Serum Prostate-Specific Antigen Determination in Prostatic Carcinoma

Prostate-specific antigen (PSA) is a tissue-specific glycoprotein identified by Wang in 1979. It is synthesized in the prostate independently of prostatic acid phosphatase (PAP). A total of 199 subjects were divided into four groups: controls aged less than 50 years, controls aged more than 50 years, patients with benign prostatic hyperplasia (BPH) and patients with prostatic carcinoma.

PSA cut-off value was set at 10 ng/ml (mean for the BPH group plus 2 SD). With this cut-off value PSA could not be used as an early predictor of prostatic carcinoma. The association of PSA and PAP in prostatic cancer increases the number of patients with positive biological markers.

Prostatic Duct Carcinoma with Combined Prostatic Duct Adenocarcinoma and Urothelial Carcinoma Features

We report a unique case of prostatic duct carcinoma (PDC) featuring both prostatic duct adenocarcinoma (PDA) and high-grade urothelial carcinoma (HG-UC). An 84-year-old man presenting with hematuria showed at ultrasonography and cystoscopy a papillary neoplasia located near to the verumontanum. Histopathologic examination of specimens from transurethral resection revealed a tumor originating from large prostatic ducts showing 2 different components: PDA with endometrioid features (main pattern) and HG-UC (minor part). Immunohistochemically, the areas of PDA were positive for prostatic acid phosphatase (PAP), prostatic specific antigen (PSA), and androgen receptors (AR), while negative for estrogen (ER) and progesterone receptors (PGR). Prognostic factors evaluation pointed out a low proliferation index (10%) and focal expression of p53 (6%); c-erb-B2 was not overexpressed. The HG-UC areas were negative for all previous markers, while positive for thromobomodulin. The proliferation index was high (60%), and p53 was diffusely expressed (55%). The incidence and significance of PDC with combined features is discussed with reference to literature data.

The clinical use of statistical permutation test methodology: a tool for identifying predictive variables of outcome

OBJECTIVES

To identify the predictive variables affecting the outcome after radical surgery for bladder cancer by a newer statistical methodology, i.e. nonparametric combination (NPC).

METHODS

A multicenter study enrolled 1,312 patients who had undergone radical cystectomy for bladder cancer in 11 Italian oncological centers from January 1982 to December 2002. A statistical analysis of their medical history and diagnostic, pathological and postoperative variables was performed using a NPC test. The patients were included in a comprehensive database with medical history and clinical and pathological data. Five-year survival was used as the dependent variable, and p values were corrected for multiplicity using a closed testing procedure. The newer nonparametric approach was used to evaluate the prognostic importance of the variables. All of the analyses were performed using routines developed in MATLAB© and the significance level was set at α = 0.05.

RESULTS

A significant prognostic predictive value (p < 0.01) for tumor clinical staging, hydronephrosis, tumor pathological staging, grading, presence of concomitant carcinoma in situ, regional lymph node involvement, corpora cavernosa invasion, microvascular invasion, lymphatic invasion and prostatic stroma involvement was found.

CONCLUSIONS

The NPC test could handle any type of variable (categorical and quantitative) and take into account the multivariate relation among variables. This newer methodology offers a significant contribution in biomedical studies with several endpoints and is recommended in presence of non-normal data and missing values, as well as solving high-dimensional data and problems relating to small sample sizes.

Randomized Phase II trial assessing estramustine and vinblastine combination chemotherapy vs estramustine alone in patients with progressive hormone-escaped metastatic prostate cancer

Based on the results of combined data from three North American Phase II studies, a randomised Phase II study in the same patient population was performed, using combination chemotherapy with estramustine phosphate (EMP) and vinblastine (VBL) in hormone refractory prostate cancer patients. In all, 92 patients were randomised into a Phase II study of oral EMP (10 mg kg day continuously) or oral EMP in combination with intravenous VBL (4 mg m² week for 6 weeks, followed by 2 weeks rest). The end points were toxicity and PSA response in both groups, with the option to continue the trial as a Phase III study with time to progression and survival as end points, if sufficient responses were observed. Toxicity was unexpectedly high in both treatment arms and led to treatment withdrawal or refusal in 49% of all patients, predominantly already during the first treatment cycle. The mean treatment duration was 10 and 14 weeks, median time to PSA progression was 27.2 and 30.8 weeks, median survival time was 44 and 50.9 weeks, and PSA response rate was only 24.6 and 28.9% in the EMP/VBL and EMP arms, respectively. There was no correlation between PSA response and survival. While the PSA response in the patients tested was less than half that recorded in the North American studies, the toxicity of EMP monotherapy or in combination with VBL was much higher than expected. Further research on more effective and less toxic treatment strategies for hormone refractory prostate cancer is mandatory.

