Individualized medicine for renal cell carcinoma: establishment of primary cell line culture from surgical specimens

BACKGROUND

The lack of effective "in vivo" and "in vitro" models to predict success of pharmacological therapy for patients with renal cell carcinoma, as well as, the variety of cancer cell types demands the development of better experimental models to understand the pathophysiology of the disease and evaluate drug sensitivity in vitro.

PURPOSE

To develop primary renal cancer cell culture irrespective of tumor grade and tumor type, harvested from the patient's pathological specimen immediately after the laparoscopic radical nephrectomy to study potential "in vivo" pharmacological sensitivity.

MATERIALS AND METHODS

A total of 24 patients (17 males and 7 females). Mean age of 63.1+/-3.1 y.o. The mean size of the renal masses was 7.56+/-3.1 cm. Normal and pathological renal tissue was collected immediately after the specimen was extracted and submitted to enzymatic digestion for 16-24 hours. Clear cell carcinoma cells were selected through multiple passages in DMEM medium supplemented with glucose and antibiotics.

RESULTS

Establishment of cell line culture from all the patients' specimens irrespective of tumor grade and tumor type was achieved successfully. In addition to the tumor cell line culture, normal parenchyma tissue yielded primary cell lines to allow testing the response of tumor types to various pharmacological therapeutic agents and toxicity of such treatments to healthy tissue. From the initial collection of the specimens obtained after the removal of the kidney to the development of cell lines took occurred in average 32+6 hrs. The cells in culture showed characteristics of epithelial cells; like expression on cytokeratin and were maintained in culture for more than 20 passages.

CONCLUSION

The development of renal cancer cell cultures in vitro is labor intense but may yield a more realistic model to tailor pharmacological therapies and predict therapeutic success prior to "in vivo" application-a step in the direction of individualized medicine for RCC.

Comparison of prostate volume measured by transrectal ultrasonography and MRI with the actual prostate volume measured after radical prostatectomy

AIM

To compare the prostate volume, as measured by transrectal ultrasonography (TRUS) and by MRI, with that of the actual prostate volume measured after a radical prostatectomy (RRP).

MATERIALS AND METHODS

This prospective study included 21 patients who had undergone RRP. TRUS prostate volumes were calculated using the prolate ellipsoid volume formula, with the anteroposterior diameter measured from axial (TRUS-V1) and mid-sagittal images (TRUS-V2). Two prolate ellipsoid volumes (MRI-EV1 and MRI-EV2) were calculated from the MRI using the same method, and planimetric volume (MRI-PV). The actual prostate volume (Actual-V) was measured in a measuring jug within 1 h after RRP.

RESULTS

Mean of Actual-V was 40.3ml (21.0-82.0). In paired sample tests, the correlation coefficients (R) for all methods were over 0.8. In a Student's t test (paired), MRI-PV (p = 0.620), MRI-EV2 (p = 0.703) and TRUS-V1 (p = 0.099) showed no significant differences compared to the Actual-V. The linear regression models of these three methods were y = 1.025x - 0.268, y = 0.946x + 2.979 and y = 1.046x + 0.381, respectively.

CONCLUSIONS

Between two TRUS volumes, TRUS-V1 was shown to be superior to TRUS-V2. In MRI, MRI-EV2 was more accurate than MRI-EV1. However, MRI-PV was the most accurate method. TRUS-V1 and MRI-EV2 could be used instead of MRI-PV in general clinical settings.

Evaluation of pT2 subdivisions in the TNM staging system for prostate cancer

OBJECTIVE

To evaluate the subclassifications of pT2 diseases in tumour-nodes-metastases (TNM) staging system for prostate cancer.

PATIENTS AND METHODS

We retrospectively analysed the data of 372 patients who underwent radical retropubic prostatectomy (RRP) for pathologically organ-confined prostate cancer at our institution. Pathological staging of all subjects were re-evaluated using the 1997 and the 2002 TNM staging system for prostate cancer. Various clinicopathological features along with biochemical recurrence-free survival (BRFS) of pT2 subgroups were assessed.

RESULTS

Using the 2002 TNM staging criteria, 87 of the tumours (23.4%) were pT2a, and 284 (76.3%) were pT2c. Of all subjects, there was only one (0.3%) pathological 2002 T2b tumour identified. When subjects were classified according to the 1997 versions of the T2 subclassification (pT2a vs pT2b), the 1997 pT2a and pT2b cases showed no significant difference regarding BRFS (log-rank P = 0.645) among those who were followed-up for >2 years after RRP. Also, pathological stage (1997 pT2a vs pT2b) was not a significant predictor of BRFS in either uni- or multivariate analysis (P = 0.289 and P = 0.241, respectively). Only preoperative serum PSA level and pathological Gleason score along with positive surgical margin were significant predictors of PSA outcome after RRP on multivariate analysis.

