Diversity in treatment modalities of Stage II/III urothelial cancer in Japan: sub-analysis of the multi-institutional national database of the Japanese Urological Association

OBJECTIVE

We aimed to survey treatment modalities for the patients with Stage II/III urothelial cancer in Japan.

METHODS

We used the multi-institutional national database of the Japanese Urological Association from 348 Japanese institutions, in which a total of 3707 patients with muscle-invasive bladder cancer and 1538 with upper urinary tract urothelial carcinoma were registered in 2008 and 2011, respectively. Primary treatment was classified as surgery alone, surgery with chemotherapy, surgery with radiation, radiation alone, chemotherapy alone, combination of radiation and chemotherapy and observation. Overall and cancer-specific survivals were examined using the Kaplan-Meier method, and survival in the subgroups was analyzed using the log-rank test.

RESULTS

In Stage II/III bladder cancer patients, 49.7% of those were treated with radical operation and 22.3% received observation only. A total 97.2% of Stage II/III upper urinary tract urothelial carcinoma patients treated with radical surgery. A total 30.4% of Stage II/III bladder cancer patients received chemotherapy. Majority of the patients received cisplatin-based regimen, however, regimens of chemotherapy was rich in variety up to 13 regimens. Chemotherapy regimens for the patients with upper urinary tract urothelial carcinoma were also various up to eight regimens. Overall and cancer-specific survivals were statistically significantly stratified according to the clinical stage. The upper urinary tract urothelial carcinoma patients diagnosed with clinical stage T3 had significantly poor prognosis compared with those diagnosed with clinical stage T2.

CONCLUSIONS

This study demonstrated the variety of treatments used for Japanese patients with Stage II/III urothelial cancer. Treatment standardization for these entities may be necessary.

Laparoscopic Versus Open Nephroureterectomy in Muscle-Invasive Upper Tract Urothelial Carcinoma: Subanalysis of the Multi-Institutional National Database of the Japanese Urological Association

OBJECTIVES

Open nephroureterectomy (ONU) is the current standard for muscle-invasive upper tract urothelial carcinoma (UTUC) in the European Association of Urology/Japanese Urological Association (JUA) guidelines. In this study, we compared the postsurgical survival of muscle-invasive UTUC patients treated with ONU or with laparoscopic nephroureterectomy (LNU), using the multi-institutional national database of the JUA.

METHODS

The 1509 patients with UTUC who were diagnosed at 348 Japanese institutions in 2005 were registered. We collected the clinical data of the patients in 2011. The muscle-invasive UTUC patients who underwent ONU or LNU were identified, and survival curves were estimated using the Kaplan-Meier method.

RESULTS

Overall, 749 pT2≥cNxM0 patients underwent a nephroureterectomy (ONU, n = 527 and LNU, n = 222). The overall survival and cause-specific survival rates were not significantly different between the ONU and LNU groups (p = 0.1263 and p = 0.0893, respectively). In addition, 459 of the 749 (61.3%) patients experienced disease recurrence (bladder recurrence, local recurrence, or distant metastasis), with no significant difference between the ONU and LNU groups. Even when patients were stratified by pT3/pT4 and/or pN+, overall survival was not significantly different between the ONU and LNU groups (p = 0.2876). The results of a univariate analysis showed that lymphovascular invasion was an independent prognostic factor for overall survival, but the surgical approaches were not found to be associated with overall survival.

CONCLUSIONS

Our data suggest that there is no evidence that the oncologic outcome of LNU is inferior to that of ONU in muscle-invasive UTUC, when the appropriate patients are selected.

Efficacy and Safety Profile of Enzalutamide for Japanese Patients with Castration-resistant Prostate Cancer

Enzalutamide is a novel, non-steroidal anti-androgen that was approved for the treatment of patients with castration-resistant prostate cancer (CRPC) in 2014 in Japan. To assess the potency of enzalutamide treatment in Japan, we performed a pilot retrospective study. Among 91 patients who received treatment in our Institution between May 2014 and July 2015, 51 patients with docetaxel-naïve CRPC (56.0%) underwent enzalutamide therapy. The median progression-free survival (PFS) and overall survival (OS) were 10.2 months and 27.9 months, respectively. The remaining 40 patients with CRPC (44.0%) underwent enzalutamide therapy after docetaxel. The median PFS and OS were 4.4 months and not reached, respectively. Among patients with docetaxel-naïve CRPC, 12 (24%) experienced adverse events, whereas 16 (40%) experienced adverse events after docetaxel. Fatigue (15%) and appetite loss (13%) were the most common. We partially clarified the characteristics of enzalutamide therapy in Japan. The PFS associated with enzalutamide might be shorter in Japanese patients.

