Hypericum perforatum L. extract – Novel photosensitizer against human bladder cancer cells

The polar methanolic fraction (PMF) of the Hypericum perforatum L. extract has recently been developed and tested as a novel, natural photosensitizer for use in the photodynamic therapy (PDT), and photodynamic diagnosis (PDD). PMF has been tested on HL-60 leukemic cells and cord blood hemopoietic progenitors. In the present study, the efficacy of PMF as a phototoxic agent against urinary bladder carcinoma has been studied using the T24 (high grade metastatic cancer), and RT4 (primary low grade papillary transitional cell carcinoma) human bladder cancer cells. Following cell culture incubation, PMF was excited using 630 nm laser light. The photosensitizer exhibited significant photocytotoxicity in both cell lines at a concentration of 60microg/ml, with 4-8 J/cm(2) light dose, resulting in cell destruction from 80% to 86%. At the concentration of 20microg/ml PMF was not active in either cell line. These results were compared with the results obtained in the same cell lines, under the same conditions with a clinically approved photosensitizer, Photofrin. Photofrin was used in the maximum clinically tolerable dose of 4microg/ml, and it was also excited with 630 nm laser light. In the T24 cell Photofrin exhibited slightly less photocytotocixity, compared with PMF, resulting in 77% cell death with 8J/cm(2) light dose. However, against the RT4 cells Photofrin resulted in minimal cell death (9%) with even 8J/cm(2) light dose. Finally, the type of cell death induced by PMF photoactivation was studied using flow cytometry and DNA laddering. Cell death by PMF photodynamic action in these two bladder cell lines is caused predominently by apoptosis. The reported significant photocytotoxicity, selective localization, natural abundance, easy, and inexpensive preparation, underscore that the PMF extract hold the promise of being a novel, effective PDT photosensitizer.

CD44 standard form expression as a predictor of progression in high risk superficial bladder tumors

OBJECTIVE

The purpose of this study was to assess the significance of the standard CD44 adhesion molecule expression in predicting progression of high risk superficial bladder carcinoma in the short term.

METHODS

Sixty-six patients (51 males and 15 females, aged 27 to 89 years (mean 64.75 years) with primary superficial transitional cell bladder cancer initially treated with transurethral resection (TURBT) were enrolled in the study. Only pTa/pT1 grade 2 multiple tumors as well as all grade 3 tumors were included in this study. All tumor samples obtained after the resection were immunohistochemically evaluated for the expression of the CD44 standard molecule. Fifty eight patients remained during the follow up period which ranged from 3 to 36 months (mean 11.8 months). Tumor progression in the short term was considered as the critical end point of interest in this study. The prognostic significance of tumor stage, grade, presence of carcinoma-in-situ (CIS) and expression of CD44 in determining the risk for progression, was studied with both univariate (log rank test) and multivariate (Cox proportional hazards) methods of analysis.

RESULTS

Kaplan-Meier survival curves indicated that a shorter median progression-free survival is expected for those patients with G3 bladder tumors (p = 0.0055), concomitant CIS (p = 0.0051), and loss of expression of CD44 (p = 0.0015), whereas a similar association with stage was not detected (p = 0.5793). The cox regression multivariate analysis did not yield a significant result for any of the studied parameters therefore no one of the factors taken into account can serve as an independent predictor of progression in superficial bladder cancer in the short term.

CONCLUSION

The immunohistochemically detectable loss of the expression of CD44 standard form from superficial bladder tumor samples may be, complementary to the established prognostic factors, a useful predictor of tumor progression in the short term.

Primary testicular seminoma in a patient with a history of extragonadal non-seminomatous germ cell carcinoma

Extragonadal germ cell carcinoma represents between 3% and 5% of all germ cell carcinomas. A metachronous primary germ cell carcinoma is exceedingly rare in these patients. We report the eighth case, which occurred in a 29-year-old man who presented with testicular seminoma 7 years after his initial presentation with extragonadal non-seminomatous germ cell carcinoma. The seven other patients also presented with extragonadal non-seminomatous germ cell carcinoma, followed subsequently by testicular seminoma in 6 patients and non-seminomatous germ cell carcinoma in the seventh. The mean time to presentation was 8 years. Although rare, this case emphasizes the need for long-term surveillance, including testicular evaluation of patients with a history of extragonadal germ cell carcinoma.

Photodynamic therapy using porfimer sodium as an alternative to cystectomy in patients with refractory transitional cell carcinoma in situ of the bladder. Bladder Photofrin Study Group

PURPOSE

Photodynamic therapy combines a photosensitizer, such as porfimer sodium (Photofrin), with red laser light (630 nm.) to destroy cancer cells. Investigators have reported the effectiveness of photodynamic therapy in the treatment of patients with recurrent superficial bladder cancer. We assess the safety and efficacy of 1 or 2 photodynamic treatments using porfimer sodium and controlled uniform laser light (630 nm.) as an alternative to cystectomy in patients with refractory vesical carcinoma in situ of the bladder.

