Suppression of plasma androgen levels with a combination therapy of depot-estrogen (Turisteron) and Dexamethasone in patients with prostatic cancer

Treatment of patients with prostatic cancer with a combination of 1-2 mg depot-estrogen (ethinylestradiol sulfonate = Turisteron) per week and 1 mg dexamethasone per day suppressed the mean testosterone (T) level to 2.8% (0.53 nmol/l), the free T to 0.8% (1.9 pmol/l) and the adrenal androgens (AA) -- androstenedione (A), dehydroepiandrosterone (DHEA) and its sulfate (DHEAS) -- to more than 40% of the initial values. Treatment with Turisteron alone (2 mg per week) did not change the DHEA and DHEAS levels but decreased plasma A concentration to 65% (2.96 nmol/l) of the initial values.

Dehydroepiandrosterone (DHEA) levels in patients with prostatic cancer, heart diseases and under surgery stress

DHEA levels in patients with prostatic cancer were significantly lower, but total and free testosterone (T) significantly higher as those in an age-matched control group. Therefore, the calculated quotients DHEA/free T and DHEA/T were especially different between both groups. DHEA and DHEAS levels in patients with heart diseases were also significantly lower but cortisol (F) levels were significantly higher as those in a control group. The quotients DHEA/F and DHEAS/F were also of greater significance between both groups than the hormone values alone. The response of DHEA and F levels in patients undergoing surgery showed an increase of both steroids under surgery. On the second postoperative day, however, F levels were still significantly higher but DHEA levels were significantly lower as the initial values. The differences between the initial values and those on the second postoperative day of F and DHEA showed a significant correlation, i.e. the higher the elevation of F levels above the initial values the greater was the diminution of DHEA levels below the initial values.

Cross-over kidney transplantation with simultaneous laparoscopic living donor nephrectomy: initial experience

With cross-over living donor kidney transplantation, immunologic incompatibilities within the original donor/recipient pair can be overcome. As minimal invasive techniques for organ recovery are increasingly applied, this should also be performed in a cross-over kidney transplantation. We present the first report of a successful simultaneous laparoscopic kidney recovery for cross-over kidney transplantation as well as a review of the international practice of cross-over kidney transplantation in the context of national laws. Cross-over kidney transplantation should be encouraged. A databank on pairs willing to participate in organ exchange programs should be created.

Clinical value of vesical leukoplakia and evaluation of the neoplastic risk by mutation analyses of the tumor suppressor gene TP53

AIM

Leukoplakia has been found to be precancerous in organs covered with squamous epithelium. The present study was conducted to determine whether leukoplakia described in the female bladder is also a premalignant lesion.

METHODS

Between 1973 and 1996, 77 female patients were diagnosed with vesical leukoplakia by cystoscopy and cytology and were followed-up until 2004 (mean follow-up time: 8.3 years). A survey was conducted to analyze exposure to cocarcinogens. Additionally, DNA was isolated from 36 urine sediments and analyzed for TP53 mutations. The results were compared to the mutation frequency of TP53 in urine sediments from patients diagnosed with transitional cell carcinoma (TCC) of the bladder and healthy controls.

RESULTS

The whitish lesion was mostly located at the trigone and varied in size and location during the follow-up years. TP53 mutations were detected in 6 out of 36 urine samples in exons 5, 6 and 7 (mutation frequency: 16.7%). Among control patients with no leukoplakia or TCC of the bladder (n = 70), the spontaneous mutation frequency was similar (14.3%). In contrast, the mutation frequency in patients with TCC of the bladder (n = 148) revealed 39.9% in exons 5, 6, 7 and 8. The present study did not show any statistically significant correlations between chronic inflammations, TP53 mutations, exposure to carcinogens and vesical leukoplakia.

CONCLUSIONS

Our data suggest that vesical leukoplakia does not necessarily hold neoplastic potential and needs to be clearly distinguished from leukoplakia in other localizations. Therefore, we suggest that a biopsy can be omitted, if follow-up controls by cystoscopy are performed regularly.

Diagnostic and Prognostic Validity of Serum Bone Turnover Markers in Metastatic Renal Cell Carcinoma

PURPOSE

We assessed the diagnostic accuracy of bone markers in the serum of patients with renal cell carcinoma to detect bone metastases and evaluate the prognostic potential concerning renal cell carcinoma caused mortality.

MATERIALS AND METHODS

The bone formation markers total and bone specific alkaline phosphatase, the bone resorption markers cross-linked N-terminal and tartrate-resistant acid phosphatase isoenzyme 5b, and the osteoclastogenesis markers osteoprotegerin and ligand of the receptor activator of nuclear factor-kappaB, were measured in the serum of 72 patients with renal cell carcinoma, including 28 with pN0M0, 8 with pN1M0 and 36 with M1, and in 32 female and 36 male controls by enzyme-linked immunosorbent assay techniques. Data were evaluated by receiver operating characteristics and survival analysis.

RESULTS

Bone specific alkaline phosphatase, tartrate-resistant acid phosphatase isoenzyme 5b and ligand of the receptor activator of nuclear factor-kappaB did not significantly differ between patients with renal cell carcinoma and controls. Compared with controls tartrate-resistant acid phosphatase isoenzyme 5b, cross-linked N-terminal and osteoprotegerin showed increased concentrations in patients with nonbone metastases but not in those with bone metastases. No bone turnover marker led to differentiation between patients with nonbone and bone metastases. Increased osteoprotegerin above the upper 95% cutoff limit, tumor stage and distant metastatic spread were associated with renal cell carcinoma related survival on Kaplan-Meier analyses. A multivariate Cox proportional hazards regression model revealed that these 3 variables were independent prognostic factors for cancer related death.

CONCLUSIONS

Bone turnover markers are hardly useful to diagnose bone metastases in patients with renal cell carcinoma. However, osteoprotegerin together with clinicopathological characteristics may be helpful as prognosticator of cancer specific death.

Long-term benefit of 5-aminolevulinic acid fluorescence assisted transurethral resection of superficial bladder cancer: 5-year results of a prospective randomized study

PURPOSE

As shown in various studies 5-aminolevulinic acid (ALA) induces fluorescence of malignant and dysplastic bladder tissue and increases tumor detection rates by about 20%. However, data on the long-term benefits are sparse. Thus, the 5-year outcome data of a prospective randomized trial comparing patients who initially underwent bladder tumor resection (TUR) under standard white light or with ALA induced fluorescence were evaluated.

