Discontinuation of Tamsulosin Treatment in Men with Lower Urinary Tract Symptoms: A Pilot Study

OBJECTIVES

Since little investigation has been undertaken to determine if alpha1-blockers should be given continuously to sustain their efficacy, we conducted a pilot study to determine symptom change following discontinuation of tamsulosin after an initial improvement in symptoms in men with lower urinary tract symptoms (LUTS).

PATIENTS AND METHODS

Thirty-three of 78 patients with mild-to-moderate prostate hyperplasia, who had symptom improvement according to the International Prostate Symptom Score (IPSS) to <10 or the quality of life (QOL) index to < or =3 after initial treatment with tamsulosin, were enrolled in this study. Subjective parameters (IPSS and QOL index) and objective parameters (maximum and mean urinary flow rates) were evaluated at baseline and after initial treatment, and 4, 8, 12 and 24 weeks after discontinuing tamsulosin.

RESULTS

The rates of successful discontinuation of tamsulosin were high throughout the follow-up period, i.e., 80.6% at 4 weeks, 80.6% at 8 weeks, 80.0% at 12 weeks, and 68.9% at 24 weeks. Temporary worsening in both subjective and objective parameters was observed only at 4 weeks; however, these parameters recovered to almost post-treatment levels at 24 weeks.

CONCLUSION

The present study suggests that continuous treatment is not always needed to maintain urinary symptom relief in a specific subset of patients who felt symptom improvement after initial treatment with tamsulosin.

Vascular endothelial growth factor-C (VEGF-C) expression predicts lymph node metastasis of transitional cell carcinoma of the bladder

PURPOSE

It has been found that expression of vascular endothelial growth factor-C (VEGF-C) in several carcinomas is significantly associated with angiogenesis, lymphangiogenesis and regional lymph node metastasis. However, VEGF-C expression in bladder transitional cell carcinoma (TCC) has not yet been reported. To elucidate the role of VEGF-C in bladder TCC, we examined VEGF-C expression in bladder TCC and pelvic lymph node metastasis specimens obtained from patients who underwent radical cystectomy.

METHODS

Eighty-seven patients who underwent radical cystectomy for clinically organ-confined TCC of the bladder were enrolled in the present study. No neoadjuvant treatments, except transurethral resection of the tumor, were given to these patients. The VEGF-C expressions of 87 bladder tumors and 20 pelvic lymph node metastasis specimens were examined immunohistochemically and the association between VEGF-C expression and clinicopathological factors, including angiogenesis as evaluated by microvessel density (MVD), was also examined.

RESULTS

Vascular endothelial growth factor-C expression was found in the cytoplasm of tumor cells, but not in the normal transitional epithelium. Vascular endothelial growth factor-C expression was significantly associated with the pathological T stage (P = 0.0289), pelvic lymph node metastasis (P < 0.0001), lymphatic involvement (P = 0.0008), venous involvement (P = 0.0002) and high MVD (P = 0.0043). The multivariate analysis demonstrated that VEGF-C expression and high MVD in bladder TCC were independent risk factors influencing the pelvic lymph node metastasis. Moreover, the patients with VEGF-C-positive tumors had significantly poorer prognoses than those with the VEGF-C-negative tumors (P = 0.0087) in the univariate analysis. The multivariate analysis based on Cox proportional hazard model showed that the independent prognostic factors were patient age (P = 0.0132) and pelvic lymph node metastasis (P = 0.0333).

CONCLUSION

The present study suggests that VEGF-C expression is an important predictive factor of pelvic lymph node metastasis in bladder cancer patients.

Intraindividual variation in total and percent free prostate-specific antigen levels in prostate cancer suspects

OBJECTIVES

To investigate intraindividual total and percent free serum prostate-specific antigen (PSA) in prostate cancer suspects and to understand the clinical implications.

PATIENTS AND METHODS

Total and percent free PSA were measured using Tandem-R or chemiluminescent enzyme-linked immunoassay for a median of three times in 126 men. Prostate biopsies were performed in all patients; benign prostatic hyperplasia was diagnosed in 81 patients and prostate cancer in 45 patients.

RESULTS

The overall mean coefficients of variation for total and percent free PSA were 16.10 +/- 11.94% and 15.45 +/- 15.91%, respectively. A significant correlation (p = 0.0056) was observed between the two variations. The variations in total and percent free PSA were related to none of such stratifications as baseline total PSA level, histology, age, or measurement interval, but for measurement interval on that for total PSA.

CONCLUSION

Intraindividual variation in serum PSA should be considered in decision-making about performing prostate biopsies. Also, care should be taken in interpreting repeated percent free PSA measurements in order to enhance the specificity of total PSA, because it had a similar variation to total PSA variation.

Vesicoureteral reflux after intravesical instillation of bacillus Calmette-Guérin against carcinoma in situ of the bladder

We report a case of vesicoureteral reflux (VUR) 3 years after intravesical instillation of bacillus Calmette-Guérin (BCG, Tokyo 172 strain) against carcinoma in situ of the bladder. The present case suggests that a long-term careful follow-up is needed to detect not only tumor recurrences but also VUR as a late complication after intravesical BCG instillation.

[A case of advanced rhabdomyosarcoma of the spermatic cord who occurred epilepsy-like symptoms, but was completely responded to chemotherapy]

A 19-year-old man presented with left aggressive painless scrotal swelling. On the diagnosis of left intrascrotal tumor, left high orchiectomy with partial scrotal skin resection was performed. Pathological examination of the specimen and systemic metastasis survey revealed embryonal rhabdomyosarcoma of left spermatic cord with multiple lung metastasis (Intergroup Rhabdomyosarcoma Study Group IV). Systemic chemotherapy with etoposide (VP-16), cisplatin (CDDP), and ifosfamide (IFO) (VIP therapy) was started. Although epilepsy-like symptoms occurred at the first course of VIP therapy, these symptoms immediately improved by diazepam administration. These symptoms were thought to be due to the adverse effects of IFO. To our knowledge, there were little reports on epilepsy-like symptoms caused by IFO in Japan. On the other hand, his multiple lung metastasis disappeared after the second course of VIP therapy. Although IFO may be effective in rhabdomyosarcoma, the toxicity of various nervous systems may be discovered.

