Shared Decision-Making in Patients With Prostate Cancer in Japan: Patient Preferences Versus Physician Perceptions

This article adds the Japanese perspective to our knowledge of shared decision-making (SDM) preferences by surveying patients with prostate cancer (PCA) and physicians in Japan. In 2015, 103 Japanese patients with PCA were asked about their SDM preferences by using an Internet-based 5-point-scale questionnaire. Concurrently, 127 Japanese physicians were surveyed regarding their perceptions of patient preferences on SDM. Drivers of preferences and perceptions were analyzed using univariable ordinal logistic regression and graphing the fitted response probabilities. Although 41% of both patients and physicians expressed and expected a desire for active involvement in treatment decisions (a higher rate than in a similar study for the United States in 2001), almost half the Japanese patients preferred SDM, but only 33% of physicians assumed this was their choice. That is, 29% of Japanese physicians underestimated patients’ preference for involvement in making treatment decisions. Patients with lower health-related quality of life (as measured by the Functional Assessment of Cancer Therapy-Prostate [FACT-P]) expressed a stronger preference for SDM. The study shows that the worse the medical situation, the more patients with PCA prefer to be involved in the treatment decision, yet physicians tend to underestimate the preferences of their patients. Perhaps in contrast to common assumptions, Japanese patients are as interested in being involved in decision making as are patients in the United States.

[Indication of repeat prostate biopsy for the diagnosis of prostate cancer]

There is no standard criterion for repeat prostate biopsy in cases with a negative initial biopsy. We retrospectively analyzed our experience of repeat prostate biopsy to establish its indication for the diagnosis of prostate cancer. From April 1997 to March 2005, 35 consecutive patients underwent repeat prostate biopsy at the department of Urology, Asahikawa Medical College Hospital because of clinically suspicious prostate cancer despite a negative initial biopsy. We compared patients' age, number of cores obtained during repeat biopsy, digital rectal examination findings, total prostate volume, the time from the first to the last biopsy, total prostate specific antigen (PSA) value, free PSA/total PSA ratio, PSA density and PSA velocity between cancer-positive and cancer-negative groups. Prostate cancer was detected in 17 of 35 patients (49%). Fifteen patients with prostate cancer were diagnosed by the first repeat biopsy and other 2 patients were diagnosed by the second repeat biopsy. A statistically significant difference was only noted in age and PSA density. Persistently elevated total PSA and a higher PSA density in cases with a negative initial biopsy might be a good indication of repeat prostate biopsy for the diagnosis of prostate cancer.

[Clinical significance of cystoscopy in transrectal prostate biopsy]

The clinical significance of cystoscopy in patients with benign prostatic hyperplasia or prostate cancer remains open to discussion. We have always performed cystoscopy with prostate biopsy and have discovered bladder cancer in some patients. The present study investigated the clinical significance of performing cystoscopy with prostate biopsy. Subjects were 458 patients who underwent cystoscopy and ultrasound-guided transrectal prostate biopsy from January 1998 to December 2004. Mean age of subjects was 71.3 years (range, 52-93 years). Prostate biopsy was performed modified Eskews systematic 5-region prostate biopsy (12 core). Some abnormalities were found in 43 of the 458 patients (9.3%). Among these 43 patients, bladder cancer was found in 11 patients (2.4%), and transurethral resection bladder tumor (TUR-Bt) was performed on all 11 patients. Pathological staging of bladder cancer was pT1 and G2 in all cases. Bladder stones were seen in 13 patients (2.8%), benign bladder tumor in 5 patients (1.1%), urethral polyp in 7 patients (1.5%), urethral stenosis in 6 patients (1.3%) and ureteral stones associated with ureterocele in 1 patient (0.2%). Appropriate examinations and treatments were performed for all cases. Cystoscopy may be needed at the time of prostate biopsy because: the above-mentioned abnormalities were first discovered on cystoscopy; and the frequency of bladder cancer was 2.4% for the total patient population, and endoscopic surgery was performed.

Comparative study of novel endoluminal ultrasonography and conventional transurethral ultrasonography in staging of bladder cancer

BACKGROUND

Recent advances in ultrasonic techniques have improved the image quality and diagnostic accuracy for staging of bladder cancer. The aim of this study was to assess the feasibility and usefulness of endoluminal ultrasonography (ELUS) in staging of bladder cancer, and to compare them with those of conventional transurethral ultrasonography (TUUS).

