Multicenter Phase II Clinical Trial of Gemcitabine and Cisplatin as Neoadjuvant Chemotherapy for Patients With High-Grade Upper Tract Urothelial Carcinoma

PURPOSE

Neoadjuvant chemotherapy (NAC) has proven survival benefits for patients with invasive urothelial carcinoma of the bladder, yet its role for upper tract urothelial carcinoma (UTUC) remains undefined. We conducted a multicenter, single-arm, phase II trial of NAC with gemcitabine and split-dose cisplatin (GC) for patients with high-risk UTUC before extirpative surgery to evaluate response, survival, and tolerability.

METHODS

Eligible patients with defined criteria for high-risk localized UTUC received four cycles of split-dose GC before surgical resection and lymph node dissection. The primary study end point was rate of pathologic response (defined as < ypT2N0). Secondary end points included progression-free survival (PFS), overall survival (OS), and safety and tolerability.

RESULTS

Among 57 patients evaluated, 36 (63%) demonstrated pathologic response (95% CI, 49 to 76). A complete pathologic response (ypT0N0) was noted in 11 patients (19%). Fifty-one patients (89%) tolerated at least three complete cycles of split-dose GC, 27 patients (47%) tolerated four complete cycles, and all patients proceeded to surgery. With a median follow up of 3.1 years, 2- and 5-year PFS rates were 89% (95% CI, 81 to 98) and 72% (95% CI, 59 to 87), while 2- and 5-year OS rates were 93% (95% CI, 86 to 100) and 79% (95% CI, 67 to 94), respectively. Pathologic complete and partial responses were associated with improved PFS and OS compared with nonresponders (≥ ypT2N any; 2-year PFS 100% and 95% v 76%, P < .001; 2-year OS 100% and 100% v 80%, P < .001).

CONCLUSION

NAC with split-dose GC for high-risk UTUC is a well-tolerated, effective therapy demonstrating evidence of pathologic response that is associated with favorable survival outcomes. Given that these survival outcomes are superior to historical series, these data support the use of NAC as a standard of care for high-risk UTUC, and split-dose GC is a viable option for NAC.

The effect of urinary diversion on long-term kidney function after cystectomy

OBJECTIVES

Cystectomy with urinary diversion is associated with decreased long-term kidney function due to several factors. One factor that has been debated is the type of urinary diversion used: ileal conduit (IC) vs. neobladder (NB). We tested the hypothesis that long-term kidney function will not vary by type of urinary diversion.

METHODS AND MATERIALS

We retrospectively identified all patients who underwent cystectomy with urinary diversion at our institution from January 1, 2007, to January 1, 2018. Data were collected on patient demographics, comorbid conditions, perioperative radiotherapy, and complications. Creatinine values were measured at several time points up to 120 months after surgery. Glomerular filtration rate (GFR) (ml/min per 1.73 m²) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed model with inverse probability of treatment weighting (IPTW) was used to compare GFR between the IC and NB cohorts over time. Multiple sensitivity analyses were performed based on 2 different calculations of GFR (Chronic Kidney Disease Epidemiology Collaboration equation vs. Modification of Diet in Renal Disease), with and without excluding patients with preoperative GFR less than 40 ml/min per 1.73 m².

RESULTS

Among 563 patients who underwent cystectomy with urinary diversion, a NB was used for 72 (12.8%) individuals. Patients who had a NB were significantly younger, had a lower American Society of Anesthesiologists score, greater baseline GFR, better Eastern Cooperative Oncology Group performance status, lower median Charlson comorbidity index, and were less likely to have received preoperative abdominal radiation (all P < 0.05). Both NB and IC patients had decreased kidney function over time, with mean GFR losses at 5 years of 17% and 14% of baseline values, respectively. The IPTW-adjusted linear mixed model revealed that IC patients had slightly more deterioration in kidney function over time, but this was not statistically significant (estimate, 0.12; P = 0.06). The sensitivity analyses yielded a similar trend, in that GFR decrease appeared to be greater in the IC cohort. This trend was statistically significant when using Modification of Diet in Renal Disease (P = 0.04).

CONCLUSIONS

Among highly selected patients with an NB, deterioration of kidney function may potentially be lower over time than among IC patients. However, the statistical significance varied between analyses and we cautiously attribute these observed differences to patient selection.

Marital status and prostate cancer outcomes

INTRODUCTION

To evaluate the influence of marriage on the survival outcomes of men diagnosed with prostate cancer.

MATERIALS AND METHODS

We examined 115,922 prostate cancer cases reported to the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2003. Multivariate Cox regression techniques were used to study the relationship of marital status and prostate cancer-specific and overall mortality.

RESULTS

Married men comprised 78% of the cohort (n = 91,490) while unmarried men (single, divorced, widowed, and separated) comprised 22% of the cohort (n = 24,432). Married men were younger (66.4 versus 67.8 years, p < 0.0001), more likely to be white (85% versus 76%, p < 0.0001), presented with lower tumor grades (68% are well or moderately differentiated versus 62%, p < 0.0001) and at earlier clinical stages (41% AJCC stage I/II versus 37%, p < 0.0001). Multivariate analysis revealed that unmarried men had a 40% increase in the relative risk of prostate cancer-specific mortality (HR 1.40; CI 1.35-1.44; p < 0.0001), and a 51% increase in overall mortality (HR 1.51; CI 1.48-1.54; p < 0.0001), even when controlling for age, AJCC stage, tumor grade, race and median household income. Furthermore, the 5 year disease-specific survival rates for married men was 89.1% compared to 80.5% for unmarried men (p < 0.0001).

