[Development of tissue microarray technology (TMA) for immunohistochemical study of molecular expression profiling in prostate cancer (part 1)]

Tissue microarray technology (TMA) is nowadays considered as a powerful tool for the high-throughput analysis of molecular expression pattern of cancer. In this manuscript we show the experience of both groups in the design and building of a TMA for the study of protein expression pattern of prostatecancer as well as a summary of the technical points to analyze the results obtained with this technology. Today, different data generated by the immunostained tissues are studied to achieve a molecular profile in different clinical scenarios.

[Antibiotic resistance transformation in community-acquired urinary infections]

OBJECTIVE

To detect the prevalence of uropathogens in community-acquired urinary tract infection in our environment, and the degree of sensitivity to antibiotics used as empirical treatment.

PATIENTS AND METHOD

Retrospective longitudinal study on 16,392 consecutive urine cultures collected in the emergency department of Hospital del Mar, between January 1997 and December 2001. Resistance rates were compared through variance analysis.

RESULTS

8,743 urine cultures with significant count were obtained. 6,062 Escherichia coli (69.3%), 517 Proteus mirabilis (5.9%) and 390 Klebsiella pneumoniae (4.5%) were identified. Escherichia coli showed progressive growth rate and significant resistances to most of antibiotics evaluated, especially to quinolones which came close to 30%. Fosfomycin showed the least resistance rate (0.9%) and remained stable along the years studied.

CONCLUSIONS

These results suggest that higher rate of resistance to quinolones does not advise its use as empirical in community-acquired urinary tract infection treatment in our environment. According to our experience, fosfomycin can be an excellent option for cystitis treatment in patients without risk factors, while for the treatment of parenchymatous urinary tract infection, complicated urinary tract infections, and urinary tract infections associated to risk factors, preference could be second or third generation oral cephalosporins, or amoxicillin-clavulanic acid.

[Analysis of medical/surgical complications of cutaneous ileostomy]

OBJECTIVE

Our objective is to carried out a descriptive study about medical-surgical complications and alterations about quality of life in stoma patients secondary to bladder tumour.

PATIENTS AND METHOD

The series are composed of 67 patients. The mean age was 70.3 years. We analyse the following variable: early and late medical-surgical complications, the body mass index (BMI) change and the alteration of quality of life.

RESULTS

The most frequent early complication is the ischemic necrosis (7%) without posterior repercussion. The late complications in frequency order are: peristomal dermatitis (18%), plane stoma (12%), peristomal hernia (12%), stenosis (9%) and granuloma (6%). The BMI changes don't conditionate a increase in the complications. The psychological adaptation is good in 92%, although the majority affirm a little changes in life-style, but they don't have a repercussion on quality of life.

CONCLUSIONS

In this series we estimate a low incidence of complications. The preoperative counsel and the posterior following by the stoma care nurse-surgeon team, play a fundamental role on psychological adaptation after surgery.

Doxazosina en formulación de liberación retardada en la retención aguda de orina por hiperplasia benigna de próstata. acción del incremento de dosis sobre el efecto rescate

OBJECTIVE

Prospective and randomised study to assess the effectiveness of doxazosin in sustained release formulation in Acute Urinary Retention (AUR) treatment due to benign prostatic hyperplasia (BPH).

MATERIAL AND METHODS

The trial was carried out with a cohort of 40 males who had all suffered their first attack of AUR caused by BPH. Twenty were randomly selected and treated for 7 days with 4 mg of sustained release doxazosin before removing the catheter. The patients not treated that could not spontaneously urinate were also administered 4 mg of doxazosin. Finally, all the patients that still had a catheter due to unsuccessful removal were treated with 8 mg of doxazosin and the percentage of patients responding to treatment was assessed. The predictive value of the response to treatment for age, IPSS, QoL, retained urine volume, prostate volume and the evolution time of the prostratism was determined by means of logistic regression analysis.

RESULTS

82.5% of the patients (33/40) could urinate after removal of the catheter. 84.8% (28/33) were treated with doxazosin (21 with 4 mg and 7 with 8 mg). In the first attempt at removal, 60% of the patients (12/20) treated with 4 mg of doxazosin could spontaneously urinate, while only 25% (5/20) of those not treated, p=0.02. Similarly, 60% of the patients (9/15) treated with 4 mg of doxazosin in the second attempt could spontaneously urinate. Fifty per cent (7/14) of the patients still with a catheter, after the treatment with 4 mg of doxazosin, could urinate with 8 mg. In the logistic regression analysis, none of the variables analyzed allowed us to predict the response to the treatment.

