Intravesical sequential gemcitabine and docetaxel versus bacillus calmette-guerin (BCG) plus interferon in patients with recurrent non-muscle invasive bladder cancer following a single induction course of BCG

INTRODUCTION

Repeat BCG induction remains an option for select non-muscle invasive bladder cancer (NMIBC) patients who fail initial therapy. Alternative salvage intravesical regimens such as Gemcitabine and Docetaxel (Gem/Doce) have been investigated. We aimed to compare the efficacy BCG plus interferon a-2b (BCG/IFN) and Gem/Doce in patients with recurrent NMIBC after a single prior BCG course.

METHODS

The National Phase II BCG/IFN trial database and multi-institutional Gem/Doce database were queried for patients with recurrent NMIBC after one prior BCG induction course, excluding those with BCG unresponsive disease. Stabilized inverse probability treatment weighted survival curves were estimated using the Kaplan-Meier method and compared. Propensity scores were derived from a logistic regression model. The primary outcome was recurrence free survival (RFS); secondary outcomes were high-grade (HG) RFS and risk factors for treatment failure.

RESULTS

We identified 197 BCG/IFN and 93 Gem/Doce patients who met study criteria. Patients receiving Gem/Doce were older and more likely to have HG disease, CIS, and persistent disease following induction BCG (all P < 0.01). After propensity score-based weighting, the adjusted 1- and 2-year RFS was 61% and 53% after BCG/IFN versus 68% and 46% after Gem/Doce (P = 0.95). Adjusted 1- and 2-year HG-RFS was 60% and 51% after BCG/IFN versus 63% and 42% after Gem/Doce (P = 0.68). Multivariable Cox regression revealed that Gem/Doce treatment was not associated with an increased risk of failure (HR = 0.97, P = 0.89) as compared to BCG/IFN.

CONCLUSION

Patients with recurrent NMIBC after a single induction BCG failure and not deemed BCG unresponsive had similar oncologic outcomes with Gem/Doce and BCG/IFN in a post-hoc analysis. Additional prospective studies are needed.

Multi-Institution Evaluation of Sequential Gemcitabine and Docetaxel as Rescue Therapy for Nonmuscle Invasive Bladder Cancer

PURPOSE

Rescue intravesical therapies for patients with bacillus Calmette-Guérin failure nonmuscle invasive bladder cancer remain a critical focus of ongoing research. Sequential intravesical gemcitabine and docetaxel therapy has shown safety and efficacy in 2 retrospective, single institution cohorts. This doublet has since been adopted as an intravesical salvage option at multiple institutions. We report the results of a multi-institutional evaluation of gemcitabine and docetaxel.

MATERIALS AND METHODS

Each institution retrospectively reviewed all records of patients treated with intravesical gemcitabine and docetaxel for nonmuscle invasive bladder cancer between June 2009 and May 2018. Only patients with recurrent nonmuscle invasive bladder cancer and a history of bacillus Calmette-Guérin treatment were included in the analysis. If patients were disease-free after induction, maintenance was instituted at the treating physician's discretion. Posttreatment surveillance followed American Urological Association guidelines. Survival analysis was performed using the Kaplan-Meier method and risk factors for treatment failure were assessed with Cox regression models.

RESULTS

Overall 276 patients (median age 73 years, median followup 22.9 months) received treatment. Nine patients were unable to tolerate a full induction course. One and 2-year recurrence-free survival rates were 60% and 46%, and high grade recurrence-free survival rates were 65% and 52%, respectively. Ten patients (3.6%) had disease progression on transurethral resection. Forty-three patients (15.6%) went on to cystectomy (median 11.3 months from induction), of whom 11 (4.0%) had progression to muscle invasion. Analysis identified no patient, disease or prior treatment related factors associated with gemcitabine and docetaxel failure.

CONCLUSIONS

Intravesical gemcitabine and docetaxel therapy is well tolerated and effective, providing a durable response in patients with recurrent nonmuscle invasive bladder cancer after bacillus Calmette-Guérin therapy. Further prospective study is warranted.

Expectant long-term follow-up of patients with chronic urinary retention

AIMS

To describe urologic complications in patients with chronically elevated post-void residual (PVR) volumes and to evaluate other related risk factors during a long-term follow-up in patients managed conservatively.

METHODS

Non-neurogenic patients who refused surgical intervention of the prostate and had PVR volumes >300 mL on two or more separate occasions at least 6 months apart were included. We followed this cohort over time, recorded complications and evaluated risk factors for complications.

RESULTS

Twenty-eight men with a mean age of 74 were followed for a median of 56 months (IQR: 26-101 months); 26 had benign prostatic hyperplasia with a median prostate size of 55 cc. Baseline median PVR was 468 cc (IQR: 395-828) and follow-up median PVR was 508 cc (IQR: 322-714). During follow-up, 13 patients (46%) had at least one complication with acute urinary retention being the most common occurring in 10 patients (36%) with 15 episodes. Other complications presented in less than 15%, and no patients developed permanent renal insufficiency. Patients with prostate size ≥ 100 cc had significantly higher total number of acute retention episodes (P-value: 0.01).

CONCLUSIONS

Although the presence of CUR could commonly predispose to episodes of acute retention, severe complications are infrequent although present. Additionally, prostate size may play a role in increasing some adverse outcomes. With proper counseling about different complications, patients with retention who denied surgical treatment can be safely followed for at least 5 years without renal deterioration.

Gleason Misclassification Rate Is Independent of Number of Biopsy Cores in Systematic Biopsy

OBJECTIVE

To compare the utility of saturation core biopsy and 12-core biopsy in detecting true Gleason grades, using final pathology in prostatectomy specimens as outcome measures, with a particular interest in Gleason upgrading.

PATIENTS AND METHODS

We compared the concordance rates of Gleason grades diagnosed on biopsies and prostatectomy specimens in 375 consecutive patients, including 106 saturation biopsies (18-33 cores, median = 20 cores) and 269 12-core biopsies. Grading bias was addressed by a central rereview of all cases that had discordance in reporting high Gleason grades (Gleason grade ≥ 4) on biopsies and prostatectomy specimens.

RESULTS

For patients with high Gleason grades on final pathology, saturation and 12-core biopsy schemes had a comparable sensitivity, specificity, negative and positive predictive values (72.5% vs 69.5%, 91.9% vs 97.6%, 64.2% vs 58.4%, and 94.3% vs 98.5%, respectively) in detecting high Gleason grades. On multivariate analysis, prebiopsy serum prostate-specific antigen and clinical T stage independently predicted Gleason upgrading; saturation biopsy was not a significant predictor. Approximately one-third of cases where high Gleason grade was not present in the biopsy were attributed to the confinement of high-grade tumors to unusual anatomic locations such as anterior lobes, apex, bladder neck, and parasagittal zones.

CONCLUSION

Our study showed that Gleason misclassification rate is independent of the number of biopsy cores in systematic biopsy. One of the reasons for missing high Gleason grade tumors on systematic biopsy was unusual tumor location outside of the biopsy grid, supporting the need for improved detection technique such as magnetic resonance imaging-guided targeted biopsies.

Low free testosterone levels predict disease reclassification in men with prostate cancer undergoing active surveillance

OBJECTIVE

To determine whether total testosterone and free testosterone levels predict disease reclassification in a cohort of men with prostate cancer (PCa) on active surveillance (AS).