CONCLUSION

Marital status is an independent predictor of prostate cancer-specific mortality and overall mortality in men with prostate cancer. Unmarried men have a higher risk of prostate cancer-specific mortality compared to married men of similar age, race, stage, and tumor grade.

Outcome and toxicity for patients treated with intensity modulated radiation therapy for localized prostate cancer

PURPOSE

We evaluate long-term disease control and chronic toxicities observed in patients treated with intensity modulated radiation therapy for clinically localized prostate cancer.

MATERIALS AND METHODS

A total of 302 patients with localized prostate cancer treated with image guided intensity modulated radiation therapy between July 2000 and May 2005 were retrospectively analyzed. Risk groups (low, intermediate and high) were designated based on National Comprehensive Cancer Network guidelines. Biochemical control was based on the American Society for Therapeutic Radiology and Oncology (Phoenix) consensus definition. Chronic toxicity was measured at peak symptoms and at last visit. Toxicity was scored based on Common Terminology Criteria for Adverse Events v4.

RESULTS

The median radiation dose delivered was 75.6 Gy (range 70.2 to 77.4) and 35.4% of patients received androgen deprivation therapy. Patients were followed until death or from 6 to 138 months (median 91) for those alive at last evaluation. Local and distant recurrence rates were 5% and 8.6%, respectively. At 9 years biochemical control rates were 77.4% for low risk, 69.6% for intermediate risk and 53.3% for high risk cases (log rank p = 0.05). On multivariate analysis T stage and prostate specific antigen group were prognostic for biochemical control. At last followup only 0% and 0.7% of patients had persistent grade 3 or greater gastrointestinal and genitourinary toxicity, respectively. High risk group was associated with higher distant metastasis rate (p = 0.02) and death from prostate cancer (p = 0.0012).

CONCLUSIONS

This study represents one of the longest experiences with intensity modulated radiation therapy for prostate cancer. With a median followup of 91 months, intensity modulated radiation therapy resulted in durable biochemical control rates with low chronic toxicity.

Anatomic site-specific disparities in survival outcomes for penile squamous cell carcinoma

OBJECTIVE

To identify the predictors of cancer-specific mortality of penile squamous cell carcinoma (PSCC) using a population-based database.

METHODS

Using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results registry, we performed a time-to-event analysis to determine which clinical parameters were useful in predicting cancer-specific mortality.

RESULTS

Our cohort consisted of 2515 cases of PSCC diagnosed from 1973 to 2007. The patients were divided into 2 groups: primary tumors of the prepuce (n = 722) and primary tumors of the glans, body, and overlapping lesions of the skin (n = 1793). The median follow-up for the cohort was 39 months (range 1-411). Compared with tumors of the prepuce, tumors of the body (hazard ratio 1.61, 95% confidence interval 1.00-2.60, P = .05) and overlapping tumors of the skin (hazard ratio 1.79, 95% confidence interval 1.13-2.83, P = .01) had a greater risk of cancer-specific mortality, even when controlling for age, Surveillance, Epidemiology, and End Results stage, and tumor grade. Furthermore, the disease-specific 10-year survival rate of those with preputial tumors was 89.4% compared with 78.7% for the other 3 groups combined (P < .0001).

CONCLUSION

Anatomic site-specific disparities for PSCC survival appear to exist. Patients diagnosed with PSCC of the prepuce have greater overall long-term disease-specific survival than patients with primary tumors elsewhere.

Radiation dose escalation for localized prostate cancer: intensity-modulated radiotherapy versus permanent transperineal brachytherapy

BACKGROUND

In the current study, the effects of dose escalation for localized prostate cancer treatment with intensity-modulated radiotherapy (IMRT) or permanent transperineal brachytherapy (BRT) in comparison with conventional dose 3-dimensional conformal radiotherapy (3D-CRT) were evaluated.

METHODS

This study included 853 patients; 270 received conventional dose 3D-CRT, 314 received high-dose IMRT, 225 received BRT, and 44 received external beam radiotherapy (EBRT) + BRT boost. The median radiation doses were 68.4 grays (Gy) for 3D-CRT and 75.6 Gy for IMRT. BRT patients received a prescribed dose of 144 Gy with iodine-125 (I-125) or 120 Gy with palladium-103 (Pd-103), respectively. Patients treated with EBRT + BRT received 45 Gy of EBRT plus a boost of 110 Gy with I-125 or 90 Gy with Pd-103. Risk group categories were low risk (T1-T2 disease, prostate-specific antigen level <or=10 ng/mL, and a Gleason score <or=6), intermediate risk (increase in value of 1 of the factors), and high risk (increase in value of >or=2 factors).

RESULTS

With a median follow-up of 58 months, the 5-year biochemical control (bNED) rates were 74% for 3D-CRT, 87% for IMRT, 94% for BRT, and 94% for EBRT + BRT (P <.0001). For the intermediate-risk group, high-dose IMRT, BRT, or EBRT + BRT achieved significantly better bNED rates than 3D-CRT (P <.0001), whereas no improvement was noted for the low-risk group (P = .22). There was no increase in gastrointestinal (GI) toxicity from high-dose IMRT compared with conventional dose 3D-CRT, although there was more grade 2 genitourinary (GU) toxicity (toxicities were graded at the time of each follow-up visit using a modified Radiation Therapy Oncology Group [RTOG] scale). BRT caused more GU but less GI toxicity, whereas EBRT + BRT caused more late GU and GI toxicity than IMRT or 3D-CRT.