MATERIALS AND METHODS

A total of 36 patients with carcinoma in situ were treated with whole bladder photodynamic therapy as an alternative to cystectomy. In all patients at least 1 course of bacillus Calmette-Guerin (BCG) had failed. Each patient received a single whole bladder photodynamic therapy treatment, consisting of 2 mg./kg. porfimer sodium intravenously followed 40 to 50 hours later by intravesical red light (630 nm.) at 15 J./cm.2. Post-photodynamic therapy evaluations included weekly telephone contact to assess acute adverse reactions, and assessment of efficacy and bladder toxicity at 3 months and quarterly thereafter.

RESULTS

At initial clinical evaluation at 3 months 58% of the patients had a complete response as indicated by negative cystoscopy, bladder biopsy and urine cytology but in 42% treatment failed. At a mean followup of 12 months (range 9 to 48) 10 of the 21 complete responders had recurrence for an overall durable response rate of 31%. Fourteen patients subsequently underwent cystectomy for persistent carcinoma in situ (12) and carcinoma in situ recurrence (2). Of the 36 patients 7 experienced bladder contracture.

CONCLUSIONS

The initial results are encouraging for a single whole bladder photodynamic treatment of patients in whom prior intravesical therapy for carcinoma in situ has failed. While followup is short, porfimer sodium photodynamic therapy appears potentially promising as an alternative to cystectomy in patients with refractory carcinoma in situ.

Superficial bladder cancer: the role of interferon-alpha

PURPOSE

We evaluate the clinical experience with recombinant interferon-alpha in superficial transitional cell carcinoma and discuss the most rational use of recombinant interferon-alpha in the context of current treatment options.

MATERIALS AND METHODS

The available data were reviewed and discussed at a consensus conference in August 1996. The conclusions and recommendations are those of the authors based on the consensus reached at that meeting.

RESULTS

While bacillus Calmette-Guerin (BCG) is recognized as the most efficacious intravesical agent in the prophylaxis and treatment of superficial transitional cell carcinoma, it is associated with significant toxicities and a 20 to 40% relapse rate. Interferons, particularly recombinant interferon-alpha, have demonstrated efficacy against primary and recurrent papillary transitional cell carcinoma and carcinoma in situ with minimal toxicity, although the response and relapse rates are inferior to BCG. Intravesical recombinant interferon-alpha therapy has also produced responses in patients who failed to respond or were refractory to BCG or chemotherapy.

CONCLUSIONS

The clinical experience suggests that recombinant interferon-alpha has an important role in the treatment of superficial transitional cell carcinoma, particularly as second line therapy following failure of BCG or chemotherapy, and it may have synergistic effects when combined with chemotherapy or BCG. We propose a prospective randomized study comparing the efficacy of recombinant interferon-alpha, BCG and BCG plus recombinant interferon-alpha as maintenance following complete response to primary BCG therapy. The proposed study would also investigate the efficacy of BCG plus recombinant interferon-alpha as second line therapy following BCG failure. This study will be important to determine the most effective strategy to integrate recombinant interferon-alpha into current treatment options for superficial bladder cancer.

Photodynamic therapy (PDT) in the treatment of patients with resistant superficial bladder cancer: a long-term experience

INTRODUCTION AND OBJECTIVE

Photodynamic therapy (PDT) combines a photosensitizer such as Photofrin with red laser light (630 nm) to destroy cancer cells. Investigators have reported effectiveness of PDT in the management of patients with recurrent superficial bladder cancer. We retrospectively reviewed our experience in 58 patients to assess the long-term role of PDT in the management of resistant superficial transitional cell carcinoma (TCC) including Ta, T1, and refractory carcinoma in situ (CIS) of the urinary bladder.

MATERIALS AND METHODS

All 58 patients had failed at least one course of standard intravesical therapy or had contraindication for intravesical chemo- or immunotherapy. Patients with malignancy present (Ta-T1/Grade I-III, CIS) were accepted for ablative PDT. Patients undergoing prophylactic PDT after complete resection were confirmed to be tumor-free by cystoscopy and bladder was cytology before PDT. Post-PDT evaluations included weekly telephone contact to assess acute adverse reactions and assessment of efficacy and bladder toxicity at three months and quarterly thereafter.

RESULTS

These 58 patients underwent a single PDT treatment with 2.0 or 1.5 mg/kg of Photofrin and 10-60 J/cm2 light (630 nm). At three months, complete response rates were 84% and 75% for residual resistant papillary TCC and refractory CIS respectively; and 90% of patients treated prophylactically had not had recurrences. At a median followup of 50 months (range 9-110), 59% (34/58) of the responders are alive, with 31/34 still disease-free.

CONCLUSION

PDT using 1.5 mg/kg of Photofrin and 15 J/cm2 of light (630 nm) should be considered a safe and effective treatment for refractory CIS or recurrent papillary TCC.

Treatment of renal cell carcinoma with 5-fluorouracil and alfa-interferon

OBJECTIVES

Renal cell carcinoma is relatively resistant to both chemotherapy and immunotherapy. Response, survival, duration of response, and toxicity of treatment were evaluated in patients with advanced renal cell carcinoma receiving a continuous intravenous infusion of 5-fluorouracil (5-FU) and low dose subcutaneous alfa-2b-interferon.

