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.

Serum and Prostatic Tissue Concentrations of Moxifloxacin in Patients Undergoing Transurethral Resection of the Prostate

The spectrum of pathogens causing chronic bacterial prostatitis comprises Gram-negative, Gram-positive and atypical microorganisms. Because of its broad spectrum of activity, the group 4 fluoroquinolone moxifloxacin might be a suitable antibiotic for treatment of bacterial prostatitis. The aim of this prospective study was to investigate the penetration of moxifloxacin into prostatic tissue in patients with benign prostatic hyperplasia. Patients received a single dose of moxifloxacin 400 mg in an 1 hour lasting infusion (250 ml) for perioperative prophylaxis before undergoing transurethral resection of the prostate (TURP). Serum concentrations were determined in all patients before infusion, at the end of infusion (time point 0), 0.5, 1 and 2 h after the end of infusion. Patients were randomized for tissue sampling either 0, 0.5, 1 or 2 h after the end of infusion. At beginning of TURP approximately 1 g of tissue was sampled for analysis. Concentrations of moxifloxacin in serum and tissue were determined by HPLC. 39 patients were evaluated. Median serum and prostatic tissue concentrations peaked at 0 h (4.94 mg/ L and 8.50 mg/ kg, respectively). The lowest concentrations were quantified at 2 h after the end of infusion (2.46 mg/ L and 3.88 mg/ kg, respectively). The prostatic tissue concentrations of moxifloxacin were approximately twice as high as in corresponding serum. At the end of infusion the tissue and serum concentrations seemed to be already equilibrated, as their ratios did not differ significantly during the time of investigation. After an intravenous infusion of 400 mg the serum and prostatic tissue concentrations of moxifloxacin were well above the MIC values of most important prostatic pathogens. The high tissue/ serum ratio and the extended antibacterial spectrum suggests active concentration in the prostate which may translate into increased efficacy compared to group 2 and 3 fluoroquinolones in the treatment of chronic bacterial prostatitis.

[Sacral neuromodulation as second-line treatment strategy for lower urinary tract symptoms of various aetiologies: experience of a German high-volume clinic]

INTRODUCTION

Lower urinary tract symptoms (LUTS) are a common and multiform micturition disorder of various possible origins. Several second-line techniques are available in the event of first-line medicinal treatment failure. These include the intravesical injection of Botulinum toxin, bladder augmentation and sacral neuromodulation (SNM). This study presents current data and results from a prospective study of patients with LUTS of various aetiologies.

MATERIAL AND METHODS

Clinical success was investigated for all patients who underwent SNM for LUTS with or without urge incontinence caused by chronic pelvic pain syndrome, multiple sclerosis and idiopathic disease between May 2007 and December 2010. The preoperatively determined symptoms were compared with current follow-up data. Median follow-up time was 11 months (1 - 43).

RESULTS

A total of 47 patients were indicated for SNM over the investigated period. 80.9 % were female, median patient age was 67 years (19 - 84). The testing phase was successful in 38 cases (80.9 %) with 9 electrodes being explanted (19.1 %). In the case of idiopathic LUTS we could show a statistically significant increase of micturition volume and reduction of incontinence pad use. There was no statistically significant improvement of any micturition parameter for patients with multiple sclerosis, patients with chronic pelvic pain syndrome showed a statistically significant reduction of micturition frequency and a subjective improvement of symptoms in 75 %.

CONCLUSIONS

In the selected patient groups SNM is a promising and, in experienced hands, a low-complication second-line therapy for the treatment of LUTS of idiopathic aetiology. However, the general recommendation of SNM for multiple sclerosis and chronic pelvic pain syndrome patients cannot be given on the basis of our results. Further prospective, randomised multicentre studies are need to further refine the indications for SNM in LUTS of neurogenic and non-neurogenic origins.

[Analysis of Clinical, Histopathological and Follow-Up Data on Transurethral Resections of the Bladder Performed during One Year at a University Centre]

INTRODUCTION

Transurethral resection of the bladder (TURB) is one of the most common surgical treatments in urology. We examined the TURBs that had been carried out during one year for suspected bladder cancer (first findings and recurrence) and then analysed the further clinical courses of these patients within the first twelve months after TURB.

MATERIALS AND METHODS

We recorded retrospectively the course of 160 patients in whom altogether 210 elective TURBs had been performed in our clinic between April 2007 and March 2008 (observation period). In addition, the patients' further clinical course within the first twelve months after TURB was recorded (follow-up period). All initial and recurrence TURB were carried out with photodynamic diagnosis; the histological evaluation was performed at a university centre.

