Treatment of brain metastases from bladder cancer

Predicting survival after brain metastases in patients with bladder cancer

AIMS AND OBJECTIVES

Because of its rarity, limited data concerning brain metastasis (BM) from bladder cancer (BCa) are available, so this phenomenon remains unclear. We aimed to contribute to understanding this unique patient population's clinical behavior and outcomes.

METHODS/MATERIALS

This retrospective cohort study included 27 BCa patients with BM treated at our Cancer Institute between April 2009 and December 2022. The time from initial diagnosis to BM and overall survival from BM diagnosis were calculated (Kaplan-Meier method). Cox regression was used to test key clinicopathologic associations.

RESULTS

A total of 27 patients were included in the study (male/female = 23/4). The median patient age at BM diagnosis was 62.0 (47-79) years. The median interval from initial diagnosis to BM was 11.0 ± 2.59 (95 % CI, 5.91-16.08) months. Twenty (74.0 %) patients were diagnosed with BM by postsymptomatic imaging. The most common symptoms were headache-dizziness (n = 9, 33.3 %), seizure (n = 3, 11.1 %), hemiparesis (n = 2, 7.4 %), and vision defects (n = 2, 7.4 %). The most common sites of extracranial metastasis were the lung (n = 10, 52.6 %), bone (n = 7, 36.8 %), and lymph nodes (n = 6, 31.5 %). More than half of the patients (55.5 %) had multiple BMs. Eight (29.6 %) patients underwent surgery for BM. All of the patients received radiotherapy (RT) for BM (whole-brain radiotherapy (WBRT)/stereotactic radiotherapy (SRT) = 24/3), and eight patients received RT for the second time. Six patients were treated with systemic chemotherapy (CT) after BM. The median survival from BM was 3.0 ± 1.2 (95 % Cl, 0.4-5.5) months in the entire cohort. A low number of BMs (HR 0.270, 95 % CI 0.083-0.885; p = 0.031), surgery for BM (HR 0.174, 95 % CI 0.043-0.712; p = 0.015), CT after BM (HR 0.207, 95 % CI 0.057-0.755; p = 0.017), and better ECOG performance score (HR 0.248, 95 % CI 0.074-0.836; p = 0.025) were associated with better OS.

CONCLUSIONS

Factors associated with improved survival in BCa patients with BM include a few brain lesions, intracranial resection, CT after BM, and better ECOG performance scores. Larger-scale prospective studies are needed to define the optimal management strategy further.

Isolated cerebellar metastasis from urothelial carcinoma: A case report of a rare phenomenon

Introduction

Although urothelial carcinoma (UC) generally is non-invasive, contrastingly in 25% of patients UC metastasizes. Isolated central nervous system (CNS) metastasis from UC without other distant metastases are considered rare. In this report we describe a patient with an isolated and solitary cerebellar metastasis from UC.

Research question

In this case report we explore the value of histological analysis of CNS metastases, imaging, treatment options and survival.

Material and methods

A rare case is presented of a patient diagnosed with an isolated CNS metastasis originating from UC. Through a systematic review of literature route of dissemination, current imaging and treatment options, and survival are discussed.

Results

A 77-year-old male was diagnosed with a pT2N0M0 high-grade UC and treated with transurethral resection and chemoradiation therapy. Several months later, the patient presented with neurological symptoms, and radiological imaging revealed a solitary cerebellar mass. A body CT scan showed no other metastasis. After surgical resection, histology confirmed urothelial origin of the mass, matching his primary UC and the patient received post-operative stereotactic radiotherapy at the surgical site. Recurrence of the cerebellar mass occurred after 6 months for which the patient received re-resection. The patient died 5.5 months after re-resection.

Discussion and conclusion

Isolated brain metastases without other distant metastases from UC are rare, so histologic confirmation of the brain metastasis is essential, particularly when the time interval between diagnosis of the UC and brain metastasis increases. Early brain CT is not recommended. PET CT may have additional value in detection of other distant metastases from UC. Despite advancements in treatments, prognosis for CNS metastasis from UC remains poor.