METHODS

From 2000 to 2002, 19 patients with bladder cancer were evaluated by ELUS and TUUS before transurethral resection or biopsy. Clinical staging using ELUS, TUUS, computed tomography (CT) and magnetic resonance imaging (MRI) was compared with the results of pathological staging.

RESULTS

In 16 of 19 patients, both ELUS and TUUS were able to diagnose tumor stage. In the remaining three patients, both methods were unable to evaluate stage of tumor. In two of these patients, this inability to evaluate tumor state was caused by a difficulty in depicting the tumor base in rectangular scanning. In the remaining patient, the inability to evaluate tumor stage was caused by a difficulty in recognizing the normal muscularis because of edema around the tumor base. Both diagnostic accuracies of ELUS and TUUS were 84%, which were superior to those of CT (44%) and MRI (82%).

CONCLUSIONS

Endoluminal ultrasonography and TUUS were equally useful for staging diagnosis of bladder cancer. Because the ELUS probe is very small in diameter and can be manipulated under direct vision, it is superior to the TUUS in safety and in fine visualization. However, the main limitations of ELUS include an inability to evaluate the depth of invasion of large tumors and an inability to visualize the tumor base in the position of the bladder neck.

Reversal of acquired cisplatin resistance by modulation of metallothionein in transplanted murine tumors

BACKGROUND

The platinum-based chemotherapeutic agent cisplatin is involved in a broad spectrum of activities against human systemic malignancies. However, acquired resistance to cisplatin reduces its clinical efficacy. Elucidation of the molecular basis of cisplatin resistance is required to improve the effectiveness of cisplatin. In the present study, the mechanism of acquired resistance to cisplatin was studied in C3H mice inoculated with MBT-2 murine bladder tumor cells.

METHODS

C3H mice were subcutaneously inoculated with 1.0 x 10(6) MBT-2 cells/mouse on day 0. The mice were given intraperitoneal injections of 10 micro mol/kg cisplatin and subcutaneous injections of 1000 micro mol/kg propargylglycine, an inhibitor of gamma-cystathionase, once a day for 10 consecutive days from day 11 to day 20.

RESULTS

The metallothionein content of the tumors was increased to twice the control level by repeated administration of cisplatin. Co-administration of propargylglycine reduced metallothionein induction in the tumors and markedly enhanced the antitumor activity of cisplatin. In contrast, the glutathione content in the tumors did not change from the control level after cisplatin administration. The platinum accumulation in tumors treated with cisplatin alone was 1.7-fold greater than when propargylglycine was administered concomitantly. The platinum concentrations changed in accordance with the metallothionein contents.

CONCLUSIONS

These observations suggest that metallothionein, but not glutathione or reduced platinum accumulation, might play a role in the acquired resistance to cisplatin of C3H mice inoculated with MBT-2. Moreover, reversal of this resistance might be possible by biochemical modulation of metallothionein.

[Tumor enucleation for pelvic schwannoma: a case report]

A 36-year-old man with a complaint of pollakisuria visited our hospital. A non-displaceable, palm-sized tumor was palpable in the lower abdomen. Laboratory data were normal except for slightly high serum S100 protein. Intravenous pyelography revealed hydronephrosis on the right side and deviation of the bladder to the left. Computed tomogaphy revealed a heterogenous tumor in the pelvis with a cystic lesion and calcification. The tumor was 16 x 12 x 11 cm in size and in contact with the sacrum. The tumor was extirpated following diagnosis as a benign schwannoma by needle biopsy. The pelvic cavity was occupied by the tumor rigidly adhered to the sacrum. Although serious complications, such as bleeding and nerve injury were apprehended, we incised the tumor capsule and enucleated the contents as much as possible. The histopathological diagnosis of the resected specimen was benign schwannoma, type Antoni A. In the last 10 years, 37 cases of pelvic schwannoma have been reported in the Japanese literature. In most of them, surgical extirpation was difficult to perform because of adhesion to the sacrum. If the tumor is confirmed benign from histopathologic findings preoperatively, tumor enucleation may become a therapeutic option.