PATIENTS AND METHODS

Total testosterone and free testosterone concentrations were determined at the time the men began the AS protocol. Statistical analysis was performed using Student's t-test and a chi-squared test to compare groups. Odds ratios (ORs) with 95% confidence intervals (CIs) were obtained using univariate logistic regression. Receiver-operator characteristic curves were generated to determine the investigated testosterone thresholds. Kaplan-Meier curves were used to estimate time to disease reclassification. A Cox proportional hazard regression model was used for multivariate analysis.

RESULTS

A total of 154 men were included in the AS cohort, of whom 54 (35%) progressed to active treatment. Men who had disease reclassification had significantly lower free testosterone levels than those who were not reclassified (0.75 vs 1.02 ng/dL, P = 0.03). Men with free testosterone levels <0.45 ng/dL had a higher rate of disease reclassification than patients with free testosterone levels ≥0.45 (P = 0.032). Free testosterone levels <0.45 ng/dL were associated with a several-fold increase in the risk of disease reclassification (OR 4.3, 95% CI 1.25-14.73). Multivariate analysis showed that free testosterone and family history of PCa were independent predictors of disease reclassification.

CONCLUSIONS

Free testosterone levels were lower in men with PCa who had reclassification during AS. Men with moderately severe reductions in free testosterone level are at increased risk of disease reclassification.

Diagnosis of relevant prostate cancer using supplementary cores from magnetic resonance imaging-prompted areas following multiple failed biopsies

OBJECTIVES

To establish the value of MRI in targeting re-biopsy for undiagnosed prostate cancer despite multiple negative biopsies and determine clinical relevance of detected tumors.

MATERIALS AND METHODS

Thirty-eight patients who underwent MRI after 2 or more negative biopsies due to continued clinical suspicion and later underwent TRUS-guided biopsy supplemented by biopsy of suspicious areas depicted by MRI were identified. Diagnostic performance of endorectal 3T MRI in diagnosing missed cancer foci was assessed using biopsy results as the standard of reference. Ratio of positive biopsies using systematic versus MRI-prompted approaches was compared. Gleason scores of detected cancers were used as surrogate for clinical relevance.

RESULTS

Thirty-four percent of patients who underwent MRI before re-biopsy had prostate cancer on subsequent biopsy. The positive biopsy yield with systematic sampling was 23% versus 92% with MRI-prompted biopsies(p<0.0001). Seventy-seven percent of tumors were detected exclusively in the MRI-prompted zones. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of MRI to provide a positive biopsy were 92%, 60%, 55%, 94% and 71%, respectively. The anterior gland and apical regions contained most tumors; 75% of cancers detected by MRI-prompted biopsy had Gleason score≥7.

CONCLUSIONS

Clinically relevant tumors missed by multiple TRUS-guided biopsies can be detected by a MRI-prompted approach.

Comparing costs of robotic, laparoscopic, and open partial nephrectomy

Abstract Background and Purpose: Laparoscopic and robot-assisted partial nephrectomy (LPN and RPN) are common minimally invasive alternatives to open partial nephrectomy (OPN) for management of renal tumors. Cost discrepancies of these approaches warrants evaluation. We compared hospital costs associated with RPN, LPN, and OPN.

PATIENTS AND METHODS

Costs were captured for 25 patients in each group who underwent RPN, LPN, or OPN at our institution between November 2008 and September 2010. Variable costs included operating room (OR) time, supplies, anesthesia, and inpatient care costs. Fixed costs included equipment purchase and maintenance. Impact of variable and fixed costs were estimated using sensitivity analysis.

RESULTS

Overall variable costs were similar for RPN, LPN, and OPN ($6375 vs $6075 vs $5774, P=0.117, respectively). OR supplies contributed a greater cost for RPN and LPN than OPN ($2179 vs $1987 vs $181, P<0.0001, respectively), while inpatient stay costs were higher for OPN compared with LPN and RPN ($2418 vs $1305 vs $1274, P<0.0001, respectively). Sensitivity analysis of variable costs demonstrates that RPN and LPN can represent less costly alternatives to OPN if hospital stay for RPN and LPN is ≤2 days and OR time <195 and 224 minutes, respectively. Inclusion of fixed costs made OPN less expensive than LPN and RPN unless use of the robot increases and operative times are reduced.

CONCLUSION

By minimizing OR time and hospital stay, RPN and LPN can be cost equivalent to OPN regarding variable costs. When including fixed costs, RPN and LPN were more costly than OPN, but equivalence may be possible with improvements in efficiency.

Cost comparison of robotic, laparoscopic, and open partial nephrectomy

394

Background: Laparoscopic and robotic partial nephrectomy (LPN and RPN) are increasingly common minimally invasive alternatives to open partial nephrectomy (OPN) for management of renal tumors. The cost discrepancies of these approaches warrants evaluation. We compared hospital costs associated with RPN, LPN, and OPN.

Methods: Variable hospital costs including operating room (OR) time, supplies, anesthesia, inpatient care, radiology, pharmacy, and laboratory charges were captured for 25 patients who underwent OPN, LPN, and RPN at our institution between 11/2008 -9/2010. Fixed costs of acquisition of a laparoscopic suite and a robotic system (including maintenance) were amortized over 7 years. We considered alternative scenarios through one-way and multi-way sensitivity analysis.

Results: We found similar overall variable costs for OPN, LPN, and RPN. Sensitivity analysis demonstrated that RPN and LPN are more cost effective than OPN (excluding fixed costs) if the average hospital stay is < 2 days, or OR time less is than 204 and 196 mins, respectively. By including fixed costs of equipment, RPN and LPN are always more costly than OPN.

Conclusions: There was no difference among variable hospital costs of OPN, LPN, and RPN. Minimizing OR time and hospital stay reduces RPN and LPN costs to levels comparable to OPN. Inclusion of fixed costs makes LPN and RPN more expensive than OPN, but increased utilization and efficiency can decrease cost per case.

[Table: see text]

Expanded prostate cancer index composite for clinical practice: development and validation of a practical health related quality of life instrument for use in the routine clinical care of patients with prostate cancer

PURPOSE

Measuring the health related quality of life of patients with prostate cancer in routine clinical practice is hindered by the lack of instruments enabling efficient, real-time, point of care scoring of multiple health related quality of life domains. Thus, we developed an instrument for this purpose.

MATERIALS AND METHODS

The Expanded Prostate Cancer Index Composite for Clinical Practice is a 1-page, 16-item questionnaire that we constructed to measure urinary incontinence, urinary irritation, and the bowel, sexual and hormonal health related quality of life domains. We eliminated conceptually overlapping items from the 3-page Expanded Prostate Cancer Index Composite-26 and revised the questionnaire format to mirror the AUA symptom index, thereby enabling practitioners to calculate health related quality of life scores at the point of care. We administered the Expanded Prostate Cancer Index Composite for Clinical Practice to a new cohort of patients with prostate cancer in community based and academic oncology, radiation, and urology practices to evaluate instrument validity as well as ease of use in clinical practice.

RESULTS

A total of 175 treated and 132 untreated subjects with prostate cancer completed the Expanded Prostate Cancer Index Composite for Clinical Practice. The domain scores of the Expanded Prostate Cancer Index Composite for Clinical Practice correlated highly with the respective domain scores from longer versions of the Expanded Prostate Cancer Index Composite (r≥0.93 for all domains). The Expanded Prostate Cancer Index Composite for Clinical Practice showed high internal consistency (Cronbach's α 0.64-0.84) and sensitivity to prostate cancer treatment related effects (p<0.05 in each of 5 health related quality of life domains). Patients completed the Expanded Prostate Cancer Index Composite for Clinical Practice efficiently (96% in less than 10 minutes and with 11% missing items). It was deemed very convenient by clinicians in 87% of routine clinical encounters and clinicians accurately scored completed questionnaires 94% of the time.

