The clinical use of statistical permutation test methodology: a tool for identifying predictive variables of outcome

OBJECTIVES

To identify the predictive variables affecting the outcome after radical surgery for bladder cancer by a newer statistical methodology, i.e. nonparametric combination (NPC).

METHODS

A multicenter study enrolled 1,312 patients who had undergone radical cystectomy for bladder cancer in 11 Italian oncological centers from January 1982 to December 2002. A statistical analysis of their medical history and diagnostic, pathological and postoperative variables was performed using a NPC test. The patients were included in a comprehensive database with medical history and clinical and pathological data. Five-year survival was used as the dependent variable, and p values were corrected for multiplicity using a closed testing procedure. The newer nonparametric approach was used to evaluate the prognostic importance of the variables. All of the analyses were performed using routines developed in MATLAB© and the significance level was set at α = 0.05.

RESULTS

A significant prognostic predictive value (p < 0.01) for tumor clinical staging, hydronephrosis, tumor pathological staging, grading, presence of concomitant carcinoma in situ, regional lymph node involvement, corpora cavernosa invasion, microvascular invasion, lymphatic invasion and prostatic stroma involvement was found.

CONCLUSIONS

The NPC test could handle any type of variable (categorical and quantitative) and take into account the multivariate relation among variables. This newer methodology offers a significant contribution in biomedical studies with several endpoints and is recommended in presence of non-normal data and missing values, as well as solving high-dimensional data and problems relating to small sample sizes.

Enigmatic question of early reactive arthritis disclosed after researches of mycoplasmas, Chlamydia trachomatis and enteropathogens following the holistic vision of human being

An HLA-B27 genetic profile patient is fully investigated by molecular analyses after an anamnestic assessment of multi-site ecosystems, following the holistic vision of human being.VDRL and Widal-Wright (WWR) resulted positive, showing at Wright’s reaction a title of 1:40. Of all the enzymatic activities measured, only the ALP enzymatic pool activities showed a low increasing value of 297 U/L. Of all later acute phase proteins, Only C3 c protein value (127 mg/dL) and fibrinogen (376 mg/dL) were altered. Cultural and molecular oropharyngeal ecosystem investigation resulted significantly positive to Mycoplasmas(Mhand Uu) and Chlamydia trachomatis(Ct) together with a spread of saprophytic flora. From an accurate anamnesis, several and severe uro-genital clinical symptomatology emerged from birth until the beginning of rheumatologic symptomatologies that were confirmed by oldest Mh, Uu and Ctsilent chronic infections between these ecosystems. The molecular HPV research was negative, while the Thin prep pap-test was indicative of vaginosis and cellular reactive changes associated with inflammation. Parasitological research resulted positive for presence of 5-7 newly-formed G. lambliacysts for microscopic field, while digestibility test was positive for presence of several free fatty acid crystals. The remarkable presence of indigested meat fibre and several mucous dense filaments were observed. The pH value was 6.5, while blood faecal test was positive. The values observed were: ferritin 12 microg/L (10-120), total iron-binding capacity (TIBC) 310 &mgr;g/dL (300+-20), unsaturated iron-binding capacity (UIBC) 286 microg/dL (200-220) and iron seric level 24 microg/dL (60-130). Faecal research highlighted a very scarce presence of E. coli, resulting in 102 UFC/g of stool. Of all enteroinvasive pathogens, researched by molecular analyses, only Yersinia spp. was positive. After several specific cycles of antibiotic and antinflammatory therapies, the patient improved its general health condition considerably and showed almost complete regression of aching inguinal lymph node inflammation. In a picture of a worsening inflammatory process, produced by pathogens like Mycoplasmas, chronic silent or low grade inflammation atypical agents, in young HLA-B27 positive patient, VDRL test resulted positive. This value represents the first non-specific unique spy to reveal the precocious immunological signal in order to register the beginning of early innate immune system decay, keeping in mind that mycoplasmal and chlamydial infections are the triggering of cancer in patients genetically susceptible.

Jugulodigastric Lymph Node Inflammation Derived from Chronic Atypical Oropharyngeal Phlogosis Recurring Annually after Flu Virus Vaccination: A Holistic Vision and a Clinical Case Solved after Chlamydicidal Antibiotic Therapy