[A case of late recurrence of germ cell tumor]

A 19-year-old male was admitted to our hospital because of retroperitoneal tumor and metastases in the lung and liver. He underwent chemotherapy followed by retroperitoneal lymph node dissection and pathologic examination revealed mostly necrotic tissue with a small amount of teratomatous tissue. Two years later, a hyper echoic lesion was found in the left testis, and left high orchiectomy was performed. The resected specimen appeared to be a burned-out testicular tumor. Ten years later, CT scan detected lymph node swelling in the retroperitoneum, and excision of the tumor was performed. Pathologic examination revealed well-differentiated adenocarcinoma. Since no primary adenocarcinoma was found, this case was considered late relapse of a germ cell tumor.

[Pulmonary rhabdomyosarcoma generated during treatment of testicular tumor]

A 23-year-old male was admitted to our hospital for the management of pulmonary metastases. He had undergone right high orchiectomy, chemotherapy with four courses of PEB regimen (cisplatin, etoposide, bleomycin) and retroperitoneal lymph node dissection the previous year. The pathological findings showed mixed germ cell tumor (seminoma, yolk sac tumor, embryonal carcinoma) in the testis and mature teratoma in the draining lymph node. Two courses of salvage chemotherapy using a VIP regimen (etoposide, ifosfamide, cisplatin) were performed after diagnosis of pulmonary metastases, but had no affect on tumor size. Video-assisted excision of pulmonary metastases was then performed, giving a pathological diagnosis of rhabdomyosarcoma in all three resected tumors. The operation was followed by three courses of CYVADIC (cyclophosphamide, vincristine, adriamycin, dacarbazin) chemotherapy and oral cyclophosphamide, as a small residual tumor was suspected. These chemotherapeutic interventions have appeared effective, with no apparent recurrence of lesions at present, one year after the excision of pulmonary metastases.

[Retroperitoneal germ cell tumor with testicular calcification indicating tiny testicular origin: consideration of the origin of retroperitoneal germ cell tumors: report of two cases]

Two cases of germ cell neoplasm retrospectively considered to have been of testicular origin are reported. Case 1. A 19-year-old male with brain, liver and retroperitoneal tumors was diagnosed with yolk sac tumor by retroperitoneal tumor biopsy. After multidisciplinary treatment, a region of calcification was detected in the left testis on scrotal sonography and left high inguinal orchiectomy was performed. Case 2. A 57-year-old male with neck, lung and retroperitoneal tumors was diagnosed with yolk sac tumor by supraclavicular biopsy. From initial examination, scrotal sonography revealed a small calcified lesion in the right testis. After chemotherapy, high inguinal orchiectomy and retroperitoneal lymphadenectomy were simultaneously performed. Pathologic evaluation of these testicular specimens revealed calcification and a fibrous scar in correspondence with the clinical diagnosis. These changes were considered as scars of the primary testicular tumor due to burned-out tumor or the result of reaction to chemotherapy. Since a primary tumor of testicular origin may exist in the extragonadal germ cell tumor, it is important to examine the intrascrotal contents in detail in the case of so-called extragonadal germ cell tumors with palpably normal testes. In such cases, there are two possible conditions, an occult testicular tumor and a burned-out testicular tumor. We briefly reviewed 42 such cases in the Japanese literature. It appears that there are very few true extragonadal germ cell tumors, and that the possibility of primary testicular origin metastasizing from viable occult testicular tumor or burned-out testicular tumor with spontaneous regression is high in retroperitoneal germ cell tumors.

[Two cases of vesical nephrogenic adenoma]

Case 1: A 52-year-old man receiving regular treatment for quadriplegia due to Friedreich disease visited our hospital with the chief complaint of macroscopic hematuria. He had undergone cystostomy 12 years ago due to neurogenic bladder. The computed tomography and cystoscopic examination revealed a bladder tumor with a few bladder stones. Transurethral resection of bladder tumor (TUR-Bt) was performed after bladder stone removal in May 2000. The pathological diagnosis showed nephrogenic adenoma. Case 2: A 54-year-old man had been treated with bladder tumor by TUR-Bt in Nov. 1995. The pathological diagnosis showed transitional cell carcinoma, G3, pT2 and intravesical instillation therapy using THP was performed. The bladder tumor had recurred twice and the instillation therapy had been exchanged to BCG since Nov. 1997. A small bladder tumor was observed in Jan. 2001, and from the biopsy specimen it was diagnosed as nephrogenic adenoma. Forty-six cases of urothelial nephrogenic adenoma including our cases have been reported in Japan. Chronic stimulation such as bladder stone and infection is thought to induce nephrogenic adenoma. BCG instillation therapy is believed to be an initiation factors for nephrogenic adenoma.