RESULTS

71 % of the 118 initial resections performed during the observation period showed urothelial cell carcinoma of the bladder - pTa (61 %), pT1 (20 %), pT2-4 (17 %), Cis (2 %) while 60 re-TURBs in the whole period detected 17 % residual tumours. According to the guidelines, 18 patients (14 %) received instillation therapy with mitomycin C, 32 patients (25 %) with Bacillus Calmette-Guérin (BCG). Cystectomies were performed on 23 patients (18 %). 18 TURBs after suspected recurrence in the follow-up period confirmed recurrence in 28 %, which represents a recurrence rate of 4 %. In the same period 5 patients (4 %) developed distant metastases, two patients (2 %) died. Two patients (7 %) with initially benign findings developed bladder cancer in the follow-up period.

CONCLUSION

We present an analysis of TURBs performed at a university centre. When bladder cancer is diagnosed in 7 % within one year after urocystitis has been detected in the initial TURB findings, regular follow-up examination of these patients, especially with certain risk profiles, has to be discussed.

[Does technical progress mean clinical advantage? Analysis of clinical and histopathological parameters of renal cell carcinomas in long-term course]

PURPOSE

Renal cell carcinoma is the third most frequent urogenital malignancy. The increased incidence in the past few years can be attributed in particular to increased incidental findings since the introduction of routine ultrasound and radiological imaging. In the current contribution we analyse in a long-term approach the actual impact of these advances on indications for surgical management.

MATERIAL AND METHODS

From January 1992 until December 2007, 1,113 renal cell carcinoma patients underwent a total of 1,129 surgical interventions in our department. Retrospectively, we collected the clinical and histopathological data of these patients, comparing them in terms of the entire study period and the four 4-year time spans 1992-1995, 1996-1999, 2000-2003 and 2004-2007.

RESULTS

59 % of the patients were male, the median age being 64 years [range: 26-91 years]. In the study period, the number of patients <or= 45 years and > 75 years increased statistically significantly (p = 0.012). The number of incidental findings -remained constant at approximately 72 %, while that of patients who had received preoperative cross-sectional imaging diagnostics rose statistically significantly from 88 % to 98 % (p < 0.001). Tumours of stage pT1a increased statististically significantly to 42 %, the number of partial renal resections in the same period to 25 % (p < 0.001). There was no difference in residual tumour rate between nephron-sparing surgery and tumour nephrectomy.

CONCLUSIONS

We were able to confirm that the major developments in the diagnostic and surgical approaches to renal cell carcinoma over the past few years do translate into clinical benefits for patients who are increasingly being subjected to partial renal resection.

[Impact of comorbidity on perioperative mortality after radical cystectomy]

The TNM classification integrates the currently valid prognostic factors for tumour-specific survival after radical cystectomy due to bladder cancer. But it does not contain the most important criteria for general survival. We assessed the preoperative and operative aspects of our patients between 1992 and 2007 concerning the early mortality within the hospital stay or within 30 days after surgery. 3% of our 404 patients died within these periods, which is equivalent to the results of other contemporary publications. Except for the comorbidity of the patients, none of the included parameters (initial symptoms, histology, indication for cystectomy, AJCC stadium, year of surgery, durance of surgery, surgeon, concomitant interventions, type of urinary diversion, blood loss and number of transfusions) showed a significant correlation to cause or postoperative time of death. For the preoperative assessment of the health of the patient a multidisciplinary cooperation of urology, anaesthesia and general and/or internal medicine is necessary. In the era of evidence-based medicine the personal judgement of the evaluating physician is not sufficient. Instead a validated index should be used to help one to obtain an objective evaluation of the risks. The ACE-27 (Adult Comorbidity Evaluation-27) provides such a validated assistance in the assessment of the comorbidity of patients and therefore possible mortality after radical cystectomy.

[Bladder preservation or initial cystectomy in T1G3 bladder cancer: which parameters help in therapeutic decision-making?]

PURPOSE

T1G3 bladder cancers show the clinical and biological behaviour of muscle invasive tumours with progression rates of about 30%. While radical cystectomy in some cases is indicated, other patients can achieve healing with organ preservation. We present a study analysing the influence of the risk factors multifocality, tumour diameter >or= 3 cm and associated carcinoma in situ (Cis) on the outcome of initial T1G3 bladder cancers treated in various ways.

MATERIALS AND METHODS

Of 223 patients with initial T1G3 bladder cancer, 125 patients underwent transurethral resection of the tumour (TURB), second resection and adjuvant bacille Calmette-Guérin (BCG) instillations (TURB group), 98 patients chose initial radical cystectomy (CX group).

RESULTS

Median follow-up times were 56 months (TURB group) and 51 months (CX group). 5- and 10-year survival rates (82% and 65% in TURB group vs. 75% and 48% in CX group) did not show statistically significant differences. In Cox regression analysis no single risk factor showed a prognostic value. While in TURB group the combination of all risk factors (multifocality, tumour diameter >or= 3 cm and associated carcinoma in situ) was associated with a statistically significantly lower survival rate, the same combination in the CX group was not oncologically relevant.

CONCLUSIONS

While initial T1G3 bladder cancer with up to two risk factors after organ-preserving therapy is not associated with a lower tumour specific survival rate in comparison to radical cystectomy, patients with a combination of the three analysed risk factors would profit by an early radical cystectomy.

