Variations in the structure and transcription of the mitochondrial atp and cox genes in wild Solanum species that induce male sterility in eggplant (S. melongena)

In order to determine the molecular basis of cytoplasmic male sterility (CMS) in alloplasmic lines of eggplant, the genomic structures and transcription patterns of mitochondrial ATP synthase subunit (atp) and cytochrome oxidase subunit (cox) genes were studied for wild and cultivated eggplants. Alloplasmic eggplant lines with cytoplasms of wild Solanum species showing either anther indehiscent type of CMS or non-pollen production type of CMS were studied with the cultivated eggplant Solanum melongena, used as a control. Southern hybridization of the mitochondrial genes indicated the difference between the two types of CMS and showed complete identity within each type. The cytoplasmic patterns of all wild species differed from that of the cultivated eggplant. Thus, the cytoplasm of the six wild eggplants and the one cultivated eggplant was classified into three groups. Male sterile plants of both types of CMS showed novel transcription patterns of atp1, whereas a different transcription pattern of cox2 was observed only in the anther indehiscent type. Based on these differences, we determined the DNA sequences of about a 4 kbp segment in the atp1 region. Although the coding and 3' flanking regions were almost identical among the cytoplasms, the 5' flanking region was completely different and novel open reading frames (orfs) were found for each of the CMS types and the cultivated eggplant. The cytoplasm of Solanum kurzii inducing the anther indehiscent type CMS had orf312, and those of Solanum aethiopicum and Solanum grandifolium of non-pollen production type CMS had orf218. The correspondence between the transcription patterns of these orfs and phenotypic expression of male sterility strongly suggests that these orfs are causal genes for each type of CMS.

Plasma vitamin K concentration in horses supplemented with several vitamin K homologs

The effect of several vitamin K homologs on plasma vitamin K concentration was determined to assess their potential as a vitamin K supplement for adult horses. Sixteen Thoroughbred horses consisting of 8 mares and 8 geldings, aged 8.4 ± 3.6 yr and weighing 520.8 ± 36.1 kg, were allocated to 4 groups (n = 4). Each group was given phylloquinone, menaquinone-4, or menadione at 58 µmol/d, or no vitamin K supplement for 7 d. Plasma samples were collected before feeding, and 2, 4, and 8 h after feeding on d 7, and plasma concentrations of phylloquinone and menaquinone-4 were determined. Plasma phylloquinone concentration was greater in the phylloquinone group than in the other groups (P < 0.001). The phylloquinone concentration quadratically increased (P < 0.001) after feeding in the phylloquinone group but no changes in the plasma phylloquinone concentration were observed after feeding in the other groups. Plasma menaquinone-4 concentration was greater (P < 0.001) in the menadione group than the other groups, including the menaquinone-4 group. Menaquinone-4 concentration did not change (P = 0.192) after feeding in each group. Menaquinone-4 has been considered the most potent vitamin K homolog for bone metabolism; therefore, the present experiment indicates that menadione is a good source of vitamin K for bone health in horses because it is the only vitamin K homolog that increased the plasma concentrations of menaquinone-4.

Relative fitness of females and hermaphrodites in a natural gynodioecious population of wild radish, Raphanus sativus L. (Brassicaceae): comparison based on molecular genotyping

In many gynodioecious species, sex determination involves both cytoplasmic male-sterility (CMS) genes and nuclear genes that restore male function. Differences in fitness among genotypes affect the dynamics of those genes, and thus that of gynodioecy. We used a molecular marker to discriminate between hermaphrodites with and without a CMS gene in gynodioecious Raphanus sativus. We compared fitness through female function among the three genotypes: females, hermaphrodites with the CMS gene and those without it. Although there was no significant difference among the genotypes in seed size, hermaphrodites without the CMS gene produced significantly more seeds, and seeds with a higher germination rate than the other genotypes, suggesting no fitness advantage for females and no benefit to bearing the CMS gene. Despite the lack of fitness advantage for females in the parameter values we estimated, a theoretical model of gynodioecy shows it can be maintained if restorer genes impose a cost paid in pollen production. In addition, we found that females invest more resources into female reproduction than hermaphrodites when they become larger. If environmental conditions enable females to grow larger this would facilitate the dynamics of CMS genes.

[The changes of prostate specific antigen (PSA) after treatment with alpha 1-adrenergic receptor antagonists in men with 4.0-9.9 ng/ml PSA level--a study for comparison of benign prostatic hyperplasia/lower urinary tract symptom (BPH/LUTS) and prostate cancer]

The aims of this study were to define the relationships between prostate-specific antigen (PSA) and alpha 1-adrenergic receptor antagonist (alpha 1 blocker). A prospective clinical study of 48 male patients examined between May 2004 and December 2007 was performed. 4.0-9.9 ng/ml PSA level who had no notable clinical findings of urinary retention, urinary tract infections and prostate cancer (PC) received tamusulosin 0.2 mg once daily for 3 months, and then received prostate biopsy. We divided the patients into two groups: PC and benign prostate hyperplasia (BPH)/lower urinary tract symptom (LUTS) group. In total, the PSA level showed no significant change after treatment. In the PC group, PSA significantly increased after treatment. However, PSA decreased in the BPH/LUTS group. The alpha 1 blocker significantly improved urination status (the subjective symptoms and urodynamics parameters) in the BPH/LUTS group. In two groups, prostate volume showed no significant difference. Among those patients in the BPH/LUTS group, their urination status was significantly improved with alpha 1 blocker and their PSA level dropped slightly. On the other hand, the PSA level was significantly increased in the PC group. This study shows that by using an alpha 1 blocker, it may be possible to avoid conducting the prostate biopsy at an early stage or indeed one may not be needed at all for patients with only slight increases in PSA.

Validation of clinical prognostic factors for survival in 1,043 Japanese patients with metastatic renal cell carcinoma (mRCC)

20075

Background: Increasing number of patients and death of RCC has been reported in many countries including US and Japan. For choosing optimal treatment, determining risk of patients is essential. Although several prognostic factors of mRCC has been investigated, it was based on data of Caucasian. Since racial difference in biological character of cancer has been identified in several types of cancer, we validated the relationship between reported prognostic factors and survival in patients with mRCC in Japanese patients. Methods: We reviewed the medical records of 1,043 patients who had mRCC in the period to follow up, or at the first visit examination between 1988 and 2001 of 26 center in Japan. Results: Average survival of the 708 patients who died for renal cell carcinoma was 20.84 months. On the other hand, histological high grade (> WHO grade 2), metastasis at the first visit examination, short period from the first visit to recognition of metastasis (within 12 months), brain, bone or, liver metastasis, a number of metastatic sites (>1), high performance status (ECOG PS >0), high corrected serum calcium, low hemoglobin, and high CRP were prognostic factors for survival. However, LDH were not related. The median time to death with zero risk factor was 38.5 months, but those with >3 risk factors was 10 months. The patients with >4 risk factors was 4 months. Conclusions: Almost all prognostic factors reported in previous studies mainly based on Caucasian data had same impact on Japanese patients with mRCC. However, elevation of LDH did not have relationship to prognosis. Moreover, the time to death from diagnosis of mRCC in patients with poor prognostic factors was likely shorter compared with other studies. These results suggest Japanese with mRCC might have different character from those in US or European countries though further study in patient’s and tumor characteristics is warranted.