[A case of urolithiasis associated with short bowel syndrome]

We report a case of urolithiasis associated with short bowel syndrome. A 56-year-old woman was admitted to our hospital for asymptomatic bilateral renal stones. She had received extensive resection of small intestine due to strangulating obstructive ileus 7 years ago (residual intestine, only 20 cm). Subsequently, she was in a state of short bowel syndrome. Plain film of kidney, uteter, bladder and computed tomography revealed bilateral renal stones (right 4 mm, left 10 mm). The left renal stone was successfully treated by extracorporeal shock wave lithotripsy. Since the right renal stone was small, no treatment was performed. The stone fragments were composed of calcium oxalate and calcium phosphate, and excessive urinary excretion of oxalate (103.8 mg/day) was observed. In this patient, urolithiasis was diagnosed to be due to enteric hyperoxaluria caused by short bowel syndrome. To prevent the recurrence of stone formation, she was treated with oral administration of calcium lactate, sodium/potassium citrate and magnesium oxide. We review the Japanese literatures on urolithiasis with short bowel syndrome.

Immunohistochemical expression of metallothionein in human bladder cancer: correlation with histopathological parameters and patient survival

PURPOSE

We assessed metallothionein expression and its patterns of distribution as possible prognostic variables in bladder cancer with regard to histopathological parameters.

MATERIALS AND METHODS

We stained 91 formalin fixed, paraffin embedded tissue specimens of bladder cancer from 91 patients with no history of treatment using an immunohistochemical technique for metallothionein. Relationships between immunoreactivity for metallothionein and histopathological parameters were examined. In addition, these parameters, including metallothionein, were evaluated as potential prognostic markers.

RESULTS

Metallothionein was detected in 33 of 91 bladder cancers (36.3%). There were significant relationships of metallothionein expression with high grade, high stage and nonpapillary growth pattern tumors. There was no specific correlation of metallothionein expression with the interval to intravesical recurrence. In the 31 patients who underwent radical cystectomy a significant relationship between metallothionein immunoreactivity and cancer specific survival was found.

CONCLUSIONS

Our findings suggest that a close correlation exists of metallothionein expression with histopathological parameters and metallothionein expression can be a useful prognostic variable for bladder cancer.

Immunohistochemical expression of metallothionein in human bladder cancer: correlation with histopathological parameters and patient survival

PURPOSE

We assessed metallothionein expression and its patterns of distribution as possible prognostic variables in bladder cancer with regard to histopathological parameters.

MATERIALS AND METHODS

We stained 91 formalin fixed, paraffin embedded tissue specimens of bladder cancer from 91 patients with no history of treatment using an immunohistochemical technique for metallothionein. Relationships between immunoreactivity for metallothionein and histopathological parameters were examined. In addition, these parameters, including metallothionein, were evaluated as potential prognostic markers.

RESULTS

Metallothionein was detected in 33 of 91 bladder cancers (36.3%). There were significant relationships of metallothionein expression with high grade, high stage and nonpapillary growth pattern tumors. There was no specific correlation of metallothionein expression with the interval to intravesical recurrence. In the 31 patients who underwent radical cystectomy a significant relationship between metallothionein immunoreactivity and cancer specific survival was found.

CONCLUSIONS

Our findings suggest that a close correlation exists of metallothionein expression with histopathological parameters and metallothionein expression can be a useful prognostic variable for bladder cancer.

[Nephrogenic adenoma of the bladder in children]

We report an unusual case of a 3-year-old girl with multiple nephrogenic adenomas in the urinary bladder following previous surgical intervention. When she was 6-month-old, right vesicoureter-alreflux (VUR) and left marked hydronephrosis with ectopic urethral opening were found. The left renal pelvis and ureter were incompletely duplicated with a short common segment. Bilateral ureterocystoneostomy and closure of ectopic opening of the left ureter were performed. Left ureteral orifice resulted in double barreled pattern. Postoperative voiding-cystourethrography revealed VUR in the ureter belonging to the lower part of the left kidney. At the age of 3 year, cystoscopic examination revealed multiple papillary lesions in the urinary bladder. These lesions were resected transurethrally and the pathologic diagnosis was nephrogenic adenoma. The patient is the 27th case of nephrogenic adenoma of bladder reported in the Japanese literature.