In this report, we evaluated the case history of a patient with longstanding chronic pharyngitis who had periodic clinical manifestation for three years after a flu vaccine administration, and after various treatments tried to resolve the chronic pharyngitis with unsuccessful antibiotic and anti-inflammatory therapies. The patient occasionally presented a slight ocular inflammation, while dysuria occurred after sexual activity. The search for common pathogens by use of pharyngeal swabs resulted only in Corynebacterium ulcerans growth. After this first result, we focused our investigations on ocular and uro-genital infections of Chlamydiaceae (Ct and Cp) and Mycoplasmataceae (Mh and Uu) families. We examined the patient's pharynx using molecular and culture techniques from three different sites. Although several infectious agents, including viruses and bacteria, causing chronic pharyngitis are reported in the literature, these ocular and uro-genital pathogens are seldomly routinely investigated in the same patient in ORL. Furthermore, while episodes of chronic pharyngitis is one of the most common clinical manifestation in ENT patients, these atypical pharyngitis represent ever-increasing infections which must always be considered and researched by suitable instruments such as PCR. Only from the collection of detailed medical history and careful observations of clinical manifestation, indicative of an oral chronic pathologic phenomenon of low intensity initiated several years previously, starting with sudden outbreak and relapse like a bout of flu', we suggest to study these atypical infecting agents frequently localized in the urogenital human area, awhich would allow to highlight and to recognize these clinical cases that manifest themselves as chronic inflammation of jugulodigastric lymph nodes, remaining still unrecognized and rarely associated to chlamydial infection, confused with the response to flu vaccination. After several specific cycles of antibiotic therapy, the patient's health improved considerably and showed almost complete regression of jugulodigastric lymph node inflammation.

Can latent synergism of intestinal pathogens be responsible for inflammaging process causing Reiter's syndrome in a young patient HLA-B27 infected by atypical pathogens? A holistic view and clinical biochemical reinterpretation

A case of a genetically HLA-B27 patient fully investigated by molecular analyses, following a holistic vision and an anamnestic assessment of multi-site ecosystems is repeated. VDRL, Lupus anti-coagulant (LAC) and Widal-Wright (WWR), resulted positive. The antibodies (IgG/IgA anti-Ct) against chronic Chlamydia trachomatis inflammation were positive. In the context of all the enzymatic activities in reference range, the AMS and the ALP enzymatic activities showed an increasing trend and a time course augment depending respectively. Cultures, parasitological, digestibility tests and molecular analyses were then performed to investigate the different human ecosystems. Parasitological research and digestibility test were performed, resulting a latent chronic bowel inflammation, including certain enteroinvasive pathogens, such as, Salmonella, Shigella, Yersinia and Campylobacter (Enteric Pathogens Group, EPG) and Escherichia Coli pathogens (Escherichia Coli Pathogens Group, ECPG). The Salmonella typhi-DNA resulted positive, while 90% of the total microbic charge (TMC) was represented by C. freundi in culture analyses. Interpreting the VDRL positive test as early triggering of autoimmune disease, a few acute phase proteins as a pauci-symptomatic chronic phlogistic process, the amylase and alkaline phosphatase alterations as tissue markers of early intestinal inflammation, the Widal's reaction positivity together with the precocious clinical and faecal manifestations, this study suggests the prime triggering role of these atypical pathogens to cause a chronic low grade autoimmune response against the tissue/organ susceptible target, causing inflammaging phenomenon in young patient with chronic latent infection by Salmonella typhi, leading to Reiter's syndrome, in HLA-B27 positive patient.

Physiological analysis of 8-ISO-PGF2 alpha: a homeostatic agent in superficial bladder cancer

Recent studies underscore the importance of oxygen supply in bladder cancer. Tumour growth stimulates the production of vasoactive factors to increase oxygen delivery to tissues by vasodilatation. Any vasoconstrictor mediator could impair this vasodilatation reducing the oxygen supply. 8-Iso-PGF2 alpha is a potent vasoconstrictor agent. The aim of this work is to determine 8-Iso-PGF2 alpha release in healthy bladder mucosa and in superficial bladder cancer in order to investigate a pathophysiological vasoconstrictor answer of the superficial bladder cancer. The study was conducted on a sample of 12 patients; for every subject studied 8-Iso-PGF2 alpha release was assayed in healthy bladder mucosa and in superficial bladder tumour. 8-Iso-PGF2 alpha release was significantly reduced (p less than 0.001) in superficial bladder cancer compared with healthy bladder mucosa. The inhibition of the production of a powerful vasoconstrictor such as 8-Iso-PGF2 alpha in the vascular homeostatic mechanism of bladder cancer can represent a response of the tumor tending to contrast an antagonist effect of vasodilatation and the necessary to support the oxygen supply.

Pampiniform plexus and oxidative stress during chronic hypoxia and hyperoxia

The aim of the present study is to investigate oxidative stress produced by experimental hypoxia and hyperoxia in young and old pampiniform plexus rats, in order to evaluate the oxidative role of oxygen. Oxidative stress causing molecular and cellular dysfunction increases in hypertension and can therefore be considered a state of oxidative stress. This consideration makes us reflect on the responsibility of oxidative stress in the veins of the pampiniform plexus, notoriously under high hydrostatic pressure. After experimental hypoxia and hyperoxia we studied the 8-iso-PGF2alpha release (a specific index of cellular oxidative stress) in young and old left pampiniform plexus rats. The basal 8-iso-PGF2alpha release showed a statistically significant difference P=0.0067 between young and old rats PP. After hypoxia and hyperoxia, the release was higher in young rats as compared to normoxia, respectively P=0.0001 and P=0.0002. After hypoxia the release was not modified in old rats P=0.544 while after hyperoxia the release was increased in old rats as compared to control P less than 0.0001. The results show how chronic hypoxia and hyperoxia represent two important causes of oxidative stress and lipid peroxidation in pampiniform plexus rats. In young rats an increase of oxidative stress suggests that pampiniform plexus is sensitive to variations of oxygen supply. In old rats the pampiniform plexus is liable to a reduction of oxygen-sensing mechanisms and it is possible that the missing oxidative answer to the hypoxia in old rats is attributable in all likelihood to adaptation to a hypoxic condition typical of aging.