CONCLUSIONS

The data from the current study indicate that radiation dose escalation improved the bNED rate for the intermediate-risk group. IMRT caused less acute and late GU toxicity than BRT or EBRT + BRT.

Bilateral laparoscopic nephrectomy for significantly enlarged polycystic kidneys: a technique to optimize outcome in the largest of specimens

OBJECTIVE

To present our experience with bilateral laparoscopic nephrectomy (BLN) for symptomatic autosomal-dominant polycystic kidney disease (ADPKD), as surgical management of massively enlarged polycystic kidneys can be a daunting task.

PATIENTS AND METHODS

The study was a retrospective chart review of all patients undergoing BLN for ADPKD. Patient demographics, indications for the procedure, perioperative data, and pathological data were analysed.

RESULTS

In all, 12 patients underwent BLN at our institution; eight were performed before transplant, three after transplant, and one with a concomitant kidney transplant. Indications for surgery included abdominal pain, fullness and early satiety, recurrent urinary tract infections, and need for space for future transplant. The mean patient age was 49.6 years, with a body mass index of 27.0 kg/m(2). The mean operative duration was 214 min, estimated blood loss was 169 mL, and the hospital stay was 4 days. There were no conversions to open surgery. The mean (range) pathological kidney mass was 2243 (656-4200) g on the left and 2379 (789-5042) g on the right. No patients with a previous renal transplant had deterioration in postoperative renal function. There was one minor intraoperative complication, one postoperative complication, and one patient with preoperative anaemia required a blood transfusion.

CONCLUSIONS

Symptomatic patients with ADPKD due to massively enlarged kidneys should be considered for BLN when performed by an experienced laparoscopic surgeon. This includes patients with an existing renal allograft and candidates for concomitant transplantation. The approach should be tailored to avoid injury to adjacent structures secondary to displacement from the mass effect of these kidneys.

Salvage radiotherapy for men with isolated rising PSA or locally palpable recurrence after radical prostatectomy: do outcomes differ?

OBJECTIVES

To compare, in a retrospective analysis, the outcome of salvage external beam radiotherapy (EBRT) for isolated prostate-specific antigen (PSA) elevation or palpable local recurrence after radical prostatectomy (RP).

METHODS

We evaluated 102 men who underwent EBRT from 1993 to 1999, 60 for a rising PSA level alone and 42 for palpable local disease after RP. Biochemical disease-free survival and overall survival were calculated. Prognostic factors were evaluated to determine associations with biochemical disease-free survival.

RESULTS

The 5-year rate of biochemical disease-free survival, local control, freedom from distant metastasis, and overall survival for all 102 patients was 38%, 94%, 87%, and 88%, respectively. All palpable disease resolved completely after salvage EBRT. The greatest 5-year rate of biochemical control (69%) was obtained in patients with a pre-EBRT PSA level of 0.5 ng/mL or less. The 5-year overall survival rate was significantly better for those who underwent salvage EBRT for a rising PSA level than for those with palpable recurrence (96% versus 78%, P = 0.02). A low pre-EBRT PSA level and a less than 2-year interval from RP to EBRT were independent predictors of biochemical failure. Five patients (5%) experienced chronic grade 3 or 4 RT-related toxicity.

CONCLUSIONS

Salvage EBRT provides excellent local control of recurrent disease after RP. Salvage EBRT before the development of palpable local disease may confer a survival benefit and decrease the risk of metastasis, and durable biochemical control was achieved best in those whose pre-EBRT PSA level was 0.5 ng/mL or less. Early referral and careful patient selection is vital for salvage EBRT to be of optimal benefit.

THE MALE SLING FOR POST-PROSTATECTOMY INCONTINENCE: MEAN FOLLOWUP OF 18 MONTHS

PURPOSE

We review our experience with 42 consecutive patients undergoing the bone anchored male sling procedure.

MATERIALS AND METHODS

A retrospective chart review was performed, and complete data and followup were available in 38 of the 42 patients. Success was defined as wearing 1 thin pad or less per day, or social continence. Variables such as severity of incontinence, age, detrusor overactivity, previous artificial urinary sphincter, history of radiation and intraoperative flow pressures were analyzed for success and risk of failure.

RESULTS

With a mean followup of 18 months (range 6 to 26), 39.5% (15 of 38) were considered a success (socially continent). A statistically significant trend in the degree of preoperative incontinence predicting success was identified. Social continence in mild, moderate and severe cases was achieved in 67%, 50% and 0%, respectively (p =0.001/95% CI). Only 15.8% of patients were completely dry and not wearing pads. Significant perineal pain was reported in the early postoperative period but resolved in all patients. Infection occurred in 3 patients with erosion found in 1.

CONCLUSIONS

Although these results are not as encouraging as previous reports, carefully selected patients with mild to moderate incontinence are good candidates for the male sling. Patients with a history of radiation, previous artificial urinary sphincter or severe incontinence should be counseled about the higher risk of treatment failure. Patients should be informed of the possibility of progressive failure with time and the occurrence of significant perineal pain in the early postoperative period.