Early stage of urolithiasis formation in experimental hyperparathyroidism

PURPOSE

We have previously noted marked acceleration in the proliferative activity of parathyroid cells in rats with spontaneous hypercholesterolemia and secondary hyperparathyroidism. Using this proliferative potential we investigated whether transplantation of these enlarged parathyroids into normal rats would induce hyperparathyroidism and renal stones.

MATERIALS AND METHODS

We used 26-week-old male rats with spontaneous hypercholesterolemia as donors, and 5-week-old normal male Sprague-Dawley rats and rats with spontaneous hypercholesterolemia as recipients. Enlarged parathyroid glands were transplanted into group 1--Sprague-Dawley rats with no treatment, group 2--Sprague-Dawley rats that received FK-506 as an immuno-suppressor, group 3--rats with spontaneous hypercholesterolemia rats that underwent parathyroidectomy plus FK-506 administration and group 4--Sprague-Dawley rats that underwent parathyroidectomy plus FK-506 administration. Parathyroidectomy was performed in recipients before transplantation to ensure a low calcium condition.

RESULTS

Grafts were rejected within 11 and 15 weeks in groups 1 and 2, respectively. In group 3, 78% of the grafts were successful even after 19 weeks. In group 4 graft survival was 30% at 15 weeks with complete rejection at 19 weeks. In group 3 gradually elevated serum parathyroid hormone was observed as well as stone plaques containing calcium oxalate and calcium phosphate in renal tubules located mainly in the corticomedullary junction. An increased number of plaques was associated with higher parathyroid hormone.

CONCLUSIONS

Our study shows that transplanted parathyroid glands function with an immunosuppressive agent and the maintenance of hypocalcemic conditions, and they secrete sufficient parathyroid hormone to demonstrate hyperparathyroidism. Plaque in these kidneys indicates an early stage of urolithiasis caused by hyperparathyroidism.

Immunohistochemical expression of P-glycoprotein in the rat urinary bladder and the effect of verapamil on intravesical chemotherapy

BACKGROUND

The expression of P-glycoprotein (Pgp) is thought to be common in bladder epithelium and the multidrug resistance mediated by Pgp must be considered to improve the efficacy of chemotherapy for bladder tumors.

METHODS

The expression of Pgp in normal and tumor tissue of the rat urinary bladder was first examined immunohistochemically. The effect of verapamil, an expected modulator of Pgp, on intravesical chemotherapy of the rats was then investigated.

RESULTS

Pgp was immunohistochemically detected in normal epithelium and in tumor tissue of the rat urinary bladder. In those normal and tumor-bearing bladders, verapamil promoted the uptake of intravesically instilled pirarubicin, but the efflux of intracellular accumulated pirarubicin was observed subsequently in both conditions with and without verapamil. The drug concentration decreased more rapidly in the verapamil group than in the control group.

CONCLUSIONS

Verapamil is thought to be useful in promoting uptake of intravesically instilled pirarubicin, but it did not appear to be so efficient at limiting the efflux of intracellular accumulated pirarubicin.

[Successful complete androgen blockade (CAB) therapy for prostatic cancer detected from multiple lung metastases: a case report]

Prostatic cancer is rarely diagnosed by detection of lung metastases. We report a case of prostatic cancer in a 73-year-old man detected by abnormalities in chest X-ray and serum prostate specific antigen (PSA) level. He was initially admitted to our hospital due to elevation of PSA level. On the first transperineal prostatic needle biopsy, prostatic cancer was not detected and he was followed. Seven months after the first biopsy, chest X-ray revealed multiple abnormal nodules in the lung fields bilaterally and PSA level was again elevated. A second prostatic biopsy and whole-body examination were performed, and he was diagnosed with moderately differentiated prostatic adenocarcinoma with multiple lung metastases. Complete androgen blockade therapy was performed immediately. Two months after the beginning of treatment, PSA level was normalized and the multiple lung metastases had completely disappeared. There has been no evidence of recurrence or PSA relapse 24 months after detection of the prostatic cancer. This is the 26th case of prostatic cancer diagnosed in Japan following detection of multiple lung metastases.

