Electrical property sensing biopsy needle for prostate cancer detection

BACKGROUND

Significant electrical property differences have been demonstrated to exist between malignant and benign prostate tissues. We evaluated how well a custom designed clinically deployable electrical property sensing biopsy needle is able to discriminate between these tissue types in an ex vivo prostate model.

METHODS

An electrical impedance spectroscopy (EIS) sensing biopsy (Bx) needle was developed to record resistive (ρR) and reactive (ρX) components of electrical impedance from 100 Hz to 1 MHz. Standard twelve-core biopsy protocols were followed, in which the EIS-Bx device was used to gauge electrical properties prior to extracting tissue cores through biopsy needle firing from 36 ex vivo human prostates. Histopathological assessment of the cores was statistically compared to the impedance spectrum gauged from each core.

RESULTS

The magnitudes of the mean resistive and reactive components were significantly higher in cancer tissues (P < 0.05). ROC curves showed that ρR at 63.09 kHz was optimal for discriminating cancer from benign tissues; this parameter had 75.4% specificity, 76.1% sensitivity, and ROC AUC of 0.779. Similarly, 251.1 kHz was optimal when using ρX to discriminate cancer from benign tissues; this parameter had a 77.9% specificity, 71.4% sensitivity, and ROC AUC of 0.79.

CONCLUSION

Significant electrical property differences noted between benign and malignant prostate tissues suggest the potential efficacy an EIS-Bx device would provide for cancer detection in a clinical setting. By sensing a greater fraction of the prostate's volume in real-time, the EIS-Bx device has the potential to improve the accuracy of cancer grading and volume estimation made with current biopsy procedures.

Phase I pilot trial of the bispecific antibody MDXH210 (anti-Fc gamma RI X anti-HER-2/neu) in patients whose prostate cancer overexpresses HER-2/neu

The goal of this study was to evaluate, in patients with prostate cancer, the toxicity profile and biologic activity of the bispecific antibody MDXH210, which has specificity for the non-ligand-binding site of the high-affinity immunoglobulin G receptor (Fc gamma RI) and the extracellular domain of the HER-2/neu proto-oncogene product. Patients with prostate cancer that expressed HER-2/neu were entered into a phase I dose-escalation trial of MDXH210. Patients received an intravenous infusion MDXH210 during a period of 2 h three times per week for 2 weeks and were monitored for toxicity. Pharmacokinetic and pharmacodynamic parameters were measured and included the biologic end points of monocyte-bound MDXH210, cytokine production, and clinical response. Seven patients were treated with MDXH210 doses ranging from 1 to 8 mg/m2. In general, MDXH210 was well tolerated, with only mild infusion-related malaise, fever, chills, and myalgias. No dose-limiting toxic effects were observed. Biologic effects included induction of low plasma concentrations of tumor necrosis factor-alpha and interleukin-6 observed immediately after MDXH210 infusion and 70% saturation of circulating monocyte-associated Fc gamma RI with MDXH210 at a dose level of 4 to 8 mg/m2. Five of six patients had stable prostate-specific antigen levels during the course of 40 days or more. Circulating plasma HER-2/neu levels decreased by 80% at days 12 and 29 (p = 0.03 and 0.06, respectively, by the Wilcoxon signed rank test). MDXH210 can be given safely to patients with HER-2/neu-positive prostate cancer in doses of at least 8 mg/m2. At the doses studied, biologic activity was demonstrated and characterized by binding of MDXH210 to circulating monocytes, release of monocyte-derived cytokines, a decrease in circulating HER-2/neu, and short-term stabilization of prostate-specific antigen levels.

A randomized phase II trial comparing two different sequence combinations of autologous vaccine and human recombinant interferon gamma and human recombinant interferon alpha2B therapy in patients with metastatic renal cell carcinoma: clinical outcome and analysis of immunological parameters

PURPOSE

The clinical observation of spontaneous regression in patients with renal cell carcinoma (RCC) and the response to various immunotherapeutic therapies strongly suggest a role for the host immune system in this disease. Prior studies showed that sequential administration of interferon (IFN) gamma and IFN alpha to RCC patients was safe. Clinical responses as well as immune changes in the peripheral blood mononuclear cell compartment were observed. Autologous tumor cell vaccines (AV) have also demonstrated activity in renal cell carcinoma. We hypothesize that the addition of AV to sequential IFN gamma and a therapy might improve the tumor-specific immune response by providing an appropriate source of antigen in the appropriate cytokine environment. To our knowledge, this is the first trial using AV combined with IFN alpha and IFN gamma. The purpose of this study was to evaluate the feasibility of manufacturing and administering (AV) from resected tumor samples, and administration of AV with combination IFN gamma and IFN alpha therapy. Finally, the impact on immunological parameters of these treatment options was assessed.