Giant stercoral stone and catheterization difficulty

An unusual case of giant calcification in the midline of the pelvis is reported herein. An 84-year-old male, whose urination was managed by clean intermittent self-catheterization (CIC), presented with catheter insertion difficulty. The patient had a history of transurethral operations for benign prostatic hyperplasia and small bladder stones. Kidney, ureter and bladder (KUB) X-ray of post-enhanced computed tomography (CT) suggested a giant ball-shaped calcification in the bladder. A recurrent bladder stone was suspected. However, pelvic CT scan revealed that the giant calcification was, in fact, situated in the rectum. Thus, a diagnosis of giant stercoral stone was made. After the stone was removed manually, the patient had no difficulty in inserting the catheter. His prior complaint may have been caused by urethral bladder neck obstruction due to the giant stercoral stone.

Quantitative analysis of thymidine phosphorylase and dihydropyrimidine dehydrogenase in renal cell carcinoma

OBJECTIVE

The purpose of the present study was to clarify the clinicopathological significance of both thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) in renal cell carcinoma (RCC) based on a quantitative analysis of RCC patients.

METHODS

Levels of TP and DPD in RCC and/or uninvolved renal tissues from 65 RCC patients were measured by enzyme-linked immunosorbent assay.

RESULTS

The TP level and TP/DPD ratio were significantly higher in RCC than in adjacent uninvolved renal tissues (p < 0.0001). There was no significant difference in DPD levels between RCC and uninvolved renal tissues. The ratio of the highest to the lowest level was 623 in TP level, 28.9 in DPD level, and 985 in TP/DPD ratio. In the univariate analysis, patient's age (p = 0.04), tumor stage (p < 0.0001), tumor size (p = 0.007), TP expression (p = 0.03), and DPD expression (p = 0.04) were significantly associated with increased risk of death. Multivariate analysis showed that patient's age, tumor stage, and TP expression were independent prognostic factors.

CONCLUSIONS

TP and DPD in RCC provide prognostic information although DPD was not an independent prognostic factor. The present finding of a wide range in these enzyme expressions in RCC suggests that a certain subpopulation with a high TP/DPD ratio has potential responsiveness to fluoropyrimidines, especially 5'-deoxy-5-fluorouridine and capecitabine.

Elevated serum progastrin-releasing peptide (31-98) level is a predictor of short response duration after hormonal therapy in metastatic prostate cancer

BACKGROUND

The neuroendocrine (NE) pathway has been attracting attention as a mechanism for the androgen-independent progression because the neuropeptide provokes tumor growth and inhibits apoptosis under androgen-deprived milieu in prostate cancer cells. On the basis that serum progastrin-releasing peptide (ProGRP) is elevated in patients with advanced disease stage, we examined the prognostic value of the neuropeptide.

METHODS

Serum ProGRP status was determined with an enzyme-linked immunosorbent assay (ELISA) in 460 men with benign and malignant prostatic diseases, chronic renal failure, and healthy controls. Seventy patients with metastatic prostate cancer including four patients (5.7%) with NE carcinoma who underwent hormonal therapy were enrolled in the prognostic analyses by Cox proportional hazards model.

RESULTS

The serum status steadily shifted toward predominant expression of ProGRP with the progression of prostate cancer into metastatic and androgen-independent stages. Univariate analysis revealed that the deteriorated performance status (PS) and extent of bony disease (EOD), and high serum alkaline phosphatase (ALP), serum ProGRP, and nadir prostate-specific antigen (PSA) levels were associated with a lower progression-free survival (PFS) rate (P < 0.005). Multivariate analysis demonstrated that PS, serum ProGRP, and nadir PSA held an independent predictive value for PFS (P < 0.05), and all correlated with bone-related factors. Serum ProGRP was the most significant predictor among pre-treatment factors in this model (P = 0.0094).

CONCLUSIONS

The neuropeptide precursor ProGRP is a distinct serum marker that is useful to know the NE milieu and provides prognostic information in patients with advanced prostate cancer. Standard therapy for metastatic prostate cancer may make progress when further studies will clarify the causative link between serum ProGRP level and androgen-independent disease progression.

[Clinical evaluation of hot flushes developing during endocrine therapy for prostate carcinoma]

OBJECTIVE

There are few clinical investigations on the hot flushes that develop during endocrine therapy for prostate cancer in Japan, although there are many reports in the Western countries. Therefore, we evaluated the incidence of hot flushes and the association between hot flushes and clinical characteristics of prostate cancer patients receiving endocrine therapy.

PATIENTS AND METHODS

Sixty-eight prostate cancer patients receiving endocrine therapy (LH-RH analog (group LH-RHA); 22 patients, LH-RHA + non-steroidal antiandrogen (group LH-RHA + NSAA); 20 patients, LH-RHA + steroidal antiandrogen (group LH-RHA + SAA); 8 patients, LH-RHA + estramustine phosphate (group LH-RHA + EP); 1 patient, bilateral orchiectomy (group O); 5 patients, O + non-steroidal antiandrogen (group O + NSAA); 11 patients, and O + steroidal antiandrogen (group O + SAA); 1 patient) were evaluated by a fixed questionnaire. The incidence of the hot flush, the association between hot flushes and the clinical factors, as well as the therapy of hot flushes including SAA and Kampo therapy were analyzed.

RESULTS

The overall incidence of hot flushes was 37% (36% in group LH-RHA, 45% in group LH-RHA + NSAA, 13% in group LH-RHA + SAA, 0% in group LH-RHA + EP, 20% in group O, 45% in group O + NSAA, 100% in group O + SAA). No significant association between the hot flushes and the clinical factors of the patients was observed. On the other hand, in 3 of 4 patients treated by SAA, hot flushes improved after 4 weeks. In 2 of 3 patients treated by Kampo, hot flushes improved after 4 weeks.

CONCLUSION

Hot flushes are the major side effect of endocrine therapy for Japanese prostate cancer patients. SAA and Kampo are thought to be effective for treatment of hot flushes.