Proteomic analysis of chromatin-modifying complexes in Saccharomyces cerevisiae identifies novel subunits

Epigenetics is the alteration of phenotype without affecting the genotype. An underlying molecular mechanism of epigenetics is the changes of chromatin structure by covalent histone modifications and nucleosome reorganization. In the yeast, Saccharomyces cerevisiae, two of the most well-studied macromolecular complexes that perform these epigenetic changes are the ATP-dependent Swi/Snf chromatin-remodelling complex and the SAGA histone acetyltransferase complex. To understand fully the mechanism by which these large protein complexes perform their functions in the cell, it is crucial that all the subunits of these complexes are identified. In an attempt to identify new subunits associated with SAGA and Swi/Snf, we used tandem affinity purification, followed by a multidimensional protein identification technology to analyse the subunit composition. Our analysis identified two novel proteins, one associated with SAGA, YPL047W (Sgf11), and another associated with Swi/Snf, Rtt102.

Complications of laparoscopic nephrectomy: the Mayo clinic experience

PURPOSE

We present the incidence of complications and conversions during laparoscopic nephrectomy performed for various indications and discuss methods to help prevent future complications.

MATERIALS AND METHODS

From June 1999 to February 2003 at our institution 285 laparoscopic nephrectomy cases were performed, consisting of 113 radical nephrectomies, 101 donor nephrectomies, 27 simple nephrectomies, 23 partial nephrectomies and 21 nephroureterectomies. We reviewed the data base of patients who underwent laparoscopic nephrectomy to examine complications and analyze factors related to conversion to an open surgical procedure.

RESULTS

Major complications occurred in 16 patients (5.6%). Major complications were surgical in 12 patients and medical in 4. Of the major surgical complications 3, 6, 1, 1 and 1 occurred during laparoscopic radical nephrectomy, donor nephrectomy, nephroureterectomy, simple nephrectomy and partial nephrectomy, respectively. The predominant major surgical complication was bleeding requiring conversion to an open surgical procedure. The overall conversion rate was 4% (12 patients), consisting of 6 emergency and 6 elective conversions. The remaining 27 patients experienced minor surgical or postoperative medical problems, such as urinary retention or wound infection. The mortality rate in our series was 0%.

CONCLUSIONS

Laparoscopic renal surgery is becoming a routine procedure in the armamentarium of many urologists. Complications that are unique to laparoscopy exist but they should decrease with time with repetition and experience. We have learned many different precautions and procedures that should help decrease the risk of future complications associated with laparoscopic renal surgery.

Salvage radiotherapy for palpable, locally recurrent prostate cancer after radical prostatectomy

PURPOSE

A retrospective study to evaluate the outcome of salvage radiotherapy (RT) for clinically apparent, palpable prostate cancer recurrence after radical prostatectomy (RP).

METHODS AND MATERIALS

Forty-two patients underwent RT for clinically apparent recurrent prostate cancer after RP between 1993 and 1999. The end points and treatment variables of biochemical disease-free survival were evaluated statistically.

RESULTS

The median follow-up was 4.3 years. All 42 patients experienced resolution of clinically detectable recurrence within 1 year after RT. The 5-year biochemical disease-free survival, local control, freedom from distant metastases, and overall survival rate was 27%, 94%, 82%, and 78%, respectively. The initial pathologic stage (T3 or T4; p = 0.04) and interval (<2 years from RP to RT; p = 0.01) were independent predictors of biochemical failure, and RT simulation without contrast (p = 0.05) was nearly significant on multivariate analysis. Three patients (7%) experienced chronic Grade 3 or 4 RT-related toxicity.

CONCLUSION

Salvage prostate bed RT for clinically apparent locally recurrent prostate cancer after RP provides effective local tumor control with modest durable biochemical control. Patients irradiated with a better simulation technique were found to have a more favorable outcome. A consensus on a definition of biochemical disease-free survival after salvage RT is critical for meaningful comparison of the available data and to future progress in treating this disease process.

Radiotherapy for Men With Isolated Increase in Serum Prostate Specific Antigen After Radical Prostatectomy

PURPOSE

In this retrospective study we determined the results of salvage external beam radiation therapy (RT) to the prostate bed for isolated increase of serum prostate specific antigen (PSA) after radical prostatectomy.

MATERIALS AND METHODS

A total of 60 patients underwent RT for PSA failure after radical prostatectomy from 1993 to 1999. Median followup was 51 months. Biochemical disease-free survival (bDFS) with a serum PSA of 0.3 ng/ml or less was estimated using the Kaplan-Meier method. Potential prognostic factors were evaluated for significant associations with bDFS.

RESULTS

Median PSA before RT was 0.69 ng/ml. Median radiation dose was 64.8 Gy. The 5-year actuarial bDFS was 45%. There were 32 patients with a minimum followup of 4 years (median 73 months) who experienced a 5-year bDFS rate of 43%. PSA before RT (p = 0.016), RT dose (p = 0.026), surgical margin involvement (p = 0.017) and Gleason score (p = 0.018) were identified as prognostic factors for bDFS. A significant association with bDFS was present at 5 years of 65%, 34% and 0% for PSA before RT less than 0.6, 0.6 to 1.2, and greater than 1.2 ng/ml, respectively (p = 0.036). Patients with PSA before RT less than 0.6 ng/ml and total RT dose greater than 64.8 Gy had improved bDFS at 5 years compared to all others (77% vs 32%, p = 0.04). Of 60 patients 3 (5%) experienced chronic grade 3 toxicity.

CONCLUSIONS

Optimal benefit from salvage RT was achieved in patients with a PSA less than 0.6 ng/ml and doses of RT greater than 64.8 Gy. Early treatment with a sufficiently high dose of RT maximizes the potential for salvage.

