FGFR3 and Cyclin D3 as urine biomarkers of bladder cancer recurrence

AIM

To assess the diagnostic performance of FGFR3 and Cyclin D3 urinary protein levels in detecting bladder cancer recurrence.

PATIENTS & METHODS

Urine of 321 patients in follow-up for bladder cancer and 150 non-neoplastic urine controls was included. Cytology, cystoscopy and FGFR3 and Cyclin D3 expression by western blot were performed.

RESULTS

One hundred ten (34.3%) patients had evidence of tumor recurrence. The sensitivity and specificity of cytology/cystoscopy was 80 and 84%, and for FGFR3/Cyclin D3 was of 73 and 90%.

CONCLUSION

Combined urinary FGFR3/Cyclin D3 expression shows improved detection rates for bladder cancer recurrence with high specificity and sensitivity, and within the same range of detection shown by cystoscopy, therefore supporting its potential use as noninvasive diagnostic biomarker for bladder cancer recurrence.

Comparative analysis of the incidence of bladder cancer in the communities of Andalusia, Catalonia and Madrid in 2011

OBJECTIVES

To determine the incidence of bladder cancer (BC) in the autonomous communities that include the largest number of cases in the national hospital BC registry (Andalusia, Catalonia and Madrid) and report the clinical, pathological and diagnostic differences and similarities of BC in these regions.

MATERIAL AND METHODS

An observational epidemiological study was performed in 2011 in 12 public hospitals with reference population areas according to the National Health System (Spain). Demographic and clinical variables were collected from new cases and relapses, with histopathologic confirmation of BC. The raw incidence rate was calculated using the number of diagnosed cases in all the participating centers compared with the aggregate total population assigned to each center. The raw rates by age and sex were obtained from the National Institute of Statistics (2011) by weighting the assigned population with the distribution by age and sex.

RESULTS

The 3 autonomous communities recorded 51% of the 4285 cases included in the national registration, with relapses corresponding to 42.8% of these cases. The raw annual incidence rate for new episodes was 22.6 (95% CI: 20.7; 24.6) in Andalusia, 23.5 (95% CI: 20.9; 26.0) in Catalonia and 22.0 (95% CI: 19.9; 24.1) in Madrid.

CONCLUSIONS

Except for the larger proportion of smokers and lower tumor grade of lesions in Andalusia, the 3 autonomous communities studied are similar in terms of clinical characteristics, comorbidities, patient symptoms and diagnostic processes for BC.

The protective role of coenzyme Q10 in renal injury associated with extracorporeal shockwave lithotripsy: a randomised, placebo-controlled clinical trial

OBJECTIVE

To determine the efficacy of coenzyme Q10 (CoQ10) in preventing renal injury in patients with lithiasis undergoing extracorporeal shockwave lithotripsy (ESWL).

PATIENTS AND METHODS

Prospective, randomised, double-blind, placebo-controlled clinical trial of 100 patients with renal lithiasis who were treated with ESWL. The patients were distributed randomly into two groups receiving either placebo or CoQ10 (200 mg/day), a powerful antioxidant with vasoactive properties, orally administered during the week before ESWL and for 1 week after. Renal dysfunction markers, vasoactive hormones, oxidative stress, plasma levels of several interleukins and vascular resistance index (VRI) using Doppler ultrasound were evaluated the week before ESWL, 2 h before ESWL and at 2 h, 24 h and 7 days after ESWL.

RESULTS

There was a significant increase in glomerular filtration (P = 0.013), as well as a decrease in the albumin/creatinine ratio and the β2 -microglobulin level (P = 0.02) after 1 week of treatment in the CoQ10 group. These changes were maintained at the follow-up after ESWL. The administration of CoQ10 was associated with improvement in vasoactive hormone parameters, VRI and interleukin levels. These improvements were maintained until the end of the follow-up period. However, the administration of CoQ10 was not associated with significant changes in the oxidative stress parameters.

CONCLUSION

Our results indicate that CoQ10 administration improves renal function and vasoactive and inflammation parameter values, allowing for preconditioning before the tissue insult caused by ESWL.

Percutaneous radiofrequency ablation of renal tumors in solitary kidney patients

OBJECTIVES

In solitary kidney patients with renal cell carcinoma (RCC), radiofrequency ablation (RFA) could be effective in achieving complete tumor necrosis without increasing the risk of complications or renal failure. To analyze the outcomes of a group of solitary kidney patients treated for RCC by RFA considering tumor size and location, renal function involvement and complications.