Immunohistochemical study of bcl-2, p53 and Ki-67 expressions in collecting duct carcinoma of the kidney. Five cases and review of the literature on bcl-2, p53 and Ki-67 expressions in renal cell carcinoma and transitional cell carcinoma

OBJECTIVES

This study was designed to examine the expressions of bcl-2, p53 and Ki-67 antigen in collecting duct carcinoma (CDC) of the kidney by an immunohistochemical method.

METHODS

The diagnosis of CDC was based on the criteria proposed by Srigley and Eble. The clinical courses of 5 CDC cases examined in this study suggested that 3 cases were low grade and 2 cases high grade. The expressions of bcl-2, p53 and Ki-67 antigen were evaluated in paraffin-embedded surgical specimens using anti-bcl-2 and anti-p53 antibodies and Ki-67 antigen, respectively.

RESULTS

The expression of bcl-2 was recognized in 3 of 5 cases (60%), p53 expression also in 3 of 5 cases (60%). The Ki-67 labeling index was 7.46 +/- 7.40 (mean +/- SD).

CONCLUSIONS

It was suggested that there were two clinical types in CDC; the expression of bcl-2 did not correlate with the CDC patients' clinical courses and the cellular proliferation, and p53 expression was recognized in the CDC patients with highly cellular proliferation.

Forced Expression of Cytidine Deaminase Confers Sensitivity to Capecitabine

<i>Objective:</i> Cytidine deaminase (CDD) is involved in the metabolism of new pyrimidine analogues, capecitabine (N⁴-pentyloxycarbonyl-5′-deoxy-5-fluorocytidine) and gemcitabine (2′,2′-difluorodeoxycytidine). The purpose of the present study was to directly examine the role of CDD in tumor cells themselves in mediating the sensitivity to capecitabine compared with gemcitabine. <i>Methods:</i> The human bladder cancer cell line T24 was transfected with human <i>CDD2</i> cDNA by the lipofectin method. <i>Results:</i> Transfection of <i>CDD2</i> cDNA did not change the levels of thymidine phosphorylase, dihydropyrimidine dehydrogenase and thymidylate synthase (TS) but increased the CDD activity significantly (p < 0.01). Forced expression of CDD made T24 sensitive to 5′-deoxy-5-fluorocytidine (5′DFCR) in vitro and capecitabine in vivo, but resistant to gemcitabine both in vitro and in vivo. Tetrahydrouridine, a specific CDD inhibitor, abrogated the changes in the in vitro sensitivity to 5′DFCR and gemcitabine by transfection of <i>CDD2</i> cDNA. Transfection of <i>CDD2</i> cDNA resulted in a significant increase in cellular 5-fluorouracil level (p < 0.01) and inhibition of TS activity (p < 0.01) after treatment with 5′DFCR in vitro. <i>Conclusions:</i> The present study clearly showed direct evidence for the contribution of CDD in tumor cells themselves to the sensitivities to capecitabine and gemcitabine.

A deserosalized muscle layer covering method for antireflux ureteroileostomy: a preliminary clinical trial

PURPOSE

To achieve complete protection of the upper urinary tract in patients with a neobladder we designed and clinically applied the deserosalized muscle layer covering method, a new antireflux ureteroileal reimplantation technique in which the terminal ureter is implanted in the muscle layer of the ileum. We present the operative procedure and preliminary results.

MATERIALS AND METHODS

We created an orthotopic ileal neobladder after radical cystectomy in 5 patients with invasive bladder cancer. The ureters were reimplanted into the reservoir using the deserosalized muscle layer covering method. The functional outcome of this procedure was evaluated by radiological studies.

RESULTS

No patients died during the perioperative period and no reimplanted ureters showed ureteral reflux or ureteral stricture during the observation period. Video cystometrograms demonstrated the complete prevention of reflux during the voiding and storage phases.

CONCLUSIONS

The deserosalized muscle layer covering method provided a nonobstructed unidirectional flow of urine in all renal units examined in this study. The efficacy of this method was proved during short-term followup.

A deserosalized muscle layer covering method for antireflux ureteroileostomy: a preliminary clinical trial

PURPOSE

To achieve complete protection of the upper urinary tract in patients with a neobladder we designed and clinically applied the deserosalized muscle layer covering method, a new antireflux ureteroileal reimplantation technique in which the terminal ureter is implanted in the muscle layer of the ileum. We present the operative procedure and preliminary results.

MATERIALS AND METHODS

We created an orthotopic ileal neobladder after radical cystectomy in 5 patients with invasive bladder cancer. The ureters were reimplanted into the reservoir using the deserosalized muscle layer covering method. The functional outcome of this procedure was evaluated by radiological studies.

RESULTS

No patients died during the perioperative period and no reimplanted ureters showed ureteral reflux or ureteral stricture during the observation period. Video cystometrograms demonstrated the complete prevention of reflux during the voiding and storage phases.

CONCLUSIONS

The deserosalized muscle layer covering method provided a nonobstructed unidirectional flow of urine in all renal units examined in this study. The efficacy of this method was proved during short-term followup.

Isoliquiritigenin suppresses pulmonary metastasis of mouse renal cell carcinoma

Isoliquiritigenin is a chalcone isolated from licorice and shallots. The ability of isoliquiritigenin to suppress metastasis was examined in a pulmonary metastasis model of mouse renal cell carcinoma. Isoliquiritigenin significantly reduced pulmonary metastasis, without any weight loss or leukocytopenia. Isoliquiritigenin suppressed in vitro proliferation of carcinoma cells, potentiated nitric oxide production by lipopolysaccharide-stimulated macrophages, and facilitated cytotoxicity of splenic lymphocytes in vitro. These findings suggest activation of macrophages, activation of cytotoxicity of lymphocytes, and direct cytotoxicity as possible mechanisms of metastasis suppression by isoliquiritigenin. In addition, isoliquiritigenin prevented severe leukocytopenia caused by administration of 5-fluorouracil.

Giant bladder diverticulum due to previous bullet injury: findings of gadolinium-enhanced magnetic resonance imaging

Non-obstructive acquired giant bladder diverticulum is rare. An 84-year-old man presented with difficulty in urination. Radiological examinations including pelvic magnetic resonance imaging, urethrocystography and urethrocystoscopy demonstrated a giant bladder diverticulum with normal infravesical urinary tract. The patient had a past history of gunshot bladder injury and underwent surgical removal of the bullet. The giant bladder diverticulum was thought to be associated with the injury or the operation.