Impact of multimodal treatment on prognosis for patients with metastatic upper urinary tract urothelial cancer: Subanalysis of the multi-institutional nationwide case series study of the Japanese Urological Association

OBJECTIVES

To describe the nature of metastatic upper urinary tract urothelial cancer and determine the prognostic predictors or treatment modality associated with all-cause mortality.

METHODS

Within the nationwide case series study of the Japanese Urological Association, consisting of 1509 patients with urinary tract urothelial cancer diagnosed in 2005, we identified 102 patients with metastatic urinary tract urothelial cancer. Univariate and multivariate survival analyses identified prognostic outcome variables.

RESULTS

Predominant sites of distant metastasis at diagnosis were the lungs (54.9%), distant lymph nodes (37.3%), bone (32.4%) and liver (19.6%). Of 102 patients, 70 patients (68.6%) died during the median follow-up period of 6 months, and the 2-year overall survival rate was estimated at 22%. The median survival time to all-cause mortality was 8.5 months (95% confidence interval 6.4-10.7 months). On multivariate analysis, independent predictive factors for all-cause mortality were age (hazard ratio 2.36, P = 0.015) and liver metastasis (hazard ratio 2.35, P = 0.037). Patients who received multimodal treatment including chemotherapy and surgery showed significantly better prognosis (median survival time 25.8 months) compared with patients treated with chemotherapy alone (median survival time 7.3 months) or best supportive care (median survival time 4.3 months).

CONCLUSIONS

Age at diagnosis and the presence of liver metastasis seem to have an impact on survival of metastatic urinary tract urothelial cancer patients. Multimodal treatment including systemic chemotherapy and surgery might result in better prognosis in some of these patients.

Prognostic factors of recurrent disease in upper urinary tract urothelial cancer after radical nephroureterectomy: Subanalysis of the multi-institutional national database of the Japanese Urological Association

OBJECTIVES

To explore predictive factors of disease recurrence after radical nephroureterectomy in patients with upper urinary tract urothelial cancer.

METHODS

A multi-institutional national database promoted by the Japanese Urological Association including 293 institutions and 1172 patients was used for the present study. Patient with non-metastatic upper urinary tract urothelial cancer who underwent primary radical nephroureterectomy with curative intent were analyzed. Univariate analysis using the Kaplan-Meier method and multivariate Cox regression models with stepwise selection was used to evaluate time to recurrence after surgery.

RESULTS

The median duration of follow up was 55.8 months, and disease recurred in 325 (27.7%) patients at a median of 11.4 months after radical nephroureterectomy. According to a Cox proportional hazards model, the Union International Contre le Cancer 2002 pathological stage of the primary tumor, lymph node status, presence of lymphatic and/or vascular invasion, infiltrative growth pattern, and age were independent predictors (P < 0.05) of recurrence-free survival.

CONCLUSIONS

Despite several limitations, our analysis suggests that pathological tumor stage, lymph node status, lymphovascular invasion, infiltrative growth pattern and age represent important prognostic variables after radical nephroureterectomy in Japanese patients with upper urinary tract urothelial cancer. This information could be potentially used to select patients for adjuvant systemic therapy.

Risk stratification for bladder recurrence of upper urinary tract urothelial carcinoma after radical nephroureterectomy

OBJECTIVES

To identify risk factors and develop a model for predicting recurrence of upper urinary tract urothelial carcinoma (UTUC) in the bladder in patients without a history of bladder cancer after radical nephroureterectomy (RNU).

PATIENTS AND METHODS

We retrospectively reviewed 754 patients with UTUC without prior or concurrent bladder cancer or distant metastasis at 13 institutions in Japan. Univariate and multivariate Fine and Gray competing risks proportional hazards models were used to examine the cumulative incidence of bladder recurrence of UTUC. A risk stratification model and a nomogram were constructed. Two prediction models were compared using the concordance index (c-index) focusing on predictive accuracy and decision-curve analysis, which indicate whether a model is appropriate for decision-making and determining subsequent patient prognosis.