METHODS

A transversal retrospective study was performed, in which we selected 11 solitary kidney patients with 19 tumors in total treated by RFA for one or more renal tumors. A CT protocol was used for follow up. It included unenhanced series and contrast enhanced series at 1 month, 3-6 months, 12 months and yearly after RFA. Serum creatinine levels of each patient, pre RFA and within the first 48 hours after RFA, were collected.

RESULTS

Complete ablation was achieved in 17 tumors (89.4%) after one or two RFA sessions. 100% of exophytic and parenchymal tumors, and 3 cm size or smaller, were completely ablated. Renal failure, immediate complications or more than 24 hours hospitalization were not observed in 10 (90.1%) of our patients.

CONCLUSIONS

RFA treatment for RCC in solitary kidney patients has a high success rate; it does not affect renal function and achieves complete initial tumor necrosis, especially in exophytic, parenchymal and 3 cm or smaller lesions.

Plasmacytoid urothelial carcinoma of the bladder

In this report, we present the clinicopathologic features of 11 cases of the plasmacytoid variant of urothelial carcinoma. This is a rare variant of bladder cancer recognized by the current World Health Organization classification of urologic tumors. The plasmacytoid component varied from 30% to 100% of the tumor specimen; in 8 cases, the plasmacytoid component comprised greater than 50% of the tumor with 2 cases showing pure plasmacytoid carcinoma. The architectural pattern of the tumor varied from solid expansile nests with noncohesive cells to mixed solid and alveolar growth; a streaking discohesive architecture was additionally present in 2 cases (18%). At histology, the individual tumor cells had an eccentrically placed nucleus and abundant eosinophilic cytoplasm reminiscent of plasma cells. Most neoplastic cells had nuclei of low to intermediate nuclear grade with occasional nuclear pleomorphism. Seven of 9 mixed cases had concurrent conventional high-grade urothelial carcinoma, and the remaining 2 cases presented features of nested or micropapillary urothelial carcinoma. Small intracytoplasmic vacuoles were variably present in all cases. All patients had advanced stage cancer (>pT3), and 8 (73%) had lymph node metastasis. Immunohistochemical staining demonstrated that both plasmacytoid and associated conventional urothelial carcinoma were positive for cytokeratins 7, 20, and AE1/AE3 and epithelial membrane antigen; CD138 was positive in 3 cases. Follow-up information was available in all cases (range, 2-16 months; mean, 7 months). Nine of the patients died of disease from 2 to 11 months, and 2 patients were alive with disease at 8 and 16 months. In summary, plasmacytoid variant of urothelial carcinoma is an aggressive variant associated with poor prognosis that presents at an advanced clinical stage. In limited samples, it may be misdiagnosed as chronic cystitis or plasmacytoma, a pitfall further compounded by CD138 expression in some cases. Morphological distinction from other malignant neoplasms with plasmacytoid phenotype is critical for its clinical management.

Apoptotic and proliferation indexes in primary superficial bladder tumors

Whether apoptotic index [AI] and/or Ki-67 labeling index [Ki-67LI] add prognostic information in bladder cancer remains unclear. Mean AI and Ki-67 LI increased with grade and stage in 147 superficial bladder tumors. AI (>1.7%) correlated with tumor size, grade and proliferation. Ki-67 LI (>10%) correlated with higher grade and stage. Tumor size and Ki-67 LI were independent predictors of disease-free and progression-free survival, respectively. Tumor size, patient's age and tumor's recurrence predicted overall survival. We conclude that conventional clinical parameters and Ki-67 LI define risk groups of bladder tumors, while AI has limited value.

Squamous differentiation in primary urothelial carcinoma of the urinary tract as seen by MAC387 immunohistochemistry

Squamous differentiation (SqD) is variably present in urinary tract tumours, but its significance remains unclear. In this study, SqD was assessed by immunohistochemistry using the monoclonal antibody Mac387 in 145 urothelial tumours (bladder, n = 115; renal pelvis, n = 30). Mac387 detects the myelomonocytic L1 antigen; a member of the calgranulin family shared by epithelial cells and keratinocytes. L1 antigen was shown in SqD in urothelial carcinomas of the bladder or the renal pelvis, including 11 cases with focal SqD unrecognised by conventional analysis. SqD is more frequent in renal pelvic tumours (p = 0.027) and increases with grade/stage mainly in bladder carcinoma (grade, p = 0.05; stage, p = 0.005). Stage Ta/T1 bladder carcinomas with SqD recurred more (p = 0.021). In conclusion, Mac387 efficiently shows SqD in urothelial tumours.

