DNA Content of Normal and Neoplastic Urothelial Cells

In search for suitable parameters to detect neoplastic urothelial cells in Acriflavine-Feulgen-SITS stained specimen we compared the cytofluorometric DNA content with the morphology of normal urothelial cells (bladder scrapings) and neoplastic urothelial cells from grade 1, 2, 3 and 4 tumors. An individual normal urothelial cell could not be distinguished from a grade 1 tumor cell, neither morphologically nor fluorometrically. However, the shape of the histograms of DNA measurements of the cell populations of respectively normal bladder scrapings and grade 1 tumors differs. It is postulated that also morphometry of these cell populations may be of some aid to distinguish well-differentiated neoplastic cells from normal urothelial cells. Seventy-one percent of the morphologically malignant cells in the grade 2, 3 and 4 tumor samples could be identified by applying the combined parameters: high DNA content (> 5 C) and nuclear-cytoplasmic ratio (> 0.5) and all grade 2, 3 and 4 tumor samples contained cells which were objectively classified as malignant. Using the same parameters morphologically malignant cells could be distinguished from normal, polyploid umbrella cells, thus these malignant cells are detectable objectively without using chromatin pattern as parameter.

An Adult Atypical Fibromyxoid Tumor of the Urinary Bladder

A case of atypical fibromyxoid tumor of the urinary bladder in a 32-year-old woman is reported. The patient had never complained of urinary symptoms, and bladder tumefaction was revealed fortuitously at pelvic ultrasound. Cystoscopy revealed a peanut-sized mass. Microscopically, the lesion was composed of strap- and tadpole-shaped cells resembling rhabdo-myoblasts. For this reason, the tumor was initially diagnosed as embryonal rhabdomyosarcoma. However, immunohistochemical study was negative for muscle origin, and the tumor has subsequently proved benign. The reported case illustrates the value of immunohistochemical study in the evaluation of the true type of bizarre stroma cells in this pseudo-sarco-matous lesion. Their recognition is important, because the therapeutic consequences of misinterpreting this tumor as a sarcoma are great.

Prognostic Value of Computerized DNA Analysis in Noninvasive Papillary Carcinomas of the Urinary Bladder

DNA parameters and a DNA status index were calculated in cases of noninvasive urothelial papillary carcinomas and apparently normal urothelium. DNA feature analysis included the measurement of basic parameters as well as those related to DNA deviation. Normal urothelium had a diploid content with a few values between 2c and 4c. The papillary lesions in the three grades showed a progressive decrease in diploid nuclei and steadily increasing percentages of tetraploid ones. One case of grade 1 papillary carcinoma and some of grade 2 showed a small proportion of aneuploid cells; the proportion quintupled in grade 3. The values of parameters related to DNA deviation increased progressively in the three grades, numerically expressing the shift from diploidy. The DNA status index is a multiparameter classification in which a single number, ranging from 0.5 to 3.7, expresses the degree of DNA deviation from a non-proliferating diploid population. The cases of normal urothelium and of grade 1 had the lowest values, from 0.5 to 1.9, whereas grade 3 cases had the highest, from 2.2 to 3.7. The index values of grade 2 cases were partly intermediate and partly in the range of the neighboring grades. The DNA status index has a prognostic significance. In fact, associated lesions and recurrences were only observed in cases with index values over 2.0.

Flow cytometric DNA analysis after immunoselection of bladder tumor cells with monoclonal antibody DU83.21

Adequate preservation of neoplastic cells and the elimination of interference by inflammatory cells in measuring tumor cell DNA content represent two important objectives necessary for accurate flow cytometric analysis of bladder carcinomas. An experimental model consisting of a mixture of cultured bladder carcinoma cells (T24) and human buffy-coat (BC) cells was used to evaluate various preservatives and an anti-bladder carcinoma monoclonal antibody (MoAb), DU83.21, for separating inflammatory cells (BC cells) from T24 cells. A final concentration of 25% ethanol was found to be the most effective preservative of several tested. After incubation with the MoAb DU83.21 and propidium iodide (DNA stain), the T24 cells could be separated from the BC cells, permitting accurate DNA analysis of the tumor cells. Application of this system to specimens from bladder cancer patients enhanced the detection and DNA analysis of the tumor cell populations.

Rhodamine 123 phototoxicity in laser-irradiated MGH-U1 human carcinoma cells studied in vitro by electron microscopy and confocal laser scanning microscopy

Rhodamine 123 (R123) is a permeant, cationic, fluorescent dye that localizes preferentially within mitochondria of living carcinoma cells. MGH-U1 human bladder carcinoma cells incubated in vitro with 10 microM R123 for 30 min and then irradiated at 514.5 nm with an argon ion laser underwent selective, phototoxic injury to mitochondria. Ultrastructurally, treatment with R123 plus irradiation with 10 J/cm2 caused selective, progressive mitochondrial alterations consisting of disruption of cristae, vacuolization, swelling, increasing numbers of ring-shaped and angulated mitochondria at 4 to 8 h after irradiation, and obliteration of many mitochondria at 24 to 48 h. Confocal laser scanning microscopy after treatment with R123 plus irradiation with 10 to 30 J/cm2 demonstrated altered uptake and localization of subsequently administered R123, accompanied by striking mitochondrial fragmentation. Irradiation caused a dose-dependent depletion of extractable R123, due to a photosensitized efflux that began immediately and progressed by 4 h after irradiation with 10 to 30 J/cm2; further uptake after reincubation in the presence of R123 was also quantitatively impaired in cells previously irradiated with 30 J/cm2.

Flow cytometric analysis of primary and metastatic bladder cancer

A total of 22 patients with high grade P2-4N+ transitional cell carcinoma of the bladder underwent flow cytometric analysis of nuclei obtained from paraffin embedded specimens from the primary (bladder) and metastatic (lymph node) sites. Tumor heterogeneity was defined as polyclonal aneuploidy of the primary tumor (not identified in the population studied) or as a difference in the deoxyribonucleic acid index of the primary and metastatic sites of 0.20 or more (8 patients). With these criteria 8 patients (36%) had heterogeneous tumors and 14 (64%) had homogeneous tumors. The median survival of 14 patients with aneuploid and 8 with diploid primary tumors was 17.5 and 8.0 months, respectively (p equals 0.08, Lee-Desu test). When patient survival was compared to the ploidy of the metastatic site, or in patients with diploid primary and metastatic lesions versus deoxyribonucleic acid aneuploidy at either the primary and/or metastatic site, the aneuploid tumors had a longer survival but this difference was not significant (p equals 0.13 and 0.23, respectively). Our study demonstrates the value of flow cytometry to identify primary metastatic tumor heterogeneity. It also suggests that the presence of metastasis may be a more important factor to define the biological potential of transitional cell carcinoma than is deoxyribonucleic acid ploidy.