CONCLUSIONS

The Expanded Prostate Cancer Index Composite for Clinical Practice is a valid instrument that enables patient reported, health related quality of life to be measured efficiently and accurately at the point of care, and thereby facilitates improved emphasis and management of patient reported outcomes.

Risk stratification and validation of prostate specific antigen density as independent predictor of progression in men with low risk prostate cancer during active surveillance

PURPOSE

We assessed risk stratification in patients with low grade prostate cancer managed by active surveillance using a 20-core saturation biopsy technique.

MATERIALS AND METHODS

A total of 135 consecutive patients with low risk prostate cancer were prospectively entered in an active surveillance program in a 10-year period. The study entrance requirement and progression definition followed Epstein criteria using only pathological parameters, ie fewer than 3 positive cores, Gleason score 6 or less and 50% or less of any single core involved. All patients were monitored by restaging 20-core saturation biopsy every 12 to 18 months. A total of 120 patients with at least 1 rebiopsy form the basis of this report.

RESULTS

Of the cohort 30% progressed during a median of 2.4 years. Three multivariate analyses were performed. The first analysis used variables only at diagnosis biopsy and revealed that prostate specific antigen density greater than 0.08 ng/ml/cc and prostate cancer family history were significant predictors of progression. When combined in a 3-level risk factor score, they were significant (p = 0.003). The second multivariate analysis considered changes in characteristics between diagnosis biopsy and first rebiopsy. Prostate specific antigen velocity along with prostate specific antigen density and family history highly predicted progression according to a 4-level risk factor score (p <0.0001). The third multivariate analysis validated the previously reported prostate specific antigen density cutoff of 0.08 ng/ml/cc at first rebiopsy as a significant predictor of subsequent progression (HR 3.16, 95% CI 1.12, 8.93; p = 0.03).

CONCLUSIONS

Risk factor stratification can be used to significantly predict the outcome in patients on active surveillance. Prostate specific antigen density 0.08 ng/ml/cc at first rebiopsy was validated as a significant predictor of subsequent progression.

Lower limits of detection using magnetic resonance imaging for solid components in cystic renal neoplasms

OBJECTIVES

We determined the positive predictive value (PPV) for malignancy in complex renal cysts with focal nodular enhancement seen on magnetic resonance imaging (MRI).

METHODS

A surgical database was reviewed to identify all patients having both a preoperative 3 dimensional (3D) renal MRI and a radical or partial nephrectomy from January 2000 through April 2004 at our hospital. A group of 21 patients were identified with focal nodular enhancement within cystic renal masses. Pathologic correlation was made in each case.

RESULTS

We performed 286 nephrectomies during the study period. Of these patients, 159 (56%) had a preoperative MRI studies. There were 21 of 159 (13%) patients with complex cystic lesions that displayed focal nodular enhancement, 14 of which (67%) measured 10 mm or larger in size. Twenty (95%) of the 21 lesions were renal cell carcinoma. The single, benign lesion was a cystic nephroma. Fuhrman grade 1 or grade 2 cancers were found in the majority of patients (80%), and there were no grade 4 cancers. Fifteen patients had a preoperative computerized tomography (CT) scan as well and nodular enhancement was suspected in only 4 patients (27%). MRI findings upgraded these lesions in 11 patients (73%).

CONCLUSIONS

The demonstration of solid enhancing nodular components with high-resolution 3D MRI provides excellent positive predictive value for diagnosing neoplastic cystic renal lesions, including a large percentage 10 mm or larger in size. Our experience suggests a 95% likelihood that cystic renal lesions with focal nodular enhancement are malignant. We recommend that such lesions be considered malignant.

c-Fos as a proapoptotic agent in TRAIL-induced apoptosis in prostate cancer cells

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)/Apo-2L promotes apoptosis in cancer cells while sparing normal cells. Although many cancers are sensitive to TRAIL-induced apoptosis, some evade the proapoptotic effects of TRAIL. Therefore, differentiating molecular mechanisms that distinguish between TRAIL-sensitive and TRAIL-resistant tumors are essential for effective cancer therapies. Here, we show that c-Fos functions as a proapoptotic agent by repressing the antiapoptotic molecule c-FLIP(L). c-Fos binds the c-FLIP(L) promoter, represses its transcriptional activity, and reduces c-FLIP(L) mRNA and protein levels. Therefore, c-Fos is a key regulator of c-FLIP(L), and activation of c-Fos determines whether a cancer cell will undergo cell death after TRAIL treatment. Strategies to activate c-Fos or inhibit c-FLIP(L) may potentiate TRAIL-based proapoptotic therapies.

MR classification of renal masses with pathologic correlation

To perform a feature analysis of malignant renal tumors evaluated with magnetic resonance (MR) imaging and to investigate the correlation between MR imaging features and histopathological findings. MR examinations in 79 malignant renal masses were retrospectively evaluated, and a feature analysis was performed. Each renal mass was assigned to one of eight categories from a proposed MRI classification system. The sensitivity and specificity of the MRI classification system to predict the histologic subtype and nuclear grade was calculated. Subvoxel fat on chemical shift imaging correlated to clear cell type (p < 0.05); sensitivity = 42%, specificity = 100%. Large size, intratumoral necrosis, retroperitoneal vascular collaterals, and renal vein thrombosis predicted high-grade clear cell type (p < 0.05). Small size, peripheral location, low intratumoral SI on T2-weighted images, and low-level enhancement were associated with low-grade papillary carcinomas (p < 0.05). The sensitivity and specificity of the MRI classification system for diagnosing low grade clear cell, high-grade clear cell, all clear cell, all papillary, and transitional carcinomas were 50% and 94%, 93% and 75%, 92% and 83%, 80% and 94%, and 100% and 99%, respectively. The MRI feature analysis and proposed classification system help predict the histological type and nuclear grade of renal masses.

Spaced education improves the retention of clinical knowledge by medical students: a randomised controlled trial

PURPOSE

Medical knowledge learned by trainees is often quickly forgotten. How can the educational process be tailored to shift learning into longer-term memory? We investigated whether 'spaced education', consisting of weekly e-mailed case scenarios and clinical questions, could improve the retention of students' learning.

METHODS

During the 2004-5 surgery clerkships, 3rd-year students completed a mandatory 1-week clinical rotation in urology and validated web-based teaching programme on 4 core urology topics. Spaced educational e-mails were constructed on all 4 topics based on a validated urology curriculum. Each consisted of a short clinically relevant question or clinical case scenario in multiple-choice question format, followed by the answer, teaching point summary and explanations of the answers. Students were randomised to receive weekly e-mailed case scenarios in only 2 of the 4 urology topics upon completion of their urology rotation. Students completed a validated 28-item test (Cronbach's alpha = 0.76) on all 4 topics prior to and after the rotation and at the end of the academic year.

RESULTS

A total of 95 of 133 students (71%) completed the end-of-year test. There were no significant differences in baseline characteristics between randomised cohorts. Spaced education significantly improved composite end-of-year test scores (P < 0.001, paired t-test). The impact of the spaced educational e-mails was largest for those students who completed their urology education 6-8 and 9-11 months previously (Cohen's effect sizes of 1.01 and 0.73, respectively).