Ki-67 MIB1 labelling index and the prognosis of primary TaT1 urothelial cell carcinoma of the bladder

AIMS

To evaluate whether ki-67 labelling index (LI) has independent prognostic value for survival of patients with bladder urothelial tumours graded according to the 2004 World Health Organisation classification.

METHODS

Ki-67 LI was evaluated in 164 cases using the grid counting method. Non-invasive (stage Ta) tumours were: papilloma (n = 5), papillary urothelial neoplasia of low malignant potential (PUNLMP; n = 26), and low (LG; n = 34) or high grade (HG; n = 15) papillary urothelial carcinoma. Early invasive (stage T1) tumours were: LG (n = 58) and HG (n = 26) carcinoma. Statistical analysis included Fisher and chi2 tests, and mean comparisons by ANOVA and t test. Univariate and multivariate survival analyses were performed according to the Kaplan-Meier method with log rank test and Cox's proportional hazard method.

RESULTS

Mean ki-67 LI increased from papilloma to PUNLMP, LG, and HG in stage Ta (p<0.0001) and from LG to HG in stage T1 (p = 0.013) tumours. High tumour proliferation (>13%) was related to greater tumour size (p = 0.036), recurrence (p = 0.036), progression (p = 0.035), survival (p = 0.054), and high p53 accumulation (p = 0.015). Ki-67 LI and tumour size were independent predictors of disease free survival (DFS), but only ki-67 LI was related to progression free survival (PFS). Cancer specific overall survival (OS) was related to ki-67 LI, tumour size, and p27kip1 downregulation. Ki-67 LI was the main independent predictor of DFS (p = 0.0005), PFS (p = 0.0162), and cancer specific OS (p = 00195).

CONCLUSION

Tumour proliferation measured by Ki-67 LI is related to tumour recurrence, stage progression, and is an independent predictor of DFS, PFS, and cancer specific OS in TaT1 bladder urothelial cell carcinoma.

Cyclin D3 expression in primary Ta/T1 bladder cancer

Cyclin D3 deregulation has recently been reported in bladder cancer but its prognostic significance remains uncertain. A cohort of 159 patients with stage Ta or T1 primary bladder tumours was investigated to determine the significance of cyclin D3 expression in association with other G1-S phase regulators of the cell cycle (p53, p21Waf1, p27kip1, cyclin D1), including tumour proliferation (ki67-MIB1); its association with conventional clinicopathological parameters; and the relationship between cyclin D3 and loss of heterozygosity (LOH) at the 9p21 (p16INK4a locus) chromosome region. The end point of the study was progression-free survival. Cyclin D3, other G1-S phase regulators, and tumour proliferation were investigated by immunohistochemistry and measured by the grid-counting method. To validate the immunohistochemical expression, cyclin D3 was additionally assessed by western blotting in selected cases. LOH at the 9p21 chromosome region (marker D9S171) was assessed in 125 cases using an AB Prism 310 genetic analyser and a set of microsatellite fluorescence-labelled primers. Cyclin D3 overexpression was related to larger tumour size (>5 cm; p < 0.0001) and high tumour proliferation (>10%; p = 0.025). Mean cyclin D3 expression increased with 2004 WHO grading categories in stage Ta (p = 0.035, ANOVA) and stage T1 (p = 0.047, t test) tumours. Cyclin D3 was not related to other clinicopathological parameters, G1-S phase modulators, or 9p21 LOH. Cox's multivariate analysis selected cyclin D3 as an independent predictor of progression-free survival (p = 0.0012, relative risk (RR) = 5.2366) together with tumour size (p = 0.0115, RR = 4.4442) and cyclin D1 (p = 0.0065, RR = 3.3023). Cyclin D3 expression had the highest risk ratio. Our results suggest that expression of cyclin D3 is relevant to the progression-free survival of patients with Ta/T1 bladder carcinomas.