No significant financial relationships to disclose.

Variation of female frequency and cytoplasmic male-sterility gene frequency among natural gynodioecious populations of wild radish (Raphanus sativus L.)

In gynodioecious plant populations, sex determination often involves both cytoplasmic male-sterility (CMS) genes and specific nuclear genes that restore male function. How gynodioecy is maintained under the joint dynamics of CMS and restorer genes remains controversial. Although many theoretical models deal with interactions between CMS genes and restorer genes with sexual phenotypes and predict changes in their frequencies, it is difficult to observe the frequencies because no molecular markers have been established for either CMS or restorer genes in well-studied gynodioecious plants. This is the first report of the frequency of a CMS gene determined using a molecular marker in natural populations of a gynodioecious plant. Using a set of CMS gene-specific polymerase chain reaction primers, we compared female and CMS gene frequencies in 18 natural populations of Raphanus sativus. Female frequency was relatively low, ranging from 0 to 0.21. In contrast, the CMS gene frequency was highly variable among populations, ranging from 0 to 1. Estimated restorer gene frequency seemed less variable than observed CMS gene frequency, probably due to higher gene flow than in the CMS gene. Genetic drift may play a role in maintaining high variability of the CMS gene, although other possibilities are not excluded.

Structural features of a wheat plastome as revealed by complete sequencing of chloroplast DNA

Structural features of the wheat plastome were clarified by comparison of the complete sequence of wheat chloroplast DNA with those of rice and maize chloroplast genomes. The wheat plastome consists of a 134,545-bp circular molecule with 20,703-bp inverted repeats and the same gene content as the rice and maize plastomes. However, some structural divergence was found even in the coding regions of genes. These alterations are due to illegitimate recombination between two short direct repeats and/or replication slippage. Overall comparison of chloroplast DNAs among the three cereals indicated the presence of some hot-spot regions for length mutations. Whereas the region with clustered tRNA genes and that downstream of rbcL showed divergence in a species-specific manner, the deletion patterns of ORFs in the inverted-repeat regions and the borders between the inverted repeats and the small single-copy region support the notion that wheat and rice are related more closely to each other than to maize.

Sequence analysis on the mitochondrial orfB locus in normal and Ogura male-sterile cytoplasms from wild and cultivated radishes

In order to gain a better understanding of the origin and evolution of Ogura male-sterile cytoplasm in radish, sequence analysis was conducted for the mitochondrial locus, orfB, using wild and cultivated radishes. The nucleotide sequence of the entire coding and flanking regions of orfB (approximately 1 kb) was determined for six radishes with normal and Ogura cytoplasm and they were classified into three types (types 1-3). The sequence of the 5' flanking region of orfB was further analyzed in 40 additional plants. Irrespective of the category of radish, plants with Ogura male-sterile cytoplasm contained only the type 1 sequence, whereas plants with normal cytoplasm had either type 2 or type 3. The results suggested that the mutational event, which led to the association of orfB with the male-sterile gene orf138, had occurred only once in the history of radishes.

[Progression from adenocarcinoma to small cell carcinoma of the prostate during endocrinotherapy: a case report]

A 72-year-old man had undergone surgical castration for metastatic prostate cancer (stage D2, the PSA value was 4,300 ng/ml) in September, 1997. He was well clinically for 16 months with undetected level of PSA. However, he presented with general malaise and gross hematuria in May, 1999. After admission to our hospital his condition rapidly deteriorated and he died one week later with respiratory failure. Autopsy revealed extensive involvement of the prostate and bladder by solid tumor with multiple metastases in lungs, liver, spleen, kidneys and bone. Histological examination revealed pure small cell carcinoma of the prostate.

The prevalence of renal cell carcinoma: a nation-wide survey in Japan in 1997

BACKGROUND

The present study was conducted to investigate the incidence of renal cell carcinoma by sex, age group and different regions in Japan.

METHODS

The survey was conducted from the beginning of January 1997 to the end of December 1997. A total of 1306 Institutions in all 47 prefectures throughout Japan were requested to register cases.

RESULTS

There were 6358 persons with renal cell carcinoma, consisting of 4372 men and 1986 women. The age-specific incidence rates showed a peak in the age group of 65-70 years in both men and women. The crude incidence rates per 100 000 population for men and women were 7.1 and 3.1, respectively, and age-standardized incidence rates per 100 000 population for men and women were 4.9 and 1.8, respectively. The incidence rates in the Hokkaido region were significantly higher than in other regions (P < 0.05), among which there was no significant difference in incidence rates.

CONCLUSIONS

The present study showed that the incidence rates of renal cell carcinoma in Japan were approximately the same as among Japanese in Los Angeles. The rates were, however, lower than North American and European countries, but higher than China, Central or South American countries and African countries. The reasons for the high incidence of renal cancer in the Hokkaido region are not entirely clear. Further epidemiologic research is required.

Activation of caspase-3 in renal cell carcinoma cells by anthracyclines or 5-fluorouracil

The caspase family of proteases is speculated to have a crucial role in apoptosis. The effect of treatment with adriamycin (ADR), cisplatin (CDDP), 5-fluorouracil (5-FU), vinblastine (VLB), IFN-alpha, or IFN-gamma on the activation of caspase-3, -6, -8, and -9 in renal cell carcinoma (RCC) cells was investigated, to clarify the mechanisms of chemo- and immunotherapeutic agent-mediated apoptosis. Caspase activity was determined by a quantitative colorimetric assay. Apoptosis was monitored by acridine-orange staining assay. Treatment of ACHN cells with CDDP, VLB, IFN-alpha, or IFN-gamma did not activate caspase-3, but its activity was increased 7.2-fold (p = 0.0001) with ADR and 2.8-fold (p = 0.0385) with 5-FU in comparison with control. Furthermore, when the ADR treatment time was shortened from 24 to 8 or 2 h, the same caspase-3 activation occurred. Activation of caspase-3 was also observed in six freshly isolated human RCC cells after the treatment with ADR. Of the six freshly derived RCC cells treated with 5-FU, caspase-3 activity was increased 3.1-fold (p = 0.0051) and 2.4-fold (p = 0.0346) in two of them, respectively. Epirubicin and pirarubicin, compounds closely related to ADR, also respectively enhanced 4.2-fold (p = 0.0052) and 2.8-fold (p = 0.0147) caspase-3 activity in ACHN cells. The activation of caspase-3 observed with a colorimetric assay was confirmed with immunocytochemical analysis using the anti-active caspase-3 mAb, which specifically recognizes the active form of caspase-3. Furthermore, both active caspase-3 and apoptosis triggered by either ADR or 5-FU were inhibited significantly by the general caspase inhibitor Z-VAD-FMK, or a specific caspase-3 inhibitor DMQD-CHO. These findings provide a mechanistic explanation for anthracyclines and 5-FU induced-apoptosis.