RESULTS

The cumulative incidence rates of bladder UTUC recurrence at 1 and 5 years were 15 and 29%, respectively; the median time to bladder UTUC recurrence was 10 months. Multivariate analysis showed that papillary tumour architecture, absence of lymphovascular invasion and higher pathological T stage were both predictive factors for bladder cancer recurrence. The predictive accuracy of the risk stratification model and the nomogram for bladder cancer recurrence were not different (c-index: 0.60 and 0.62). According to the decision-curve analysis, the risk stratification was an acceptable model because the net benefit of the risk stratification was equivalent to that of the nomogram. The overall cumulative incidence rates of bladder cancer 5 years after RNU were 10, 26 and 44% in the low-, intermediate- and high-risk groups, respectively.

CONCLUSIONS

We identified risk factors and developed a risk stratification model for UTUC recurrence in the bladder after RNU. This model could be used to provide both an individualised strategy to prevent recurrence and a risk-stratified surveillance protocol.

First-line combination chemotherapy with cisplatin, etoposide and ifosfamide for the treatment of disseminated germ cell cancer: re-evaluation in the granulocyte colony-stimulating factor era

BACKGROUND

This study re-evaluated the efficacy and tolerability of cisplatin, etoposide, and ifosfamide (VIP) combination chemotherapy as an alternative first-line regimen for patients with disseminated germ cell cancer (GCC) in this granulocyte colony-stimulating factor (G-CSF) era.

METHODS

The medical records of 91 consecutive patients with previously untreated disseminated GCC who received first-line VIP between 1995 and 2011 were retrospectively reviewed.

RESULTS

The 5-year overall survival rates for patients with good (n = 49), intermediate (n = 22) and poor (n = 20) prognoses according to the International Germ Cell Cancer Collaborative Group classification were 100, 79 and 83%, respectively. G-CSF was given to all patients, and no treatment-related deaths due to myelosuppression occurred.

CONCLUSION

The present study is the first to examine the therapeutic outcomes and safety profile of first-line VIP after routine G-CSF use. VIP might be an alternative first-line regimen for patients with disseminated GCC in this G-CSF era.

First-line chemotherapy with gemcitabine, etoposide, and cisplatin in combined-multimodality treatment for patients with advanced urothelial carcinoma

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Background: We had previously reported the phase I/II study of a combination regimen of gemcitabine, etoposide, and cisplatin (GEP) in second-line treatment for patients with advanced UC. This study sought to examine the combination chemotherapy of GEP as first-line treatment for advanced urothelial carcinoma (UC) to assess efficacy, feasibility, prognostic factors, and the impact of postchemotherapy surgery on outcomes. Methods: Forty-two patients were treated with GEP as first-line treatment for metastatic or unresectable locally advanced UC. GEP was recycled every 4 weeks. Etoposide and cisplatin were given on days 1 through 3 at doses of 60 mg/m2 and 20 mg/m2, respectively, and gemcitabine was given on days 1, 8, and 15 at a dose of 800 mg/m2. Results: The median patient age was 64 years. Twenty-three male patients and 19 female patients were included. The primary cancer site is urinary bladder in 21 patients, and upper urinary tract in 21 patients. Nineteen had visceral/bone metastases, 16 had disease restricted to lymph nodes, and the remaining 7 had unresectable disease at primary site. The median number of GEP courses was 4. Thirty of 42 assessable patients (71.4%) demonstrated objective responses. At a median follow-up of 14.6 months, the median overall survival time (OS) was 16.2 months. Twenty-four of 30 responders underwent postchemotherapy surgeries. Median OS in the patients with postchemotherapy surgery was 25.4 months. In the multivariable analysis, anemia and visceral/bone metastasis were significant pretreatment prognostic factors for OS. In addition, being male and anemic were independent poor prognostic factors in patients with postchemotherapy surgery. Grade 3-4 neutropenia, anemia and thrombocytopenia occurred in 84%, 73% and 57%. There were no treatment-related deaths. Conclusions: GEP as first-line chemotherapy in combined-multimodality treatment is active and moderately tolerable for advanced UC. Postchemotherapy surgery may yield favorable outcomes in patients who achieved objective responses. Anemia and visceral/bone metastasis were independent pretreatment predictors for OS.