Association of human herpesvirus type 6 DNA with human bladder cancer

We examined the presence of human herpesvirus type 6 (HHV6) DNA in a series of 74 bladder carcinomas from a Mediterranean population to elucidate their possible role as cofactor in the development of bladder cancer with or without associated human papillomavirus (HPV) infection. HHV-6 type B DNA was present in 5 men (6.8%) out of the 74 tumors investigated; two of them had associated HPV-16 DNA in the same specimen. In one case that had associated urothelial carcinoma in situ, both HHV-6B and HPV-16 DNA were present. In conclusion, the low incidence of HHV-6B in bladder cancer and the ubiquitous nature of HHV-6 infection are more consistent with a bystander role rather than cofactor in the oncogenesis of bladder cancer.

Prognostic factors in survival of patients with stage Ta and T1 bladder urothelial tumors: the role of G1-S modulators (p53, p21Waf1, p27Kip1, cyclin D1, and cyclin D3), proliferation index, and clinicopathologic parameters

We studied 159 cases of superficial (stage Ta or T1) bladder tumors to determine the significance on survival of a subset of regulators of transition from G1 to S phase of the cell cycle (p53, p21Waf1, p27Kip1, cyclin D1, cyclin D3) and tumor proliferation (Ki-67 [MIB-1]). Clinical findings (patient age, sex, tumor size, grade, stage [Ta or T1]) were included in the analysis. Univariate analysis revealed association of tumor size (P = .0353), grade in stage Ta tumors (P = .0074), cyclin D1 expression (P = .0182), and Ki-67 index (P = .0033) with disease-free survival and of tumor size (P = .0005), stage (P = .0494), cyclin D3 expression (P = .0105), and Ki-67 index (P = .0272) with overall survival. Cox multivariate analysis revealed cyclin D1 expression and high proliferation index (disease-free) and tumor size, cyclin D3 expression, and high proliferation index (overall survival) as independent predictors. Results suggest that alterations of the progression from the G1 to S phase of the cell cycle are common in papillary urothelial bladder tumors. High tumor proliferation, expression of cyclins D1 and D3, and tumor size at diagnosis might be relevant predictors of survival in patients with stage Ta and T1 bladder urothelial tumors.

Prognostic Factors in Stage T1 Grade 3 Bladder Cancer Survival: The Role of G1–S Modulators (p53, p21Waf1, p27kip1, Cyclin D1, and Cyclin D3) and Proliferation Index (ki67-MIB1)

OBJECTIVE

To determine the prognostic value of a subset of regulators of the transition from G1-to-S phase of cell cycle in stage T1 grade 3 bladder cancers.

METHODS

Fifty-one such cases were investigated to determine the significance on patient's survival of p53, p21Waf1, p27Kip1, Cyclin D1, Cyclin D3, and ki67-MIB1 (proliferation index). The statistical analysis included Kaplan-Meier methodology with Log-rank test and Cox' proportional hazard analysis.

RESULTS

Tumor size (p=0.0034), and the labeling index of ki67-MIB1 (p=0.0034), p53 (p=0.0332), p27kip1 (p=0.0059) and Cyclin D1 (p=0.0103) were associated to disease-free survival. Progression-free survival was related to tumor size (p<0.0001), ki67 (p=0.0163), p53 (p=0.0041), p27kip1 (p=0.0161), Cyclin D1 (p<0.0001) and Cyclin D3 (p<0.0001). Patient's overall survival was associated to Cyclin D3 (p<0.0001), p53 (p=0.0017), p21Waf1 (p=0.0142), Cyclin D1 (p<0.0001), ki67-MIB1 (p=0.0450), and tumor size (p=0.0296). Down-regulation of p27kip1 and Cyclin D3 over-expression (disease-free), over-expression of p53, Cyclin D1 and Cyclin D3 (progression-free), and over-expression of Cyclin D3 (overall survival) were independent predictors by Cox's multivariate analysis. Down-regulation of p27kip1 (p<0.001, R.R. 0.997, 95%C.I. 0.995-0.999), and over-expression of Cyclin D1 (p<0.001, R.R. 1.009, 95%C.I. 1.004-1.014) and Cyclin D3 (p=0.005, R.R. 1.013, 95%C.I. 1.004-1.022) were the main independent predictors.

CONCLUSION

Down-regulation of p27kip1 and over-expression of Cyclin D1 and Cyclin D3 might be relevant predictors of survival in stage T1 grade 3 bladder cancers, thus selecting a group of patients at higher risk of malignant behavior.

