Radical cystectomy under continuous antiplatelet therapy with acetylsalicylic acid

INTRODUCTION

Aim of this study was to analyse the perioperative outcome of patients undergoing radical cystectomy under continuous antiplatelet therapy with acetylsalicylic acid.

MATERIALS AND METHODS

Using prospectively maintained databases of two departments of urology, we identified 461 consecutive patients who underwent radical cystectomy for bladder cancer (2011-2017). Patients were divided into three groups: 1) on-going antiplatelet therapy with acetylsalicylic acid (n = 50), 2) discontinuing antiplatelet therapy (n = 65) and 3) no antiplatelet therapy (n = 346). Perioperative outcome was compared between the three groups using ANOVA, likelihood ratio or Kruskal Wallis test with post-hoc testing. Uni- and multivariate analyses were performed to identify predictor for perioperative complications and transfusion.

RESULTS

Group 1 showed an average estimated blood loss of 732 ± 424, group 2 752 ± 488 and group 3 810 ± 544 ml (p = 0.51). There was no significant difference in transfusion rate (44% in group 1, 45% and 39% in groups 2 and 3, p = 0.63). Severe complications occurred in 26%, 15% and 15% in groups 1-3 (p = 0.19). Ischemic complications were more often observed in group 1 (n = 4, 8%) and 2 (n = 5, 8%) than group 3 (n = 7, 2%), p = 0.02. 90-day readmission (n = 99, 22%) and mortality rate (n = 10, 2.2%) were low and did not show any significant differences between the groups. In uni- and multivariate analysis ongoing therapy with acetylsalicylic acid was no independent risk factor for transfusion or severe complications.

CONCLUSION

Perioperative continuation of therapy with acetylsalicylic acid in radical cystectomy is safe with no difference in intraoperative blood loss, transfusion rate, complications or mortality.

Biomodulatory Treatment of Patients with Castration-Resistant Prostate Cancer: A Phase II Study of Imatinib with Pioglitazone, Etoricoxib, Dexamethasone and Low-Dose Treosulfan

Therapeutic options for patients with castration-resistant prostate cancer (CRPC) remain limited. In a multicenter, Phase II study, 65 patients with histologically confirmed CRPC received a biomodulatory regimen during the six-month core study. Treatment comprised daily doses of imatinib mesylate, pioglitazone, etoricoxib, treosulfan and dexamethasone. The primary endpoint was prostate-specific antigen (PSA) response. Responders could enter an extension phase until disease progression or intolerable toxicity occurred. Mean PSA was 45.3 ng/mL at baseline, and 77 % of patients had a PSA doubling time <3 months. Of the 61 evaluable patients, 37 patients (60.6 %) responded or had stable disease and 23 of them (37.7 % of 61 patients) were PSA responders. Among the 23 responders mean PSA decreased from 278.9 ± 784.1 ng/mL at baseline to 8.8 ± 11.6 ng/mL at the final visit (week 24). The progression-free survival (PFS) was 467 days in the ITT population. Of the 947 adverse events, 57.6 % were suspected to be drug-related, 13.8 % led to dose adjustment or permanent discontinuation and 40.2 % required concomitant medication. This novel combination approach led to an impressive PSA response rate of 37.7 % in CRPC patients. The good PSA response and PFS rate combined with the manageable toxicity profile suggest an alternative treatment option.

[Metastatic renal cell cancer in Germany in 2010. Impact of different target therapies]

BACKGROUND

Since 2006 in Germany six different target drugs for therapy in metastatic renal cell cancer (mRCC) have been used. Comparative studies for the application with the same indication are absent, and the order of potential sequential therapy is up to now unclear. The aim of the study was to collect data on therapy decisions in Germany regarding mRCC in the age of "targeted therapy". At the same time the study addressed the central question of sequencing of the different therapy options. In addition, the data of this study were to be compared to a study already published in 2008.

PATIENTS AND METHODS

In 2010, four groups of doctors specialized in the therapy of patients with mRCC were asked for their behaviour in the first-, second- and third-line or sequential therapy. Those questioned included urologists in private practice (n=40), oncologists in private practice (n=40), hospital urologists (n=35) and hospital oncologists (n=35). Further the reasons for a therapy decision should be stated or weighted.

RESULTS

Altogether 92% of all patients with mRCC were treated. Urologists in private practice treat only 30% of their patients themselves. The earlier used immune therapies (IFN, IL-2) no longer play a role. Sunitinib is used most often in first-line therapy by urologists in private practice (50.4%) and oncologists in private practice (47.1%). In second- and third-line therapy everolimus is used by urologists in private practice (27.1%, 26.3%) and sorafenib (28.6%) or everolimus (26.4%) by oncologists in private practice. Hospital oncologists use primarily sunitinib (56.1%), in second-line sorafenib (45.5%) and in third-line above all everolimus (19.4%). Hospital urologists use sunitinib most often for first-line therapy (57.6%) and sorafenib for second-line treatment (37.3%), while in third-line therapy temsirolimus (49.6%) and also everolimus (30.4%) were used.

CONCLUSIONS

The therapy of mRCC is determined very strongly by the substances sunitinib and sorafenib. The mTOR inhibitors have recently been increasingly included in the second- and third-line therapy. With the introduction of the new targeted therapies, the treatment of these special patients is performed less by urologists and increasingly more by oncologists. This trend is strengthened in comparison to the DGFIT study from 2008.

A clinical phase I/II trial with the monoclonal antibody cG250 (RENCAREX®) and interferon-alpha-2a in metastatic renal cell carcinoma patients

PURPOSE

To evaluate the efficacy and safety of WX-G250, a chimeric monoclonal antibody that binds to carboxy anhydrase IX, combined with low-dose interferon-alpha (LD-IFNα) in patients with progressive metastatic renal cell carcinoma (mRCC).