A novel equation and nomogram including body weight for estimating prostate volumes in men with biopsy-proven benign prostatic hyperplasia

Anthropometric measurements, e.g., body weight (BW), body mass index (BMI), as well as serum prostate-specific antigen (PSA) and percent-free PSA (%fPSA) have been shown to have positive correlations with total prostate volume (TPV). We developed an equation and nomogram for estimating TPV, incorporating these predictors in men with benign prostatic hyperplasia (BPH). A total of 1852 men, including 1113 at Tokyo Medical and Dental University (TMDU) Hospital as a training set and 739 at Cancer Institute Hospital (CIH) as a validation set, with PSA levels of up to 20 ng ml(-1), who underwent extended prostate biopsy and were proved to have BPH, were enrolled in this study. We developed an equation for continuously coded TPV and a logistic regression-based nomogram for estimating a TPV greater than 40 ml. Predictive accuracy and performance characteristics were assessed using an area under the receiver operating characteristics curve (AUC) and calibration plots. The final linear regression model indicated age, PSA, %fPSA and BW as independent predictors of continuously coded TPV. For predictions in the training set, the multiple correlation coefficient was increased from 0.38 for PSA alone to 0.60 in the final model. We developed a novel nomogram incorporating age, PSA, %fPSA and BW for estimating TPV greater than 40 ml. External validation confirmed its predictive accuracy, with AUC value of 0.764. Calibration plots showed good agreement between predicted probability and observed proportion. In conclusion, TPV can be easily estimated using these four independent predictors.

Performance of prostate-specific antigen mass in estimation of prostate volume in Japanese men with benign prostate hyperplasia

OBJECTIVES

Obese men with benign prostate hyperplasia might have lower serum prostate-specific antigen because of hemodilution, resulting in underestimation of total prostate volume by serum prostate-specific antigen. The aim of this study was to compare the performance of prostate-specific antigen mass as the absolute amount of prostate-specific antigen protein secreted into circulation with that of serum prostate-specific antigen in the prediction of total prostate volume.

METHODS

A total of 1517 men with serum prostate-specific antigen up to 10 ng/mL, including 1425 with biopsy-proven benign prostate hyperplasia, were enrolled in this study. Height and weight were used to estimate body mass index, body surface area and plasma volume. Prostate-specific antigen mass was calculated as serum prostate-specific antigen multiplied by plasma volume. The association between serum prostate-specific antigen or prostate-specific antigen mass and transrectal ultrasound-measured total prostate volume were evaluated by Pearson's correlation coefficient (Υ), linear regression analyses and receiver operating characteristic curves.

RESULTS

Serum prostate-specific antigen had an inverse relationship with plasma volume, decreasing as plasma volume increased, after adjustment of total prostate volume. Larger total prostate volume per serum prostate-specific antigen was found in men with higher body mass index or plasma volume. Among all participants, the correlation (Υ = 0.456) between prostate-specific antigen mass and total prostate volume was apparently stronger than that (Υ = 0.442) between serum prostate-specific antigen and total prostate volume. Prostate-specific antigen mass outperformed serum prostate-specific antigen at estimating total prostate volume cut-off values of 30 and 40 mL. These findings were more significant in men aged ≥60 years.

CONCLUSIONS

Prostate-specific antigen mass performs better than serum prostate-specific antigen in estimating TPV, especially in men aged ≥60 years.

Contribution of C-reactive protein to predicting overall survival in patients with advanced urothelial carcinoma: Development of a nomogram and evaluation by decision curve analysis

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Background: To accurately estimate the individual survival of patients with advanced urothelial carcinoma (UC), the application of prediction models such as nomograms has been warranted in clinical use. We therefore constructed a nomogram which included C-reactive protein (CRP) as a novel biomarker in order to increase its predictive accuracy. Furthermore, the clinical usefulness of this nomogram was evaluated by decision curve analysis which incorporated the negative consequences of each decision to generate a net benefit (Vickers et al, BMC Med Inform Decis Mak, 2008).

Methods: A total of 232 consecutive patients with locally advanced or metastatic urothelial carcinoma (UC) were treated at our institute. Among them, 9 patients with missing data were excluded. The current study cohort was comprised of the remaining 223 patients. A nomogram predicting 6- and 12-month survival probability was developed based on the results of the final multivariate analytic model. To evaluate the efficacy of this nomogram, a quantified concordance-index (c-index) was computed and a decision curve analysis was performed.

Results: Overall, 184 patients died of the primary disease and the remaining 39 were censored. The median follow-up period and length of overall survival were 5 and 6 months, respectively. The 6- and 12-month survival rates were 48% and 30% respectively. A nomogram was developed which included the parameters of age, PS, visceral metastasis, hemoglobin and CRP. The c-index of this prediction model was 0.79 compared with 0.75 for that of a model without CRP. The decision curve analysis revealed that a novel nomogram which incorporated CRP had a superior net benefit to that without CRP for most of the examined threshold probabilities.