De-serosalized muscle layer covering method for antireflux ureteroileostomy: a new operative technique and pressure study with ureterometry at the ureteroileal anastomotic site in dogs

PURPOSE

In pursuit of a more effective antireflux ureteroileostomy with a lower postoperative complication rate we performed a new operative technique and evaluated intraureteral pressure with ureterometry to examine the mechanism of antireflux function.

MATERIALS AND METHODS

A total of 11 beagle dogs were used in this study. A 3 x 2 cm. section of the ileal serosa was removed, the severed ureter was directly anastomosed to the de-serosalized area and 1 cm. of terminal ureter and the direct anastomotic site were covered with the de-serosalized ileal wall. The bladder was augmented with the ileum containing the ureter. Postoperative evaluations were performed monthly and ureterometry of the reimplanted ureter was done 6 months postoperatively.

RESULTS

Complete reflux prevention and a low stricture rate were achieved with this procedure. Direct ureteroileal anastomosis caused stricture in 1 of the 11 ureters but the covering procedure to prevent ureteral reflux caused no ureteral strictures. When the bladder was empty, ureteral closure pressure at the intramural portion of the ureter was low. At the phase of high intravesical pressure ureteral closure pressure at the intramural ureter was as high as intravesical pressure.

CONCLUSIONS

The de-serosalized muscle layer covering method prevented ureteral reflux completely with a low stricture rate. The antireflux function of this method seems to depend on the flexibility of the terminal ureter covered with the de-serosalized ileal wall. Reflux prevention in the low intravesical pressure phase seems to be due to extension of the ileal wall.

Elevated serum progastrin-releasing peptide (31-98) in metastatic and androgen-independent prostate cancer patients

BACKGROUND

Increases in neuroendocrine phenotype and secretory products are closely correlated with tumor progression and androgen independence in prostate cancer. In this study, we explored this correlation using serum progastrin-releasing peptide (ProGRP), a carboxy-terminal region common to three subtypes of precursors for gastrin-releasing peptide (GRP), which is released from the neuroendocrine phenotype to act as a growth factor.

METHODS

In 60 patients with benign prostatic hyperplasia (BPH) and 200 with prostate cancer, serum ProGRP levels were determined with an enzyme-linked immunosorbent assay (ELISA) kit and evaluated in relation to clinical stage, hormonal treatment, and prostate-specific antigen (PSA) values. Fourteen randomly selected patients were entered in the follow-up study. Additionally, expression of ProGRP as determined by immunohistochemical analysis was compared to that of chromogranin-A (CgA) in tissue samples from several subjects.

RESULTS

We found a positive correlation between PSA and ProGRP in patients with untreated prostate cancer; no correlation was found in the treated groups. The increases in the ProGRP value and in the percentage of patients with higher than normal values were significant (P < 0.0001), especially in the androgen-independent group (P < 0.0001). A longitudinal study showed that, in a subset of patients, the ProGRP values tended to increase transiently when the cancer became androgen independent, but remained unchanged or decreased at the androgen-dependent stage. Positive staining for ProGRP occurred in a different distribution in neuroendocrine tissues than that of staining for CgA.

CONCLUSIONS

The clinical results demonstrated the existence of a regulatory mechanism for GRP, which to date had only been observed in cell lines. These findings suggest that GRP is a growth factor potentially upregulated by androgen but that does not rely principally on androgen modulation. The large overlap in levels of ProGRP among the groups limits the use of this value as a monitoring tool. Measurement of ProGRP, however, does have potential as an independent parameter to evaluate androgen-independent progression and to facilitate a new therapeutic strategy that may compensate for current limitations of diagnosis based on PSA alone.

The correlation of serum carbohydrate antigen 19-9 with benign hydronephrosis

PURPOSE

High serum carbohydrate antigen 19-9 in patients with hydronephrosis but without malignant disease is reportedly rare but to our knowledge the clinical features of hydronephrosis that affect this level have not yet been clarified. We examined the correlation of serum carbohydrate antigen 19-9 with hydronephrosis status in patients with benign hydronephrosis.

MATERIALS AND METHODS

We used 123 serum samples from 68 patients with and 55 without hydronephrosis. All patients enrolled in this study had no malignant disease. Serum carbohydrate antigen 19-9 was measured by immunoradiometric assay and that level was correlated with clinical factors.

RESULTS

Serum carbohydrate antigen 19-9 in patients with hydronephrosis was significantly higher than in those without hydronephrosis (p <0.0001). The serum level was elevated to greater than 37 units per ml. in 25% of the patients with but in only 1.8% of those without hydronephrosis. In the hydronephrosis group the clinical features that significantly correlated with the increased serum level were bilateral hydronephrosis, urinary tract infection, proteinuria, increased serum blood urea nitrogen, severe urinary tract occlusion and high grade hydronephrosis.

CONCLUSIONS

Serum carbohydrate antigen 19-9 was significantly elevated in patients with benign hydronephrosis. Hydronephrosis causes false-positive results when screening for malignant disease by serum carbohydrate antigen 19-9 measurement.

Post-traumatic high flow priapism: demonstrable findings of penile enhanced computed tomography

Post-traumatic high flow priapism is a rare disease. A review of English published reports revealed 63 cases. Enhanced computed tomography (CT) of the penis has not previously been used as a diagnostic method for post-traumatic high flow priapism. We present a case of post-traumatic high flow priapism diagnosed with enhanced CT of the penis. Additionally, diagnostic modalities for post-traumatic high flow priapism are discussed with review of published work.