PATIENTS AND METHODS

Thirty-one patients, nephrectomized for the primary tumor, clear cell progressive mRCC, were enrolled to receive weekly infusions of WX-G250 (20 mg i.v.; week 2-12) combined with LD-IFNα (3 MIU s.c. 3 times/week; week 1-12). At week 16, patients were evaluated for response and stratified into two groups: (a) responders into the extended treatment group for an additional 6 weeks of treatment or (b) the progressive group with no further study treatment.

RESULTS

Of the 31 treated patients, 26 were evaluable for response to treatment. Two patients showed partial remission and 14 patients had stable disease as assessed in week 16. One patient experienced partial remission resulting in a complete remission lasting at least 17 months. Nine patients had durable stable disease of 24 weeks or longer. Clinical benefit was obtained in 42% (11/26) patients. The median overall survival achieved was 30 months and the 2-year survival was 57%. Patients receiving extended treatment showed a significantly longer 2-year survival rate than discontinued patients (79 vs. 30%; P=0.0083). In general, treatment was well tolerated with little toxicity.

CONCLUSION

Treatment with the antibody WX-G250 in combination with LD-IFNα is safe, well tolerated, led to clinically meaningful disease stabilization and demonstrated clinical benefit in this progressive mRCC patient population.

[Impact of immunotherapy in metastatic kidney cancer in Germany after introduction of new target therapy--results of a telephone survey of the German Society of Immuno- and Targeted Therapy (DGFIT)]

INTRODUCTION

Until recently, the standard therapy for metastatic renal cell carcinoma (mRCC) in Germany consisted of interleukin-2 (IL-2), interferon-alfa (IFN) as single agents or in combination, with or without chemotherapy. Since 2005, new drugs (target drugs) in the therapy for mRCC are available. The aim of this study was to analyse the current therapy standard in Germany.

METHODS

By representative telephone interviews (GFK-Nürnberg by order of DGFIT) the following colleagues were contacted A: urologists in private practice (n = 40), B: oncologists in private practice (n = 40), C: hospital urologists (n = 35) and D: hospital oncologists (n = 35). Screening criteria were 1) responsibility for therapy in mRCC; 2) therapy of at least 10 patients with mRCC per year.

RESULTS

Patients/year: A: n = 19, B: n = 17, C: n = 43, D: n = 21. 98% of patients with mRCC were treated: A: the most frequent therapy was sunitinib (43%, 42%, 33% as first-, second-, third-line), B: the most frequent therapy was sunitinib (45% as first-line, 37% as second-line), the most frequent third-line therapy was sorafenib (35%); C: the most frequent therapy were sorafenib and sunitinib (first-line 26% vs. 27%, second-line 46% vs. 42%), in third-line therapy additionally temsirolimus 24%; D: primary sorafenib and sunitinib (first-line 33% vs. 40%, second-line 46% vs. 42%), in third-line therapy additionally temsirolimus 23%. Immunotherapy (IL-2, IFN with or without chemotherapy) in mRCC plays in Germany for the second- and third-line therapy in A-D no major role (less than 10%). Otherwise, for first-line therapy immunotherapy has some relevance: A: 25%, B: 37%, C: 33%, D: 16%. The most important criteria for therapy decision making in A-D were: efficacy, toxicity, drug approval status.

CONCLUSIONS

Most patients with mRCC in Germany were seen by hospital urologists. Sunitinib (in first-line) and sorafenib (in second-line) are currently the most frequent prescribed drugs in mRCC. Temsirolimus is used mostly for third-line therapy (followed by sunitinib/sorafenib). Treatment of mRCC in Germany is increasingly being performed by oncologists.

Interleukin-2- and interferon alfa-2a-based immunochemotherapy in advanced renal cell carcinoma: a Prospectively Randomized Trial of the German Cooperative Renal Carcinoma Chemoimmunotherapy Group (DGCIN)

PURPOSE

We conducted a prospectively randomized clinical trial to compare the efficacy of three outpatient therapy regimens in 341 patients with progressive metastatic renal cell carcinoma.

PATIENTS AND METHODS

Patients were stratified according to known clinical predictors and were subsequently randomly assigned. Treatment arms were: arm A (n = 132), subcutaneous interferon alfa-2a (sc-IFN-alpha-2a), subcutaneous interleukin-2 (sc-IL-2), and intravenous (IV) fluorouracil; arm B (n = 146): arm A treatment combined with per oral 13-cis-retinoic acid; and arm C (n = 63), sc-IFN-alpha-2a and IV vinblastine.

RESULTS

Treatment (according to the standard 8-week Hannover Atzpodien regimen) arms A, B, and C yielded objective response rates of 31%, 26%, and 20%, respectively. Arm B, but not arm A, showed a significantly improved progression-free survival (PFS) compared with arm C (P =.0248). Both arm A (median overall survival, 25 months; P =.0440) and arm B (median overall survival, 27 months; P =.0227) led to significantly improved overall survival (OS) compared with arm C (median OS, 16 months). All three sc-IFN-alpha-2a-based therapies were moderately or well tolerated.

CONCLUSION

Our results established the safety and improved long-term therapeutic efficacy of sc-IL-2 plus sc-INF-alpha-2a-based outpatient immunochemotherapies, compared with sc-INF-alpha-2a/IV vinblastine.

[Surgical treatment of pulmonary metastases from renal cancer]

Based on a large single-center follow-up database, we evaluated the long-term results after curative resection of pulmonary metastases from renal cancer. During a 20-year period, 105 patients underwent a total of 150 resections with curative intention. Hospital mortality was 0.95%, 5- and 10-year survival rates were 40% and 33%, respectively. Significant prognostic relevance was shown for complete pulmonary resection, lymph node involvement upon primary resection as well as size of the resected lung metastasis. Our findings of low perioperative morbidity and mortality rates lead us to propose that in patients without additional metastases curative resection of pulmonary lesions should be considered. Moreover, recurrent pulmonary metastases should also be considered for surgical treatment since resection for cure significantly improves survival in these patients.