Conclusions: Incorporation of CRP increased the predictive accuracy of a prognostic nomogram for advanced UC. In clinical practice, this nomogram would contribute to the decision making process in the treatment of patients suffering from this form of carcinoma.

Perioperative complications of radical cystectomy after induction chemoradiotherapy in bladder-sparing protocol against muscle-invasive bladder cancer: a single institutional retrospective comparative study with primary radical cystectomy

OBJECTIVE

To compare rates of early morbidity after radical cystectomy in patients treated with or without induction chemoradiotherapy (CRT) using a standardized reporting methodology.

METHODS

All 193 consecutive patients undergoing radical cystectomy for bladder cancer between 1989 and 2010 were retrospectively reviewed. Induction chemoradiotherapy consists of radiation at 40 Gy to the small pelvis and two cycles of concurrent cisplatin at 20 mg/day for 5 days. Deaths within 90 days after radical cystectomy and complications arising within 30 days were recorded and graded according to the Clavien-Dindo classification. Grades 1-2 were considered minor; Grades 3-5 were considered major.

RESULTS

Eighty-seven patients underwent radical cystectomy following chemoradiotherapy (chemoradiotherapy group) while the remaining 106 primarily underwent radical cystectomy (no chemoradiotherapy group). No Grade 4-5 complication was observed. Overall, 118 patients (61%) experienced 36 major and 122 minor complications. There was no significant difference in the incidence of overall complications between the chemoradiotherapy and no chemoradiotherapy groups (67 vs. 57%). Overall urinary anastomosis-related complications and major gastrointestinal complications, most of which were Grade 3 ileus, were more frequent in the chemoradiotherapy group than the no chemoradiotherapy group (11 vs. 2%, P = 0.007; and 14 vs. 4%, P = 0.02; respectively). Multivariate analysis identified induction chemoradiotherapy as an independent risk factor for overall urinary anastomosis-related complications (relative risk 6.0, P = 0.01) but not for major gastrointestinal complications.

CONCLUSIONS

Induction chemoradiotherapy at 40 Gy in bladder-sparing protocols against MIBC is unlikely to increase the rate of severe complications of radical cystectomy.

Characteristics and clinical significance of prostate cancers missed by initial transrectal 12-core biopsy

OBJECTIVE

• To characterize prostate cancers missed by initial transrectal 12-core biopsy.

PATIENTS AND METHODS

• Between 2002 and 2008, 715 men with prostate-specific antigen levels in the range 2.5-20 ng/mL or abnormal digital rectal examination underwent three-dimensional 26-core prostate biopsy (i.e. a combination of transrectal 12-core biopsy and transperineal 14-core biopsy) on initial examination. • Of the 257 patients diagnosed with cancer, 120 patients subsequently underwent radical prostatectomy. • Cancers were grouped into TR12-negative cancers (i.e. not detected through transrectal 12-core biopsy but detected through transperineal 14-core biopsy) and TR12-positive (i.e. detected through transrectal 12-core biopsy) cancers. • Clinicopathological characteristics of the TR12-negative and TR12-positive cancers were evaluated.

RESULTS

• TR12-negative cancers comprised 21% of the three-dimensional 26-core biopsy-detected cancers. • The frequency of cancers with a biopsy Gleason score ≤ 6 and that of cancers with a biopsy primary Gleason grade ≤ 3 was higher in TR12-negative cancers, at 58% and 83%, respectively, than in TR12-positive cancers, at 25% (P < 0.001) and 53% (P < 0.001), respectively. • The median number of positive cores in TR12-negative cancers was two out of 26. • TR12-negative cancers were more frequently located anteriorly than posteriorly. • The incidence of the TR12-negative cancers was not associated significantly with any clinical variable.

CONCLUSION

• Many of the cancers missed by initial transrectal 12-core biopsy are probably low-grade and low-volume diseases, although initial transrectal 12-core biopsy has a small but definite risk of missing anterior significant cancers.

A novel repeat biopsy nomogram based on three-dimensional extended biopsy

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Background: There is no perfect cohort in which nomograms are developed because no biopsy method can detect all cancers. To minimize this inherent verification bias, having a cohort with fewer false negative cases is advantageous. Based on a cohort examined with three-dimensional (3D) extended biopsy protocol, we developed a novel nomogram for diagnosis of prostate cancer on repeat biopsy.