CONCLUSION

Our results suggest that two- or three-tiered subclassification of pT2 organ-confined prostate cancer via methods used in the previous or current TNM staging system may not be appropriate. Efforts should be made to upgrade the current TNM staging system for prostate cancer.

Body mass index influences prostate-specific antigen in men younger than 60 years of age

OBJECTIVES

Prostate-specific antigen (PSA) levels can be affected by many factors. Body mass index (BMI) is suspected to influence PSA levels, but the associations are controversial. The aim of this study was to examine whether PSA levels were affected by BMI and age in Koreans.

METHODS

We evaluated the association between BMI and PSA in a group of 8640 Korean men (aged 40-79 years) without prostate cancer who received a general health checkup. Eligible men were classified into age groups spanning 10 years. BMI was categorized as normal (BMI <22.9), overweight (BMI 23.0-24.9), obese (BMI 25.0-29.9), and very obese (BMI > or =30) according to the re-defined World Health Organization (WHO) criterion for the Asia Pacific Region. PSA levels were stratified by age and BMI category.

RESULTS

Prostate-specific antigen levels decreased with increasing BMI (P trend <0.001). However, the inverse correlations between PSA and BMI were significant only among men 40-59 years old (P trend <0.05, respectively). BMI showed no significant associations with PSA in 60-79 years old (P trend >0.05, respectively).

CONCLUSIONS

Our study demonstrates that increased BMI is associated with decreased PSA levels only in men younger than 60 years of age. When determining whether to carry out prostate biopsy as part of early prostate cancer detection, obesity should be considered as a factor associated with reduced PSA in healthy young men (<60 years old) with marginal PSA levels.

Effect of Intraprostatic Local Anesthesia During Transrectal Ultrasound Guided Prostate Biopsy: Comparison of 3 Methods in a Randomized, Double-Blind, Placebo Controlled Trial

PURPOSE

We evaluated the effect of intracapsular anesthesia and periprostatic nerve block during transrectal ultrasound guided prostate biopsy.

MATERIALS AND METHODS

In a prospective, randomized, double-blind, placebo controlled study 152 consecutive patients were randomized into 3 groups. Group 1 of 41 patients was administered intraprostatic local anesthesia into the right and left sides with a total of 2 ml 1% lidocaine and a periprostatic injection of 2 ml saline later. Group 2 of 49 patients was administered intraprostatic injection of 2 ml saline, followed by periprostatic local anesthesia with 2 ml 1% lidocaine. Group 3 of 62 patients received intraprostatic and periprostatic local anesthesia with 2 ml 1% lidocaine. Patients were asked to grade the pain level using a 10-point linear visual analog pain scale 1) when the transrectal ultrasound probe was inserted, 2) during anesthesia, 3) during biopsy and 4) 20 minutes after biopsy. One-way ANOVA and the Kruskal-Wallis test with the Tukey post hoc test were used to compare patient characteristics and pain scale responses among the 3 groups.

RESULTS

No major complications, including sepsis and severe rectal bleeding, were noted in any patient. There were statistically significant differences in pain scores among groups 1 to 3 during anesthesia (mean +/- SD 5.6 +/- 2.5, 6.7 +/- 2.3 and 4.9 +/- 2.1, p = 0.003) and during biopsy (4.3 +/- 2.7, 4.5 +/- 2.6 and 2.7 +/- 2.1, respectively, p = 0.032). There were no differences in pain scores among the 3 groups during probe insertion (p = 0.39).

CONCLUSIONS

A combination of intracapsular anesthesia and periprostatic nerve block is an effective and useful technique that is well tolerated by the patient. It decreases the level of pain and discomfort associated with the prostatic biopsy procedure.

Impact of variations in bony pelvic dimensions on performing radical retropubic prostatectomy

OBJECTIVES

To investigate the impact of variations in bony pelvic dimensions observed from preoperative magnetic resonance imaging on operative time, intraoperative blood loss, and surgical margin status on performing open radical retropubic prostatectomy.

METHODS

A prospective study was undertaken in which preoperative magnetic resonance imaging was performed in 190 patients who were diagnosed with clinically localized prostate cancer before radical retropubic prostatectomy. Using the magnetic resonance image findings, various bony pelvic dimensions were measured. The associations of the measured pelvic dimensions and various clinicopathologic factors with the operative time, estimated blood loss, and surgical margin status were analyzed on multivariate analyses.