METHODS

Between 1989 and 1994, 21 patients with advanced renal cell carcinoma underwent treatment with continuous intravenous infusion of 5-FU, 200 mg/m2/day, and subcutaneous injections of recombinant interferon alfa-2b (IFN-alpha), 1 x 10(6) U/day.

RESULTS

Objective response was observed in 9 patients (43%). Complete response occurred in 4 patients (19%): 2 with lung, 1 with bone, and 1 with liver metastasis. Partial response occurred in 5 patients (24%). Three of 4 complete responders remain alive without recurrence. Mean survival rate was 195 weeks among complete responders, 184 weeks among partial responders, and 88 weeks among nonresponders. The overall mean duration of response was 101 weeks. Responders developed progression of disease a mean of 62 weeks after the initial response to therapy. Mild dose-dependent toxicity was related to 5-FU infusion. Nearly all toxicities subsided with the temporary cessation of 5-FU infusion and/or decreasing the dose of the infusion. Few if any of the toxicities appear to be directly related to the low dose interferon injections.

CONCLUSIONS

Although this study is based on a small sample size, we believe that the encouraging complete and partial responses, apparent prolongation of survival, and manageable toxicity of this combination therapy warrant further investigation with larger randomized trials.

Immunotherapy of bladder cancer

Intravesical therapy has been used in the management of superficial transitional cell carcinoma (TCC) of the urinary bladder (i.e., Ta, Tl, and carcinoma in situ) with specific objectives which include treating existing/residual tumor, preventing recurrence of tumor, preventing disease progression, and prolonging survival. The initial clinical stage and grade remain the main determinant factors in survival irrespective of the treatment. Presently, bacillus Calmette-Guerin (BCG) immunotherapy remains the most effective treatment and prophylaxis for TCC (Ta, Tl, CIS) and has positive outcomes on tumor recurrence rate, disease progression, and prolongation of survival. Prostatic urethral mucosal involvement with bladder cancer can be effectively treated with BCG intravesical immunotherapy-it has demonstrated a reduction in tumor recurrence rates, but has had no positive impact on disease progression or prolongation of survival. Interferons, keyhole-limpet hemocyanin (KLH), bropirimine, and PHOTOFRIN-photodynamic therapy (PDT) are under investigation in the management of TCC and early results are encouraging. This comprehensive review highlights recent developments in intravesical therapy of bladder cancer and summarizes the mechanisms of action of BCG, and the important role of intravesical BCG immunotherapy and other immunotherapeutic agents in the therapy and prophylaxis of superficial TCC of the urinary bladder.

Therapy of superficial bladder cancer

Intravesical therapy has been used in the management of superficial transitional cell carcinoma (TCC) of the urinary bladder (Ie, Ta, Tl, and carcinoma in situ [CIS]) with specific objectives that include treating existing/residual tumor, preventing recurrence of tumor, preventing disease progression, and prolonging survival. The initial clinical stage and grade remain the main determinant factors in survival irrespective of the treatment. Intravesical chemotherapy has shown a decrease in short-term tumor recurrence rates, but has had no positive impact on disease progression or prolongation of survival. Presently, bacillus Calmette-Guèrin vaccine (BCG) immunotherapy remains the most effective treatment and prophylaxis for TCC (Ta, Tl, CIS) and has positive outcome on tumor recurrence rate, disease progression, and prolongation of survival. Prostatic urethral mucosal involvement with bladder cancer can also be effectively treated with BCG intravesical immunotherapy. Interferons, keyhole limpet hemocyanin and photofrin-photodynamic therapy are under investigation in the management of TCC and early results are encouraging. This review highlights and summarizes the recent advances in intravesical therapy and prophylaxis of superficial TCC.

Photodynamic therapy in the management of bladder cancer

Photodynamic therapy (PDT) is primarily suggested for the therapy of papillary transitional cell carcinoma (TCC) and refractory carcinoma in situ (CIS), and prophylaxis of recurrent superficial TCC in those patients who have failed intravesical chemotherapy or immunotherapy. We reviewed our 13-year experience to assess the long-term role of PDT in the management of superficial bladder cancer, and propose a standard protocol. Fifty eight patients underwent a single PDT treatment with 1.5-2.0 mg/kg of Photofrin and 10-25 J/cm2 of light (630 nm). This single PDT treatment produced overall response rates of 84.2% in 19 patients with recurrent superficial papillary TCC, 80% in 20 patients with refractory CIS, and 89.5% in 19 patients receiving prophylaxis. The PDT dose of 2.0 mg/kg and 15-25 J/cm2 produced the most durable tumor response at the expense of severe local morbidity. However, the PDT dose of 1.5 mg/kg and 10-15 J/cm2 yielded variable tumor responses, with minimal local morbidity. Overall our data confirm that PDT is an effective therapy for superficial bladder cancer. We recommend PDT as a second line or immediate therapy for BCG or chemotherapy failures using a standard PDT dose of 1.5 mg/kg of Photofrin and 15 J/cm2 (630 nm) and a scheduled repeat treatment with 1.5 mg/kg and 10 J/cm2 at 6 and 12 months.