Increased intracellular doxorubicin by anti-FAS monoclonal antibody: a mechanism that enhances the cytotoxicity in renal cell carcinoma cells

OBJECTIVES

To investigate the effect of anti-Fas monoclonal antibody (mAb) on the intracellular concentration of doxorubicin in renal cell carcinoma (RCC) cells. Little is known about the influence of anti-Fas mAb on the intracellular concentration of chemotherapeutic agents.

METHODS

The concentration of intracellular doxorubicin was determined by high-performance liquid chromatography. The mRNA and protein levels of multidrug resistance-associated protein gene were evaluated by reverse transcriptase-polymerase chain reaction and immunocytochemistry, respectively.

RESULTS

An increased concentration of doxorubicin inside the cells was found: 2.4-fold in ACHN cells (a human RCC cell line) after treatment with doxorubicin combined with anti-Fas mAb compared with doxorubicin alone. Of the five cases of freshly derived RCC cells treated with doxorubicin and anti-Fas mAb, the intracellular concentration of doxorubicin was increased 2.3 and 2.7-fold in two of them, respectively. Furthermore, both the mRNA and the protein levels of the multidrug resistance-associated protein gene were downregulated after treatment of ACHN cells with anti-Fas mAb. Treatment of ACHN cells with a combination of anti-Fas mAb and doxorubicin resulted in a potentiation of the doxorubicin-mediated cytotoxicity.

CONCLUSIONS

The increased intracellular concentration of doxorubicin by anti-Fas mAb might be one of the mechanisms responsible for the enhancement of doxorubicin-mediated cytotoxicity in RCC cells.

Distinct microsatellite alterations in upper urinary tract tumors and subsequent bladder tumors

PURPOSE

Although synchronous and/or metachronous tumor development is common in urothelial cancer, genetic and biological differences in upper urinary tract and bladder tumors are unclear. We compared the genetic alteration pattern in multifocal disease in patients with upper urinary tract and subsequent bladder tumors, and those with recurrent bladder tumor.

MATERIALS AND METHODS

Using 21 microsatellite markers on the 8 chromosomal arms 2q, 4p, 4q, 8p, 9p, 9q, 11p and 17p we analyzed 34 tumors from 15 patients with upper urinary tract and subsequent bladder disease, and 70 tumors from 22 with recurrent bladder disease.

RESULTS

Judging from the patterns of genetic alterations multifocal tumors were considered to have derived from an identical progenitor cell in 7 of 13 evaluable patients (54%) with upper urinary tract and subsequent bladder tumors, and 16 of 19 (84%) who were evaluable with recurrent bladder tumor. These data confirm the view that seeding or intraepithelial spread is a major mechanism for the multifocal development of urothelial cancer in general. However, a discordant microsatellite alteration pattern in multifocal tumors was observed in 6 of 7 patients (86%) with upper urinary tract and subsequent bladder lesions but in 2 of 16 (13%) with recurrent bladder cancer (p <0.005).

CONCLUSIONS

Our results imply that upper urinary tract neoplasms may be genetically more unstable than bladder neoplasms. The implantation of tumor cells from upper urinary tract to bladder may involve additional and diverse genetic alterations. Furthermore, a considerable number of multifocal upper urinary tract and subsequent bladder lesions may arise independently via field cancerization mechanism. Our study indicates that the factors contributing to multifocal development are different in the 2 groups.

[A case of malignant fibrous histiocytoma arising from the renal capsule]

A 62-year-old man was admitted with a chief complaint of general malaise. Computed tomography showed a large mass adjacent to the parenchyma of the left kidney. The mass was 17 x 13 x 12 cm in size. Preoperative diagnosis was left renal cell carcinoma and left radical nephrectomy was performed. Histopathologically, the tumor was diagnosed as malignant fibrous histiocytoma (MFH), and the tumor was considered to have arisen from the renal capsule. There has been no recurrence for 7 months postoperatively. We review 40 cases of MFH arising from the kidney or the renal capsule in the literature.

[Long-term clinical results of 5 cases of urachal carcinoma]

Five cases of urachal carcinoma experienced in our hospital during the past 20 years are reported. Surgical resection is considered as the first treatment option of this disease, and other therapies to be less beneficial. Complete surgical extirpation and detection of recurrence in the early stage are considered to be important since local recurrence occurs frequently. We enforced the bladder preserving operation for 4 patients with urachal carcinoma except for 1 case with peritonitis carcinomatosa in the initial diagnosis, and multiple surgical treatment was performed again for 2 patients with recurrence. The bladder was preserved with no evidence of malignancy in three patients for 24, 19 and 5 years, respectively. In the initial management of urachal carcinoma, we believe that bladder-preserving surgery should be considered in selected cases though close follow-up is demanded. Herein, we also report the immunohistochemical study of paraffin-embedded specimens using anti-CEA, CA19-9, CA125 and p53 monoclonal antibodies. The positive reaction was observed in 100% (5/5) for CEA, 80% (4/5) for CA19-9, and 20% (1/5) for CA125. These results suggest that CEA may be a useful marker in the diagnosis of this neoplasm and early detection of its recurrence. Nuclear accumulation of p53 was observed in 80% (4/5), but it did not correlate with the disease progression.

Future of urologic laparoscopy

Laparoscopy has become increasingly popular in urology, reducing the invasiveness of treatment and shortening the period of convalescence. Adrenalectomy is one of the procedures most widely accepted for urologic laparoscopy. During the twenty-first century, most urologic operations will likely be performed laparoscopically, benefiting from advancements in medical engineering. The development of new tissue approximation methods, tissue retrieval systems, microlaparoscopic instruments, sensor technology, and telerobotics, as well as virtual reality, will contribute to the establishment of safe, easy laparoscopic urologic surgery.

Molecular diagnosis of metastatic origin in a patient with metachronous multiple cancers of the renal pelvis and bladder

It is not uncommon for patients with urothelial cancer to have synchronous and metachronous multifocal invasive tumors of the bladder and upper urinary tract. If a metastatic lesion becomes evident in such a patient, the origin of the metastasis is often not determinable using conventional histopathologic examination of the surgical or autopsy specimen. Here, we report a patient in whom the clonal relationship among the histologically undistinguishable multifocal urothelial cancers and metastatic tumors could be clarified by molecular genetic analysis. Furthermore, the potential role for each genetic alteration in the multifocal and metastatic tumor development and the treatment efficacy for each multifocal tumor were also clearly demonstrated.

Per-operative frozen section examination of pelvic nodes is unnecessary for the majority of clinically localized prostate cancers in the prostate-specific antigen era

BACKGROUND

The incidence of unsuspected lymph node metastasis seems to be decreasing in the prostate-specific antigen (PSA) era. It remains controversial as to whether routine pelvic lymph node dissection and per-operative frozen section examination should be performed. In addition, it is still unclear whether an aggressive approach to local disease by surgery or irradiation confers survival benefits on stage D1 patients.