RESULTS

For operative time, none of the individual pelvic dimensions measured demonstrated significant associations on univariate analysis. In contrast, only the newly developed parameter, the pelvic dimension index, approached significance (P = 0.095). Only body mass index (BMI) proved to be independently associated with the operative time on multivariate analysis (P = 0.030). Also, only the prostate volume (P = 0.015) was independently associated with the estimated blood loss. For the surgical margin status, the preoperative PSA level (P = 0.041), pathologic Gleason score (P = 0.015), and BMI (P = 0.020), along with the pelvic dimension index (P = 0.048), demonstrated significant associations on univariate analyses. However, only the PSA level (P = 0.071) and BMI (P = 0.059) approached significance on multivariate analysis.

CONCLUSIONS

Our results have demonstrated that variations in the bony pelvic dimensions might have some impact, but not significantly so, on open radical retropubic prostatectomy compared with other patient-related baseline factors such as the BMI or prostate volume.

Association of Prostate Size and Tumor Grade in Korean Men with Clinically Localized Prostate Cancer

OBJECTIVES

To investigate the association of prostate size with aggressiveness of prostate cancer in Korean men who received radical retropubic prostatectomy (RRP) for clinically localized prostate cancer.

METHODS

We evaluated the association of RRP specimen weight and prostate volume measured by transrectal ultrasound (TRUS) with pathologic tumor grade, extraprostatic extension of disease, surgical margin status, and seminal vesicle invasion by reviewing data of 346 consecutive patients who underwent RRP for clinically localized prostate cancer at our institution without receiving preoperative radiation or hormonal treatment.

RESULTS

A strong correlation was observed between RRP specimen weight and TRUS-measured prostate volume (Spearman r = 0.76; P <0.001). After adjustment for multiple variables including age, body mass index, and preoperative prostate-specific antigen level, RRP specimen weight was observed to be significantly associated with presence of Gleason pattern 4 or greater at RRP in an inverse fashion (P = 0.03). Regarding other adverse pathologic features, prostate weight was also significantly inversely associated with extraprostatic extension of prostate cancer (P = 0.04) and surgical margin positivity (P = 0.002). When TRUS-measured prostate volume was applied in place of RRP specimen weight, results were the same.

CONCLUSIONS

Our data indicate that prostate size may be a useful predictor of tumor aggressiveness in Korean men with clinically localized prostate cancer. Further efforts should be made to elucidate actual mechanisms behind the association of prostate size and/or in vivo androgenicity with aggressiveness of prostate cancer.

Effect of statin therapy on early return of potency after nerve sparing radical retropubic prostatectomy

PURPOSE

We prospectively investigated whether postoperative statin use would contribute to earlier recovery of erectile function in men who underwent bilateral nerve sparing radical retropubic prostatectomy for clinically localized prostate cancer.

MATERIALS AND METHODS

A total of 50 potent men without hypercholesterolemia undergoing bilateral nerve sparing radical retropubic prostatectomy for clinically localized prostate cancer were prospectively randomized into 2 equal groups. Group 1 patients were instructed to ingest only 50 mg sildenafil per day if needed following hospital discharge after radical retropubic prostatectomy. Group 2 patients were prescribed atorvastatin at a dose of 10 mg daily from postoperative days 1 to 90 and they were also instructed to ingest sildenafil, as in group 1. Patient status regarding potency and adverse events were assessed 6 months after surgery.

RESULTS

The 2 groups demonstrated no significant differences regarding various baseline factors, including International Index of Erectile Function-5 scores. Group 2 had a significantly higher postoperative International Index of Erectile Function-5 score than group 1 at 6 months postoperatively (p = 0.003). Meanwhile, as judged by a preset definition, the incidence of potent patients 6 months after prostatectomy was 26.1% in group 1 and 55% in group 2 (p = 0.068). Also, 17.4% and 40% of the men reported achieving intercourse by vaginal penetration without a phosphodiesterase 5 inhibitor in groups 1 and 2, respectively (p = 0.172). No serious adverse events associated with medication were reported.

CONCLUSIONS

Postoperative treatment with atorvastatin in men who report normal erectile function preoperatively may contribute to earlier recovery of erectile function after nerve sparing radical retropubic prostatectomy.

Prospective analysis on the relation between pain and prostate volume during transrectal prostate biopsy

OBJECTIVE

We wanted to assess the relationship between pain and the prostate volume during transrectal ultrasound (TRUS) guided biopsy.

MATERIALS AND METHODS

Between July and September 2006, 71 patients scheduled for TRUS biopsy of the prostate were considered for inclusion to this study. These patients underwent periprostatic neurovascular bundle block with lidocaine prior to biopsy. Pain was assessed using a Visual Analogue Scale (VAS) during periprostatic neurovascular bundle block (VAS 1), during biopsy (VAS 2), and 20 minutes after biopsy (VAS 3). The mean pain scores were analyzed in the large prostate group (prostate volume > 40 cc) and the small prostate group (prostate volume< or =40 cc). P values < 0.05 were considered significant.