MATERIALS AND METHODS

Patients with metastatic RCC were randomly assigned to receive AV plus bCG along with a sequential administration of IFN gamma and a either together or after initiation of vaccine. Toxicity and clinical responses were evaluated. Modulations of the immune system were investigated by analyzing phenotype, cytokine mRNA expression, T cell proliferation and cytotoxicity in the peripheral blood mononuclear cell compartment.

RESULTS

Fourteen patients with metastatic renal cell carcinoma were enrolled in this study; 9 were available for response evaluation. In a 70 day period, 3 (33%) showed mixed responses, 5 (56%) stable disease and 1 (11%) progression of disease. Toxicities were consistent with previous clinical reports. In the flow-cytometry phenotype analysis, stimulation of distinct subsets of circulating T-lymphocytes and a decrease of CD8+ T cell subsets was demonstrated. T-cell proliferation to allogeneic tumor cell stimulation improved following treatment. IL-4 and IL-5 mRNA levels were reduced in all patients after treatment. Patients who responded to treatment did not produce any IL-4 mRNA at all, before or after treatment.

CONCLUSIONS

AV with IFNgamma and IFNalpha therapy might induce a MHC class-mediated cytotoxic T lymphocyte (CTL) response. We suggest that adequate therapy might direct T cell response toward a Th1 type response. We hypothesize a state of improved immune readiness in patients who might eventually respond to immunotherapy.

The effect of hospital volume on mortality and resource use after radical prostatectomy

PURPOSE

The value of radical prostatectomy for patients with prostate cancer depends on low morbidity and mortality. We assessed whether patient outcome is associated with how many of these procedures are performed at hospitals yearly.

MATERIALS AND METHODS

Using the Nationwide Inpatient Sample, which is a stratified probability sample of American hospitals, we identified 66,693 men who underwent radical prostatectomy between 1989 and 1995. Cases were categorized into volume groups according to hospital annual rate of radical prostatectomies performed, including low-fewer than 25, medium-25 to 54 and high-greater than 54. We performed multivariate logistic regression to control for patient characteristics when assessing the associations of hospital volume, in-hospital mortality and resource use.

RESULTS

Overall adjusted in-hospital mortality after radical prostatectomy was relatively low (0.25%). However, patients at low volume centers were 78% more likely to have in-hospital mortality than those at high volume centers (adjusted odds ratio 1.78, 95% confidence interval 1.7 to 2.6). Overall length of stay decreased at all hospitals between 1989 and 1995. However, average length of stay was longer and total hospital charges were higher at low than at high volume centers (7.3 versus 6.1 days, p<0.0001, and $15,600 versus $13,500, p<0.0001, respectively).

CONCLUSIONS

Hospital volumes inversely related to in-hospital mortality, length of stay and total hospital charges after radical prostatectomy. Further study is necessary to examine the association of hospital volume with other important outcomes, including incontinence, impotence and long-term patient survival after radical prostatectomy.

Trends in the use of radical prostatectomy for treatment of prostate cancer

CONTEXT

The incidence of prostate cancer and rates of radical prostatectomy increased sharply in the Medicare population (men older than 65 years of age) after the introduction of prostate-specific antigen screening in the late 1980s.

PRACTICE PATTERN EXAMINED

Trends in age-specific rates of use of radical prostatectomy in U.S. men between 1989 and 1995.

DATA SOURCE

The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program.

RESULTS

Overall, rates of radical prostatectomy more than doubled between 1989 and 1992 (from 78 per 100,000 men to 206 per 100,000 men) but decreased by a third between 1992 and 1995 (to 146 per 100,000 men). The pattern in overall radical prostatectomy rates between 1992 and 1995, however, obscures changes that occurred for men in different age groups. Decreases in radical prostatectomy rates were most dramatic in elderly persons, dropping 51% in men 70 to 74 years of age and 71% in men 75 years of age or older. In contrast, rates in younger men continued to increase between 1992 and 1995, rising 42% in men 45 to 49 years of age and 18% in men 50 to 54 years of age. In each age group, trends in surgery rates mirrored trends in cancer detection rates.

CONCLUSIONS

Surgical treatment of prostate cancer in older men is decreasing; however, surgery rates are increasing in younger men. These divergent trends reflect the pattern of prostate cancer detection in clinical practice.

In vivo description of dendritic cells in human renal cell carcinoma

PURPOSE

Dendritic cells (DCs) are efficient and effective antigen-presenting cells that play a major role in initiating the primary immune response. They are the most potent stimulators of T-cell activation and would thus be expected to be of great importance in the antitumoral immune response. Although DC phenotype and function have been described under in vitro conditions, their in vivo characteristics are less well detailed. Human renal cell carcinoma (RCC) is an excellent model to explore tumor infiltrating dendritic cells (TiDCs) because of rare clinical spontaneous regressions and the association of high numbers of tumor infiltrating lymphocytes (TiLs), suggesting a strong immune response.

MATERIALS AND METHODS

We determined the in situ phenotype of mature CD83+ TiDCs using monoclonal antibodies to known activation molecules (CD86 [B7.2], CD80 [B7.1], CD40, CD54, CD1a and HLA-DR). Seventeen primary RCCs, representing four distinct histologies, were evaluated using double-staining immunohistochemical techniques and light microscopy.

