocardial ischemia. The present study investigated potential implication of TH signaling in the pathophysiology of postischemic remodeling. Acute myocardial infarction was induced in rats by coronary artery ligation (AMI). After 34 weeks, 6 animals were on congestive heart failure (CHF) as indicated by measurements in lung and right ventricular weight. 7 animals were in compensated state (Non-CHF) and 8 sham-operated animals (SHAM) served as controls. Progression to congestive heart failure was characterized by marked decrease in EF% and all other functional echocardiographic parameters. Furthermore, beta-MHC expression was significantly increased in CHF. A distinct pattern of thyroid hormone receptor (TR) expression was observed in the course of postischemic remodeling; TR alpha 1 was upregulated and TR beta 1 was downregulated in Non-CHF, and TR alpha 1 expression was markedly decreased during the transition from Non-CHF to CHF resulting in tissue hypothyroidism. Circulating T3 and T4 remained unchanged. This response was associated with marked decrease in mTOR activation. A potential link between mTOR and TR alpha 1 expression was shown in a neonatal cardiomyocytes model of PE (phenylephrine)-induced pathological growth. Phenylephrine increased the expression of TR alpha 1 in nucleus and this response was abrogated in the case of mTOR inhibition by rapamycin. In conclusion, progression to congestive heart failure after myocardial infarction is associated with suppressed expression of TR alpha 1 and results in tissue hypothyroidism. This process may, at least in part, be mTOR dependent.

Thyroid hormone at supra-physiological dose optimizes cardiac geometry and improves cardiac function in rats with old myocardial infarction

Thyroid hormone (TH) is critical in cardiac cell differentiation (regulating contractile proteins and cell geometry) and this effect could be potentially exploited therapeutically in reversing the process of de-differentiation which underlies postischemic cardiac remodeling. Acute myocardial infarction was induced in male Wistar rats by ligating left coronary artery (AMI, n=8), while sham operated animals served as control (SHAM, n=8). 13 weeks after AMI, TH was administered in a group of animals for 4 weeks (AMI-THYR, n=9). TH significantly increased beta-MHC and decreased alpha-MHC expression in the myocardium. This response was accompanied by changes in cardiac geometry: sphericity index, (SI, long to short axis ratio) was found to be 1.95 (SEM, 0.02) in SHAM, 1.51(0.03) in AMI and 1.64(0.03) in AMI-THYR, p<0.05. As a consequence, cardiac function was significantly improved: left ventricular ejection fraction (EF%) was 74.5% (SEM, 2.8) in SHAM vs 29.5% (2.1) in AMI, and 40.0% in AMI-THYR, p<0.05. Furthermore, +dp/dt and -dp/dt were 4250 (127) and 2278 (55) in SHAM vs 2737(233) and 1508 (95) in AMI vs 3866 (310) and 2137(111) in AMI -THYR, respectively, p<0.05. TH treatment partially reverses cardiac dysfunction in rats with old myocardial infarction by favorably changing cardiac chamber geometry and expression of myosin isoforms. Thyroid hormone, unlike current treatments, appears to be a paradigm of therapeutic intervention which aims at restoring cardiac geometry and may prove new effective treatment for heart failure.

Metallic double pigtail ureteral stent usage during extracorporeal shock wave lithotripsy in the swine model: is there any effect on the ureter?

PURPOSE

To examine the safety and compatibility of full-length metal ureteral stent usage with extracorporeal shock wave lithotripsy (SWL).

METHODS

Four Resonance ureteral stents and four special Resonance ureteral stents modified to contain thermocouples were placed unilaterally in eight pigs, with contralateral ureter of each pig serving as its own control. All pigs were subjected to the same SWL protocol in both their ureters. In the animals containing the modified stents, ureter temperature was monitored during treatment. The animals were sacrificed on days 1 and 15 after treatment, and both their ureters were histologically examined.

RESULTS

No statistically significant increase (mean increase of 0.5 degrees C, p > 0.05) of stent temperature was observed during treatment. No differences in histology were observed among ureters containing stents and control ureters at both days 1 and 15 after treatment.

CONCLUSION

SWL appears to be harmless for the ipsilateral ureter.

Contemporary diagnosis of bladder cancer

BACKGROUND

Early diagnosis of bladder cancer is mandatory, as a delay in treatment has been shown to affect prognosis. The current diagnostic standard of cystoscopy and cytology is costly, invasive and inconvenient, whereas advances in molecular biology have resulted in the evolvement of several markers.

OBJECTIVE

To review diagnostic considerations in the use of old and new technical modalities and tests for the detection of bladder cancer.

METHODS

A PubMed search of the literature concerning bladder cancer diagnosis was performed. Reviews are included on certain topics to avoid extensive reference to separate studies.

CONCLUSION

Recent technical advances have an impact on the management of patients with suspected bladder cancer. Cytology is still an important adjunct in the diagnostic work-up, whereas urine-bound tests may have a role in screening and surveillance. However, cystoscopy is the standard of care for the detection of bladder cancer. Fluorescence cystoscopy is an adjunctive tool, especially for the prompt identification of carcinoma in situ.

Thyroid hormone receptor alpha 1: a switch to cardiac cell "metamorphosis"?

Thyroid hormone receptor alpha1 (TRalpha1) is predominantly expressed in the myocardium but its biological function under physiological or pathological conditions remains largely unknown. The present study investigated possible interactions between alpha1 adrenergic and thyroid hormone signaling at the level of TRalpha1, potential underlying mechanisms and physiological consequences, as well as the role of TRalpha1 in cell differentiation. This may be of physiological relevance since both thyroid hormone and adrenergic signalling are implicated in the pathophysiology of cardiac remodelling. Neonatal cardiomyocytes obtained from newborn rats (2-3 days) were exposed to phenylephrine (PE, an alpha1 adrenergic agonist) for 5 days, in the absence or excess of T3 in the culture medium. PE, in the absence of T3, resulted in 5.0 fold increase in TRalpha1 expression in nucleus and 2.0 fold decrease in TRalpha1 expression in cytosol, P<0.05. As a result, a fetal pattern of myosin isoform expression with marked expression of beta-MHC was observed in PE treated vs the untreated cells, P<0.05. PD98059 (an ERK signalling inhibitor) abrogated this response. In the presence of T3 in the culture medium, TRalpha1 expression was increased 1.6 fold in nucleus and 2.0 fold in cytosol in PE-T3 vs PE treated cells, P<0.05, and the fetal pattern of myosin isoform expression was prevented. Parallel studies with H9c2 myoblasts showed that reduction of T3 binding to TRalpha1 receptor delayed cardiac myoblasts differentiation without affecting proliferation. In conclusion, in neonatal cardiomyocytes, nuclear TRalpha1 is overexpressed after prolonged activation of the alpha1- adrenergic signalling by PE. This response seems to be an ERK kinase dependent process. Over-expression of TRalpha1 may lead to fetal cardiac phenotype in the absence of thyroid hormone availability. Furthermore, TRalpha1 seems to be critical in cardiac myoblast differentiation.