RESULTS

The mean prostate volume was 42.2 cc (standard deviation: 8.6). The mean pain scores of VAS 1, 2 and 3 were 4.70+/-1.61, 3.15+/-2.44 and 1.05+/-1.51, respectively. In the large prostate group, the mean pains scores of VAS 1, 2 and 3 were 4.75+/-1.76, 3.51+/-2.76 and 1.29+/-1.70, respectively, whereas in the small prostate group, the means pain scores were 4.66+/-1.46, 2.77+/-2.0, and 0.80+/-1.26, respectively. Although there were no statistical differences of VAS 1, the larger prostate group revealed higher pain scores of VAS 2 and 3 compared with the small prostate group (p < 0.05).

CONCLUSION

Patients with larger prostate volumes tend to feel more pain during and after TRUS guided prostate biopsy. Our findings suggest that additional analgesic strategies may be necessary when the patients with larger prostate undergo TRUS guided prostate biopsy.

Significance of Neurovascular Bundle Formation Observed on Preoperative Magnetic Resonance Imaging Regarding Postoperative Erectile Function After Nerve-Sparing Radical Retropubic Prostatectomy

OBJECTIVES

To investigate the significance of variations in neurovascular bundle (NVB) formation observed on preoperative magnetic resonance imaging (MRI) regarding postoperative potency after nerve-sparing radical retropubic prostatectomy (RRP).

METHODS

Preoperative MRI was performed in 93 patients who underwent bilateral nerve-sparing RRP for clinically localized prostate cancer and were followed up for at least 12 months after surgery. Judging from the MRI scans, patients were categorized into three groups: group 1, patients with no definite NVB observed on MRI, group 2, those with probable NVB formation observed on MRI but not definite, and group 3, those with NVB more definitely observed on MRI. Patients' erectile function status was assessed preoperatively and postoperatively using the International Index Erectile Function 5-item (IIEF-5) questionnaire.

RESULTS

Of the 93 patients, 40.9% were in group 1, 21.5% in group 2, and 37.6% in group 3 according to the MRI findings. The patient characteristics, including age, serum prostate-specific antigen, pathologic Gleason score, and preoperative IIEF-5 scores, were not significantly different among the three groups. However, the changes in the IIEF-5 scores after bilateral nerve-sparing RRP demonstrated a significantly larger decrease for group 1 compared with groups 2 and 3. Similar trends were observed when patients 60 years old or younger and those older than 60 years were analyzed separately.

CONCLUSIONS

In patients with no definite NVB formation observed on MRI, the nerves associated with erectile function may run along both sides of the prostate and spread more anteriorly than those with the NVB more definitely observed. Thus, to preserve the NVBs completely at all times, it would be important to widely dissect the lateral aspects of the prostate during nerve-sparing RRPs.

Assessing the body mass index of patients might help to predict blood loss during radical retropubic prostatectomy in Korean men

OBJECTIVE

To examine the intraoperative blood loss and patient characteristics in patients treated with radical retropubic prostatectomy (RRP), to determine the independent risk factors that predict increased blood loss and transfusion requirements in Korean men.

PATIENTS AND METHODS

We retrospectively analysed the records of 264 consecutive patients who had RRP; all medical records were reviewed for various factors before RRP, including prostate volume and body mass index (BMI), and during RRP, e.g. operative duration, estimated blood loss (EBL), calculated blood loss (CBL) and neurovascular bundle preservation. We evaluated differences in clinical characteristics and intraoperative factors in patients categorised by BMI. Multivariate logistic regression analysis was used to establish the relationship between preoperative independent variables and endpoints related to a high CBL.

RESULTS

The mean EBL was lower than the CBL (387.3 vs 716.9 mL). When the group of men was stratified by BMI, although the difference in mean EBL (P = 0.160) and transfusion rate (P = 0.511) among normal, overweight and obese categories were not statistically significant, the difference in mean CBL (P = 0.011) and operative duration (P = 0.022) was statistically significantly higher in overweight and obese men. Patients who had their neurovascular bundles preserved had no statistically differences in CBL, EBL and operative duration from those with did not. The multivariate logistic regression analysis showed that BMI was the only preoperative variable that predicted a high CBL.

CONCLUSIONS

The EBL was underestimated by the CBL, and the BMI was the only predictor before RRP of blood loss during RRP in these Korean men.

Expression of survivin in renal cell carcinomas: association with pathologic features and clinical outcome

OBJECTIVES

To investigate the expression of survivin in renal cell carcinoma and try to define its association with certain pathologic features and the clinical outcome.