CONCLUSION

Spaced education consisting of clinical scenarios and questions distributed weekly via e-mail can significantly improve students' retention of medical knowledge.

The TRA-1-60 and TRA-1-81 human pluripotent stem cell markers are expressed on podocalyxin in embryonal carcinoma

We have previously identified the cell adhesion protein podocalyxin expressed in a human pluripotent stem cell, embryonal carcinoma (EC), which is a malignant germ cell. Podocalyxin is a heavily glycosylated membrane protein with amino acid sequence homology to the hematopoietic stem cell marker CD34. Since the initial discovery of podocalyxin in a cancerous stem cell, numerous new studies have identified podocalyxin in many different human cancers and in embryonic stem cells lines (ES) derived from human embryos. Embryonal carcinoma, as do all human pluripotent stem cells, expresses TRA-1-60 and TRA-1-81 antigens, and although their molecular identities are unknown, they are commonly used as markers of undifferentiated pluripotent human stem cells. We report here that purified podocalyxin from embryonal carcinoma has binding activity with the TRA-1-60 and TRA-1-81 antibodies. Embryonal carcinoma cells treated with retinoic acid undergo differentiation and lose the TRA-1-60/TRA-1-81 markers from their plasma membrane surface. We show that podocalyxin is modified in the retinoic acid-treated cells and has an apparent molecular mass of 170 kDa on protein blots as compared with the apparent 200-kDa molecular weight form of podocalyxin expressed in untreated cells. Furthermore, the modified form of podocalyxin no longer reacts with the TRA-1-60/TRA-1-81 antibodies. Thus, embryonal carcinoma expresses two distinct forms of podocalyxin, and the larger version is a molecular carrier of the human stem cell-defining antigens TRA-1-60 and TRA-1-81.

A multi-institutional randomized controlled trial of adjuvant Web-based teaching to medical students

PURPOSE

To investigate the impact of an adjuvant Web-based teaching program on medical students' learning during clinical rotations.

METHOD

From April 2003 to May 2004, 351 students completing clinical rotations in surgery-urology at four U.S. medical schools were invited to volunteer for the study. Web-based teaching cases were developed covering four core urologic topics. Students were block randomized to receive Web-based teaching on two of the four topics. Before and after a designated duration at each institution (ranging one to three weeks), students completed a validated 28-item Web-based test (Cronbach's alpha = .76) covering all four topics. The test was also administered to a subset of students at one school at the conclusion of their third-year to measure long-term learning.

RESULTS

Eighty-one percent of all eligible students (286/351) volunteered to participate in the study, 73% of whom (210/286) completed the Web-based program. Compared to controls, Web-based teaching significantly increased test scores in the four topics at each medical school (p < .001, mixed analysis of variance), corresponding to a Cohen's d effect size of 1.52 (95% confidence interval [CI], 1.23-1.80). Learning efficiency was increased three-fold by Web-based teaching (Cohen's d effect size 1.16; 95% CI 1.13-1.19). Students who were tested a median of 4.8 months later demonstrated significantly higher scores for Web-based teaching compared to non-Web-based teaching (p = .007, paired t-test). Limited learning was noted in the absence of Web-based teaching.

CONCLUSIONS

This randomized controlled trial provides Class I evidence that Web-based teaching as an adjunct to clinical experiences can significantly and durably improve medical students' learning.

Quality of life following simultaneous placement of penile prosthesis with radical prostatectomy

PURPOSE

The present study examined erectile functioning, frequency of sexual contact, psychological functioning, partner/marital satisfaction and overall quality of life (QOL) after immediate sexual rehabilitation for prostate cancer via simultaneous placement of a penile prosthesis at radical retropubic prostatectomy (RP).

MATERIALS AND METHODS

Questionnaire packets were sent to and received from 51 men who had undergone simultaneous implantation of a penile prosthesis at the time of RP (PP+) and from a comparison group of 47 men who undergone RP alone (PP-) matched by age and year of surgery. Questionnaires included the Erectile Dysfunction Inventory of Treatment Satisfaction, the Depression Anxiety Stress Scales, the Dyadic Adjustment Scale and a prostate specific European Organization for the Research and Treatment of Cancer (EORTC) QOL questionnaire. Further comparisons were performed for a PP- subgroup consisting of 15 patients who had undergone nerve sparing RP.

RESULTS

Higher Erectile Dysfunction Inventory of Treatment Satisfaction, EORTC Sexual Functioning, EORTC Total scores and more frequent sexual contact were reported by the PP+ group compared with the PP- group. The PP+ group also had better outcomes that approached but did not reach statistical significance compared with the nerve sparing subgroup with regard to Depression Anxiety Stress Scales and EORTC Emotional Functioning scores.

CONCLUSIONS

Men who chose simultaneous placement of a penile prosthesis with RP reported greater overall QOL, erectile function and more frequent sexual contact than a comparison group of men who underwent RP alone. Placement of penile prosthesis at the time of RP may be a desirable option for men with prostate cancer in whom a nerve sparing procedure may not be ideal. These results underscore the importance of sexual function for men undergoing prostate cancer treatment.

Development of a sensitive and specific enzyme-linked immunosorbent assay for thymosin beta15, a urinary biomarker of human prostate cancer

OBJECTIVES

In tissue-based assays, thymosin beta15 (Tbeta15) has been shown to correlate with prostate cancer (CaP) malignancy and with future recurrence. To be clinically effective, it must be shown that Tbeta15 is released by the tumor into body fluids in detectable concentrations. Toward this end, we have worked to develop a quantitative high-throughput assay that can accurately measure clinically relevant concentrations of Tbeta15 in human urine.

DESIGN AND METHODS

Sixteen antibodies were raised against recombinant Tbeta15 and/or peptide conjugates. One antibody, having stable characteristics over the wide range of pH and salt concentrations found in urine and minimal cross-reactivity with other beta thymosins, was used to develop a competitive enzyme-linked immunosorbent assay (ELISA). Urinary Tbeta15 concentration was determined for control groups; normal (N = 52), prostate intraepithelial neoplasia (PIN, N = 36), and CaP patients; untreated (N = 7) with subsequent biochemical failure, radiation therapy (N = 17) at risk of biochemical recurrence.

RESULTS

The operating range of the competition ELISA fell between 2.5 and 625 ng/mL. Recoveries exceeded 75%, and the intra- and inter-assay coefficients of variability were 3.3% and 12.9%, respectively. No cross-reactivity with other urine proteins was observed. A stable Tbeta15 signal was recovered from urine specimens stored at -20 degrees C for up to 1 year. At a threshold of 40 (ng/dL)/mug protein/mg creatinine), the assay had a sensitivity of 58% and a specificity of 94%. Relative to the control groups, Tbeta15 levels were greater than this threshold in a significant fraction of the CaP patients (P < 0.001), including 5 of the 7 patients who later experienced PSA recurrence.

CONCLUSIONS

We have established an ELISA that is able to detect Tbeta15 at clinically relevant concentrations in urine from patients with CaP. The assay will provide a tool for future clinical trials to validate urinary Tbeta15 as a predictive marker for recurrent CaP.

Use of thymosin beta15 as a urinary biomarker in human prostate cancer

BACKGROUND

Additional prostate cancer (CaP) biomarkers are needed to increase the accuracy of diagnosis and to identify patients at risk of recurrence. In tissue-based assays, thymosin beta15 (Tbeta15) has been linked to an aggressive CaP phenotype and correlated with future tumor recurrence. We hypothesized that Tbeta15 may have clinical utility in biological fluids.