Insuline-Like Growth-Factors (IGFs) as Marker of Risk and Progression of Prostate Cancer

The growing incidence of prostate cancer is stimulating investigations on cancer differentiation and proliferation. Studies on guinea-pigs showed IGF can cause and stimulate cancer as hepatocarcinoma, breast cancer, pancreas cancer and prostate cancer. Between April 2001 and February 2002 we investigated 17 patients (50–75 years old) with prostate cancer. IGF1 serum concentration before surgery was higher than physiological level, at 2 months and, above all, at 6 months after radical prostatectomy this level decreased significantly. Furthermore IGF growing was related with protein and hormone variations (protein and hormone levels were measured before surgery, at 2 and 6 months after surgery; BMI was measured in the same periods). IGF1R concentration on the prostate glande was low expressed as we showed with immunohistochemistry: this could mean a low sensibility to apoptosis. IGF1/PSA was significantly low in patients with prostate cancer. These results suggest the possible role of IGF1 in differentiation-progression of prostate cancer and in metabolic alterations. Other studies about IGF might investigate its diagnostic and therapeutic role.

Permanent Interstitial Brachytherapy in the Treatment of Localized Prostatic Carcinoma: The Piedmont Experience

The modern interstitial brachytherapy plays a first-rate role in the treatment of the organ-confined prostatic carcinoma as a substantial alternative to radical prostatectomy and external beam radiotherapy in selected patients.

Materials and Methods

In our Centre 50 patients with a localized prostatic carcinoma were treated with transperineal and transrectal ultrasound-guided permanent implantation of I-125 radioactive seeds. 35 patients also underwent a neoadjuvant hormonal-therapy. Main end points were the biochemical control of the neoplasia and the treatment complications during a 24 months follow-up.

Results

We had two biochemical neoplasia recurrences, both in the neoadjuvant group. The most frequently observed complications were: slight irritative symptoms (12%), severe irritative symptoms (30%), urinary retention (10%), hematuria (8%), loss of seeds (6%), erectile dysfunction (46%). Urinary incontinence, urethral stricture and proctitis were not observed.

Conclusions

So far no large clinical trial compared the clinical efficacy of interstitial brachytherapy versus the other “conventional” treatments options (radical prostatectomy, external beam radiotherapy). The results of our study and the actual evidences, based on cohort observation studies and case-control ones comparing brachytherapy versus surgery or external irradiation, support the therapeutical value of permanent interstitial implant with regard to oncological results and complications.

Clear cell sarcoma of the kidney with invasion of the inferior vena cava

OBJECTIVE

We present a case of clear cell sarcoma of the kidney (CCSK) in 53-year-old white man who was treated with surgery. This case represents the oldest patient with CCSK published in the English literature.

METHODS

Right radical nephrectomy with lymphadenectomy and thrombectomy was performed.

RESULTS

Histological findings indicated a CCSK. Tumor cells showed positive vimentin staining.

CONCLUSION

CCSK is considered a rare and highly malignant renal tumor. The malignant nature may relate not only to the biological features of these tumor cells, but also to the high resistance against radiation and chemotherapy. The treatment of CCSK has been a subject of controversy.

[Communication between urologist and pathologist. Proposal for the standardization of histological tests requests for neoplasms]

The aim of this work is to propose a new clinical data system which should accompany the histological sample for the histologic diagnosis made by the pathologist. Six different schedules on the most important urological tumours are presented: prostate (needle biopsies and surgical approach), bladder (endoscopic procedure and open surgery), kidney and ureter, testis. In each schedule the urologist provides, in a scheme, the clinical report needed for the pathologist's final diagnosis. A clear explanation of the clinical data and a faster method of filling in the form are the qualifying elements of these schedules.

Progression from superficial to invasive carcinoma of the bladder: genetic evidence of either clonal heterogeneous events

Until now, no definitive molecular evidence proving or disproving a true progression from superficial to invasive bladder tumors has been reported. A total of 36 lesions from 6 patients affected by invasive bladder cancer after multiple superficial recurrences were analyzed for loss of heterozygosity on 8 loci of chromosome 9 and 2 loci of chromosome 17. In addition, the clonal composition of the tumors from two female patients was examined using the human androgen receptor assay. Our data suggest that papillary bladder lesions can and sometimes do make a true progression into invasive life-threatening tumors; however, this progression is not an invariable sequence because it was definitely proven in 2 but not confirmed in 3 of the cases we examined.

Bladder tumor antigen assay as compared to voided urine cytology in the diagnosis of bladder cancer

BACKGROUND

The study was aimed at comparing the diagnostic accuracy of the quantitative bladder tumor antigen (BTA) TRAK immunoassay with exfoliative urine cytology in the detection of primary and recurrent bladder cancer.

METHODS

The analysis was carried out on 194 high risk patients undergoing a diagnostic cystoscopy, 279 patients with previous history of transitional cell carcinoma awaiting a follow-up cystoscopy, and 45 healthy controls. Urine cytology was performed by a skilled cytopathologist on three consecutive samples.