A rare case of bladder cancer that metastasized to brain, heart, and lung lymph nodes benefited from immunotherapy

Bladder cancer is a common malignant tumor of the genitourinary system, with the primary cause of death being metastasis. The most common metastatic sites are the lymph nodes, liver, lung, bone, peritoneum, pleura, kidney, adrenal gland, and the intestine. Brain and heart metastases are rare. In this report, we describe a patient who had pulmonary lymph node metastases more than a year after being diagnosed with bladder cancer, followed by brain and cardiac metastases more than two years later. Following the failure of standard first-line chemotherapy, the patient accepted 6 cycles of tislelizumab immunotherapy. The re-examination revealed that the bilateral frontal brain metastases had vanished, the right temporal lobe metastases had been greatly decreased, the neurological symptoms had been alleviated, and the cardiac metastases had disappeared. This is a rare clinical case with encouraging effects of tislelizumab and can serve as a model for the treatment of similar patients.

Metastatic Urothelial Cell Carcinoma Presenting as an Isolated Malignancy to the Posterior Fossa: A Case Report and Review on the Literature

Urothelial cell carcinoma (UCC) of the bladder infrequently metastasizes to the central nervous system (CNS). The incidence worldwide is approximately 1%. The cerebral hemispheres of the anterior and middle cranial fossa are the most common sites of CNS spread, and usually, multiple metastatic lesions are present. Infrequently, metastasis presents as a single solitary metastatic malignancy to the posterior fossa. Here, we present the case of a patient with bladder UCC who presented with a single solitary metastatic malignancy to the cerebellum. The authors discuss the signs, symptoms, mechanism of metastatic spread to the CNS, diagnosis, management, and prognosis of isolated posterior fossa metastasis originating from bladder UCC. We also performed an extensive literature search to identify all cases of metastatic bladder UCC presenting as an isolated malignancy to the posterior fossa in the past 20 years.

Review: Brain Metastases in Bladder Cancer

Nearly 50% of bladder cancer patients either present with metastatic disease or relapse distantly following initial local therapy. Prior to platinum-based chemotherapy, the incidence of bladder cancer central nervous system metastases was approximately 1%; however, their incidence has increased to 3–16% following definitive treatment as platinum-based regimens have changed the natural history of the disease. Bladder cancer brain metastases are generally managed similarly to those from more common malignancies such as non-small cell lung cancer, with surgery +/–adjuvant radiotherapy, or radiotherapy alone using stereotactic radiosurgery or whole brain radiotherapy. Limited data suggest that patients with inoperable urothelial carcinoma brain metastases who are not candidates for stereotactic radiosurgery may benefit from shorter whole brain radiation therapy courses compared to other histologies, but data is hypothesis-generating. Given improvements in the efficacy of systemic therapy and supportive care strategies for metastatic urothelial carcinoma translating in improved survival, the incidence of intracranial failures may increase. Immune checkpoint blockade therapy may benefit cisplatin-ineligible metastatic urothelial carcinoma patients as first-line therapy; however, the effectiveness of immune checkpoint blockade to treat central nervous system disease has not been established. In this review, we discuss the incidence and management of bladder cancer brain metastases and considerations regarding variations in management relative to more commonly encountered non-urothelial histologies.

Central Nervous System Metastasis in Patients With Urothelial Carcinoma: Institutional Experience and a Comprehensive Review of the Literature

INTRODUCTION

Central nervous system (CNS) metastasis in patients with urothelial carcinoma (UC) is uncommon and poorly understood. We aimed to explore the clinical behavior and outcomes of this unique patient population.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with UC and CNS metastasis, treated in our institution (2006-2018), along with an exploratory patient-point meta-analysis of a similar patient population derived from a comprehensive literature review. Data regarding diagnosis, management, and outcomes were extracted. Overall survival, time to CNS metastasis (TTCM), and residual survival (RS) from CNS involvement to death were calculated (Kaplan-Meier method). Cox regression was used for testing key clinicopathologic associations.

RESULTS

We identified 20 "institutional" and 154 "literature" patients with adequate data granularity for analysis. Median TTCM was 17.7 (institutional cohort) and 10 (literature cohort) months. Most patients who developed CNS metastases had previous non-CNS metastasis (15/20 [75%] and 103/154 [67%], respectively). CNS lesions without previous history of metastasis were identified in 5/20 (25%) and 33/154 (21%) cases and those patients had a shorter TTCM. CNS lesions in the absence of known UC history were also documented in 18/154 (12%) literature cases. Multifocal CNS disease was associated with shorter RS in both cohorts in univariate, but not multivariate, analysis.

CONCLUSION

We observed a variability in disease presentation and course, with a subset of patients showing an early predilection for CNS insult, potentially reflecting a diverse underlying biology. Genomic profiling studies, elucidating the molecular landscape, and driving future treatments should be considered in this setting.

