Predictive factors for urinary retention following kidney transplantation in male patients

OBJECTIVE

Urinary retention frequently occurs in patients after kidney transplantation. This study aimed to identify predictive factors for urinary retention requiring transurethral resection of the prostate (TURP) following kidney transplantation.

MATERIAL AND METHODS

Seventy male patients (median age 56 years, range 37-73 years) who underwent kidney transplantation between 1995 and 2006, and experienced urinary retention and consecutively required TURP, were studied retrospectively. Residual diuresis before transplantation, duration of dialysis, patient age, prostate size, rejection reactions, transplant loss, combined kidney and pancreas transplantation, type 1 and 2 diabetes mellitus, and carcinoma of the prostate were evaluated as predictive factors.

RESULTS

Duration of dialysis longer than 120 months (p = 0.0174), patient age over 60 years (p = 0.0045) and the absence of diabetes (n = 46, p = 0.0029) were associated with a significantly higher risk of urinary retention requiring TURP following kidney transplantation. Residual diuresis, prostate size, frequency of rejection reactions, transplant loss and detection of carcinoma, however, could not be identified as predictive factors.

CONCLUSIONS

In male patients after kidney transplantation with a long history of dialysis, early TURP due to urinary retention must be anticipated. Surprisingly, the presence of type 1 or 2 diabetes seems to prevent the occurrence of retention, independently of age.

Effect of raloxifene on human pancreatic adenocarcinoma growth in vitro and in vivo

207

Background: The role of estrogen receptor (ER) signaling in pancreatic cancer is unknown. Recently, we demonstated that expression of the isoform ER beta correlates with an adverse prognosis in patients with pancreatic cancer. Here, we show that raloxifene, a specific estrogen receptor modulator (SERM), suppresses in vitro and in vivo tumor growth by interfering with ER beta signaling in human pancreatic adenocarcinoma.

Methods: The human pancreatic adenocarcinoma cell line L3.6pl was cultured and exposed to raloxifene in vitro, and cell proliferation was determined by the BrdU assay. To analyze the specificity of raloxifene induced effects, ER knockdown was performed using siRNA specific for ER alpha and ER beta. In an in vivo model of orthotopic tumor xenografts in nude mice, raloxifene was administered daily, and tumor growth was monitored. Expression of ER beta and the proliferation marker Ki-67 were determined by immunohistochemistry.

Results: Raloxifene treatment resulted in a potent, dose dependent reduction of proliferation in vitro over a nanomolar dose range. This effect was completely reversed by siRNA knockdown of ER beta, but not ER alpha, indicating an ER isotype specific signaling. In vivo, orthotopic tumor growth, as well as lymph node and liver metastases, was significantly suppressed in raloxifene treated mice. Analogous to the in vitro data, Ki-67 expression in vivo was significantly reduced in raloxifene treated mice, while ER beta expression was not changed in vivo.

Conclusions: Inhibition of ER beta signaling by raloxifene results in a potent reduction of human pancreatic adenocarcinoma growth in vitro and in vivo. Treatment with SERMs may be an attractive therapeutic option in subjects expressing the ER beta isotype.

No significant financial relationships to disclose.

Heterogeneous expression of prognostic and predictive antigens in primary and metastatic gastric cancer

e22030

Background: Metastatic spread of cancer cells is a key event in tumor progression and in determining the prognosis of patients with malignant disease. This study evaluated the expression of prognostic and predictive molecules in primary and metastatic gastric cancer. Our objectives were to correlate the expression pattern with the clinicopathological features and patient survival and confirm the results using a coculture spheroid model. Methods: The clinicopathological features of 94 patients (57,4% male, 42,6% female, median age of 66,2 years) with gastric cancer were characterized using multivariate and univariate analysis. Further we compared the expression profile of biomarkers, namely EPCAM, CD44s, HLA-ABC and the associated β chain, HLA-DR, ICAM-1, LFA-3 and E-Cadherin in primary gastric tumors (n=94) and their synchronous metastases (regional lymph nodes n=32, liver n=14, peritoneum n=17) using immunoperoxidase staining. A coculture in vitro model, i.e. the homo- and heterotypic spheroid model were performed as a functional test system to confirm the microenvironmental impact on the biomarker expression level. Results: Strong HLA-ABC expression was found in both primary and metastatic tumors. High expression of HLA-ABC in liver metastases significantly correlated with metastatic disease (UICC TNM stage IV, p=0,026). Contrary, the detection of HLA-DR on the cancer cells correlated with the degree of the inflammatory infiltrate (CD45, p=0,019). With respect to CD44s, the prognostic marker was upregulated in the metastatic tumors independently of their localisation (p=0.009) compared to the primary lesions. E-cadherin and LFA-3 expression were preferentially increased in distant metastases, but not in locally advanced gastric tumors (liver: E-cadherin, p=0.001; liver and peritoneum: LFA-3, p=0.0067). E-cadherin expression was upregulated in the heterotypic spheroid model coculturing primary liver cells and N87 gastric cancer cells (80% E-cadherin positive N87 cells) compared to the homotypic spheroid model consisting of N87 cells alone (40% E-cadherin positive N87 cells). Conclusions: These data suggest the consideration of the metastatic protein profile for the selection of cancer patients in new molecular therapeutic strategies.