[Ambulatory radiosurgery in cerebral metastatic renal cell carcinoma. 5-year outcome in 58 patients]

Brain metastases (BM) indicate an advanced stage of renal cell cancer (RCC). They pose an increasing challenge to urologists as a result of improved survival due to modern therapy. Median survival of untreated patients with BM who often suffer from neurological deficits is 3 months. Radiosurgery with the Gamma Knife (GK) has increased in use as an alternative to whole brain radiation therapy (WBRT) and/or surgery. This study reports the results of a consecutive series of RCC patients treated for BM by GK radiosurgery during a 5-year period. Between 1994 and 1999, 58 patients with a total of 277 BM and 3.0 (1-19) BM/patient were treated. Because of recurrent BM, 23 (40%) patients received repeated (multiple) GK sessions. The median tumor volume was 3.4 cm3 (0.1-19.1). The median interval between diagnosis of RCC and GK treatment was 2.2 years (0.1-17.2). Symptomatic side effects were detected in 9 (16%) of 58 patients. The median actuarial survival time was 9.9 months. Local tumor control could be achieved in 95% of patients. The GK therapy induced a significant tumor remission accompanied by rapid neurological improvement in 70% of patients. Compared to standard radiotherapy, GK radiosurgery is more effective, less time consuming, and can be repeated. Compared to surgery, radiosurgery is less invasive and better suited to treat multiple metastases in one single session. Surgery and radiosurgery, however, are supplementary methods that are highly effective to control intracerebral metastasizing RCC.

[Telerobotic surgery between Baltimore and Munich]

The rapid development of laparoscopy in urology necessitates the training of specialists to guarantee the high standard of patient care. The real-time data communication of medical information between physicians in different locations is known as telemedicine. Telementoring describes the assistance of an experienced surgeon, while telerobotics requires the use of robots. Two robots, the established AESOP and the PAKY + RCM developed at the Johns Hopkins Hospital (JHH), were used to perform a telerobotic laparoscopic renal cyst ablation in cooperation between Baltimore and Munich. The telementor maneuvered the robots over a distance of 8000 km using eight ISDN lines and a PC. AESOP moved the camera, while PAKY allowed the use of a fan retractor in the abdomen. The telerobotic operation was performed without complications or system and communication failures. Telementoring can be used for training purposes but also for consultation between specialists in emergency settings.

Application of Photofrin II as a specific radiosensitising agent in patients with bladder cancer--a report of two cases

BACKGROUND

The effect of ionizing radiation on tumour tissues can be optimised by adding radiosensitising agents to enhance tumour inactivation. Photofrin II has been approved as a photosensitising agent for the photodynamic therapy (PDT) of selected solid tumours. At present, no chemical modifier has been found to act as a selective radiosensitiser. We report here the first use of Photofrin II as a radiosensitising agent to enhance radiation therapy.

PATIENTS

Two patients, one female with unresectable bladder cancer and one male with recurrent inoperable bladder cancer, were treated with radiation therapy (44.8 Gy + 14 Gy boost) of the pelvic region. 24 hours before initiation of therapy the patients were intravenously injected with 1 mg kg(-1) Photofrin II (Axcan, Canada).

RESULTS

Magnetic resonance imaging of the pelvis with a standardized protocol demonstrated a reduction in tumour volume of approximately 40% in the female patient and 35% in the male patient. The female patient was operated upon after conclusion of radiotherapy, the male patient refused the operation. No severe side effects were observed.

CONCLUSION

Photofrin II is a promising radiosensitising agent in the treatment of patients with advanced solid tumours.

Use of hydro-jet cutting for laparoscopic partial nephrectomy in a porcine model

OBJECTIVES

To evaluate whether a laparoscopic hydro-jet device can provide a safe and effective partial nephrectomy. Partial nephrectomy is still one of the most challenging operations in urologic laparoscopy. The control of hemorrhage is very difficult to achieve with laparoscopic techniques. In open surgery, hydro-jet resection is used to cut the renal parenchyma selectively, avoiding damage to the vascular structures or collecting system.Methods. Laparoscopic wedge, as well as pole, resections of the kidney were performed in 5 pigs under general anesthesia. After exposure of the kidney, the renal capsule was incised using electrocautery. The hydro-jet was then used to dissect the renal parenchyma. In pole resections, the collecting system and central vessels were divided using an Endo-GIA. Hemostasis was achieved by electrocoagulation or clips. The dissection time and intraoperative complications were evaluated.Results. The operations were performed successfully in all animals without temporary ischemia. The hydro-jet generator allowed precise and effective tissue dissection without significant hemorrhage. The parenchymal vessels were selectively coagulated. The collecting system and central vessels remained intact and could be divided after application of the Endo-GIA. The mean dissection time was 42 +/- 6 minutes for the wedge resections and 54 +/- 8 minutes for the pole resections.

CONCLUSIONS

These experimental results demonstrate the suitability of hydro-jet dissection for safe laparoscopic partial nephrectomy without temporary ischemia and with reduction of the operative trauma to the kidney. On the basis of our own experiences with other techniques, including electrocautery and laser technology for partial nephrectomy, we conclude that laparoscopic hydro-jet resection represents an interesting alternative to other techniques.

Endoscopic detection of transitional cell carcinoma with 5-aminolevulinic acid: results of 1012 fluorescence endoscopies

OBJECTIVES

The initial encouraging results using 5-aminolevulinic acid (5-ALA) induced fluorescence endoscopy (AFE) have promised a procedure with an outstanding sensitivity for the detection of early stage bladder cancer. Summarized here is our clinical experience and data comprising 1012 fluorescence endoscopies.