Human chorionic gonadotropin, neuron specific enolase and deoxyribonucleic acid flow cytometry in patients with high grade bladder carcinoma

Biopsies from 64 patients with transitional cell carcinoma of the bladder (World Health Organization grade 3 and undifferentiated) were studied with deoxyribonucleic acid flow cytometry of fresh tissue and immunohistochemical staining on the histopathological slides for the presence of neuron specific enolase and human chorionic gonadotropin. No correlation was found among the presence of neuron specific enolase or human chorionic gonadotropin and T category, deoxyribonucleic acid ploidy, percentage of cells in the S phase, presence of metastatic disease or response to therapy. The prognosis for patients with muscle invasive disease and tumors positive for neuron specific enolase or human chorionic gonadotropin was similar to that for patients with tumors negative for these substances. When a possible new marker or prognostic factor is evaluated, it is important to investigate whether the new marker adds information on prognosis to what already is known by established standard methods. Further studies are needed to evaluate the clinical importance of human chorionic gonadotropin (and neuron specific enolase) as a marker in urothelial cancer with regard to prognosis and response to therapy.

[Blood and urine determinations of tissue polypeptide antigen in patients with bladder carcinoma]

The Tissue Polypeptide Antigen (TPA) is an oncofetal antigen widely used in the diagnosis and follow-up of several urothelial cancers. Its urinary and serum detection is performed by means of RIA technique. We determined urinary and serum TPA in 30 patients with bladder cancer who underwent a transurethral resection. Ten out of 30 patients were correctly diagnosed by serum TPA, 22 by urinary TPA. The ANOVA test showed a statistically significant correlation between grade and urinary TPA between stage and serum TPA. Urinary TPA showed a good sensibility in low grade and moreover in Ta stage carcinoma. Serum TPA increased its performance with higher grade carcinoma and in presence of a muscle infiltration, but it never reached a sufficient sensibility to be considered a bladder cancer marker. In conclusion the simultaneous determination of urinary and serum TPA does not give more information than the urinary determination alone.

Transferrin receptor expression in primary superficial human bladder tumours identifies patients who develop recurrences

A group of 65 patients with superficial bladder carcinoma was followed for 2 years and tumour recurrence rate was correlated both with transferrin receptor status of the initial primary tumour and with the results of voided urine cytology. Nine of 24 patients with transferrin receptor negative tumours had recurrences compared with 30 of 41 patients with transferrin receptor positive tumours. This difference was highly significant. Urine cytology at presentation was also predictive of further tumour formation: of 30 patients who were transferrin receptor positive and had positive urine cytology, 25 developed recurrences.

Computerized morphonuclear cell image analyses of malignant disease in bladder tissues

We analyzed the relationship between several morphonuclear parameters related to nuclear size, densitometry (deoxyribonucleic acid content and ploidy) and the chromatin pattern versus the histopathological grading of 46 bladder cancer samples graded according to the World Health Organization classification. We used a SAMBA 200 cell image processor with software allowing for the discrimination of 15 different parameters on Feulgen-stained imprint smears. In addition, we set up preliminary data banks that enable objective and reproducible grading of unknown cases. This approach must be validated in a large series of cases to create an expert system for bladder malignancy diagnosis.

The epidermal growth factor receptor and the prognosis of bladder cancer

Epidermal growth factor is found in high concentrations in urine, and its receptor (EGFr) has been identified in certain bladder tumors. This study was performed to determine whether receptor positivity in the tumor was associated with a poor clinical outcome. One hundred one patients with newly diagnosed bladder cancer were studied prospectively by immunohistochemical staining for the EGFr. There were 76 men and 25 women, with a mean follow-up of 30 months; 49 had tumors invading muscle: 18 were pTl (tumor invading lamina propia) and 34 were pTa (tumor confined to urothelium). Strong staining for the EGFr was found in 48% of tumors and was associated with high stage (P less than 0.001). Death of bladder cancer (40 of 101) was associated independently with high stage (P less than 0.0001) and EGFr positivity (P less than 0.001). In patients with pTa and pTl tumors, EGFr positivity was associated with multiplicity (P less than 0.01), time to recurrence (P less than 0.03), and recurrence rate (P less than 0.004). Tumor progression was associated with EGFr positivity (P less than 0.0001) and multiplicity (P less than 0.05). EGFr were found on a significant proportion of bladder tumors: such tumors were more likely to result in death, recurrence, and progression.

Clinical cancer progression in urinary bladder tumors evaluated by multiparameter flow cytometry with monoclonal antibodies. Laval University Urology Group

Multiparameter flow cytometry studies were performed on clinical samples of human bladder tumors to simultaneously analyse DNA content and the expression of surface glycoproteins defined by monoclonal antibodies T16, Om5, T43, and T138. The results of tests performed on 80 samples of bladder irrigations and tumors from 68 patients were correlated with clinical findings at the time of sampling and with disease outcome prospectively (mean follow-up 2 years). Measuring the level of the panurothelial antigen T16 provided more precision in DNA analysis and served as an internal standard to measure the relative expression of the other cell surface antigens studied. The panel of monoclonal antibodies improved the analytical capacity to study the heterogeneity of antigenic phenotypes within individual samples. Aneuploidy frequently correlated with high stage cancers and with a high rate of clinical cancer progression defined as metastasis or death by cancer. However ploidy was not an entirely reliable prognostic indicator since a significant proportion of Ta and T1 nonprogressing tumors were aneuploid, while in 6/20 cases of cancer progression, the samples were near diploid. Contrary to Om5, T43 and T138 antigens were expressed significantly more often on aneuploid samples, although they appear to provide additional information. T138 was positive on 17/18 samples from patients with high stage cancers of which five were near diploid. It was also positive on 4/5 samples from patients with Ta and T1 tumors in whom disease progressed to metastasis and death. Overall, the expression of T138 antigen was a better single indicator of clinical cancer progression than was ploidy. Further stratification was obtained with combined results of DNA and T138 antigen studies. Within the near diploid group, the incidence of bladder cancer death was 0/26 for T138 negative and 5/13 (38%) for T138-positive patients (P less than 0.01). In the aneuploid group incidence of bladder cancer death was 2/10 (20%) for T138-negative and 12/19 (63%) for T138-positive patients (P less than 0.05). These results suggest that simultaneous flow cytometry measurements of DNA and surface antigens may better assess the prognostic behavior of human bladder tumors.