MATERIALS AND METHODS

A total of 115 patients with suspected superficial bladder cancer were randomized to undergo standard or ALA assisted TUR. After the second look TUR at 6 weeks patients were followed for a median of 39 (standard) and 42 (ALA) months.

RESULTS

Median time to first recurrence was 5 months in the standard and 12 months in the ALA group. Recurrence-free survival was 25% in the standard and 41% in the ALA group. The recurrence rate at 2, 12, 36 and 60 months after initial TUR was 41%, 61%, 73% and 75%, and 16%, 43%, 59% and 59% in the white light and ALA groups, respectively. The total number of recurrences was 82 in the standard and 61 in the ALA group. Tumor progression occurred in 9 patients in the standard and 4 in the ALA group. Cost analysis suggests a considerable economical advantage of ALA fluorescence assisted TUR compared to the standard procedure.

CONCLUSIONS

The initial advantage of improved tumor detection and decreased recurrence rates by ALA fluorescence assisted TUR is maintained for years, and effectively reduces morbidity and costs in patients with superficial bladder tumors.

Ureteral Complications in the Renal Transplant Recipient after Laparoscopic Living Donor Nephrectomy

OBJECTIVES

We report on ureteral and surgical complications in our first 110 consecutive recipients of kidneys procured with laparoscopic living donor nephrectomy (LLDN).

METHODS

The records of all living donor transplants with LLDN performed between February 1999 and December 2004, including 10 pediatric transplants, were reviewed retrospectively. Three urologists performed LLDN using a pure laparoscopic non-hand-assisted transperitoneal technique. Kidney transplantation was performed in a standard fashion. For ureteroneocystostomy, the intravesical Politano-Leadbetter (P-L) technique was used.

RESULTS

Two-year patient and graft survival was 99% and 98%, respectively. Serum creatinine at 12 months was 1.36+/-0.1mg/dl in adult and 0.99+/-0.23 mg/dl in pediatric recipients. Nineteen right donor kidneys were transplanted into adult recipients. Surgical complications included three symptomatic lymphoceles, one peritransplant haematoma and one kinking of a lower pole artery. All five (4.5%) ureteral complications occurred in adult recipients with a mean age of 33.2+/-2.8 years. The incidence of ureteral complications was not clustered around the early phase of our LLDN experience. Of the three (2.7%) patients diagnosed with ureteral obstruction, two required ureteral reimplantation, and one was managed conservatively. Another two patients (1.8%) with a urinary leak received a double J stent and a cystostomy catheter for 3 and 5 months, respectively. Of the five patients with a ureteral complication, three had received a donor kidney with more than one renal artery.

CONCLUSIONS

LLDN combined with the intravesical (P-L) ureteral implantation technique provides excellent graft outcomes with low recipient morbidity. Renal artery multiplicity may increase the risk of ureteral complications.

Combined determination of plasma MMP2, MMP9, and TIMP1 improves the non-invasive detection of transitional cell carcinoma of the bladder

Background

Matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) play a major role in the maintenance of extracellular matrix homeostasis and are involved in the process of tumour invasion and metastasis in several malignant tumour entities. The goal of this study is to evaluate the diagnostic value of various circulating MMPs and TIMPs in blood plasma for a non-invasive detection of transitional cell carcinoma of the bladder (TCC).

Methods

In this study the concentrations of MMP1, MMP2, MMP3, MMP9, their inhibitors TIMP1, TIMP2, and the MMP1/TIMP1-complex (MTC1) were quantified in blood plasma with the sandwich enzyme-linked immunosorbent assay (ELISA). Blood plasma samples were investigated from 68 patients (non-metastasized, n = 57 and metastasized, n = 11) with TCC of the bladder and from 79 healthy controls. The mROC program was used to calculate the best two- and three- marker combinations. The diagnostic values for all single markers and the marker combinations were estimated both by the overall diagnostic performance index area under the ROC curve (AUC) and the sensitivity and specificity at cutoff limits with the highest diagnostic accuracy and at the 90% and 95% limits of sensitivity and specificity, respectively.

Results

The median MMP2 concentration was elevated in blood plasma in all patient groups with TCC in comparison to the controls (p < 0.001). The concentrations of TIMP1, TIMP2, and MTC1 in plasma probes were significantly lower from patients with non-metastasized TCC compared to the controls. MMP2 tested alone reached the highest sensitivity and specificity at 75%, respectively. The sensitivity and specificity increased when tested in combination with MMP9 and TIMP1 (97%, 94%, respectively). The combination of MMP9 and TIMP1 also showed an improved sensitivity (80%) and specificity (99%) than tested alone.

Conclusion

MMP2 is a statistically significant marker in blood plasma for bladder cancer detection with an increased diagnostic value in combination with MMP9 and TIMP1. This study showed that the highest sensitivities and specificities are not obtained by testing each marker alone. As shown by the best two-marker combination, which includes MMP9 and TIMP1, the optimized combination does not always include the best single markers.

Anwendung der optischen Kohärenztomographie (OCT) bei der Darstellung von Urothelerkrankungen der Harnblase

PURPOSE

The technique of optical coherence tomography (OCT) has significantly improved over the last few years. This new diagnostic procedure allows imaging of tissue structure of the bladder wall during cystoscopy with high resolution.

MATERIALS AND METHODS

The penetration depth of OCT is limited to 2.5 mm. The resolution is approximately 15 microm. Fifty patients with different clinical conditions of the bladder were examined. Altogether 488 OCT images were generated.

RESULTS

OCT of normal bladder mucosa clearly shows a differentiation between urothelium, lamina propria, and smooth muscle. Cystitis and metaplasia are characterized by blurring of the laminated structure and thickening of the epithelial layer. In malignant areas there is complete loss of the regular layered tissue structure.

CONCLUSION

OCT improves the diagnosis of flat lesions of the urothelium. It has the potential for facilitating intraoperative staging of malignant areas in the bladder.