Apparent failure of current intravesical chemotherapy prophylaxis to influence the long-term course of superficial transitional cell carcinoma of the bladder

During the 4 decades since the first introduction of intravesical chemotherapy, 3,899 patients were enrolled in 22 randomized prospective controlled studies. Of these 22 studies 13 reported a statistically significant benefit of intravesical chemotherapy. With varying followup, the reported decrease in the incidence of patients with tumor recurrence averaged only 14% (range -3 to +43%). Unfortunately, long-term (5-year) studies show no decrease in the incidence of recurrent tumor. Maintenance chemotherapy has failed to improve these results and data suggest that a single early postoperative instillation may, in fact, be most effective. Among 10 studies that include progression data none showed decreased tumor progression, and overall among 2,011 randomized patients progression occurred in 7.5% of those receiving intravesical chemotherapy and 6.9% of those treated by surgery alone. Since intravesical chemotherapy has been demonstrated in animal models to be carcinogenic, these data raise the concern that intravesical chemotherapy might possibly be carcinogenic in humans. In the absence of demonstrated long-term benefit we question the advisability of routine prophylactic intravesical chemotherapy.

Predicting the risk of lymph node involvement using the pre-treatment prostate specific antigen and Gleason score in men with clinically localized prostate cancer

PURPOSE

To evaluate the predictive value of an empirically derived equation for identifying patients with clinically localized prostate cancer at low and high risk for harboring occult lymph node metastasis.

METHODS AND MATERIALS

A simple equation for estimating the risk of positive lymph nodes was empirically derived from a nomogram published by Partin et al. demonstrating the value of combining the pre-treatment prostate specific antigen and Gleason Score in predicting the risk of lymph node metastasis for patients with clinically localized prostate cancer. The risk of positive nodes (N+) was calculated using the equation; N+ = 2/3(PSA) + (GS-6) x 10, where PSA and GS are the pre-treatment prostate specific antigen and Gleason Score respectively, and the calculated risk is constrained between 0-65% for a PSA < or = 40 ng/ml (as in the nomogram). To test the general applicability of this equation, we reviewed the pathologic features of 282 of our patients who had undergone a radical prostatectomy.

RESULTS

Based on 212 patients for whom the pre-operative prostate specific antigen's and Gleason Scores were available, we identified 145 patients with a calculated risk of positive nodes of < 15%, (low risk group) and 67 patients with a calculated risk as > or = 15% (high risk group). The observed incidence of positive nodes was 6% and 40% among the low and high risk groups respectively (p < 0.001). When used alone neither clinical stage, pre-treatment prostate specific antigen nor the pre-treatment Gleason Score was as useful in identifying the largest low and high risk groups.

CONCLUSION

Using the equation described we confirmed the general applicability of the nomogram reported by Partin et al. and identified patients at low and high risk for lymph node involvement. Based on these data we have adopted a policy of omitting whole pelvic irradiation in patients identified as low risk.

Green light photodynamic therapy in the human bladder

We conducted this pilot clinical study to investigate the safety, primarily acute toxicity, of green light (514.5 nm) whole bladder photodynamic therapy (PDT) in human bladders with transitional cell carcinoma. We enrolled five patients who were scheduled to undergo radical cystectomy and urinary diversion for locally muscle invasive bladder cancer. Four patients received intravenous injection of Photofrin at 1 mg/kg, while one patient received no drug, 48 hr before undergoing green light whole bladder photoactivation with light doses of 20-60 J/cm 2. Each patient underwent radical cystectomy on day 7 following light treatment. Post-PDT evaluation included daily monitoring of voiding symptoms, cystometric measurements of bladder capacity, and gross and histopathologic examination of the excised bladders. Our results show that the intensity of acute bladder irritation and acute post-PDT loss in bladder volume depended on the light dose and extent of bladder tumor with the associated inflammation. There was no transmural bladder injury and no treatment related morbidity. These data on acute toxicity suggest that green light whole bladder PDT treatment with 1 mg/kg of Photofrin and 20-40 J/cm 2 of laser power is safe.

Canine bladder response to red and green light whole bladder photodynamic therapy

A normal canine bladder model was used to compare the effects of red and green light whole bladder photodynamic therapy (PDT). Eighteen dogs were treated with Photofrin 1 mg/kg and whole bladder irradiation with red or green light at doses ranging from 20 to 60 J/cm2. Toxicity was assessed using cystometry, cystoscopy, and histopathology. Green light produced more significant vesical toxicity than red light, and this toxicity tended to vary with the light dose administered. Whole bladder PDT with green light at doses greater than 20 J/cm2 resulted in permanent reductions in bladder capacity. Conversely, a green light dose of 20 J/cm2 and red light doses ranging from 20 to 60 J/cm2 did not produce any significant permanent reductions in bladder capacity. Thus, while green light may be more toxic to the bladder than red light, there are distinct combinations of red or green light and Photofrin which can be used in the canine bladder to achieve mucosal degradation without causing permanent vesical dysfunction.