Correlation of cytokeratin patterns with histopathology during neoplastic progression in the rat urinary bladder

The discrimination of atypical (premalignant) cells from invasive neoplastic cells in primary bladder lesions is a major diagnostic problem in cytopathology and surgical pathology. We have used an animal model of urinary bladder carcinogenesis to determine the specific changes which occur in the expression of certain cytokeratins (CK) during the progression of lesions from regenerative hyperplasia and carcinoma in situ to transitional cell carcinomas. At sequential time points following exposure of the rat bladder epithelium to N-methyl-N-nitrosourea in vivo, immunohistochemical staining of CKs was evaluated in ethanol-fixed samples from the induced urothelial lesions using commercially available anti-CK mouse monoclonal antibodies. Specific changes were found in the expression of CKs 13, 18, and 19 during the neoplastic progression of induced urothelial lesions in the rat. These changes included the reciprocal loss of expression of CK 19 and the reappearance of CK 18 as malignant tumors developed. Invasive cells also did not express CK 13. Our results, based on the rat model, are similar to those reported by others on CK expression in human bladder tumors. Because these changes in CK expression occurred at specific points in the progression of urothelial lesions, the antibodies utilized in this study may be helpful in predicting the invasive potential of cells present in cytopathological specimens and tissue biopsies from human urothelial lesions.

Carcinoma of the prostate simulating primary bladder cancer

After encountering two patients who were diagnosed as having primary bladder cancer but were ultimately found to have carcinoma of the prostate invading the bladder, a prospective study was undertaken. In five patients with known carcinoma of the prostate invading the bladder, cup biopsies of the bladder lesions were reported as primary bladder cancer in four patients. To prevent this error, immunohistochemical studies are required and discussed in this paper.

Comparative flow cytometric deoxyribonucleic acid studies on exophytic tumor and random mucosal biopsies in untreated carcinoma of the bladder

In 290 patients with untreated carcinoma of the bladder the deoxyribonucleic acid properties, as measured by flow cytometry, of 3 random mucosal biopsies were studied and compared to those of the exophytic tumors. Mucosal aneuploidy was found with few exceptions in aneuploid tumors only, and in a significantly lower frequency in aneuploid tumors of grade 2 than grade 3. The individual specificity of bladder tumors is emphasized by the observation that the level of ploidy was mostly the same in aneuploid mucosal biopsies as in the exophytic tumor. This is underlined further by the occurrence of cell populations of the same ploidy in different parts of the bladder mucosa. However, S-phase values of the concomitant intraurothelial lesions were significantly lower than those of the exophytic tumors. Therefore, we concluded that the process of evolution from malignantly transformed lesions, confined to the urothelium, to an exophytic or invasive tumor is dependent on a further elevated proliferation of the urothelial lesions.

Measurement variability in DNA flow cytometry of replicate samples

A Bladder Cancer Flow Cytometry Network study has been carried out aimed at identification of the sources of inter- and intralaboratory variability. Replicate "cocktail" samples containing a mixture of peripheral blood lymphocytes and an aneuploid cell line and samples of peripheral blood lymphocytes serving as a DNA reference standard were distributed to five network laboratories. The samples were stained for DNA using propidium iodide, with each laboratory using its own staining protocol. Sets of these samples were analyzed by flow cytometry to obtain cellular DNA distributions. DNA index and hyperdiploid fraction were calculated for each histogram using an automated technique. Results were evaluated by analysis of variance to identify sources of variability. Three important sources of variation were found that affect flow cytometry in general and- the transportability of flow cytometry results to routine clinical use in particular. The significant variation among laboratories that is constant across time most probably represents stable differences in instrumentation, instrument set-up, and laboratory techniques. This variation can be compensated for, if it is known and stable, to develop transportable classification criteria. The second type of variation, termed the interaction component, represents differences among laboratories that are not constant across time. Sources of this variation include inconsistency in sample preparation, staining, and analysis. The elimination of this type of variation is required for meaningful comparison of data within and among laboratories and the creation of interlaboratory data-bases. The third type of variation represents pure measurement variability and affects the sensitivity of the technique.

[Human chorionic gonadotropin and carcinoembryonic antigen in small cell carcinoma (oat cell) of the urinary bladder]

Patient suffering from vesical carcinoma, which is identified as small cells (oat cells) carcinoma. We carried out a histochemical study with H.C.G. and C.E.A. and analyse the results obtained.

Characterization and quantitation of the epidermal growth factor receptor in invasive and superficial bladder tumors

Epidermal growth factor receptors (EGFr) have been measured on primary human bladder tumor membranes by 125I-EGF ligand binding. High affinity receptors were detected on both superficial (Kd 0.2-1.45 nM; mean, 0.86 nM; median, 0.88 nM) and invasive tumors (Kd 0.19-2.38 nM; mean, 0.9 nM, median, 0.79 nM). There was one class of binding sites and EGFr concentration was quantified by competitive binding and Scatchard analysis. The EGFr was further characterized and shown to be cleaved at the major autophosphorylation site by a calcium-activated mechanism. Thus the EGFr from primary bladder tumors exhibits similar biochemical characteristics to those in established cell lines. Tumors classified as invasive on the basis of muscle invasion had higher EGFr levels [EGF binding, 99 +/- 252 (SD) fmol/mg protein; median, 21; n = 24] than superficial tumors (12 +/- 12 fmol/mg protein; median, 11; n = 23) or normal bladder mucosa (9 +/- 12 fmol/mg protein; median, 6; n = 6) (P = 0.05). When the two largest subgroups of superficial and invasive tumors were compared (15 pTa, 16 T3), the invasive tumors had significantly higher EGFr levels (P less than 0.05). EGFr may therefore be involved in mechanisms of tumor progression. EGFr may be a target for selective therapy with EGF-linked drugs in a subset of invasive bladder cancers.