[Ten years of laparoscopic living kidney donation. From an extravagant to a routine procedure]

Ten years ago the first laparoscopic living donor nephrectomy (LDN) was performed. Today, LDN is a routine operation in many US-American transplantation centers and an increasing number of centers in Europe are practicing LDN. In this article the different aspects of LDN for donor, kidney, recipient and operating surgeon are evaluated. We performed a literature research concerning LDN and the different aspects. Our own experience, as the largest LDN center in Germany, is part of the evaluation. Laparoscopic extraction of a kidney from a living donor is as safe for the donor as the open approach. At the same time, LDN offers multiple advantages like reduced pain and shorter convalescence. For the donated kidney and the recipient no disadvantages occur from the laparoscopic technique, as long as special intra- and perioperative demands are met. For the operating surgeon multiple developments have expanded the technical armentarium. LDN is safe for donor, recipient and kidney. Central issue of an optimal LDN is sufficient experience with laparoscopic urological techniques.

In situ gene expression and localization of metalloproteinases MMP1, MMP2, MMP3, MMP9, and their inhibitors TIMP1 and TIMP2 in human renal cell carcinoma

Matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) play a major role in the maintenance of extracellular matrix homeostasis. Alterations of MMP and TIMP expressions have been found in several malignant tumour entities. In this study the expression pattern of MMP1, MMP2, MMP3, MMP9, and their inhibitors TIMP1, and TIMP2 were investigated at mRNA and protein levels in human renal cell carcinoma (RCC). Formalin fixed paraffin embedded tumour samples of 10 patients and adjacent non-malignant controls were analysed by radioactive labelled riboprobe in situ hybridisation (isH) and immunohistochemistry. The slides were evaluated semiquantitatively. MMP1-antigen was strongly expressed in tumour epithelium with moderate stroma expression in one case. The gelatinases MMP2 and MMP9 showed moderate to strong signals in tumour epithelial cells at the mRNA and protein level, while the expression in tumour stroma was moderate. MMP3-mRNA and -antigen were expressed moderately to strong in tumour epithelium and focally in stroma cells. mRNA or TIMP1- and TIMP2-mRNA and -antigen were also predominantly expressed in tumour epithelium; only few samples showed positive expression in stroma cells. mRNA expression could be generally correlated to the protein expression in our study group, except for MMP1 (mRNA expression was only expressed in two cases). We found a pronounced expression for the gelatinases MMP2 and MMP9 and for MMP3 in RCC at the mRNA and protein level. The expression of TIMP1 and TIMP2 appears also to be relevant in RCC. Due to the small sample size further investigations need to be done to prove a statistical significant correlation between the MMP/TIMP expression and clinicopathological parameters.

Interchangeability of measurements of total and free prostate-specific antigen in serum with 5 frequently used assay combinations: an update

BACKGROUND

The comparability of total and free prostate-specific antigen (tPSA and fPSA) results among commercial PSA assays has been suggested to be improved by calibration to WHO PSA reference materials and the development of equimolar-response assays. To characterize the current situation, we assessed 5 frequently used commercial assay combinations for tPSA and fPSA regarding the interchangeability of the PSA values and the ratio of fPSA to tPSA (%fPSA), equimolar characteristics, and diagnostic accuracy.

METHODS

Sera from 314 patients with prostate cancer (PCa) and 282 men with no evidence of prostate cancer (NPCa) were measured with tPSA and fPSA assays from Abbott (AxSYM), Beckman Coulter (Access), Diagnostic Products Corporation (Immulite 2000), and Roche (Elecsys 2010) and with tPSA and complexed PSA (cPSA) assays from Bayer (ADVIA Centaur).

RESULTS

Method comparisons (Passing and Bablok regressions; Bland-Altman plots) showed assay-dependent results for tPSA, fPSA, and %fPSA. With the Access tPSA values taken as 100%, tPSA concentrations varied from 87% (AxSYM and ADVIA Centaur) to 115% (Immulite), leading to different numbers of patients classified according to the commonly recommended tPSA cutoffs for performing a biopsy. Different %fPSA values also led to assay-dependent ROC analysis results, a finding that shows the importance for the diagnostic accuracy.

CONCLUSION

Interchangeability of tPSA, fPSA, and %fPSA values obtained by commercial PSA assays remains inadequate, but attention to this issue may minimize the misinterpretation of PSA results obtained by different assays.

MRI of prostate cancer at 1.5 and 3.0 T: comparison of image quality in tumor detection and staging

OBJECTIVE

This prospective study was performed to compare the image quality, tumor delineation, and depiction of staging criteria on MRI of prostate cancer at 1.5 and 3.0 T.

SUBJECTS AND METHODS

Twenty-four patients with prostate cancer underwent MRI at 1.5 T using the combined endorectal-body phased-array coil and at 3.0 T using the torso phased-array coil, among them 22 before undergoing radical prostatectomy. The prostate was imaged with T2-weighted sequences in axial and coronal orientations at both field strengths and, in addition, with an axial T1-weighted sequence at 1.5 T. Preoperative analysis of all MR images taken together was compared with the histologic findings to determine the accuracy of MRI for the local staging of prostate cancer. In a retroanalysis, the image quality, tumor delineation, and conspicuity of staging criteria were determined separately for both field strengths and compared. Statistical analysis was performed using Wilcoxon's and the McNemar tests.

RESULTS

In the preoperative analysis, MRI (at both 1.5 and 3.0 T) had an accuracy of 73% for the local staging of prostate cancer. The retroanalysis yielded significantly better results for 1.5-T MRI with the endorectal-body phased-array coil in terms of image quality (p < 0.001) and tumor delineation (p = 0.012) than for 3.0-T MRI with the torso phased-array coil. Analysis of the individual staging criteria for extracapsular disease did not reveal a superiority of either of the two field strengths in the depiction of any of the criteria.

CONCLUSION

Intraindividual comparison shows that image quality and delineation of prostate cancer at 1.5 T with the use of an endorectal coil in a pelvic phased-array is superior to the higher field strength of 3.0 T with a torso phased-array coil alone. As long as no endorectal coil is available for 3-T imaging, imaging at 1.5 T using the combined endorectal-body phased-array coil will continue to be the gold standard for prostate imaging.