The role of hypoxia in erectile dysfunction mechanisms

Chronic hypoxia is related to many pathological conditions: aging, heart and respiratory failure, sleep apneas, smoke, chronic obstructive pulmonary disease (COPD), diabetes, hypertension and arteriosclerosis, all characterized by reductions of sleep-related erections (SREs) and by erectile dysfunction (ED). Sleep-related erections occur naturally during rapid eye movement (REM) sleep in sexually potent men. Hypoxia is also a physiological condition at altitude. The level of inspired oxygen decreases progressively with the increase of altitude; for this reason, this study was performed to evaluate the relationship of SREs with hypoxic environment. SREs have been recorded by an erectometer (RigiScan) on three mountain climbers (mean age: 32.5) during a 26-day stay at an altitude ranging from 2000 to 5600 m above sea level. Twenty-four records have been made at progressively increasing altitudes. A data analysis was carried out on a statistical mean of the three values of each variable and an analysis of variance (ANOVA) and Newman-Keuls test were carried out for multiple comparison among groups. At altitudes over 4450 m, we found lack of rigidity at 80-100% and 60-79%. Mean % of rigidity and rigidity time of 80-100% (tip and base) decreased progressively with altitude. No significant reductions were shown in rigidity time at 0-19% and at 20-39% (tip and base), of total number, of total and mean duration of SREs. Pathological rigidometric records at high altitude in sexually potent men at sea level clarify the primary role of hypoxia in physiopathological ED pathway.

Simple renal cysts in hypertensive patients: relation between cyst growing and anti-hypertensive therapy

The study investigates relationship between simple renal cyst enlargement studied by ultrasonography and anti-hypertensive treatment. To this purpose we enrolled 42 patients with newly diagnosed hypertension affected by simple renal cysts. Fourteen were randomly assigned to treatment with ACE-Inhibitors (group 1), twelve to diuretics (group 2) and sixteen to Ca-Antagonists (group 3). Patient performed a basal ultrasonography to evaluate basal cyst dimension before starting anti-hypertensive treatment. Following 12 months of the anti-hypertensive regimen, a new echograph was performed to evaluate changes in cyst size. A control group consisting of 15 patients with normal blood pressure and simple renal cysts was enrolled (group 0). An enlargement of cysts was detected in all patients. However, the enlargement observed in patients treated by Ca-Antagonists was significantly greater than that observed in the other groups (p<0.05). Our study supports the hypothesis that Ca-Antagonists may favor cyst enlargement by enhancing cyclic AMP production. In fact, cAMP and cAMP agonists stimulate fluid secretion by lining cells of the cyst wall, inducing cyst enlargement.

[Betamethasone versus placebo in Peyronie's disease]

The Peyronie's disease or Induratio Penis Plastica, represents one of the most controversial and uncertain points of the modern andrology, since its real etiology is still disputable. Consequently also the non-surgical therapy results as still confused and variable as shown in the considerable number of drugs utilized till now. Our study takes into consideration the injection therapy, by the use of the Betamethasone (corticosteroid), and it tries to explain, how it is possible, the real efficacy of drug versus placebo. The randomized study includes 30 patients. The valuation of the results has been effected in reference to three parameters: disappearance of pain, decrease of plaque volume and consistency of 50%, decrease subjective penile curvature. The data obtained show no significant differences between group A (treated with Betamethasone) and group B (treated with placebo). At twelve months of mean follow-up the pain at erection disappeared in 66.6% of the patients of group A, in 53.3% of the patients of group B. The curvature diminished in 20% of the patients of group A and in 26.6% of the patients of group B. A decrease in plaque volume and consistency was noted in 40% of the patients of group A and in 40% of the patients of group B. The data show that probably the clinical results of the therapy is to refer to a mechanical effect of injected volume and not to the drug action itself.

A quarter of men with idiopathic oligo-azoospermia display chromosomal abnormalities and microdeletions of different types in interval 6 of Yq11

Cytogenetic investigations and molecular analysis of the Y chromosome by the polymerase chain reaction amplification of sequence-tagged sites (STS-PCR) technique were performed in 126 patients affected by idiopathic oligo-azoospermia following accurate selection of cases. Seventeen patients evidenced an abnormal karyotype. Fourteen patients with a normal karyotype had microdeletions of the Y chromosome within interval 6. In azoospermic patients microdeletions were scattered along different subintervals, while in oligozoospermic patients they were clustered in subinterval 6E. The size of the deletion was not apparently related to the severity of the disease. These results suggest that cytogenetic analysis and the STS-PCR technique can detect a genetic cause of infertility in about one-quarter of patients with idiopathic oligo-azoospermia.