RESULTS

BTA TRAK values resulted significantly higher in tumor positive cases than in absence of bladder tumor for both groups of patients. Non neoplastic urothelial diseases as well as the absence of mucosal abnormalities were associated with a marked increase in BTA TRAK levels with respect to the control group. Overall sensitivity and specificity was 63 and 63% for BTA TRAK (cut-off 34 U/ml), and 68.3 and 73.4% for urine cytology, respectively. The diagnostic advantage of urine cytology was maintained when patients were stratified by tumor grade.

CONCLUSIONS

The clinical performance of the BTA TRAK in the detection of primary or recurrent bladder cancer is acceptable and reproducible as shown by similar results with previous reports, although urine cytology performed on three samples showed the highest sensitivity and specificity.

Bladder pheochromocytoma: a 3-year follow-up after transurethral resection (TURB)

We report a case of a 75-year-old female with pheochromocytoma of the bladder. Clinical evaluation included ultrasonography, intravenous pyelography, CT scan, I-MIBG scintiscan. A transurethral resection was performed for a exophytic tumor of 2 cm diameter. The histological result indicated the diagnosis of bladder pheochromocytoma. Three years later the patient remains disease free. Preoperative diagnosis is established by determination of blood and urine levels of catecholamines and their metabolites is a nonspecific diagnostic tool. The sensitivity of CT scan is 82%. Iodine-methyliodobenzylguanidine (I-MIBG), used by scintiscanning, specifically accumulates in pheochromocytomas. Life-long follow-up is necessary to diagnose late recurrences.

BTA quantitative assay and NMP22 testing compared with urine cytology in the detection of transitional cell carcinoma of the bladder

PURPOSE

Both BTA TRAK and NMP22 urine concentrations have shown a sensitivity superior to urine cytology in the detection of bladder cancer. We compared these tumor markers with urine cytology performed on 3 consecutive samples and evaluated by an expert cytopathologist.

PATIENTS AND METHODS

The investigations were conducted on 94 patients undergoing a diagnostic cystoscopy for a high suspicion of bladder cancer (group 1) and on 102 patients with previous history of transitional cell carcinoma awaiting a follow-up cystoscopy (group 2). Biopsy specimens were obtained also from tumor negative patients. Immunoassays for BTA TRAK and NMP22 were carried out according to standard methods. The choice of the cut-off was based on the ground of sensitivity and specificity curves intersection. Urine cytology results were expressed as positive, negative and 'dubious'.

RESULTS

Overall sensitivity was 56% for NMP22 (cut-off 11 U/ml) and 57% for BTA TRAK (cut-off 60 U/ml). When dubious results were considered as positive cases, urine cytology achieved a sensitivity of 73.3%. Assuming dubious cases as negative results, urine cytology sensitivity resulted 59.3%. When the 2 groups of patients were evaluated separately with different cut-off, there was no significant gain in sensitivity for BTA TRAK and NMP22 over urine cytology.

CONCLUSIONS

Urine cytology performed on 3 samples showed the highest sensitivity and specificity. The diagnostic advantage of urine cytology over BTA TRAK and NMP22 was maintained when patients were stratified by tumor grade.

Evaluation of P53 protein overexpression, Ki67 proliferative activity and mitotic index as markers of tumour recurrence in superficial transitional cell carcinoma of the bladder

OBJECTIVES

To confirm the interrelationship between p53, ki67, mitotic index with others known prognostic factors such us stage, grade, multifocality, tumour size, history of recurrence in transitional cell carcinoma (TCC) of the bladder and to determine the prognostic impact of p53, Ki67 and mitotic index in predicting recurrence in superficial bladder cancer.

METHODS

Two hundred and fourteen patients with apparently superficial TCC of the bladder underwent TURBT and the 192 histologically Ta-T1 were divided into 104 primary lesions (group 1, mean follow-up 26 months) and 88 recurrent tumours (group 2, mean follow-up 28 months). Data concerning focality, tumour size, number of recurrences and recurrence-free survival were considered in each patients. All samples were immunohistochemically stained with p53 and Ki67 monoclonal antibodies. Mitotic index (MI) was calculated on haematoxylin and eosin stained sections.

RESULTS

Recurrence-free survival was significantly lower in superficial recurrent tumours (group 2) compared with primary tumours (group 1). P53 staining was correlated with grade and stage for both 5 and 20% positivity thresholds. Ki67 and MI were significantly different over strata defined by stage, grade and focality in both patients groups but only Ki67 showed a correlation with p53 status. Recurrence-free survival could not be predicted either by p53 status or MI. A 20% cut-off level of Ki67 staining resulted a good predictor of recurrence in group 1 Ta-T1/G1-G2 tumours (p = 0.03). Only Ki67 and multifocality were found to be independent prognostic factors of recurrence in multivariate analysis. Stratifying Ta-T1/G1-G2 patients according to these variables, Ki67 provided a useful tool to predict early recurrence in monofocal lesions from both groups.