Nierentransplantation im Kindes- und Jugendalter

The reasons for end-stage renal disease in pediatric patients differ from adults. The therapy of choice is renal transplantation. A total of 117 children and adolescents were treated with renal transplantation in 2003 in Germany. Immunosuppressive therapy and related comorbidities are the main problems in pediatric patients. The following article provides a summary of transplantation in children, preparation, and follow-up.

A MULTICENTER CLINICAL TRIAL ON THE USE OF (–5, –7) PRO PROSTATE SPECIFIC ANTIGEN

PURPOSE

The determination of pro prostate specific antigen (proPSA) forms has been suggested to be promising in prostate cancer diagnosis. In this multicenter trial we evaluated the diagnostic usefulness of (-5, -7) proPSA.

MATERIALS AND METHODS

A total of 2,055 white men, including 1,046 with and 1,009 without prostate cancer, with total PSA (tPSA) between 0.28 and 81 ng/ml were retrospectively analyzed. Of these men 2,026 and 1,727 had tPSA less than 20 and less than 10 ng/ml, respectively. All subjects were untreated for prostatic disease and underwent multisector needle biopsy of the prostate. An Elecsys 2010 analyzer was used to determine tPSA, free PSA (fPSA) and (-5, -7) proPSA in the 2,055 serum samples. ROC analyses were performed to discriminate men with biopsy positive and negative results in the entire and in select tPSA ranges.

RESULTS

In the select tPSA range 2 to 4 ng/ml the area under the ROC curve for proPSA (0.53) and proPSA/fPSA (0.59) was not significantly larger than that for tPSA (0.60) or the fPSA/tPSA (f/tPSA) ratio (0.64). In the tPSA range 4 to 10 ng/ml the area under the curve for the ratio proPSA/fPSA (0.67) was larger than for tPSA (0.53) but not larger than for f/tPSA (0.69). The f/tPSA ratio demonstrated the best discriminatory power in this tPSA range of 4 to 10 ng/ml.

CONCLUSIONS

In this multicenter study no improvement in diagnostic accuracy was shown when comparing (-5, -7) proPSA and the corresponding ratios with tPSA or f/tPSA. Further studies using other proPSA forms or tumor associated proteins should be done.

Differential gene expression of urokinase-type plasminogen activator and its receptor in human renal cell carcinoma

The urokinase-type plasminogen activator (uPA) system plays a central role in extracellular matrix degradation, cell migration, and invasion. uPA belongs to the family of serine proteases. It has been shown that its proteolytic activity is involved in the metastatic process by activation and binding to its receptor (uPAR). Previous studies in several organ systems have elucidated a higher uPA expression in malignant tissue in comparison to normal tissue. In this study uPA and uPAR gene expression were investigated in 18 human renal cell carcinoma (RCC) specimens in comparison with adjacent non-malignant renal tissues. mRNA in situ hybridisation and immunohistochemical staining were performed. mRNA of uPA and uPAR was significantly higher expressed in 56% (10/18) and 72% (13/18) of the RCC specimens in comparison to the adjacent non-malignant renal tissue (p<0.0001), respectively. uPA-mRNA and uPAR-mRNA were expressed predominantly in malignant renal cells and in very few surrounding stromal cells. The elevated expression of uPAR-protein in RCC reached statistical significance compared to adjacent normal tissue (p=0.007). uPAR genes were higher expressed in comparison to uPA alone. There was a statistical trend that higher expression of uPA and uPAR corresponded with TNM tumour stage and grade in RCC. Further investigations need to be done with larger sample sizes to prove a correlation of expression between uPA and uPAR to a more aggressive phenotype. We conclude that uPA- and uPAR are overexpressed in RCC and could function as tumour markers.

Phase II Trial of Weekly Paclitaxel and Carboplatin Chemotherapy in Patients with Advanced Transitional Cell Cancer

OBJECTIVE

We investigated the efficacy and toxicity of a first-line combination chemotherapy using weekly paclitaxel and carboplatin in patients with metastatic transitional cell cancer (TCC).

PATIENTS AND METHODS

Thirty-three patients with advanced measurable TCC of the urothelium were entered onto this trial. Patients were treated once weekly with a combination therapy of paclitaxel (100mg/m(2)) and carboplatin (AUC 2, according to the Calvert formula). Therapy courses were administered for six consecutive weeks. After two cycles, a re-staging was carried out to evaluate response.

RESULTS

Objective response rate was 57.6% with 6 complete (18.2%) and 13 partial remissions (39.4%). Seven patients had stable disease (21.2%) and 7 patients had progressed at the first evaluation of response (21.2%). Median progression-free interval and median survival was 6.5 (1-35) and 12 (2.5-58) months, respectively. Toxicity was moderate and manageable with grade 3 and 4 neutropenia in 8 patients (24%), but no case of neutropenic fever. Other hematological grade 3 toxicities occurred in 9 patients (27%) and grade 3 peripheral neuropathy in 2 patients (6%). There was no treatment-related death. Dose reduction or short delay of treatment was necessary in 3 patients.

CONCLUSIONS

Combination therapy using weekly paclitaxel and carboplatin was active in patients with advanced TCC and adverse prognostic features. The weekly dosing used in this trial warrants further investigation as an alternative first-line approach in patients with poor renal reserve and/or performance status or as a second-line management of advanced TCC.

Increased CD59 protein expression predicts a PSA relapse in patients after radical prostatectomy

BACKGROUND

Human protectin (CD59) is a regulator of complement activation that inhibits complement-mediated cell lysis, and thus might confer immune resistance to tumor cells. CD59 expression has been described in a variety of human malignancies, including breast cancer. Since a comprehensive investigation of CD59 expression in prostate cancer has not been conducted yet, we aimed to determine the significance of CD59 expression in prostate cancer.

METHODS

Eighty-six primary adenocarcinomas of the prostate were immunostained using a monoclonal CD59 antibody (clone MEM-43) and a standard detection system. The immunoreactivity of the tumor was evaluated as low versus high for statistical analysis. Additionally, CD59 mRNA levels were determined by real-time PCR in matched (tumor/normal) microdissected tissues from 26 cases.