METHODS

Tbeta15 was measured in urine from CaP patients; untreated (N = 61), prostatectomy (RP, N = 46), androgen deprivation therapy (ADT, N = 14) and control groups; normal (N = 52), genitourinary carcinoma (N = 15), non-malignant prostate disease (N = 81), and other urology (N = 73). We evaluated the utility of urinary Tbeta15 for CaP diagnosis, alone or in combination with prostate-specific antigen (PSA), and the relationship to CaP progression.

RESULTS

A normal threshold of 40 (ng/dl)/(mug_protein/mg_creatinine) was defined using receiver operating characteristic analysis and marked the 19th centile for age-matched controls. The proportion of untreated CaP patients with urinary Tbeta15 above the threshold was significantly higher than normal and genitourinary disease controls (P < 0.001). RP caused urinary Tbeta15 to drop significantly (P = 0.005). Pre-surgery Tbeta15 concentrations greater than the normal threshold may confer greater risk of CaP recurrence. Relative to normal controls, patients receiving ADT for aggressive CaP were 12 times more likely to have elevated urinary Tbeta15 (P = 0.001, 95% CI = 2.8, 51.8). Combining PSA and Tbeta15 (PSA > 4, or PSA > 2.5, Tbeta15 > 40, or PSA = 2.5, Tbeta15 > 90) provided the same sensitivity as a 2.5 ng/ml PSA cutoff, but markedly improved diagnostic specificity.

CONCLUSIONS

We report that Tbeta15 is a urinary biomarker for CaP and suggest that Tbeta15, in combination with PSA, can be used to improve both the sensitivity and specificity of CaP diagnosis.

Persistent c-FLIP(L) expression is necessary and sufficient to maintain resistance to tumor necrosis factor-related apoptosis-inducing ligand-mediated apoptosis in prostate cancer

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) has been shown to induce apoptosis in a variety of tumorigenic and transformed cell lines but not in many normal cells. Hence, TRAIL has the potential to be an ideal cancer therapeutic agent with minimal cytotoxicity. FLICE inhibitory protein (c-FLIP) is an important regulator of TRAIL-induced apoptosis. Here, we show that persistent expression of c-FLIP(Long) [c-FLIP(L)] is inversely correlated with the ability of TRAIL to induce apoptosis in prostate cancer cells. In contrast to TRAIL-sensitive cells, TRAIL-resistant LNCaP and PC3-TR (a TRAIL-resistant subpopulation of PC3) cells showed increased c-FLIP(L) mRNA levels and maintained steady protein expression of c-FLIP(L) after treatment with TRAIL. Ectopic expression of c-FLIP(L) in TRAIL-sensitive PC3 cells changed their phenotype from TRAIL sensitive to TRAIL resistant. Conversely, silencing of c-FLIP(L) expression by small interfering RNA in PC3-TR cells reversed their phenotype from TRAIL resistant to TRAIL sensitive. Therefore, persistent expression of c-FLIP(L) is necessary and sufficient to regulate sensitivity to TRAIL-mediated apoptosis in prostate cancer cells.

Expression of transforming growth factor-beta 1 and growth in soft agar differentiate prostate carcinoma-associated fibroblasts from normal prostate fibroblasts

Carcinoma-associated fibroblasts (CAF) promote tumor progression of pre-neoplastic epithelial cells. To investigate the basis of this phenomenon, we compared the properties of fibroblasts cultured from normal human prostate (NHPF) to prostate CAF. NHPF and CAF were assayed for growth potential, cell death and proliferative capacity by measuring population doubling time, cell cycle distribution and capability to form colonies in soft agar. Resistance to genotoxic (UV radiation: 0-50 J/cm2) and chemotoxic (0-200 nM Taxol) agents were compared between CAF and NHPF by measuring cell viability and cell cycle analysis. Transforming growth factor beta1 (TGF-beta1) immunoreactivity was assessed in non-malignant and malignant prostatic tissue. No detectable differences were found when comparing CAF and NHPF with respect to population doubling time, cell cycle distribution and response to genotoxic and chemotoxic agents. The mean number of colonies in soft agar was 120.5 for CAF vs. 18.2 for NHPF (p < 0.05). Because TGF-beta1 and matrix metalloproteinase (MMP)-9 have been associated with growth of fibroblasts in soft agar and tumor promotion, we measured the expression of these factors in NHPF and CAF by ELISA. There was no difference in expression of MMP-9; however, TGF-beta1 was expressed in higher concentrations in CAF than in NHPF (p < 0.0014). Furthermore, TGF-beta1 expression was higher in the carcinoma-associated stroma of prostate cancer tissue than stroma of non-malignant prostatic tissue. Increased capability of CAF as compared to NHPF to form colonies in soft agar may be due to a higher expression of TGF-beta1 and correlates with the ability of CAF to promote malignant progression of prostate epithelial cells.

DEVELOPMENT AND INITIAL EVALUATION OF A NOVEL UROLOGY CURRICULUM FOR MEDICAL STUDENTS

PURPOSE

After the development and implementation of a novel urology curriculum for medical students we evaluated urological learning by medical students using a validated measure of learning in the 4 clinical areas of benign prostatic hyperplasia, erectile dysfunction, prostate cancer and prostate specific antigen screening.

MATERIALS AND METHODS

Third year medical students completed an online validated pre-test and post-test immediately before and after the mandatory 1-week clinical rotation in urology. Online pre-surveys and post-surveys were also administered. Overall student participation was 90% (37 of 41) with 63% of students (26 of 41) completing all 4 tests and surveys.

RESULTS

Student overall test scores improved significantly upon completion of the 1-week clinical rotation in urology (p <0.001). A trend toward increased learning by male students was identified (p = 0.07). Significant variation in exposure to outpatient clinics and in the performance of physical examination skills was observed among the different teaching sites.

CONCLUSIONS

This study demonstrates significant learning by medical students during their 1-week clinical rotation in urology. Further data are needed to confirm the trend toward increased learning by males and elucidate its etiology. Scheduling changes have been implemented to address the inconsistencies across clinical sites.

Percent of cores positive for cancer is a better preoperative predictor of cancer recurrence after radical prostatectomy than prostate specific antigen

PURPOSE

We examined the prognostic significance of clinical and pathological variables on outcome following radical retropubic prostatectomy (RRP) in a cohort of patients in the post-prostate specific antigen (PSA) era.

MATERIALS AND METHODS

We reviewed the clinical and pathological data on a cohort of 476 patients who underwent RRP for localized prostate cancer between January 1990 and July 2001 by 1 urologist (WCD). Median age, preoperative PSA and followup were 61 years, 5.8 ng/ml and 49 months, respectively. We used Cox proportional hazard modeling to evaluate the prognostic significance of clinical and pathological variables for cancer recurrence, defined as 2 successive PSA determinations 0.3 ng/ml or greater.

RESULTS

Of the 476 patients 53 (11%) had recurrence. Estimated cancer nonprogression probability was 86% (95% CI 83 to 90) and 76% (95% CI 68 to 86) at 5 and 10 years, respectively. Two multivariate analyses were performed. The first analysis, using only preoperative indicators, found that the percent of biopsy cores positive for cancer and biopsy Gleason score were the best predictive indicators of recurrence. The second multivariate analysis, using preoperative and postoperative indicators, found that the percent of biopsy cores positive for cancer, RRP Gleason score and the combined pathological stage/margin status variable were the best predictive indicators of recurrence. PSA was not found to be an important predictor of recurrence on either multivariate analysis. Patients with a percent of biopsy cores in the upper half of the distribution (greater than 28% positive) were at significantly increased risk for recurrence compared with those in the lower half of the distribution (28% or less positive) (HR 3.86, p <0.001).