Verrucous carcinoma in situ of the bladder, not associated with urinary schistosomiasis

Verrucous carcinoma is a variant of well differentiated squamous cell carcinoma that rarely affects the bladder. The bladder localization of this carcinoma is usually associated with urinary schistosomiasis. In this work we report on a rare case of verrucous carcinoma of the bladder not associated with urinary schistosomiasis. To complete this study, analysis of DNA was carried out on the histologic sections of the tumour.

Deoxyribonucleic acid flow cytometry on primary adenocarcinoma of the bladder: an analysis of 36 cases

Deoxyribonucleic acid flow cytometry was applied retrospectively to 36 primary pure adenocarcinomas of the bladder, stages A through D. Six tumors were enteric, 3 mucinous, 11 signet ring, 3 papillary, 5 unspecified and 8 mixed. Eight tumors were urachal in origin and 28 were nonurachal. The deoxyribonucleic acid pattern was diploid in 12 cases, aneuploid in 19, tetraploid in 3 and uncertain in 2. Nineteen patients died of disease after a mean of 27.4 months, 7 were well at a mean of 73.9 months, 8 had died of an unrelated cause and 1 was alive with metastatic disease. Ploidy pattern did not correlate with tumor stage, histological pattern or type of outcome: 6 of 12 patients with diploid and 12 of 22 with nondiploid tumors died of disease. However, if the tumor was urachal 1 of 4 patients with a diploid pattern died of disease, while 3 of 4 with an aneuploid pattern either died or were alive with disease. Our data suggest that deoxyribonucleic acid ploidy pattern apparently is not a significant predictor of outcome for primary adenocarcinoma of the bladder except possibly when the origin is urachal.

Detection of bladder carcinoma in females by flow cytometry and cytology

The sensitivity of bladder wash flow cytometry (BWFCM), voided urinary cytology (VUC), and cytology of catheterized urine obtained at the time of cystoscopy (CUC) were reviewed on all women evaluated for bladder cancer at Memorial Sloan-Kettering Cancer Center between June 1985 and December 1986. This comprised sixty-four episodes of pathologically proven bladder cancer in 48 women. Considering positive and suspicious results jointly the sensitivities of BWFCM, CUC and 3 VUC were 75%, 64% and 56%, respectively. If only positive results were considered (i.e., suspicious results considered as negative), the sensitivities of BWFCM, CUC and 3 VUC were 64%, 31% and 32%, respectively. The sensitivities of these tests are less than for a predominantly male population, presumably related to the presence of squamous epithelium and greater frequency of pyuria. However, bladder wash flow cytometry and conventional cytology are still a very valuable addition to cystoscopic examination, and the combination of BWFCM with conventional cytology is more sensitive than either procedure alone.

[The DNA content of bladder carcinoma in relation to pathologic grading, staging and prognosis: a flow cytometric study]

DNA ploidy analysis of 90 paraffin embedded specimens in bladder carcinoma were carried out by flow cytometry (FCM). Emphasis was paid on grade II tumors which usually have variable clinical course. DNA ploid level determined by FCM correlates highly with pathologic grade, stage, and prognosis of bladder carcinoma. Among grade II tumors, the patients with diploid and peridiploid carcinoma had a favourable prognosis whereas the patients with aneuploidy of high average DNA index had a bad prognosis, in particular, those with triploid and peritriploid tumors had poorer prognosis. DNA ploid level by which the prognosis of patients with bladder carcinoma is evaluated, appears to be more accurate than pathologic grade and clinical stage, particularly stage T0-T or grade II tumors. It therefore can serve as a tumor marker in bladder carcinomas.

A comparison between stereological estimates of mean nuclear volume and DNA flow cytometry in bladder tumours

The correlation between stereological estimate of mean nuclear volume and DNA-content was studied in 55 human urinary bladder tumours. The DNA-content was determined by flow cytometry on isolated nuclei stained with ethidium bromide. Trout erythrocytes were used as a biological internal standard providing an accurate determination of the DNA-histogram. An unbiased estimate of the mean nuclear volume (vv) was obtained after standard formaline fixation, paraffin-embedding, sectioning and hematoxylin-eosin staining using the equation vv = pi/3.l3(0). Here l0 is the length of an intercept measured in a random direction through a test point, which hit a nucleus. A highly significant correlation was found between vv and mean DNA-content of nuclei (2p = 0.0004). A highly significant correlation was also found between vv and the highest DNA-content present in tumours having cell populations with different DNA content (2p = 0.0016). The mean nuclear volume and the DNA-content also correlated well with the pathologic grade. Although significant the correlations were far from perfect, which indicates that DNA content and mean nuclear volume may provide partly independent biological information. The methods provide objective, unbiased and reproducible data which may improve the possibility of grading and predicting the disease course of human urinary bladder tumours.

Small cell carcinoma of the urinary bladder. A clinicopathologic, morphometric, immunohistochemical, and ultrastructural study of 18 cases

A multiinstitutional review of 3778 patients with a primary malignancy of the urinary bladder revealed 18 cases (0.48%) of small cell carcinoma which were histologically and morphometrically identical to pulmonary small cell undifferentiated carcinoma. Age, sex, and symptoms at first presentation were comparable to that known in transitional cell carcinoma. Sixteen patients (89%) developed metastatic disease, with most frequent involvement of regional lymph nodes, liver, skeleton, and abdominal cavity. The unfavorable clinical outcome was worse as compared with that reported in advanced stage poorly differentiated transitional cell carcinoma, and was similar to the rapidly fatal outcome of pulmonary small cell undifferentiated carcinoma. Fourteen patients (78%) died by tumor at a mean follow-up period of 9.4 months, and only one patient was free of recurrent disease more than 5 years after cystectomy. This apparent aggressive tumor behavior was independent of the presence of neuroendocrine differentiation characteristics at immunohistochemical (13 cases, 72%) or electron microscopic study (eight cases, 44%). The prolonged survival periods (15-38 months) of the five patients who received combination chemotherapy suggested that, just as in small cell lung carcinoma, chemotherapy may be profitable. A unified concept of histogenesis of bladder cancer with a common origin from a multipotent mucosal stem cell is proposed.