No significant financial relationships to disclose.

[Diabetes mellitus - perioperative management]

The prevalence of diabetes in hospitalized adults is conservatively estimated at 12-25% and rising. Poor glucose control and presence of diabetes complications (e.g. diabetic nephropathy, diabetic neuropathy, atherosclerosis) are commonly regarded as risk factors for perioperative morbidity and mortality. Thus it is crucial to determine diabetes comorbidities preoperatively in order to avoid perioperative renal and cardiovascular complications. Perioperative glycemic control is challenging due to preoperative changes in diabetes treatment and the effects of surgery-associated stress hyperglycemia. For patients in general surgical units, evidence for specific glycemic goals is based on epidemiologic and physiologic data rather than clinical trials. According to guidelines of the German Society of Nutrition, the approximation of normoglycemia is reasonable as long as hypoglycemia is avoided (suggested range for plasma glucose 80-145 mg/dL).

Immunological and clinical response after vaccination therapy of pancreatic carcinoma patients with autologous, tumor-lysate pulsed dendritic cells: Results of a phase II-study

4579

Background: Multiple studies in the experimental and in the clinical setting have shown that vaccine therapy using dendritic cells can induce antitumor immunity. Here, we report about the results of a phase II-study using autologous, tumor-lysate pulsed dendritic cells for the treatment of patients with advanced pancreatic carcinoma. Methods: Pancreatic carcinoma patients receiving abdominal surgery were included into to the study protocol. Tumor-lysate was derived by freeze-taw-cycles from surgically derived tissue specimens. Patients were eligible for DC vaccination after recurrence of pancreatic carcinoma or in a primarily palliative situation. DC were derived from PBMC according to a six-day protocol, loaded with tumor lysate and stimulated with TNF-a and PgE2. DC were applicated intracutaneously into the groin region every other week for three cycles, then monthly. All patients received standard chemotherapy with gemcitabine concomitantly. Immune response was controlled by DTH skin testing. Samples of non adherent cells were frozen for MLR and ELISPOT assays to monitor immune response ex vivo. Main study end point was partial or complete remission. Results: Ten patients have received dendritic cell vaccination so far. Of these, one patient developed a partial remission after a four-months course of vaccination therapy. Another patient showed stable disease after having received five vaccinations. Both patients showed immunological response. The patient with stable disease had a mean of 56 IFN-γ positive spots per 50E3 DC-stimulated non adherent cells prior to vaccination. After vaccination, this number increased to 191 spots per 50E3 cells (negative control: 5; positive control: 315). Both patients are alive 13 and 7 months after the start of vaccination therapy, respectively. Conclusions: Vaccination therapy with dendritic cells can be of clinical benefit in the setting of advanced pancreatic carcinoma. Clinical responses were associated with the induction of a stable immunological response.

No significant financial relationships to disclose.

Regional hyperthermia (RHT) improves response and survival when combined with systemic chemotherapy in the management of locally advanced, high grade soft tissue sarcomas (STS) of the extremities, the body wall and the abdomen: A phase III randomised pros