CONCLUSIONS

The percent of cores positive for cancer was a better predictor of cancer recurrence than PSA in this post-PSA era RRP series. In addition, surgical Gleason score and pathological stage/surgical margins were also independent predictors of cancer recurrence after RRP. These 3 predictors are displayed in a nomogram-type format to summarize estimated 5 and 10-year recurrence-free probabilities.

The cell cycle and its relevance to the urologist

PURPOSE

We surveyed fundamental concepts of the cell cycle to help the average urologist better understand the molecular basis for specific aspects of urological disease.

MATERIALS AND METHODS

Important publications that have shaped our current understanding of the cell cycle were selected for review. Definitions of key terms are provided in a glossary.

RESULTS

Cell proliferation, survival and programmed cell death (apoptosis) are the net result of a complex interaction of molecular signals that regulate DNA and protein synthesis. Many of the abnormal patterns of cell behavior that contribute to the pathology of malignant urological disease arise from disruptions in the molecular controls that normally regulate the cell cycle. Benign urological conditions, including cystic diseases and hypertrophy, also reflect abnormal growth that results from the disruption of cell cycle controls.

CONCLUSIONS

This review is designed for the clinician and for the nonspecialist who is interested in the science of the cell cycle and its regulation as it broadly pertains to urological disease. Recent advances in the understanding of cell cycle regulation are presented with clinical correlations illustrating how these processes are involved in coordinating cell growth and cell death at the molecular level.

Heat-induced testicular apoptosis occurs independently of hormonal depletion

Previous studies have demonstrated that testicular germ cell apoptosis can be induced both by heat stress and by withdrawal of androgens and gonadotrophins. To investigate whether heat-induced germ cell apoptosis occurs independently of the altered levels of hormones that occur with heat exposure, mouse testicular apoptosis was studied using an in vitro system with controlled levels of testosterone, FSH and LH. It was observed that cells underwent apoptosis sooner in the absence of hormones at the same temperature. Apoptosis also occurred earlier at abdominal temperature compared to scrotal temperature with the same hormonal levels. No somatic tissues studied underwent apoptosis at 37 degrees C under the same culture conditions. These results suggest that heat stress may independently activate an apoptotic pathway in the testis, and that hormone deprivation may induce apoptosis via a separate mechanism.

Preoperative serum acid phosphatase and alkaline phosphatase are not predictors of pathological stage and prostate-specific antigen failure after radical prostatectomy

OBJECTIVE

To examine the utility and prognostic significance of enzymatic serum acid phosphatase (total acid phosphatase, TAP, and prostatic fraction of acid phosphatase, PFAP) and alkaline phosphatase (ALP) for staging, grading and outcome of patients who underwent radical retropubic prostatectomy (RRP) after the introduction of prostate-specific antigen (PSA) testing.

PATIENTS AND METHODS

In all, 180 consecutive patients with clinically localized prostate cancer who underwent RRP with standard obturator lymph-node dissection between 1 January 1990 and 31 December 1995 were evaluated. Levels of TAP of > 5.4 IU/L, PFAP of > 1.2 IU/L and ALP of > 120 IU/L were classified as abnormally high. The relationship between abnormally high values and prostate cancer stage, grade and time to recurrence after RRP were calculated. The median follow-up was 86 months (approximately 7 years).

RESULTS

Of the 180 patients, information about preoperative TAP, PFAP and ALP were available in 164, 163 and 154, respectively; TAP was abnormal in seven (4%), PFAP in 33 (20%) and ALP in only 13 (8%). None of the markers examined was associated with any variables of disease severity, as measured by pathological stage, Gleason score, perineural invasion, capsular penetration, positive margins, seminal vesicle involvement, and lymph node involvement. Abnormal TAP, PFAP or ALP were not associated with recurrence (P = 0.96, 0.45 and 0.41, respectively). In contrast, a PSA level of > 4 ng/mL was predictive of recurrence after RRP (P < 0.001). In the sample overall, 25 (14%) of the patients had recurrence and only one died from prostate cancer.

CONCLUSIONS

Preoperative enzymatic serum TAP, PFAP and ALP levels are not predictors of the severity of disease or PSA disease-free recurrence after RRP.

Determinations of prostate volume at 3-Tesla using an external phased array coil: comparison to pathologic specimens

RATIONALE AND OBJECTIVES

To compare techniques for measuring in vivo prostate volumes using torso phased-array imaging at 3-Tesla.

METHODS

Eleven patients imaged at 3-Tesla with a torso-phased array coil using multiplanar fast spin echo (FSE) T2-weighted imaging who underwent radical prostatectomy comprised the study population. Surgical specimens were imaged. The pathologic specimen volume was compared with varieties of magnetic resonance volume determinations, the latter using ellipsoid and planimetric assessments. Three-dimensional images of the excised prostate were generated. Linear correlation coefficients were calculated comparing volume determinations from image data and pathologic data.

RESULTS

Correlation coefficient (r2) values from the ellipsoid formula among six different data sets ranging between 0.325 to 0.751; the highest in vivo r2 value was obtained by multiplying the anterior-posterior and the superior-inferior dimensions from the sagittal image by the right-left dimension from the axial image. The r2 values of the planimetric volume and specimen 3-dimensional volume rendering were 0.652 and 0.86, respectively.

CONCLUSIONS

Surface coil prostate imaging at 3-Tesla provides undistorted images for volume assessment and in vivo volume determinations very close to ex vivo imaging volume determinations.

Clinical management of prostatic intraepithelial neoplasia as diagnosed by extended needle biopsies

OBJECTIVE

To examine the results of the clinical management of patients with high-grade prostatic intraepithelial neoplasia (PIN), as diagnosed by extended needle biopsies.

PATIENTS AND METHODS

The clinical data were reviewed from a cohort of 387 men who underwent > or = 10 core prostate needle biopsies between 1 January 1996 and 31 December 1997 by one urologist (W.C.D.). Two study groups were identified; the first comprised 47 patients with only high-grade PIN and the second was a control group of 137 patients with only benign findings on their biopsies. Those patients with cancer, atypia or a prostatic biopsy with fewer than 10 cores were excluded. The clinical and histological data were evaluated. The criteria for re-biopsy were two successive increases in prostate specific antigen (PSA) level or any change in the findings on digital rectal examination (DRE). All patients were monitored at 6-12 month intervals.

RESULTS

Of the 387 patients, 46% had normal findings, 5.2% had atypia, 12.6% had PIN alone, 15 (3.9%) had PIN plus atypia, 6.7% had PIN plus cancer and 32.3% had cancer. There was no significant difference between the PIN and control groups in age, DRE, PSA level, prostate size (by ultrasonography), free testosterone level, number of the cores and time of follow-up (median 34.8 and 36.6 months for the PIN and control groups, respectively). Of the PIN and control groups, 21 (45%) and 43 (31%) respectively had at least one re-biopsy. Five patients (24%) in the PIN and one (2.3%) in the control group developed cancer (P = 0.0124). All these patients had organ-confined disease and were found to have either Gleason scores 3 + 3 or 3 + 4 on surgical specimens. There was no correlation between the original location of PIN and the location of subsequent malignancy.

CONCLUSIONS

Patients with one set of extended needle biopsies with high-grade PIN should be followed clinically every 6-12 months, and it may be safe to reserve repeat biopsy for those with changes in PSA level and/or in the DRE.