RESULTS

Cytoplasmic CD59 immunoreactivity was found in epithelia of prostate cancer, prostatic intraepithelial neoplasia, benign hyperplasia, atrophic, and normal glands. High rates of CD59 expression were noted in 36% of prostate cancer cases and were significantly associated with tumor pT stage (P = 0.043), Gleason grade (P = 0.013) and earlier biochemical (PSA) relapse in Kaplan-Meier analysis (P = 0.0013). On RNA level, we found an upregulation in 19.2% (five cases), although the general rate of CD59 transcript was significantly lower in tumor tissue (P = 0.03).

CONCLUSION

CD59 protein is strongly expressed in 36% of adenocarcinomas of the prostate and and is associated with disease progression and adverse patient prognosis.

Diagnostic validity of macrophage migration inhibitory factor in serum of patients with prostate cancer: a re-evaluation

BACKGROUND

Recent studies suggest that macrophage migration inhibitory factor (MIF) in serum is of prognostic significance for prostate cancer. The aim of this study was to re-evaluate this hypothesis.

METHODS

Serum MIF levels were measured in healthy men (n = 86), untreated patients with benign prostate hyperplasia (BPH; n = 50), prostate cancer (PCa; n = 163), and after radical prostatectomy for 3 days (n = 5). PCa patients were classified according to the TNM system and the WHO grading scale. Prostate specific antigen (PSA) and C-reactive protein (CRP) were additionally determined.

RESULTS

The MIF concentrations of healthy men and BPH patients did not differ (mean +/- SD, 2.08 +/- 1.08 microg/L vs. 2.04 +/- 1.08 microg/L), whereas the mean value of MIF in PCa patients was significantly decreased (1.77 +/- 1.12 microg/L). There was no any correlation between MIF and PSA (r(s) = -0.049, P = 0.271). MIF concentrations in patients with T1 tumors were higher than in those with T2 tumors (2.29 +/- 1.26 vs. 1.67 +/- 1.11 microg/L; P = 0.044). No any effect of grading was observed. After prostatectomy, the changes of PSA and MIF were not always concordant as MIF partly increased while PSA continuously decreased. Analyses of receiver-operating curves and logistic regressions did not show that MIF alone or MIF related variables (MIF/tPSA; fPSA/(tPSA x MIF); fPSA x MIF/tPSA) could improve specificity or sensitivity to detect prostate cancer in comparison to total PSA.

CONCLUSION

Serum MIF alone or MIF to PSA related variables did not seem suitable for providing additional information on PCa patients. That re-evaluated diagnostic validity of MIF was in contrast to results by another group shown previously.

The ratio of prostate-specific antigen (PSA) to prostate volume (PSA density) as a parameter to improve the detection of prostate carcinoma in PSA values in the range of < 4 ng/mL

BACKGROUND

The objective of this study was to evaluate the prostate specific antigen (PSA) density (PSAD) (the quotient of PSA and prostate volume) compared with the percent free PSA (%fPSA) in different total PSA (tPSA) ranges from 2 ng/mL to 20 ng/mL. Possible cut-off levels depending on the tPSA should be established.

METHODS

In total, 1809 men with no pretreatment of the prostate were enrolled between 1996 and 2004. Total and free PSA were measured with the IMMULITE PSA and Free PSA kits (Diagnostic Products, Los Angeles, CA). Prostate volume was determined by transrectal ultrasound. The diagnostic validity of tPSA, %fPSA, and PSAD was evaluated by receiver operation characteristic (ROC) curve analysis.

RESULTS

The PSAD differed significantly (P < 0.0001) between patients with prostate carcinoma and patients with benign prostatic hyperplasia in all analyzed ranges of tPSA and prostate volume. At the 90% and 95% sensitivity levels and regarding the area under the ROC curve (AUC) within the tPSA range of 2-4 ng/mL, The PSAD was significantly better than tPSA and %fPSA. Within the tPSA range of 4-10 ng/mL, the PSAD did not perform better than %fPSA.

CONCLUSIONS

PSAD showed a better performance than %fPSA at tPSA concentrations < 4 ng/mL for detecting prostate carcinoma, with a significantly larger AUC for PSAD (0.739) compared with %fPSA (0.667). PSAD did not perform better than %fPSA when the tPSA range of 4-10 ng/mL was analyzed. Different PSAD cut-off values of 0.05 at tPSA 2-4 ng/mL, 0.1 at tPSA 4-10 ng/mL, and 0.19 at 10-20 ng/mL were necessary to reach 95% sensitivity.

Analysis of Subforms of Free Prostate-Specific Antigen in Serum by Two-Dimensional Gel Electrophoresis: Potential to Improve Diagnosis of Prostate Cancer

Background: The aim of this study was to develop a method to separate and quantify subforms of free prostate-specific antigen (fPSA) in serum by two-dimensional electrophoresis and to assess the diagnostic accuracy of these subforms for prostate cancer (PCa) diagnosis in comparison with total PSA (tPSA) and the ratio of fPSA to tPSA (%fPSA).

Methods: Sera from 50 patients with and without PCa, respectively, were studied. PSA was isolated by immunoadsorption on streptavidin-coated magnetic beads with biotinylated anti-PSA antibodies and separated by two-dimensional electrophoresis. After semidry blotting, the intensities of the fPSA spots were quantified by chemiluminescence using an imager analyzer.

Results: The method detected subforms to a concentration of 0.1 μg/L fPSA with an imprecision (CV) &lt;16%. We detected 15 immunoreactive fPSA spots of different intensities. Spots F2 and F3 were present in all samples. F2 was lower in samples from non-PCa patients (median, 23%) than in samples from PCa patients (49%), whereas F3 behaved inversely (non-PCa, 73%; PCa, 45%). Ratios of F2 to F3 and F2/F3 to %fPSA, respectively, showed improved diagnostic accuracy compared with tPSA and %fPSA. Better differentiation by F2/F3 or by F2/F3 to %fPSA was particularly evident in patients with %fPSA values &gt;15%. There were no associations between the PCa grading scale and fPSA subforms.

Conclusions: fPSA subforms separated by two-dimensional electrophoresis may improve both sensitivity and specificity in prostate cancer diagnostics compared with tPSA and %fPSA. The development of a practicable assay based on the immunologic properties of these different fPSA subforms seems to be promising.