[Clinical efficacy of intravesical BCG treatment for superficial bladder neoplasms with respect to the iduced immune response]

We evaluated the immune response after BCG treatment in superficial bladder cancer analyzing the modifications induced on lymphocytic sub-populations. In 21 patients with superficial bladder cancer we performed TURB and after 12 days began the induction cycle of 6 weeks with Pasteur BCG (75 mg/50 micromilligrams), followed by one instillation monthly for one year. Before treatment every patients underwent Mantoux intradermoreaction, blood-count and determination of peripheral blood lymphocytic subpopulations. Blood-count and lymphocytic subpopulations were repeated after 1 week, after 6 weeks, after 3 months and after 1 year. During cystoscopy after 3 months every patients underwent vesical biopsy. CD4+ and CD8+ are mainly interested among lymphocytic subpopulations at the beginning: BCG decreased CD4+ value in the patients with complete response and then it increased CD4+ and reversed the ratio between CD4+ and CD8+ on vesical mucosa.

Clustering of Y chromosome deletions in subinterval E of interval 6 supports the existence of an oligozoospermia critical region outside the DAZ gene

Y chromosome molecular analysis was performed using the STS-PCR technique in 50 patients with oligozoospermia. Microdeletions of interval 6 of the Y chromosome were detected in seven patients, in six of whom subinterval E was affected. All patients retained the RBM1 and DAZ genes, while in one deletion involved the SPGY gene. The size of the deletion was not apparently related to the severity of the disease. These results suggest the presence of an oligozoospermia critical region on the Y chromosome within subinterval E of interval 6.

[Orthotopic continent urinary diversion according to Hautmann: 1989-1995. Physiopathologic, morphologic and urodynamic, metabolic considerations and follow-up]

The orthotopic ileal neobladder is a completely detubularized, low pressure, high capacity reservoir created from the ileum without any valve. After cystoprostatectomy, a bowel segment of 40-60 cms is dissected free at a distance of 15 cms from the ileo-cecal valve. The bowel is detubularized and configurated in a cylinder. Then the neobladder is anatomized to the urethra and ureters. From 1989 to 1995 20 patients underwent ileal orthotopic urinary diversion according to Hautmann. Two patients died, the others are still disease free (mean follow up 36 months). The high capacity and low pressure allow a good continence control, while among metabolic alterations the most frequent is metabolic acidosis. The ileal neobladder represents a valid alternative to any form of cutaneous urinary diversion and is associated to a low incidence of complications.

[Role of MCP-1 chemokine in the response of monocytes of patients with superficial tumors of the bladder treated with BCG immunotherapy]

Mechanism by which intravesical BCG treatment mediates antitumor activity are currently poorly understood. We initiated studies to determine the sequence and the factors that produce the immunological events. During the inflammatory answer a lot of molecules are produced. Chemokines MCP-1 and RANTES induces the mast-cell recruitment, that begins the "immunological fall". In our study 5 patients with superficial bladder cancer treated with BCG present an improvement of this cytokines correlated with a tumor-free status.

[Levels of monokines in peripheral monocytes in patients with superficial tumors of the bladder treated with BCG. Results after 1- and 3-year follow-up]

BCG has been shown in prospective randomized clinical trials to provide superior therapeutic results when composed to transurethral resection alone, or to adjuvant therapy with Thiotepa or Adriamicin. Even if the mechanism by which BCG mediate antitumor activity are not clearly established, an association between the immunological response and antitumoral activity is known IL-1 and TNF alfa are the monokines that have multiple biological effects, including linfocyte proliferation, production of fever, augmentation of cytotoxicity and production of cytokines. The goal of this study is show the response from LPS induced and not peripheral monocytes of superficial bladder cancer patients BCG treated and not, i.e. the levels of TNF alfa, IL-1 and not IL-6.

[Clinico-experimental study of low-mineral "Monteferrante" water: monitoring the recurrences in patients with calculi]

This study presents the use and effects of a low mineral content water called "Monteferrante" on patients with urinary stone disease. We evaluated the blood and urine sample of twenty stone formers and ten healthy volunteers at three and six months after "Monferrante" water intake. Besides a benefic increasing of diuresis, the results show: an increase of: urinary magnesium (p < 0.001), urinary calcium (p < 0.01), uricosuria (p < 0.01), and reduction of: blood uric acid (p < 0.01), blood sodium (p < 0.05), azotemia (p < 0.05) and cholesteremia (p < 0.01). The "Monferrante" oligomineral water can be considered as an efficacy presidium in the prevention of stone disease.

[Half-life of blood PSA after radical prostatectomy. Correlations with pathological stage and clinical course of the disease]

PSA half-life was calculated in 37 patients after radical prostatectomy to identify earlier patients with residual disease. The half-life calculated in patients potentially "cured" with absolute PSA values inferior to 0.5 ng/ml after 28 days, was significantly different (P = 0.0008) from the group of patients "uncured" (PSA > 1.0 ng/ml) and from those ones that, despite of detectable PSA level, had evidence of recurrence in the following follow-up. In comparison with the absolute value, the PSA half-life is able to define in the group of patients potentially "cured" those who could have a recurrence in the future.