CONCLUSIONS

P53 and MI despite a fairly good correlation with traditional prognostic factors in bladder TCC seem to play no role in the prediction of tumoural recurrence. A Ki67 index over 20% predicts those single well-differentiated (Ta-T1/G1-G2) tumours which are likely to recur within one year of treatment.

Enhanced urinary gelatinase activities (matrix metalloproteinases 2 and 9) are associated with early-stage bladder carcinoma: a comparison with clinically used tumor markers

Matrix metalloproteinases (MMPs) are involved in tumor growth and metastasis, promoting the migration and invasion of cells. In this study, the amount of MMP-2 and MMP-9 activity was measured in urine from superficial bladder carcinoma patients (pTa, pT1) to evaluate their possible diagnostic value. The active and total amount of MMP-2 and MMP-9, respectively, in urine from tumor patients were compared with the levels in urine from age- and gender-matched healthy volunteers. Both MMP-2 and MMP-9 activity levels were significantly enhanced in urine from patients with high invasive cancers (pT2, PT3), whereas in urine from healthy controls no or very low MMP activities were found. More importantly, a substantial number of urine samples from patients with superficial tumors contained elevated MMP-2 and MMP-9 activities, suggesting that enhanced urinary MMP activity levels, indeed, might be indicative for early-stage bladder cancer. Overall, urinary MMP-2 and MMP-9 activity levels were significantly correlated to each other, with some individual exceptions. A comparison between urinary MMP-9 activity and a recently proposed urinary marker for bladder cancer, NMP-22, showed slightly lower numbers of patients with elevated levels for MMP-9. But because MMP-9 and NMP-22 levels were not correlated, enhanced urinary MMP activity might be useful as a marker for superficial bladder carcinoma like, or especially in combination with, other markers.

[Rare renal tumors (neoplasms other than conventional renal cell carcinoma). Clinico-pathologic aspects and review of the literature]

The clinical and pathological findings in 94 patients with surgically confirmed renal neoplasm from 1990 to 1998 have been retrospectively reviewed and a literature review is made. The heterogeneous group of rare renal tumours has been particularly considered: renal oncocytoma and oncocytomatosis, renal angiomyolipoma and renal medullary fibroma; chromophobe renal cell carcinoma (RCC), papillary RCC, multiple primary malignant RCC, hereditary RCC, renal sarcoma and sarcomatoid RCC, renal malignant fibrous histiocytoma, renal hemangiopericytoma and renal lymphoma.

Presence of urokinase-type plasminogen activator receptor in urine of cancer patients and its possible clinical relevance

High levels of urokinase-type plasminogen activator receptor (uPAR) are expressed in various types of cancer. Recent studies showed that cancer patients may have increased levels of soluble (s)uPAR in their serum. In the present study, we show that urine samples from healthy volunteers contain measurable amounts of suPAR. suPAR/creatinine levels from healthy controls showed only little variation over the day and were even stable during a month of continued monitoring. Importantly, urinary suPAR/creatinine levels were highly correlated with serum suPAR concentrations. Urinary suPAR levels were elevated in patients with different types of cancer. Interestingly, part of the urinary suPAR seemed to be present in a cleaved form, as has been found in tumor tissue extracts. Together with the recently established, cell migration-promoting effect of certain cleaved fragments of suPAR, the present data suggest that the measurement of urinary suPAR and/or its cleaved forms might have clinical implications.

Immunohistochemical evaluation of the safety of transurethral electrovaporization of the prostate and its clinical results

Short term follow up studies on transurethral electrovaporization (TUEVP) have shown a relative low morbidity over TURP. The use of high power current has been claimed as a source of possible damage on the neuronal structures surrounding the prostate. The aims of our study were to assess longer follow up results as well as the safety of this technique. Over an 18 month mean follow up period symptom relief remained relatively stable. Postoperative dysuria was detected in a higher percentage of patients and was seen for a longer period in comparison with previous reports. Immunohistochemical staining performed using S-100 and NF monoclonal antibodies showed anatomical integrity of the prostatic neuronal fibres surrounding the vaporization edge. In conclusion, although the effectiveness and safety of TUEVP are confirmed by the present study, the occurrence of a significant rate of long-lasting postoperative irritative symptoms must be taken into account.