[Malignant mesodermal mixed tumor of the bladder: report of a case]

An 81-year-old woman was admitted to our clinic due to gross hematuria. A large bulky pedunculated mass was found in the bladder by cystoscopic examination. Subtotal cystectomy and bilateral cutaneostomy was performed on January 12, 1987. Histologically the tumor was composed of carcinomatous and sarcomatous elements. The carcinomatous element was composed fundamentally of grade 2, transitional cell carcinoma with numerous foci of squamous metaplasia. The sarcomatous element was composed of myxosarcomatous, chondro-sarcomatous pattern and non-differentiated malignant spindle cell component. Immunohistochemical examination demonstrated the presence of cytokeratin and epithelial membrane antigen in the spindle cell and more obvious carcinomatous regions, using the avidin-biotin conjugated immunoperoxidase technique. The patient died 3 months after operation. Autopsy findings showed multiple organ metastasis which were composed of carcinomatous and sarcomatous elements.

Flow cytometric analysis of DNA content of deparaffinized nuclei in urinary bladder carcinomas. Comparison of different isolation methods and relation to histological grade and stage

A consecutive series of 230 patients with transitional cell carcinoma of the urinary bladder was analyzed with respect to the DNA content of the primary tumor, as determined by flow cytometry on material obtained from paraffin blocks. A new method for this analysis was elaborated, based on proteolytic digestion with protease (type VII, Sigma) and density separation of the nuclei by Percoll centrifugation. The method provided DNA flow histograms with less baseline debris and a smaller coefficient of variation in the peaks than published techniques. In eight of 70 cases tested (11%) the method revealed aneuploid peaks that were not distinguished with the original technique and in 197/230 case (86%) interpretable DNA histograms were obtained. The distribution of diploid and aneuploid tumors in different grades and T categories was assessed. None of the grade 1 tumors was aneuploid; 11% of grade 2A, 63% of grade 2B and 83% of grade 3-4, respectively, were aneuploid. The corresponding figures for categories Ta, T1, T2, T3 and T4 were 16, 55, 72, 65 and 100%, respectively.

Small cell carcinoma of the bladder. Report of five cases with immunohistochemistry and review of the literature with evaluation of prognosis according to stage

Five cases of small cell carcinoma (SCC) of the bladder are reported with pathologic and immunohistochemical findings and clinical follow-up. Sixteen additional cases reported in the literature are studied and staged according to depth of tumor infiltration of the bladder wall. In our series of five cases and those reviewed from the literature, survival appeared to be dependent on stage of the tumor, analogous to the more common transitional cell carcinoma (TCC). We report two of five patients with the longest recorded follow-up times in the literature who are alive with no evidence of disease at 4 and 6 years. Contrary to the belief that SCC of the bladder is an aggressive, rapidly disseminating tumor similar to SCC of the lung, our findings support the notion that this is a potentially curable neoplasm with a prognosis that appears to be dependent on stage and surgical resectability.

[Studies on biological characteristics of transitional cell carcinoma of the bladder in patients under 30 years of age]

The incidence of transitional cell carcinoma (TCC) of the bladder has been increasing in men with a peak incidence occurring in the sixth decade. However, development of tumors under the age of 30 is relatively rare. In this regard, it has been reported that vesical tumors in the young group is less malignant and rare to recur when compared with those in the elderly group. Recently, flow cytometric DNA histograms (FCM) provides quantitative and objective informations for detection and evaluation of malignant potential of bladder neoplasms. Here we report patients with tumor of the bladder under 30 years old and assess the clinical properties and biological characteristics of their tumors based on FCM. A total of 11 patients from 1975 through 1988 were reviewed. Their mean age at the diagnosis was 22.6 years old (range from 22 to 29 years old). Male/female ratio was 2.7:1. The mean follow-up period was 4 years and 7 months (range from 8 months to over 13 years). An asymptomatic gross hematuria was found in all of the patients, which is the most common sign. Filling defects of the bladder on excretory urograms were observed in six out of the 11 patients (54.5%). Cystoscopically, the size of tumors was less than 2 cm in diameter. Ten patients had a single tumor and one patient had multiple tumors at the time of the initial diagnosis. Endoscopically tumors were papillary in all but one patient, who had a non-papillary tumor. Their urine cytology showed class I in one, class II in eight, class III in one, class IV in one and class V in none.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of altered H-ras proteins in human tumors using western blot analysis

H-ras p21 protein expression was investigated in bladder and colonic tumor tissues using an H-ras specific antibody in Western blot analysis. The specificity of this antibody to H-ras proteins was established using NIH/3T3 transfectants expressing oncogenic counterparts of the different ras gene family members. Use of this antibody to detect altered H-ras proteins was demonstrated using a panel of transfectants bearing different mutated H-ras genes and established cell lines previously characterized in transfection assays. Extension of this technique to direct analysis of human tumor material confirmed previous observations of H-ras activation within a group of bladder tumors and identified three more urothelial tumors expressing altered H-ras proteins. The altered migrational properties of these three were suggestive of point mutational events in 12 (1 case) and 61 (2 cases) codon hot spots. This study extends previous observations on the preferential activation of H-ras in urinary tract tumors and provides a rapid technique for evaluating the status of H-ras proteins in human tumor tissue.

[Signet-ring cell carcinoma of the urinary bladder: study of 4 cases and review of the literature]

Four cases of primary signet-ring cell adenocarcinoma of the urinary bladder are described. All patients were men, with ages ranging from 46 to 81 years. The number of signet-ring cells varied and showed a direct correlation with poor prognosis. PAP analyses of acid phosphatase and prostate-specific antigen were negative. The results show that signet-ring cell carcinoma has a poor prognosis. This cell type should be sought in all bladder carcinomas since its presence is likely to worsen prognosis.