Tumori superficiali della vescica: Presentazione di uno studio comparativo tra la sola resezione endoscopica e I'uso di BCG, epirubicina o mitomicina C adiuvanti

A retrospective clinical study was carried out to compare results obtained with just endoscopic resection and with adjuvant use of the Bacillus Calmette-Guérin (BCG), epirubicin and mitomycin C after TURB in patients with superficial bladder tumour (stage pTa/1 grade 1-3). At an average follow-up of 44 months, a decrease in the percentage of recurrences was noted in all the adjuvant therapy groups compared to that in the group subjected to TURB only. The risk of recurrence for the BCG group was 0.427, for the epirubicin group 0.609 and for the mitomycin C group 0.668. There was progression of the disease in: 5.6% of the TURB, 9.1% of the BCG, 5% epirubicin and 3.6% mitomycin C, for a total of 26 patients (7.3%). Twenty-four cystectomies were performed and 2 patients died due to progression of the disease. At 44 months average follow-up, 353 (98.6%) patients are alive and 329 (93.2%) still have their own bladder.

Carcinoma del pene: Chirurgia e chemioterapia

Spinocellular carcinoma of the penis is rare and potentially fatal, especially when there are lymph node metastases. From January 1992 to December 1995 we treated 6 stage T3 N1 M0 tumours of the penis. Six to eight weeks after total penectomy, bilateral inguinal lymphadenectomy and pelvic lymphadenectomy were carried out. These patients also underwent 8 cycles of chemotherapy with vincristine, bleomycin and methotrexate. At an average follow-up of 36 months, all the patients are disease-free with no signs of recurrence either in the lymph nodes or in any organ.

[Hemospermia: role of transrectal echography]

Hemospermia is a common benign condition, but is prevalence remains unknown, and can result from several causes. The etiology is idiopathic in about 50% of cases. The advent of transrectal ultrasonography has afforded the opportunity to best evaluate patients with hemospermia. Eighty patients affected by hemospermia were studied with Stamey test, semen analysis and culture, and transrectal ultrasonography (TRUS). Infection was detected in 16/80 of the cases (20%), while in 11/80 patients (14%) was present only excessive white blood cells in expressed prostatic secretions. TRUS showed abnormalities in 70/80 of patients (88%), including periurethral and ejaculatory calculi (42/70 pt., 60%), dilated seminal vesicles (22/70 pt., 31.4%) and müllerian duct cyst (6/70 pt., 8.6%). Stamey test and TRUS are the more usefulness investigations in hemospermia, since they can demonstrate the pathologic causes in about 90% of the cases.

[Role of transrectal echography in the evaluation of obstructive seminal vesicle pathology in prostatitis syndrome]

Prostatitis syndromes are frequent and cause pain and discomfort in adult males. Non bacterial types occur more often than bacterial prostatitis. Transrectal ultrasound permits a perfect evaluation of prostate, seminal vesicles and ejaculatory ducts. Fifty-five patients affected by prostatis syndrome and with negative bacteriological studies, underwent transrectal ultrasonography performed with 7.5 MHz probe. In 38 cases (70%) we found abnormalities such as subacute vesiculitis, asymmetric dilation of the seminal vesicle, dilated and calcific ejaculatory ducts, mullerian duct cyst, utricular cyst and calcification. Ultrasonography is able to detect these lesions that often are responsible of the clinical symptom of the prostatitis syndrome, and may have a therapeutic value through guided transperineal needle aspiration or in the planning specific endoscopic surgery.

[Dynamic magnetic resonance imaging versus dynamic echography in the staging of Peyronie's disease]

Clinical examination and ultrasonography are often the only evaluation needed for patient with Peyronie's disease. Magnetic resonance angiography (MRA), a new magnetic resonance imaging (MRI), improves tissue contrast between the fibrous plaque and the near structures. A total of 25 patients with Peyronie's disease underwent palpation, ultrasonography and MRI after dynamic improvement with intrapenile 10 micrograms prostaglandin E1. The patients were studied with conventional ultrasonography (US) (7.5 MHz) and with 1.5 T superconductive magnet (two-dimensional Fourier transform gradient-echo time-of-flight, 2DFT-TOF, sequences and conventional T1 and T2 spin echo (SE) sequences). The US evaluation demonstrated the presence of plaques in 18/25 patients (72%). The SE sequences revealed evidence of plaques in 10/25 patients (40%). MR angiograph enabled the correct evaluation of plaques in 23/25 patients (92%), and identified the involvement of the septum intercavernosum, that was not detected on both US and SE images. MRA provides accurate preoperative information fo correct evaluation of plaque extension in IPP.