[The impact of ALA (5-aminolevulinic acid)-fluorescence detection on the prognosis of superficial bladder cancer]

PURPOSE

Throughout the past years, several studies have shown that fluorescence cystoscopy with ALA (5-aminolevulinic acid) improves the detection rate of superficial bladder tumors by approximately 20 % compared to standard white light cystoscopy. These results suggest a reduced rate of residual/recurrent tumors with the routine use of ALA fluorescence technique prior to bladder tumor resection. The present prospectively randomized study was performed to verify this hypothesis.

MATERIALS AND METHODS

A total of 115 bladder tumor patients were randomized for initial resection under white light or ALA fluorescence. After 6 to 8 weeks, a second-look resection was performed in all patients guided by ALA fluorescence. Additional white light cystoscopies were performed after 3, 6 and 12 months.

RESULTS

The second-look resection did not find a tumor in 31 of 51 (59 %) patients initially resected under white light guidance compared to 43 of 51 (84 %) patients in the fluorescence group. This difference was statistically significant (p = 0.005). At 12 months, a tumor was not found in 17 of 48 patients from the white light group vs. 25 of 47 patients from the fluorescence group (p = 0.03). Seven patients were lost to follow-up.

CONCLUSIONS

By reducing otherwise inevitable re-operations, fluorescence cystoscopy decreases morbidity and lowers treatment costs.

In situ gene expression of urokinase-type plasminogen activator and its receptor in transitional cell carcinoma of the human bladder

The urokinase-type plasminogen activator (uPA) system plays a central role in the blood clot dissolution and tissue plasticity. uPA is a serine protease that is also involved in the metastatic process upon activation and binding to its receptor (uPAR). Studies have shown that levels of uPA in malignant tumors are higher than in the corresponding normal tissue or in benign tumors of the same tissue. We investigated uPA and uPAR gene expression in 20 human transitional cell carcinomas (TCC) of the bladder (n=19) and the renal pelvis (n=1) in comparison with adjacent non-malignant tissues. We performed mRNA in situ hybridization (isH) and immunohistochemical staining. uPA-mRNA and uPAR-mRNA were present in 95% (19/20) and 85% (17/20) of the TCC samples, respectively and significantly higher expressed than in the adjacent normal tissue. uPA-mRNA was expressed only in malignant urothelial cells, whereas uPAR-mRNA was localized in malignant urothelial cells as well as in surrounding stromal cells. There was a statistically significant lower expression of uPA/uPAR-protein in adjacent normal tissue. Strong uPAR-protein signal intensity was related to a marked protein expression as semi-quantitatively determined by immunohistochemistry. For uPA-protein this observation was less frequent. There was a statistical trend that higher expression of uPA and uPAR corresponded with tumor stage and grade of TCC. Statistical significance was reached for uPAR-antigen compared to tumor stage (p=0.025). We conclude that higher expression of uPA and uPAR could indicate a more aggressive phenotype of TCC.

Comparison of 10 serum bone turnover markers in prostate carcinoma patients with bone metastatic spread: diagnostic and prognostic implications

Our aim was to assess the diagnostic accuracy of bone markers in serum of patients with prostate cancer (PCa) for early detection of bone metastases and their usefulness as predictors of PCa-caused mortality. In sera of 117 PCa patients (pN0M0, n = 39; pN1M0, n = 34; M1, n = 44), 35 healthy men and 35 patients with benign prostatic hyperplasia, bone formation markers [total and bone-specific alkaline phosphatase (tALP, bALP), amino-terminal procollagen propeptides of type I collagen (P1NP), osteocalcin (OC)], bone resorption markers [bone sialoprotein (BSP), cross-linked C-terminal (CTX) and cross-linked N-terminal (NTX) telopeptides of type I collagen, tartrate-resistant acid phosphatase isoenzyme 5b (TRAP)] and osteoclastogenesis markers [osteoprotegerin (OPG), receptor activator of nuclear factor kappaB ligand (RANKL)] were measured. tALP, bALP, BSP, P1NP, TRAP, NTX and OPG were significantly increased in PCa patients with bone metastases compared to patients without metastases. OPG showed the best discriminatory power to differentiate between these patients. Logistic regression analysis resulted in a model with OPG and TRAP as variables that predicted bone metastasis with an overall correct classification of 93%. Patients with concentrations of OPG, P1NP, tALP, bALP, BSP, NTX, TRAP and CTX above cut-off levels showed significantly shorter survival than patients with low marker concentrations. Multivariate Cox proportional hazards regression revealed that only OPG and BSP were independent prognostic factors for PCa-related death. Thus, the importance of serum OPG in detecting bone metastatic spread, alone or in combination with other bone markers, and predicting survival in PCa patients has been clearly demonstrated.

Expression of cathepsins B, H, and L and their inhibitors as markers of transitional cell carcinoma of the bladder

OBJECTIVES

It has been shown that the expression of the lysosomal proteolytic enzymes cathepsin B, H, and L (CB, CH, and CL, respectively) correlate with tumor progression in various neoplasms. However, no data are available in cell lysates and supernatants of differently differentiated human bladder cell lines or in noncancerous and cancerous bladder tissue.

METHODS

Using spectrofluorometric assays, catalytic activities of CB, CH, CL, and their inhibitor (CIP) were measured both in differently differentiated human bladder cell lines (HCV29, normal; RT4, well differentiated; J82, poorly differentiated) and in noncancerous and cancerous tissue samples (n = 20) of transitional cell carcinoma obtained from transurethral resections of the bladder or cystectomies. Enzyme activities were related to the protein content in tissue samples or to the cell count in cell lines.

RESULTS

In comparison to the intracellular activities of CB, CH, and CL in the poorly differentiated cell line J82, the intracellular activities in the normal cell line HCV29 were significantly greater (P <0.05), independent of stage or grade. In contrast, the portion of cathepsins released from cell line J82 into the supernatant revealed higher values than that from cell line HCV29. In cancerous bladder tissue, CB and CH were significantly greater than in the matched normal tissue (P <0.05). CL and CIP did not show any statistically significant differences.

CONCLUSIONS

Increased cathepsin concentrations in the supernatant of the poorly differentiated J82 carcinoma cell culture, as well as in cancerous bladder tissue, are indicative of a proteolytic imbalance and potential indicators of bladder cancer.