Induction of complete remission in metastatic hormone-refractory prostate cancer: A combined anti-inflammatory therapy approach

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Background: The present multi-centre phase II study was designed to support the hypothesis that networking agents binding to ubiquitous accessible targets in metastatic hormone-refractory prostate cancer (HRPC) may counteract neoplasia-specific aberrant cellular functions, thereby mediating objective response (primary endpoint). Method: Patients with metastatic HRPC, received both an anti- inflammatory and angiostatic therapy consisting of low-dose chemotherapy with capecitabine 1 g twice daily for 14 days every 3 weeks, day 15+, COX-2 blockade with etoricoxib 60 mg daily, day 1+, combined with two transcription modulators, pioglitazone 60 mg daily, day 1+, plus dexamethason 1 mg daily for 14 days, every 3 weeks, day 15+, until disease progression. The study was planned using the Simon optimal design. Results: Thirty-six consecutive patients (N= 22 (61%) chemo-naive, n= 14 (39%) with preceding chemotherapies, mean 2.1 regimen) with metastatic HRPC, confirmed PSA increase, assessable response, and ECOG 0–2 were enrolled between 1/03 to 5/06. Objective response occurred in 10 of 13 cases (N/n: 41%/7%) with PSA (and C-reactive protein) response >50% (N/n: 45%/21%). Median time to PSA response was 2.4 months (range 1.0 to 7.3 months). Two of three patients responding with PSA <4 ng/ml achieved complete remission after 9 and 16 months, 16 patients stable disease (N/n: 41%/64%), and 5 patients experienced progressive disease (N/n: 14%/14%). Median progression-free survival (PFS) was 3.6 months (range 0.5 to 28.5) and median overall survival (OS) 14.4 months (range 0.6 to 37.2). Multivariate analysis recognized pre-treatment with chemotherapy as negative predictor for both OS (hazard ratio 2.26 (CI 95%: 0.970; 5.277), p=0.05) and PFS (HR 2.47 (CI 95%: 1.146; 5.348), p= 0.02), and <50% PSA response as negative predictor for PFS (HR 0.38 (CI 95%: 0.171; 0.857), p= 0.01). Toxicities > WHO grade II were reported: Hand-foot syndrome (n=1), anemia (n=6), edema (n=1), cushing syndrome (n=1), hydronephrosis (n=1). Conclusions: This is the first study reporting continuous complete remissions in HRPC with a biomodulatory therapy approach. Further, the study may clinically support the upper mentioned hypothesis.

No significant financial relationships to disclose.

Pararektale Miniinzision zur streng retroperitonealen Nephrektomie in der Lebendspende

PURPOSE

In this study we present the technique of a strictly retroperitoneal donor nephrectomy via a pararectal mini-incision.

MATERIAL AND METHODS

Data of 34 living kidney donations were analyzed. All donors underwent a pararectal mini-incision and strictly retroperitoneal nephrectomy (MIDN).

RESULTS

Total operation time, perioperative use of pain medication, length of hospital stay after successful mobilization, and return to full enteral nutrition and regular digestion were evaluated retrospectively. Total operation time for MIDN was 132+/-26 min. The total average application was 22.2+/-19.4 mg of opioid in morphine equivalent dosage (MED), 7.7+/-6.1 g metamizol, and 512+/-325 mg NSAR during hospital stay, which was 4.9+/-1.4 days. Patients were mobilized primarily 2.9+/-8.0 h after surgery. Mobility was achieved 33.8+/-15.8 h after surgery. Enteral nutrition with fluids was started after 1.9+/-7.0 h, full enteral nutrition was accomplished after 37.4+/-19.0 h, and normal digestion returned 58.6+/-23.0 h after the procedure.

CONCLUSIONS

The strictly retroperitoneal nephrectomy via a mini-incision is an elegant, minimally traumatic, safe, and quickly learnable method, resulting in short hospital stays, good cosmetic results, and a low grade of complications.

Effect of anti-inflammatory therapy in patients with metastatic renal cell carcinoma on clinical response