CONCLUSION

The treatment for 7 days with 4 mg of sustained release doxazosin shows greater success when removing the catheter after suffering AUR due to BPH. With this treatment, 60% of the patients could spontaneously urinate again. By increasing the dose to 8 mg, the catheter can be removed in half the patients that did not initially respond. Before removing the catheter it is not possible to predict which patients would be able to spontaneously urinate.

[Cystectomy in superficial bladder tumours. Analysis of criterion include and prediction factors]

INTRODUCTION

Though usually the treatment of a superficial bladder tumour consists in transurethral resection, exceptionally because of several clinical conditions, in this kind of patients a radical cystectomy may be suitable.

PATIENTS AND METHOD

From june 1986 through december 2001, 127 radical cystectomies were performed. A series of 25 patients with a radical cystectomy performed in superficial bladder tumours were analysed. Indications, anatomo-pathological correlation and clinical evolution with survival curves are analysed.

RESULTS

The mean time of follow-up was 47 months. Extensive GIIIpT1 tumours (40%) were the chief indication. The remaining of the series consisted in carcinoma uncontrollable by endoscopy and refractory to chemotherapy. Anatomo-pathological correlation coincided in 48% of patients, existing supra and understaging in 25% and 28% respectively. A period of 54 months was without relapse. Seven patients died during the evolution (28%), and 18 patients are alive without disease. 128,48 months were the mean actuarial survival.

CONCLUSIONS

GIIIpT1 tumours were the chief indication of our series. The significant percentage of understaging, poor morbidity and good survival curves are emphasized. Because of these results we consider that radical cystectomies are a viable choice for selected patients with superficial vesical tumour.

[Cystoscopic impression versus histologic diagnosis in bladder tumors. Do they coincide?]

OBJECTIVE

How quality control in a university hospital and immediatly after to resents publications; we planed to evaluation of the correlation of cystoscopy impression with the histologic diagnosis after of transurethral resection (TUR).

MATERIAL AND METHODS

To give more truthfulness to the study, we requested to all department member's, that to base in your experience to describe the endoscopic characteristic of the next bladder tumors groups: superficial and low-grade GI-II Ta, superficial and high-grade GIII Ta and high grade and/or T1-< T2. In a total of 172 patients, we evaluated the initial cystoscopy impression and we to compared it with histologic diagnosis after to TUR.

RESULTS

In 172 tumors the cystoscopy classifed in 69 cases how superficial and low grade GI-II Ta-T1, 40 how superficial and high grade and 55 how high grade and/or invasive tumors GIII T1-< T2. When, we compared it with the histologic diagnosis, the cystoscopy to coincided in 46 de 69 cases (66.6%) (PNS) with the group of low-grade GI-II Ta-T1 in 13 of 40 (32.5%) (P < 0.005) with the group of superficial high grade GIII Ta and 45 of 51 (88.2%) (PNS) with the group of GIII T1 and/or invasive tumors. In 15 of 172 the endoscopic description its not conclusive. And finally in 12 cases the histologic diagnosis were normal.

CONCLUSIONS

In order of this results, we to consider that in a university hospital is essential the histologic diagnosis before any therapeutic decision, because the initial cystoscopy impression have a low correlation with the histologic diagnosis. We are disagreement with recent publication that propose the outpatient cystoscopy with fulguration to base only to the cystoscopy impression.

[Effect of antibiotic treatment on PSA and percentage of free PSA in patients with biochemical criteria of prostatic biopsy]

INTRODUCTION

PSA serum level measurement in the most important tool in the early diagnosis of prostate cancer patients. However, it is recognised it low specificity is due mainly to prostatic benign diseases. Although it is known that inflammation can contribute on this lack of specificity, there is disagreement in the effect of no symptomatic prostatic inflammatory focus on total PSA and percent free PSA serum levels.

AIM

To analyse the biological variability in total PSA and percent free PSA serum levels in patients with biochemical criteria of prostatic biopsy and to compare them with the antibiotic induced variability in a previous urinary infections cohort patients.

PATIENTS AND METHODS

We analysed 60 patients with previous urinary infections, normal digital rectal examination and PSA between 4 and 20 ng/ml. We measured total PSA and percent free PSA serum levels. Thirty were treated with 3 weeks of ofloxacin and following a new marker determination. Sextant ultrasound guided prostatic biopsy was performed in all cases.