Chromosomal localization of three vacuolar-H+ -ATPase 16 kDa subunit (ATP6V0C) genes in the murine genome

Vacuolar-H(+)-ATPase (V-H-ATPase) is a large multimeric protein composed of at least 12 distinct subunits. The 16-kDa hydrophobic proteolipid subunit (ATP6V0C; ATPase, H(+ )transporting, lysosomal 16 kDa, V0 subunit C) plays a central role in H(+) transport across cellular membranes. We have mapped three ATP6V0C genes (Atp6v0c, Atp6v0c-ps1 and Atp6voc-ps2) in the murine genome. Atp6v0c-ps1 and Atp6v0c-ps2 map to Chromosomes 7 and 6, respectively. Atp6v0c maps to Chromosome 17, closely linked to the Tsc2 locus and D17Mit55. This region of Chromosome 17 in mouse is homologous with chromosome 16 in human where the ATP6V0C gene is localized.

Interstitial cystitis in men

OBJECTIVES

To determine the personal characteristics, the mode of presentation, the duration of the delay in diagnosis, the number of misdiagnoses, the means to achieve diagnosis, and previous treatment provided for a group of men with interstitial cystitis (IC).

METHODS

A chart review of 29 men diagnosed with IC at our facility from 1988 to 1996 was performed. Basic demographic data, historical information, laboratory findings, and endoscopic and biopsy results were tabulated.

RESULTS

IC in this series of men was diagnosed at a mean age of 67.3 years. There was approximately a 4-year diagnostic lag between presentation and diagnosis. The most common prior erroneous diagnoses were prostatitis in 48% and benign prostatic hypertrophy (BPH) in 38% of the men. Ulcers were encountered cystoscopically in about 70% and biopsy specimens uniformly showed nonspecific chronic cystitis at the time of diagnosis.

CONCLUSIONS

IC should be considered in the differential diagnosis of voiding disorders accompanied by irritative symptoms and pelvic pain in older men. The diagnosis should be especially considered in men who are refractory to the usual treatments for BPH and prostatitis. Cystoscopy and bladder distention under anesthesia provided the most useful objective information in our hands. Biopsy is useful to rule out inflammatory cancer but adds little to the diagnosis of IC.

Comparison of the modified vest and the direct anastomosis for radical retropubic prostatectomy

OBJECTIVES

This retrospective study was undertaken to compare the efficacy of the Vest and direct vesicourethral anastomosis for radical prostatectomy.

METHODS

Five hundred six patients who underwent consecutive radical prostatectomies at our institution were analyzed. Two hundred fifty-nine patients underwent vesicourethral anastomosis using the Vest technique and 247 underwent a direct suture anastomosis. The groups were analyzed relative to time until healing, the occurrence of anastomotic strictures, and the continence rate 1 year after surgery.

RESULTS

Approximately twice as many patients who underwent the Vest procedure experienced delayed healing and 8.5% developed anastomotic strictures compared with 1.2% of the direct anastomosis group. The Vest group experienced slightly better urinary continence 1 year postoperatively.

CONCLUSIONS

The Vest procedure is a reasonable alternative to direct anastomosis for radical prostatectomy and provides similar results. We suggest specific circumstances when the Vest anastomosis may be particularly useful.

The use of radiotherapy for patients with isolated elevation of serum prostate specific antigen following radical prostatectomy

PURPOSE

An analysis was performed to assess the outcome of patients who received radiotherapy for isolated elevation of serum prostate specific antigen (PSA) levels following radical retropubic prostatectomy.

MATERIALS AND METHODS

Forty-six patients were initially treated for localized prostate cancer with radical retropubic prostatectomy following negative pelvic lymphadenectomy. These patients had detectable serum PSA 6 or more months postoperatively. No patient had other clinical evidence of recurrent disease as determined by history, physical examination, bone scan, computerized tomography of the abdomen and pelvis, chest radiographs, complete blood cell counts and serum chemistry profiles. The patients received prostate bed irradiation using 10 MV. x-rays and a 4-field approach. Doses ranged from 60.0 to 67.0 Gy. in 1.8 to 2.0 Gy. fractions. Freedom from failure after radiotherapy was defined as maintaining a PSA of 0.3 ng./ml. or less without hormonal intervention.

RESULTS

In 27 of the 46 patients (59%) PSA had decreased to 0.3 ng./ml. or less at last measurement without hormonal intervention. The freedom from failure rate was 50% at 3 and 5 years. More favorable responses to salvage radiotherapy occurred in patients with low grade tumors and serum PSA 1.1 ng./ml. or less at initiation of radiotherapy. Patients, receiving radiation doses of 64 Gy. or more had more favorable response rates than those receiving lesser doses.

CONCLUSIONS

Isolated elevations of serum PSA following prostatectomy reflect residual disease. Radiotherapy administered to the prostate bed effectively decreased serum PSA in approximately half of the cases. This effect appears to be accomplished by eradicating tumor cells in the prostate bed.

Detection of residual prostate cancer after radical prostatectomy with the Abbott IMx PSA assay

OBJECTIVES

This analysis was performed to define the level of serum prostate-specific antigen (PSA) measured with the Abbott IMx assay that indicates residual or progressive prostate cancer after radical retropubic prostatectomy (RRP).

METHODS

Since March 1992, we have used the Abbott IMx assay to determine PSA levels. Between March 1992 and June 1994, 102 of those patients having RRPs were found to have pathologic Stage C prostate cancer. Fifty-one of these patients had at least one serum PSA measurement of 0.1 ng/mL or greater. Eight patients were excluded from the analysis because they received postoperative radiotherapy that might have influenced subsequent PSA levels. The remaining 43 patients are the subjects of this analysis and were evaluated to determine the "clinical threshold" or minimal serum PSA level after RRP indicative of progressive disease. Patients were followed for 6 to 36 months (median 23 months) from the date of the RRP. Failure was defined as a subsequent increase of PSA to greater than 0.3 ng/mL. Freedom from failure was determined using the Kaplan-Meier product limit method.