METHODS

The tissue samples from 85 consecutive renal cell carcinoma specimens were obtained from patients who had undergone radical or partial nephrectomy. The mean follow-up was 45 months (range 3 to 60). Immunohistochemical staining of the paraffin sections of the pathologic sample was performed using monoclonal antibody for survivin with the standard avidin-biotin-peroxidase technique. The mean expression rate of survivin was assessed by inspection of at least five microscopic fields at 400x magnification. Expression of survivin was considered positive when more than 10% of the cancer cells in the microscopic fields demonstrated immunostaining. The degree of expression of survivin was compared with the clinicopathologic features.

RESULTS

Survivin was expressed in 67 (79%) of 85 samples. Immunostaining for survivin was demonstrated in the cytoplasm of tumor cells and in vascular endothelial cells. A significant increase in survivin expression was associated with increased T stage (P = 0.044), increased tumor grade (P = 0.0013), and low recurrence-free survival (P = 0.046). Multivariate Cox regression analysis revealed that survivin expression is an independent prognostic parameter (P = 0.021) in renal cell carcinoma.

CONCLUSIONS

The results of this study suggest that survivin-mediated inhibition of apoptosis is associated with progression and recurrence of renal cell carcinoma. Thus, survivin is a useful independent prognostic marker for this condition.

Prognostic Significance of Tumor Necrosis in Primary Transitional Cell Carcinoma of Upper Urinary Tract

OBJECTIVE

We investigated the prognostic significance of tumor necrosis in primary transitional cell carcinoma (TCC) of upper urinary tract.

METHODS

We retrospectively analyzed the records of 119 patients who received surgical management for primary TCC of upper urinary tract. The presence or absence of tumor necrosis was evaluated based on the macroscopic description of the tumor. Along with pathologic features of tumor necrosis, we assessed the impacts of various prognostic factors previously reported for TCC of upper urinary tract.

RESULTS

Tumor necrosis was identified in 19 (16.0%) patients. Patients with tumor necrosis were more likely to have higher local stage, nodal involvement, higher tumor grade, lymphovascular invasion (LVI), and recurrence of disease. Among all subjects, disease-specific survival rates at 5 years after surgery for patients with and without macroscopic tumor necrosis were 36.7 and 83.2%, respectively (P = 0.0001). In multivariate analysis, only pathologic T stage, LVI and tumor necrosis were shown to be independent predictors for disease-specific survival. For solely the invasive tumors, variables including age, surgical margin and tumor necrosis were observed to be independent prognostic factors for disease-specific survival in multivariate analysis, with tumor necrosis showing the highest rank order of statistical significance.

CONCLUSIONS

Our results suggest that macroscopic tumor necrosis may be a useful prognostic indicator for primary TCC of upper urinary, especially for invasive tumors. Further investigation would be warranted for the prognostic implications of tumor necrosis in TCCs of upper urinary tract and on actual pathogenesis of tumor necrosis in upper tract TCC.

Assessing the body mass index of patients might help to predict blood loss during radical retropubic prostatectomy in Korean men

OBJECTIVE

To examine the intraoperative blood loss and patient characteristics in patients treated with radical retropubic prostatectomy (RRP), to determine the independent risk factors that predict increased blood loss and transfusion requirements in Korean men.

PATIENTS AND METHODS

We retrospectively analysed the records of 264 consecutive patients who had RRP; all medical records were reviewed for various factors before RRP, including prostate volume and body mass index (BMI), and during RRP, e.g. operative duration, estimated blood loss (EBL), calculated blood loss (CBL) and neurovascular bundle preservation. We evaluated differences in clinical characteristics and intraoperative factors in patients categorised by BMI. Multivariate logistic regression analysis was used to establish the relationship between preoperative independent variables and endpoints related to a high CBL.

RESULTS

The mean EBL was lower than the CBL (387.3 vs 716.9 mL). When the group of men was stratified by BMI, although the difference in mean EBL (P = 0.160) and transfusion rate (P = 0.511) among normal, overweight and obese categories were not statistically significant, the difference in mean CBL (P = 0.011) and operative duration (P = 0.022) was statistically significantly higher in overweight and obese men. Patients who had their neurovascular bundles preserved had no statistically differences in CBL, EBL and operative duration from those with did not. The multivariate logistic regression analysis showed that BMI was the only preoperative variable that predicted a high CBL.

CONCLUSIONS

The EBL was underestimated by the CBL, and the BMI was the only predictor before RRP of blood loss during RRP in these Korean men.

Prognostic significance of common preoperative laboratory variables in clear cell renal cell carcinoma

OBJECTIVE

To investigate the prognostic significance of common preoperative laboratory variables evaluated before surgery for clear cell renal cell carcinoma (RCC).