Placental proteins in high-grade urothelial neoplasms. An immunohistochemical study of human chorionic gonadotropin, human placental lactogen, and pregnancy-specific beta-1-glycoprotein

We examined the presence of human chorionic gonadotropin (HCG) in 16 low-grade and 47 high-grade urothelial neoplasms, including two cases with trophoblastic-like differentiation. In HCG-positive tumors, the presence of human placental lactogen (HPL) and pregnancy-specific beta-1-glycoprotein (SP-1) also was assessed. HCG immunoreactive cells were found in nine of the 47 high-grade tumors (19%), whereas none of the low-grade tumors were positive for HCG. This hormone was predominantly detected in the most undifferentiated and pleomorphic areas; however, HCG-positive cells also were found in areas of carcinoma in situ and well-differentiated transitional cell carcinoma in two cases. The serum HCG level was increased in two of the four cases studied. HPL and SP-1 immunoreactive cells were observed in seven and five cases, respectively, and it was found that tumors positive for SP-1 also were positive for HPL. Five tumors, including the two with trophoblastic differentiation, contained the three placental proteins. The HPL and SP-1 immunostained cells were usually found in the same areas of the tumor that were positive for HCG, but there was always a lower number of HPL and SP-1 immunoreactive cells than HCG immunoreactive cells. In one case, HPL and SP-1 could be found in areas of well-differentiated transitional cell carcinoma. These findings suggest that the morphologic and functional trophoblastic differentiation in urothelial carcinomas is a progressive phenomenon evolving from transitional cell carcinomas.

[Primary choriocarcinoma of the bladder: a case report of autopsy]

The patient was a 70-year-old male with complaint of macrohematuria at the first visit to our clinic on June 10, 1986. At that time, cystoscopy revealed a thumb sized papillary tumor and a rice sized non papillary tumor, and the biopsy specimen was pathologically diagnosed as undifferentiated carcinoma. But, he refused admission. On January 30, 1987, he came back to our clinic with complaints of dyspnea, general fatigue and weight loss. Moderate lt. gynecomastia was found and the level of serum hCG-beta was detected as high as 101 ng/ml. Excretory urogram and enhanced CT revealed a large mass in the bladder. In the seventeenth day after admission, he died of lung edema and heart failure. The findings of autopsy showed a large light greenish to light brownish tumor of 10 X 10 X 3 cm in the bladder. Distant metastases were observed in internal, common iliac and paraaortic lymph nodes, but without other distant metastasis. In histological and immunohistochemical studies, the final diagnosis is choriocarcinoma of the bladder, containing syncytiotrophoblastic giant cells with hCG-beta granules as an undifferentiated carcinoma. To our knowledge this case is the eighth described in Japan. Herein we report a new case of primary choriocarcinoma of the bladder and make a brief review of the literatures.

Initial evaluation of a new epithelial antigen (T16) for bivariate flow cytometry of bladder irrigation specimens

Bivariate flow cytometry (FCM) was used to study immunofluorescent T16 mouse monoclonal antibody (Mab) binding simultaneously with propidium iodide DNA measurements in bladder irrigation specimens from 30 patients with a history of bladder cancer. Aliquots of the same samples were stained with acridine orange (AO) and examined by conventional FCM. T16 Mab is believed to be specific for epithelial cells in this type of specimen and stained from 13% of the cells in a patient with cystitis to 95% of the cells in a patient with an atypical papilloma. In combination with DNA measurements, this antibody increased the sensitivity of FCM in patients with severe cystitis and relatively small numbers of tumor cells, but the diagnostic specificity may be decreased and the criteria established for interpreting univariate flow cytometry may have to be re-evaluated and modified.

Phenotyping of 76 human bladder tumors with a panel of monoclonal antibodies: correlation between pathology, surface immunofluorescence and DNA content

Phenotyping of 76 bladder tumors (11 grade I, 33 grade II and 32 grade III) has been carried out by flow cytometry on cell suspensions with simultaneous determination of DNA content and surface immunofluorescence using G4 and 5 new monoclonal antibodies (10D1, 7C12, 6D1, 3C6 and 12F6) directed against bladder tumor cells. Ten normal bladder samples were used as control. Antibodies 6D1 and 12F6 were specific for tumor cells whereas the others also labelled umbrella cells. Cells from grade I tumors were labelled with 10D1, 6D1, 7C12 and 12F6 antibodies, and cells of grade II tumors with 7C12 and to a lesser degree with 12F6 but not with 10D1 and 6D1. Grade III tumor cells were specifically labelled with antibodies 3C6 and G4. Reactivity of antibodies with tissue sections was well correlated with cytometry results, except for the antibody 3C6. Finally, most of the cells stained by 3C6 and G4 were shown to have a DNA index greater than 1.0. In conclusion cells of low grade tumors can be identified with 10D1 and 6D1 antibodies, and antigens recognized by 3C6 and G4 antibodies are mostly expressed by aneuploid cells.

[Study of flow cytometric bromodeoxyuridine (BrdU)/DNA analysis using human solid tumors]

In spite of the development of a staining principle and the method for simultaneous flow cytometric bromodeoxyuridine (BrdU)/DNA analysis, this technic was seldom used clinically, because, it can not be applied for the study of solid tumors. In this paper, we described a new method to overcome this problem by combining proteolytic enzyme digestion with previously reported immunofluorescent procedure. The difficulty of two-color analysis in solid tumors using previously reported method came from the non-specific staining of resulted cells which have Fc receptors on each cell surface and hence the gaps between S- and G1- or G2M-phase were unclear. By combining proteolytic enzyme digestion, the normal cell population can be excluded easily and the gaps between these phases be clearly distinguished, therefore the results obtained by this new method seemed to be more precise. This new method can be applied for solid tumor studies and the development for clinical application is expected.

Flow cytometry study of cytokeratin 18 expression according to tumor grade and deoxyribonucleic acid content in human bladder tumors

Cytokeratin 18 expression in transitional cells of 76 bladder tumors (11 grade 1, 33 grade 2 and 32 grade 3) and 10 normal biopsies was quantified by flow cytometry after immunolabeling with the anti-cytokeratin 18 monoclonal antibody RGE 53. Combined cytometric analysis of deoxyribonucleic acid content and cytokeratin 18 expression was conducted. Of 76 tumor biopsies 38 had a unimodal deoxyribonucleic acid profile with a deoxyribonucleic acid index close to 1.0, while the other 38 showed a bimodal profile: 1 peak with an index of 1.0 and a second peak with an index of greater than 1.0. The 11 grade 1 tumors belonged to the first group, whereas 10 of the 33 grade 2 and 28 of the 32 grade 3 tumors belonged to the second group. Antibody RGE 53 reacted with 4 per cent of the normal bladder cells (umbrella cells), 14 +/- 3 per cent of the cells from grade 1, 33 +/- 8 per cent from grade 2 and 56 +/- 10 per cent from grade 3 tumors. Analysis of cytokeratin 18 expression according to deoxyribonucleic acid content at the single cell level in tumors with a bimodal deoxyribonucleic acid profile showed that cytokeratin 18 was detected frequently in cells with a high deoxyribonucleic acid index but much less so in cells with an index of 1.0. Therefore, expression of cytokeratin 18 can be recognized as a marker of aggressiveness in bladder tumors, since it increases in parallel with tumor grade and cell deoxyribonucleic acid content.