RESULTS

CD83+ TiDCs were found in all tumors. Expression of CD40 correlated with expression of CD1a on CD83+ TiDCs. Expression of CD54 (ICAM-1) correlated with a lower expression of CD86 (B7.2) as well as a decrease in CD3+ and CD8+ TiLs.

CONCLUSIONS

These data suggest a de novo lipid or sugar-based immunogenic antigen presentation by TiDCs. Also, the data support an impaired antigen-presenting capability for CD54+ TiDCs based on the decreased coexpression of CD86 (B7.2) and the decrease of associated CD8+ TiLs.

Vulvar metastases secondary to transitional cell carcinoma of the bladder. A case report

BACKGROUND

Gynecologists are frequently asked to evaluate patients with vulvar lesions. Although the differential diagnosis of a vulvar lesion is varied, the main concern is to rule out a vulvar malignancy. Primary vulvar carcinoma is uncommon, and a metastatic cancer from an extragenital site involving the vulva is even more rare.

CASE

A 78-year-old woman with a history of a transitional cell carcinoma (TCC) of the bladder presented with two painful vulvar lesions, which represented the first manifestation of metastatic disease. This is the fifth reported case of TCC from the bladder with metastases to the vulva.

CONCLUSION

The differential diagnosis of a vulvar lesion, especially in a woman with a prior history of renal tract malignancy, should include metastatic lesions.

Expression of Fas(APO-1/CD95) in tumor-infiltrating and peripheral blood lymphocytes in patients with renal cell carcinoma

The functional expression of Fas-ligand on tumor cells reported in a variety of neoplasms has been proposed by several groups as a mechanism of tumor escape from immunological detection. To better support this hypothesis, we have evaluated and quantified for the first time the presence of the Fas(CD95)-R molecule on tumor-infiltrating lymphocytes and on matched peripheral blood lymphocytes (PBLs) of renal cell cancer patients. By two-color flow cytometry we have detected a significant increase in the Fas(CD95)-R expression on tumor-infiltrating lymphocytes compared with matched patient and normal volunteer PBLs. We also observed a decreased expression of the Fas(CD95)-R expression on PBLs from renal cell cancer patients compared with normal healthy controls. The Fas(CD95)-R expression was observed predominantly on the CD4+ subset in all three groups. These different distributions of the Fas(CD95)-R molecule support the hypothesis that the Fas(CD95)-R/Fas(CD95)-L pathway and tumor microenvironment play a major role in the modulation of T-cell function and differentiation to either memory and activation or apoptosis.

T-cell receptor zeta-chain expression on tumor-infiltrating lymphocytes from renal cell carcinoma

Loss of the T-cell receptor-associated zeta chain in tumor-infiltrating lymphocytes (TILs) has been proposed as one mechanism of acquired immunosuppression in cancer patients. Recent reports suggest that zeta-chain loss may be related to contaminating monocyte/macrophage protease activity. Using flow cytometry and Western blot analysis, we have confirmed the expression of zeta chain in matched peripheral blood mononuclear cells and TILs from eight patients with primary renal cell carcinoma, when the cells were exposed to sufficient quantity of protease inhibitors. A small decrease in zeta-chain expression was found in three TIL samples. The loss of zeta-chain expression that was noted by others may be related to differences in laboratory method, and the small changes we have noted are unlikely to be sufficient in explaining the immunosuppression of TILs.

Adrenal insufficiency from bilateral adrenal hemorrhage after total knee replacement surgery

Adrenal hemorrhage is a rare cause of adrenal insufficiency in adults. We examine the incidence, etiology, diagnosis, and therapy of adrenal insufficiency secondary to adrenal hemorrhage. This case illustrates the nonspecific presentation of adrenal insufficiency and the necessity of maintaining a high index of suspicion in a clinically confusing scenario.

Prospective development of a cost-efficient program for the pubovaginal sling

OBJECTIVES

We designed and implemented a cost-containment program for patients undergoing a pubovaginal sling procedure. We sought to test the hypothesis that preoperative patient education could reduce the length of hospital stay in these patients. Our goal was to decrease hospital charges while maintaining quality of care.

METHODS

A multidisciplinary group of clinic and hospital staff identified factors that contribute to a patient's hospital charges for a pubovaginal sling procedure. A program of preoperative patient education to teach intermittent self-catheterization was combined with the elimination or control of items considered unnecessary to the delivery of safe, efficient care. Patient care was standardized from the preoperative visit to discharge planning. The difference in the mean values of 38 prestudy patients was compared with 15 study patients with a Wilcoxon rank sum test.