METHODS

Two hours, 30 minutes before endoscopy, 1.5 g 5-ALA dissolved in 50 mL of 5.7% sodium monohydrogen phosphate was instilled in patients intravesically. Before AFE, all patients underwent white light endoscopy, and a bladder washing cytologic specimen was obtained. A special light source provided blue light (375 to 440 nm) for fluorescence excitation. Suspicious sites were identified by their red fluorescence contrasting against backscattered blue light when observed through the long pass filter (445 nm) integrated into the telescope eyepiece.

RESULTS

Two thousand four hundred seventy-five specimens were obtained (2.4 biopsies per AFE). In 552 AFEs (54.5%), neoplastic urothelial lesions were detected, in 34.2% only because of their positive fluorescence; 38.7% of these additionally detected neoplastic foci had poorly differentiated histologic features.

CONCLUSIONS

AFE has proved to be a clinically feasible procedure with an outstanding detection rate for flat, urothelial, high-risk lesions.

Immunomagnetic cell enrichment detects more disseminated cancer cells than immunocytochemistry in vitro

PURPOSE

We describe a method to improve tumor cell detection compared to currently available immunocytochemical methods by using immunomagnetic cell enrichment.

MATERIALS AND METHODS

Two different methods of immunomagnetic cell enrichment using antibody coated magnetic beads were tested and compared with unenriched immunocytochemistry. One method was positive selection of epithelial cells from mononuclear cells with the antiepithelial antibody BER-EP4 and the other was depletion of mononuclear cells with the antileukocyte antibody CD45. Mononuclear cells were isolated from peripheral blood by density centrifugation and various numbers of tumor cells were added. The 5 different cell lines from urological malignancies used in the study were DU-145, RT-4, CAKI-2, KTCTL-2 and KTCTL-30. Following incubation of cell suspensions with the beads, cell separation was performed in a magnetic field. After centrifugation on glass slides immunocytochemical staining for cytokeratin was performed. A total of 112 experiments were completed and negative controls were obtained.

RESULTS

The number of tumor cells detected by positive selection and depletion was significantly higher than by immunocytochemistry (p <0.001). The median enrichment factor and tumor cell recovery rate for positive selection and depletion were 15.3 and 61.2%, and 13.0 and 57.3%, respectively (not significant). With less than 1 tumor cell suspended in 106 mononuclear cells, the probability of tumor cell detection was 23% for immunocytochemistry alone and 93.3% for both enrichment methods (p <0.01). No false-positive results were observed.

CONCLUSIONS

Compared to immunocytochemistry, immunomagnetic cell enrichment significantly improves the sensitivity of detection of epithelial cells added to mononuclear cells. Both methods of enrichment were equally effective and may be important for clinical practice in the future.

Immunomagnetic cell enrichment detects more disseminated cancer cells than immunocytochemistry in vitro

PURPOSE

We describe a method to improve tumor cell detection compared to currently available immunocytochemical methods by using immunomagnetic cell enrichment.

MATERIALS AND METHODS

Two different methods of immunomagnetic cell enrichment using antibody coated magnetic beads were tested and compared with unenriched immunocytochemistry. One method was positive selection of epithelial cells from mononuclear cells with the antiepithelial antibody BER-EP4 and the other was depletion of mononuclear cells with the antileukocyte antibody CD45. Mononuclear cells were isolated from peripheral blood by density centrifugation and various numbers of tumor cells were added. The 5 different cell lines from urological malignancies used in the study were DU-145, RT-4, CAKI-2, KTCTL-2 and KTCTL-30. Following incubation of cell suspensions with the beads, cell separation was performed in a magnetic field. After centrifugation on glass slides immunocytochemical staining for cytokeratin was performed. A total of 112 experiments were completed and negative controls were obtained.

RESULTS

The number of tumor cells detected by positive selection and depletion was significantly higher than by immunocytochemistry (p <0.001). The median enrichment factor and tumor cell recovery rate for positive selection and depletion were 15.3 and 61.2%, and 13.0 and 57.3%, respectively (not significant). With less than 1 tumor cell suspended in 106 mononuclear cells, the probability of tumor cell detection was 23% for immunocytochemistry alone and 93.3% for both enrichment methods (p <0.01). No false-positive results were observed.

CONCLUSIONS

Compared to immunocytochemistry, immunomagnetic cell enrichment significantly improves the sensitivity of detection of epithelial cells added to mononuclear cells. Both methods of enrichment were equally effective and may be important for clinical practice in the future.

Allogeneic vaccination for renal cell carcinoma: development and monitoring

An allogeneic tumor cell vaccine should display a natural immunogenicity that allows the stimulation of tumor-reactive effector cells in patients. Furthermore, the vaccine should express antigens that are shared by many tumors to which patients are not tolerant. A variety of tumor peptides should be presented by different HLA-molecules due to limited MHC matching with recipients and last but not least, the vaccine should have a strong growth potential in vitro to allow adequate amounts of vaccine to be generated for long-term usage. In vitro and in situ studies with the renal cell carcinoma cell line RCC-26 demonstrate: (1) RCC-26 can induce complex allospecific responses through direct priming; (2) RCC-26 can not only reactivate cytotoxic T lymphocytes (CTL) of a memory phenotype but they also can induce de novo tumor-antigen associated responses in normal donors; (3) these cells present epitopes restricted by several MHC molecules, allowing the vaccination of patients matched for different HLA alleles; and (4) they stimulate HLA-A*0201-restricted T cells bearing characteristic T cell receptors (TCR). Thus, in addition to using limiting dilution killer and ELISPOT assays, molecular tracking of a tumor-specific TCR can be used to judge the development of antitumor reactivity and vaccine efficiency.