RESULTS

45 patients demonstrated BPH (29 with prostatitis) and 15 prostate cancer (T1c). Significant variations were found on total PSA serum levels (6.97 ng/ml vs 5.82 ng/ml, p = 0.001) and percent free PSA (14.73% vs 17.77%, p = 0.01) only in treated patients. These differences were significant in BPH and BPH with prostatitis patients but not in prostate cancer patients. Treated patients trend was to decrease PSA (13 treated patients shown PSA < 4 ng/ml vs 2 control patients) and to increase percent free PSA. The median variation of percent free PSA was higher than total PSA and was not influenced by PSA level or prostatic volume. Taking 25 as cut-off of percent free PSA, 18.3% of prostatic biopsies could be avoided in the first determination and 20% in the second. Adding the total PSA reduction, 56% of prostates biopsies in the treated patients could be avoided.

CONCLUSIONS

Biochemical criteria of prostatic biopsy could be modified in patients with previous urinary infections due to higher variations on serum markers than those explained by biological variations. These variations could be induced by the antibiotic treatment. These results suggested that the inflammatory focus could influence on total PSA and percent free PSA serum levels.

[Vesico-sphincter dysfunction in 108 cases of multiple sclerosis]

OBJECTIVE

To study vesicosphincteric dysfunction in 108 patients with multiple sclerosis.

METHODS

We reviewed the clinical records of 108 patients with multiple sclerosis and analyzed those with voiding symptoms ascribable to multiple sclerosis. These patients underwent complete urodynamic assessment and complementary tests according to their symptoms. The Blaivas classification was used for the clinical classification of multiple sclerosis.

RESULTS

64 of the 108 patients presented voiding symptoms ascribable to multiple sclerosis (59.2%). The clinical features presented as episodes in 75% and were progressive in 25% of the cases. In 6% of the patients, the voiding symptoms were the first symptoms of multiple sclerosis. Urodynamic assessment showed detrusor hyperreflexia in 73% of the patients, hyporeflexia in 14%, and 13% showed normal urodynamics. All complications were infective; no patient showed upper urinary tract complications.

CONCLUSIONS

Vesicosphincteric dysfunction in multiple sclerosis is frequent. Most of the patients present bladder hyperreflexia. The urological complications are usually infective. Involvement of the upper urinary tract is rare.

[Anemia and neoadjuvant hormone therapy in radical surgery of localized cancer of the prostate]

RATIONALE

Erythropoiesis is stimulated by androgens either through a direct action on bone marrow cells or through increased erythropoietin production. Androgen deprivation is a known cause for anaemia. The aim of this study was to evaluate the effect of neoadjuvant hormone therapy prior to radical surgery on haemoglobin (Hb) and haematocrit (Ht) levels in localised prostate cancer.

MATERIAL AND METHOD

47 patients with clinical localised prostate cancer were given LH-RH analogs plus flutamide for complete androgenic blockade (CAB) for at least 3 months prior to radical prostatectomy. A blood profile was obtained prior to start CAB and 3 months after therapy, and peri-operative transfusional requirements were evaluated. To assess any significant changes. Student's t test was used in the statistical analysis of paired data.

RESULTS

In our study all patients (100%) showed decreased Hb and Ht levels after 3 months on CAB. Mean decline for Hb was 1.9 g/dL (range 1.6-2.2) p:0.0001, and for Ht 5.8% (range 4.8-6.8) p:0.0001. Hb was lower than 12 g/dL in 10.6% patients after hormone therapy and anaemia results were normocytic-normochromic. 60% patients needed peri-operative blood transfusion, 2 units of packed cells on average.

CONCLUSIONS

Neoadjuvant CAB prior to radical prostatectomy results in a significant decline of Hb and Ht levels after 3 months treatment. Such decline may contribute to increase peri-operative transfusional requirements in a group of patients undergoing aggressive surgery which in itself involves a significant blood loss.

[Analysis of biologic changes in PSA blood concentration and free PSA percentage in patients with normal rectal digital examination]

OBJECTIVE

To study intra-individual variations in serum PSA and percent free PSA in patients with normal digital rectal examination.

MATERIAL AND METHODS

Analysis of changes in serum PSA levels and percent free PSA in two blood measurements conducted in 107 non-consecutive patients prior to prostate biopsy, over a period of time ranging from 23 to 60 days. Both total and free PSA were measured with two dual monoclonal antibody assays, Tandem-E and Tandem-R, Hybritech. Diagnosis was benign hyperplasia in 63 patients and cancer in 44.