Hepatoid adenocarcinoma of the urinary bladder

Hepatoid adenocarcinoma is rare in the urinary bladder with only three well-illustrated previously reported cases. Pathological diagnosis is based on a combination of histological features resembling hepatocellular carcinoma and the positive immunostaining for alpha-fetoprotein. We present the clinicopathological features of four additional cases. The patients were males 66, 85, 61 and 68 years old. Hematuria was the initial symptom in all four patients. Two cases were treated by cystoprostatectomy and the remaining two by transurethral resection of the bladder. On histology, the cases showed a mixture of cells growing in a solid fashion and sheets or anastomosing trabeculae of hepatoid cells merging focally with a secondary glandular pattern of adenocarcinoma. Intracytoplasmic hyaline globules in all and bile production in three of the cases also supported the impression of hepatocytic differentiation. Immunoreactivity for alpha-fetoprotein, low molecular weight cytokeratin, alpha-1-antitrypsin, albumin, epithelial membrane antigen and a striking canalicular pattern when stained against polyclonal carcinoembryonic antigen (CEA), all indicate hepatocellular differentiation. The hepatic nature of the cells was further assessed by detecting the recently incorporated marker hepatocyte paraffin 1, by means of immunohistochemistry and albumin gene mRNA non-isotopic in situ hybridization, both of which had positive signals in all four cases. Three patients died 12, 14 and 19 months after diagnosis. The fourth patient was alive with disease at 26 months of follow-up. In conclusion, hepatoid adenocarcinoma seems to be an aggressive malignant neoplasm that is rare in the bladder whose correct diagnosis may need appropriate immunohistochemical and in situ hybridization means in addition to a complete patient clinical and pathological evaluation. The exact histogenesis and classification of these tumors remains to be established.

High incidence of autoimmune alterations in chronic myeloid leukemia patients treated with interferon-alpha

Interferon-alpha is the frontline therapy of the majority of chronic myeloid leukemia (CML) patients who are not eligible for bone marrow transplantation. Many patients are treated for long periods, and there is concern about the long-term immune effects of its use. Autoimmune disorders in patients treated with IFN-alpha may be related to the direct immunomodulating properties of IFN or may be linked to a possible toxic effect in target organs, triggering autoimmunity. On the other hand, the immune effects of IFN may play a role in its therapeutic actions. The aims of our study were to assess the incidence of autoimmune phenomena in these patients, and to measure the possible association between the generation of autoimmune phenomena and the antileukemic effect of IFN alpha. Therefore, 46 patients with Ph1(+) CML in the first chronic phase were studied for the appearance of immune complications, their connection to IFN dose, time of appearance, and the possible association with the response to treatment. Autoimmune abnormalities have been found in 28% of our patients. Moreover, a significant association was found between autoimmune alterations and female sex (P = 0.02, OR 4.5, 95% CI 1.13-17.9) and a longer treatment time (1.6 vs. 4.1 years) (P = 0.02; OR 1.01, 95% CI 1-1.02). The Kaplan-Meier estimated probability of obtaining a cytogenetic response was significantly higher in patients who developed autoimmune alterations (P = 0.049), and this difference was also evident in Cox's analysis when controlling with other potentially confounding variables (P = 0.078). We conclude that CML patients treated with IFN alpha have a high incidence of autoimmune phenomenon.

Lymphoepithelioma-like carcinoma of the urinary bladder: a clinicopathologic study of 13 cases