RESULTS

Of the patients with at least one postoperative serum PSA level of 0.1 ng/mL, the subsequent freedom from failure was 80% at 23 months as compared with 13% in patients with at least one postoperative PSA level of 0.2 ng/mL (P = 0.003).

CONCLUSIONS

Following RRP for pathologic Stage C prostate cancer, a solitary PSA level of 0.1 ng/mL (measured with the IMx assay) was followed by a progressive rise in PSA levels in only a minority of patients within the first 2 years after surgery. In contrast, the majority of patients with a postoperative PSA level of 0.2 ng/mL subsequently had progressively rising PSA levels. This indicates that a serum PSA level of 0.2 ng/mL is reflective of residual prostate cancer.

The result of radical retropubic prostatectomy and adjuvant therapy for pathologic stage C prostate cancer

PURPOSE

The results of therapy in 288 men with pathologic Stage C prostate cancer who underwent radical retropubic prostatectomy (RRP) were analyzed to determine the effects of adjuvant therapy.

METHODS AND MATERIALS

Twenty-seven of the 288 patients received preoperative neoadjuvant hormonal therapy (leuprolide acetate). Postoperatively, 60 patients received adjuvant radiotherapy (RT) to the prostate bed. Follow-up ranged from 3 to 83 months (median = 32 months). Freedom from failure (FFF) was defined as maintaining a serum PSA level of < or = 0.3 ng/ml.

RESULTS

The FFF was 61% at 3 years and 45% at 5 years for the entire group. The FFF following RRP plus RT was 75% at 3 years and 57% at 5 years as compared to 56% at 3 years and 40% at 5 years for RRP without RT (p=0.049). The FFF following RRP plus neoadjuvant hormonal therapy was 58% at 3 years and 40% at 5 years as compared to 60% at 3 years and 45% at 5 years following RRP without hormonal therapy (p=0.3). In patients without seminal vesicle (SV) invasion, the FFF was 81% at 3 years and 5 years for RRP plus RT as compared to 61% at 3 years and 50% at 5 years for RRP without RT (p=0.01). In patients with SV invasion, the FFF was 61% at 3 years and 36% at 5 years for RRP plus RT as compared to 44% at 3 years and 23% at 5 years for RRP without RT (p=0.23). The projected local control rate was 83% at 5 years for those with RRP alone as compared to 100% for RRP plus RT (p=0.02). Survival at 5 years was projected to be 92% and was not significantly altered by the administration of adjuvant therapies.

CONCLUSIONS

Postoperative RT was associated with significantly improved local control and FFF rates, especially in patients with tumors which did not involve the seminal vesicles.

Urinary tract stones in pregnancy

The presence of stones during an otherwise uneventful pregnancy is a dramatic and potentially serious issue for the mother, the fetus, and the treating physicians alike. The incidence and predisposing factors are generally the same as in nonpregnant, sexually active, childbearing women. Unique metabolic effects in pregnancy such as hyperuricuria and hypercalciuria, changes in inhibitors of lithiasis formation, stasis, relative dehydration, and the presence of infection all have an impact on stone formation. The anatomic changes and physiologic hydronephrosis of pregnancy make the diagnosis and treatment more challenging. Presenting signs and symptoms include colic, flank pain, hematuria, urinary tract infection, irritative voiding, fever, premature onset or cessation of labor, and pre-eclampsia. The initial evaluation and treatment are again similar to those used for the nonpregnant population. The most appropriate first-line test is renal ultrasonography, which may, by itself, allow the diagnosis to be made and provide enough information for treatment. Radiographic studies, including an appropriately performed excretory urogram, give specific information as to size and location of the stones, location of the kidneys, and differential renal function and can be used safely, but the ionizing radiation risks should be considered. All forms of treatment with the exception of extracorporeal shock wave lithotripsy and some medical procedures are appropriate in the pregnant patient. Close coordination by the urologist, the obstetrician, the pediatrician, the anesthesiologist, and the radiologist is required for the appropriate care of these patients.

Assessment of bladder function after lumbar decompressive laminectomy for spinal stenosis: a prospective study

Lumbar spinal stenosis is a common problem in elderly patients. In its more advanced forms, it typically causes intractable leg pain, but many patients also manifest varying degrees of bladder dysfunction. The goal of lumbar decompressive laminectomy is relief of leg pain and paresthesias, yet some patients also achieve improvement in bladder function. This study prospectively investigated patients with lumbar spinal stenosis to determine whether laminectomy had any effect on urological function. Of the 20 patients in the study, 10 were men and 10 women (average age 70.9 years). All patients had severe lumbar stenosis affecting between two and four spinal segments, and all reported some degree of bladder dysfunction. Cystoscopy and urodynamic testing were completed preoperatively. A standard decompressive laminectomy was performed over the appropriate number of spinal segments. Urodynamic studies were repeated at 2 and 6 months postoperatively. At the 6-month follow-up review, bladder function was subjectively improved in 12 patients (60%) and unchanged in eight (40%). Postvoiding residual urine volume was the urodynamic factor most likely to be improved by laminectomy. In nine patients (45%), baseline postvoiding residual urine volume was elevated and all nine had improvement postoperatively. In the remaining 11 patients (55%), this urine volume was normal before and after surgery. Maximum urine flow rates also improved, but the results of cytometrography and electromyography, urine flow pattern, and bladder capacity were unchanged postoperatively. Cystoscopy detected previously undiagnosed malignancy of the lower urinary tract in two patients (10%). It is concluded that lumbar decompressive laminectomy can have a beneficial effect on bladder function in a significant number of patients with advanced lumbar spinal stenosis.