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Background: Interaction among signalling networks from tumor and neighbouring stroma cells in complex disease traits is poorly understood. Methods: Two consecutive multi-centre phase II trials were designed (case calculation according response rate, T. Chen two stage design) to prove the hypothesis, whether the activation of presumably complementary receptor-triggered transcriptional cascades (via pioglitazone, and interferon alpha, IFNa) could result in synergistic clinical effects. Therapy in both trials consisted of low-dose capecitabine 1 g/m2 twice daily po for 14 days, every 3 weeks, day 1+, and rofecoxib 25 mg daily, day 1+ (from 11/04 etoricoxib 60 mg daily instead) plus pioglitazone 60 mg daily, day 1+. In study II low-dose IFNa 4.5 MU sc three times a week, week 1+, was added until disease progression. Results: Eighteen, and 33 patients (pts, 31 eligible for analysis), respectively, with clear cell carcinoma, progressive disease, and ECOG 0–2 were enrolled between 2/02 to 2/03 and 4/03 to 4/05, respectively. Mean Bradley score in both trials was not significantly different, 4.1(I)/4.9(II), however, the rate of previous systemic treatments 33%/19%. Objective response (48%) was exclusively observed in study II (PR 35%, CR 13%), and paralleled by a strong CRP response (after 4 weeks on treatment) in all 29 pts with elevated CRP levels (93%) (study I: no significant CRP response): CRP values decreased from mean 41.3 mg/l, range 8.1 to 221, to 5.1 mg/l, range 2.1 to 15.6, p = 0.005. Stable disease > 2 months (mos) occurred in 50%/48%. Median progression-free survival could be more than doubled from a median of 4.7 mos (95% CI, 1.0 to 10.4) to 11.5 mos (6.8 to 16.2) in study II, p = 0.0000. Median overall survival of population II has not been reached, yet. Toxicities > WHO grade II were reported (study I/II): Hand-foot syndrome (3/3), diarrhoea (2/2), depression (0/1), pneumonia (0/1). Conclusions: (1) Clinical results of anti-inflammatory/angiostatic therapy compare with available immuno-therapies. (2) Improved outcome with additive IFNa argues for a synergistic drug interaction. (3) Control of tumor-associated inflammation is an important therapeutic principle in metastatic clear cell carcinoma.

No significant financial relationships to disclose.

Adjuvant treatment with interleukin-2- and interferon-alpha2a-based chemoimmunotherapy in renal cell carcinoma post tumour nephrectomy: results of a prospectively randomised trial of the German Cooperative Renal Carcinoma Chemoimmunotherapy Group (DGCIN)

We conducted a prospectively randomised clinical trial to investigate the role of adjuvant outpatient immunochemotherapy administered postoperatively in high-risk patients with renal cell carcinoma. In total, 203 renal carcinoma patients' status post radical tumour nephrectomy were stratified into three risk groups: patients with tumour extending into renal vein/vena cava or invading beyond Gerota's fascia (pT3b/c pN0 or pT4pN0), patients with locoregional lymph node infiltration (pN+), and patients after complete resection of tumour relapse or solitary metastasis (R0). Patients were randomised to undergo either (A) 8 weeks of outpatient subcutaneous interleukin-2 (sc-rIL-2), subcutaneous interferon-alpha2a (sc-rIFN-α2a), and intravenous 5-fluorouracil (iv-5-FU) according to the standard Atzpodien regimen (Atzpodien et al, 2004) or (B) observation. Two-, 5-, and 8-year survival rates were 81, 58, and 58% in the treatment arm, and 91, 76, and 66% in the observation arm (log rank P=0.0278), with a median follow-up of 4.3 years. Two, 5-, and 8-year relapse-free survival rates were calculated at 54, 42, and 39% in the treatment arm, and at 62, 49, and 49% in the observation arm (log rank P=0.2398). Stage-adapted subanalyses revealed no survival advantages of treatment over observation, as well. Our results established that there was no relapse-free survival benefit and the overall survival was inferior with an adjuvant 8-week-outpatient sc-rIL-2/sc-rIFN-α2a/iv-5-FU-based immunochemotherapy compared to observation in high-risk renal cell carcinoma patients following radical tumour nephrectomy.

Oligoclonality of early lesions of the urothelium as determined by microdissection-supported genetic analysis

AIM

To contribute to the ongoing discussion of clonality of human urothelial cancer it was considered a valuable approach to analyze multiple areas from cystectomy specimens for deletions of chromosomes known to be involved early in bladder cancer development.

MATERIAL AND METHODS

Thus, in 86 biopsies of 4 human cystectomies with different histological findings (maximal diagnosis: pT1G2, pTaG3, pT2G2, normal) loss of heterozygosity (LOH) was investigated as a deletion marker using markers of chromosomes 8p, 9p, 9q and 17p. Findings were compared to histology of the lesion.

RESULTS

Findings indicate: (1) no changes in the markers investigated in the bladder with histologically normal urothelium in contrast to detection of LOH in normal urothelium of tumour-bearing bladders; (2) an accumulation of the number of LOH with increasing malignancy of lesions within one bladder, and (3) indications of oligoclonal neoplastic lesions in two of the urinary bladders investigated.

CONCLUSIONS

The investigation of multiple lesions within one bladder presents a snapshot of genetic changes in differently advanced tumour stages. The hypotheses of tumour evolution and oligoclonality as derived from our LOH data need to be supported by deletion-independent clonality studies as X-chromosomal inactivation analysis.