RESULTS

PSA variations ranged between -6.8 and +3.2 ng/ml in BPH patients, and between -2.8 and +9.0 when cancer was detected. The median coefficient of variation was 15.4 and 15.7, respectively. Variations in percent free PSA ranged between -30.7 and +40.9 in the BPH group and between -17.9 and +15.8 in the cancer group. The median coefficient of variation was 32.2 and 32.3%, respectively. Should prostate biopsy had been indicated when percent free PSA was equal to or lower than 25 in the 4 to 10 ng/ml PSA range, 15% patients would have exhibited discrepancies. Sensitivity would have ranged between 100 and 94.4%, with a reduction rate in negative biopsies between 16.6 and 19.4%.

CONCLUSIONS

Intra-individual variations in serum PSA levels and percent free PSA may condition the decision of whether to perform a prostate biopsy.

[Extragonadal germ-cell tumors located in the mediastinum]

INTRODUCTION

The extragonadal germ-cell tumors (EGGCT) represent 5% of all germ-cell tumors at presentation. Histologically, they are identical to testis germ cell tumors. They may arise in such sites as the mediastinum, retroperitoneal area, sacrococcygeal area, or pineal area without a primary in the testis.

MATERIAL AND METHODS

The medical records of 10 patients with mediastinal EGGCT were reviewed between 1973 and 1996. All patients were males and his mean age was 26.7 years old (21-24). Follow-up was 19 months (3-72).

RESULTS

The first symptoms are diverse. The histology results nonseminomatous tumor at 9 patients and seminomatous tumor at the restant. All of the scrotal examination was normal and only five patients presented increased tumoral markers (alpha-FP in 4 and beta-HCG in 1). Previous at 1990 didn't exist a standard treatment, resulting the four patients treated in this period exitus. After 1990 the treatment was cisplatin-based chemotherapy: BEP (bleomicyn, etoposide-VP-16- and cisplatin-CDDP) then we obtained the best results, a patient died after 6 months but the restants five are alive and without evidence of disease during a follow-up between 3 and 72 months.

[Antiandrogen suppression syndrome in patients with hormone-resistant cancer of the prostate]

OBJECTIVE

To analyze the evolution of serum prostate specific antigen (PSA) levels and the clinical response following the suppression of the antiandrogen in patients with metastatic prostate cancer who undergo complete androgen blockade in a hormone refractory status.

MATERIAL AND METHODS

19 patients were evaluated. Following flutamide suppression, their PSA serum levels were measured monthly and the subjective clinical response assessed. Additionally, the objective clinical response was also assessed at three months.

RESULTS

In 11 patients (57.9%), PSA serum concentration continued to increase and no clinical response was seen in any of them. In the 8 remaining cases (42.1%) there was a decrease in PSA serum levels ranging between 2.1 and 84.5%; this decrease was greater than 50% in 5 patients (26.3%). Mean duration of the biochemical response was 4.5 months (2-11). Subjective clinical responses were reported in 5 patients (26.2%), while an objective clinical response was seen in 2 (10.5%) cases who had PSA reductions greater than 50% and were maintained for periods of over 6 months.

CONCLUSIONS

Antiandrogen suppression in patients with hormone refractory prostate cancer with complete hormone blockade, can result in considerable albeit short biochemical and clinical responses. For this reason, this should be considered as the first therapeutical approach, whereas in responder patients any other second line treatment could be delayed until a new PSA increase or symptomatic worsening is detected.

[Polypoid cystitis, isolated lesion with a unique presentation]

OBJECTIVES

To report on an uncommon case of polypoid cystitis.

METHODS/RESULTS

The patient had consulted because urinary stream was suddenly interrupted due to a mass protruding into the urethral meatus. The US, IVP, cystoscopic and pathological findings are documented. The literature on polypoid cystitis is briefly reviewed with special reference to its forms of presentation and the pathological findings which permit making the differential diagnosis from other pathologies, the most important being transitional cell papillary carcinoma.

CONCLUSIONS

An uncommon case of cystitis is described, which emphasizes the varied forms of presentation of this condition and the need to distinguish this lesion from other pathologies, particularly bladder carcinoma.

[Two new Leydig cell testicular tumors presenting with gynecomastia in adults]

Presentation of two cases of Leydig cell tumor in adult patients who presented with gynecomastia, and slightly abnormal hormonal profiles. One patient had a non palpable tumor. The pathophysiology of this entity is commented, as well as the importance of the different modalities in its diagnosis.