METHODS

Eighty-eight consecutive patients with clinically localized prostate cancer who underwent pelvic lymph node dissection prior to radical prostatectomy during the period between 1985 and 1998 were analyzed. The incidence of lymph node metastases after 1992 was compared with that before 1992. Sensitivity and specificity of frozen section examination was assessed. Progression-free survival and cause-specific survival curves of node-positive patients who underwent radical prostatectomy were estimated by the Kaplan-Meier method.

RESULTS

Six of 17 patients (35.3%) treated before 1992 and five of 71 patients (7.0%) treated after 1992 showed unsuspected lymph node metastasis (P = 0.0059). Eight of 11 node-positive patients underwent radical prostatectomy and two have so far demonstrated clinical progression and cancer death with a median follow-up period of 63 months. The 5 year progression-free rate and the cause-specific survival rate for these patients were 71.4 and 85.7%, respectively. Sensitivity of frozen section examination for micrometastasis and gross-metastasis cases, respectively, was 3/6 (50%) and 4/4 (100%), while specificity was 85/85 (100%).

CONCLUSIONS

The incidence of unsuspected lymph node metastases has been significantly decreased in the PSA era. Frozen section examination of pelvic nodes can be omitted and radical prostatectomy is an acceptable choice of treatment in patients without macroscopically apparent nodal metastases.

[National trend of management of benign prostatic hyperplasia in Japan during 1990s: analysis of national health statistics]

To review the contemporary management of benign prostatic hyperplasia (BPH) in Japan during 1990s, we analyzed several nationwide health statistics by the Ministry of Health and Welfare of Japan. The cross-sectional surveys revealed that the estimated total number of patients receiving treatment increased from 202,000 in 1987, to 335,000 and 590,000, respectively, in 1995 and 1998. Approximately 73-80% of patients were men aged 65 years or over and 94-98% 55 years or older. Urologists treated two thirds of the BPH patients. The incidence of prostatectomies remained relatively stable at 50,000/year (3.0-3.8 prostatectomies/1,000 men aged 55 or over). The average hospital stay in 1996 was 24.7 days. The total cost of BPH therapy nearly doubled between 1988 and 1998. The ratio of outpatient to inpatient costs ranged from 1.5 to 2.2 and 60% of the outpatient cost was spent for medical therapy. The total value of the market for medical therapy increased from 30-40 billion yen in 1989 to more than 80 billion yen in 1998. The application of alpha-blockers increased from 243,000 men (70% of all patients) in 1995 to 452,000 (77%) in 1998, whereas the number of patients taking antiandrogens, plant extracts and antispasmodic agents/Ca antagonists (for pollakisuria), respectively, remained relatively stable at 60,000-70,000, 180,000 and 300,000. Because Japan is a rapidly aging society and men aged 55 or older are expected to increase from 15 million in 1995 to 21 million in 2010, cost-effective treatment guidelines for the Japanese BPH patients are needed.

[Epididymal sperm aspiration for obstructive azoospermia]

Epididymal sperm aspiration technique combined with assisted reproductive technology (ART) including intracytoplasmic sperm injection (ICSI) has provided new frontiers for the treatment of unreconstructable obstructive azoospermia, including congenital bilateral absence of the vas deferens and failed surgical intervention. Epididymal sperm is obtained by several procedures, including microsurgical epididymal sperm aspiration (MESA), mini-MESA (Modified MESA), macroscopic epididymal sperm aspiration (MaESA) and percutaneous epididymal sperm aspiration (PESA). Since 1991 in our department, epididymal sperm aspiration combined with ART was performed by MESA (26 cases, 41 times) and PESA (3 cases, 4 times). Motile sperm retrieval using MESA and PESA was obtained in 34 out of 36 times (94.4%) and 2 out of 4 times (50%), respectively. MESA-ICSI resulted in a 47.3% 2PN (metaphase II) fertilization rate per eggs and a 28.8% pregnancy rate per transfer. With advancement of ICSI technique in which frozen sperm can be used, elective sperm retrieval can be planned at our convenience. PESA is a convenient, inexpensive and effective outpatient clinic procedure for retrieving sperm assisted with ICSI. In summary, infertile couples need to be given realistic options regarding treatment outcome. The fertility potential and age of the female partner need to be considered when addressing male treatment options.

[Urologic laparoscopy]

Recent applications of laparoscopy to urologic surgery have demonstrated the efficacy, safety, and shorter convalescence times with these techniques. Laparoscopy still is the most accurate diagnostic tool for impalpable testes and allows surgeons to select the proper treatment. Because of the need for general anesthesia, laparoscopic varicocelectomy is not considered less invasive than subinguinal low ligation under local anesthesia. However, a future trend toward day surgery might favor laparoscopy, which requires a smaller skin incision and thus enables young men to return to work earlier. Laparoscopic adrenalectomy has been established as a standard operative technique because it offers many advantages in comparison with conventional open surgery. Laparoscopic nephrectomy is also a minimally invasive operation, although the most appropriate method for kidney retrieval has not been determined, and currently in Japan insurance reimbursements are limited to benign disease. Laparoscopic nephrectomy for renal cell carcinoma and upper urinary tract transitional cell carcinoma is very promising, although there is debate on laparoscopic cancer surgery. Furthermore, the recent great success with laparoscopic radical prostatectomy in France is stimulating Japanese investigators. In the 21st century, laparoscopy will be standard for many surgical procedures in urology.

Detection of circulating cancer cells by reverse transcription-polymerase chain reaction for uroplakin II in peripheral blood of patients with urothelial cancer

Few attempts have been made at the molecular detection of urothelial cancer cells in the blood or lymph nodes mainly because of an absence of good candidate molecular or genetic changes specific to urothelial cancer or urothelium. In 1990, however, genes that encode urothelium-specific transmembrane proteins, uroplakins (UPs), were cloned. We have established a method of detecting circulating cancer cells in peripheral blood of patients with transitional cell carcinoma by nested reverse transcription-PCR assay for UP II. UP II mRNA-positive cells were detected in 3 (10.3%) of 29 patients with superficial cancers (pTa-1N0M0), 4 (28.6%) of 14 patients with muscularly invasive cancers (pT2-4N0M0), 2 (40.0%) of 5 loco-regional node-positive patients (pN1-2M0), and 6 (75.0%) of 8 patients with distant metastases. Positive rates, therefore, increased with tumor extension (P = 0.0033, Kruskal-Wallis test). Furthermore, sequential blood sampling was performed in three patients with metastases during and after systemic chemotherapy, and UP-II-positive cells were found to have disappeared in two patients who responded well to the systemic chemotherapy. These results suggest that our nested reverse transcription-PCR assay for UP II is highly specific and might be used as a tumor marker for molecular staging of urothelial cancers, although the sensitivity is not so optimal.