PATIENTS AND METHODS

We retrospectively analysed the records of 355 patients who had surgery for clear cell RCC, assessing: clinical factors, including preoperative laboratory measurements, i.e. haemoglobin level, leukocyte count, platelet count, erythrocyte sedimentation rate (ESR), serum calcium, alkaline phosphatase (ALP), albumin, bilirubin, alanine aminotransferase, aspartate aminotransferase, and red blood cells in urine; and pathological factors, with the survival rates after surgery.

RESULTS

The presence of metastasis, tumour stage and tumour size, with the ESR and ALP before surgery, were identified as significant prognostic factors for progression-free survival in a multivariate analysis. The same factors were significant independent factors for disease-specific survival, except for ESR and ALP, which were nearly statistically significant. When limited to non-metastatic tumours only, the multivariate analysis showed that ESR and ALP, with tumour stage, grade, size and necrosis, were independent prognostic factors for disease-specific survival.

CONCLUSIONS

Along with traditionally accepted prognostic factors, these results suggest that common laboratory variables assessed before surgery, e.g. ESR and ALP, might also be useful in assessing the prognosis for patients with non-metastatic clear cell RCC. Including various laboratory variables in prognostic algorithms for RCC should be considered after further validation in RCCs of various histological subtypes and stages.

Significance of Macroscopic Tumor Necrosis as a Prognostic Indicator for Renal Cell Carcinoma

PURPOSE

We investigated the prognostic significance of macroscopic tumor necrosis in renal cell carcinoma.

MATERIALS AND METHODS

We retrospectively analyzed the records of 485 patients who underwent surgical treatment for organ confined or metastatic renal cell carcinoma. The presence or absence of tumor necrosis was evaluated based on macroscopic description of the tumor, and tumors were considered necrotic only if they exhibited more than 10% macroscopic necrosis.

RESULTS

Macroscopic tumor necrosis was identified in 27% of total patients. Patients with macroscopic necrotic renal cell carcinoma were more likely to have larger tumor, metastatic disease, higher local stage and higher tumor grade (all p < 0.001). Pathological features of microvascular invasion (p = 0.026) and sarcomatoid differentiation (p = 0.002) along with several laboratory findings were also observed to be associated with macroscopic tumor necrosis. Among the total subjects those without macroscopic tumor necrosis had significantly higher progression-free (p < 0.0001) and disease specific survival (p < 0.0001). When survival analysis was limited to nonmetastatic tumors only, the same logic applied, which was not the case for the patients with metastatic disease (p > 0.05). Among the different histological subtypes of renal cell carcinoma, macroscopic tumor necrosis was observed to have a significant impact only for the clear cell subtype. In patients with nonmetastatic RCC multivariate analysis revealed that macroscopic tumor necrosis (p = 0.004) was an independent prognostic predictor of disease specific survival along with pathological T stage, tumor grade and tumor size.

CONCLUSIONS

Our results suggest that macroscopic tumor necrosis may be a reliable prognostic indicator for nonmetastatic clear cell renal cell carcinoma which should routinely be examined for during pathological analysis.

Impact of variations in prostatic apex shape on early recovery of urinary continence after radical retropubic prostatectomy

OBJECTIVES

To investigate the impact of the variations in the shape of the prostatic apex observed on preoperative magnetic resonance imaging (MRI) on patients' status regarding urinary continence after undergoing radical retropubic prostatectomy, as well as the prevalence of such variations.

METHODS

We performed a retrospective analysis of 156 patients who had undergone preoperative MRI of the prostate and were followed up postoperatively by review of the records. For our analyses, patients were categorized into four different groups according to the shape of the prostatic apex shown on the midsagittal MRI scan. Patient status, including early (within 3 months after surgery) recovery of urinary continence, was also assessed.

RESULTS

Group 1 was the largest with 59 patients (37.8%), group 2 had 39 patients (25%), group 3 had 24 (15.3%), and group 4 had 34 patients (21.8%). Group 4 was composed of patients with the prostatic apex not overlapping with membranous urethra either anteriorly or posteriorly on MRI and had a significantly greater percentage (83.3% versus 66.7%) of patients with an early return of urinary continence after radical retropubic prostatectomy compared with the other groups (P = 0.014). On multivariate analysis of the predictive factor for the early return of urinary continence, anterior or posterior overlapping of the membranous urethra with the prostatic apex as shown on preoperative MRI was the only variable significantly associated with an early return of continence.

CONCLUSIONS

The results of our study provide objective evidence that variations in the shape of the prostatic apex in relation to the membranous urethra may significantly affect early recovery of urinary continence after radical retropubic prostatectomy.