Evaluation of flow-cytometric three-parameter analysis for EGFR quantification and DNA assessment in human bladder carcinomas

Flow-cytometric multi-parameter staining is an excellent method for defining tumour subpopulations. This provides further understanding of tumour heterogeneity and defines the biological relevance of tumour subpopulations. A method of quantifying the epidermal growth factor receptor (EGFR) in parallel with DNA staining, which was previously established in bladder carcinoma cell lines, was applied to twenty-five biopsies of urothelium and urothelial neoplasms. Uro5, a surface glycoprotein, was used to identify urothelial cells. Objective quantification of receptor content via flow cytometry was achieved with beads of defined numbers of antigen-binding sites, and receptor numbers obtained from urothelial and nonurothelial cells were compared with staining intensity in a three-step immunoperoxidase detection of the EGFR. The data obtained matched the immunohistochemical findings and were more sensitive in the low range (ca. 5x103) of receptors. Parallel definition of the proliferative fraction and DNA-ploidy of tumour cells means that this method satisfies the requirements of objective quantification for oncological diagnosis.

Maxillofacial growth after neck burn injury at a young age: an experimental study in the rabbit

An experimental model was designed to define alterations in the normal mandibular growth process under the influence of postburn neck contractures. Additionally, this craniofacial growth model was used to compare two early treatment modalities of neck burns in their capability to minimize contracture and hence allow for normal mandibular growth and development. Growth implies increase in size as well as change in shape and position. These three aspects of growth were defined accordingly to Björk as rotations. The intramatrix rotation expresses the change in mandibular shape, and the matrix rotation expresses the change in mandibular position relative to surrounding structures. The total rotation expresses both, and together with the measurement of the mandibular length, they represent the increase in mandibular size. Thirty-two 7-week-old rabbits were divided at random in four groups of eight rabbits each and randomized for selection for the 14 operation days defined as t = 0: Group A: controls to define normal mandibular growth Group B: untreated third-degree neck burns Group C: third-degree neck burns treated by a full-thickness skin graft Group D: third-degree neck burns treated by a myocutaneous flap All animals underwent placement of two bone markers in the maxilla. With biweekly intervals, standardized lateral skull roentgenographs were taken until the rabbits reached the age of 21 weeks. In this time period, major growth accelerations including the pubertal growth spurt took place. By the use of 13 reference points and 7 reference lines, rotations and distances were calculated. Statistical analysis of the data was performed. The results show that the normal mandibular length was unaffected in all groups. There were no statistically significant changes in matrix, intramatrix, and total rotations of the mandible and the maxilla. There was a statistically significant difference in the displacement of the mandibular reference point between all groups, suggesting a variable degree of normal backward skull rotation, namely, due to group B. Explanations to be considered concerning the fact that the only minor differences were found in group B: 1. Drawbacks of the animal model: differences in skin texture, postnatal mandibular growth, and head position compared with those of humans. 2. Other functional adaptation mechanisms such as changes in head position, which are recruited at first in adapting to disturbances of homeostasis, were not measured. Soft-tissue compensation probably has overcome major bony deformations. Nevertheless, some drawbacks of the model can be viewed as ideal concerning treatment of neck burns.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro and ex vivo expression of nucleolar proteins B23 and p120 in benign and malignant epithelial lesions of the prostate

The expression of two specific nucleolar antigens, p120 and B23, has been investigated in the prostatic carcinoma cell line LNCaP as well as in 40 frozen and 40 formalin-fixed tissue samples of benign and malignant prostatic lesions (15 benign hyperplasias, 5 grade 1, 15 grade 2, and 5 grade 3 carcinomas). In vitro, immunoreactivity of p120 was confined to nucleoli of proliferating cells, with virtually no negative staining during S and G2/M phases. Unlike p120, B23 was expressed in the nucleoli of all LNCaP cells independently of growth and cell cycle phases. Hence, B23 was detectable in all stromal as well as in normal and malignant epithelial prostatic cells, both in fresh and in formalin-fixed tissue sections after microwave treatment. In contrast, the immunoreactivity of p120 was almost completely restricted to the nucleoli of prostate carcinoma cells: frozen sections of benign prostatic hyperplasia (n = 15) were either totally negative for p120 (n = 13) or had a low percentage of positively stained cells (labeling index = 3.3% in 3 cases). In the carcinoma group 76% (19/25) of the specimens were p120 positive, and there was a significant rise of labeling index from 18.1% in grade 1 to 82.2% in grade 3 carcinomas (P < 0.001). In contrast to B23, p120 could not be reliably demonstrated in formalin-fixed and paraffin-embedded tissue. We therefore conclude that anti-B23 is a general marker of nucleoli, whereas expression of p120 appears to correlate with "hyperactivity" of the nucleolus and provides a new tool for flow cytometrical and immunohistochemical assessment of nucleolar activity in tumor pathology.