[Role of echography in the diagnosis, screening, and follow-up of patients with von Hippel-Lindau syndrome]

Von Hippel-Lindau (VHL) disease is a genetic disorder characterized by hemangioblastomas of the brain and spinal cord, retinal angiomas, pancreatic cysts, pheochromocytomas, epididymal cystadenomas and renal cysts and neoplasms. These disease is transmitted in an autosomal dominant fashion and the gene associated with transmission of VHL has been localized to the 3p25-3p26 region of chromosome 3. In this study we examined a family with von Hippel-Lindau disease established of mother and three children and five progeny. These patients were evaluated with urinary tract echography, computerized tomography, DNA sequencing with polymerase chain reactions (PCR) and SSCP analysis. The ultrasonography is utilized to diagnosis, screening and in the follow-up of undergone surgery patient's. With this study we examined the role of echography in patients with von Hippel-Lindau disease.

[Acute urinary retention caused by intraprostatic cysts: diagnostic and therapeutic role of transrectal prostatic echography]

There are two type of congenital prostatic cyst, the müllerian duct cyst and the utricular cyst. They are not common and rarely symptomatic. We report a 16-year-old male who presented with acute urinary retention and a 3-month history of urine stream diminished in force and reduced sperm volume. Transrectal ultrasonography showed a prostatic cyst in the midline near the seminal colliculus. Transperineal aspiration of the cyst resulted in return to normal miction and sperm volume.

[Induratio penis plastica: the diagnostic possibilities of gradient-echo sequences (magnetic resonance angiography)]

The authors investigated the diagnostic capabilities of gradient echo sequences (magnetic resonance angiography) in the study of induratio penis plastica. Twenty patients (mean age: 39 years) were examined. MRA was performed with a superconductive magnet (1.5 T) and a Helmoutz coil; the dynamic test with PGE (20-40 mg) was also carried out. The images acquired on the axial and sagittal planes were processed according to the MIP. The FLASH 2D sequence was used with the following parameters: FA 18 degrees, TR 40 ms, TE ms, MA 256 x 256, slice thickness 5 mm. A multiple choice card was filled in by a reader with the following diagnostic information: identification and localization of the plaques and involvement by the plaques of the albuginea, corpora cavernosa, septum and dorsal vein; surgery was the gold standard. MRA showed 10/11 plaques ranging 8-30 mm in diameter and missed a 5-mm plaque. Moreover, MRA depicted the infiltration of the albuginea in 10/10 cases, of the septum in 3/3 cases, of the dorsal vein in 4/4 cases and of the corpora cavernosa in 9/9 cases. Our preliminary experience shows that in the study of induratio penis plastica, the gradient echo sequence (MRA) permits better depiction of the plaques and of the infiltration of the corpora cavernosa, septum and albuginea.

Microdeletions in interval 6 of the Y chromosome detected by STS-PCR in 6 of 33 patients with idiopathic oligo- or azoospermia

It has been proposed that interval 6 of the human Y chromosome contains the gene or genes that control spermatogenesis (AZF, azoospermia factor). We have studied this region in 33 patients with oligo- or azoospermia, using PCR amplification of the YRRM1 (RBM1) gene and of 13 sequence-tagged sites (STSs), all mapping within interval 6. Six of the 33 patients showed no amplification of specific STSs, whereas there was no failure of amplification in normal male controls. We deduce that these six patients had microdeletions in interval 6 of the Y chromosome that correlated with the oligo- or azoospermia of these individuals. On biopsy of the testis, two of these patients showed a low number of germ cells, and four showed arrest with spermatides. We conclude that PCR amplification of Y-specific regions is a powerful and very sensitive tool for screening infertile men.

Glyoxalase activities in tumor and non-tumor human urogenital tissues

Glyoxalase I and glyoxalase II activities have been measured in human tumor and non-tumor samples of 15 kidneys, 15 bladders, 4 testes, 2 adrenals as well as in 4 samples of prostatic adenomas. In all tissues examined glyoxalase I and glyoxalase II activity values varied widely from one patient to another. No significant difference in glyoxalase I activity between the tumor and non-tumor samples was found. When comparison was made between normal and neoplastic tissues of the same patients, glyoxalase I activity was found to be lower in tumor tissues of 10 out of 15 kidneys, and 2 out of 8 bladders and 1 out of 3 testes. A significant (P < 0.004) decrease of glyoxalase II activity was found only in tumor kidney. The possibility of using the present data to predict the relative sensitivity of human tumor tissues to glyoxalase-related chemotherapy is discussed.

Glutathione peroxidase and glutathione reductase activities in cancerous and non-cancerous human kidney tissues

Selenium-dependent (Se-GSH-Px), selenium-independent (non-Se-GSH-Px) glutathione peroxidase and glutathione reductase (GSSG-Rx) activities have been determined in cancerous and non-cancerous human adult kidney. Large inter-individual variation in the activities of all enzymes tested were found in both tumour and non-tumour specimens. In general a significant decrease in the activities of the three enzymes was found in tumours. When a comparison was made between cancerous and non-cancerous tissues of the same individual, Se-GSH-Px activity was found to be lower in tumour in 17 cases out of 29, and the non-Se-GSH-Px activity in 20. In 20 cases out of 29 GSSG-Rx was found to be lower in tumour. It was concluded that changes in the factors involved in the anti-oxidative protection actually occur in human kidney tumour.