Growth hormone has no direct effect on human adrenal steroid and insulin-like growth factor-binding protein secretion

Although it is known that growth hormone (GH) exerts its growth-promoting effects mainly via Insulin-like growth factor-I (IGF-I), an increasing number of direct effects of GH has been described in many tissues. In vivo, mice transgenic for human growth hormone (hGH) show significantly elevated levels of corticosterone, enlarged adrenal glands, and altered levels of insulin-like growth factor binding proteins (IGF-BPs). Recently, we have shown that IGF's induce the secretion of cortisol and IGF-BP's in adult human adrenocortical cells. However, since human adrenal glands express the intact GH-receptor, the objective of this study was to investigate whether GH exerts a direct effect on the steroidogenesis and IGF-BP synthesis in adult human adrenocortical cells. Primary cell cultures in monolayer were incubated under serum-free conditions with human growth hormone and/or ACTH for up to 72 hours. Cortisol was measured by specific RIA and the secretion of insulin-like growth factor binding proteins was analyzed by Western ligand blotting. hGH alone was unable to stimulate basal or ACTH-induced cortisol secretion. Additionally, neither hGH alone or in combination with ACTH did significantly alter the secretion of IGF-BP's. Therefore we conclude that hGH is unable to directly stimulate cortisol secretion and IGF-BP secretion in cultured human adrenocortical cells.

Expression of plakoglobin in renal cell carcinoma

Little is known about the role of molecules involved in cell-cell interactions during the progression of renal cell carcinoma (RCC). We investigated the expression of plakoglobin (a component of the cadherin-catenin adhesion system) in 94 samples of normal kidney tissue from patients with RCC, in 109 primary renal cell carcinomas and in 16 metastases by immunohistochemistry. Expression of plakoglobin was significantly diminished in tumor tissue, particularly in metastatic lesions, as compared to normal kidney tissue (p < 0.001). Follow-up data were available from 87 patients. Patients with a diffuse plakoglobin expression (91-100% positive cells) in primary tumor tissue had a significant better survival rate than patients with a disturbed plakoglobin expression (p < 0.05) as determined by the log rank test. These results indicate that loss of plakoglobin may play an important role in malignant transformation of renal cells. Plakoglobin expression status could give additional information about the individual prognosis.

Limitations of reverse-transcriptase polymerase chain reaction analyses for detection of micrometastatic epithelial cancer cells in bone marrow

PURPOSE

This study was designed to evaluate the potential of reverse-transcriptase polymerase chain reaction (RT-PCR) analyses for the detection of micrometastatic carcinoma cells in bone marrow (BM).

PATIENTS AND METHODS

The specificity of RT-PCR assays with primers specific for various tumor-associated and organ-specific mRNA species was examined by analysis of 53 BM aspirates from control patients with no epithelial malignancy. In addition, BM samples from 63 patients with prostate cancer (n = 53) or breast cancer (n = 10) were analyzed by RT-PCR with primers specific for prostate-specific antigen (PSA) mRNA. As a reference method, all samples were analyzed simultaneously by an established immunocytochemical assay, using monoclonal antibodies (mAbs) against cytokeratins (CK) for tumor-cell detection.

RESULTS

Seven of eight marker species could be detected in a considerable number of BM samples from control patients: epithelial glycoprotein-40 (EGP-40; 53 of 53 samples), desmoplakin I (DPI I; five of five), carcinoembryonic antigen (CEA; five of 19), erb-B2 (five of seven), erb-B3 (six of seven), prostate-specific membrane antigen (PSM; four of nine), and CK18 (five of seven). Only PSA mRNA was not detected in any of the 53 control BM samples. In serial dilution experiments, the PSA RT-PCR assay was able to detect five LNCaP prostate carcinoma cells in 4 x 10(6) BM cells. CK-positive cells were found in 20 patients (37.7%) with prostate cancer, while PSA mRNA was found in only 15 (28.3%; P = .04). Moreover, despite the recent observation that PSA is also expressed in mammary carcinomas, none of the 10 CK-positive BM samples were PSA mRNA-positive.

CONCLUSION

Limiting factors in the detection of micrometastatic tumor cells by RT-PCR are (1) the illegitimate transcription of tumor-associated or epithelial-specific genes in hematopoietic cells, and (2) the deficient expression of the marker gene in micrometastatic tumor cells.

Cellular and molecular analyses of major histocompatibility complex (MHC) restricted and non-MHC-restricted effector cells recognizing renal cell carcinomas: problems and perspectives for immunotherapy

Renal cell carcinomas belong to the small group of tumors that are able to induce antitumor responses. Here we describe two general types of cytotoxic effector lymphocytes that can eliminate autologous tumor cells and discuss the role that major histocompatibility complex encoded molecules play in governing their specificities. Improved understanding of the cellular and molecular basis of renal cell carcinoma recognition opens new avenues of research with the potential to develop better immunotherapies for patients with metastatic disease.

[Immunotherapy of metastatic renal cell carcinoma. Is clinical use justified in view of outcome, side effects and costs?]

The immunogenic potential of renal cell carcinoma and the resistance of its metastases against chemotherapy, radiation and hormonal treatment have led to the development of a great number and variety of different strategies, summarized under the term immunotherapy. Objective remissions can be expected in about 20-40% of patients. Another 30-40% show stable disease for a limited time, only occasionally for longer. Most results are from uncontrolled phase II studies. A cancer cure can usually not be expected, long-term remissions are rare (5%), and high remission rates are only observed in studies with strong patient selection. Some authors have reported a higher survival rate in patients treated with IL-2 or IFN. Survival of patients with objective remissions is significantly improved. A standard therapy cannot be defined. Even presuming an increased survival rate, the toxicity, which can lead to a dramatic reduction in quality of life, and the high costs have to be considered carefully. We think that in view of the lack of therapeutic alternatives, the improving efficacy, the potential survival benefit, the reduction of toxicity and the perspectives, immunotherapy is essential in the treatment of metastatic renal cell carcinoma. Its use should be confined to clinical studies.