Lymphoepithelioma-like carcinoma (LELCA) of the urinary bladder is a rare variant of bladder cancer characterized by a malignant epithelial component densely infiltrated by lymphoid cells. It is characterized by indistinct cytoplasmic borders and a syncytial growth pattern. These neoplasms deserve recognition and attention, chiefly because they may be responsive to chemotherapy. We report on the clinicopathologic features of 13 cases of LELCA recorded since 1981. The chief complaint in all 13 patients was hematuria. Their ages ranged from 58 years to 82 years. All tumors were muscle invasive. A significant lymphocytic reaction was present in all of these tumors. There were three pure LELCA and six predominant LELCA with a concurrent transitional cell carcinoma (TCC). The remainder four cases had a focal LELCA component admixed with TCC. Immunohistochemistry showed LELCA to be reactive against epithelial membrane antigen and several cytokeratins (CKs; AE1/AE3, AE1, AE3, CK7, and CK8). CK20 and CD44v6 stained focally. The lymphocytic component was composed of a mixture of T and B cells intermingled with some dendritic cells and histiocytes. Latent membrane protein 1 (LMP1) immunostaining and in situ hybridization for Epstein-Barr virus were negative in all 13 cases. DNA ploidy of these tumors gave DNA histograms with diploid peaks (n=7) or non-diploid peaks (aneuploid or tetraploid; n=6). All patients with pure and 66% with predominant LELCA were alive, while all patients having focal LELCA died of disease. Our data suggest that pure and predominant LELCA of the bladder appear to be morphologically and clinically different from other bladder (undifferentiated and poorly differentiated conventional TCC) carcinomas and should be recognized as separate clinicopathological variants of TCC with heavy lymphocytic reaction relevant in patient management.

Severe autoimmune hepatitis in a chronic myeloid leukemia patient treated with interferon alpha and with complete genetic response

A patient with chronic myeloid leukemia (CML) treated with interferon alpha (IFN alpha) and who developed autoimmune hepatitis (AIH) is described. The patient was treated with IFN alpha 2a, a complete cytogenetic response was achieved 5 months later, and this response has lasted now more than 7 years. Autoimmune hypothyroidism appeared at 18 months of treatment, and 1 year later severe type I autoimmune hepatitis developed. To our knowledge this is the first report of such complication in an IFN alpha-treated CML patient.

Absence of influence of prior treatment with interferon on the outcome of allogeneic bone marrow transplantation for chronic myeloid leukemia

Timing of transplantation in the chronic phase of chronic myeloid leukemia (CML) and previous treatment with interferon remains controversial. We have tried to discover what influence pretreatment with interferon alpha (IFN-A) has on the results of allogeneic bone marrow transplantation for CML patients treated in a single institution. Fifty-one consecutive patients with chronic phase Ph-positive CML who received an allogeneic bone marrow transplantation from a HLA-identical familial donor were evaluated. Thirty had been treated with IFN-A (IFN+ group) prior to BMT and twenty-one had not (IFN- group). Both groups were homogeneous for clinical characteristics such as age, sex, previous chemotherapy, disease status, and time from diagnosis to transplant. No difference was found in neutrophil and platelet count recovery between the IFN+ and IFN- group. The incidence of acute and chronic GVHD, VOD and severe mucositis was not significantly different. Relapse and both overall survival and DFS were similar for both groups. No adverse effects of prior IFN exposure on the outcome of HLA-identical sibling donor BMT for chronic phase CML patients were found in this study.

Southern technique and cytogenetics are complementary and must be used together in the evaluation of Ph1, M-BCR positive chronic myeloid leukemia (CML) patients treated with alpha interferon (IFN-alpha)

Cytogenetic analysis is the gold standard for the follow-up of CML patients. The sensitivity of cytogenetics is fairly similar to that of Southern detection of M-BCR rearrangement (5%); this last technique has the potential advantage of being independent of cell division and yield of metaphases. IFN alpha treatment can induce lack of growth of hemopoietic precursors and poor yield of metaphases has been observed. For this reason we decided to study the grade of concordance and complementarity between analysis of karyotype and detection of M-BCR rearrangement of Southern blot. We studied 43 Ph1 positive, M-BCR positive pre-BMT CML patients (48 samples) treated with IFN alpha 2a. Karyotype was done on bone marrow cells by direct method, culture, and banding. Southern technique was performed onto DNA from peripheral blood leukocytes treated with BgIII (and Xbal if necessary) and hybridized with the universal probe (Ph1/bcr-3, Transprobe 1) labelled with dCTP32. A highly significant association between both tests was obtained. Of 48 samples analyzed, 34 were evaluable by both methods and 28 gave the same result for both tests. The concordance between the tests was good (kappa index: 0.63). Of total samples 27.1% was not evaluable by cytogenetics; this figure was 31.2% in samples from patients who were previously in complete cytogenetic response. All of the specimens not evaluable by karyotyping were evaluable by Southern. One sample was not analyzable by Southern but it was evaluable by cytogenetic analysis. The information obtained by Southern technique was clinically relevant, and decisions were made according to its results. We conclude that both tests show a significant association and a good concordance, although they are not interchangeable. Cytogenetic and molecular studies are complementary and must be employed together in CML patients treated with alpha-interferon.

