Two cases of urogenital malignancies in male patients undergoing maintenance haemodialysis

Prostate Cancer Screening with Prostate-Specific Antigen in Hemodialysis Patients

BACKGROUND/AIMS

The diagnostic validity of prostate-specific antigen (PSA) among men receiving hemodialysis (HD) has not been well defined. The aim of this study was to evaluate PSA levels in HD men and to compare them with those of non-uremic controls.

METHODS

PSA levels were measured in 620 HD men (40-89 years old, mean age 62.4 years). In patients with PSA >4.1 ng/ml, prostate biopsies were performed. Cancer-free men were defined as having PSA ranging between 0 and 4.0 ng/ml, or PSA >4.1 ng/ml but with a pathologically negative biopsy. The resulting data was compared with that for 3,636 non-uremic controls (55-59- (n = 468), 60-69- (n = 2,220), and 70-79-year-old men (n = 948)).

RESULTS

Of 45 HD men with PSA >4.1 ng/ml, 22 consented to undergo a biopsy. Ten were positive and 12 were negative. The mean PSA of cancer-free HD men of 50-59 (n = 159), 60-69 (n = 214), 70-79 (n = 116), and 80-89 (n = 30) were 1.0, 1.0, 1.3, and 2.1 ng/ml, respectively. Cancer-free HD men demonstrated significantly lower PSA compared to controls.

CONCLUSIONS

HD men had lower PSA levels than those of controls.

Diagnostic value of serum prostate-specific antigen in hemodialysis patients

BACKGROUND

The value of serum prostate-specific antigen (PSA) screening was examined to detect prostate cancer in men receiving hemodialysis.

METHODS

Forty-one male patients age 60-95 (median age, 70 years) receiving hemodialysis were investigated for PSA levels. We set the cut-off point at 4 ng/mL (the usual reference range). Digital rectal examination (DRE) and transrectal ultrasonography (TRUS) of the prostate were performed in patients whose PSA was more than 4 ng/mL and/or who expected further examination of the prostate. When prostate cancer was suspected, biopsy of the prostate was performed. In patients with prostate cancer, magnetic resonance imaging, computed tomography and bone scintigraphy were performed to diagnose the clinical stage.

RESULTS

The mean serum level of PSA was 2.10 +/- 0.49 ng/mL. In this screening study, four of 41 men required further examinations for prostate cancer. Two of four refused further examinations. The other two were diagnosed with prostate cancer. The incidence of prostate cancer was at least 5% in our hemodialysis patients. One man, whose clinical stage was T2aN0M0, was treated with radical retropubic prostatectomy. Another man, whose clinical stage was T2bN0M0, was treated with luteinizing hormone-releasing hormone analogue.

CONCLUSION

In our preliminary study, prostate cancer screening with PSA was useful for the early detection of prostate cancer in hemodialysis patients. If possible, DRE and TRUS should be performed in conjunction with PSA tests.

The pharmacokinetics of fosfestrol and diethylstilbestrol in chronic hemodialysis patients with prostate cancer

BACKGROUND

Fosfestrol drip infusion therapy is an available endocrinotherapy for prostate cancer. But since there have been few reports of its use in chronic dialysis patients, the pharmacokinetics of fosfestrol in these patients remains unclear. We conducted fosfestrol drip infusion therapy as an induction therapy in chronic hemodialysis patients with prostate cancer.

METHODS

Two male patients were included in this study. One was a 68-year-old man who had been in hemodialysis for 15.7 years and had stage B2 prostate cancer. The other was a 74-year-old man who had been in hemodialysis for 4.4 years and had stage C prostate cancer. A total of 250 mg of fosfestrol was dissolved in 250 mL of 5% glucose solution and administered by drip infusion. The drug was given subcutaneously during 14 consecutive days and a luteinizing hormone-releasing hormone agonist was injected on day 15.