[A case of bilateral renal cell carcinoma showing a rapid course of death in a long-term hemodialysis patient due to polycystic kidney]

A case of bilateral renal cell carcinoma in a 42-year-old polycystic kidney male is reported. He had been treated with hemodialysis for 22 years. An abnormal small mass was found in one of the left renal cystic lesions by screening ultrasonography and CT scan at the 19th year of the hemodialysis. Left radical nephrectomy was performed and the histological diagnosis was a renal cell carcinoma (RCC). There was no evidence of recurrence and metastasis, however, he presented with asymptomatic macrohematuria two years after the operation. CT scan demonstrated the rapidly progressing right renal tumor and multiple para-aortic lymph node swelling. Right nephrectomy and lymphadenectomy were performed and pathological examination showed the advanced RCC with multiple lymph node metastasis. Eleven months after the second operation followed by interferon therapy. he died of multiorgan metastasis of the RCC. This is the first bilateral RCC case in polycystic kidney patient treated with hemodialysis in Japan.

Roles of p53 and MDM2 in tumor proliferation and determination of the prognosis of transitional cell carcinoma of the renal pelvis and ureter

BACKGROUND

The significance of p53 overexpression for the prognosis of transitional cell carcinoma (TCC) of the renal pelvis and ureter remains controversial. Simultaneous evaluation of p53 and MDM2 may enable better prediction of tumor proliferation and patient prognosis than that obtained with evaluation of p53 alone.

METHODS

Immunohistochemical detection of p53 protein, MDM2 protein and Ki-67 antigen as proliferation markers was performed for tissue samples obtained from 74 patients with TCC of the renal pelvis and ureter. The correlations of p53/MDM2 overexpression with conventional pathological features, Ki-67 labelling index (LI) and patient survival were studied.

RESULTS

Overexpression of p53 was related to progression of each of the pathological features examined (grade, stage, type of infiltration, vascular invasion and lymphatic invasion) and Ki-67 LI was significantly higher with high p53 expression than with low p53 expression. However, overexpression of MDM2 was related to neither disease progression nor Ki-67 LI. Survival analyses were performed for 66 patients. Univariate analysis showed p53 to be a useful prognostic indicator, but in a multivariate analysis only type of infiltration and Ki-67 LI were independent survival markers, while p53 was not. Overexpression of MDM2 was unrelated to patient survival, and the combination of p53 and MDM2 for survival indication was found not to be useful.

CONCLUSIONS

Overexpression of p53 is related to disease progression, increased tumor proliferation and patient survival for TCC of the renal pelvis and ureter, but the independent prognostic value of p53 did not reach statistical significance. Combined analysis of MDM2 with p53 cannot be recommended for examination of the malignant potential of TCC of the renal pelvis and ureter.

[A case of bilateral testicular tumors with congenital adrenal hyperplasia]

We report a case of congenital adrenal hyperplasia (CAH) occurring in a 21-year-old man. He was found to have 21-hydroxylase deficiency shortly after birth in search for the cause of vomiting and adrenal insufficiency, and placed on steroid therapy. He had an uneventful childhood with normal onset of puberty. At the age of 21 years he was hospitalized with bilateral testicular masses. They were non-tender, firm and nodular on palpation. The levels of adrenocorticotrophic hormone (ACTH), 17 alpha-hydroxyprogesterone (17 alpha-OHP) were found to be elevated. Testicular biopsy revealed that the nodule comprised mainly eosinophilic sheets and nests and polygonal cells with abundant, granular cytoplasm, but no crystals of Reinke were seen. Testicular tumor with congenital adrenal hyperplasia is typically bilateral and develops in untreated or inadequately treated males with CAH.