Fluorescence detection of tumors. Early diagnosis of microscopic lesions in preclinical studies

BACKGROUND

The growth of microscopic tumor lesions at or beyond treatment field margins poses a major problem in the diagnosis and treatment of cancer. Early detection techniques that clearly define the location or field spread of disease may improve the planning of disease treatment.

METHODS

In vivo fluorescence photometry is a non-imaging technique that digitally displays relative fluorescence values in volts proportional to the luminescence intensity detected by a silicon photodiode. The sensitivity of the instrument has allowed the detection of micrometastases in preclinical studies.

RESULTS

Statistical analysis demonstrates that the photosensitizer Photofrin (dihematoporphyrin ether and/or ester) (Quadra Logic Technologies, QLT, Vancouver, B.C., Canada), currently used for photodynamic therapy, administered in doses lower than those used in clinical studies, is useful for the detection of occult disease. With the drug doses used, cutaneous photosensitivity was avoided in the animal models tested. The results in Lobund-Wistar rats with transplantable prostatic adenocarcinoma (PA-III) demonstrated the utility of this technique in detecting clinically occult disease, with a prediction rate of approximately 94% with drug doses as low as 0.25-0.5 mg/kg.

CONCLUSIONS

With the use of the hamster buccal cavity model involving the initiation and promotion of premalignant and malignant conditions by 9,10 dimethyl-1,2-benzanthracene, the technique could discern these two stages of disease with significance levels that were less than 0.05 and 0.01, respectively.

Photodynamic therapy

The preliminary data suggest that red-light whole-bladder photodynamic therapy is safe and effective in the treatment of Tis and may be useful in the prophylactic management of superficial bladder cancer. Theoretically, whole-bladder photodynamic therapy has the advantage of higher efficacy after a single treatment than most conventional modalities for superficial bladder cancer. In patients with Tis, the complete response rate is 88%, and 25% have recurrences during a mean follow-up of 20 months (range 12-60). In patients undergoing prophylaxis, the recurrence rate is 31% and the median time to recurrence is 18 months. Importantly, none of the high-risk patients treated with whole-bladder photodynamic therapy has developed disease progression in stage or grade at the time of recurrences. Whole-bladder therapy also has the potential advantage of repeat treatment without increased tumor resistance or increased morbidity. Data from the present phase II-III clinical trials involving a large number of patients will define the role of photodynamic therapy in the management of superficial bladder cancer.

Regulation of the proliferation and biosynthetic activities of cultured human Peyronie's disease fibroblasts by interferons-alpha, -beta and -gamma

To determine the therapeutic potential of interferon (IFN) treatment for Peyronie's disease, we investigated the effect of human recombinant (hu-r) IFNs on cultured fibroblasts derived from a Peyronie's disease penile plaque. Treatment of cultured fibroblasts with hu-r-IFN-alpha2b, hu-r-IFN-beta-ser17 and hu-r-IFN gamma caused a concentration dependent inhibition of both fibroblast proliferation and collagen production, as well as an increase in collagenase production. Hu-r-IFN-alpha and beta had no effect on fibroblast glycosaminoglycan (GAG) or fibronectin production, while hu-r-IFN-gamma markedly increased both GAG and fibronectin production. These results demonstrate that IFNs, especially IFNs-alpha and beta, exhibit antifibrotic activity on Peyronie's disease fibroblasts and suggest a rationale for using IFNs to treat Peyronie's disease.

Whole bladder photodynamic therapy: critical review of present-day technology and rationale for development of intravesical laser catheter and monitoring system

Present-day whole bladder photodynamic therapy (WBPDT) is cumbersome and time consuming because cystoscopic and ultrasonic manipulations are necessary to position the light emitter within the bladder. More important, WBPDT is inherently unsafe and often ineffective since neither uniform photoirradiation nor accurate light dosimetry can be achieved with the techniques employed to photoirradiate the bladder wall. The intravesical laser catheter (IVLC) eliminates the need for cystoscopy and ultrasonography because passage of the treatment fiber into the catheter's central lumen automatically positions its light-diffusing tip within the center of the bladder. Use of the IVLC delivery system also assures accurate photoirradiation of the bladder wall since inflation of the catheter's balloon transforms the asymmetric bladder into a sphere of known diameter. The light sensor incorporated in the balloon wall provides a method to monitor light fluence and measure total light dose. When provided the parameters of bladder volume, laser energy output, and desired light dose, the computerized control system calculates treatment time and automatically adjusts the period of photoirradiation to compensate for variations in laser light production, energy losses during transmission, and for variations in light intensity resulting from the integrating sphere effect of the bladder wall. This delivery system also increases the safety of WBPDT since the monitor automatically discontinues treatment if any unsafe situation, with respect to light fluence, develops during photoirradiation.