Quantitative determination of chromium and nickel in tumour and tumour-free human tissue

Environmental pollution with carcinogenic substances, in addition to individual abuse, are discussed as important factors causing development of cancer. We must assume that certain nickel and chromium compounds, which are ubiquitous in our ecosystem, must have carcinogenic effects on humans too. The aim of this study is therefore to examine the extent to which the accumulation of the potentially carcinogenic metal ions nickel and chromium could be measured in tissue from tumour patients. We examined tumour and tumour-free tissue obtained from a total of 48 patients who had carcinomas of the stomach, bowel, or kidney. We also analyzed nickel and chromium content in whole blood and urine samples from these persons. The quantitative metal estimations were done using atomic absorption spectrophotometry. Differences between chromium and/or nickel content in tumour or tumour-free tissue were not observed. An accumulation of these metal ions in tumour tissue is therefore improbable. We were also unable to find differences in metal content with regard to chromium and nickel as related to the appearance of tumour in the organ. In contrast, tumour patients had a 5- to 7-fold increase over normal values for chromium and nickel in blood and urine. This was attributable to unavoidable contamination of tissue and body fluids with chromium- and nickel-containing instruments during major surgical procedures.

[A case of small cell carcinoma of the urinary bladder]

A case of small cell carcinoma with a high serum alpha-fetoprotein level of the urinary bladder is reported. Histologically, in addition to the small cell carcinoma, there were small areas of atypical carcinoids and larger epithelial cells. Immunohistochemically, the small cell carcinoma and the atypical carcinoids showed positivity for neuron-specific enolase, chromogranin, and vimentin. On the other hand, the larger epithelial cells showed positivity for alpha-fetoprotein, keratin, and carcinoembryonic antigen. Electron microscopically, a few neurosecretory granules were noted in the cytoplasm of the small cell carcinoma. After a total cystectomy, the serum alpha-fetoprotein level decreased to within a normal range. Postmortem examination of recurrent tumorous masses revealed only features of the small cell carcinoma. This case supports a theory that a small cell carcinoma of the urinary bladder develops from multipotential epithelial cells.

The value of morphometry and DNA flow cytometry in addition to classic prognosticators in superficial urinary bladder carcinoma

In 80 patients with primary superficial bladder carcinoma Tumor Nodes Metastasis (TNM classification: stages Ta and T1) with adequate follow-up of at least four years, the value of selective nuclear morphometry and DNA flow cytometry on paraffin-embedded material in addition to classic prognosticators was assessed. Only the quantitative techniques appeared to be valuable predictors of new tumor occurrence. The recurrence rate in patients with large nuclei (mean nuclear area greater than 95 micron 2; n = 29) and in aneuploid cases (n = 30) was significantly higher (Wilcoxon: P = 0.05 and P = 0.0001) than in those with small nuclei (mean nuclear area less than = 95 micron 2; n = 51) and diploid cases (n = 50). The prevalence of large nuclei and aneuploidy also appeared useful to predict progressive recurrence, i.e., grade 3 or/and muscle invasive carcinoma (TNM classification: stages T2-T4) (chi-square: P less than 0.0001). Clinical follow-up showed that only 62.1% of the cases with large nuclei remained free of progressive recurrence, compared with 92.2% of those with small nuclei (Mantel-Cox: P less than 0.0001). For the aneuploid and diploid cases, these figures came to 53.3% and 98% (Mantel-Cox: P less than 0.0001). By multivariate analysis DNA ploidy was selected as the best discriminator. None of the classic prognosticators, including histologic grade, had additional prognostic value. Also, morphometry did not add to the prognosis prediction, which can be explained by the considerable overlapping between the prevalence of large nuclei and aneuploidy (24 of 29 and 30 cases, respectively). These findings practically suggest that patients presenting with superficial carcinoma with large nuclei (mean nuclear area greater than 95 microns 2) or aneuploid DNA values should be treated more aggressively.

Malignant rhabdoid tumour of the bladder with immunohistochemical and ultrastructural evidence suggesting histiocytic origin

A malignant rhabdoid tumour of the bladder is reported from a girl aged 6. Detailed immunohistochemical and ultrastructural investigations provide evidence which suggests a histiocytic origin for this controversial neoplasm.

Biochemical characteristics and partial amino acid sequence of the receptor-like human B cell and carcinoma antigen CDw40

The Ag CDw40 (p50, Bp50) is a phosphoprotein expressed on the surface of both B lymphocytes and on certain malignant cell types of nonhemopoietic origin. Antibodies to this Ag have been shown to act as a potent co-mitogen for B cells. In order to elucidate the function of this Ag, we have now investigated some of its biochemical characteristics as well as the relationship of B cell derived CDw40 to that derived from urinary bladder carcinoma (transitional cell carcinoma, TCC) cells. CDw40 from normal B cells or from the Burkitt lymphoma line Raji showed a characteristic pattern of three bands when analyzed by SDS-PAGE and Western blotting: a main band of 47 kDa, a degradation product of 43 kDa, and a dimer of 85 kDa. The dimer was disrupted by reduction with 2-ME but was reformed spontaneously from the purified monomers under nonreducing conditions. CDw40 from two bladder cancer cell lines gave a similar pattern but formed little or no dimer. Thirty amino acids of the amino terminal end of CDw40 from Raji and 22 amino acids of that from TCC cells (HU549) were sequenced. The sequences were unusually rich in cysteines and differed only in that the cysteine in position 6 in Raji CDw40 had been replaced by glutamine in HU549. In addition there were two conservative changes in positions 15 and 19. Taken together these results show that CDw40 derived from B cells or from TCC cells are the same or closely related molecules. Comparisons of the amino acid sequence and biochemical characteristics of CDw40 with proteins having receptor functions indicated a close structural resemblance of CDw40 to the nerve growth factor-receptor.