R56865, a Na(+)- and Ca(2+)-overload inhibitor, reduces myocardial ischemia-reperfusion injury in blood-perfused rabbit hearts

The cardioprotective effects of R56865 were studied in isolated rabbit hearts, blood-perfused with a support rabbit system. The effect on ischemic injury was evaluated by comparing myocardial contracture and contents of ATP catabolites and of lactate during 60 min of normothermic ischemia in untreated hearts (group I) and in hearts treated with 0.63 mg/kg of R56865 starting 20 min before ischemia (group II; n = 5 in each group). R56865 delayed the onset, and decreased the extent of ischemic contracture, but had no effect on the myocardial content of ATP, of its catabolites of lactate. The effect on reperfusion injury was studied by monitoring left ventricular function during 80-min reperfusion after the 60-min ischemia in three groups (n = 6 in each): an untreated group (group I) and two groups treated with R56865 given either before (group II) or after ischemia (group III). Ultrastructural changes and cellular calcium distribution after reperfusion were also studied. R56865 improved the recovery of function and prevented contracture during reperfusion. Left ventricular end-diastolic pressure was 13.2 +/- 2.8 mmHg in group II and 31.3 +/- 8.1 mmHg in group III vs 45.0 +/- 2.6 mmHg in group I (P < 0.0001 for II vs I; P > 0.05 for III vs I). Left ventricular developed pressure, maximum dP/dt and minimum dP/dt recovered to 71.0 +/- 5.4%, 98.9 +/- 6.1%, 85.3 +/- 4.8% of baseline values, respectively, in group II, to 64.5 +/- 3.0% (P > 0.05), 76.8 +/- 3.0%, 70.2 +/- 4.0% in group III, vs 52.0 +/- 6.5%, 58.9 +/- 6.9% and 53.6 +/- 5.8% in untreated hearts (P < 0.05 for II or III vs I). Coronary flow was 24.5 +/- 2.2 ml/min and 19.8 +/- 1.8 ml/min in groups II and III vs 14.8 +/- 0.7 ml/min (P < 0.05) in the untreated group. On histology the myocardium in hearts treated either before or after ischemia was well protected and calcium distribution was almost normal after reperfusion, while in untreated hearts, most of the myocardium displayed irreversible damage accompanied by massive intracellular calcium accumulation. We conclude that R56865 could attenuate Ca(2+)-overload, thereby reducing myocardial ischemia-reperfusion injury after an extended period of ischemia.

Determination of the energy-dependent extent of vascular damage caused by high-energy shock waves in an umbilical cord model

To determine the spatial extent of shock-wave-induced vascular damage human umbilical cords were exposed to electromagnetically generated, focused ultrasound waves of different energy densities. During treatment macroscopically visible hematoma and superficial holes appeared. Following exposure specimens were fixed and examined histologically. In addition to vessel wall necrosis and rupture, complete detachment of endothelial cells in defined regions was observed. A correlation of the extent of the damage with the energy density distribution revealed that a local energy density of 0.3 mJ/mm2 is the lower threshold for the occurrence of severe vascular damage.

[In vivo and ex vivo expression of nucleolar proliferation-associated antigens (p120, B23) in the prostate]

Expression of two nucleolar antigens, p120 and B23, was studied in a prostatic carcinoma cell line (LNCaP) and in frozen and paraffin embedded tissue sections of 40 benign and malignant prostatic lesions. The percentage of p120 negative G0/G1 phase cells rose significantly during transition from exponential to plateau growth phase in vitro (from 9% to 32%). In contrast, B23 was equally expressed throughout different cell cycle and growth phases. Thus, nucleoli of almost all stromal and epithelial cells were stained by B23 in tissue sections. P120, however, selectively stained nucleoli of proliferating prostatic epithelium. Whereas 88% (13/15) of benign hyperplasia were p120 negative this was the case in only 24% (6/25) of carcinomas. Using microwave procedure both MoAbs reacted in paraffin sections, but the percentage of p120 negative cases doubled. A routine application to formalin fixed and paraffin embedded tissue cannot be recommended thus far.

Variable effects of explosive or gradual increase of intracranial pressure on myocardial structure and function

BACKGROUND

Studies done in potential donors for heart transplantation and in experimental animals have suggested that brain death can have major histopathological and functional effects on the myocardium.

METHODS AND RESULTS

We developed experimental models of brain death using dogs to study the hemodynamic and catecholamine changes, the extent of myocardial structural damage, and the recovery potential of donor hearts obtained from brain-dead donors. Brain death was caused by increasing the intracranial pressure (ICP) suddenly or gradually by injecting saline in an epidural Foley catheter. In a first series of experiments, dogs given a sudden rise in ICP (n = 5) showed a hyperdynamic response and a 1,000-fold increase in the level of epinephrine after brain death. Histology revealed 93 +/- 2% of the myocardium to be severely ischemic. Dogs given a gradual rise in ICP (n = 6) showed a lesser hyperdynamic response, almost 200-fold increase in the level of epinephrine after brain death, and mild ischemic damage to the myocardium (23 +/- 1%). In a second series, hearts obtained from brain-dead and non-brain-dead donors were transplanted in recipients, and the weaning and recovery potential were studied. All four recipients with hearts from non-brain-dead donors were weaned with good functional recovery. Also, all four recipients with hearts from brain-dead dogs given a gradual rise in ICP were weaned with only moderate functional recovery. However, only two of four recipients with hearts from donors given a sudden rise in ICP were weaned and showed poor functional recovery.