Methods: Of 4,074 consecutive male patients undergoing prostate biopsy at our institutions between 2000 and 2009, 775 men with at least one previous negative biopsy underwent repeat biopsy with 3D protocol. Men with previous atypical glands or atypical small acinar proliferation and/or without available prostate-specific antigen (PSA) kinetics information were excluded. The remaining 515 men constituted the study cohort. We developed a logistic regression-based nomogram with 70% of the cohort selected randomly; we validated it with the remaining 30%. Predictive accuracy and performance characteristics were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plots, respectively. The threshold probability was evaluated with decision curve analysis.

Results: We developed a novel repeat biopsy nomogram incorporating age, free to total PSA ratio, prostate volume, history of previous extended biopsy, and PSA doubling time. Validation confirmed predictive accuracy with an AUC value of 0.791. Calibration plots showed good agreement. The decision curve of the nomogram was superior to the decision curve of biopsying all men in a range of threshold probability over 0.15. At the threshold of 0.2, the number of unnecessary biopsies could be reduced by 10 per 100, without missing PCa.

Conclusions: We developed a novel repeat biopsy nomogram based on a cohort examined with 3D extended biopsy. This repeat biopsy nomogram is clinically beneficial, saving a substantial number of unnecessary biopsies.

No significant financial relationships to disclose.

A novel repeat biopsy nomogram based on three-dimensional extended biopsy

OBJECTIVES

To develop a nomogram based on a cohort examined with 3-dimensional (3D) protocol for diagnosis of prostate cancer on repeat biopsy.

METHODS

Of 4074 consecutive men undergoing prostate biopsy at our institutions between 2000 and 2009, 775 men with at least 1 previous negative biopsy underwent repeat biopsy with a 3D protocol. Men with previous atypical glands or atypical small acinar proliferation and/or without available prostate-specific antigen (PSA) kinetics information were excluded. The remaining 515 men constituted the study cohort. We developed a logistic regression-based nomogram with 70% of the cohort selected randomly; we validated it with the remaining 30%. Predictive accuracy and performance characteristics were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plots, respectively. The threshold probability was evaluated with decision curve analysis.

RESULTS

We developed a novel repeat biopsy nomogram incorporating age, free to total PSA ratio, prostate volume, history of previous extended biopsy, and PSA doubling time. Validation confirmed predictive accuracy with an AUC value of 0.791. Calibration plots showed good agreement. The decision curve of the nomogram was superior to the decision curve of biopsying all men in a range of threshold probability over 0.15. At the threshold of 0.2, the number of unnecessary biopsies could be reduced by 10 per 100, without missing prostate cancer.

CONCLUSIONS

We developed a novel repeat biopsy nomogram based on a cohort examined with 3D protocol. This repeat biopsy nomogram is clinically beneficial, preventing a substantial number of unnecessary biopsies.

Rolipram, a specific type-4 phosphodiesterase inhibitor, inhibits cyclophosphamide-induced haemorrhagic cystitis in rats

OBJECTIVE

To investigate the protective roles of type 4 phosphodiesterase (PDE4) inhibitor in cyclophosphamide (CYP)-induced haemorrhagic cystitis, as the PDE4 inhibitor has anti-inflammatory effects but its characterization is still unknown in urinary tract diseases.

MATERIALS AND METHODS

In female Sprague-Dawley rats, CYP was administered intraperitoneally and bladders were harvested 24 h after CYP injection. In another group, rolipram as a PDE4 inhibitor was administered before CYP treatment. The effects and mechanisms of CYP with/without rolipram pretreatment were evaluated by microscopic features, bladder wet weight, myeloperoxidase (MPO) activity, nitric oxide (NO)-metabolite production and expression levels of inflammation-related genes.

RESULTS

CYP injection resulted in severe cystitis. Pretreatment with rolipram significantly reduced the increase in bladder wet weight and MPO activity, and ameliorated histological inflammatory changes caused by CYP. The levels of inflammation-related transcripts including inducible NO synthase (iNOS), interleukin-1beta and tumour necrosis factor-alpha, induced by CYP, were down-regulated significantly by pretreatment with rolipram. Also, rolipram reduced the NO-metabolite production and iNOS protein expression in the immunohistochemical examination.

CONCLUSION

These results indicate that rolipram can attenuate the development of CYP-induced cystitis in rats by suppressing cytokine production and iNOS induction. Thus, treatment with PDE4 inhibitor has potential clinical implications of the prevention of bladder inflammatory diseases.