[A case of multiple endocrine neoplasia type I with primary hyperparathyroidism, prolactin secreting pituitary microadenoma and gastrin secreting duodenal carcinoid]

A case of MEN type I in a 64-year-old man is reported. He had undergone partial duodenectomy because of gastric ulcer and multiple duodenal polyps (gastrin secreting carcinoid). Blood examination revealed hypercalcemia, hyperPTHemia, and hyperprolactinemia. Neck US and CT showed enlargement of 4 parathyroid glands. Brain MRI revealed the microadenoma in left pituitary gland. Total parathyroidectomy with auto-transplantation in the left forearm were performed. Histological examination showed the hyperplasia of the parathyroid. Three and a half year after parathyroidectomy, there was no evidence of recurrence of gastrin secreting tumor and hyperparathyroidism, and enlargement of pituitary microadenoma. This is the first MEN type I case in Japan which have detected 3 endocrine tumors clinically with gastrin secreting duodenal carcinoid.

[A clinicopathological study on carcinoma of the renal pelvis and ureter]

We investigated the clinicopathological features of 62 patients with transitional cell carcinoma of the renal pelvis and ureter. Four patients had been treated for bladder cancer. Among 58 patients without precedent bladder cancer, 6 had coexistent bladder cancer and bladder cancer subsequently developed in 13. The 5-year cause-specific survival rate was 33% in cases with coexistent bladder cancer, 75% in those with subsequent bladder cancer and 62% in patients without association of bladder cancer. Distant metastases were found in 23 of 62 (37%) cases, the most frequent site being lymph nodes. The site of the primary tumor (renal pelvis and/or ureter) and the pathological findings such as grade, stage, type of infiltration, venous and lymphatic invasion, were significantly correlated to cause-specific survival. Multivariate analysis showed the most influential factors to be the type of infiltration and the site of the primary tumor. Therefore, patients with INF beta or gamma tumors both in the renal pelvis and ureter had a poor prognosis. However, association of bladder cancer was not related to survival.

[Transurethral microwave thermotherapy for benign prostatic hyperplasia]

BACKGROUND

We studied the clinical efficacy of transurethral microwave thermotherapy (TUMT) using Endotherm UMW system (OLYMPUS).

METHODS

TUMT was performed in 28 patients with benign prostatic hyperplasia (BPH). Three patients of them were catheterized because of urinary retention. The treatment was performed in a single session for an hour. The urethral surface temperature was set at 39 degrees C, and the coolant flow of the urethral applicator (21 Fr balloon catheter) was set at 30 ml/min, to heat up the broad area of the prostate up to 45 degrees C. The clinical efficacy was evaluated by analyzing subjective responses, using the International Prostate Symptom Score (I-PSS) scale (S) and QOL score (L), and objective responses, using peak urinary flow rate (Qmax), average flow rate (Qave), residual urine volume and prostate volume following the treatment.

RESULTS

At 24 weeks after the treatment, significant improvement were observed in S score (41%), L score (37%), Qmax (53%) and Qave (62%). Although there was no significant decrease in residual urine and prostate volume. The three patients, with a catheter indwelled because of urinary retention, were all free of the catheter within 4 weeks after the treatment. During and after the treatment, no severe adverse effects, including transient urinary retention needed for indwelling a catheter, was detected.

CONCLUSION

A single session of TUMT by Endotherm UMW considered to be safe and useful for symptomatic BPH patients, even who are not indicated for transurethral resection of the prostate (TUR-P) because of underlying disorders.

[Overexpression of c-erbB-2 and p53 oncoprotein in renal pelvic and ureteral carcinomas with reference to the expression of Ki-67 antigen as a proliferation marker]

PURPOSE

We determine the significance of c-erbB-2 and p53 gene in the progression of renal pelvic and ureteral carcinomas.

METHODS

Overexpression of c-erbB-2 and p53 oncoprotein was investigated using immunohistochemical staining with reference to pathological features. The expression of Ki-67 antigen was also studied as a proliferation marker.