Urinary cytokines following photodynamic therapy for bladder cancer. A preliminary report

This preliminary study was undertaken to test for the presence of urinary cytokines whose detection would provide evidence in support of the theory that photodynamic therapy (PDT) produces an immunologic response in patients treated for bladder cancer. Gamma interferon, interleukin 1-beta, interleukin 2, and tumor necrosis factor-alpha were assayed for in the urine of 4 patients treated with photodynamic therapy for bladder cancer, in 7 control patients undergoing transurethral surgical procedures, and in 5 healthy control subjects. Quantifiable concentrations of all cytokines, except gamma interferon, were measured in urine samples from the PDT patients with the highest light energies, while no urinary cytokines were found in the PDT patient who received the lowest light energy nor in any of the control subjects. These findings suggest that a local immunologic response may occur following PDT for bladder cancer.

Primary penile lymphoma in a patient with Peyronie's disease

Malignant lymphoma involving the penis is rare, with only 5 cases reported in the literature. We report a case of primary lymphoma of the penis in a 60-year-old white man with Peyronie's disease who underwent ablation followed by brief chemotherapy. There was no evidence of systemic lymphoma involvement 6 years after therapy.

Palliative hemibody irradiation in hormonally refractory metastatic prostate cancer

Ten patients with hormonally refractory symptomatic metastatic prostate carcinoma underwent palliative hemibody irradiation (HBI). Four of the patients also had had previous irradiation to symptomatic focal sites. Two of the patients underwent upper body HBI with 5 Gy, while 6 patients underwent lower body HBI with 7 Gy. Two patients received sequential lower body HBI followed by upper body HBI. All 10 patients reported subjective pain relief within the immediate forty-eight to ninety-six hours following therapy. The average response lasted four months. Therefore the majority of our patients achieved symptomatic pain relief for the remainder of their lives which averaged five months (range 1.5-12 months). All 10 patients suffered transient but clinically insignificant hematologic toxicity. There was no death or other significant morbidity attributable to the treatment. We conclude that HBI is safe and effective palliation of bone pain in patients who have failed conventional therapy for prostate cancer.

Intraprostatic tumor location and pelvic lymph node metastatic pattern in early prostate cancer

Recently we treated 54 patients with clinically localized prostate cancer: 8 had Stage A disease, 13 had Stage B1, 32 Stage B2, and 1 Stage C. Fifty of these patients underwent bilateral pelvic lymphadenectomy and retropubic radical prostatectomy, while the other 4 patients underwent bilateral pelvic lymphadenectomy only. Pathologic staging revealed pelvic lymph node metastases in 12 patients. We reviewed these 12 Stage D1 cases to see whether or not the intraprostatic tumor location influenced the locoregional metastatic nodal pattern. We found that metastases occurred ipsilaterally in 5 cases, while the other 7 patients experienced bilateral pelvic involvement. We failed to find any case in which contralateral nodal involvement occurred without the tumor also involving the pelvic lymph nodes ipsilateral to the intraprostatic tumor. The data suggest that it would be reasonable to perform pelvic lymphadenectomy only on the same side of the prostatic lesion. This modified approach potentially could reduce morbidity and cost to the patient.

Primary mediastinal germ cell tumors. Histologic patterns of treatment failures at autopsy

Twenty-five patients presented with primary mediastinal germ cell tumors at Roswell Park Memorial Institute between 1959 and 1984. All patients were treated by surgery and chemotherapy with or without radiotherapy. Four patients are still alive, and 21 patients died of mediastinal germ cell tumor and its sequelae. Two patients were found to have testicular scars and were dropped from the study. Nongerm cell malignant transformation of a teratoma occurred in five of the remaining 17 patients (29%), resulting in three adenocarcinomas and two sarcomas. Another patient developed leukemia. Metastatic disease most commonly involved the lungs, mediastinal lymph nodes, liver, bone, retroperitoneum, and heart. Respiratory failure was the cause of death in 12 patients. Of the possible mechanisms of germ cell transformation into malignant nongerm cell tumors discussed, this study suggests that chemotherapy alone is unlikely to induce stem cell differentiation. The presence of mature, differentiated teratoma within the primary lesion may be indicative of a poorer prognosis.

Study of factors mediating effect of photodynamic therapy on bladder in canine bladder model

The canine bladder model was employed to study the factors mediating the effect of photodynamic therapy (PDT) on the bladder. The recovery (time taken for the bladder volume to return to pre-PDT value), gross and microscopic findings, implicate both bladder high filling pressure (60 cm H2O) and high light dose as factors mediating the effect of photodynamic therapy on bladder capacity. We recommend that photodynamic therapy to the bladder be performed under a filling pressure of 30 cm H2O, which is physiologic, and whole bladder illumination at a light dose not greater than 30 J/cm2.