Pancreatic lesions in von Hippel-Lindau syndrome: the coexistence of metastatic tumors from renal cell carcinoma and multiple cysts

Multiple cysts and benign cystadenomas of the pancreas have been documented occasionally in von Hippel-Lindau syndrome (HLS); however, the malignant involvement of the pancreas in HLS is very rare. We report a case of HLS in which metastatic tumors from renal cell carcinoma (RCC) coexisted with multiple cysts in the pancreas. A 22-year-old woman with a history of HLS had undergone a partial resection of the left kidney for RCC 3 years earlier, at which time a solid mass in the pancreatic tail and multiple pancreatic cysts were also incidentally detected by computed tomography. Over the following 3 years, the mass enlarged slightly, thus raising suspicions that it might be a primary neoplasm of the pancreas. She was referred to the Department of Surgery and Surgical Basic Science to undergo surgery. In addition to the tumor in the pancreatic tail, however, further tumors in the pancreatic head were also disclosed by preoperative celiac arteriography and intraoperative palpation and ultrasonography. A distal pancreatectomy was performed, because the enucleation of all the tumors in the pancreatic head was technically impossible and because the patient declined a total pancreatectomy. A histologic examination of the mass in the pancreatic tail revealed metastatic RCC. This case emphasizes that metastatic disease should be included in the differential diagnosis when evaluating the pancreas in a patient with HLS.

Complications of laparoscopic and retroperitoneoscopic adrenalectomies in 370 cases in Japan: a multi-institutional study

A total of 370 laparoscopic adrenalectomies, including 311 transperitoneal (TP) and 59 retroperitoneal (RP) approaches, were performed in nine urologic centers, where the laparoscopic adrenalectomy was first begun independently in Japan, and their affiliated hospitals between January 1992 and September 1996. The clinical diagnoses of those 370 adrenal diseases were primary aldosteronism in 155 patients, Cushing's syndrome in 61. preclinical Cushing's syndrome in 21. pheochromocytoma in 16, nonfunctioning adenoma in 87, complicated cyst in ten, myelolipoma in nine, adrenal cancer in four and other diagnoses in eight (table 1). There was no mortality in this series. Intraoperative complication rate was 33/370 (9%) in total: 26/311(8%) in the TP procedures and 7/59 (12%) in the RP procedures (table 11). Postoperative complication rate was 24/370 (6%) in total: 22/311 (7%) in the TP procedures and 2/59 (3%) in the RP ones (table 111). Conversion rates to open surgery in total, in the TP and in the RP procedures were 13/370 (3.5%), 10/311 (3.2%) and 3/59 (5.1 %). respectively (table IV). Although the RP procedure has a lower morbidity rate compared to the TP procedure, more skill is required to overcome the drawback of the narrow working space and fewer anatomical landmarks.

Radical retropubic prostatectomy: time trends, morbidity and mortality in Japan

OBJECTIVES

To assess the time trends, morbidity and mortality of contemporary anatomical radical retropubic prostatectomy (RRP) in a multi-institutional study in Japan, where RRP has become more popular in the last decade.

PATIENTS AND METHODS

Between January 1991 and August 1998, 638 patients underwent RRP at seven urological centres in Japan. Major complications (within 30 days of surgery) and the 30-day mortality were reviewed retrospectively. Of the patients, 12.9% were < 60 years old, 56.3% were 60-69 years old and 30.9% were >/= 70 years old (median age 67). Results The number of RRPs increased markedly, by more than sevenfold, from 1991-92 to 1996-97, mainly because there were more patients undergoing RRP in their sixth decade. The contribution of T1c disease increased in absolute and relative terms, from 13.9% in 1991-92 to 37.9% in 1997-98. Over time, the mean blood loss and the allogeneic transfusion rate decreased steadily. There was a trend toward more favourable outcomes for pathological variables (an increased percentage of organ-confined disease, decreased margin positivity and a decreased incidence of positive lymph node metastasis). The most common complications were wound-related (7.5%), or anastomotic leakage (4.1%). Major cardiopulmonary complications occurred in only two patients (0.31%, both pulmonary embolisms). One patient died from cerebral haemorrhage within 30 days of surgery, giving a mortality rate of 0.16%.

CONCLUSION

s This study indicates a trend towards selecting patients most likely to benefit from RRP. Although the procedure is technically demanding, it can have an acceptably low rate of early complications, little mortality and need for allogeneic transfusion. The assessment of morbidity suggests a lower incidence of catastrophic thrombo-embolic and cardiac complications in Japanese patients than in Western men. The present data may be useful in decision-analysis models evaluating the role of therapy for Asian men with early-stage prostate cancer.

[Treatment of advanced testicular cancer and toxicity of chemotherapy]

To assess the efficacy and toxicity of chemotherapy for advanced germ cell tumors, 115 patients with testicular and extragonadal germ cell tumors were reviewed. Five-year survival rates of 19 seminoma patients and 96 non-seminoma patients were 84% and 68%, respectively. According to the analysis using three sets of prognostic criteria, Indiana University Classification, International Germ Cell Consensus Classification and K Classification, the 5-year survival rate of poor-prognosis patients was 42-45%. BEP regimen (bleomycin, etoposide and cisplatin) salvaged with VIP (etoposide, ifosfamide and cisplatin) would be the standard therapy for advanced germ cell tumors since high-dose chemotherapy had no advantage on survival over the standard-dose regimen. Early serious toxicities were observed in 18 patients (15.7%), including pulmonary fibrosis, respiratory distress, and sepsis. Poor performance status and prior radiotherapy were risk factors for fatal adverse effects. In terms of late toxicites, out of 76 patients in complete remission for at least one year after cessation of chemotherapy, 31 had numbness of extremities and 29 had tinnitus. Serial semen analyses of 38 patients showed continuous azoospermia or severe oligozoospermia in 22. These data indicated that less toxic therapy was required for good-risk patients to improve the quality of life, while more intensive therapy for poor-risk patients to be cured. Several prognostic criteria should be utilized to properly distinguish good- from poor-risk patients, and decide how to treat each patient.

[High-dose chemotherapy with peripheral blood stem cell autotransplantation for patients with poor-risk testicular germ cell tumors--pilot study of the Japan Blood Cell Transplantation Study Group]

The efficacy and toxicity of a single cycle of high-dose chemotherapy with peripheral blood stem cell autotransplantation (PBSCT) in patients with poor-risk testicular germ cell tumors (GCT) enrolled in the Japan Blood Cell Transplantation Study Group was investigated. Previously untreated poor-risk testicular GCT patients were treated with BEP therapy (cisplatin, etoposide and bleomycin) with or without high-dose chemotherapy (carboplatin, etoposide and ifosphamide) followed by PBSCT. Patients were qualified for a change to high-dose chemotherapy if elevated serum tumor markers (human chorionic gonadotropin-beta, alpha-fetoprotein and lactate dehydrogenase) was observed after 3 cycles of BEP therapy. Eighteen patients were treated with BEP therapy alone and 16 with BEP and high-dose chemotherapy. At the completion of high-dose chemotherapy, all tumor markers had returned to normal in 6 patients. Among them, 1 had only teratoma found at resection and 5 had carcinoma resected. Nine patients who had persistent elevation of any tumor marker were treated with high-dose chemotherapy or another anticancer drug. Thirteen are alive (81%) and 9 (56%) are continuously disease-free at a median follow up of 11 months. The median time from PBSCT to a granulocyte count > 500/microL was 9.5 days and to a platelet count > 50,000/microL was 13 days.