RESULTS

Length of hospital stay was reduced from a mean of 2.8 to 1.1 days after implementation of the program (P < 0.0001). This decreased length of stay, combined with a reduction in routine laboratory studies (97% decrease; P < 0.0001), operating room charges (11% decrease; P < 0.01), and medications (35% decrease; P < 0.01), led to significantly reduced hospital charges. Total hospital charges decreased by 35%, from a mean of $4862 to a mean of $3153 (P < 0.0001). There was no increase in morbidity. Patient satisfaction with length of hospital stay did not change significantly following implementation of the program.

CONCLUSIONS

With a program of preoperative patient education combined with a critical review of the factors contributing to a patient's hospital charges, it is possible to implement a cost-efficient program for a pubovaginal sling, leading to a 35% reduction in mean total hospital charges. This approach directed toward other incontinence procedures could be expected to yield comparative results.

Tissue-shrinkage correction factor in the calculation of prostate cancer volume

Many studies that have calculated prostate cancer volumes from microscopic slides have used correction factors, ranging from 1.22 to 1.5, to compensate for tissue shrinkage during tissue processing. We undertook a study to measure tissue shrinkage directly because our experience suggested less shrinkage than that reported by others. Ten prostatectomy specimens were processed in a uniform manner. Multiple identical linear measurements were taken at four stages of processing: in the fresh state, following fixation, following processing, and from the microscopic slide. Linear shrinkage following fixation was minimal (4.1%) but increased to 14.5% following tissue processing. With rehydration and expansion on the flotation bath, tissues swelled so that net linear tissue shrinkage was 4.3%, and net volumetric tissue shrinkage was 12.4%, which translates into a correction factor for tissue shrinkage of 1.14. The following variables had no statistically significant effect on shrinkage: concentration of formalin, whole-mount versus quadrant sections, thickness of tissue slices, length of time in the alcohol dehydration steps, and temperature of the flotation bath over a range of 35 to 45 degrees C. This study suggests that (a) tissue-shrinkage correction factors that have been used in some previous studies may not be applicable for all laboratories because of interlaboratory variations in tissue-processing procedures or differences in measuring shrinkage; and (b) some calculated tumor volumes that have been used for prognostic thresholds may be high because of inflated tissue-shrinkage correction factors.

5-fluorouracil and allopurinol combined with recombinant interferon-alpha 2b in the treatment of patients with advanced prostate cancer: a phase I/II study

PURPOSE

We determined the toxicity and preliminary response rate of escalating doses of 5-fluorouracil (670 to 1,500 mg./m.2 per day) combined with a fixed dose of interferon-alpha 2b (5 million units) and allopurinol (300 mg. every 8 hours) in cohorts of patients with metastatic prostate cancer.

MATERIALS AND METHODS

The trial included 11 men with metastatic prostate cancer. Cohorts of patients received a 5-day constant infusion of 5-fluorouracil combined with subcutaneous interferon-alpha 2b 3 times weekly and allopurinol for 1 week during 5-fluorouracil infusion. Treatment was repeat every 3 weeks.

RESULTS

Of 10 patients evaluable for treatment response and toxicity 3 had a partial response as judged by significant decreases in prostate specific antigen measurements (mean followup 13.5 months). Significant dose limiting toxicities encountered included mucositis, diarrhea and leukoneutropenia.

CONCLUSIONS

Further evaluation of this treatment to determine overall response rates and benefit should take into consideration the significant toxicity experienced.

Fatal genitourinary mucormycosis in a patient with undiagnosed diabetes

We present what we believe is the first report in the world literature of penile necrosis due to mucormycosis, a rare and often fatal fungal infection. This case of rhizopus mucormycosis began with a penile lesion in a 27-year-old patient with undiagnosed diabetes; it led to necrosis of the phallus, lower urinary tract, rectum, and pelvic musculature and finally to death. Despite repeated aggressive surgical debridement in conjunction with medical therapy, we were unable to halt the progression of the fungal and synergistic bacterial infections.

Staging of prostate cancer with endorectal MR imaging: lessons from a learning curve

Endorectal magnetic resonance (MR) imaging is the most accurate noninvasive method of staging prostate cancer. However, inexperienced radiologists may lack the necessary technical and interpretative skills to use this technique, and both radiologists and referring urologists may become frustrated with this method because of its inaccuracy compared with analysis of the radical prostatectomy specimen. Meticulous pathologic correlation is necessary to evaluate endorectal MR imaging findings. The authors compare their initial experience using endorectal MR imaging for staging prostate cancer (25 cases) with their later experience (25 cases) to highlight the various diagnostic pitfalls and "pearls" one may encounter when using endorectal MR imaging. Knowledge of the pathways of tumor spread inside and outside the gland may be helpful in interpreting endorectal MR images. The authors achieved a substantial improvement in the overall staging accuracy of endorectal MR imaging by careful pathologic correlation and by considering the anatomic features of prostate cancer.