Long-term Survival From Muscleinvasive Bladder Cancer With Initial Presentation of Symptomatic Cerebellar Lesion: The Role of Selective Surgical Extirpation of the Primary and Metastatic Lesion

A 59-year-old man was diagnosed with urothelial carcinoma involving an isolated cerebellar metastasis after presenting to the emergency department for headache complaints. After selective surgical excision of the symptomatic brain lesion and delayed cystectomy due to intractable hematuria, he survived 11 years without evidence of recurrence or subsequent systemic chemotherapy. He eventually expired after delayed recurrence in the lung, supraclavicular lymph node, and brain. To our knowledge, this is the only case of prolonged survival from urothelial carcinoma after selective surgical extirpation of the primary and metastatic lesion without subsequent systemic chemotherapy.

Solitary cystic cerebellar metastasis in a patient with invasive transitional cell carcinoma of the bladder

Transitional cell carcinoma of the bladder (TCC) represents nearly 90% of genitourinary malignancies and typically presents with locally invasive symptoms. Metastasis to the central nervous system (CNS) is uncommon occurring in <5% of patients. When present, metastatic lesions are typically solid, isolated and located in the cerebrum. We report a case of a patient with a history of TCC who presented with lethargy and ataxia and was found to have a solitary cystic cerebellar lesion consistent with metastatic disease. Unfortunately, the prognosis for patients with TCC and CNS metastases is poor. Treatment options include debulking surgery, whole brain radiation, stereotactic radiosurgery and chemotherapy. Unfortunately, treatment may not appreciably extend survival and care is often supportive in previously reported cases. Though uncommon, TCC can metastasise to the CNS and should be considered in the differential diagnosis of patients, particularly those who were treated with aggressive surgery or combination chemotherapy previously.

Advanced neuroimaging studies in a patient with brain metastases from transitional cell carcinoma of the bladder

BACKGROUND AND PURPOSE

The differential diagnosis in single or oligo-brain lesions in metastatic cancer patients remains broad. Advanced imaging studies can be employed to help refine the differential and potentially guide treatment.

METHODS

Case report of a 52-year-old male patient with known transitional cell carcinoma of the bladder presented with headaches, cognitive symptoms, and episodic presyncope. Brain magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), and octreotide scans were performed to evaluate the underlying etiology of his symptoms.

RESULTS

MRI revealed two enhancing mass lesions in left temporal and left cerebellar locations. Both lesions were octreotide avid and MRS of the temporal lesion showed a single large lipid peak at 1.3 ppm, a small NAA peak, and a markedly increased choline:creatine ratio that was relatively characteristic for metastases. Pathology from surgical resection revealed transitional cell carcinoma of the bladder.

CONCLUSIONS

Resection of both lesions revealed metastatic transitional cell carcinoma. This is the first report of octreotide scan characteristics in a patient with transitional cell carcinoma with central nervous system (CNS) metastases. The octreotide avidity of these transitional cell CNS metastases suggests the presence of somatostatin receptors that may be considered as a potential therapeutic target.

Urine and serum cathepsin B concentrations in the transitional cell carcinoma of the bladder

BACKGROUND

It has been shown that expression and activity of lysosomal proteolytic enzymes (i.e., cathepsin B) correlate with tumor progression in various neoplasms. We investigate possible correlation of cathepsin B concentrations with grading and invasivity of tumorous bladder tissue.

METHOD

Cathepsin B concentrations in serum and urine were measured in 40 patients (29 men, 11 women, mean age 68 years) with transitional cell carcinoma (TCC) of the bladder without metastases and in control group of 64 healthy subjects (28 men, 36 women, mean age 55 years) using commercially available enzymatic immunoassay. Concentration of cathepsin B in urine was adjusted on creatinine. Urinary creatinine in all samples was measured by enzymatic creatinase method. Patients were divided into groups according to the grading (low grading: 18 patients, high grading: 22 patients) and invasivity of the carcinoma (nonmuscle-invasive tumors: 23 patients, invasive tumors: 17 patients).

RESULT

Concentrations of cathepsin B in urine were significantly elevated in patients than in control group (Median = 3.87 μg/L vs. 1.35 μg/L, P = 0.0002). Similarly, the ratio of U-cathepsin B/creatinine was significantly higher in patients (Median: 0.44 μg/mmol creatinine vs. 0.17 μg/mmol creatinine, P < 0.0001). U-cathepsin B may prove to be useful biomarker (area under the curve [AUC] = 0.72 and 0.73 for the U-cathepsin B/creatinine ratio, respectively). S-cathepsin B significantly correlated with grading of carcinoma (P = 0.02) and U-cathepsin B and U-cathepsin B/creatinine are positively associated with invasive tumors (P = 0.0001 and P = 0.002).