[The prognostic value of adjuvant and neoadjuvant chemotherapy in total cystectomy for locally advanced bladder cancer]

PURPOSE

Adjuvant chemotherapy and neoadjuvant chemotherapy have been widely used as adjuvant treatment in patients requiring total cystectomy for locally advanced transitional cell carcinoma of the bladder. However, there has been no conclusive evidence that the adjunctive chemotherapy improves survival and no agreement exists concerning what subsets of such patients receive significant benefits from the adjunctive chemotherapy. The study retrospectively sought to clarify these points.

PATIENTS AND METHODS

We retrospectively analyzed clinical and pathological records of the 229 patients with transitional cell carcinoma of the bladder who underwent total cystectomy with or without lymph node dissection in our University Hospital from January 1975 to December 1997. Forty-two patients received 1-4 cycles (mean = 1.7) of adjuvant chemotherapy with VPMisCF (n = 19), CisCA (n = 4), MVAC (n = 8), or MEC (Methotrexate, Epirubicin and Cisplatin) (n = 11). Twenty-three patients received 1-4 cycles (mean = 2.1) of neoadjuvant chemotherapy with CisCA (n = 2), MVAC (n = 5), or MEC (n = 16). Using the Kaplan-Meier method, disease-specific survival rate was assessed according to various clinical and pathological factors as well as the administration of adjuvant or neoadjuvant chemotherapy. The generalized-Wilcoxon test was used to evaluate statistical significance (p < 0.05) of survival curves for two or more groups. In addition, a multivariate analysis using the Cox proportional hazards model was performed with respect to multiple clinical and pathological parameters, and treatment modalities.

RESULTS

In patients who received neither adjuvant chemotherapy nor radiotherapy, the disease-specific survival rate was significantly lower in those with pT3a and/or more advanced tumors compared with those with pT2 or less advanced tumors. The survival rate in patients with positive lymph node metastasis was significantly lower than that in patients without lymph node metastasis. No apparent survival benefit was noted for those patients who received adjuvant chemotherapy when compared with patients who had pT3a or more advanced tumor and were followed without any adjunctive therapy. In patients with pN2 or more advanced lymph node metastasis, the survival rate of those who received adjuvant CisCA/MVAC/MEC chemotherapy was significantly higher than that those without any adjunctive therapy. Although no apparent survival benefit was observed in patients who received neoadjuvant chemotherapy, the survival rate in patients whose tumor was considered to be down-staged to pT1 or lower was significantly higher than patients who did not receive neoadjuvant chemotherapy and had pT3a or higher pT-stage tumor. The survival rate in patients whose tumor showed clinical partial or complete response by neoadjuvant chemotherapy was also significantly higher than the same control patients. However, the multivariate analysis revealed no significant survival benefit after adjuvant chemotherapy or after neoadjuvant chemotherapy.

CONCLUSIONS

Adjuvant chemotherapy after total cystectomy is an acceptable approach in patients with pN2 or higher pN-stage bladder cancer. The significant survival benefit may be obtained who acquired pathological downstaging or partial to complete clinical response after neoadjuvant chemotherapy. To get maximum survival benefit from the present chemotherapeutic regimens and exclude administration of toxic chemotherapeutic agents to unresponsive patients, there should be more reliable markers that give clear information to differentiate tumors that will respond fairly to present chemotherapeutic regimens from tumors that will respond poorly.

Measurement of polymorphic trinucleotide repeats in the androgen receptor gene by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry

Trinucleotide repeats are polymorphic in normal individuals. CAG repeats in the X-linked androgen receptor gene were counted by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI/TOF-MS). A region of approximately two hundred base-pairs containing the repeats was amplified by polymerase chain reaction, then measured after a simple purification procedure. The single-charged molecular ion species was detected using 0.1 pmol of DNA sample and the number of repeats was determined from the molecular mass. The results indicated that MALDI/TOF-MS is a high-throughput alternative to polyacrylamide gel electrophoresis for precise determination of polymorphic trinucleotide repeats.

Orthotopic ileal neobladder in male patients: functional outcomes of 66 cases

BACKGROUND

Orthotopic urinary diversion has become the preferred form of bladder reconstruction after cystectomy. We report on our experience with 66 male patients undergoing this procedure from November 1990 to February 1998.

METHODS

A neobladder was constructed using an ileal segment with a Hautmann type bladder. Complications were assessed and subdivided into early and late types. Voiding function was evaluated in terms of voiding pattern and continence. Median follow up was 19.5 (range 3.5-87.7) months.

RESULTS

There was one (1.5%) perioperative death. The most frequent pouch-related and unrelated early complications were persistent urine leak (7.6%) and prolonged ileus (16.7%), respectively, the majority of cases of which were managed conservatively. Analysis of late complications revealed 6.2% ureteroileal stenosis and 1.5% urethrointestinal stenosis rates, but no case of bladder stone formation. Of the 61 patients in whom voiding function was evaluable, 95.1% achieved excellent daytime continence, while only 67.2% had night-time continence. With regard to posture at voiding, 23 (37.7%) voided in a sitting position. Three of the patients (4.9%) were unable to void and required regular intermittent catheterization.

CONCLUSIONS

An orthotopic neobladder can be constructed with acceptable morbidity and excellent functional results. We believe that orthotopic urinary diversion offers an attractive alternative to a bladder substitute when cystectomy is required.

[Bilateral breast metastases from prostatic carcinoma: a case report]

We report a case of bilateral breast metastases from prostatic carcinoma. A 49-year-old man with stage D2 prostate cancer, who had been treated by chemoendocrine therapy and radiotherapy for 2 years, complained of bilateral enlarged breasts. Oral administration of diethylstilbestrol diphosphate was started 2 months before the onset of this symptom. A firm mass that was not tender was palpable beneath the skin without fixation on each side. A needle biopsy of the masses showed poorly differentiated adenocarcinoma with positive immunohistopathological staining for prostate-specific antigen. The masses were diagnosed as metastatic adenocarcinoma of prostate gland origin. The patient died 3 months after the diagnosis of breast metastases. Autopsy revealed diffuse lymphogenous metastatic disease. Metastatic prostatic carcinoma to the breast is uncommon. Breast metastases in this patient might be associated with diffuse lymphogenous metastases as well as increased local blood and lymphatic supply caused by extrinsic estrogens.

Interferon-alpha and 5-fluorouracil therapy in patients with metastatic renal cell cancer: an open multicenter trial. The Japanese Study Group Against Renal Cancer

OBJECTIVES

Recent clinical trials have implied the cytotoxic and antiproliferative effects of combining 5-fluorouracil and interferon-alpha in the treatment of metastatic renal cell cancer. We therefore conducted an open multicenter trial to test the efficacy of such a combination on this cancer.