Successful management of life-threatening choriocarcinoma syndrome with rupture of pulmonary metastatic foci causing hemorrhagic shock

We report a case of a man with testicular cancer metastatic to the lung and retroperitoneal lymph node, with significant elevation of serum levels of human chorionic gonadotropin, 534,000 mIU/mL. Just after the initiation of chemotherapy, life-threatening hemothorax occurred and hemorrhagic shock ensued. The pulmonary tumor had broken off, and lower lobectomy was carried out. Pathologic examination of the specimen revealed choriocarcinoma and yolk sac tumor. Through multimodal treatments he achieved complete remission. To our knowledge, this is the first case report of choriocarcinoma syndrome with life-threatening hemorrhage caused by rupture of pulmonary metastases, resulting in complete remission through multimodal treatments.

False tumor marker surge evoked by peripheral blood stem cell transplantation

Peripheral blood stem cell transplantation (PBSCT) allows multiple intensive chemotherapy treatments and hematopoietic progenitor cell rescues for poor-risk patients with a variety of malignancies. We report false surges of a tumor marker, serum human chorionic gonadotropin (hCG), evoked by PBSCT in the course of chemotherapy for a poor-risk testicular cancer patient. We confirmed that this phenomenon resulted from reinfusion of peripheral blood stem cells (PBSCs) containing hCG at a high concentration, collected when the patient's serum hCG levels were remarkably elevated. This is the first report to demonstrate false tumor marker surges caused by PBSCT. Because a rapid rise in tumor markers may demand an immediate change in the therapeutic strategy, physicians should be aware of the possibility of this phenomenon when treating poor-risk cancer patients whose tumor markers are remarkably elevated at the time of PBSC harvest.

Successful therapy of a malignant phyllodes tumor of the prostate after postoperative local failure

A 19-year-old student who had presented with acute urinary retention was referred to our hospital with biopsy diagnosis of proliferating mesenchymal tumor of the prostate. Magnetic resonance imaging showed enlarged prostatic masses. Suspecting prostate sarcoma, we performed a nerve-sparing radical prostatectomy. Histologic diagnosis of the tumor was prostatic malignant phyllodes tumor. Five months after the operation, bilateral obturator lymph node metastases appeared, which were treated with etoposide, ifosfamide, and cisplatin chemotherapy. After a good response was achieved with four cycles of the chemotherapy, pelvic irradiation was added. Since then, there has been no evidence of recurrence for more than 4 years.

[The result of VIP chemotherapy as an induction therapy in 6 patients with non-seminomatous extragonadal germ cell tumor]

We treated 6 patients with non-seminomatous extragonadal germ cell tumor (NSEGCT) by VP-16 + ifosfamide + cisplatin (VIP) chemotherapy as an induction therapy to investigate the effectiveness and safety. Primary lesions were located at the mediastinum in 4 patients and the retroperitoneum in 2 patients. As a rule, all patients were treated with VIP chemotherapy of 4 courses with or without second-line treatment such as chemotherapy, residual tumor resection and/or radiation. Following the induction therapy (VIP), 4 of 6 patients (67%) achieved complete or partial responses. After salvage therapy, 4 patients (67%) achieved complete responses and two other patients also achieved partial responses. However, only 2 of the 5 patients who had been follow-up for more than 2 years have remained disease free. The effects of VIP chemotherapy on non-seminomatous extragonadal germ cell tumor appeared to be similar to those of the conventional chemotherapies though the number of patients was small in the current study. It appears to be necessary to design more effective regimen.

[A case of locally advanced prostate cancer with low serum testosterone associated with intake of an androgenic medicine]

A 74-year-old man was referred to our clinic for the work-up of digitally hard and irregularly surfaced prostate and elevated serum prostate-specific antigen (PSA). His serum PSA was elevated to 41 ng/ml, but testosterone and LH level were decreased to 23.5 ng/dl and 0.5 mIU/ml, respectively. He had a history of taking an androgenic medicine containing methyl-testosterone 2 to 3 times a week for 2 year and 6 months. Transrectal sextant prostatic biopsy revealed moderately differentiated adenocarcinoma (Gleason score: 3 + 4) in 6 of 6 specimens and CT scan of the abdomen showed an enlarged obturator lymph-node (15 mm), resulting in the diagnosis of stage D1 (T3aN1M0) prostate cancer. Since serum testosterone level seemed to recover around the normal level after discontinuation of the exogenous androgen, we treated him with combination androgen blockade with LHRH agonist and bicaltamide, although his testosterone level was very low. Indeed, serum PSA decreased to 0.09 ng/ml and the right obturator node was markedly reduced by the hormone treatment. After the neoadjuvant therapy of 6 months duration, radical prostatectomy and limited pelvic lymph node dissection was carried out. Histologically, viable cancer cells were not found in any of resected lymph nodes, but they remained in bilateral lobes of the prostate (pT2bN0). The histological effect of the neoadjuvant hormone therapy according to General rule for Clinical and Pathological Studies on Prostate Cancer (3rd ed.) was grade 2. The patient has been well with undetectable PSA and no evidence of clinical failure for more than 12 months, though serum testosterone level recovered to near normal (288 ng/dl) 8 months after the cessation of the hormone treatment following the operation. Combination androgen blockade or non-steroidal anti-androgen agent appears to be effective for the treatment of prostatic cancer patients who takes exogenous androgenic medicine, even with a suppressed low serum testosterone level.

