Tobacco smoke, recurrences, and p53/bcl-2 expression in bladder cancer

Overexpression of p53 is considered to be predictive of mutations of the p53 gene. Exposure-specific mutations of the p53 gene have been described for cancers at different sites. An association between p53 mutation/overexpression and smoking has been described in early stage bladder cancer, but results were conflicting. We have conducted a study on 131 bladder cancer cases, considering p53 expression and smoking habits in an area where the use of air-cured tobacco, rich in carcinogenic arylamines, is common. The study suggests that the use of air-cured tobacco induces p53 overexpression (possibly via mutation) in early stage-low grade bladder cancer, more frequently than flue-cured tobacco (odds ratios = 3.4, 95% confidence intervals 0.9-13 in stage 1; odds ratios = 24, 95% confidence intervals 1.1-519 in stage 1, grade 1). However, all the excess associated with air-cured tobacco was concentrated in recurrences. When available, the biopsies of recurrent cases with early-stage disease were re-examined and all showed p53 expression at first diagnosis (with 10-50% of cells positive) (n = 5). It is hypothesized that exposure to tobacco-related chemicals increases the risk of recurrences via p53 overexpression/mutation. Expression of the bcl-2 gene was detected in only 2 out of 13 p53-positive smokers.

p53 expression compared with other prognostic factors in OMS grade-I stage-Ta transitional cell carcinoma of the bladder

OBJECTIVE

Recent studies have investigated the possibility that p53 protein and some macroscopic tumoral features, such as diameter and focality of the lesion, play a significant prognostic role in bladder cancer progression. A retrospective study was conducted on papillary grade-I stage-Ta transitional cell carcinoma (TCC) of the bladder.

METHODS

p53 expression was evaluated using the immunohistochemical method. A group of 31 patients with papillary grade-I and stage-Ta TCC of the bladder with no recurrence or who recurred with no histological grading and staging variation in a 4-year mean follow-up period was compared with 28 grade-I and stage-Ta papillary TCC patients who underwent recurrences and a worsening in histological grading (grade II or grade III) or staging (T1) within the same period of time. The aim of this study was to investigate the hypothesis that altered patterns of expression of the protein products of the mutated p53 tumor-suppressor gene, when independently evaluated in comparison with other tumoral prognostic factors, are associated with tumor recurrence and progression in patients with Ta papillary grade-I TCC of the bladder.

RESULTS

Our data show that when a p53 threshold of > 0% was considered, 53.6% of patients with tumor progression in the follow-up period were p53-positive compared with only 16.1% of the nonprogressing group (chi 2 = 6, p = 0.02). On the contrary, p53 failed to show any value in predicting progression when a 5% threshold was considered (chi 2 = 1.12, p = 0.92). The multifocality of the tumoral lesion and recurrent tumor was highly predictive of tumor progression for both variables (chi 2 = 5.16, p = 0.003, and chi 2 = 0.23, p = 0.006, respectively). Multivariate analysis revealed p53 nuclear overexpression (at a threshold of > 0%) to be a single valuable prognostic factor of progression (OR = 10.20, p = 0.009) and recurrence (OR = 54.19, p = 0.01).

CONCLUSIONS

Our results lead to the conclusion that p53 immunohistochemical detection has no prognostic value in predicting tumoral relapse or progression of TaGI TCC of the bladder when a 5% positivity threshold is considered. On the contrary, when a p53 nuclear labelling of > 0% is considered as positive staining, this tumor marker becomes highly predictive of tumor recurrence and progression. These findings seem therefore to suggest the use of a slight p53 positivity (> 0%) as a valid tool in predicting the clinical behavior of TaGI bladder TCC. The prognostic impact of a multifocal lesion and a recurrent tumor as markers of progression is also confirmed by these results.

Urethral prostheses. An overview

The first report in Literature dealing with an endourethral prosthesis in the treatment of recurrent bulbar strictures dates back to 1988. Since then other prostheses with different design and materials have been proposed. The Urolume by A.M.S., the first ever, is used worldwide and its indications are better known due to a longer follow-up time. In 6 months epithelium covers the prosthesis and it is generally well tolerated, but some Authors do not agree with its use in the treatment of traumatic strictures. Titanium prostheses have been used in few cases. A temporary steel alloy prosthesis, the Urocoil, has been proposed recently. Not enough follow-up data are available about this and the new “thermic memory” prosthesis. The bigdegradable prosthesis, used till now only on rabbits, actually represents the new frontier in the treatment of urethral strictures.