METHODS

Human lymphoblastoid interferon (3 MIU per patient) was administered subcutaneously three times weekly for 12 weeks, while 5-fluorouracil was administered (600 mg/m2/day) as a continuous infusion for the first 5 days, followed by an intravenous bolus infusion of 600 mg/m2 once a week from the 3rd week until the 12th week.

RESULTS

Of the 63 patients entered into the trial, 55 were eligible and evaluable for systemic toxicities, and 53 were evaluable for their response. All patients had undergone a prior nephrectomy, and their European Cooperative Oncology Group (ECOG) performance status ranged from 0 to 3 (median 0). Three complete and eight partial responses were induced, with an overall response rate of 20.0%. The median time to progression and the median survival time were 11 and 33 months, respectively. World Health Organization grade 3 toxicities were observed in 8 patients; however, no grade 4 toxicities or toxicity-related deaths were noted.

CONCLUSIONS

Combination therapy of interferon-alpha plus 5-fluorouracil at the above-described dosage and schedule produced no better responses than interferon monotherapies. Prolongation of survival could be attributable to the fair performance status of the patients. This regimen has limited value for the treatment of patients with advanced renal cell cancer.

Clonal and chronological genetic analysis of multifocal cancers of the bladder and upper urinary tract

Recent molecular genetic studies have suggested that multifocal urothelial cancers are derived from an identical progenitor cell. However, the clonal origin of multifocal urothelial cancers of a low-grade superficial type has not been fully defined. Using microsatellite markers, we examined genetic alterations at 20 loci on eight chromosomal arms (2q, 4p, 4q, 8p, 9p, 9q, 11p, and 17p) in 87 metachronous and/or synchronous multifocal urothelial cancers, which included 84 low-grade superficial papillary tumors from 29 patients. Judging from the patterns of loss of heterozygosity, microsatellite shifts, and the subchromosomal partial deletion, multifocal tumors in at least 20 (80%) of the 25 evaluable patients were considered to be derived from a single progenitor cell, although the possibility remained that multifocal tumors in a small subset of patients might develop from distinct progenitor cells due to field cancerization. In 13 of the 20 patients, a chronological genetic analysis was available: genetic heterogeneity was detected in 3 (23%) patients, and an apparent accumulated pattern of genetic alterations was detected in only 1 (8%) patient. In the 20 patients with multifocal tumors of an identical clonal origin, discordant microsatellite alterations were observed, with significantly lower frequencies on chromosome 9 compared to those on the other chromosomes tested. The results indicate that most multifocal low-grade superficial urothelial cancers are genetically stable despite their incidence of frequent recurrence, and genetic divergence occurs in a subset of patients. This heterotopic spread and genetic divergence may occur long before the clinical manifestation of multiplicity from a single transformed cell. These data support the previous view that heterotopic spread of transformed progenitor cells and genetic divergence occur after chromosome 9 alterations in most of low-grade superficial urothelial cancers.

[Synchronous multifocal development of invasive transitional cell carcinoma of the urinary tract in a patient with renal failure receiving long-term hemodialysis: a case report]

We report a case of transitional cell carcinoma in a patient with chronic renal failure receiving hemodialysis for 22 years. A 55-year-old man was admitted to our hospital. Under diagnosis of invasive bladder cancer and left renal pelvic tumor, removal of the whole urinary tract, e.g., bilateral nephroureterectomy and total cystourethrectomy was performed. Transitional cell carcinoma was found in bilateral renal pelvis, left ureter, bladder and prostate in the resected specimen. Thirteen months after the operation, multiple lung metastases and pathologic bone fracture of the 4th lumber vertebra were found. Chemotherapy (3 courses of modified CISCA, consisting of cisplatin, adriamycin and cyclophosphamide) was performed, but the died of systemic metastases of cancer and bleeding due to perforation of multiple gastric ulcers.

Synchronous testicular seminoma and adrenocortical carcinoma: a case report

We report a rare case of synchronous testicular seminoma and adrenocortical carcinoma. A 57-year-old man had a left testicular seminoma (clinical stage IIIB) with metastases to the lung and paraaortic lymph node. A complete response was obtained after 3 courses of chemotherapy with single-agent carboplatin. However, a left adrenal tumor was detected 1 2 months later and demonstrated a tumor volume doubling time of 2.1 months. Chemotherapy with bleomycin, etoposide and cisplatin failed to stop the tumor growth. A laparoscopic adrenalectomy was performed and pathology revealed an adrenocortical carcinoma. The patient has been free of recurrence for 42 months postoperatively.

[Three cases of the nephrogenic adenoma of the bladder]

Nephrogenic adenoma is a rare, benign tumor of the urinary tract. The origin of this tumor is supposed to be a metaplastic transformation of urothelium in response to stimulation such as recurrent urinary tract infections or surgical trauma. We experienced three cases of nephrogenic adenoma originating in the bladder. The first patient was a 29-year-old man with right vesicoureteral reflux (VUR). When Teflon injection for VUR was performed, a papillary tumor was found on the right wall of the bladder. Transurethral resection of the bladder tumor (TUR-Bt) was performed. The second patient was a 72-year-old woman who was suffering from chronic cystitis. Although she was treated with antibiotics for one year, the symptoms were not improved. Cystoscopy showed multiple papillary tumors at the retrotrigonum of the bladder and TUR-Bt was performed. The third patient was a 75-year-old man who had a history of the left pelvic and bilateral ureteral tumors. Left radical nephroureterectomy and right radical ureterectomy with an ileal graft replacement was performed. Three years later, cystoscopy demonstrated a papillary tumor at the retrotrigonum, which was resected transurethrally. Our cases are the 20th to 22nd cases of the nephrogenic adenoma of the bladder reported in the Japanese literature.

[Expression of major histocompatibility complex antigens and adhesion molecules on renal cell carcinoma cells, and effect of interferon-alpha and/or cimetidine on the expression]

Recently the combined therapy with interferon-alpha (IFN-alpha) and cimetidine has been reported to be effective against advanced renal cell carcinoma (RCC). IFN-alpha and cimetidine have an antitumor effect partly due to enhancement of cytotoxic activity of lymphocytes against cancer cells. We examined the expression of major histocompatibility complex (MHC) antigens and adhesion molecules on 4 fresh RCC cells and 5 RCC cultured cell lines, which have an important role in recognition and killing of cytotoxic lymphocytes against cancer cells. The effect of treatment with IFN-alpha and/or cimetidine on the expression of MHC antigens and adhesion molecules on RCC cells was also investigated. MHC class I and leukocyte function-associated antigen-3 (LFA-3) were expressed on all RCC cells, but not MHC class II. Intercellular adhesion molecule-1 (ICAM-1) and B7 were expressed on 6 and 5 of 8 RCC cells, respectively. IFN-alpha significantly augmented the expression of MHC class I in 6 of 9 RCC cells, ICAM-1 in 1 and LFA-3 in 2 of 8 RCC cells. However, IFN-alpha did not affect the expression of MHC class II and B7. On the other hand, cimetidine enhanced the expression of LFA-3 in 2 of 8 RCC cells, but not MHC antigens, ICAM-1 or B7. The combination of IFN-alpha and cimetidine did not show a synergistic enhancing effect on the expression of MHC antigens, ICAM-1, LFA-3 or B7. These results suggest that IFN-alpha augments the sensitivity of RCC cells to lysis by cytotoxic lymphocytes partly due to the enhancement of expression of MHC class I, ICAM-1 and LFA-3 on RCC cells, and that cimetidine also augments the susceptibility of RCC cells to lymphocytes by the enhanced expression of LFA-3 on RCC cells.