Phase I and pharmacokinetic study of the P-glycoprotein modulator dexniguldipine-HCL

Dexniguldipine (DNIG) is the R-enantiomer of the dihydropyridine derivate niguldipine. DNIG showed a binding affinity to the P-glycoprotein (P-gp) and therefore it is to be assumed to block the P-gp pumping mechanism. This open phase I study was conducted to determine the maximal tolerated dose (MTD) and safety of intravenously administered DNIG alone and in combination with vinblastine in patients with a metastatic or locally advanced cancer. Additionally, serum levels of DNIG were assessed and compared between dosage groups to investigate the intravenous dose linearity. The study was divided into two parts concerning DNIG administration. In part I the patients received DNIG for four hours daily over four consecutive days and additionally 0.15 mg/kg vinblastine at day 3. Treatment was started with 1 mg/kg/4h, and whenever the drug was well tolerated the dosage was increased. In part II the patients received up to three courses of a four-hour infusion (5 and 7 mg/kg/4h) of DNIG followed by a continuous infusion for 48 hours (5 and 7 mg/kg/24h). Twenty-six patients entered this trial and were given at least one infusion of DNIG; vinblastine was given immediately after the 4-hour infusion. One to seven courses and dosages from 1-11 mg/kg were administered. In five patients the dose limiting toxicity was seen in cardiovascular adverse events such as a drop in blood pressure, decreased heart rate and in one patient an AV block III. Most frequent adverse events were nausea, dizziness, vomiting, peripheral paresthesia, atactic gait, mild constipation, polyuria, hypocalcemia; all disappeared within 24 hours after discontinuation of infusion. A linear increase in DNIG serum concentration with increasing doses was found following intravenous infusion of DNIG over a four-hour period. Long-term infusion regimes over a period of two or five days resulted in reasonably constant DNIG serum levels. MTD was determined at 5 mg/kg/4h. It is to be assumed that the MTD for continuous infusion of DNIG is higher than 5 mg/kg/24h, but this was not followed up in the study and must be the aim of a later trial.

Establishment of micrometastatic carcinoma cell lines: a novel source of tumor cell vaccines

BACKGROUND

Cancer cells of microscopic metastases can be envisaged as ideal constituents for the development of a genetically modified, autologous tumor cell vaccine. However, their extremely low number has thus far blocked this approach.

PURPOSE

The aim of this study was to culture micrometastatic tumor cells present in bone marrow of patients with various forms of epithelial cancer and to thereby establish immortalized cell lines.

METHODS

Bone marrow aspirates from the upper iliac crest of 152 patients with cancer of the prostate, kidney, lung, breast, or colorectum were cultured at 1 x 10(7) to 6 x 10(7) mononuclear cells (MNC) per flask in fetal calf serum-containing RPMI-1640 medium supplemented with 10 ng/mL epidermal growth factor and 10 ng/mL basic fibroblast growth factor. The proliferation of epithelial cells on extracellular matrix-coated plates was monitored by sampling and staining aliquots with cytokeratin-specific antibodies. After 3-6 weeks in culture, the cells were transferred to Petri dishes, and 200-300 epithelial cells per plate were microinjected with DNA encoding for the simian virus 40 (SV40) large T antigen. Cells were screened at various time points for expression of large T antigen and epithelial markers, such as cytokeratins, prostate-specific antigen, prolactin-inducible protein, or intestinal-specific annexin; their bone marrow-seeking potential was tested in immunodeficient SCID (i.e., severe combined immunodeficiency) mice given subcutaneous transplants of the immortalized cells.

RESULTS

Prior to culture, more than 90% of all samples presented with fewer than 10 tumor cells per 8 x 10(5) MNC. In 68 cases (44.7%), the established culture conditions allowed a two to four log transient expansion of these cells with rather small differences among the tumor types studied. Epidermal growth factor and basic fibroblast growth factor were found to be essential for this culture system. After microinjection of the propagated cells with T-antigen DNA, permanent cell lines were obtained; some of these cell lines (prostate and lung cancer cell lines) are now beyond culture passage 80. The cells showed no notable changes in the pattern of expressed epithelial antigens and were able to disseminate into bone marrow in SCID mice.

CONCLUSIONS

This procedure allows the selective immortalization of micrometastatic carcinoma cells. Integration of SV40 DNA and expression of T antigen did not substantially change the epithelial phenotype of the propagated cells.

IMPLICATIONS

The established system will allow an in-depth molecular analysis of human micrometastatic cancer cells and could become a useful source for the generation of autologous tumor cell vaccines.

[Tumor cell vaccination for treatment of renal cell carcinoma]

Vaccination, mostly with inactivated autologous tumour, has been carried out for the treatment of renal cell cancer since 1976. Attempts to enhance immunogenicity have involved the use of different modifications and added adjuvants for preparation of the vaccines. In metastatic renal cell cancer vaccination has proved to be ineffective, apart from remissions observed in isolated cases. In principle, however, it does seem that vaccination might be valuable as an adjuvant treatment for renal cell cancer. Following resection of the primary tumour, the blood and lymphatic system should be sterilized by cytotoxic T cells and antitumour antibodies induced by vaccination. The effectiveness of such therapeutic procedures cannot be proven except in prospective randomized trials with untreated patients as controls. Clinical trials of autologous tumour vaccines modified by bacillus Calmette Guérin have failed to demonstrate increased disease-free survival. New prospects for future vaccine preparations are opened up by the recent detection of MHC-restricted tumour-specific T cells and by the possibility of genetically modified vaccines.