Predominant expression of fibroblast growth factor (FGF) 8, FGF4, and FGF receptor 1 in nonseminomatous and highly proliferative components of testicular germ cell tumors

Nonseminomatous components within testicular germ cell tumors affect patient prognosis to varying degrees. These components are well known to mimic early embryonic totipotential tissues. Prompted by the recent observation that fibroblast growth factor (FGF) 8, FGF4, and FGF receptor (FGFR) 1 are required for the growth of early postimplantational embryonic tissues, we investigated the expressions of FGF8, FGF4, and FGFRI in surgically resected specimens of primary testicular germ cell tumors using an immunohistochemical method. All cases of embryonal carcinoma (14 cases), yolk sac tumor (3 cases), and choriocarcinoma (3 cases) showed positive immunostaining for FGF8, FGF4, and FGFR1. In contrast, out of 13 cases of seminoma, immunostaining was negative for FGF8, FGF4, and FGFR1 in 8 cases (61.5%), 6 cases (46.1%), and 7 cases (53.8%), respectively. In 7 cases of mature and immature teratoma, most areas showed negative immunostaining. In addition, the Ki-67 labeling index showed extremely high mitogenic activity in embryonal carcinoma, yolk sac tumor, and choriocarcinoma, which are precisely the carcinomas with the highest expressions of FGF8, FGF4, and FGFR1. It is in keeping with the immunohistochemical result that murine teratocarcinoma P19 cells were shown to express FGF8, FGF4, and FGFRI only under undifferentiated growth conditions. Taken together, these findings confirm the involvement of FGF8, FGF4, and FGFR1 in highly proliferative conditions of nonseminomatous germ cell tumors.

A technique for resection of small bladder tumors using a flexible cystoscope on an outpatient basis: bladder tumor resection with newly designed hot cup forceps

PURPOSE

We describe a technique for resecting small papillary superficial bladder tumors using a new device and flexible cystoscope.

MATERIALS AND METHODS

In a 79-year-old man 3 small recurrent papillary bladder tumors were resected transurethrally on an outpatient basis. The procedure was performed using a flexible cystoscope and a newly designed type of cup forceps with the patient under topical anesthesia. No urethral catheter remained indwelling after surgery and the patient was discharged home the same day.

RESULTS

Bladder tumor resection using this technique was tolerable to the patient and postoperative bladder hemorrhage was not noted. Resected specimens were adequate for pathological tumor evaluation, which revealed grade 1 stage Ta superficial transitional cell carcinoma of the bladder.

CONCLUSIONS

This easy technique seems to be tolerated well by the patient. Resected specimens should be adequate for evaluating the pathological grade and depth of stage Ta or T1 superficial bladder cancer. This technique may be an alternative to standard transurethral resection for removing small recurrent bladder lesions in select patients who prefer outpatient management of bladder tumors.

Transitional cell carcinoma in the ileal conduit following radical cystectomy and nephroureterectomy

We report a case of transitional cell carcinomas (TCCs) at the terminal of ileal conduit and right ureteroileal junction after cystectomy and left nephroureterectomy. When upper urinary tract tumor occurs after cystectomy with ileal conduit, it is necessary to beware of the recurrence of TCC in the ileal conduit.

Role of thymidine phosphorylase in biomodulation of fluoropyrimidines

Thymidine phosphorylase (TP) is a key enzyme in the activating pathway of 5'DFUR and capecitabine. On the other hand, TP is identical to platelet-derived endothelial cell growth factor (PD-ECGF) which is known to be an angiogenic factor. Recent studies show TP expression is increased in various malignancies compared with the surrounding normal tissues. These reports demonstrate that elevated TP expression indicates a predisposition for aggressive disease and/or poor prognosis. Therefore, it is a reasonable strategy to target TP in cancer treatment by using fluoropyrimidines including 5-fluorouracil (5FU), 5'DFUR and capecitabine. TP-mediated biomodulation of fluoropyrimidines to enhance their anti-tumor effects has been investigated. TP up-regulators including cytokines, anti-tumor drugs and X-ray irradiation significantly increase cytotoxicity of fluoropyrimidines. Also, transfection of TP cDNA significantly enhances cytotoxicity of fluoropyrimidines. Biomodulation of fluoropyrimidines is clinically successful in treating some malignancies. We report a review on roles of TP in biomodulation of fluoropyrimidines.

Cisplatin-induced vomiting depends on circadian timing

We examined whether the clock time of cisplatin plus antiemetic and diuretic administration affects the amount of cisplatin-associated emesis and severity of renal toxicity. We treated 22 patients with urogenital cancer with two courses of chemotherapy containing 70 mg/m2 of cisplatin. Cisplatin together with furosemide was administered in the morning (05:00) or evening (17:00) during two courses 1 month apart in a crossover fashion. Ondansetron was given either before or after cisplatin to control nausea and vomiting. The number of vomiting episodes, serum creatinine, serum urea nitrogen (BUN), creatinine clearance, and urinary beta-N-acetyl glucosamidase (NAG) concentration were evaluated before and after each treatment course. Regardless of the timing of ondansetron, morning compared to evening cisplatin was always associated with greater vomiting in the first treatment course. However, prophylactic administration of ondansetron markedly diminished the impact of the clock time of cisplatin administration. Serum creatinine transiently decreased rather than increased 14 days after cisplatin and furosemide administration, while NAG excretion increased 3 days after cisplatin and furosemide administration. In the first course, serum creatinine levels were similar regardless of the clock time of cisplatin and furosemide administration. However, in the second course, serum creatinine rose in patients given evening cisplatin and furosemide, while it remained unchanged in those given morning cisplatin and furosemide. Moreover, the first course morning cisplatin and furosemide treatment was associated with less change in NAG excretion (less kidney toxicity) than the first course of evening cisplatin and furosemide treatment. The second course evening cisplatin and furosemide treatment was associated with an increase in NAG excretion compared to the first course of treatment, while morning cisplatin and furosemide treatment in the second course showed less change in NAG excretion compared to the first course. The clock time of cisplatin administration had an impact on the frequency of emesis. Prophylactic ondansetron, however, diminished the time-of-day dependency of cisplatin-induced vomiting. Administration of cisplatin and furosemide in the morning rather than evening appears to cause less renal damage, and this damage may be further reduced with aggressive hydration and routine administration of furosemide.

Primary signet ring cell carcinoma of female urethra

A 69-year-old woman presented with difficulty in urination and bloody fluid discharge from the urethra. Based upon a diagnosis of primary urethral carcinoma, she underwent total cysto-urethrectomy and hysterectomy with pelvic lymph node dissection and urinary diversion of ileal conduit. Microscopically, the tumor was composed of mucinous adenocarcinoma and signet ring cell carcinoma. There was no recurrence 17 months after the surgery.