RESULTS

Serum fosfestrol levels increased rapidly after the drip infusion was started and remained at high levels during infusion, but fell quickly after the treatment ended. Diethylstilbestrol (DES) was also detected in blood after the infusion was started and its levels peaked when infusion ended. But on the next day, neither fosfestrol nor DES were detected in the blood of the patients. Moreover, neither fosfestrol nor DES was detected in the blood of the two patients before administering fosfestrol on day 15. Fosfestrol was quickly eliminated from the blood after hemodialysis was started, while DES remained in the blood during hemodialysis. The adverse reactions were mild hepatic dysfunction and gynecomastia.

CONCLUSIONS

Fosfestrol drip infusion therapy appeared to be safe as an endocrinotherapy for prostate cancer in chronic hemodialysis patients.

Prostate cancer with multiple lung metastases in a hemodialysis patient

In hemodialysis patients, few cases of prostate cancer have been reported until recently. We present a case of prostate cancer with multiple lung metastases in a chronic hemodialysis patient. A 65-year-old Japanese man who had maintained hemodialysis for 5 years was referred to our hospital with multiple metastatic lung tumors. Serum prostate tumor markers were highly elevated although his plasma testosterone level was within the normal range. A transrectal needle prostate biopsy confirmed a histologic diagnosis of moderately differentiated adenocarcinoma. Androgen blockade therapy was very effective as evidenced by a quick decrease of serum tumor markers. The follow-up computed tomography scan of the chest performed 3 months later showed a complete disappearance of the coin lesions. The early detection of prostate cancer in hemodialysis patients is difficult because of a lack of urologic symptoms, which indicate the importance of periodic screening by serum tumor markers. Combined androgen blockade is effective even in hemodialysis patients. However, close follow up is necessary because long-term results and prognoses are still unknown.

Impact of chronic dialysis on serum PSA, free PSA, and free/total PSA ratio: is prostate cancer detection compromised in patients receiving long-term dialysis?

OBJECTIVES

The increased incidence of malignancy (ie, prostate cancer) in patients with end-stage renal failure is well known. However, little is known of the impact of hemodialysis and various membrane types on total and free prostate-specific antigen (PSA). We prospectively studied the impact of high- and low-flux dialysis membranes and kidney function on total PSA (tPSA), free PSA (fPSA), and free/total PSA ratio (f/t PSA).

METHODS

A total of 149 men were included. tPSA, fPSA, and f/t PSA were measured before and immediately after dialysis with high-flux (n = 101) and low-flux (n = 48) membranes in the serum and in the dialysis ultrafiltrate. A multivariate analysis of the impact of kidney function and age on the rate of change of all parameters was performed.

RESULTS

Overall, a significant decrease of fPSA (from 0.49 +/- 0.3 to 0.35 +/- 0.3 ng/mL, P <0.0001) and f/t PSA (from 45 +/- 19% to 38 +/- 13%, P <0.0001) and a nonsignificant decrease in serum tPSA were observed. However, fPSA (from 0.51 +/- 0.5 to 0.27 +/- 0.3 ng/mL, P <0.0001) and f/t PSA (from 47 +/- 19% to 31 +/- 18%, P <0.0001) decreased significantly in high-flux membranes only. The ultrafiltrate contained 100% fPSA in high-flux membranes and no fPSA in low-flux membranes. Age, serum creatinine, blood urea nitrogen, and dialysis evaluation parameters (Kt/V) had no impact on correlation with changes in tPSA and fPSA.

CONCLUSIONS

tPSA molecules do not pass high- and low-flux membranes; fPSA passes high-flux membranes only. The nonsignificant decrease of tPSA is due to adsorption to both dialysis membranes. Although tPSA can safely be used to screen patients on dialysis, independently from the dialysis procedure and membrane, fPSA and f/t PSA are only reliable with low-flux membranes. Finally, we can state that the fPSA is most probably cleared through the kidneys by glomerular filtration.