Interferon alfa and vinblastine versus medroxyprogesterone acetate in the treatment of metastatic renal cell carcinoma

OBJECTIVES

Since the beginning of the 1980s, when gene technology provided sufficient amounts of cytokines, numerous Phase II studies in metastatic renal cell carcinoma were carried out mostly with interferon alfa (IFN-alpha) and interleukin-2 (IL-2). So far, no randomized prospective trials including untreated control groups have been reported. We present a prospective study comparing IFN-alpha and vinblastine (VBL) versus medroxyprogesterone acetate (MPA).

METHODS

Immunochemotherapy schedule consists of IFN-alpha 8 million U/day subcutaneously for 3 days per week and VBL 0.1 mg/kg body weight intravenously at 3-week intervals. MPA was administrated intramuscularly at a dosage of 500 mg/week. The response rates, toxicities, and actuarial overall survival were analyzed.

RESULTS

The overall response rate in 41 patients receiving IFN-alpha and VBL treatment was 20.5% (95% confidence interval, 9% to 33%). Four patients reached a complete and 5 patients reached a partial remission. No remissions were observed in 35 patients of the control group. A statistically significant survival benefit for the IFN-alpha and VBL group could not be demonstrated. Excluding fever, mild to moderate toxicities were observed. About one third of patients refused the proposed schedule due to general malaise and fatigue.

CONCLUSIONS

A survival benefit or a favorable outcome of patients with metastatic renal cell carcinoma, treated with IFN-alpha and VBL, could not be demonstrated. As judged from this analysis, IFN-alpha and VBL therapy does not sufficiently meet the requirements of a palliative treatment of renal cell carcinoma.

Immunocytochemical detection and phenotypic characterization of micrometastatic tumour cells in bone marrow of patients with prostate cancer

Monoclonal antibodies (mAbs) specific for cytokeratins are potent probes for the identification of disseminated individual epithelial tumour cells in mesenchymal organs such as bone marrow. We have used a monoclonal antibody (mAB) against cytokeratin 18 (CK18) for the detection of individual metastatic tumour cells in bone marrow aspirates from 84 patients with carcinoma of the prostate. CK18+ cells were detected in a sensitivity of 1 per 8 x 10(5) marrow cells using the alkaline phosphatase anti-alkaline phosphatase (APAAP) system for staining. We were able to detect CK18+ tumour cells in the marrow of 33% of patients with stage N0M0 prostate cancers. The incidence of CK18+ cells showed a significant correlation with established risk factors, such as local tumour extent, distant metastases and tumour differentiation. For further characterization of such cells in patients with prostate cancer, we developed an immunocytochemical procedure for simultaneous labelling of cytokeratin component no. 18 (CK18) and prostate-specific antigen (PSA). In a first step, cells were incubated with a murine mAb against PSA, followed by gold-conjugated goat anti-mouse antibodies. In a second step, a biotinylated mAb to CK18 was applied as primary antibody and subsequently incubated with complexes of streptavidin-conjugated alkaline phosphatase, which were developed with Newfuchsin substrate. The binding of gold-labelled antibodies was visualized by silver enhancement. CK18+ cells co-expressing PSA were found in bone marrow aspirates from 5 out of 14 patients with carcinomas of the prostate. The specificity of CK18 for epithelial tumour cells in bone marrow was supported by negative staining of 12 control aspirates from patients with benign prostatic hyperplasia (BPH).(ABSTRACT TRUNCATED AT 250 WORDS)

Tumor-specific lysis of human renal cell carcinomas by tumor-infiltrating lymphocytes. I. HLA-A2-restricted recognition of autologous and allogeneic tumor lines

Metastatic renal cell carcinoma (RCC), like melanoma, belongs to the small group of human tumors in which partial or complete remission has been observed in some patients after treatment with various forms of immunotherapy. In contrast to melanoma, CTL showing MHC-restricted lysis of RCC have not been easily found among tumor-infiltrating lymphocytes (TIL). This has led to the suggestion by some that responses to immunotherapy are mediated predominantly by non-MHC-restricted effector cells. We have characterized an MHC-restricted, CD8+ CTL line obtained from an uncloned TIL population of a primary RCC using a low concentration of rIL-2; in fact, these CTL represented a majority of the short-term cultured TIL population. The CTL lysed autologous tumor cells but not normal kidney cells or target cells sensitive to non-MHC-restricted effector cells. In contrast, lymphokine-activated killer (LAK) cells grown in a high concentration of rIL-2 from the patient's PBL lysed autologous tumor and normal kidney cells in addition to several allogeneic tumors. The TIL could be expanded optimally using an autologous tumor line retrovirally transduced with the human cDNA encoding IL-2. TIL were 20-fold more potent than LAK cells in eliminating the IL-2 expressing tumor cells in vitro. The cultured TIL utilized a restricted number of V alpha gene families, suggesting that they may recognize only a limited number of MHC-peptide complexes presented by autologous tumor cells. HLA-A2 was identified as an MHC restriction molecule for presentation of one tumor-derived peptide to these CTL. Only some allogeneic HLA-A2 RCC tumors were lysed. Sequencing of the second and third exons of the HLA-A2 alleles of these cells revealed that both heterogeneity in MHC and peptide availability influenced CTL recognition. These studies demonstrate that some RCC express common antigenic determinants that can be recognized by MHC-restricted CTL and open the possibility of defining the nature of RCC-derived peptides, which, combined with HLA-A2, can generate specific immune responses.