Covering of the terminal ureter with de-serosalized muscle layer of the ileum for antireflux ureteroileostomy: an experimental study in dogs and a preliminary clinical trial

We demonstrated a new operative technique for antireflux ureteroileostomy in dogs. The severed ureter was reimplanted into the isolated ileum. Ten terminal ureters were covered with a 2 x 2 cm2 section of de-serosalized ileal wall after direct ureteroileostomy, and another six terminal ureters were covered with a 2 x 2 cm2 section of non-de-serosalized full-thickness ileal wall. Thirteen ureters were directly anastomosed to the ileum without any additional procedures. The bladder was augmented by the detubularized ileum with the ureter. Postoperative evaluations on ureteral stenosis and reflux were performed monthly for 3 months. The ureters covered with the de-serosalized ileal wall prevented ureteral reflux even when the intravesical pressure climbed as high as 100 cm H2O. Although two of these ten ureters demonstrated strictures at the precise site of direct ureteroileostomy, the sections of the ureters covered with the de-serosalized ileal wall were opened and did not collapse. In the resected specimens, the terminal ureters were found in the intramural part of the ileum. The ureters covered with the full-thickness of ileal wall did not prevent reflux. Our method of covering the terminal ureter with the de-serosalized ileal wall worked well as an antireflux mechanism, and the intramural ureter did not cause ureteral stricture. After this animal experiment, we introduced this antireflux mechanism clinically.

[Serum CA19-9 levels in testicular germ cell tumor patients]

This study was designed to examine whether measurement of serum CA19-9 was useful in testicular germ cell tumor patients. We analyzed the clinical courses of 55 testicular germ cell tumor cases diagnosed after high orchiectomy. The patients in this study consisted of 33 seminomas and 22 non-seminomatous germ cell tumors (NSGCT), and their mean age was 32.7 +/- 12.7 years (mean +/- SD). The mean follow-up period after the operation was 33.7 months. The positive rate of the pre-treatment serum CA19-9 level was 16.4% (3.0% in seminomas versus 36.4% in NSGCT, p = 0.0017). The pre-treatment serum CA19-9 levels in NSGCT patients were significantly higher than those in seminoma patients (46.6 +/- 50.0 U/ml versus 10.6 +/- 9.6 U/ml, p = 0.0008). We divided the patients into two groups according to the detailed histological types, and found that the serum CA19-9 levels in the patients with embryonal carcinoma (EC) were significantly higher than in those without EC (p = 0.0160), and the levels in those with yolk sac tumor (YS) were higher than in those without YS (p = 0.0099). Moreover, the levels in those with either EC or YS were significantly higher than in those with neither EC nor YS (p = 0.0004). In 9 patients with a high serum pre-treatment CA19-9 level, the serum CA19-9 level was useful as a monitoring marker through the treatment or tumor progression. On the other hand, the pre-treatment serum CA19-9 level did not correlate with the clinical stage or prognosis. In conclusion, the phenomenon that the serum levels of CA19-9 increase in testicular germ cell tumor patients is not extremely rare, and in NSGCT, especially in EC or YS, the serum CA19-9 can be a useful tumor marker.

Lower ureteral replacement using a tubularized gastric segment

OBJECTIVES

To review our early experience with the use of a gastric segment for lower ureteral replacement in patients with bilateral ureteral stenosis after pelvic radiotherapy.

METHODS

Four adult patients (three women and one man) underwent bilateral ureteral substitution using stomach. All patients received whole pelvic irradiation for malignant disease and had undergone bilateral nephrostomy because of severe bilateral ureteral stenosis. The postoperative follow-up period was 11 to 50 months.

RESULTS

No major complication was recognized, and the bilateral nephrostomy tubes were removed in all patients. Three female patients could void urethrally without incontinence, and the male patient needed regular self-catheterization. The three women were alive with normal renal function at a follow-up of 11 to 50 months. The man had a vesicorectal fistula 8 months postoperatively, and colostomy was performed. He died of a cause unrelated to the operation 11 months after surgery.

CONCLUSIONS

Stomach has not been used commonly for ureteral replacement. In patients with bilateral severe ureteral stenosis after pelvic radiotherapy, ureteral substitution with a gastric segment can be safely performed and will increase the patient's quality of life.

Isolation of an androgen-inducible novel lipocalin gene, Arg1, from androgen-dependent mouse mammary Shionogi carcinoma cells

Here we report isolation of an androgen-regulated novel gene from an androgen-dependent mouse mammary Shionogi carcinoma SC-3 cell line. Using a polymerase chain reaction-based subtraction method and Northern blotting analysis, we isolated four androgen-inducible genes from SC-3 cells. Nucleotide sequencings identified three of the genes as cyclin D1, beta-catenin, and fatty acid synthase, respectively, but the fourth, a gene tentatively named as Arg1 (androgen-regulated gene 1), remained undefined. The cloned 2.0-kb sized Arg1 cDNA encoded 414 amino acid sequences. The deduced amino acid sequences, sharing about 30% homology with cathepsin family members at a protein level, had relatively conserved residues around the three proteinase active sites reported earlier. In Northern blotting, Arg1 mRNA was found in kidney, heart, lung, and to a lesser degree, in spleen and liver. Its transcripts were also detected in male reproductive organs on RT-PCR. In addition, its expression levels in prostate were markedly reduced after castration. Unexpectedly, Arg1-expressing COS1 cells showed no significant proteinase activity to various synthesized substrates under neutral or acidic conditions in this study. This might have been due to the replacement of the cysteinyl active site for proteinase to serine residue in the Arg1 amino acid sequences. Given that Arg1 also contains a lipocaline signature known as a binding motif for small hydrophobic molecules at the center of its amino acid sequences, Arg1 is a lipocalin family gene regulated by androgens in prostate and Shionogi carcinoma cells.