Surgical treatment of verrucous carcinoma of the bladder unassociated with bilharzial cystitis: case report and literature review

Verrucous carcinoma of the bladder unassociated with bilharzial cystitis is rare with only 6 cases reported to date. Verrucous carcinoma of the bladder, like that involving the cervix, vagina, oral cavity, perineum and lower extremities, may invade surrounding structures but remain surgically curable. Although it is similar to condyloma acuminatum, verrucous carcinoma is considered malignant because of its invasive growth pattern and it should be treated accordingly. However, no evidence of metastases has been noted to date. To our knowledge we report the first case of extravesical extension of verrucous carcinoma of the bladder that was treated successfully by surgical removal.

Metastatic renal cell carcinoma presenting as a skin nodule: case report and review of the literature

Cutaneous metastasis from renal cell carcinoma is unusual. A patient is described who presented with a solitary skin metastasis 6 months after unilateral radical nephrectomy for renal cell carcinoma. In most instances, once cutaneous involvement is manifest the disease is widespread and has a poor prognosis. The skin should be examined during tumor evaluation as part of the physical examination and skin lesions in patients with renal cell carcinoma should be evaluated aggressively to rule out cutaneous metastasis.

Diuretic renal scan: is it always reliable?

The differentiation between significant mechanical obstruction and nonobstructive dilation of the kidneys and ureters is fundamental to patient management. The diuretic renal scan is a useful test in this situation because it usually is reliable and reproducible and is noninvasive and objective, providing information about the function of each kidney. However, this study has given variable results in a small number of patients. We report our experience with five such patients and recommend an algorithm for evaluating patients with equivocal scan results. This report emphasizes the importance of continued follow-up and the need for periodic reevaluation of patients with unexplained urinary symptoms or persistent flank pain, even when the initial diuretic renal scan is normal.

Theoretical and experimental analysis of air cooling for intracavitary microwave hyperthermia applicators

An intracavitary microwave antenna array system has been developed and tested for the hyperthermia treatment of prostate cancer at Thayer School of Engineering and Dartmouth-Hitchcock Medical Center. The antenna array consists of a choked dipole antenna inserted into the urethra and a choked dipole antenna eccentrically embedded in a Teflon obturator inserted into the rectum. To prevent unnecessary heating of the healthy tissue that surrounds each applicator, an air cooling system has been incorporated into the rectal applicator. The air cooling system was designed and modeled theoretically using a numerical solution of heat and momentum equations within the applicator, and an analytical solution of the Pennes bioheat equation in tissue surrounding the applicator. The 3-D temperature distribution produced by the air-cooled rectal applicator was measured in a perfused canine prostate.

Respiratory distress following cesarean section: cryptic presentation of bladder injury

A case documenting the development of massive urinary ascites with associated pleural effusions and respiratory compromise due to an unrecognized cystotomy at the time of a tertiary low-vertical cesarean section is reported. The diagnosis was supported by elevated levels of serum blood urea nitrogen and creatinine and a peritoneal fluid to plasma creatinine ratio of 3:1. Imaging studies confirmed urinary extravasation into the peritoneum as well as bilateral pleural effusions and ascites. Primary intervention was to improve the patient's respiratory status and then to surgically repair the bladder wound.

Recurrent ileal conduit hemorrhage in an elderly cirrhotic man

One recognized complication of portal hypertension in a patient with an ileal urinary conduit is variceal hemorrhage. The definitive treatment for this rare complication is controversial. Local measures, sclerotherapy, stomal revision and various operative portacaval shunts have been described but they have had limited long-term success. Using a recently developed interventional radiological technique, a transjugular intrahepatic portosystemic shunt was created in a cirrhotic man who had recurrent massive ileal conduit variceal hemorrhage. After the procedure the patient experienced no further life threatening stomal hemorrhage. He died of hepatic failure 6 months later.

Psoas abscess following intravesical bacillus Calmette-Guerin for bladder cancer: a case report

An 87-year-old man with an abdominal aortic aneurysm received intravesical bacillus Calmette-Guerin therapy for transitional cell carcinoma of the bladder. He presented 9 months later with a psoas abscess that mimicked a contained retroperitoneal abdominal aortic aneurysm rupture. The abscess cultures yielded Mycobacterium bovis. Recent transurethral resection and high voiding pressures after instillations of bacillus Calmette-Guerin may have led to distant dissemination of the drug.

A coaxial microwave applicator for transurethral hyperthermia of the prostate

Benign prostatic hyperplasia (BPH) is a common disease of elderly men. The current definitive treatment for urinary obstruction caused by this disease is surgery (transurethral resection of the prostate, or TURP). Recent evidence suggests that hyperthermia may be a useful nonsurgical alternative for treatment of symptomatic BPH. A transurethral microwave applicator has been designed around a Foley catheter for delivery of local hyperthermia to the prostate. The Foley balloon is used to maintain the antenna position within the prostatic urethra. The Foley catheter also features an antenna choke to confine power deposition to the intended region. The antenna is a coaxial dipole designed to operate at 915 MHz. Qualitative and quantitative specific absorption rate (SAR) patterns are shown for this antenna. In vivo experiments in dog prostate demonstrate that temperatures > 42 degrees C can be obtained > 1 cm away from the catheter, while maintaining a maximum urethral temperature of 47 degrees C to 48 degrees C. Histology obtained acutely after the hyperthermia treatments showed minimal damage to the periurethral tissues. We conclude from these studies that this microwave applicator is capable of providing local hyperthermia to the prostatic tissues with a predictable and well-circumscribed thermal distribution.