Circadian antidiuretic hormone variation in elderly men complaining of persistent nocturia after urinary flow obstruction removal

Persistence of nocturia after prostatic resection in healthy patients without symptoms referred to residual bladder instability and to pathological polyuria seems to be caused by an increased urine production at night. The more accreditate mechanism involved is the relevant decreased ADH secretion pattern which occurs at night. In our study, patients with nocturnal poliuria showed significantly low plasmatic vasopressin levels compared with a control group. The aim of this study was to evaluate whether the persistence of nocturia after prostatic resection in healthy patients, without symptoms referred due to residual bladder instability and important polyuria, could be due to a decrease or a lack of increase in antidiuretic hormone (ADH) nocturnal levels following increased urine production at night. Serum ADH, atrial natriuretic peptide (ANP) and osmolality were assessed at 4-h intervals in 12 patients complaining of residual nocturia (group A) and in a control group of 13 patients who had undergone a complete resolution of nocturia after prostate ablation (group B). In the 25 patients involved in the study (mean age 65.8 years), no significant differences were observed in the two groups concerning mean age (67.5 years for group A, 64 years for group B). Mean nocturnal urine volume (1080 +/- 490 ml) in group A patients was significantly higher than in group B (500 +/- 100 ml) (p < 0.001), while no significant differences were found in diurnal diuresis. Mean plasma vasopressin levels of the 12 patients showing an increased nocturnal micturition were found to be significantly lower at all 4-h intervals when compared with the control group (p < 0.05). Individual fluctuations in serum osmolality were slight and insignificant within the normal range in all patients. The diurnal variation of plasma atrial natriuretic peptide was within the reference limits for all subjects during the 24-h period. Our results lead us to believe that residual nocturia after prostatic resection seems to be caused by an increased urine production at night due to a decreased ADH secretion pattern.

White blood cell DNA adducts, smoking, and NAT2 and GSTM1 genotypes in bladder cancer: a case-control study

We conducted a case-control study on 114 bladder cancer patients and 46 hospital controls. DNA adducts were measured in WBCs by 32P postlabeling and showed no association with smoking habits and the glutathione-S-transferase M1 genotype. A strong association between adduct levels and the N-acetyltransferase (NAT2) genotype was found (P = 0.0002). The NAT2 genotype was associated in a nonstatistically significant way to the case-control status (odds ratio, 1.6; 95% confidence interval, 0.8-3.2). In a logistic regression model, the log of DNA adduct levels was associated in a highly significant way to the risk of bladder cancer (regression coefficient, 0.75; P = 0.0006), independently of smoking habits. Using the median of DNA adducts (RAL, 0.3) as a cutoff point, the odds ratio for the risk of bladder cancer was 4.1 (age-adjusted; 95% confidence interval, 1.9-9.0). Our study suggests that sources other than tobacco smoke contribute to the formation of aromatic DNA adducts in WBCs. The role of WBC-DNA adducts in predicting bladder cancer is still to be clarified.

[Renal multifocal carcinoma with adrenal gland metastasis in a patient previously treated with radical nephrectomy: what kind of therapy. Review of the literature]

A case of multiple adrenal metastases due to renal cells carcinoma, associated with a multifocal simultaneous renal cells carcinoma has been observed in a female patient previously submitted to radical contralateral nephrectomy for the same disease. In particular, stress is laid on computerized tomography scan diagnosis and surgical procedure.

DNA flow cytometry and 67Ki proliferating index as prognostic factors of early recurrence and progression in G1-G2/Ta-T1 and G3/Ta-T1 transitional cell carcinoma of the bladder

Using flow cytometry, gross genomic alterations, defined as DNA ploidy, and the fraction of S-phase cells, can be calculated in bladder cancer cells. In aneuploid superficial bladder cancer the recurrence rate has been reported to be three times higher than in diploid forms. A correlation between the S-phase fraction and progression has been reported for G1-G2/Ta-T1 tumours, but not for G3/Ta-T1. The aim of our study is to evaluate whether the traditional cytometric parameters can be used as valid predictors of early recurrences and progression in G1-G2/Ta-T1 and G3/Ta-T1 bladder cancer patients and to compare the proliferation indexes as defined by S-phase fraction and 67Ki monoclonal antibody in the two groups of patients.

Tobacco smoke, recurrences, and p53/bcl-2 expression in bladder cancer

Overexpression of p53 is considered to be predictive of mutations of the p53 gene. Exposure-specific mutations of the p53 gene have been described for cancers at different sites. An association between p53 mutation/overexpression and smoking has been described in early stage bladder cancer, but results were conflicting. We have conducted a study on 131 bladder cancer cases, considering p53 expression and smoking habits in an area where the use of air-cured tobacco, rich in carcinogenic arylamines, is common. The study suggests that the use of air-cured tobacco induces p53 overexpression (possibly via mutation) in early stage-low grade bladder cancer, more frequently than flue-cured tobacco (odds ratios = 3.4, 95% confidence intervals 0.9-13 in stage 1; odds ratios = 24, 95% confidence intervals 1.1-519 in stage 1, grade 1). However, all the excess associated with air-cured tobacco was concentrated in recurrences. When available, the biopsies of recurrent cases with early-stage disease were re-examined and all showed p53 expression at first diagnosis (with 10-50% of cells positive) (n = 5). It is hypothesized that exposure to tobacco-related chemicals increases the risk of recurrences via p53 overexpression/mutation. Expression of the bcl-2 gene was detected in only 2 out of 13 p53-positive smokers.