[Surgical treatment of benign prostatic hypertrophy and Kelami syndrome]

The authors analyze a group of 116 consecutive patients treated with transvesical prostatic adenomectomy or transurethral prostatic resection for benign prostatic hypertrophy (BPH) isolated five of them with a Kelami syndrome. These patients, aged between 53 and 70 years old, had a relevant ventral penile deflection with severe sexual impairment postoperatively. Among them only one asked for a corrective surgical procedure. Aetiology, preventive measures and therapeutic choices are discussed. Authors pointed out that this syndrome is actually underestimated considering the high number of transurethral or open surgery procedures for BPH.

[Measurement of skeletal alkaline phosphatase in prostatic carcinoma. Preliminary report]

Bone metastases frequently occur in prostate carcinoma. Total body radionuclide scan with diphosphonate methylene labelled with 99Tc is commonly used to diagnose such metastases. However this technique is aspecific and frequently unreliable. In recent years several biological markers dealing with bone metabolism were studied. Serum determination of skeletal alkaline phosphatase (ALP) and moreover of its bone isoenzyme (BAP) could be considered a reliable index of osteoblastic activity. In this preliminary report we analyzed a group of 43 patients affected by prostate carcinoma with or without bone metastases. The American Urological Association (AUA) staging system was adopted. Sixteen patients were D2, bone metastases had been suspected by means of radionuclide bone scan and confirmed by Computerized Tomography and/or aimed X-rays. Tandem R-Ostase by Hybritech was used to measure BAP, normal value is set to 20 micrograms/L. All D2 tumours had pathological BAP values (mean value 87.50 micrograms/l); 1/3 stage A, 5/13 stage B, 5/9 stage C and 0/2 stage D1 patients had pathological findings. One of this patients, stage C, revealed a bone metastase at a later bone scan.

Carcinogen-DNA adducts in bladder biopsies and urothelial cells: a risk assessment exercise

We have determined the levels of DNA adducts (using 32P-postlabelling) in the biopsies of 20 bladder cancer patients and in the exfoliated bladder cells of 36 healthy volunteers. The aims of the study were (a) to estimate the concentration of DNA adducts in cancer cases and controls according to the level of smoking; and (b) to investigate whether bladder cancer cases had higher levels of adducts in bladder cells than healthy controls had. A dose-response relationship between smoking levels and adduct levels was present among both cancer cases and controls. Cancer cases and the controls had similar adduct levels for the same level of smoking. According to a risk assessment exercise, adduct levels among heavy smokers were roughly comparable with those found in mice and dogs treated with bladder carcinogens, at doses which induce a 50% lifetime risk of bladder cancer.

Urinary levels of tumour associated antigens (CA 19-9, TPA and CEA) in patients with neoplastic and non-neoplastic urothelial abnormalities

The urinary excretion of carbohydrate antigen 19-9 (CA 19-9), tissue polypeptide antigen (TPA) and carcinoembryonic antigen (CEA) was evaluated in 264 patients with bladder cancer. Cut-off levels were established using a pool of healthy blood donors. The combined determination of CA 19-9 and TPA had a sensitivity of 74% in pTa and 83% in pT1 tumours, and 62% in grade 1, well differentiated tumours. Absence of disease at follow-up was related to a significant decrease in CA 19-9 and TPA in 129 patients with superficial (pTa or pT1) bladder carcinoma, followed up for at least 3 years. Recurrences, defined as new tumours at the same site or elsewhere in the bladder, were associated with an increase in the mean values but this was not statistically significant. A poor prognosis was indicated in patients with infiltrating tumours and the following pre-operative levels: TPA > 1500 u/l or CA 19-9 > 300 u/ml or CEA > 50 ng/ml.

[A case of priapism of the proximal corpora cavernosa]

A young man presented with a little perineal mass that was found to be secondary to partial priapism of the proximal corpora cavernosa. This is a very rare condition with only 3 previously recorded cases in the urology literature. The patient made a good recovery and was able to resume sexual activity.