Continuous infusion of intrathecal morphine to control acquired immunodeficiency syndrome-associated bladder pain

A 36-year-old man with acquired immunodeficiency syndrome had incapacitating dysuria and vesical pain secondary to interstitial cystitis. When medical management and suprapubic urinary diversion failed to control the symptoms the patient was started on subarachnoid morphine sulfate. Bupivacaine was added 1 year later via an implanted Therex M-3000 implantable continuous infusion pump, which has continued successfully for more than 18 months. We believe that subarachnoid narcotics and other analgesic agents, such as clonidine, bupivacaine hydrochloride and baclofen, may prove equally valuable in the treatment of bladder spasm and pain. Furthermore, implanted intrathecal ports and pumps may have less associated risk of infection than the percutaneous vascular access catheters presently used for the continuous delivery of medications in immunosuppressed patients.

Hemorrhagic myelolipoma of adrenal gland after blunt trauma

A case of adrenal myelolipoma is reported in a patient in whom symptoms of hematuria and flank pain developed after the patient had sustained blunt trauma. Adrenal myelolipomas are usually found incidentally at autopsy. However, the symptomatic presentation of this patient was probably caused by traumatic intratumor hemorrhage. The etiology and pathogenesis of these tumors are discussed in relation to their occasional symptomatic presentation and to their differential diagnosis.

Angiographic management of retroperitoneal hemorrhage from renal angiomyolipoma in polycystic kidney disease

Angiographic management of bilateral angiomyolipomas complicated by hemorrhage in autosomal dominant polycystic kidney disease is presented. The patient had mild stigmata of tuberous sclerosis, and a family history of tuberous sclerosis and autosomal dominant polycystic kidney disease. The radiographic features at diagnosis, and those present during and after embolization are described. Radiological criteria for diagnosis and successful control of bleeding with intra-arterial selective embolization are discussed. Radiographic features before, during and after embolization are exhibited.

MR and CT imaging of perirenal amyloidosis

The radiographic findings of perirenal amyloidosis have not previously been described. A patient with multiple myeloma and primary amyloidosis (AL) with secondary hydronephrosis as examined on plain film, retrograde ureteropyelography, computed tomography, and magnetic resonance imaging is presented. This case illustrates perirenal amyloidosis and demonstrates the utility of CT and MRI in patient management and surgical treatment.

Retroperitoneal leiomyosarcoma: a rare cause of adrenal pseudotumor on CT and MRI

Numerous causes of adrenal pseudotumors have been previously described based on computed tomography findings, (CT) with normal anatomical structures being more common causes than extraadrenal neoplasms. This case describes a rare retroperitoneal tumor: a primary vascular leiomyosarcoma arising from the renal hilus, which mimicked an adrenal malignancy on CT and magnetic resonance imaging.

Multifocal pigmentation of prostatic and bladder urothelium

Multifocal pigmentation of the bladder and prostatic urothelium is described in 2 white men. The light microscopic, electron microscopic and histochemical characterization of these foci identified the contained pigment as melanin.

Non-Hodgkin lymphoma arising in lower urinary tract

Primary involvement of the bladder and prostate by non-Hodgkin lymphoma is exceedingly rare. Usually bladder lymphoma can be cured by aggressive local therapy, but the prognosis of prostatic lymphoma is poor. The devastating clinical course of a young man with primary lymphoma involving the prostate and bladder base is reported to emphasize the heterogeneity of this group of tumors and to encourage precise tumor classification. Prognosis depends on the tumor stage and the specific lymphoma cell-type as defined by conventional histologic and immunologic criteria. Management should be tailored according to tumor grade, stage, and site.

Computed tomographic findings in renal angiomyolipoma: an histologic correlation

Accurate preoperative diagnosis of renal angiomyolipomas is essential if conservative resection or angiographic embolization is to be used. Computed tomographic (CT) scanning failed to diagnose angiomyolipoma preoperatively in 2 patients, and this led to a retrospective review of 6 patients to define the limits of CT scanning in preoperative diagnosis. The CT findings were correlated with the histology of the tumors. Two tumors with positive attenuation coefficients suggestive of renal adenocarcinoma had significant amounts of immature "fetal" fat, and one of these had a virtual absence of mature fat. The relative inability of CT scanning to identify immature "fetal" fat, especially in the presence of abundant vessel and muscle elements, is a limitation to its use in the preoperative diagnosis of angiomyolipoma. A negative attenuation coefficient is highly characteristic of renal angiomyolipoma with mature fat elements. A positive attenuation coefficient, although suggestive of renal cell carcinoma, may be found in angiomyolipomas with paucity of mature fat or high proportions of immature fat.