Argyrophilic proteins of the nucleolar organizer region in bladder-tumours

The introduction of a simple one-stage silver nitrate stain as a method of displaying nucleolar organizer regions (NOR's) in formalin-fixed tissue has made it possible to examine the significance of these structures in tumour pathology. In the current study argyrophilic proteins of the NOR's were studied in 39 consecutive patients with bladder tumours. The results indicate that the counting of silver staining particles is only of limited value in grading bladder tumours and that this method is not superior to other additional grading techniques such as histo-morphometry and flow cytometry.

Human chorionic gonadotrophin expression and histological findings as predictors of response to radiotherapy in carcinoma of the bladder

A retrospective analysis of the prognostic value of pretreatment histology and expression of human chorionic gonadotrophin (B-hCG) was carried out in 100 invasive (T2/T3) transitional cell carcinomas of the bladder treated in a uniform manner. After transurethral resection of the tumour, all patients received a course of radical radiotherapy, with salvage cystectomy for those who failed to respond. Forty-nine of 100 patients responded to radiation; thus 51 did not. Forty-seven of 60 (78%) patients whose tumours contained areas of squamous differentiation and 22 of 29 (76%) of tumours staining positively for HCG failed to respond to radiotherapy. Twenty-two of 23 (96%) patients with tumours that had both these features did not respond to radiotherapy. The other histological features studied (grade of tumour, necrosis, inflammation, vascular invasion, and growth pattern) appeared unrelated to each other or to clinical outcome.

The immunocytochemical demonstration of basement membrane deposition in transitional cell carcinoma of bladder

We assessed the staining characteristics of the basement membrane of transitional cell carcinoma of bladder using a monoclonal antibody to type IV collagen. Basement membranes were clearly stained at the stromal/carcinoma interface. As transitional cell carcinoma became less well differentiated and the depth of invasion increased interruptions to basement membrane staining became more extensive and these findings are comparable to those described in similar series of transitional cell carcinoma using polyclonal antibodies to type IV collagen. The defects in basement membrane staining may be related to the degree and direction of tumour cell differentiation or may be explained by increased degradation compared to synthesis of basement membrane components. Demonstration of the basement membrane may be of value in diagnostic histopathology as a marker of the biological behaviour of transitional cell carcinoma of bladder.

Immunohistochemistry of cytokeratin proteins in squamous and transitional cell lesions of the urinary tract

Expression of low and high molecular weight cytokeratin proteins was investigated immunohistochemically in a variety of transitional and squamous epithelial lesions of the urinary tract with and without schistosomiasis. The monoclonal antibodies used were CAM 5.2 and NCL5D3 for low, PK 63 and 121 for high, and MAK 6 for a broad range of intermediate molecular weight cytokeratins. On staining with CAM 5.2 and NCL5D3, urothelial hyperplasias (n = 12) and grades 1 (n = 5) and 2 (n = 10) papillary transitional cell carcinomas showed labelling patterns quite distinct from carcinoma in situ (n = 4) and non-papillary grades 2 (n = 6) and 3 tumours (n = 3). Among squamous lesions only focal positivity was obtained in 14 of 22 moderate to poorly differentiated squamous cell carcinomas. By contrast, PK 63 and 121 stained squamous lesions exclusively. MAK 6 stained the whole range of urothelial and squamous lesions with the exception of squamous metaplasias. Polyclonal antikeratin adequately labelled spindle cell areas of high grade tumours. The distinctive staining patterns given by these or similar antibodies may help in the identification of squamous metaplasia and in diagnosing tumours of the urothelium.

Immature neural elements in immature teratomas. An immunohistochemical and ultrastructural study

Immature neural tissue pathobiology in teratomas may have important implications for clinical prognosis, nervous system embryology, and neurological oncology. However, immunohistochemical and ultrastructural examinations of these neoplasms have been scarce. The authors examined immunohistochemically the immature neural elements in nine immature teratomas. Using modified peroxidase-antiperoxidase (PAP) immunoperoxidase (IP) techniques, they evaluated the immunoreactivity to glial fibrillary acidic protein (GFAP), neuron-specific enolase (NSE), neurofilament (NF), chromogranin (CG), and vimentin (VM). All nine teratomas were immunoreactive for both GFAP and NSE, one was reactive for NF, and five (56%) were immunoreactive for vimentin. All cases were nonreactive for chromogranin. In addition, ultrastructural examination (electron microscopic [EM]) was performed on eight of these tumors. By EM examination, both astrocytes and oligodendroglia were identified in varying stages of development. Astrocytes often displayed abundant intermediate filaments. However, primitive undifferentiated cells were also found. Neuronal differentiation included long cell processes with tubules and filaments, vesicles, rare dense-core granules, and synapses. Ependymal differentiation (cilia, microvilli, prominent junctions) was observed in two cases. Pigmented retinal epithelium was seen in one tumor. No ambiguous (hybrid) cells were identified. Cellular interactions usually resembled the relationships found in normal adult brain tissue.

Immunocytochemical demonstration of p21ras in normal and transitional cell carcinoma urothelium

Activation and/or overexpression of the protein product of the ras gene family (p21ras) has been implicated in the development of various cancers, including bladder carcinoma. We have used the anti-p21ras monoclonal antibody, RAP-5, to assess the level and pattern of expression in formalin-fixed, paraffin-embedded tissue sections of both normal and malignant urothelium. All 14 random normal bladder biopsies and 67 of 68 transitional cell carcinomas of the urinary bladder were positively stained with the RAP-5 antibody. In normal urothelium, p21ras staining tended to be localized to the superficial cell layer. With increasing histological grade and/or depth of invasion of the tumour, a greater proportion of tissue sections demonstrated a staining pattern which was more uniform with respect to the different epithelial cell types. Serially diluting the primary antibody did not reveal any significant differences in the staining patterns observed. Despite the change in staining pattern with increasing grade, these results suggest that p21ras expression by itself is not a useful indicator of the malignant phenotype.