[Taxanes in the chemotherapy of hormone-refractory prostate carcinoma]

Prostate cancer represents one of the most prevalent malignancies in men. Standard therapy of metastatic prostate cancer consists of androgen deprivation, which is a palliative therapy yielding a clinical response of limited duration. In hormone-refractory prostate cancer (HRPC), response to chemotherapy with regimens available until about ten years ago has been disappointing. Nowadays, due to increasing life expectancy and earlier diagnosis and therapy of prostate cancer, more patients with hormone-refractory disease are still in relatively good overall condition. With the taxanes, much more effective cytostatic substances for chemotherapy of HRPC are available today. Using modern taxane-based chemotherapy, effective palliation of pain can be achieved in 50-70% of patients with HRPC, while retaining an acceptable quality of life. There is also evidence for improved overall survival after taxane-based chemotherapy, although this remains to be proven by ongoing studies. This article presents an overview of current studies investigating the outcome after taxane-based chemotherapy, as well as new therapeutic approaches in combination with docetaxel.

Increased cell-free DNA in plasma of patients with metastatic spread in prostate cancer

We compared the plasma DNA concentrations in patients with different prostate cancer (PCa) stages and with benign prostate hyperplasia (BPH) and in healthy persons. Patients with localized cancer had DNA plasma within the reference interval. Increased plasma DNA was found in patients with lymph node and distant metastases and also in BPH. The association between plasma DNA and the survival time was similarly strong as with prostate-specific antigen. It can be concluded that plasma DNA has a limited validity as metastatic marker in PCa patients but follow-up studies combined with the investigation of tumor-related characteristics of plasma DNA would be reasonable.

Increased mRNA expression of ADAMs in renal cell carcinoma and their association with clinical outcome

ADAMs (a disintegrin and metalloproteinase) are cell-surface proteins with adhesion and protease activity which play important roles in many biological processes. Little is known about their role in cancer. The aim of the study was to assess the quantitative expression of the ADAMs in human renal cell carcinoma (RCC) and to associate expression levels with clinicopathological data. We investigated the mRNA expression of ADAM-8, -17, -19, -28, ADAM-TS1, and ADAM-TS2 in paired tissue samples from cancerous and non-cancerous parts of the kidneys of 27 patients with RCC who underwent tumour nephrectomy. Measurements were performed by means of the quantitative real-time RT-PCR on a LightCycler instrument. ADAM-8, -17, and -19 were significantly higher expressed (p<0.05 at least) in cancerous compared with the matched non-cancerous tissue in pT1 and > or =pT2 tumours, ADAM-28 and ADAM-TS2 only in pT1 tumours, and ADAM-TS1 was not differently expressed. All ADAMs except ADAM-TS1 showed an increase of expression in the non-cancerous tissue with rising pT stage suggesting an early involvement of ADAMs in the development of RCC. The expression of ADAM-8 was related to a shorter survival of patients and was the best predictor of distant metastases. Our results indicate a potential role for ADAMs in RCC and that the overexpression might be a useful predictive tool.

Serum Osteoprotegerin and Receptor Activator of Nuclear Factor-κ B Ligand as Indicators of Disturbed Osteoclastogenesis in Patients With Prostate Cancer

PURPOSE

We evaluated the behavior and diagnostic usefulness of the osteoclastogenesis proteins osteoprotegerin and receptor activator of nuclear factor-kappaB ligand (RANKL) in the serum of patients with prostate cancer (PCa).

MATERIALS AND METHODS

Serum osteoprotegerin and RANKL were retrospectively measured in 117 patients with prostate cancer, including 39 with stage pN0M0, 34 with stage pN1M0 and 44 with bone metastases, in 35 presumably healthy men and in 35 patients with benign prostatic hyperplasia (BPH). The association of these components with clinical data (tumor stage and grade) and receiver operating characteristics curves compared with the bone formation marker alkaline phosphatase and bone resorption marker crosslaps (cross-linked C-terminal telopeptides of type I collagen) were calculated.

RESULTS

Osteoprotegerin was increased in patients with bone metastases, while those with localized cancer or lymph node metastases had values similar to those in presumably healthy controls and patients with BPH. RANKL did not differ among the control, BPH and PCa subgroups. Thus, the ratio of osteoprotegerin-to-RANKL showed behavior similar to that of osteoprotegerin. Osteoprotegerin and RANKL did not show any significant correlation with tumor stage, histological tumor grade, total prostate specific antigen, alkaline phosphatase activity or crosslaps. ROC analysis data proved that osteoprotegerin had a better diagnostic accuracy than alkaline phosphatase or crosslaps for detecting bone metastases in PCa cases.

CONCLUSIONS

Serum osteoprotegerin but not RANKL indicates disturbed osteoclastogenesis in patients with PCa and bone metastatic spread. It could be used as a marker for bone metastases.

A Multicenter Clinical Trial On the Use of Complexed Prostate Specific Antigen in Low Prostate Specific Antigen Concentrations

PURPOSE

The determination of complexed prostate specific antigen (cPSA) has been suggested to be promising for prostate cancer (PCa) diagnosis. In a multicenter trial we evaluate the diagnostic use of PSA forms in the low total PSA (tPSA) range.

MATERIALS AND METHODS

A total of 283 white men with and 417 without PCa and tPSA concentrations between 0 and 6 ng/ml were retrospectively analyzed. All 700 untreated subjects underwent a multisector needle biopsy of the prostate. The Elecsys analyser 1010 (Roche Diagnostics, Mannheim, Germany) was used for determination of tPSA and free PSA. Determination of cPSA and tPSA was performed using immunoassays of the Bayer Immuno 1 system (Bayer Diagnostics, Tarrytown, New York).

RESULTS

Receiver operating characteristics analyses for discrimination between cases with and without PCa were performed. The areas under the curves (AUC) for cPSA, tPSA and free-to-total PSA (f/tPSA) showed no significant differences in the tPSA ranges of 0 to 6 (700 cases), 0 to 4 (510) and 0.5 to 2.5 ng/ml (253). Within the tPSA range of 2.5 to 4 ng/ml (230 cases) the AUC for cPSA (0.61) was significantly larger than that for tPSA (Roche 0.51, Bayer 0.54) but did not differ from the AUC of f/tPSA (Roche). On the basis of the cutoffs for 95% specificity or sensitivity, no significant increase in corresponding sensitivity or specificity was found between tPSA with cPSA.