Inhibition of calcineurin by cyclosporin A-cyclophilin requires calcineurin B

The interaction of the immunosuppressive complex cyclosporin A-cyclophilin (CsA-CyP) with the Ca2+/calmodulin-dependent protein phosphatase calcineurin is investigated using a recombinant form of the A subunit of calcineurin (rCNA). Only in the presence of purified calcineurin B (CNB) does rCNA show the response of native calcineurin, i.e. 50% inhibition of rCNA phosphatase activity at 6 nM human cyclophilin B and 0.6 microM human cyclophilin A using [32P]casein as substrate, yet stimulation of activity with p-nitrophenyl phosphate as substrate. This study demonstrates that the B subunit is necessary to confer sensitivity of calcineurin to CsA-CyP.

Clinical trials of the Northgate SD-3 dual-purpose lithotriptor for renal calculi

The Northgate SD-3 is a bathless, portable shock wave lithotriptor made in the United States. It uses ultrasound localization and spark-gap, electrode-generated shock waves to fragment calculi in the upper urinary tract. Since October 1987, 312 treatments have been performed on 281 patients (286 kidneys) with stone burdens less than 2 cm. during clinical trials at 6 investigational sites in the United States. A fragmentation rate of 94% was achieved. Of the treatments 78% were judged successful (stone-free or fragments of less than 5 mm. remaining in an asymptomatic patient) and a 3-month stone-free rate of 58% was noted. The retreatment rate was 9% and the ancillary procedure rate was 5%. The complications (hematuria, ecchymosis, pain, obstruction) were mild and not unlike those seen in patients undergoing lithotripsy with other devices.

Cyclosporin-mediated inhibition of bovine calcineurin by cyclophilins A and B

The Ca(2+)- and calmodulin-dependent protein phosphatase calcineurin is inhibited by the immunosuppressant drug cyclosporin A in the presence of cyclophilin A or B. Of the two isoforms, cyclophilin B is more potent by a factor of 2-5 when either the phosphoprotein [32P]casein or the [32P]phosphoserine [Ser(32P)] form of the 19-residue bovine cardiac cAMP-dependent protein kinase regulatory subunit peptide RII, [Ser(32P)15]RII, is used as substrate. With [Ser(32P15]RII as substrate, the concentrations of the cyclosporin A.cyclophilin A and cyclosporin A.cyclophilin B complexes, which cause 50% inhibition of calcineurin activity, are 120 and 50 nM, respectively. Lowering the concentration of calcineurin 80% with [32P]casein as substrate lowered the apparent inhibition constant for each complex even further; 50% inhibition of calcineurin was observed at 40 nM for cyclosporin A.cyclophilin A, whereas it was less than 10 nM for cyclosporin A.cyclophilin B. In all inhibition assays with [32P]casein or [Ser(32P)15]RII, the concentration of calcineurin required for measurable phosphatase activity is such that these complexes behave as tight-binding inhibitors of calcineurin, and steady-state kinetics cannot be used to assess inhibition patterns or Ki values. Limited trypsinization of calcineurin produces a fragment that is still inhibited, indicating that the interaction of cyclosporin.cyclophilin with calcineurin does not require either calmodulin or Ca2+.

Excretory urography during extracorporeal shock-wave lithotripsy: a localization alternative

An alternative localization technique or extracorporeal shock wave lithotripsy using devices that use fluoroscopic targeting is presented. Excretory urography during lithotripsy can provide valuable targeting information and the results of treatment in a manner that may prove useful in the treatment of urinary calculi.

Direct sequencing from touch preparations of human carcinomas: analysis of p53 mutations in breast carcinomas

A new technique for characterizing somatic mutations in very small samples of cellularly heterogeneous human cancer tissue was developed and tested using mutations in the p53 gene in breast carcinomas as a model system. The technique combines touch preparation of specimens to obtain homogeneous clusters of carcinoma cells free of normal cells with a nested pair of polymerase chain reaction (PCR) amplifications of DNA to increase the amount of target gene sequence sufficiently to permit direct sequencing of the p53 gene. Touch preparations of fresh or previously frozen tissue from human adenocarcinomas derived from several organs were stained, and clusters of 10-50 malignant cells were transferred by pipette into microfuge tubes for PCR amplification. Exons 5-9 of the p53 gene, which contain the major mutational hot spots associated with most human cancers, were sequenced by the following steps: 1) two rounds of PCR amplification using DNA Taq polymerase and two sets of oligonucleotide primers, the second set being nested within the segment amplified by the first set and having attached T7 and SP6 phage promoter sequences, 2) transcription of the amplified DNA sequences with T7 and SP6 RNA polymerases, and 3) dideoxy sequencing of single-stranded RNA transcripts with reverse transcriptase and with additional oligonucleotide primers to achieve specificity for this unique region of the genome. The utility of this approach is illustrated by our success in detecting and analyzing point mutations in cell clusters from four of 11 primary adenocarcinomas of the human breast.