Quinton-Mahurkar catheter as short-term central venous access for PBSC collection: single-center experience of 370 aphereses in 110 patients

We retrospectively analyzed our experience with the Quinton-Mahurkar dual-lumen hemodialysis catheter as short-term central venous access for harvesting peripheral blood stem cells (PBSC) for autologous transplantation. For intensification therapy for various malignancies 370 leukaphereses were performed in 110 candidates. The catheter was placed percutaneously under local anesthesia only for the time of blood collection and in no case was it used for the PBSC transplant. No systemic antithrombotic prophylaxis was administered. PBSC were collected using a continuous flow cell separator, COBE Spectra, after mobilization with chemotherapy followed by cytokine: rhGM-CSF and rhG-CSF s.c. (35 patients) or rhG-CSF s.c. alone (75 patients). The median number of aphereses was two (1-13). Eighty-nine patients (81.3%) required three or fewer sessions to collect the minimum mononuclear cell target number of 6 x 10(8) MNC/kg. The volume of blood per kg body weight processed for each apheresis was 240 ml (range 150-560 ml) equivalent to 13 l (6-30 l) and the median flow rate was 61 ml/min (range 30-90 ml/min). The total CD34+ cell yield per patient was 3.55 x 10(6)/kg (0.26-34.8) and the MNC yield was 6.1 x 10(8)/kg (2.96-12.6). We observed the following complications: local infection in four cases (3.6%), catheter occlusion for local thrombosis in two cases (1.8%) and pneumothorax in one case (0.97%). In our experience the Mahurkar-Quinton catheter, when placed specifically for apheresis sessions, was very effective and safe for PBSC harvesting with a low incidence of complications.

Study of chimerism in long-term survivors after bone marrow transplantation for severe acquired aplastic anemia

Chimerism studies employing PCR and Southern techniques targeting VNTR loci were performed in 17 severe acquired aplastic anemia patients who were long-term survivors after BMT. They were studied a median of 4 years after BMT (1-12). All patients had normal blood counts. All patients conditioned with radiation-based schemes showed a full donor pattern of hemopoiesis. Conversely, out of five patients who received only cyclophosphamide as conditioning therapy, two of them had a late graft failure (2.4 and 3 years after BMT). One of these relapsing patients had a durable mixed chimerism, which was first detected 1 month after BMT. Our results seem to suggest that durable mixed chimerism can antecede graft failure in some patients conditioned only with cyclophosphamide, and that a more stringent monitoring can be clinically rewarding in this group of patients.

[Alfa-2a interferon induces molecular remission in post-BMT relapse of chronic myelogenous leukaemia. Report of a case with loss of bcr-abl RNA]

Alpha-interferon (alpha-IFN) has been used in relapsed CML post-BMT, cytogenetic responses being attained in a number of cases (33 to 42%). In first chronic phase-CML patients such cytogenetic response has been correlated with the disappearance of the bcr region rearrangement, as seen with Southern-blot, but when RT-PCR is used only a small number of patients maintain undetectable traces of the Ph1 clone. A case of CML in haematological and cytogenetic relapse after BMT is reported who showed criteria of "accelerated" phase and, after treatment with alpha-IFN achieved haematologic, cytogenetic and molecular remission (Southern-blot and PCR negative) and disappearance of the abnormal clone with recovery of the donor haemopoiesis. The duration of the alpha-IFN cytogenetic response is longer than that of BMT (5 vs 3.5 yr), which is noteworthy. Taking the low toxicity of alpha-IFN into account, as compared with that of the other choices (a second BMT, IL2), this treatment should be offered to all patients with cytogenetic relapse after BMT.