CONCLUSIONS

Our results indicate that a sudden rise in ICP can cause irreversible myocardial damage.

Techniques for studies on growth characteristics of human prostatic cancer cells

The methods described in this article seem to be useful for studies on the growth characteristics of malignant epithelial prostate cells which are still under the influence of healthy cells. Before establishing primary cultures, pieces of tissue were sectioned in such a way that they could be unfolded to obtain a large surface. These pieces were treated enzymatically and then incubated for at least 4-6 weeks. In this time, cells grew or migrated out of the tissue and spread over the surface of the culture flasks. The viable single cells harvested from these primary cultures were characterized flow cytometrically, fractionated by countercurrent centrifugal elutriation, or further incubated above agarose so that they formed three-dimensional spheroids. Cytometric determinations of cellular cytokeratin, vimentin, and DNA were performed before and after incubation. They suggested that the percentages of cytokeratin-positive (epithelial) cells, vimentin-positive cells (fibroblasts), and aneuploid cells remained at levels (in vitro) similar to those within the pieces of tissue used for the culturing experiments, respectively. Since our culture technique allows the propagation of human epithelial prostate cells in vitro as they would grow in vivo under the control of the surrounding tissue, the method should help to investigate which particular treatment of the cells influences the growth of the malignant cells, while they are still surrounded by other cells of the same prostatic organ.

[Percutaneous kidney cyst sclerosing]

STUDY DESIGN

In the period between January 1986 and July 1990, 28 patients with renal cysts varying in size between 3 and 12 cm were treated with percutaneous sclerotherapy. Results, complications and further course were recorded and submitted to retrospective analysis.

TECHNIQUE

After ultrasound--controlled puncture of the cyst under local anesthesia, contrast medium is initially instilled in order to check the position of the needle and to exclude a tumor or calyceal cyst. After emptying the cyst, 96% ethanol was instilled and, after a delay of 1 to 2 minutes, completely aspirated again.

RESULTS

No complications were observed; in only one of the 27 patients followed up did a recurrence occur. In all other cases, an average regression of the cyst of 98% of the initial volume was achieved.

CONCLUSIONS

Percutaneous sclerosing of renal cysts is an unproblematical, low-invasive, non-stressful technique that is indicated as the treatment of choice in the case of renal cysts associated with clinical symptomatology.

Training-overtraining. A prospective, experimental study with experienced middle- and long-distance runners

Overtraining may be one frequent cause of stagnation or decrease in performance capacity of athletes. Israel (19) differentiates between addisonoid (parasympathetic) and basedowoid (sympathetic) overtraining, characterized by inhibition or excitation. We tried to induce an overtraining syndrome in 8 experienced middle- and long-distance runners, based on an increase in training volume from an average 85.9 km (week 1) to 115.1 km (week 2) and 143.1 km (week 3) to 174.6 km per week (week 4). The influence of this training on cardiovascular, metabolic and hormonal parameters was examined with special respect to plasma and urinary catecholamines. Laboratory testing including graded treadmill running was performed on the days 0, 14 and 28. Training was held six days each week, with nearly 30 km per day in the fourth week. A stagnation in endurance performance capacity (running velocity at the aerobic-anaerobic transition range) and a decrease in maximum working capacity were observed in 6 and a stagnation in 2 of the 8 sportsmen, indicated by a decrease in total running distance from 4719 + 912 m to 4361 + 788 m during incremental treadmill ergometry. The sportsmen could neither improve nor could they even approximately reach their personal records during the subsequent competitive season. Subjective complaints, classified on a four-point scale, increased from 1.2 (week 1) to 3.2 in week 4. Glucose, lactate, ammonia, glycerol, free fatty acids, albumin, LDL, VLDL cholesterol, hemoglobin level (transient), leukocytes, and heart rate (before and during exercise) decreased significantly. Urea, creatinine, uric acid, GOT, GPT, gamma-GT, serum electrolytes (except phosphate and calcium) remained constant at the measuring times, CPK was elevated.(ABSTRACT TRUNCATED AT 250 WORDS)

[Paraneoplastic acrokeratosis: Bazex disease. A tumor-specific dermatosis in squamous cell cancers in the area of the head and neck]

Bazex syndrome is a rare paraneoplastic syndrome with characteristic acral hyperkeratosis, seen only in men with either carcinoma of or metastases to the head and neck. The author describes a case of Bazex syndrome in which recognition of the hyperkeratosis led to diagnosis and treatment of the underlying tumour.