Characterization of Vero cells

A cell line used in the production of biologicals should be free of infectious agents, and 'described with respect to cytogenetic characteristics and tumorigenicity'. Vero, a continuous cell line derived from a normal African green monkey kidney, was examined for the presence of retroviruses and for tumorigenic potential. We were unable to detect the presence of retroviruses by reverse transcriptase assay, electron microscopy or hybridization of cellular genomic DNA with Mason-Pfizer monkey virus DNA probes. In addition, passage 156 Vero cells did not form progressively growing tumors in nude mice or grow with high efficiency in soft agarose.

Several classes of retroviruses are produced by an AKR mouse T lymphoma cell line

Characterization of the viruses produced by the spontaneous T lymphoma cell line SL3 is presented. Using supernatant fluids or direct co-cultivation of cells, the SL3 cell line was found to produce replication-defective viruses in excess of replication-competent viruses. The replication-competent viruses released were predominantly those negative in the XC plaque assay (XC-); XC+ viruses represented a minor population. However, when the SL3-derived viruses were passed in mouse embryo fibroblasts, XC- viruses were rarely recovered, and XC+ viruses were readily isolated. These viruses were all ecotropic and lymphomagenic. Viruses with dual host range and non-oncogenic ecotropic viruses were not isolated from the lymphoma cells. Two replication-defective viruses from SL3 cells were studied. Both could be rescued by non-oncogenic retroviruses and were then lymphomagenic. One defective virus appeared related to XC+ viruses. In these studies, the XC+ and XC- viruses appeared to represent two different interference classes using separate cell receptors. Taken together, these experiments show that the SL3 T lymphoma cells replicate a variety of viruses most of which are lymphomagenic. Virus replication and/or virus integration may be the means of maintaining the malignant phenotype of these T lymphoma cells.

Relationship of leukoplakia to urothelial malignancy

The records of 108 patients presenting with leukoplakia of the urinary tract during the last 35 years were reviewed to define the natural history of this disease, with emphasis upon its association with urothelial cancer. Of the 108 patients 24 had upper urinary tract, 78 bladder and 10 urethral leukoplakia (1 with renal and bladder involvement, 3 with bladder and urethral involvement, and 1 with ureteral and renal involvement). Presenting complaints were primarily irritative. To date, 41 patients (37 per cent) have had associated carcinoma of the urothelium: 23 (21 per cent) presented with a concomitant or previous carcinoma and 18 of 85 (21 per cent) presenting without a concomitant or previous neoplasm have had documented progression to cancer. These figures support the concept that leukoplakia is a premalignant disease and that patients with this diagnosis deserve careful and frequent followup.

Thymic stroma in AKR mice: its function and virus production

This study reports experiments with thymic stromal remnants in AKR mice, a strain with a high natural incidence of thymic lymphoma. A method has been developed in which thymic stromal cells which survive a 4-week culture period, 1 week at 24 degrees C and 3 weeks at 37 degrees C are suitable for grafting. Most thymic lymphocytes die under these conditions. Stromal remnants were studied by culturing and grafting under the kidney capsule of 2-month-old syngeneic mice. Their in vitro morphology and virus production, their ability to reconstitute a new thymus from host progenitors and their eventual lymphoma development was evaluated. The stromal remnants were from: 1- and 3-month-old normal mice; 6-10-month-old normal mice; 21-28-day-old animals treated with the lymphomagenic virus, SL3-3, at 3 days of age. Our data show that thymic stromal function as measured by lymphoid reconstitution of thymic stromal grafts of AKR mice is not impaired with age or by the presence of oncogenic virus. Oncogenic viruses are found in the thymic stroma of old mice and in thymic stroma of young virus-treated mice. Oncogenic viruses are not found in thymic stroma of young normal mice. Lymphoma can develop in the grafted stromal remnants expressing lymphomagenic virus.

Spontaneous leukemia viruses: lymphomagenic ecotropic viruses of AKR mice

The spontaneous leukemia (SL) viruses are ecotropic lymphomagenic viruses isolated from AKR spontaneous lymphomas. These viruses are produced stably by continuous cell lines from spontaneous lymphomas and by a cell line derived from the bone marrow stroma of an AKR mouse neonatally inoculated with an SL virus. All cell lines cloned from the parent lymphoma cell lines consistently produce SL viruses. These viruses can be passaged in vivo and maintain their leukemogenic properties. Cloned isolates of SL viruses accelerate lymphoma in AKR mice and induce thymic lymphoma in mice of other strains. Thus their lymphomagenic properties are conclusively shown. In a study with the use of a sensitive host range assay, xenotropic and/or dual-host range viruses are consistently found in spontaneous lymphoma and cell lines derived from them. However, viruses able to replicate in mink lung cells are not expressed in SL virus-induced lymphomas or their derived cell lines.

Bilateral renal cell carcinoma: influence of synchronous and asynchronous occurrence on patient survival

Twenty-seven patients with synchronous (19 cases) or asynchronous (8 cases) bilateral renal cell carcinoma were treated and followed for as long as 20 years. Tumor grade and stage generally were more favorable in the former group, which is reflected in the higher surgical intervention rate. Nonsurgical treatment yielded poor results. The 5-year survival rate for patients with synchronous bilateral renal cell carcinoma (77.8 per cent) was significantly higher than that for patients with asynchronous lesions (37.5% per cent). Because of its different presentation and favorable prognosis when treated surgically synchronous bilateral renal cell cancer should be distinguished from the asynchronous form, with its dismal outcome. For the latter cases thorough long-term followup may make early surgical intervention feasible, and thus, improve patient survival.