Telomerase activity in adrenal cortical tumors and pheochromocytomas with reference to clinicopathologic features

Telomeres consist of short repeated sequences that are shortened on continuous cell proliferations and synthesized by telomerase, an RNA-dependent DNA polymerase. Recent molecular studies have reported that telomerase is activated in most human cancers, whereas it is not detected in most somatic cells. These findings indicate that the positive telomerase activity is closely related to the malignant potential of human tumors. In several types of human tumors, including adrenal cortical tumors and pheochromocytomas, it is very difficult to predict the malignant potential using conventional histopathologic examination. To determine whether telomerase activity is useful as a diagnostic marker, we examined telomerase activity in adrenal cortical tumors and pheochromocytomas with special reference to their clinicopathologic features. Using a highly sensitive polymerase chain reaction (PCR)-based detection method, telomerase activity was demonstrated in one of 13 adrenal cortical tumors and two of seven pheochromocytomas, whereas all seven normal portions of adrenal gland failed to showed any telomerase activity. Although none of the tumors examined in this study was associated with metastasis, these three telomerase-positive tumors were accompanied by clinicopathologic features suggesting malignant potential. Telomerase activity might be a potential marker for estimating the biologic characteristics of adrenal cortical tumors and pheochromocytomas.

Learning curve and conversion to open surgery in cases of laparoscopic adrenalectomy and nephrectomy

PURPOSE

We examine how the level of experience acquired by the laparoscopist affects the outcome of laparoscopic adrenalectomy and nephrectomy, and what is necessary to avoid complications in these surgeries.

MATERIALS AND METHODS

We retrospectively evaluated the experience levels of 8 urological laparoscopists between 1991 and 1995. In addition, other cases that were converted to open surgery were collected from the institutes with which the 8 laparoscopists were affiliated.

RESULTS

The rates of conversion to open surgery were 6.4% in 204 cases of adrenalectomy and 14.3% in 63 of nephrectomy. Conversion rates were related to blood loss volume but not operative time. The major causes of conversion were bleeding in 45% of cases and adhesion in 34%. There were no mortalities. Mean operative time decreased significantly, reaching that of open surgery as the number of procedures increased up to 20 adrenalectomies and 10 nephrectomies. The volume of blood lost remained low from the early experience. Blood transfusion rates were 4.4% for adrenalectomy and 11.1% for nephrectomy.

CONCLUSIONS

Operative time of these procedures decreased significantly with surgeon experience and reached that of open surgery. Cases in which adhesion is anticipated should be restricted to avoid conversion. These laparoscopic procedures are acceptable as a standard operative techniques for adrenal and renal diseases.

Transcript levels of aquaporin 1 and carbonic anhydrase IV as predictive indicators for prognosis of renal cell carcinoma patients after nephrectomy

Since failure of differentiation has been suggested to be involved in the neoplastic process and progression of tumors, we evaluated whether the transcript levels of differentiation markers of proximal renal tubular cells, from which renal cell carcinoma (RCC) arises, could be used as prognostic markers. We used Northern blot analysis to study the expression of aquaporin 1 (aqp1) and carbonic anhydrase IV (ca4) genes in 66 paired samples of primary RCC and non-tumorous kidney tissues. Poor differentiation of tumor cells and non-clear cell-subtype RCC were significantly associated with low levels of aqp1 transcripts. When patients were divided into 2 groups according to level of aqpI transcript in RCC, a low level of aqp1 was significantly associated with unfavorable outcome. Among 18 patients with metastatic RCC and 40 patients with moderately differentiated RCC, those with RCC expressing low levels of aqpl mRNA demonstrated poorer survival than those with RCC expressing relatively high levels of aqp1. Similarly, decreased expression of ca4 mRNA in RCC was associated with poor survival. On multivariate analysis, transcript levels of aqpI and stage of the tumor were the independent factors predicting disease-specific survival. Transcript levels of aqp1 may serve as a new molecular prognostic marker in patients with RCC following nephrectomy.

[Clinical application of intraoperative ultrasonography for bilateral multilocular cystic renal cell carcinoma: a case report]

A 45-year-old man was referred to our department for further examination of the renal complicated cyst which was found incidentally by ultrasonography. Another complicated cyst in the left kidney was detected by subsequent dynamic CT and ultrasonography, which suggested bilateral cystic renal cell carcinoma. Bilateral partial nephrectomy was performed. Intraoperative ultrasonography was useful for diagnosis of multilocular cystic renal cell carcinoma (MCRCC). It disclosed multiple septa of the right renal complicated cyst which were not revealed by any preoperative examinations. It was also a useful adjunct to partial nephrectomy. It helped to identify the extent of deep intra-parenchymal lesions. The final diagnosis was bilateral synchronous multilocular cystic renal cell carcinoma. This is the second case of bilateral synchronous multilocular cystic renal cell carcinoma reported in Japan. We reviewed the clinical characteristics of 59 cases of MCRCC in the Japanese literature including the present case.

Low frequency of positive telomerase activity in a chromophobe subtype of renal cell carcinoma

PURPOSE

In malignant tumors, telomerase reactivation plays an important role in the acquisition of cellular immortality. We evaluated the telomerase activity in renal cell carcinomas (RCCs) with special reference to their clinicopathologic features.

MATERIALS AND METHODS

Telomerase activity was examined in 47 RCCs and 9 RCC cell lines by telomeric repeat amplification protocol assay (TRAP). The telomere lengths were assessed by Southern analysis of terminal restriction fragments (TRFs) generated by Hinfl-digested DNA.

RESULTS

Thirty-six (77%) of the 47 RCCs and all 9 RCC cell lines showed telomerase activity, whereas no activity was detected in any of 30 normal kidneys. When the tumors were histopathologically classified, only one (17%) of the 6 chromophobe cell carcinomas was telomerase-positive. This frequency was significantly low (p < 0.001) when compared with those in clear cell RCCs (93%; 26/28). In 40 of the 47 patients, DNA from the tumor tissues and the paired normal kidneys was available for analysis of the TRF lengths. No tumor showed elongated TRF length compared to its paired normal kidney. Regarding the relationship between telomere length and telomerase activity, 23 (74%) of the 31 telomerase-positive RCC and 6 (67%) of the 9 telomerase-negative RCC exhibited reduced TRF. There was no significant correlation between the telomere reduction and telomerase activity.

CONCLUSION

The mechanism for preventing telomere shortening may differ according to RCC subtype. Alternatively, telomerase-negative tumors may have yet to reach the immortal stage when they progress to clinical cancer. The telomerase activity status may contribute to the biological potential and the prognosis of RCCs.