CONCLUSION

Cathepsin B concentrations correlate well with grading and invasivity of tumors and may have diagnostic value in investigation of bladder cell carcinoma. New index U-cathepsin B/Creatinine ratio is more appropriate biomarker to monitor TCC, than U-cathepsin B so far.

Solitary cerebral metastasis from transitional cell carcinoma after a 14-year remission of urinary bladder cancer treated with gemcitabine: Case report and literature review

BACKGROUND

Brain metastases are the most common adult brain tumors, frequently arising from primary tumors in the lung, breast, skin, kidneys, and colon. Transitional cell carcinoma (TCC), the most common type of urinary bladder cancer, is a rare cause of brain metastasis with an ominous prognosis.

CASE DESCRIPTION

A 68-year-old female presented with right-sided paresis and focal motor seizures of her right upper and lower extremities 14 years after being diagnosed and treated for primary TCC of the urinary bladder with gemcitabine-based chemotherapy. MRI imaging revealed a 3.1 × 3.1 × 2.7 cm heterogeneously enhancing mass located along the posterior aspect of the left frontal convexity. The lesion was accessed using a transsulcal approach and was surgically debulked along the motor cortex with motor strip mapping, followed by adjuvant whole-brain radiation therapy. Pathological examination confirmed metastatic carcinoma with features of TCC, a rare entity among metastatic brain tumors.

CONCLUSION

Brain metastases may present several years later in patients with TCC of the urinary bladder who have been treated with surgery and chemotherapy. Chemotherapeutic agents that penetrate the blood-brain barrier, such as gemcitabine, may delay development of cerebral metastasis from primary TCC of the urinary bladder.

A comparison of radiotherapy with radiotherapy plus surgery for brain metastases from urinary bladder cancer: analysis of 62 patients

PURPOSE

To evaluate the role of radiotherapy (RT) and prognostic factors in 62 patients with brain metastases from transitional cell carcinoma (TCC) of the urinary bladder.

PATIENTS AND METHODS

62 patients received either RT (n = 49), including whole-brain radiotherapy (WBRT) and/or stereotactic radiosurgery (SRS), or surgery (OP) combined with WBRT (n = 13). Overall survival (OS), intracerebral control (ICC) and local control (LC) were retrospectively analyzed. Six potential prognostic factors were assessed: age, gender, number of brain metastases, extracerebral metastases, recursive partitioning analysis (RPA) class, and interval from tumor diagnosis to RT.

RESULTS

Median OS and ICC for the entire cohort were 9 and 7 months. No significant difference between RT and OP + RT was found for OS (p = 0.696) and ICC (p = 0.996). On multivariate analysis, improved OS was associated with lack of extracerebral metastases (p < 0.001) and RPA class (p < 0.001), and ICC with the latter (p < 0.001). SRS-incorporating RT resulted in 1-, 2-, and 3-year LC probability of 78%, 66%, and 51%. No association between LC and any of the potential prognostic factors was observed. The results of the subgroup RPA class analyses were similar to the entire cohort.

CONCLUSION

Patient outcome for the RT-alone arm was not significantly different from OP + RT. SRS-incorporating treatment offers excellent LC rates. RPA class and the presence of extracerebral metastases demonstrated a significant prognostic role for survival. The latter should be used as stratification factors in randomized trials and can help define the cohort of patients that may benefit from more aggressive therapies.

Hypofractionated whole-brain radiotherapy for multiple brain metastases from transitional cell carcinoma of the bladder

PURPOSE

Brain metastases in bladder cancer patients are extremely rare. Most patients with multiple lesions receive longer-course whole-brain radiotherapy (WBRT) with 10 × 3 Gy/2 weeks or 20 × 2 Gy/4 weeks. Because its radiosensitivity is relatively low, metastases from bladder cancer may be treated better with hypofractionated radiotherapy. This study compared short-course hypofractionated WBRT (5 × 4 Gy/1 week) to longer-course WBRT.