Nephrogenic adenoma and embryonic kidney tubules share PNA receptor sites

Nephrogenic adenoma a rare bladder, ureter, or urethral lesion, is of disputed pathogenesis, metaplastic and congenital etiologies both being implicated in its development. Since light and electron microscopy have been unable to fully resolve the lesion's pathogenesis, the authors used biotinylated lectins as probes and avidin-biotin peroxidase complex (ABC) as a visualant to study cases of nephrogenic adenomas and compared their lectin binding patterns with those of normal transitional epithelium, human embryonic kidneys, and cases of cystitis cystica and glandularis and squamous metaplasia of the bladder in an effort to clarify this issue. Only the epithelial lining of the luminal surface and tubuli in nephrogenic adenoma and tubules in embryonic kidney exhibited free PNA receptor sites. The striking staining similarities between the epithelial components of nephrogenic adenomas and mesonephric and metanephric tubules complement previous findings concerning the origin of nephrogenic adenoma.

Cell surface coat of human and rat bladder urothelium. I. Ruthenium-red studies in non-neoplastic and neoplastic cells

We have studied the ultrastructure of glycocalyx at the luminal surface of normal and diseased urothelium from humans and rats with ruthenium red staining. A correlation between the thickness and staining intensity of the glycocalyx and the surface topography of the luminal surface was observed. An intensely stained thick glycocalyx was associated with prominent surface microvilli seen in the following conditions in humans: some control urothelium, inverted papilloma, well and moderately differentiated transitional cell carcinomas and mucin producing adenocarcinomas. These changes were also present in rats with FANFT-induced preneoplastic and neoplastic changes. A thin glycocalyx was associated with a scalloped luminal surface containing asymmetric unit membrane plaques and was found in some control humans urothelium and in normal rat urothelium. A thin glycocalyx was also associated with the relatively smooth surface seen in poorly differentiated transitional cell carcinomas as well as in some mucin producing adenocarcinomas. We suggest that urothelial glycocalyx, as demonstrated by ruthenium red staining, correlates with the luminal surface topography rather than specific pathological conditions of the bladder.

Postoperative radiation therapy for muscle-invading bladder carcinoma

From 1974-1980, 15 patients with pT2-4 bladder carcinoma received adjuvant postoperative radiation therapy (XRT). The extent of initial surgery varied (six radical cystectomy, 5 partial cystectomy, four "total" transurethral resection). The planned XRT was 4,000-5,040 rads in 5-6 weeks to the pelvis (achieved in 14/15 patients) followed by a bladder boost in noncystectomized patients (achieved in 8/9). Survival at two years and five years was 54% (7/13 patients) and 27% (3/11 patients), respectively. Local-regional disease control (minimum two-year follow-up) was achieved in 7/11 (63%). Of seven patients alive at least two years later, small bowel complications (chronic diarrhea, obstruction) occurred in two; these latter patients each had had radical cystectomy. Adjuvant postoperative XRT may be useful in the multimodality management of patients with bladder carcinoma, especially those identified as high risk after pathologic staging and initial surgery. The poor regional control rate and relatively high incidence of complications seen in this and previous studies suggest that improved radiation technique is needed, both to ensure adequate coverage of the volume at risk and to minimize complications. Representative portals are shown to illustrate these features.

Acute leukemia: diagnosis and management of testicular involvement

Contemporary therapy of acute leukemia frequently achieves long-term continued complete remission (CCR) of bone marrow disease and prevents central nervous system relapse. However, accompanying improved survival is an increasing incidence of overt testicular relapse either during CCR or associated with bone marrow relapse. In 7 boys testicular abnormalities developed during CCR, 6 had open biopsy and 5 had histologically confirmed leukemic infiltration. Despite local therapy of orchiectomy or irradiation and chemotherapy reinduction, 2 of 6 had testicular relapse and 4 of 6 died. Three boys with coexistent overt testicular and systemic relapse died. Nine boys with normal testes had testicular biopsy during CCR prior to discontinuation of chemotherapy. Results of all biopsies were benign, but one boy had a relapse. The diagnosis of occult testicular leukemia prior to discontinuation of chemotherapy allows selection of high-risk boys requiring prolonged, intensive, and possibly alternative therapy. The indication for testicular biopsy in boys with acute leukemia is documented, and appropriate clinical management of testicular leukemia is presented.