Busulfan and melphalan as conditioning regimen for autologous peripheral blood stem cell transplantation in multiple myeloma

Twenty-four patients with multiple myeloma (MM), three (12.5%) in complete remission (CR) and 21 (87.5%) in partial remission (PR) were treated with high-dose chemotherapy (HDCT) (busulfan 12 mg/kg+melphalan 140 mg/m2) as preparative regimen for autologous peripheral blood stem cell (PBSC) transplantation. These cells were previously collected by leukapheresis after mobilization by high-dose cyclophosphamide (HD Cy)+rhGM-CSF (18 patients) or rhG-CSF alone (six patients). Considering 23 evaluable patients following HDCT, the CR rate was 58% (14 patients) and the PR rate was 38% (nine patients). One transplant-related death occurred following this regimen (4%). With a median follow-up of 20 months (range 4-34) after transplantation, 21 patients are alive (87%). Disease progression after transplantation was observed in four patients. Overall and relapse-free actuarial survival at 24 months was 91% and 74%, respectively. 12 patients (50%) remain in CR 15 months (4-34) post transplant. The major toxicity was mucositis. Busulfan+melphalan is a safe and feasible conditioning regimen for APBSCT in MM with acceptable toxicity and a high objective response rate, which may result in prolonged survival.

Hypertriglyceridemia may be severe in CML patients treated with interferon-alpha

We analyzed serum triglyceride (TG) levels in 22 chronic myeloid leukemia (CML) patients treated with interferon-alpha (IFN-alpha). Hypertriglyceridemia was present in one-half of patients at diagnosis, and IFN-alpha treatment was associated with a further increase in 90% of the total group of patients. This increase was maximal during the first months of therapy. Four patients (18%) reached levels higher than 1,000 mg/dl. This is the first report describing this secondary effect in CML patients treated with IFN-alpha.

[Renal hypertrophy studied by techniques of nuclear medicine in post-nephrectomy patients]

Study of group of 61 patients, nephrectomized as a result of various diseases and who before and three months after surgery underwent blood pressure, effective renal plasma flow (EPFF) and unilateral renal function determinations in order to verify the compensating ability of the remaining kidney. Effective renal plasma flow was determined by a single injection and removal of six serial blood samples with 125-I-Hippuran. Unilateral renal function was determined from the relative uptake of 99mTc-DMSA 24 hours after injection. The patients were divided into four groups according to their overall and unilateral renal function as well as the presence or absence of hypertension. Patients with normal EPFF and symmetrical renal function showed a significantly increase in the function of the remaining kidney after surgery (p < 0.001). Patients with normal or slightly reduced EPFF (< 10%) and highly asymmetrical unilateral function as well as those with decreased EPFF (> 10%) and symmetrical or asymmetrical unilateral renal function did not increased the function of the remaining kidney after nephrectomy, and hypertensive patients whose blood pressure returned to normal values after nephrectomy had a decreased function of the remaining kidney after surgery (< 0.001). It is concluded that it is possible to predict the functional behaviour of the remaining kidney after nephrectomy, and that the compensating ability will basically depend on the previously existing (overall and unilateral) renal function as well as the presence or absence of hypertension.

[Retroperitoneal hemorrhage as a complication of renal angiomyolipoma]

Renal angiomyolipoma (AML) is an uncommon, benign neoplasm of a hamartomatous origin that presents as multiple bilateral lesions occasionally associated with tuberous sclerosis, or as a single unilateral lesion. They are generally asymptomatic, and can manifest the following clinical triad: abdominal pain, palpable mass and hematuria. Retroperitoneal hemorrhage is a rare complication (9%). We report 3 cases of spontaneous rupture of renal AML with massive hemorrhage; two of these cases were associated with tuberous sclerosis. This complication was the presenting feature of renal AML in two cases. Radiologic diagnosis and management of this tumor type are highlighted.

99Tcm-MAG3 for quantitation of differential renal function

We studied two different methods for the evaluation of differential renal function in a group of 100 patients with various kidney disorders whose effective renal plasma flow (ERPF) had been calculated previously by single 125I-orthoiodohippurate (OIH) injection and multiple blood sampling. Patients were divided into three groups according to their ERPF:ERPF is greater than or equal to 250 ml min-1; ERPF less than or equal to 100 ml min-1; and ERPF greater than 100 ml min-1 and less than 250 ml min-1. The two methods used to assess differential renal function were: first, relative 99Tcm-dimercaptosuccinic acid (DMSA) uptake calculated by normalized background and attenuation corrected cumulative counts in each kidney 24 h p.i.; and second, relative 99Tcm-mercaptoacetyl-triglycine (MAG3) uptake within 1 and 2 min p.i. calculated by normalized background and attenuation corrected counts on each renal area. The results obtained with each method correlated strongly with high significance (p less than 0.0001). In the right kidney, mean values obtained with 99Tcm-MAG3 tend to be higher than mean values obtained with 99Tcm-DMSA.