Olfactory discrimination of structurally similar alcohols by cockroaches

The capability of the cockroach Periplaneta americana to discriminate odors of structurally similar aliphatic alcohols was studied by using an operant conditioning paradigm. Cockroaches were trained to discriminate three odors: one odor associated with sucrose solution (reward) and two odors associated with NaCl solution (non-reward). After training, their odor preferences were tested by counting the number of visits to each odor source. We tested the capability of cockroaches to discriminate (1) three normal aliphatic alcohols with different numbers of carbon (1-pentanol, 1-hexanol and 1-octanol), (2) three C6 aliphatic alcohols (1-hexanol, 2-hexanol and trans-2-hexen-1-ol), (3) binary mixtures of two of these three alcohols and their components, and (4) 1-hexanol solution of three different concentrations (1, 10 and 100 micro g micro l(-1)). Cockroaches exhibited higher preferences for the odors associated with reward in these tests, and we therefore conclude that cockroaches can discriminate these odors. However, discrimination of 1-hexanol and trans-2-hexen-1-ol and their binary mixture was imperfect, in that some statistical tests suggested significant level of discrimination but other tests did not. In addition, the cockroaches learned to associate a 1-hexanol solution of the highest or lowest concentration with sucrose reward but failed to learn to associate 1-hexanol of an intermediate concentration with reward.

Applicability of a mobile accelerator for intraoperative radiation therapy to colorectal cancer

PURPOSE

Intraoperative radiation therapy is reportedly effective for local control and pain relief in colorectal cancer. However, this treatment requires a large number of medical personnel, which hinders expanded use of this method. A mobile electron linear accelerator for intraoperative radiation therapy has been developed and is now commercially available. This report analyzes the applicability of this accelerator to colorectal cancer. The applicability of the mobile accelerator is analyzed based on its specifications by simulating the intraoperative radiation therapy delivered to these patients with a conventional intraoperative radiation therapy unit.

METHODS

From 1987 to 1999, 49 colorectal cancer patients underwent 54 surgical resections and received intraoperative radiation therapy to 75 sites.

RESULTS

The mean intraoperative radiation therapy dose for colorectal cancer with the conventional unit was 22 (range, 10-30) Gy. The mean electron energy level was 10 (range, 3-30) MEV. Applicator size ranged from 4 to 10 cm in diameter. The mobile accelerator can achieve a dose rate of 10 Gy/min and an applicator unit size range of 3 to 10 cm in diameter, facilitating intraoperative radiation therapy for colorectal cancer. The electron energy limitation (12 MEV at maximum) suggests that the indications for this machine are limited. In our experience, 30 percent of patients received intraoperative radiation therapy with electron energy levels exceeding 12 MEV. Of these cases, 81 percent had macroscopic residual tumor and 69 percent had pain.

CONCLUSION

An intraoperative radiation therapy mobile accelerator can cover 72 percent of the irradiation sites covered using our conventional unit. This accelerator is useful for intraoperative radiation therapy with curative intent for patients with no or slight residual tumor. Patients with gross residual tumor and pain may not be suitable.

A novel monoclonal antibody that recognizes human perivascular cells of the central nervous system under a specific immune reaction

Perivascular cells or fluorescent granular perithelial cells of the central nervous system are newly recognized members of monocyte/macrophage populations. In this study a monoclonal antibody, GP-3, that labels proteinous lysosomal antigen of human perivascular cells, has been established. It selectively label the cells in foamy-macrophage infiltrating diseased areas, such as Wallerian degeneration and contusion, without significant reaction to the cells in normal areas, infiltrating macrophages or microglia. These findings suggest that the perivascular cell is an independent cell type and the antigen molecule is fairly specific to perivascular cells and plays an unknown role in immune-nervous system interaction.