Immunohistochemical detection of estrogen and progesterone receptors in the normal urinary bladder and in pseudomembranous trigonitis

According to recent studies showing the presence of estrogens receptors (ERs) in the human female lower urinary tract, we performed ER and progesterone receptor (PR) assays in fresh frozen and paraffin embedded biopsies taken from the urinary bladder. Fourteen females undergoing endoscopy during staging for gynecological cancer (endometrium, cervix, ovary) and 15 women complaining of recurrent abacterial cystitis (pseudomembranous trigonitis) were enrolled in the study as Group 1 and Group 2, respectively. After informed consent, they were submitted to cystoscopy, during which two biopsies were taken: one on the trigonum and the other on the bladder lateral wall. ERs were identified in both groups only in the trigonum (7/14 patients in Group 1 and 8/15 in Group 2), whereas the bladder lateral wall always stained negative. PRs were found at both sites in both groups (11/14 cases on the trigonum and 7/14 on the bladder lateral wall in Group 1; 11/15 and 2/15 respectively in Group 2). Morphological localization of PRs showed intense omogeneous staining in the nuclei of the stromal fibroblasts too. A clear correspondence between the presence of steroid receptors at the squamous metaplasia of the trigonum was observed. These data are discussed speculating about a possible endocrine pathogenesis of pseudomembranous trigonitis.

[Immunohistochemical determination of antigen 19-9 (CA 19-9) in transitional carcinoma of the bladder]

Carbohydrate Antigen 19-9 (CA 19-9) histological expression in transitional cell bladder carcinoma (TCBC) was studied by means of immunohistochemistry and its findings compared with those of Tissue Polypeptidic Antigen (TPA) and Carcino Embryonic Antigen (CEA). Twenty-one TCBC of various grade and stage were analyzed by using Avidin-Biotin complex method for CA 19-9 and TPA Peroxidase-Antiperoxidase method for CEA. Grade 3 and pT1, pT2/pT3 carcinomas showed a constant staining for CA 19-9 antigen, grade 2 showed a 50% positive immunoreaction while all grade 1 cases were negative. TPA showed an inverse correlation with well differentiated carcinomas which were better and more extensively stained than anaplastic ones. CEA expression was not correlated either with grade or stage. CA 19-9 could be considered as a dedifferentiation marker in TCBC.

In-vitro efficacy of glycosaminoglycans in the inhibition of urinary calcium oxalate cristallization

Aim of this study is the evaluation of the increased overall inhibitory power of whole urine induced by the in-vitro addition of glycosaminoglycans (GAGs). The inhibitory power, and its variations are assessed with the Sarig test, using ionometric measurements to follow the oxalate precipitation in different experimental conditions. The study is performed on the urine collected from 160 patients with a history of calcium-oxalate lithiasis; mesoglycan, sulodexide and sodium citrate (for comparison) are each tested on 110 urine specimens. A statistical significant difference is found between the basic evaluation and after addition of GAGs, comparable with the results obtained with sodium citrate. No significant differences in activity among the three drugs are found in those cases where simultaneous testing is possible.

[The Sarig test. A simple method to evaluate the inhibitory effect on urinary crystallization of calcium oxalate]

In this study, the Authors evaluate a simple test proposed by Sarig for the discrimination of kidney stone-formers, based on the overall urine inhibitory effect. A solution of the tested urine is added with sodium-oxalate and the kinetics of calcium-oxalate precipitation is indirectly followed with ionometric selective measurement of the progressive reduction of free calcium ions. A Discriminating Index may be therefore calculated; higher values are obtained in lithiasic patients in comparison with normal controls.

Detection of estrogen receptors in the trigonum and urinary bladder with an immunohistochemical technique

In order to detect estrogen receptors (ER) in the female bladder, 5 premenopausal and 10 postmenopausal women affected by gynecological diseases were submitted to cystoscopy, during which both the trigonum and the bladder lateral wall were biopsied. A new, simple, cost-effective immunohistochemical technique was employed to stain the estrogen specific binding sites. ER were found in the trigonum of 3 premenopausal and 4 postmenopausal subjects, while the bladder lateral wall was always ER-negative. A comparison with previously used ER detection methods and a discussion of further hypothetical applications of the immunohistochemical technique in the study of the lower female urogenital tract are reported.

[Blood and urine determinations of tissue polypeptide antigen in patients with bladder carcinoma]

The Tissue Polypeptide Antigen (TPA) is an oncofetal antigen widely used in the diagnosis and follow-up of several urothelial cancers. Its urinary and serum detection is performed by means of RIA technique. We determined urinary and serum TPA in 30 patients with bladder cancer who underwent a transurethral resection. Ten out of 30 patients were correctly diagnosed by serum TPA, 22 by urinary TPA. The ANOVA test showed a statistically significant correlation between grade and urinary TPA between stage and serum TPA. Urinary TPA showed a good sensibility in low grade and moreover in Ta stage carcinoma. Serum TPA increased its performance with higher grade carcinoma and in presence of a muscle infiltration, but it never reached a sufficient sensibility to be considered a bladder cancer marker. In conclusion the simultaneous determination of urinary and serum TPA does not give more information than the urinary determination alone.