Enhancement of sensitivity to capecitabine in human renal carcinoma cells transfected with thymidine phosphorylase cDNA

The purpose of the present study was to examine directly the role of thymidine phosphorylase (TP) in the sensitivity of renal cell carcinoma (RCC) to a novel fluoropyrimidine carbamate, capecitabine. TP cDNA-transfected RCC are used in these experiments to provide a basis for improved therapeutic benefit in chemoimmunotherapy. Human RCC line KU2 cells were transfected with pcDNA3.1/zeo(+) with or without human TP cDNA by the lipofectin method. We established a clone transfected with pcDNA3.1/zeo(+)/TP (KU2-TP15) and a clone transfected with pcDNA3.1/zeo(+) as a control (KU2-C1). TP expression levels (mean +/- SD) examined by enzyme-linked immunosorbent assay (ELISA) were 1.3 +/- 0.14 U/mg protein in KU2, 1.6 +/- 0.57 U/mg protein in KU2-C1 and 216 +/- 25.6 U/mg protein in KU2-TP15. Immunohistochemical staining of subcutaneous tumors established in Balb/c nu/nu mice showed that KU2-TP15 was strongly positive for TP expression, whereas KU2 and KU2-C1 were negative. Sensitivities in vitro to 5-fluorouracil (5FU), 5'-deoxy-5-fluorouridine (5'DFUR) and capecitabine in KU2-TP15 were significantly enhanced compared with those in KU2 or KU2-C1. A moderate but statistically significant bystander effect was observed in vitro. KU2-TP15 tumors showed significant increase in the in vivo sensitivities to 5'DFUR and capecitabine as compared with the vehicle alone while KU2-C1 tumors did not. The difference in tumor-free rate in mice bearing KU2-TP15 at 2 months after the cessation of treatment was statistically significant between the capecitabine treatment group and the controls, the 5FU treatment group and the 5'DFUR treatment group. The present study clearly provides direct evidence for the role of TP in mediating the sensitivity of RCC to capecitabine.

[Clinical evaluation of urinary nuclear matrix protein 22 as a marker for bladder cancer]

The purpose of this study is to evaluate the clinical usefulness of urinary nuclear matrix protein 22 (NMP22) as a marker for bladder cancer. We examined the positive rates of NMP22 test, urinary cytology and bladder tumor antigen (BTA) test, and compared the positive rate of NMP22 test with that in urinary cytology and BTA test. Urine samples were obtained from 50 patients with histologically confirmed bladder cancer before the treatment. The samples were examined by NMP22 test, urinary cytology and BTA test. In 50 patients with bladder cancer, the overall positive rate was 40% for NMP22 test, 40% for urinary cytology, and 16% for BTA test. A combination of NMP22 test and urinary cytology showed a significantly higher positive rate (54%) as compared to NMP22 test or urinary cytology alone. When NMP22 test and urinary cytology were compared for tumor size, number, shape, stage and grade, NMP22 test showed a significant higher positive rate than urinary cytology in grade 1 bladder cancer. In conclusion, although NMP22 test and urinary cytology gave a similar positive rate, a combination of NMP22 test and urinary cytology is more useful than the NMP22 test or urinary cytology alone for monitoring of bladder cancer.

Segmental multicystic dysplastic kidney in an adult woman

We report a case of unilateral segmental multicystic dysplastic kidney (SMCDK) in an adult woman. A 42-year-old woman presented with abdominal distension and gross hematuria. The preoperative diagnosis was cystic renal cell carcinoma, and a radical nephrectomy was performed. Histopathologically, the resected kidney was SMCDK with severe hydronephrosis.

Primary testicular plasmacytoma with hydrocele of the testis

A case of primary testicular plasmacytoma complicated with hydrocele of the testis is reported. An 86-year-old man presented with hydrocele of the right testis. High inguinal orchiectomy was performed as the preoperative aspiration cytology of the hydrocele fluid showed atypical cells. Immunohistochemical study of the right testis revealed testicular plasmacytoma positive for IgG. He remained well 9 months after the orchiectomy. This is the second reported case where the preoperative diagnosis of testicular plasmacytoma was made based on the hydrocele fluid cytology.

Improvement of ureteroileal anastomosis in orthotopic ileal neobladder with modified le duc procedure: short submucosal tunnel technique

PURPOSE

A modified Le Duc procedure with a short submucosal tunnel was applied for ureteroileal implantation in ileal orthotopic neobladder and bladder augmentation with the ileum. We assessed the rate of stenosis and ureteral reflux at the ureteroileal anastomosis after this procedure.

MATERIALS AND METHODS

Two women and 22 men underwent radical cystectomy and creation of a Hautmann ileal neobladder for invasive bladder cancer. Another woman underwent ileal bladder augmentation with bilateral ureteral reimplantation into the ileal segment. Ureteroileal anastomosis was performed using the modified Le Duc technique in 48 renoureteral units. Followup in all patients included retrograde cystography done before discharge home and excretory urography, renal ultrasonography or abdominal computerized tomography every 4 to 6 months. Followup was 11 to 39 months in 23 of the 25 cases.

RESULTS

Retrograde cystography before discharge home revealed no urinary reflux in any reimplanted ureter. There was no ureteral stenosis or reflux in 20 male and 3 female patients (44 renoureteral units) who voided successfully without catheterization. A unilateral ureteral stricture at the ureteroileal anastomotic site in 1 man who voided successfully was treated with endoscopic surgery. Bilateral slight upper urinary tract dilatation caused by ureteral reflux was present in another man who did not void successfully.

CONCLUSIONS

The modified Le Duc technique is simple and safe for forming an ureteroileal anastomosis in ileal orthotopic neobladder creation. It appears to have a low ureteral stenosis and reflux complication rate in patients who successfully void postoperatively.

Nephron-sparing surgery is still controversial for patients with renal cell carcinoma and normal contralateral kidney: risks predictable by AgNOR counts in satellite lesions

PURPOSE

To determine whether nephron-sparing surgery is appropriate for patients with renal cell carcinoma (RCC) and a normal contralateral kidney.

MATERIALS AND METHODS

We prepared whole-area histologic sections from 58 cases of RCC to examine the features of satellite tumor lesions (STLs), the proliferative potential of which was evaluated by counting argyrophilic nucleolar organizing regions (AgNORs).