Human embryonal carcinoma tumor antigen, Gp200/GCTM-2, is podocalyxin

We previously characterized a peanut agglutinin-binding tumor antigen, gp200, a surface membrane glycoprotein expressed on human embryonal carcinoma, a malignant stem cell of testicular tumors. Gp200 is remarkably similar to another embryonal carcinoma antigen, GCTM-2, a cell differentiation marker that is also detected in blood of testis cancer patients, yet neither molecular identity is known. We now report the identity of gp200 as podocalyxin. Protein sequence results of gp200 peptides match with podocalyxin sequence. Furthermore, two distinct monoclonal antibodies, specific for podocalyxin, react positively with gp200. Therefore, gp200 is a testicular tumor form of podocalyxin, a surface membrane glycoprotein that was originally discovered as a scaffolding extracellular matrix protein of kidney podocyte cells. Podocalyxin is also expressed on subsets of hematopoietic cells where it has a putative function as a cell adhesion protein. This is the first report of podocalyxin expression on malignant cells.

The relationship of prostate gland volume to extended needle biopsy on prostate cancer detection

PURPOSE

We investigated the relationship between prostate volume and cancer detection by needle biopsy, and determined the effect of an increased number of cores on the sampling error of needle biopsy on large prostate glands.

MATERIALS AND METHODS

The study cohort included 750 consecutive patients who underwent first time transrectal ultrasound guided prostate needle biopsy from January 1995 to August 2001. Prostate volumes were divided into quartiles (13 to 34, 34.1 to 45, 45.1 to 64 and 64.1 to 244 cc). Multivariate analysis controlling for age, prostate specific antigen (PSA) and biopsy indication was performed to determine the effect of the number of cores and prostate volume on prostate cancer detection.

RESULTS

Patients diagnosed with prostate cancer were older (p = 0.0035) and had higher PSA levels (p = 0.0002) than those with no cancer on biopsy. Decreasing cancer detection rates were seen with increasing prostate volume (p = 0.0074). The OR of detection for each additional core was 0.99 (95% CI 0.93, 1.06), suggesting that increasing the number of biopsy cores did not increase the rate of prostate cancer detection. Multivariate analysis revealed that patients with larger prostates had the same, or possibly lower, cancer detection rate as the number of biopsy cores was increased. Patients with larger prostates were older (p <0.0001), had higher PSA levels (p <0.0001) and were even more likely to have undergone biopsy for increased PSA rather than abnormal digital rectal examination alone (p <0.0001).

CONCLUSIONS

Our study suggests that the lower cancer detection rate for men with large prostates may be due to a decrease in the use of increased serum PSA for prostate cancer detection in larger prostates in addition to other factors such as sampling error. Increased serum PSA levels in cases of larger prostates, although a risk factor for prostate cancer warranting biopsy, may also be due to nonmalignant sources such as benign prostatic hyperplasia.

The relationship of prostate gland volume to extended needle biopsy on prostate cancer detection

PURPOSE

We investigated the relationship between prostate volume and cancer detection by needle biopsy, and determined the effect of an increased number of cores on the sampling error of needle biopsy on large prostate glands.

MATERIALS AND METHODS

The study cohort included 750 consecutive patients who underwent first time transrectal ultrasound guided prostate needle biopsy from January 1995 to August 2001. Prostate volumes were divided into quartiles (13 to 34, 34.1 to 45, 45.1 to 64 and 64.1 to 244 cc). Multivariate analysis controlling for age, prostate specific antigen (PSA) and biopsy indication was performed to determine the effect of the number of cores and prostate volume on prostate cancer detection.

RESULTS

Patients diagnosed with prostate cancer were older (p = 0.0035) and had higher PSA levels (p = 0.0002) than those with no cancer on biopsy. Decreasing cancer detection rates were seen with increasing prostate volume (p = 0.0074). The OR of detection for each additional core was 0.99 (95% CI 0.93, 1.06), suggesting that increasing the number of biopsy cores did not increase the rate of prostate cancer detection. Multivariate analysis revealed that patients with larger prostates had the same, or possibly lower, cancer detection rate as the number of biopsy cores was increased. Patients with larger prostates were older (p <0.0001), had higher PSA levels (p <0.0001) and were even more likely to have undergone biopsy for increased PSA rather than abnormal digital rectal examination alone (p <0.0001).

CONCLUSIONS

Our study suggests that the lower cancer detection rate for men with large prostates may be due to a decrease in the use of increased serum PSA for prostate cancer detection in larger prostates in addition to other factors such as sampling error. Increased serum PSA levels in cases of larger prostates, although a risk factor for prostate cancer warranting biopsy, may also be due to nonmalignant sources such as benign prostatic hyperplasia.

Extended prostate needle biopsy improves concordance of Gleason grading between prostate needle biopsy and radical prostatectomy

PURPOSE

We examined the concordance of Gleason scores in prostate needle biopsy specimens and the corresponding radical retropubic prostatectomy specimens in a cohort of patients grouped according to the number of cores obtained during diagnostic needle biopsy.

MATERIALS AND METHODS

We reviewed clinical and pathological data on a cohort of 466 men diagnosed with localized prostate cancer by needle biopsies who underwent radical retropubic prostatectomy between January 1, 1990 and July 31, 2001. Two study groups were identified, including 126 patients diagnosed with prostate cancer by extended needle biopsies (10 or more cores) and 340 diagnosed with cancer by nonextended needle biopsies (9 or fewer cores). Mean age was 60 years and median prostate specific antigen was 5.8 ng./ml. The median number of cores in the extended and nonextended biopsy groups was 12 and 6, respectively. The concordance of Gleason score in the needle biopsy and prostatectomy specimens was compared and correlated with the number of cores on needle biopsy.

RESULTS

In the whole cohort 311 patients (67%) had identical Gleason scores on the needle biopsy and prostatectomy specimens, while 53 (11%) were over graded and 102 (22%) were under graded on needle biopsy. In patients who underwent extended needle biopsies the accuracy rate for Gleason scoring was 76% with 10% over and 14% under graded. The highest accuracy rates were in patients with 13, 14 and 16 cores (89%, 87% and 100%, respectively). No patients in the extended needle biopsy group had a discrepancy of more than 2 Gleason units in grade in the biopsy and surgical specimens. In those who underwent nonextended needle biopsies the accuracy rate for Gleason scoring was 63% with 12% over and 25% under graded. There were significantly different rates of accuracy (p = 0.008) and under grading (p = 0.01) in the 2 needle biopsy groups. Patients with a needle biopsy Gleason score of less than 7 had significantly higher concordance with the prostatectomy Gleason score when extended biopsies were done compared with nonextended biopsies (p = 0.001).

CONCLUSIONS

Prostate cancer grading by extended needle biopsy is a better predictor of the final Gleason score than nonextended needle biopsy, as determined by radical prostatectomy histological evaluation. Therefore, extended prostate needle biopsy provides better guidance to determine the appropriate treatment in patients with prostate cancer.

Association between prostate cancer and serum testosterone levels

BACKGROUND

The purpose of the current study was to determine whether the presence of prostate cancer altered serum testosterone levels.

METHODS

Initially, we evaluated both serum total and free testosterone levels in patients with either high-grade (n = 18) or moderate-grade (n = 146) prostate cancer, detected by prostate needle biopsies. Then both serum total and free testosterone levels, before and after prostatectomy, were compared in 79 of the 164 men with prostate cancer.