Bacillus Calmette-Guérin potentiates monocyte responses to lipopolysaccharide-induced tumor necrosis factor and interleukin-1, but not interleukin-6 in bladder cancer patients

During the past decade, particular attention has been focused on treatment of bladder cancer patients with the bacterial agent bacillus Calmette-Guérin (BCG). In these studies, bladder cancer patients were instilled with BCG (75 mg/50 ml) once per week for 6 weeks, 1-2 weeks following trans-urethral resection of the bladder. Cystoscopy was performed after 6 weeks and, unless tumor progression was present, monthly treatments were given for 1 year. Blood was drawn 2 h after the last instillation, and monocytes were isolated (5 x 10(6) cells/ml) and treated, or not, with lipopolysaccharide (LPS) (20 microgram/ml) for tumor necrosis factor alpha (TNF alpha), interleukin-1 alpha (IL-1 alpha) and interleukin-6 (IL-6) release. The levels of monokines were determined by a monokine-specific enzyme-linked immunosorbent assay. Our results clearly show that, after 18 h incubation, macrophages from BCG-treated bladder cancer patients produced from 2.8- to 1.9-fold and from 2.0- to 1.3-fold greater amounts of TNF alpha and IL-1 alpha respectively, compared to macrophages from healthy controls, 5-fold higher than bladder cancer patients not treated with BCG. IL-6 was not affected. In another set of experiments macrophages (5 x 10(6) cells/ml) from healthy subjects were pretreated, or not, with BCG (100 micrograms/ml) overnight and treated, or not, with LPS 20 microgram/ml alone and in combination with interleukin-1 receptor antagonist (IL-1ra) 250 ng/ml. Macrophages treated with BCG had a strong stimulatory effect on IL-1 alpha release (9.45 ng/ml) while LPS was less effective (3.59 ng/ml). The combination of BCG plus LPS produced an additive effect on IL-1 alpha release (13.71 ng/ml) compared to the effect of the compound alone. The addition of IL-1ra (250 ng/ml) to BCG was not effective, while when IL-1ra was added to BCG plus LPS only a partial inhibition of IL-1 alpha release was found (9.83 ng/ml), compared to BCG plus LPS without IL-1ra (13.71 ng/ml). These effects seem to be related to the inhibition of IL-1 alpha stimulated with LPS, but not BCG. The priming effect of BCG exerted on LPS-stimulated monocyte production of TNF alpha and IL-1 alpha from bladder cancer patients led us to study the possible modulation of fibrinogen and C-reactive protein in the serum of BCG-treated cancer patients. The plasma levels of fibrinogen and C-reactive protein were higher (approximately twice) in BCG-treated patients compared to values obtained in untreated patients or healthy controls. We conclude that the beneficial immunotherapeutic effects of BCG in bladder cancer patients are related to its capacity to prime macrophages to enhance the release of TNF alpha and IL-1 alpha, but not IL-6 in response to physiological secondary stimuli, or through the direct stimulation of BCG on IL-1 alpha or TNF alpha, which are directly involved in the killing of cancer cells.(ABSTRACT TRUNCATED AT 400 WORDS)

Lack of prognostic value of immunohistochemical determination of epidermal growth-factor receptors in human prostate-cancer

We have investigated whether the expression of Epidermal Growth Factor Receptors (EGF-Rc) evaluated by immunohistochemical technique, may influence the prognosis of patients with prostate cancer. EGF-Rc were positive in 20/76 (26.3%) of tumors. There was no correlation between EGF-Rc and other prognostic factors such as tumor size, Gleason score, metastases at diagnosis, DNA content and S-Phase fraction (SPF). In patients with locally advanced tumors EGF-Rc expression was significantly correlated with the presence of metastases at diagnosis (p=0.038). Both disease-free survival (DFS) and overall survival (OS) did not differ between patients with receptor-positive and receptor-negative tumors. It is concluded that the immunohistochemical localization of EGF-Rc is of limited prognostic value in prostate cancer.

DNA and S-phase fraction analysis by flow cytometry in prostate cancer. Clinicopathologic implications

BACKGROUND

Available prognostic factors for prostate cancer have not been proven consistently useful. The authors evaluated the prognostic value of DNA analysis by flow cytometry (FCM) in prostate cancer.

METHODS

Paraffin-embedded tumor specimens taken at tru-cut biopsy or transurethral resection (TURP) from 81 patients with prostate cancer were analyzed for DNA content and S-phase fraction (SPF) by FCM according to the method of Hedley et al (1983).

RESULTS

Thirty-five of the 63 (55.5%) evaluable DNA histograms had a diploid pattern, 18 (28.5%) a distinct aneuploid peak, and 10 (16%) a tetraploid pattern. An association was established between DNA ploidy abnormalities and Gleason score (P < 0.04) or presence of metastases at diagnosis (P < 0.0002). At Kaplan-Meier analysis, overall survival was significantly longer (P < 0.0002) in patients with diploid than in those with nondiploid tumors. Among patients with different risk categories, i.e. tumor size, Gleason score, and metastases at presentation, ploidy improved the detection of patients with poorer survival, with the exception of those with T1-T2 tumors. Cox regression analysis showed that ploidy was significantly related to survival. Bivariate models containing ploidy and SPF or Gleason score had a predictive value similar to that including all variables.