CONCLUSIONS

In the tPSA range of less than 4 ng/ml no improvement in diagnostic accuracy was shown between cPSA with tPSA or the ratio of f/tPSA. The search for a useful marker in the low PSA range must continue.

Tumor type M2 pyruvate kinase expression in metastatic renal cell carcinoma

The M2 isoenzyme of pyruvate kinase (M2-PK) is specifically expressed in tumor cells (TuM2-PK) and has been detected in the peripheral blood of patients with renal cell carcinoma (RCC). TuM2-PK is not useful as a biological marker in localized RCC. We analysed TuM2-PK in 68 patients with metastatic RCC after initial surgery and prior to or during chemoimmunotherapy of metastases. In 50 patients, the levels of TuM2-PK were measured during chemoimmunotherapy with interleukin-2, interferon-alpha2a and 5-fluorouracil for up to 8 months and were correlated to response as assessed by radiological imaging techniques. TuM2-PK was quantified with a commercially available enzyme linked immunosorbent assay kit using a cut off of 15 kU/l. In 48 of 68 patients (71%), TuM2-PK was elevated above the cut-off. TuM2-PK was significantly higher in G3 tumors than in G2 tumors. In 34 of 50 patients (68%) undergoing chemoimmunotherapy, a positive correlation between TuM2-PK values and response to treatment was observed. Based on these data, we would not recommend the routine clinical use of TuM2-PK in metastatic RCC at this point.

Nutzung von artifiziellen neuronalen Netzwerken zur Risikoabsch�tzung eines Prostatakarzinoms

In this prospective study covering 5.5 years we evaluated the diagnostic power of an artificial neural network (ANN) based on PSA, %fPSA, and clinical data in the PSA range 2-20 microg/l as prostate biopsy indicator. A total of 944 patients with prostate cancer or benign hyperplasia (BPH) were analyzed. The calculation of the individual patient's risk before prostate biopsy was performed at the 90% and 95% specificity and sensitivity levels within the PSA ranges 2-4, 4.1-10, and 10.1-20 microg/l. For the low PSA range 2-4 microg/l, we recommend a first time biopsy at an ANN specificity level of 95%. For PSA range 4.1-10 microg/l, we recommend a first time biopsy at an ANN sensitivity level of 95%. A rebiopsy at the PSA range 10.1-20 micro g/l should be performed based on a 95% sensitivity level. The use of an ANN at PSA 2-20 microg/l enhances the specificity and sensitivity of %fPSA by 9-39%. The application of an ANN based on %fPSA and clinical data improves the diagnostic performance compared to %fPSA only.

Laparoscopic radical prostatectomy--an analysis of factors affecting operating time

OBJECTIVES

Although laparoscopic radical prostatectomy (LRP) is accomplished within 2 to 3 hours by experienced surgeons, less is known about the operating times (OTs) for recently trained surgeons or the influence of additional factors. As of November 2001 at our institution, two senior surgeons had each performed more than 100 cases of LRP and two junior surgeons had each performed fewer than 30. We prospectively studied the next 100 consecutive LRPs to assess the factors influencing the OT.

METHODS

Transperitoneal LRPs were performed by two senior (n = 62) and two junior surgeons (n = 38) with random case assignment. We assessed body mass index, prostate size, prior abdominal surgery, androgen deprivation, surgeon experience, procedures in addition to LRP, lymph node dissection, nerve sparing, and sural nerve grafting as potential predictors of the OT.

RESULTS

Prostate weight, androgen deprivation, and prior abdominal surgery did not significantly affect the OT, but grade 1 obesity increased the OT by an average of 38 minutes. The mean OT by surgeon experience was 214 minutes for seniors and 347 minutes for juniors (P <0.001). By procedure type, the OT ranged from 180 minutes for LRP only by seniors to 459 minutes for LRP plus lymph node dissection plus sural nerve grafting by juniors. Lymph node dissection and sural nerve grafting significantly increased the OT by 46 and 101 minutes, respectively, and nerve sparing did not. For each combination of procedures, seniors averaged significantly shorter times than did juniors. A multiple regression model with stepwise selection showed that prostate weight, sural nerve grafting, pelvic lymph node dissection, use of a surgical robot, and surgeon experience significantly affected the OT.

CONCLUSIONS

The results of this prospective study of 100 cases of LRP showed that the OT for senior surgeons averaged 2 to 3 hours, but less experienced surgeons, and additional procedures, add significantly to the OT.

Confocal laser scanning microscopy of urinary bladder after intravesical instillation of a fluorescent dye

OBJECTIVES

To assess the potential of confocal laser scanning microscopy for imaging of the urinary bladder after intravesical instillation of a fluorescent dye.

METHODS

The study was performed on the bladder of male Copenhagen rats. For confocal fluorescence microscopy (CFM), a standard confocal laser scanning microscope (Zeiss LSM 410) was used. Before measuring, the fluorescent marker SYTO 17 was instilled intravesically. After 2 hours of incubation, the rat was killed, the bladder excised and opened, and CFM was performed starting from the surface going through the urothelium and superficial layers of the lamina propria. Except for the opening incision, the bladder was left intact and no biopsies were taken. After imaging, the bladder was sent for conventional histologic studies.

RESULTS

CFM allows imaging of cellular details of the entire urothelium (superficial umbrella cells, intermediate, and basal urothelial cells) and superficial layers of the lamina propria. CFM images are close to those obtained by standard microscopy after conventional hematoxylin-eosin staining. Cell structure (eg, shape, size, chromatin texture, nucleoli, mitotic figures, nuclear/cytoplasmic ratio), as well as the structure of the connective tissue (eg, collagen fibers, blood vessels, erythrocytes), can be studied, allowing a standard histologic evaluation. Furthermore, in contrast to conventional histologic evaluation, CFM provides three-dimensional information and allows the study of intact tissue representing the true in vivo situation.

CONCLUSIONS

CFM enables the study of the microscopic anatomy of bladder mucosa in its in vivo state. In combination with optical fiber bundles, endoscopic microscopy of the bladder may be possible in the future.