[Preliminary results of a phase II randomized controlled trial comparing M-VAC and M-CAVI in patients with bladder cancer (T2-4 N0-1 M0)]

OBJECTIVES

The combination of carboplatin, methotrexate and vinblastine (M-CAVI) is an active and well-tolerated regimen for patients with bladder cancer who are ineligible for cisplatin-based regimens. We have prospectively randomized patients with locally advanced (T2-4 N0 M0) or locoregional (Tx N1 M0) bladder cancer suitable for subsequent surgical treatment to M-VAC or M-CAVI chemotherapy.

METHODS

M-CAVI consisted of carboplatin (300 mg/m2 on day 1 and later adjusted to 4.5 mg/dl/min according to Calvert's formula), methotrexate (30 mg/m2 on days 1, 15 and 22) and vinblastine (3 mg/m2 on days 1, 15 and 22). After 3-4 cycles, the patients were assessed for surgical resection.

RESULTS

To date, 60 patients have been included. There were 58 completely evaluable patients, 27 were randomized to M-VAC and 31 to M-CAVI. The overall response rates were similar for M-VAC (48%; confidence interval 95%, 26%-67%) and M-CAVI (45%; confidence interval 95%, 28%-62%). The pathological complete responses were similar for the M-VAC and M-CAVI regimens for both the group with locally advanced (27% vs 39%, p = NS) and locoregional (14% vs 14%, p = NS) bladder cancer. The median actuarial survival for the M-VAC treated group was 23 months and 18 months for the M-CAVI. M-VAC therapy was statistically significantly associated with more events of granulocytopenic fever, grade 2-3 nausea and vomiting, grade 2 alopecia and grade 3-4 mucositis.

CONCLUSIONS

The results achieved in the 60 patients included in the study indicate that M-CAVI is better tolerated than M-VAC, although both treatment regimens have similar overall response rates, pathological response rates and survival in patients with locally advanced and locoregional bladder cancer.

[Acquired urethral diverticulum in males with spinal cord injury]

OBJECTIVES

To study the clinical features, etiology, diagnostic methods and therapeutic possibilities in male patients with medullary lesion presenting with acquired urethral diverticulum.

METHODS

A retrospective study was conducted on patients seen in our department over the past twenty years (June, 1974 to June, 1994) for acquired urethral diverticulum. Ten patients have been treated for the foregoing condition.

RESULTS

The etiology of the medullary lesion was traumatic injury in 7 cases and spina bifida in 3 cases. The most frequent cause of the acquired urethral diverticulum was a condom-like urinary collecting device associated with a septic factor. Three patients presented intradiverticular lithiasis. These 3 patients had previous or current lithiasis at other sites of the urinary tract and all of them had a condom-like collecting device. All patients underwent surgery consisting in diverticulectomy and lithectomy, when required. One patient had a recurrence 6 years later because the underlying factors causing the diverticulum were still present.

CONCLUSIONS

Personal care and hygiene of patients with medullary lesion is one of the most important factors in preventing urethral injuries. In our view, patient follow-up should include regular radiologic assessment and correct training in the use of condom-like urinary collecting devices and urinary catheters. We advocate one-stage surgical repair with temporary cystostomy, preoperative antibiotic therapy according to the antibiotic profile and culture of symptomatic and asymptomatic urinary infections and the use of methylene blue to ensure the suture is watertight.

[A vesicoileal fistula secondary to bladder cancer]

Exposition of one case of vesico-ileal fistula with atypical presentation and infrequent etiology, secondary to transitional cell vesical carcinoma. The incident is exploited to review the etiology of acquired enterovesical fistulae.

[The urological complications of anticoagulant therapy]

Patients on anticoagulant therapy may develop urologic complications, the most common being hematuria. Other less common but more severe complications are spontaneous hemorrhage arising from urological structures, as spontaneous perirenal hematoma, or from extra-urological structures, such as the iliac psoas muscle or the anterior rectus abdominis muscle. We report on four patients on anticoagulant therapy for different reasons, with no previous history of trauma, who suddenly developed spontaneous bleeding with urologic consequences: spontaneous perirenal hematoma (2), hematoma of the iliac muscle (1) and the anterior rectus abdominis muscle (1). The diagnostic strategy, the usefulness of the different imaging techniques and our approach to these complications are discussed.

[Attitudes towards the profession of medical students of the University of Navarra]

A recent sounding hold among the medicine students of the Navarra University provided us sufficient information about some aspects of this profession and the evolution that might suffer through the career time. The enquiry used 534 students of different grades. The deep and the up-to-date technical training is considered a fundamental characteristic of the good professional though the hospital medicine is the most desirable working option. However, the improvement of the present sanitary situation pass obligatorily--as stated by the inquirees--by the impulse to the primary medicine.