[Perirenal immunoblastic lymphoma. Description of a case]

The primary perirenal localization of non-Hodgkin lymphomas is rare and normal methods of image diagnosis do not enable a reliable preoperative diagnosis. In the majority of cases renal function is not affected and this pathology is often presented as an occasional finding. The pathologies included in the differential diagnosis are renal neoplasias, abscess and inflammatory processes in a perirenal site. Echotomography shows the lesion as an hypoanechoic zone surrounding the kidney. Computed tomography show it as isodense with the renal parenchyma. Histological tests together with immunohistochemical tests identified a malignant large B cell immunoblastic-type lymphoma in the case described here, with plasmoblastic-plasmocytic differentiation and high malignancy according to the Working Formulation. The pathogenesis of this rare localisation is controversial. We maintain that lymphomatous proliferation may be triggered off by lymphatic follicles present in the perirenal space. The concomitant presence of other clinical signs, such as splenomegalia and adenopathies, may contribute to the diagnosis. On the contrary, monolateral involvement in the absence of other signs, as in this case, raises considerable problems of differential diagnosis. Perirenal lymphoma must therefore always be borne in mind in the diagnosis of renal or perirenal masses.

p53 expression compared with other prognostic factors in OMS grade-I stage-Ta transitional cell carcinoma of the bladder

OBJECTIVE

Recent studies have investigated the possibility that p53 protein and some macroscopic tumoral features, such as diameter and focality of the lesion, play a significant prognostic role in bladder cancer progression. A retrospective study was conducted on papillary grade-I stage-Ta transitional cell carcinoma (TCC) of the bladder.

METHODS

p53 expression was evaluated using the immunohistochemical method. A group of 31 patients with papillary grade-I and stage-Ta TCC of the bladder with no recurrence or who recurred with no histological grading and staging variation in a 4-year mean follow-up period was compared with 28 grade-I and stage-Ta papillary TCC patients who underwent recurrences and a worsening in histological grading (grade II or grade III) or staging (T1) within the same period of time. The aim of this study was to investigate the hypothesis that altered patterns of expression of the protein products of the mutated p53 tumor-suppressor gene, when independently evaluated in comparison with other tumoral prognostic factors, are associated with tumor recurrence and progression in patients with Ta papillary grade-I TCC of the bladder.

RESULTS

Our data show that when a p53 threshold of > 0% was considered, 53.6% of patients with tumor progression in the follow-up period were p53-positive compared with only 16.1% of the nonprogressing group (chi 2 = 6, p = 0.02). On the contrary, p53 failed to show any value in predicting progression when a 5% threshold was considered (chi 2 = 1.12, p = 0.92). The multifocality of the tumoral lesion and recurrent tumor was highly predictive of tumor progression for both variables (chi 2 = 5.16, p = 0.003, and chi 2 = 0.23, p = 0.006, respectively). Multivariate analysis revealed p53 nuclear overexpression (at a threshold of > 0%) to be a single valuable prognostic factor of progression (OR = 10.20, p = 0.009) and recurrence (OR = 54.19, p = 0.01).

CONCLUSIONS

Our results lead to the conclusion that p53 immunohistochemical detection has no prognostic value in predicting tumoral relapse or progression of TaGI TCC of the bladder when a 5% positivity threshold is considered. On the contrary, when a p53 nuclear labelling of > 0% is considered as positive staining, this tumor marker becomes highly predictive of tumor recurrence and progression. These findings seem therefore to suggest the use of a slight p53 positivity (> 0%) as a valid tool in predicting the clinical behavior of TaGI bladder TCC. The prognostic impact of a multifocal lesion and a recurrent tumor as markers of progression is also confirmed by these results.

[Renal agenesis and homolateral seminal vesicle cyst. Case report]

The authors present a case of renal agenesis and seminal vesicle cyst in a young man, diagnosed because of several micturion disorders partially cleared up with antibiotic therapy. We discuss about the diagnosis technique which includes Ultrasound Scanner, Computed Tomography, Magnetic Resonance and pelvic arteriography. Then we describe the surgical approach and finally we discuss about embryogenesis.

Urethral prostheses. An overview

The first report in Literature dealing with an endourethral prosthesis in the treatment of recurrent bulbar strictures dates back to 1988. Since then other prostheses with different design and materials have been proposed. The Urolume by A.M.S., the first ever, is used worldwide and its indications are better known due to a longer follow-up time. In 6 months epithelium covers the prosthesis and it is generally well tolerated, but some Authors do not agree with its use in the treatment of traumatic strictures. Titanium prostheses have been used in few cases. A temporary steel alloy prosthesis, the Urocoil, has been proposed recently. Not enough follow-up data are available about this and the new “thermic memory” prosthesis. The bigdegradable prosthesis, used till now only on rabbits, actually represents the new frontier in the treatment of urethral strictures.