CONCLUSION

The study data show that DNA ploidy provides additional prognostic information in patients with locally advanced or metastatic prostatic cancer. The role of SPF remains to be established.

Glutathione transferase isoenzymes in normal and neoplastic human kidney tissue

Glutathione transferase (GST) activity in the cytosolic fractions of renal cortex tumour was found to be significantly lower (215 +/- 156 mU/mg) than that present in the corresponding non-tumour (466 +/- 278 mU/mg) tissues. Using the immunoblotting technique, glutathione transferase isoenzymes expression in both tumour and non-tumour kidney was investigated. Alpha and pi class glutathione transferases were the most abundant enzymes in non-tumour kidney and were expressed by all samples investigated. Immunofluorescence analysis indicated that the pi class enzymes are localized mainly in the distal convoluted tubules, whereas alpha class enzymes are localized in the proximal tubules. In the tumour moiety the alpha class GST appears to be absent or expressed at low level as compared with non-tumour samples. On the contrary, no significant differences in the expression of pi class GST were found in tumour as compared with non-tumour tissues. Mu class GST protein was detected in 12 of 26 samples tested. When present, mu class GST constitutes a few per cent of total GST protein. Immunofluorescence studies indicate that mu class GSTs are localized within the distal convoluted tubules. According to the electrophoretic mobility at least two different mu GST subunits (26.5 and 27.5 kd) were found. In one sample only the faster mu class GST subunit was present, two samples expressed both types of GST subunits, whereas nine samples expressed only the slower GST subunit. With the exception of one sample, a reduction of mu class GST expression was seen in tumour as compared with non-tumour tissues. The decrease of activity seen in the cytosolic fraction of tumour kidney must be ascribed mainly to a reduction or to a lack of expression of alpha class GST and to a lesser extent of mu class GST.

Incidental prostatic carcinoma: four-year follow-up after treatment with cyproterone acetate

This report is a retrospective clinical randomized study carried out on 114 cases of incidental prostatic carcinoma aged 55-87 years, 58 untreated and 56 treated with cyproterone acetate (CPA 200 mg/day) for 6 months, immediately after surgery. 78 cases were staged A1 and the remaining 36 A2. In stage A1, 75 cases were histologically graded G1, and 3 G2, whereas in stage A2, 7 cases were G1, 19 G2 and 10 G3. Moreover, flow cytometric DNA analysis showed in A1 20 G1 carcinomas with nuclear diploidy and 3 G2 with nuclear aneuploidy, in stage A2, 4 G3 tumors with nuclear aneuploidy. During the 4-year follow-up, 25/28 patients of the untreated group and 15/56 of the CPA-treated group were found in progression. In A1, progression was found in 6/37 untreated patients and 5/41 CPA-treated, whilst in A2 progression was observed in 19/21 untreated patients and in 10/15 treated with CPA. The critical period for progression was between the 2nd and 3rd year of follow-up. In A1, therefore, 6 months of therapy with CPA does not modify the progression rate, which is significantly improved in A2 (66% in the treated and 90% in the untreated group) during the first 30 months of follow-up. The prognosis may probably be further improved by continuing endocrine therapy.

[Etiology of bladder cancer]

Multiple agents have been suggested as urinary bladder carcinogens. Of these, certain aromatic amines and some tryptophan metabolites (Anthranilic acid, 3 hydroxy Anthranilic acid) have been proved to be carcinogenic. Others are suggested but are not conclusively proved as carcinogenic agents. Various animal species have been used as experimental models for the study of induction of cancer of the bladder and substantial progress has been made in the search for etiologic factors and pathogenesis of bladder tumors. A carcinogenic model of cancer bladder induction is proposed. However, knowledge of the tumorigenesis of cancer of the bladder is still limited and fragmentary. It appears, however, that Tryptophan dysmetabolism play a major role in this field and future experimental and epidemiologic studies should take this fact into consideration.

[Determination of the composition of renal calculi by x-ray spectrometry]

X-ray spectrophotometry shows undoubtful advantages versus conventional chemical methods employed in the analysis of kidney stones. In fact, it is possible to detect little crystals that are very important in the genesis and treatment of urinary calculosis.

[Stage P-1 primary neoplasia of the bladder. Critical evaluation of results obtained with the use of adriamycin and mitomycin C in the prevention of recurrences]

However adequately treated, surface carcinomas of the bladder recur sooner or later with infiltration found in about 10% of cases. Any development that may offer therapeutic progress and reduce the incidence of recurrences is therefore of primary importance. Two homogeneous groups of patients were selected for the present study: 35 were given Adriamycin and 25 Mitomycin C. In evaluating results, the incidence of recurrences in relation to the primary neoplasia and the existence of single or multiple tumors was analysed. It is concluded that Mitomycin C in association with either T.U.R. or T.V.R. is a particularly useful and indubitably effective form of topical chemotherapy in cases of single or multiple primary neoplasias.