RESULTS

Forty-seven cases were examined, and the overexpression of c-erbB-2 oncoprotein was revealed in 25 (53%) cases. It was not related both tumor grade (G) and tumor stage (pT). The overexpression of p53 oncoprotein was revealed in 29 (62%) cases. There were 13 p53 positive cases in 27 low grade (G1, G2) tumors, and 16 in 20 high grade (G3) tumors. There were also 8 p53 positive cases in 21 low stage (pTa, pT1) tumors, and 21 in 26 high stage (pT2-4) tumors. Thus, p53 oncoprotein was more frequently overexpressed in high grade tumors (p < 0.05) and in high stage tumors (p < 0.01). Ki-67 labelling index (LI, mean +/- SD) was 10.7 +/- 8.9 in low grade tumors and 26.3 +/- 12.5 in high grade tumors. It was also 9.0 +/- 8.1 in low stage tumors and 24.0 +/- 12.4 in high stage tumors. Thus, Ki-67 LI was higher in high grade tumors (p < 0.01) and in high stage tumors (p < 0.01). The c-erbB-2 status and Ki-67 LI were not correlated, while the LI of p53 positive cases (21. 7 +/- 13.6) was significantly higher (p < 0.01) than it of p53 negative cases (10.3 +/- 8.5). The difference of LI between p53 positive cases and p53 negative cases was significant (p < 0.05) in low grade tumors, but in high grade tumors LI was higher than it of low grade tumors independently of p53 expression.

CONCLUSION

p53 but not c-erbB-2 was considered to be associated with rapid tumor progression in renal pelvic and ureteral carcinoma and play an important role in its progression especially in low grade tumors.

Homology of p53 intronic sequences between four laboratory mouse strains and Japanese wild mouse (Mus musculus molossinus Mishima)

Strain variation in the mouse p53 gene sequences was investigated in various regions of the gene in 14 inbred strains of laboratory mice and one Japanese wild mouse strain (Mus musculus molossinus Mishima, M. MOL-MSM). Nucleotides within p53 introns 1 and 7, found to be identical in 10 of the laboratory strains (129/J, A/J, AKR/J, BALB/cJ, C3H/HeJ, C57BL/6J, CBA/J, CE/J, NZB, and SWR/J), were substituted for other nucleotide sequences in common with M. MOL-MSM and the four other strains (DBA/1J, DBA/2J, I/LnJ, and P/J). The latter were documented to have originated from a common ancestor. These observations thus suggested the possibility that the p53 gene may have become substituted by outcrossing of this ancestral strain with Asian mice; this is presumably related to the documentation that Japanese mice brought to western countries were used as laboratory mice early in this century. To establish p53 gene heterozygosity, female C3H/HeJ and male DBA/2J mice were mated to produce F1 hybrids (C3D2F1). Electrophoresis of PCR fragments including polymorphic regions with or without restriction enzyme digestion, allowed clear distinction of paternal and maternal p53 alleles. These markers, therefore, should be useful for studying the loss of heterozygosity of the p53 gene during the carcinogenic process.

Infrequent loss of heterozygosity and mutation of the p53 gene in immortal and transformed mouse embryo fibroblasts

Some of the progeny of isolated mouse embryo fibroblasts acquire the ability to grow indefinitely during cultivation, presumably through some mutational events. The relevance of p53 mutations and loss of heterozygosity to the mechanism of such immortal growth capability remains controversial. Since four bases in intron 1 of the p53 gene in C3H/HeJ mice are replaced by 13 different bases in DBA/2J mice, it is possible to distinguish maternal and paternal p53 alleles in the cells of F1 hybrids of these strains (C3D2F1) by electrophoresis of polymerase chain reaction fragments including the region. We established 23 spontaneously immortalized fibroblast cell lines from C3D2F1 mouse embryos and 29 transformed cell lines induced from one of the immortal cell lines, either by treatment with chemical carcinogens or by transfection with the c-Ha-ras gene. Of these 52 cell lines, only one, derived from fibroblasts unpassaged for 4 mo, showed p53 gene loss of heterozygosity and a structural alteration in the remaining allele. Our results demonstrated that p53 mutations are not a strict requirement for immortalization and transformation of mouse embryo fibroblasts in vitro.

[A case report of inverted papilloma of the posterior urethra]

A case of inverted papilloma of the posterior urethra is reported. A 59-year-old male was admitted with the chief complaint of hematuria. Urethrogram revealed a small defect in the neck of the bladder. Endoscopic examination revealed a polypoid tumor on the stalk arising from prostatic urethra, and transurethral resection was performed. The patient has been subsequently followed up and there has been no evidence of recurrence. Although 141 cases of inverted papilloma have been reported in many anatomical sites of the urinary tract, only 19 cases involving the posterior urethra have been described in Japan. This is the 20th case of a posterior urethra.