[Surgical treatment of benign prostatic hypertrophy and Kelami syndrome]

The authors analyze a group of 116 consecutive patients treated with transvesical prostatic adenomectomy or transurethral prostatic resection for benign prostatic hypertrophy (BPH) isolated five of them with a Kelami syndrome. These patients, aged between 53 and 70 years old, had a relevant ventral penile deflection with severe sexual impairment postoperatively. Among them only one asked for a corrective surgical procedure. Aetiology, preventive measures and therapeutic choices are discussed. Authors pointed out that this syndrome is actually underestimated considering the high number of transurethral or open surgery procedures for BPH.

[Measurement of skeletal alkaline phosphatase in prostatic carcinoma. Preliminary report]

Bone metastases frequently occur in prostate carcinoma. Total body radionuclide scan with diphosphonate methylene labelled with 99Tc is commonly used to diagnose such metastases. However this technique is aspecific and frequently unreliable. In recent years several biological markers dealing with bone metabolism were studied. Serum determination of skeletal alkaline phosphatase (ALP) and moreover of its bone isoenzyme (BAP) could be considered a reliable index of osteoblastic activity. In this preliminary report we analyzed a group of 43 patients affected by prostate carcinoma with or without bone metastases. The American Urological Association (AUA) staging system was adopted. Sixteen patients were D2, bone metastases had been suspected by means of radionuclide bone scan and confirmed by Computerized Tomography and/or aimed X-rays. Tandem R-Ostase by Hybritech was used to measure BAP, normal value is set to 20 micrograms/L. All D2 tumours had pathological BAP values (mean value 87.50 micrograms/l); 1/3 stage A, 5/13 stage B, 5/9 stage C and 0/2 stage D1 patients had pathological findings. One of this patients, stage C, revealed a bone metastase at a later bone scan.

[Appearance in 2 brothers of double primary neoplasms: right renal carcinoma and gastric adenocarcinoma]

We report a clinical case of a double primitive tumour (right kidney clear cell carcinoma and gastric carcinoma) in two brothers. There is no history of cancer in the parents. Both patients were previously affected by gastric ulcer. No report of association between the two neoplasms was found in literature. The age of the patients (61 and 70 years) and the singleness of the kidney tumour seem to exclude the case of a familial kidney cancer. The neoplastic transformation of the gastric ulcer is instead a quite frequent report with an incidence of about 1%. Alterations of oncogenes or tumour suppressor genes shared from both neoplasm are at present still unknown. Nevertheless molecular analysis of patients' neoplastic genome could point out typical chromosome translocations/deletions or gene mutations.

[Leiomyosarcoma of the spermatic cord. Case report and revision of the literature]

A 76 year old man presented with an asymptomatic, very big left scrotal mass that was found to be a leiomyosarcoma of the spermatic cord. It was treated by radical orchiectomy with ligation of the spermatic cord at the internal inguinal ring. Convalescence was uneventful. 6 months postoperatively there was no evidence of local recurrence of the neoplasm or distant metastasis.

Carcinogen-DNA adducts in bladder biopsies and urothelial cells: a risk assessment exercise

We have determined the levels of DNA adducts (using 32P-postlabelling) in the biopsies of 20 bladder cancer patients and in the exfoliated bladder cells of 36 healthy volunteers. The aims of the study were (a) to estimate the concentration of DNA adducts in cancer cases and controls according to the level of smoking; and (b) to investigate whether bladder cancer cases had higher levels of adducts in bladder cells than healthy controls had. A dose-response relationship between smoking levels and adduct levels was present among both cancer cases and controls. Cancer cases and the controls had similar adduct levels for the same level of smoking. According to a risk assessment exercise, adduct levels among heavy smokers were roughly comparable with those found in mice and dogs treated with bladder carcinogens, at doses which induce a 50% lifetime risk of bladder cancer.

[The use of hemorrhage occluder pins in radical pelvic urologic surgery]

The authors present the use of "Hemorrhage Occluder Pins" in pelvic urologic radical surgery, as a means of hemostasis for the retropubic venous plexus. The application technique and the bio-technological characteristics of the occluder pin are discussed.

Urinary levels of tumour associated antigens (CA 19-9, TPA and CEA) in patients with neoplastic and non-neoplastic urothelial abnormalities

The urinary excretion of carbohydrate antigen 19-9 (CA 19-9), tissue polypeptide antigen (TPA) and carcinoembryonic antigen (CEA) was evaluated in 264 patients with bladder cancer. Cut-off levels were established using a pool of healthy blood donors. The combined determination of CA 19-9 and TPA had a sensitivity of 74% in pTa and 83% in pT1 tumours, and 62% in grade 1, well differentiated tumours. Absence of disease at follow-up was related to a significant decrease in CA 19-9 and TPA in 129 patients with superficial (pTa or pT1) bladder carcinoma, followed up for at least 3 years. Recurrences, defined as new tumours at the same site or elsewhere in the bladder, were associated with an increase in the mean values but this was not statistically significant. A poor prognosis was indicated in patients with infiltrating tumours and the following pre-operative levels: TPA > 1500 u/l or CA 19-9 > 300 u/ml or CEA > 50 ng/ml.