Photodynamic therapy in the management of resistant lower urinary tract carcinoma

Twenty-three patients with resistant transitional cell carcinoma (TCC) of the bladder and posterior urethra had photodynamic therapy (PDT). Seventy-two hours after an intravenous injection with 2 mg/kg of the photosensitizer dihematoporphyrin ether (DHE) (Photofrin II, Photomedica, Raritan, NJ), each patient received cystoscopic light treatment. The light dose to the whole bladder using the bulb diffuser ranged from 5 to 60 J/cm2; power density ranged from 9 to 22 mW/cm2. The focal light dose ranged from 100 to 200 J/cm2 at a power density from 100 to 200 mW/cm2. To treat the urethra, a diffuser fiber was used to deliver 200 to 400 J/linear cm at a power of 110 to 300 mW/cm. In the 19 of 23 patients who were treated for resistant superficial TCC, 83.3% of the tumors had responded at the initial follow-up evaluation. Seven patients had a complete response and 10 had a partial response. Three of 19 patients who received inadequate light treatment failed to respond. Control of intractable gross hematuria was the only benefit for patients with locally invasive disease (greater than or equal to T2). Irritating lower urinary tract symptoms that varied in severity and duration occurred in all patients. Four patients experienced bladder shrinkage, which did not resolve. Although the light and drug doses remain to be determined, a whole bladder light dose of 15 to 20 J/cm2 with a drug dose of 2 mg/kg seems to be effective enough without producing permanent adverse effects in the bladder.

Photodynamic therapy with hematoporphyrin derivative in the treatment of superficial transitional-cell carcinoma of the bladder

Photodynamic therapy involves light-induced destruction of tumors containing a photosensitizer such as hematoporphyrin derivative. We conducted a collaborative study to evaluate the efficacy of this form of therapy in treating superficial transitional-cell carcinoma of the bladder. Thirty-seven patients were evaluated and 20 were selected for treatment. A total of 50 papillary tumors and 3 areas of carcinoma in situ were treated. All except two tumors were smaller than 2.5 cm. Assessments for treatment response and toxicity were carried out three months after treatment. The initial diagnosis of one patient was revised after the biopsy material was reviewed, and this patient was not included in the analysis. Complete eradication of all tumors was observed in 9 of 19 patients (47 percent), including those with carcinoma in situ. In the remaining 10 of these 19 patients, 13 tumors could not be eradicated (the overall eradication rate was 37 of 50 tumors [74 percent]), but 9 of the 10 patients had a reduction in tumor size, number, or both of 50 percent or more. We conclude that photodynamic therapy is useful in the treatment of superficial transitional-cell carcinoma of the bladder, but controlled trials will be required to define its place in the treatment of cancer.

Photodynamic therapy for palliation of locally recurrent breast carcinoma

Fourteen women with locally recurrent breast carcinoma on the chest wall following mastectomy were given 30 courses of photodynamic therapy (PDT). All patients had been heavily pretreated with conventional modes of therapy (radiation therapy, chemotherapy, hormonal therapy, surgical resection). Twenty-two courses yielded a partial response; two courses yielded a complete response; four courses showed no response; one patient was treated as an adjunct to surgery; and one patient was lost to follow-up. Duration to response was variable, ranging from 6 weeks to 8 months. Several women had chest wall disease controlled for prolonged periods of time using repeated courses of PDT. Two women had re-epithelialization of ulcerated lesions. Complications were minimal and included pain (two patients), sunburn (two), and infection (one). These results suggest that treatment with PDT can aid in local control of chest wall recurrence following mastectomy in selected patients.

Study of microscopic porphyrin fluorescence

A technique of porphyrin (hematoporphyrin derivative [Hpd]) fluorescence microscopy was evaluated by studying Hpd uptake, retention, and loss in established human cancer cell lines. Hpd uptake appeared to be qualitatively identical in the three cell lines used, but the rate of loss was slowest in the renal-carcinoma-derived line, suggesting a cellular characteristic. The technique was readily applied to demonstrate porphyrin fluorescence in exfoliated cells in urine of bladder cancer patients.

Management of bladder stones: should transurethral prostatic resection be performed in combination with cystolitholapaxy?

We report our institutional experience and review the literature in the management of bladder stones, with particular attention to combined cystolitholapaxy and transurethral prostatectomy. Vesical calculi are associated with obstructing prostatic hypertrophy two thirds of the time. Combined cystolitholapaxy and transurethral resection of the prostate have significant morbidity.

Dihematoporphyrin ether clearance in primate bladders

The techniques of in vivo tissue fluorescence photometry and chemical extractions of DHE, which have been recently developed in our laboratory, were employed to study DHE uptake and clearance in the primate bladders. Data show these techniques are readily applicable in studying porphyrin uptake and clearance in primate bladders. Quantitatively a correlation between fluorescence values and tissue extracted DHE values is found. Serum clearance and bladder clearance of DHE appeared phasic, but bladder clearance was slower than serum. The significance of these two methods lies in their applications in determination of drug dosimetry and optimum time for photoactivation in clinical photodynamic therapy.

Pelvic rhabdomyosarcoma: a review of the RPMI experience

Between 1959 and 1983, 16 patients with pelvic rhabdomyosarcoma were treated at Roswell Park Memorial Institute (RPMI). A multidisciplinary approach was utilized consisting of surgery, radiotherapy (XRT), and combined chemotherapy which resulted in prolonged survivals of thirteen to one hundred forty-four months in 10 patients. This improved survival was observed despite the fact that 63 per cent of the patients (10/16) presented with advanced stages of the disease. Herein we present a retrospective study of these 16 patients.