Role of transrectal ultrasonography in the prediction of prostate cancer: artificial neural network analysis

OBJECTIVE

The purpose of this study was to evaluate the diagnostic performance of an artificial neural network (ANN) model with and without transrectal ultrasonographic (TRUS) data.

METHODS

Six hundred eighty-four consecutive patients who had undergone TRUS-guided prostate biopsy from May 2003 to January 2005 were enrolled. We constructed 2 ANN models. One (ANN_1) incorporated patient age, digital rectal examination findings, prostate-specific antigen (PSA) level, PSA density, transitional zone volume, and PSA density in the transitional zone as input data, whereas the other (ANN_2) was constructed with the above and TRUS findings as input data. The performances of these 2 ANN models according to PSA levels (group A, 0-4 ng/mL; group B, 4-10 ng/mL; and group C, >10 ng/mL) were evaluated using receiver operating characteristic analysis.

RESULTS

Of the 684 patients who underwent prostate biopsy, 214 (31.3%) were confirmed to have prostate cancer; of 137 patients with positive digital rectal examination results, 60 (43.8%) were confirmed to have prostate cancer; and of 131 patients with positive TRUS findings, 93 (71%) were confirmed to have prostate cancer. In groups A, B, and C, the AUCs for ANN_1 were 0.738, 0.753, and 0.774, respectively; the AUCs for ANN_2 were 0.859, 0.797, and 0.894. In all groups, ANN_2 showed better accuracy than ANN_1 (P < .05).

CONCLUSIONS

According to receiver operating characteristic analysis, ANN with TRUS findings was found to be more accurate than ANN without. We conclude that TRUS findings should be included as an input data component in ANN models used to diagnose prostate cancer.

T1c prostate cancer detection rate and pathologic characteristics: Comparison between patients with serum prostate-specific antigen range of 3.0 to 4.0 ng/mL and 4.1 to 10.0 ng/mL in Korean population

OBJECTIVES

To prospectively evaluate the Stage T1c prostate cancer detection rate and pathologic characteristics of patients with a serum prostate-specific antigen (PSA) level of 3.0 to 4.0 ng/mL and compare this with the rate of patients who had a PSA level of 4.1 to 10.0 ng/mL.

METHODS

We analyzed the data of patients who had PSA levels of 3.0 to 10.0 ng/mL, benign findings on digital rectal examination, and no specific lesion identified on transrectal ultrasonography. The clinical characteristics, cancer detection rate, and pathologic findings of the biopsy and prostatectomy specimen were compared between the low (3.0 to 4.0 ng/mL) and intermediate (4.1 to 10.0 ng/mL) PSA groups.

RESULTS

A total of 450 patients met our criteria. Of these 450 patients, 85 and 365 had a low or an intermediate PSA level, respectively. Prostate cancer was diagnosed in 26% of the low and 19% of the intermediate PSA group. No significant difference was found between the two groups in the pathologic biopsy findings, including the mean Gleason score and percentage of patients with a Gleason score of 7 or more. The pathologic findings of the prostatectomy specimens also showed no significant differences between the two groups, including the mean Gleason score, pathologic stage, and percentage of insignificant prostate cancer.

CONCLUSIONS

No statistically significant difference was found in the incidence of Stage T1c prostate cancer or pathologic characteristics in comparison between the low and intermediate PSA groups. These results suggest that a lower PSA cutoff should be considered as an indication for prostate biopsy in the Korean population.

Upregulation of Bcl-2 is associated with cisplatin-resistance via inhibition of Bax translocation in human bladder cancer cells

The efficacy of cisplatin in cancer chemotherapy is limited by the development of resistance. To elucidate the molecular basis of resistance to cisplatin, we compared cisplatin-induced apoptotic responses of the parental human bladder cancer cell line, T24 and its resistant subclone, T24R2. In T24 cells, cisplatin induce apoptosis and the activation of caspase-8, -9 and -3 and poly(ADP-ribose) polymerase cleavage. The expression levels of Fas, FasL, and FADD were not changed by the treatment with cisplatin. Furthermore, neither Fas-neutralizing antibody nor dominant negative mutant of FADD affected cisplatin-induced apoptosis. Western blot analysis of subcellular fractions showed that cisplatin induced redistribution of Bax and cytochrome c. Thus, cisplatin causes apoptosis in a death receptor-independent and mitochondria-dependent fashion in T24 cells. In contrast, overexpressed Bcl-2 protein inhibited cisplatin-induced Bax translocation and its downstream events in T24R2. Downregulation of Bcl-2 by RNAi potentiated the redistribution of Bax and cytochrome c and reversed cisplatin-resistance. Our results indicate that upregulation of Bcl-2 contributes to the development of cisplatin-resistance and usage of siRNA which targets the Bcl-2 gene may offer a potential tool to reverse the resistance to cisplatin in bladder cancer.