Immunohistochemical detection of estrogen and progesterone receptors in the normal urinary bladder and in pseudomembranous trigonitis

According to recent studies showing the presence of estrogens receptors (ERs) in the human female lower urinary tract, we performed ER and progesterone receptor (PR) assays in fresh frozen and paraffin embedded biopsies taken from the urinary bladder. Fourteen females undergoing endoscopy during staging for gynecological cancer (endometrium, cervix, ovary) and 15 women complaining of recurrent abacterial cystitis (pseudomembranous trigonitis) were enrolled in the study as Group 1 and Group 2, respectively. After informed consent, they were submitted to cystoscopy, during which two biopsies were taken: one on the trigonum and the other on the bladder lateral wall. ERs were identified in both groups only in the trigonum (7/14 patients in Group 1 and 8/15 in Group 2), whereas the bladder lateral wall always stained negative. PRs were found at both sites in both groups (11/14 cases on the trigonum and 7/14 on the bladder lateral wall in Group 1; 11/15 and 2/15 respectively in Group 2). Morphological localization of PRs showed intense omogeneous staining in the nuclei of the stromal fibroblasts too. A clear correspondence between the presence of steroid receptors at the squamous metaplasia of the trigonum was observed. These data are discussed speculating about a possible endocrine pathogenesis of pseudomembranous trigonitis.

[Immunohistochemical determination of antigen 19-9 (CA 19-9) in transitional carcinoma of the bladder]

Carbohydrate Antigen 19-9 (CA 19-9) histological expression in transitional cell bladder carcinoma (TCBC) was studied by means of immunohistochemistry and its findings compared with those of Tissue Polypeptidic Antigen (TPA) and Carcino Embryonic Antigen (CEA). Twenty-one TCBC of various grade and stage were analyzed by using Avidin-Biotin complex method for CA 19-9 and TPA Peroxidase-Antiperoxidase method for CEA. Grade 3 and pT1, pT2/pT3 carcinomas showed a constant staining for CA 19-9 antigen, grade 2 showed a 50% positive immunoreaction while all grade 1 cases were negative. TPA showed an inverse correlation with well differentiated carcinomas which were better and more extensively stained than anaplastic ones. CEA expression was not correlated either with grade or stage. CA 19-9 could be considered as a dedifferentiation marker in TCBC.

[A case of retroperitoneal leiomyosarcoma]

The Authors present a case of retroperitoneal leiomyosarcoma, diagnosed because of the early symptomatic hydronephrosis due to the compression of the tumour on the lumbar ureter. Some general clinical aspects of retroperitoneal sarcomas are discussed too. In the case presented adjuvant therapy was not advised, because of the small volume of the tumour and the possibility of its complete excision.

In-vitro efficacy of glycosaminoglycans in the inhibition of urinary calcium oxalate cristallization

Aim of this study is the evaluation of the increased overall inhibitory power of whole urine induced by the in-vitro addition of glycosaminoglycans (GAGs). The inhibitory power, and its variations are assessed with the Sarig test, using ionometric measurements to follow the oxalate precipitation in different experimental conditions. The study is performed on the urine collected from 160 patients with a history of calcium-oxalate lithiasis; mesoglycan, sulodexide and sodium citrate (for comparison) are each tested on 110 urine specimens. A statistical significant difference is found between the basic evaluation and after addition of GAGs, comparable with the results obtained with sodium citrate. No significant differences in activity among the three drugs are found in those cases where simultaneous testing is possible.

[The Sarig test. A simple method to evaluate the inhibitory effect on urinary crystallization of calcium oxalate]

In this study, the Authors evaluate a simple test proposed by Sarig for the discrimination of kidney stone-formers, based on the overall urine inhibitory effect. A solution of the tested urine is added with sodium-oxalate and the kinetics of calcium-oxalate precipitation is indirectly followed with ionometric selective measurement of the progressive reduction of free calcium ions. A Discriminating Index may be therefore calculated; higher values are obtained in lithiasic patients in comparison with normal controls.

Detection of estrogen receptors in the trigonum and urinary bladder with an immunohistochemical technique

In order to detect estrogen receptors (ER) in the female bladder, 5 premenopausal and 10 postmenopausal women affected by gynecological diseases were submitted to cystoscopy, during which both the trigonum and the bladder lateral wall were biopsied. A new, simple, cost-effective immunohistochemical technique was employed to stain the estrogen specific binding sites. ER were found in the trigonum of 3 premenopausal and 4 postmenopausal subjects, while the bladder lateral wall was always ER-negative. A comparison with previously used ER detection methods and a discussion of further hypothetical applications of the immunohistochemical technique in the study of the lower female urogenital tract are reported.

[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.