Tumor-specific lysis of human renal cell carcinomas by tumor-infiltrating lymphocytes. I. HLA-A2-restricted recognition of autologous and allogeneic tumor lines

Metastatic renal cell carcinoma (RCC), like melanoma, belongs to the small group of human tumors in which partial or complete remission has been observed in some patients after treatment with various forms of immunotherapy. In contrast to melanoma, CTL showing MHC-restricted lysis of RCC have not been easily found among tumor-infiltrating lymphocytes (TIL). This has led to the suggestion by some that responses to immunotherapy are mediated predominantly by non-MHC-restricted effector cells. We have characterized an MHC-restricted, CD8+ CTL line obtained from an uncloned TIL population of a primary RCC using a low concentration of rIL-2; in fact, these CTL represented a majority of the short-term cultured TIL population. The CTL lysed autologous tumor cells but not normal kidney cells or target cells sensitive to non-MHC-restricted effector cells. In contrast, lymphokine-activated killer (LAK) cells grown in a high concentration of rIL-2 from the patient's PBL lysed autologous tumor and normal kidney cells in addition to several allogeneic tumors. The TIL could be expanded optimally using an autologous tumor line retrovirally transduced with the human cDNA encoding IL-2. TIL were 20-fold more potent than LAK cells in eliminating the IL-2 expressing tumor cells in vitro. The cultured TIL utilized a restricted number of V alpha gene families, suggesting that they may recognize only a limited number of MHC-peptide complexes presented by autologous tumor cells. HLA-A2 was identified as an MHC restriction molecule for presentation of one tumor-derived peptide to these CTL. Only some allogeneic HLA-A2 RCC tumors were lysed. Sequencing of the second and third exons of the HLA-A2 alleles of these cells revealed that both heterogeneity in MHC and peptide availability influenced CTL recognition. These studies demonstrate that some RCC express common antigenic determinants that can be recognized by MHC-restricted CTL and open the possibility of defining the nature of RCC-derived peptides, which, combined with HLA-A2, can generate specific immune responses.

Immunocytochemical double staining of cytokeratin and prostate specific antigen in individual prostatic tumour cells

Early dissemination of malignant cells is the main cause for metastatic relapse in patients with solid tumours. By use of monoclonal antibodies (mAbs) specific for cytokeratins, disseminated individual epithelial tumour cells can now be identified in mesenchymal organs such as bone marrow. Further to characterize such cells in patients with prostate cancer, an immunocytochemical procedure was developed for simultaneous labelling of cytokeratin component no. 18 (CK18) and prostate specific antigen (PSA). In a first step, cells were incubated with mAb ER-PR8 against PSA and secondary gold-conjugated goat anti-mouse antibodies. In a second step, biotinylated mAb CK2 to CK18 was applied as primary antibody and subsequently incubated with complexes of streptavidin-conjugated alkaline phosphatase, which were developed with the Newfuchsin substrate. The binding of gold-labelled antibodies was visualized by silver enhancement. The sensitivity and specificity of the technique was demonstrated on cryostat sections of hyperplastic prostatic tissue, and cytological preparations of LNCaP prostatic tumour cells. Double staining was restricted to cells derived from the secretory epithelium of the prostate. Cross-reactivity between both detection systems was excluded by several controls, including the use of unrelated antibodies of the same isotype and the staining of CK18+/PSA- HT29 colon carcinoma cells. CK18+ cells co-expressing PSA were found in bone marrow aspirates from 5 out of 13 patients with carcinomas of the prostate, a finding that is consistent with the relative fraction of double-positive LNCaP cells. The specificity of CK18 for epithelial tumour cells in bone marrow was supported by negative staining of 12 control aspirates from patients with benign prostatic hypertrophy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of the West German multicenter study "Urological traumatology"]

The West German Multicenter Study on Urological Traumatology ran from April 1984 to December 1986. During this time, 19 departments of urology evenly scattered over the Federal Republic of Germany including Berlin (West) recorded and evaluated the data pertaining to a total of 385 patients (83% male, 17% female) with urogenital trauma. The distribution of the different mechanisms of injury demonstrates that 41% were due to traffic accidents; 13% each to accidents during sports and work; 8% to sexual activities; and 6% to violence. The trauma was slight in 40% of the cases, moderate in 21%, and severe in 39%. Of a total of 427 urogenital injuries, 27% were combined with intra-abdominal and 24% with pelvic injuries. Renal injuries were recorded in 51%, ruptures accounting for 49% of these and contusions for 48%. Hilar lesions were observed in 7%, with complete destruction of the organ occurred in 6% of these cases. In all, 76% of these traumas were treated conservatively, while 8% each required surgical reconstruction and nephrectomy. Traumatic lesions of the urinary bladder, urethra, penis, and scrotum including the testes and accessory organs were recorded in about 10% each. Macrohematuria was seen with 73% of renal, 83% of urinary bladder, and 73% or urethral injuries. Microhematuria occurred with 24%, 9%, and 13% of all cases, while no hematuria was ascertained in 3%, 5%, and 13% of renal, bladder and urethral traumas, respectively. The injury-related sensitivity of the different imaging methods was calculated at 95% for cystograms, 91% for retrograde urethrograms, and 83% for angiograms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Late sequelae after urogenital trauma. Results of follow-up studies]

In the course of the Multicenter Study on Urological Traumatology ("UMCEST"), 61 patients who had been treated at the Departments of Urology of the Ludwig Maximilian University in Munich and the Heinrich Heine University in Düsseldorf were followed up. These included 39 patients with multiple trauma and 22 patients who had suffered isolated urological injuries. There were 45 patients with renal injuries, 7 with injuries to the bladder, and 11 who had presented with urethral injuries. Late complications were detected in 38% of the 45 patients with renal injuries. Of the 11 patients with urethral injuries, 6 suffered from urethral strictures, 9 from sexual dysfunction and 3 from incontinence. The 7 patients with bladder injuries had no late complications related to the bladder trauma.