METHODS AND MATERIALS

Data for 33 patients receiving WBRT alone for multiple brain metastases from transitional cell bladder carcinoma were retrospectively analyzed. Short-course WBRT with 5 × 4 Gy (n = 12 patients) was compared to longer-course WBRT with 10 × 3 Gy/20 × 2 Gy (n = 21 patients) for overall survival (OS) and local (intracerebral) control (LC). Five additional potential prognostic factors were investigated: age, gender, Karnofsky performance score (KPS), number of brain metastases, and extracranial metastases. The Bonferroni correction for multiple tests was used to adjust the p values derived from the multivariate analysis. p values of <0.025 were considered significant.

RESULTS

At 6 months, OS was 42% after 5 × 4 Gy and 24% after 10 × 3/20 × 2 Gy (p = 0.31). On univariate analysis, improved OS was associated with less than four brain metastases (p = 0.021) and almost associated with a lack of extracranial metastases (p = 0.057). On multivariate analysis, both factors were not significant. At 6 months, LC was 83% after 5 × 4 Gy and 27% after 10 × 3/20 × 2 Gy (p = 0.035). Improved LC was almost associated with a KPS of ≥70 (p = 0.051). On multivariate analysis, WBRT regimen was almost significant (p = 0.036). KPS showed a trend (p = 0.07).

CONCLUSIONS

Short-course WBRT with 5 × 4 Gy should be seriously considered for most patients with multiple brain metastases from bladder cancer, as it resulted in improved LC.

Leptomeningeal carcinomatosis from urinary bladder adenocarcinoma: A clinicopathological case study

We report a 73-year-old male patient with leptomeningeal metastasis from urinary bladder adenocarcinoma. He was presented with prominent hyperactive delirium during the course of the disease. Meningeal carcinomatosis was detected 5 days before his death, but the primary site of the malignant tumor could not be determined. Necropsy revealed leptomeningeal infiltration of many adenocarcinoma cells that covered the cerebrum. The leptomeninges of the right middle frontal gyrus, superior temporal gyrus, precentral gyrus and inferior parietal lobe were most severely affected by tumor cell infiltration. Cerebral edema was found to extensively cover the basal part of the temporal lobe. In the cerebrum, tumor cells were clustered in the perivascular spaces and had invaded localized areas of the frontal lobe. Vascular cell adhesion molecule (VCAM)-1 expression was detected in the small vessels of the cerebral upper cortical layers and of temporal subcortical u-fibers. Numerous astrocytes positive for cytokeratin AE1/AE3 were found in the frontal and temporal lobes. Meningeal carcinomatosis from urinary bladder adenocarcinoma is extremely rare and up-regulation of the adhesion molecules in the meningeal adenocarcinoma was confirmed.

Prolonged Remission in a Patient with Transitional Cell Carcinoma of the Bladder Developing Brain Metastases after Systemic Chemotherapy: A Case Report

We report a case of an excellent response to M-VAC chemotherapy in a patient with pulmonary metastases from transitional cell carcinoma of the bladder. He subsequently presented with acute neurological symptoms seven weeks after the completion of chemotherapy. Computed tomography of the brain revealed a solitary 24 mm x 26 mm lesion in the frontal lobe. The brain metastasis was resected. The patient was closely followed for disease progression and showed no evidence of disease up to 42 months after surgery. The presentation and treatment policy are discussed. This case suggests that long-term remission may be obtained after surgical resection of a single brain metastasis in patients with disseminated urothelial cancer who completely responded to systemic chemotherapy.

Gemcitabine and radiotherapy in the treatment of brain metastases from transitional cell carcinoma of the bladder: a case report

Hematogenous metastases occur in over 50% of muscle-invasive transitional cell carcinomas (TCC) of the bladder. Despite treatment (mostly surgery and radiotherapy), patients with brain metastases have an especially poor prognosis (median survival 2-5 months), making palliative treatment an important consideration. We followed a 60-year-old man with multiple brain metastases who was ultimately treated with gemcitabine chemotherapy. He underwent a cystectomy in 1997 because of a T3a N0 M0 G3 TCC of the bladder. Two years later, he developed one brain metastasis and one lung metastasis. Both metastases were resected and adjuvant chemotherapy was planned. Before chemotherapy, the patient suffered from headaches and symptoms of hemiparesis. A magnetic resonance imaging (MRI) showed multiple brain metastases of up to 2 cm, particularly in the brain stem. The patient underwent whole-brain radiotherapy with 30 Gy, followed by four cycles of a 3-week gemcitabine (800 mg/m2 on days 1 and 8) schedule. Another MRI showed a nearly complete response after four cycles of chemotherapy, with only small residual tumors remaining in the brain stem. This impressive activity was accomplished without adverse side effects, suggesting that radiotherapy combined with gemcitabine monotherapy may be an excellent choice for palliative treatment of TCC of the bladder.