RESULTS

In the first setting, serum total and free testosterone levels (307 +/- 24 ng/dl and 1.14 +/- 0.09 ng/dl) in patients with high-grade prostate cancer were significantly lower than those in patients with moderate-grade prostate cancer (452 +/- 12 ng/dl and 1.51 +/- 0.04 ng/dl) and those without prostate cancer (451 +/- 17 ng/dl and 1.55 +/- 0.06 ng/dl). After prostatectomy in 79 patients with prostate cancer, serum levels of both total and free testosterone (511 +/- 15 ng/dl and 1.78 +/- 0.05 ng/dl) were found significantly elevated when compared with their respective presurgical total and free testosterone levels (450 +/- 17 ng/dl and 1.60 +/- 0.06 ng/dl).

CONCLUSION

Our findings show that serum total and free testosterone levels in patients with prostate cancer are altered, supporting the possibility that prostate cancer may inhibit serum testosterone levels.

Does the outpatient setting provide the best environment for medical student learning of urology?

PURPOSE

To determine in which environment medical students learn clinical urology most effectively, we retrospectively reviewed a natural experiment in which medical students were randomly assigned to complete the 1-week rotation in clinical urology in an outpatient/clinic based or inpatient/operative setting.

MATERIALS AND METHODS

Exit surveys were completed by 25 of the 39 medical students (64%) who had just completed the mandatory 1-week rotation in urology. Students were asked to record on a 5-point scale the amount learned in regard to 13 urological topics and skills, and to document the number of patient encounters experienced per topic and skill.

RESULTS

Students randomized to the outpatient/clinic based setting tended to be 1) more likely to have exposure to a greater number and breadth of patients with common urological problems, 2) more likely to perform pertinent physical examination skills and 3) more likely to perceive that they learned more about a given curricular topic or skill.

CONCLUSIONS

Our data indicate that the outpatient/clinic based setting may be a higher yield environment for medical students learning clinical urology compared with the inpatient/operative setting. The development of a validated means to assess actual student learning in clinical urology is needed to confirm these findings.

P53 and Fas are sequential mechanisms of testicular germ cell apoptosis

Testicular germ cell apoptosis in the cryptorchid testis is induced by abdominal heat stress. p53-dependent apoptosis appears responsible for the initial phase of germ cell loss in experimental cryptorchidism based on a 3-day delay of apoptosis in p53-/- mice. However, the mechanisms underlying the subsequent p53-independent apoptosis have not been identified. Although studies have suggested that Fas plays a role in testicular germ cell apoptosis, no direct evidence has been shown. To test the hypothesis that Fas is involved in testicular germ cell apoptosis and is responsible for the p53-independent phase of apoptosis in the cryptorchid testis, p53-/-, lpr/lpr (a spontaneous mutation in the Fas gene, which causes autoimmune disease) double-mutant mice were generated and unilateral cryptorchidism was induced in these mice. It was found that testicular weight reduction and germ cell apoptosis were delayed by an additional 3 days, and the Fas production increased in the time frame of p53-independent apoptosis in the experimental cryptorchid testis of wild-type mice. These results suggest that Fas is involved in testicular germ cell apoptosis, and that Fas-dependent apoptosis is responsible for the p53-independent phase of germ cell apoptosis in the cryptorchid testis. The cascade of testicular germ cell apoptosis in response to heat stress implies the existence of sequential quality control mechanisms in spermatogenesis.

Long-term remission in a patient with metastatic collecting duct carcinoma treated with taxol/carboplatin and surgery

Collecting duct carcinoma of the kidney is a rare and aggressive neoplasm of the distal collecting tubules for which there is no established therapy. We describe a young woman with metastatic collecting duct carcinoma who responded to Taxol/carboplatin chemotherapy with an 80% reduction in her tumor burden, including complete regression of lymph node metastases and significant shrinkage of a renal mass. She was rendered free of disease through nephrectomy and has been without a recurrence for 20 months. This suggests that Taxol/carboplatin chemotherapy and surgery should be considered for the treatment of metastatic collecting duct carcinoma.

Salvage intravesical therapy with interferon-alpha 2b plus low dose bacillus Calmette-Guerin is effective in patients with superficial bladder cancer in whom bacillus Calmette-Guerin alone previously failed

PURPOSE

We determined whether combining low dose bacillus Calmette-Guerin (BCG) interferon-alpha 2B would be effective for patients in whom previous BCG failed.

MATERIALS AND METHODS

A total of 40 patients in whom 1 (19) or more (21) previous induction courses of BCG failed received 6 to 8 weekly treatments of 1/3 dose (27 mg.) BCG plus 50 million units interferon-alpha 2B. Additional 3 week miniseries of further decreased BCG (1/10, 1/30 or 1/100) titrated to symptoms without changing the interferon-alpha 2B dose were given at 5, 11 and 17 months. In 12 patients a second induction course was given with 1/10 BCG plus 100 million units interferon-alpha 2B. There was multifocal disease in 39 patients, previous BCG had failed within 6 months in 34, disease was aggressive (stage T1, grade 3 or carcinoma in situ in 31, there had been 2 or more previous recurrences in 25 and disease history was greater than 4 years in 13.

RESULTS

At a median followup of 30 months 63% and 53% of patients were disease-free at 12 and 24 months, respectively. Patients in whom 2 or more previous BCG courses had failed fared as well as those with 1 failure. Of the 18 failures 14 occurred at the initial cystoscopy evaluation. Of 22 patients initially counseled to undergo cystectomy 12 (55%) are disease-free with a functioning bladder. Combination therapy was well tolerated.

CONCLUSIONS

While longer followup and larger multicenter studies are required to validate these encouraging findings, intravesical low dose BCG plus interferon-alpha 2B appears to be effective in many cases of high risk disease previously deemed BCG refractory. However, early failure while on this regimen should be aggressively pursued with more radical treatment options.

Is low serum free testosterone a marker for high grade prostate cancer?

PURPOSE

The association of free and total testosterone with prostate cancer is incompletely understood. We investigated the relationship of serum free and total testosterone to the clinical and pathological characteristics of prostate cancer.

MATERIALS AND METHODS

We retrospectively reviewed the clinical records of 117 consecutive patients treated by 1 physician and diagnosed with prostate cancer at our medical center between 1994 and 1997. Low free and total testosterone levels were defined as 1.5 or less and 300 ng./dl., respectively.

RESULTS

After evaluating all 117 patients we noted no correlation of free and total testosterone with prostate specific antigen, patient age, prostatic volume, percent of positive biopsies, biopsy Gleason score or clinical stage. However, in patients with low versus normal free testosterone there were an increased mean percent of biopsies that showed cancer (43% versus 22%, p = 0.013) and an increased incidence of a biopsy Gleason score of 8 or greater (7 of 64 versus 0 of 48, p = 0.025). Of the 117 patients 57 underwent radical retropubic prostatectomy. In those with low versus normal free testosterone an increased mean percent of biopsies demonstrated cancer (47% versus 28%, p = 0.018). Pathological evaluation revealed stage pT2ab, pT2c, pT3 and pT4 disease, respectively, in 31%, 64%, 8% and 0% of patients with low and in 40%, 40.6%, 12.5% and 6.2% in those with normal free testosterone (p>0.05).

CONCLUSIONS

In our study patients with prostate cancer and low free testosterone had more extensive disease. In addition, all men with a biopsy Gleason score of 8 or greater had low serum free testosterone. This finding suggests that low serum free testosterone may be a marker for more aggressive disease.