Detection of Prostate Cancer at Low and Intermediate Serum Prostate-Specific Antigen Levels in a Country with a Low Incidence of Prostate Cancer

BACKGROUND

The objective of this study was to evaluate the cancer detection rate and the pathologic findings of biopsy in men at low and intermediate prostate-specific antigen (PSA) levels in an Asian population.

METHODS

Patients between 40 and 79 years were entered into a study and 755 patients with serum PSA level of 2.0-10.0 ng/ml underwent trus-guided systematic biopsy. Patients were divided to low (PSA 2.0-4.0 ng/ml, n = 144) and intermediate (PSA 4.1-10.0 ng/ml, n = 611) PSA groups.

RESULTS

Patients in the low PSA group had significantly smaller prostates (P = 0.003) and lower PSA density (P < 0.001). The rate of cancer detection was 16.7% (24 of 144) in the low PSA group and 23.7% (145 of 611) in the intermediate PSA group (P = 0.067). In men with normal digital rectal examination (DRE), prostate cancer was diagnosed in 14 (13.3%) of the 105 men in the low PSA group and 99 (19.5%) of the 508 men in the intermediate PSA group (P = 0.139). In all patients and patients with normal DRE, no statistically significant differences were found in the pathologic findings of biopsy between the two groups.

CONCLUSIONS

Our findings provide a rationale to recommend prostate biopsy at lower PSA threshold in this population. At present, however, it is not clear that men who are treated when their cancers are detected at lower PSA levels have better outcomes than those who are treated when the PSA is higher than 4.0 ng/ml.

Metastatectomy prior to Immunochemotherapy for Metastatic Renal Cell Carcinoma

INTRODUCTION

We reviewed our experiences in performing cytoreductive metastatectomy before initiating systemic immunochemotherapy and tried to investigate potential prognostic factors for such an approach.

PATIENTS AND METHODS

A retrospective analysis of 57 patients who received interleukin-2, interferon-alpha, and 5-fluorouracil immunochemotherapy for metastatic renal cell carcinoma was conducted. Before undergoing immunochemotherapy, 20 of the 57 patients had received metastatectomy along with nephrectomy (metastatectomy group) and the other 37 nephrectomy alone (non-metastatectomy group).

RESULTS

The metastatectomy group demonstrated median disease-specific and progression-free survival of 23 and 13 months, respectively. The patients in the metastatectomy group were identified as having a better performance status and primarily demonstrating pulmonary metastasis compared with those in the non-metastatectomy group. As assessed in the metastatectomy group, factors such as the number of metastatic lesions, completeness of metastatectomy, and location of metastatic lesions (lung only vs. others) were observed to be significantly associated with overall survivals on univariate analysis.

CONCLUSIONS

Metastatectomy may still play a significant therapeutic role for metastatic renal cell carcinoma even in the era of immunochemotherapy as part of a multidisciplinary treatment approach in a selected group of patients in adequate general condition who have pulmonary-limited metastasis that can be completely resected.

Evaluation of concordance of Gleason score between prostatectomy and biopsies that show more than two different Gleason scores in positive cores

OBJECTIVES

To evaluate variables that may predict the Gleason score of radical prostatectomy specimens in patients with more than two different Gleason scores in the positive cores of their biopsy specimens.

METHODS

We reviewed the pathologic data of 98 patients who had more than two different Gleason scores in 12-site biopsy specimens. We assessed the following biopsy parameters: the greatest Gleason score on the biopsy specimen, the Gleason score of the greatest tumor percentage in the core, the Gleason score of the largest linear cancer length, and the greatest tumor ratio score (Gleason score of the greatest total tumor length of the same Gleason score/total core length of the same Gleason score). We also assessed the concordance in Gleason scores between biopsy specimens and prostatectomy specimens.

RESULTS

The greatest tumor ratio score was associated with the greatest (67%) concordance rate. The concordance of the greatest Gleason score on biopsy specimens was only 49%. When stratified into categories of well-differentiated (Gleason score 6 or less), moderate (Gleason score 7), and poorly differentiated (Gleason score 8 or more), the grade concordance rate of the greatest tumor ratio score was 73%. The grade concordance rate of the Gleason scores of the greatest tumor percentage in the core, Gleason score core with maximal tumor length, and the greatest Gleason score was 64%, 62%, and 57%, respectively.

CONCLUSIONS

If biopsy specimen results in more than two different Gleason scores in the positive cores, the greatest tumor ratio score may be the most useful variable with regard to the prediction of the final Gleason score in the radical prostatectomy specimen.