Neuroendocrine differentiation in prostatic carcinoma

BACKGROUND

Information is presented on prostatic neuroendocrine cells and neuroendocrine differentiation in prostatic carcinoma. The prognostic and therapeutic implications of neuroendocrine differentiation in prostatic carcinoma are reviewed.

METHODS

Data are presented that support the intriguing link between neuroendocrine differentiation, tumor progression, and androgen-independent prostate cancer. The hormones, and the receptors, expressed by prostatic neuroendocrine cells are investigated in order to elucidate their significance for prognosis and therapy.

RESULTS

The prognostic significance of neuroendocrine differentiation in prostatic malignancy has been controversial, but recent studies employing markers such as chromogranin A and neuron-specific enolase suggest that neuroendocrine differentiation, as reflected by increased tissue expression and/or blood levels of these neuroendocrine secretory products, correlates with poor prognosis, tumor progression, and androgen-independence. Since all malignant neuroendocrine cells are devoid of androgen receptors and since neuroendocrine phenotypic expression is not suppressed by androgen ablation, clonal propagation of androgen receptor-negative neuroendocrine cells may play an important role in the pathway towards the androgen-independent state of prostatic carcinoma. This would have significant implications for the treatment of prostate cancer, as several of the hormones known to be expressed by neuroendocrine-differentiated, malignant prostatic cells are potential candidates for drug therapy. A limited number of hormones have been tested in this context, in particular somatostatin, bombesin, and serotonin.

CONCLUSIONS

Neuroendocrine differentiation in carcinoma of the prostate appears to be associated with poor prognosis, tumor progression, and the androgen-independent state, for which there is currently no successful therapy. Therefore, new therapeutic protocols and trials need to be developed to test drugs based on neuroendocrine hormones and/or their antagonists. An evaluation of this new therapeutic approach against prostatic carcinoma with neuroendocrine differentiation, including hormone-refractory cancer, is easily justified, since these tumors are unresponsive to current modes of therapy.

Platinum analogue combination chemotherapy: cisplatin, carboplatin, and methotrexate in patients with metastatic urothelial tract tumors. A phase II trial with evaluation of prognostic factors

BACKGROUND

Cisplatin is one of the single drugs that has shown the best documented effect in treating patients with locally recurrent or metastatic urothelial cancer. To the authors' knowledge, the effect of the combination of different platinum analogues in treating transitional cell carcinoma has not been evaluated previously neither experimentally nor in clinical studies.

METHODS

A Phase II trial of carboplatin (200 mg/m2), cisplatin (100 mg/m2), and methotrexate (250 mg/m2) with folinic acid rescue every 3 weeks was performed on 55 previously untreated patients with metastatic or locally recurrent urothelial cell carcinoma.

RESULTS

A response (complete response and partial response) was achieved in 21 of 51 evaluable patients (41%; 95% confidence limits, 28-56%). Twelve patients had no change, whereas 18 had progressive disease. Eight patients (16%) achieved a complete response, and most of these survived more than 2 years. No patient with poor performance (performance status score > or = 2) or bone metastases achieved a complete response. The median survival for all patients was 8.4 months. Multivariate survival analyses showed that performance status and alkaline phosphatase levels were significant prognostic factors for survival.

CONCLUSION

Combination therapy with cisplatin, carboplatin, and methotrexate is feasible but offers no advantage over other combinations with cisplatin and methotrexate in treating metastatic urothelial cell cancer. It is important to select patients for treatment carefully, and further studies of prognostic factors in these patients are warranted.

Neuroendocrine cells in the normal, hyperplastic and neoplastic prostate

Neuroendocrine cells can be demonstrated in normal, hyperplastic and neoplastic prostatic tissues. The products secreted by these cells can be used as tissue and/or serum markers but may also have biological effects. Neuroendocrine cells in prostate cancer most probably do not contain the androgen receptor and are therefore primarily androgen independent. Some of the neuropeptides secreted by the neuroendocrine cells may act as growth factor by activation of membrane receptors in an autocrine-paracrine fashion or by ligand-independent activation of the androgen receptor in neighboring non-neuroendocrine cells. Evidence is accumulating from experiments with tumor models that neuropeptides indeed can influence the growth of prostatic tumor cells. Future research on neuroendocrine differentiation may answer some questions concerning the biological behavior of clinical prostatic tumors.