RESULTS

We found three types of microscopic lesions: STLs, adenomas, and dysplastic foci, the latter two of which appeared to be preneoplastic. Of the 58 cases, STLs were observed in 27 (47%) and either adenomas or dysplastic foci in 19 (33%). At least one of the three types of lesion was found in 37 cases (64%). No correlation was found between the incidence of STL and the size of the main tumor, but the incidence tended to be higher in lesions of higher grade or stage. The STLs were located >2 cm from the margin of the main tumor in 6 of the 27 cases (22%). The mean number of AgNORs per high-power field was 5.09 +/- 1.53 (SD) in the main tumors, 4.21 +/- 1.36 in the STLs, and 2.27 +/- 0.07 in the adenomas and dysplastic foci.

CONCLUSIONS

These findings suggest that nephron-sparing surgery risks leaving STLs, which have considerable proliferative potential. Thus, nephron-sparing surgery must still be considered adventurous treatment in elective cases but can be recommended for patients who require nephron preservation.

Thymidine phosphorylase/platelet-derived endothelial cell growth factor (PD-ECGF) associated with prognosis in renal cell carcinoma

We investigated the correlation between thymidine phosphorylase (TP)/platelet-derived endothelial cell growth factor (PD-ECGF) expression, angiogenesis, and prognosis in renal cell carcinoma (RCC) patients. We prepared paraffin block specimens from 56 postradical nephrectomy RCC patients. The preparations were immunohistochemically stained using anti-CD34 antibody and anti-TP antibody. Angiogenic findings were evaluated based on both microvessel density (MVD) and renal arteriography findings as classified by Roosen et al. TP expression showed heterogeneity in 56 patients: 11 (19.6%) were negative, 28 (50.0%) weak, and 17 (30.4%) positive. There was no correlation between TP expression, MVD, and renal arteriography. There was no TP expression in chromophobe types. Univariate analysis showed a significant correlation between survival and TP expression, patient age, tumor infiltration type, pathologic T- and N-stages, venous involvement, distant metastasis, and tumor grade. There was no correlation between survival and MVD or renal arteriography. Multivariate analysis showed a significant correlation between survival and pathologic T-stage, distant metastasis, tumor infiltration type, and TP expression. TP expression in RCC may be an independent prognostic factor rather than just an index for angiogenesis.

[A case of giant small cell carcinoma of the prostate]

A 64-year-old man having backbone pain was referred to our institute, and laboratory examinations revealed that he was suffering from severe renal failure. Abdomino-pelvic CT revealed bilateral hydronephrosis, a giant prostate over 500 g in weight, and multiple para-aortic lymph node metastasis. Histological diagnosis of the prostate was small cell neuroendocrine carcinoma. Serum neuron-specific enolase (NSE) level was slightly high reflecting the positive immunohistochemical staining, but serum PSA remained within normal limits. The patient was treated with hormone-chemotherapy after successful treatment of the renal failure, but he died on the 74th hospital day. Small cell carcinoma is known to have a high rate of malignancy and metastasis from an early stage. Several giant prostatic tumors have been reported previously, but this case is considered to be the second gigantic small cell carcinoma in the Japanese literature.

[Clinical usefulness of cross-linked N-telopeptide of type I collagen (NTx) as a bone metastatic marker in patients with prostate cancer--comparison with serum PICP, PINP and ICTP]

Type I collagen cross-linked N-telopeptide (NTx) in urine, the degraded form of type I collagen cross-linked in bone, has been evaluated as a marker of bone resorption. In this study, the clinical usefulness of NTx as a marker of bone metastasis of prostate cancer was compared with that the carboxyterminal propeptide of type I procollagen (PICP), the aminoterminal propeptide of type I procollagen (PINP), and the pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (ICTP) in serum. We assessed 37 cases of prostatic cancer in which the diagnosis had been confirmed pathologically. The patients were 15 patients with prostatic cancer with bone metastasis (before treatment or during a relapse) (Group 1); 11 patients, with bone metastasis, but for whom treatment was effective and condition had stabilized (Group 2); and 11 patients, with localized prostatic cancer and no evidence of bone metastasis (Group 3). The serum PICP, PINP, and ICTP levels and concentration of NTx in urine were compared among the three groups with the Mann-Whitney U test, with p values less than 0.05 considered significant. Urine NTx concentrations in Groups 1, 2 and 3 were 539.3 +/- 202.9, 160.6 +/- 97.6 and 48.6 +/- 7.6 nMBCE/mMCr, respectively. The differences between the Group 1 and Group 2 and between Group 1 and Group 3 were significant (p < 0.01 and p < 0.001). The differences between Group 1 and Group 3 and between Group 2 and Group 3 were significant for serum PICP, PINP and ICTP concentrations (p < 0.05). The correlation coefficient between urine NTx and each serum bone metabolic marker was 0.8 for PICP, 0.4 for PINP and 0.5 for ICTP. These bone metabolic markers are promising clinical markers of bone metastatic and may be useful for prediction of therapeutic efficacy and recurrence in bone and quantification of the extent of bone metastates.

Effects of dosing time and schedule on cisplatin-induced nephrotoxicity in rats

Renal dysfunction induced by a single injection of cisplatin depends on the timing of the dose. However, the effects of repeated administration of cisplatin on time-dependent toxicity have not been evaluated despite the fact that in clinical practice high doses are repeatedly injected at intervals or low doses are administered daily. We studied chrononephrotoxicity in rats after weekly or daily cisplatin injections. Weekly high doses (5 mg kg(-1)) or daily low doses (1.2 mg kg(-1)) of cisplatin were injected at four time points (3, 9, 15 and 21 h after the light was turned on (HALO)) for 3 weeks. Changes in body weight after weekly cisplatin administration were independent of the timing of the doses. In the group that received daily cisplatin, the loss in body weight in the 3 HALO group was smaller than in animals receiving injections at 15 and 21 HALO (P < 0.05 and 0.001, respectively). The blood urea nitrogen and serum creatinine levels in the control rats showed a significant circadian change (peak at 15 HALO and trough at 9 HALO), but these parameters were markedly elevated in both trials and their circadian variations were disturbed. In conclusion, cisplatin-induced nephrotoxicity was the lowest at 3HALO compared with other time points of both dose regimens.