Obstructive uropathy--a potentially serious complication of reconstructive vascular surgery

We treated successfully 3 patients with upper urinary tract obstruction after an aortoiliac reconstructive vascular operation: 2 with ureterolysis and 1 with transureteroureterostomy. A review of the literature reveals that the incidence of this complication of reconstructive vascular surgery is unknown. Obstruction occurred whether the ureter was anterior or posterior to the graft, and usually presented within 1 year postoperatively in 62 per cent of the patients and was silent in 13 per cent. The obstruction was caused by retroperitoneal fibrosis in 90 per cent of the patients, direct surgical injury in 5 per cent and pseudoaneurysm formation in 5 per cent. Prior pelvic irradiation, and extensive and/or repeat vascular surgical procedures may have been contributory. Ureterolysis, the most common form of treatment, resulted in improvement in 85 per cent of the upper tracts, while renal loss occurred in 10 per cent. The ureter should be placed anterior to the graft during aortoiliac graft procedures. A prospective study is needed to ascertain the true incidence of this complication after reconstructive vascular surgery.

Segmental calculus disease: potential of parital nephrectomy

Partial nephrectomy was performed on 71 renal units between 1962 and 1978 for segmental calculus disease. Parenchymal scarring associated with an infundibulocalyceal stone, which was usually branched, was the indication for resection. Stone analysis demonstrated an equal incidence of idiopathic and struvite stones. Perioperative morbidity was minimal, but pyelocutaneous urinary drainage prolonged the hospitalization of 5 patients. In 2 cases, the cause was an obstructing retained calculus. Retained calculi occurred in 3 other patients, one requiring early nephrectomy for sepsis. Fifty-seven patients were followed for longer than twelve months. Ipsilateral calculi recurred in 12 per cent of kidneys, and contralateral new calculi developed in the same number. Ninety-four per cent of patients with preoperative urinary tract infections had sterile urine at follow-up. From the results of this and other series, partial nephrectomy compares favorably with extended pyelolithotomy and anatrophic nephrotomy for segmental calculus disease associated with parenchymal scarring and/or a deformed collecting system.

Immunological detection of metastases from prostatic adenocarcinoma

In six patients with known prostatic adenocarcinoma, extraprostatic (metastatic) tumor was suspected on radiographic or radionucleotide studies. When cytological examination of tissue obtained by needle aspiration or biopsy was nondiagnostic, radial gel immunodiffusion was used to identify the presence of prostatic acid phosphatase in the tissue. Four specimens demonstrated prostate-specific acid phosphatase activity, permitting the diagnosis of metastatic prostatic adenocarcinoma. The technique is simple and highly specific.

Ileal conduit undiversion: experience with tunneled vesical implantation of tapered conduit

Reconstruction of the urinary tract after ileal conduit diversion was done in 9 patients by antirefluxing vesical implantation of the tapered conduit. Of the patients 5 required prior operative rehabilitation of the lower tracts, while 4 had urodynamically normal lower tracts. Reoperation for post-undiversion reflux was necessary in 2 patients; reimplantation was satisfactory in 1 but ileocecocystoplasty was required in the other. Followup showed a stable or improved upper tracts and renal function in the remaining patients.

Nodal involvement as a prognostic indicator in patients with prostatic carcinoma

Between 1969 and 1976, 92 patients with proved prostatic carcinoma in stages T0 and T4 underwent pelvic lymphadenectomy. Median followup has been 43 months. All patients had normal serum acid phosphatase levels and no clinical evidence of metastases as determined by physical examination, bone scans and metastatic bone surveys. Pelvic lymph node metastases were noted in 32 cases. Radical prostatectomy was done in 34 cases and 45 patients received radiotherapy, 11 of whom had 125iodine seeds implanted. Progression of the neoplastic process, almost exclusively in the form of bony metastases, occurred in 18 of the 32 patients who had positive pelvic nodes and in 6 of the 60 patients with negative nodes (p less than 0.001). Patients with poorly differentiated carcinoma were more likely to have progression of the disease than those with moderately differentiated carcinoma (p less than 0.01) and no patient with a well differentiated carcinoma had disease progression.

Biopsy of apparently normal urothelium in patients with bladder carcinoma

We obtained 246 cold cup biopsies from pre-selected sites of apparently non-tumor-bearing bladder urothelium from 82 patients who presented with bladder cancer for the first time. Of 75 patients with transitional cell carcinoma 32 (43 per cent) suffered coincidental urothelial abnormalities, the most common being atypia. Significant abnormalities occurred more commonly (77 per cent) in association with high grade tumors than with low grade tumors (15 per cent).

In vivo growth of human bladder cancer cell lines

Two human bladder cancer cell lines grew predictably in rats immunosuppressed with antilymphocyte serum. Intraperitoneal inoculation of tumor cell suspensions resulted in diffuse intraabdominal carcinomatosis with consequent host death after 10 to 20 days. Subcutaneous inoculation of tumor cell suspensions resulted in local tumors which grew exponentially for 20 to 30 days before eventual regression after 40 to 50 days; lung metastases developed in at least 13 per cent of the animals with subcutaneous tumors. The histologic appearance of the xenografted tumors closely resembled that of the original tumors. Subsequent in vitro culture of the xenografted tumors provided cell lines that were morphologically identical to the primary lines and that retained a human karyotype. It is proposed to employ this model of human bladder cancer to evaluate chemotherapeutic agents for possible use in the clinical disease.