[Experimental studies on the regeneration capability and prognosis of hydronephrosis]

There are conflicting opinions regarding the ability of kidneys to return to normal functioning following removal of an obstruction. Opinions also differ on the precision of radioactive iodine for the measurement of functional ability in obstructed kidneys. We tried to assess the value of nuclear medical methods in comparison to the classical physiological clearance methods. Furthermore, we tried to answer the following questions: how long can an obstruction be present before total recovery becomes impossible and when is it no longer worthwhile to perform conservative surgery?

[Urologic complications following radiotherapy of cancers of the corpus uteri]

Patients with endometrial carcinomas who have undergone only radiation therapy represent a negative selection, because of the many concomitant diseases. In the author's group of 134 cases such patients were on average 7 years older than those who had undergone surgery. Even with computer-calculated opposing-field therapy with intracavity packing, radiation damage to the urinary tract must be expected. Of the 134 patients, 75 (55.9%) had pathologic urological findings following radiation therapy. The most commonly affected organ was the bladder (55.2%), followed by the kidneys (21.6%) and the ureter (7.5%). Radiation damage to the urethra could not be verified. The urological complications were hardly affected by the stage of the tumor, but considerably so by the time interval: the rate of urological complications was 68.9% higher after 5 years than after 1 year. Therefore, accurate statements concerning urological complications following primary radiation therapy for endometrial carcinoma cannot be made until 5 years have elapsed.

[Sonography of the efferent urinary tract. Suprapubic and intravesical methods]

The ability of sonographic methods to demonstrate the urinary passages and their abnormalities were studied systematically. The ureters can only be demonstrated if they are dilated. Sonography of the bladder can be used as a screening method for tumours, diverticula and stones. Intravesical sonography is useful for staging of bladder tumours. The value of these methods is discussed.

[Ureteral reimplantation using the psoas bladder-hitch. Experience based on 111 operations in 100 patients]

In a 12-year period we performed 111 ureteral reimplantations with vesico-psoas hitch in 100 patients. The indication was a stricture of the lower third of the ureter in 51 ureters, vesicoureteral reflux in 31 ureters, and intraoperative laceration of the ureter in 25 patients. A congenital megaureter was the indication for ureteral reimplantation with psoas hitch in 4 cases. The operative result was classified excellent or good in 72% of the cases, and only 16% had to be regarded as operative failures. Ureteral reimplantation with vesico-psoas hitch is a versatile procedure that suits a number of indications, it is invaluable for the replacement of the lower third of the ureter in difficult cases, and it leads to a good long-term result in a high percentage of patients.

[Results of functional scintigraphy using 131J-hippurate in preoperative diagnosis of patients with kidney tumors: influence on surgical treatment and predictive value for retentional serum levels]

156 patients with renal tumors were studied using 131J-hippurate to assess the validity of functional scintigraphy in preoperative diagnosis and to compare it with the serum levels of Creatinine and Urea before and after tumor nephrectomy. If the contralateral, non tumor bearing kidney had a clearance (RNCL) of more than 200 ml/min, no pathological elevation was found postoperatively. If the RNCL was between 150 and 200 ml/min, the postoperatively elevated serum levels of Creatinine and Urea normalized within 3 weeks after surgery. Elevation persisted for longer than 3 weeks if the RNCL was between 100 and 150 ml/min. In RNCL below 120 ml/min an elevation was found even 6 months after surgery. Only if the RNCL was less than 100 ml/min (2% of all cases), instead of tumornephrectomy, an organ-conserving surgery was performed. In these cases, the results of renal scintigraphy yielded additional information in deciding the type of non-radical surgery. Therefore, renal functional scintigraphy does not need to be performed in patients with renal tumors under the following conditions: 1. no elevation of Creatinine and Urea preoperatively and 2. normal morphological findings (sonography, IVP, angiography, CT) of the contralateral kidney.

[Cystic acne and clinocomptodactyly in Klinefelter's syndrome (46XY/47 XXY mosaic)]

Klinefelter's syndrome was found in a 18 year old patient, suffering for four years from nodulocystic acne. Serum gonadotropins were within normal range, while histology of the testes revealed beginning tubular hyalinization. The case report shows that young patients with Klinefelter's syndrome may present symptoms that seem to exclude this syndrome. Furthermore, our patient exhibited klinokamptodaktylia of hands and feet, a congenital anomaly occurring very rarely in Klinefelter's syndrome.

The lymphogram in abdominal tuberculosis

Lymphograms of 11 patients with histologically proven abdominal tuberculosis have been assessed in an attempt to define a typical pattern of appearance in retroperitoneal lymph glands. Glandular enlargement, poor glandular filling and lymphovascular obstruction were present. A gradient of abnormality with more marked adenopathy in the upper para-aortic chain extending to a lesser involvement below in the iliac chain was demonstrated in keeping with a retrograde spread of the tuberculosis process from the abdominal lymphatics cauded along the retroperitoneal chain. Lymphography may be valuable in cases where data from clinical observations and routine radiological studies is inconclusive in cases of vague abdominal disease.