Clinical significance of erythropoietin levels in renal carcinoma

The bioassay using the polythemic mice demonstrated persistent erythropoietin (Ep) activity in 24 renal carcinoma patients. Eight patients without clinical evidence of renal carcinoma had Ep levels that were slightly higher than those of controls, suggesting the possibility of occult disease. Increased levels of Ep were noted in 5 patients with other genitourinary carcinomas. This selective study reaffirms the value of Ep as a biologic marker in some renal cell cancers, and occasionally in other genitourinary tumors.

Single ectopic ureter: unusual presentation in adult male

We present a case of an unusual and late presentation of a single ectopic ureter in an adult male. The patient presented with gross painless hematuria. The left ureter draining a dysplastic kidney terminated in the ipsilateral seminal vesicle.

Whole bladder photodynamic therapy for transitional cell carcinoma of bladder

Our preliminary studies indicate that the bulb-tip technique for whole bladder photodynamic therapy (PDT) illuminates the entire bladder mucosa and is applicable to the management of superficial transitional cell carcinoma of the bladder. This treatment modality may be an option to patients who are failures to other standard treatments. A randomized clinical study is needed to decide on PDT as a primary treatment of choice for transitional cell carcinoma of the bladder.

Protection of germinal epithelium with luteinizing hormone-releasing hormone analogue

A dog model for chemotherapy and radiation-induced testicular damage was created to study the protective potential of superactive analogue of luteinizing hormone-releasing hormone, buserelin. Buserelin appeared to offer protection of the canine germinal epithelium against cyclophosphamide, cisplatinum and radiation. Clinical trials with buserelin in patients of reproductive age undergoing treatment for cancer should be encouraged.

Experimental photodynamic treatment of canine bladder

In urology, important limiting factors in the application of hematoporphyrin derivative and photodynamic therapy appear to be the problems of standardization of dosimetry and the technique of transurethral photoradiation. Experimental photodynamic therapy on canine bladder with normal and altered epithelium was performed using an argon laser as an energy source. A 630 nanometer wavelength of light was delivered through a quartz-optical fiber with either a regular flat end for focal illumination or a bulb-type end which produced an isotropic light pattern. It was demonstrated that normal canine bladder was resistant to photodynamic therapy and that the bulb tip produced whole bladder illumination. With a moderate light dose of 18 to 30 Joules/cm.2 the effect following whole bladder illumination on the bladder was generalized and superficial. This approach appears to be ideal for treating superficial transitional cell carcinoma of the bladder. Additional work is needed in selecting appropriate energy doses.

Histological patterns of treatment failures in testicular neoplasms

We reviewed 77 consecutive autopsies performed between 1965 and 1982 on patients who had been treated for germ cell tumors of the testis at our institute. Identifiable germ cell tumor was present at autopsy in 64 cases. On review, a single pattern was seen at autopsy in the majority of the cases (69.7 per cent) compared to the primary tumors, in which single patterns were seen in only 45 per cent. The occurrence of yolk sac tumor as the sole element in 6 of 29 autopsy specimens of nonseminomatous tumors after the introduction of the current standard 3-drug therapy and only once in 32 autopsies before 1976 appears significant. A possible explanation for this finding is that the yolk sac element was obscured by more aggressive and rapidly growing varieties of tumor in the earlier years but proved less responsive to chemotherapy.

Aspiration biopsy of testis: another method for histologic examination

The most important method for evaluating the pathogenesis of male infertility is open testicular biopsy. Herein we describe a method of aspiration biopsy of testis for histologic examination. Sexually mature dogs and rats treated with chemotherapeutic agents and ionizing radiation were followed with periodic testicular aspiration biopsy during and after treatment. The histologic findings from the aspiration biopsy compare with the results of routine histologic examinations in assessing spermatogenetic activity and delineating pathologic changes. The puncture in the experimental animals was performed under general anesthesia. In human patients testicular biopsy could be done under local anesthesia in an outpatient clinic. The procedure would be less painful, minimally invasive, and more cost-effective.

Penile xenon (133Xe) washout: a rapid method of screening for vasculogenic impotence

The radioactive inert gas xenon (133Xe) is a well-established isotopic indicator used to assess vascular status in many organ systems. We employed xenon-133 to evaluate male impotence. Xenon-133 was injected subcutaneously at the level of the coronal sulcus in the detumescent state. Using the gamma camera, sequential images were obtained and computer-generated curves calculated. The clearance time for 50 per cent washout of the injected 133Xe (T1/2) was then calculated for each patient, as well as a control group. Preliminary findings indicate a correlation with such established techniques of evaluating erectile impotence as history, physical examination, penile pulse Doppler tracings, and brachial-penile blood pressure index. The xenon-133 washout study was a rapid, minimally invasive, reproducible, and cost-effective method of screening those impotent patients for vasculogenic etiology of their erectile impotence. We recommend the addition of this method to the surgeon engaged in the care of impotent males.