[Comparison of fluoroquinolones (norfloxacin, enoxacin, ofloxacin) in the therapy of lower urinary tract infections]

The present study was carried out to assess comparatively the effectiveness and tolerance of norfloxacin, enoxacin and ofloxacin in the treatment and prophylaxis of infections of the low urinary tract in non-hospitalised patients. Thirty patients presenting positive uroculture on clinical evidence of ongoing infection were treated. Doses were 400 mg b.i.d. for norfloxacin, and 300 mg b.i.d. for ofloxacin and enoxacin; duration of treatment was 7 days in treatment. The pathogen was eradicated in 94% of cases at the control carried out after 5 days from the end of treatment; in the follow-up at 20 days, recurrences or reinfections were observed in 30% of the cases, almost all of them consisting of complicated infections. Slight side-effects were observed in 8 patients. No significant differences in effectiveness or tolerance were reported between the 3 quinolones under study which are therefore considered reliable overall for urological treatment. The absence of greater side-effects is related to the restriction of indications and the brevity of the therapeutic cycles.

Wheat bran in the selective therapy of absorptive hypercalciuria: a study performed on 18 lithiasic patients

The binding properties of raw vegetable fiber towards bivalent cations suggested the prescription of brain as a dietary supplement to limit intestinal calcium absorption in hypercalciuric patients. A group of 18 patients with a specific diagnosis of absorptive hypercalciuria received a dietary supplement of 14 gm. wheat bran at the 2 principal meals for 90 days. A complete assessment of mineral metabolism was performed after 45 and 90 days. Mean basal calciuria was 357 mg. per 24 hours and a significant decrease was noted after 45 days (245 mg. per 24 hours) and 90 days (240 mg. per 24 hours), with a p value of less than 0.01. Urinary oxalate did not vary significantly (0.34 to 0.38 to 0.31 mMol. per 24 hours) and neither did phosphate levels (1,020 to 900 to 893 mg. per 24 hours). A slight and pathologically insignificant decrease was noted in serum iron and urinary magnesium; this fact could be considered a side effect owing to the nonselective binding properties of fiber. Therefore, the positive results achieved confirm the effective action of wheat bran in the treatment of correctly diagnosed absorptive hypercalciuria.

CA-50 as tumour marker in transitional bladder carcinoma

Monoclonal antibody CA-50 is a useful tumour marker in gastrointestinal carcinoma. We report an assessment of its value in bladder cancer patients. We found raised levels in 2 of 2 patients with infiltrating carcinoma and in 8 of 35 with superficial carcinoma. The recurrence rate was higher in patients with raised levels, since 6 of 8 with elevated levels and 15 of 27 with normal values had a recurrence within 6 months. T1 and T3 carcinoma had a mean CA-50 level higher than normal. G3 tumours had a mean level slightly above normal. A statistically significant difference emerged when comparing Ta with T1 + T3 carcinomas. A longer study, with serial determinations, could assess the role of CA-50 as a prognostic indicator in bladder cancer.

Low dosage treatment with propiono-hydroxamic acid in paraplegic patients

Severe urinary tract infections due to urease-producing bacteria are frequently associated with neurourologic pathologies and complicated by infected nephrolithiasis. Hydroxamic acids, acting as urease inhibitors, can effectively reduce lithiasic risk, normalizing the urinary environment, as well as enhancing the action of antibiotic treatments. A low dosage propiono-hydroxamic acid (PHA) treatment, 60 mg twice a day for 7 days and then 60 mg/day, was used in 15 patients affected with neurourologic pathologies for 3 months. Nine patients were stone-free and 6 stone-bearers. Urinary pH and ammonium decreased in both groups. Halving the PHA dose did not cause any variation in urinary pH or ammonium trends. In the stone-bearing group an increase in these parameters was correlated with urinary infection recurrences. Complete sterilization was achieved in 11 of 14 patients who completed the trial. In the stone-free group no patient had an infectious recurrence after the first month. Two patients in the stone-bearing group had repeated recurrences. One patient dropped out after 45 days due to a decrease in platelets. The efficacy of such low dose treatment makes even long-term or repeated therapies possible, as is often needed by neurourologic patients.