10009

Background: Patients (Pts) with locally advanced, high-grade STS are at significant risk for local failure and for metastasis. We evaluated the ability of RHT to improve the outcome in pts who are treated with neoadjuvant chemotherapy. Methods: Eligibility included pts with STS = 5 cm, grade II/III, deep and extracompartmental, stratified according to site (E = extremity vs. Non-E = body wall and abdomen). Pts were randomly assigned to systemic chemotherapy (etoposide 250 mg/m2; ifosfamide 6 g/m2; adriamycin 50 mg/m2) alone (EIA) or to systemic chemotherapy combined with RHT (EIA + RHT) administered for 4 cycles every 3 weeks both prior and after local aggressive therapy (surgery + radiotherapy), respectively. Primary endpoints were local progression free survival (LPFS) and disease free survival (DFS). Objective (CR + PR) response rate (ORR) evaluated after 4 cycles (EIA vs EIA + RHT) was a secondary endpoint. A total of 340 pts was required to show an improvement in median LPFS of 19.2 mos for EIA + RHT (a=5% type I, 20% type II error). Results: Pts characteristics were well balanced between treatment arms. After median follow-up of 24.9 months (mos) an intention-to-treat analysis showed a significantly superior DFS for pts who received EIA + RHT (n=169) compared to those treated with EIA alone (n=172) (median DFS: 31,7 mos and 16,2 mos; log-rank p=0.003; Hazard ratio=0.65; CI95=0.48- 0.87, p=0.004). The median LPFS was estimated 45,3 mos for EIA + RHT and 23,7 mos for EIA (log-rank p=0.015; Hazard ratio=0.66; CI95=0.48 - 0.90, p=0.01). At 2 years, LPFS rates for E (149 pts) and for Non-E (192 pts) were significantly better for EIA + RHT vs EIA alone (E: 84% vs 64%; Non-E: 57% vs 39%) (p<0.02). The ORR was significantly better for EIA + RHT (28,7%) vs EIA alone (12,6%) (p=0.002). Conclusions: Compared to chemotherapy alone, RHT combined with chemotherapy yields a statistically significant improvement in tumor response , DFS and LPS, in patients with locally advanced, high-grade STS. (Supported by Deutsche Krebshilfe and HGF VH-VI- 140)

[Table: see text]

Preliminary results of a phase II-study: Vaccination therapy of pancreatic carcinoma patients with autologous, tumor lysate pulsed dendritic cells

14102

Background: Vaccination trials in the experimental and in the clinical setting have shown that it is possible to use dendritic cells (DC) to induce a specific antitumoral immune response. In this study, a protocol for the treatment of patients with metastasised pancreatic carcinoma with autologous, tumor-lysate pulsed dendritic cells was established. Methods: Patients with strong suspicion of pancreatic carcinoma receiving abdominal surgery are recruited to the study. Tumor-lysate is derived by freeze-taw-cycles from surgically derived tissue specimens. After recurrence of histologically verified pancreatic carcinoma or in a primarily palliative situation, patients are eligible for DC vaccination. DC are derived from PBMC according to a six-day protocol, loaded with tumor lysate and stimulated with TNF-alpha and PgE2. DC are applicated intracutaneously into the groin region three times in twice weekly cycles, then in monthly cycles. Immune response is controlled by DTH skin testing. Samples of non adherent cells are frozen for future MLR and ELISPOT assays. Main study end point is partial or complete remission four months after the start of vaccination. Alternative end points are adverse effects, quality of life, one-year survival and immuno-monitoring. Results: Tumor material of 49 patients has been worked up to tumor lysate and stored for future vaccinations. Four patients have received dendritic cell vaccination. Two of these patients have received their four months staging CT. In one case local disease was stable. The other patient showed progressive disease. A more pronounced proliferation of specific T cells compared to the control setting could be demonstrated by MLR assay. Discussion: A protocol for vaccination with tumor lysate pulsed dendritic cells of patients with pancreatic carcinoma has been established. Four patients have been vaccinated with dendritic cells according to a phase II study protocol. Vaccination was tolerated well. Because of a severe adverse reaction after the beginning of gemcitabine therapy, vaccination had to be omitted intercurrently with this patient. Results of most immuno monitoring assays are pending. One patient receiving DC vaccination therapy showed stable local disease.

No significant financial relationships to disclose.

Laparoscopic liver resection with the water-jet dissector

Laparoscopic liver resection requires careful patient selection. Tumor size and location have a major influence on the feasibility of a laparoscopic operation. Isolation and ligation of blood vessels and bile ducts after selective liver dissection by suitable techniques are important for visual control of the operating field. Since the Jet-Cutter has proven to give excellent clinical results in conventional liver surgery, we carried out laparoscopic liver resections with the Jet-Cutter in six patients. Five tumors were located in the left liver lobe; the fifth was in segment 6. There were no intra- or postoperative complications. The patients were discharged from the hospital after a mean of 5.4 +/- 2.1 days.