Transarterial ethiodised oil marking before CT-guided renal cryoablation: evaluation of tumour visibility in various renal cell carcinoma subtypes

AIM

To evaluate ethiodised oil retention of transarterial embolisation using ethiodised oil (ethiodised oil marking) before computed tomography (CT)-guided percutaneous cryoablation (PCA) according to renal cell carcinoma (RCC) subtype.

MATERIALS AND METHODS

Ethiodised oil marking was performed 1-3 days before PCA in 99 patients with 99 RCCs from 2016 to 2020. Ethiodised oil retention on CT images was evaluated retrospectively and CT attenuation values in the tumour were measured. Regions of interest (ROI) were placed on the tumours to calculate: average (ROI-average), maximal (ROI-max), minimum (ROI-min), and standard deviation (ROI-SD). Qualitative scores comprising a five-point scale (5, excellent; 1, poor) were evaluated for the retention scores (RS) of ethiodised oil in the tumour (ethiodised oil-RS) and the visualisation scores (VS) of the boundary between the tumour and renal parenchyma (boundary-VS).

RESULTS

The histological subtypes comprised clear cell (ccRCC; n=85), papillary (pRCC; n=6), and chromophobe/oncocytoma renal cell carcinoma (chrRCC; n=8). The mean ROI-average, ROI-max, and ROI-SD were significantly higher in ccRCCs than in chrRCCs and pRCCs (p<0.05). The mean ethiodised oil-RS was significantly lower in pRCCs than in ccRCCs (p=0.039), and the mean boundary-VS was >4 in all subtypes. Even with poor intratumour ethiodised oil retention (n=6), sufficient boundary-VS was obtained due to "inverted marking." All PCA procedures were completed without additional intravenous contrast material injection at the time of PCA.

CONCLUSION

Regardless of the tumour subtypes, ethiodised oil marking aids in visualising the boundary between the tumour and parenchyma on non-contrast CT in PCA.

Safety and efficacy of PD-1/PD-L1 blockade in patients with preexisting antinuclear antibodies

PURPOSE

Immune checkpoint inhibitors (ICIs) show promising clinical activity in advanced cancers. However, the safety and efficacy of PD-1/PD-L1 blockade in patients with preexisting antinuclear antibodies (ANA) are unclear.

METHODS

191 patients treated with nivolumab, pembrolizumab, atezolizumab, or durvalumab for unresectable advanced cancers between September 2014 and December 2018 were identified retrospectively. Patients were divided into positive (ANA titers ≥ 1:160) and negative ANA groups (ANA titers < 1:160). Development of immune-related adverse events (irAEs), the overall response rate (ORR), and disease control rate (DCR) were monitored.

RESULTS

Positive ANA titers were seen in 9 out of 191 patients. Four patients in the positive ANA group and 69 patients in the negative group developed irAEs of any grade without a significant difference between the groups. The development of endocrine, pulmonary, and cutaneous irAEs was not significant, whereas positive ANA was significantly higher in patients who developed colitis (2/9) than in patients who did not (3/182, P = 0.0002). DCR in the positive and negative ANA group was 37.5% and 67.5%, respectively, and was not statistically significant, but had better efficacy in patients without ANA (P = 0.08). ANA-related autoimmune diseases such as SLE, Sjögren's syndrome, MCTD, scleroderma, dermatomyositis, and polymyositis was not induced in either group. However, one patient with preexisting dermatomyositis had a flare up after initiation of atezolizumab.

CONCLUSION

Further studies to identify predictive factors for the development of irAEs are required to provide relevant patient care and maximize the therapeutic benefits of ICIs.

[Interest using 3D ultrasound and MRI fusion biopsy for prostate cancer detection]

INTRODUCTION

The strategic therapy for prostate cancer depends on histo-pronostics data, which could be upgraded by obtaining targeted biopsies (TB) with MRI (magnetic resonance imagery) fusion 3D ultrasound.

OBJECTIVES

To compare diagnostic yield of image fusion guided prostate biopsy using image fusion of multi-parametric MRI (mpMRI) with 3D-TRUS.

MATERIALS AND METHODS

Between January 2010 and April 2013, 179 consecutive patients underwent outpatient TRUS biopsy using the real-time 3D TRUS tracking system (Urostation™). These patients underwent MRI-TRUS fusion targeted biopsies (TB) with 3D volume data of the MRI elastically fused with 3D TRUS at the time of biopsy.

RESULTS

A hundred and seventy-three patients had TBs with fusion. Mean biopsy core per patient were 11.1 (6-14) for SB and 2.4 (1-6) for TB. SBs were positive in 11% compared to 56% for TB (P<0.001). TB outperformed systematic biopsy(SB) in overall any cancer detection rate, detection of clinically significant cancer (58% vs. 36%), cancer core length (6.8mm vs. 2.8mm), and cancer rate per core (P<0.001). In multivariable logistic regression, with TB we have more chance to find a clinically significant cancer (OR:3.72 [2-6.95]). When both TRUS and MRI are positive, there is 2.73 more chance to find a clinically significant cancer.

CONCLUSION

MR/TRUS elastic fusion-guided biopsies outperform systematic random biopsies in diagnosing clinically significant cancer. Ability of interpretation of real-time TRUS is essential to perform the higher level of MR/US fusion and should be use for active surveillance.

LEVEL OF PROOF

4.

Standardization of definitions in focal therapy of prostate cancer: report from a Delphi consensus project

PURPOSE

To reach standardized terminology in focal therapy (FT) for prostate cancer (PCa).

METHODS

A four-stage modified Delphi consensus project was undertaken among a panel of international experts in the field of FT for PCa. Data on terminology in FT was collected from the panel by three rounds of online questionnaires. During a face-to-face meeting on June 21, 2015, attended by 38 experts, all data from the online rounds were reviewed and recommendations for definitions were formulated.

RESULTS

Consensus was attained on 23 of 27 topics; Targeted FT was defined as a lesion-based treatment strategy, treating all identified significant cancer foci; FT was generically defined as an anatomy-based (zonal) treatment strategy. Treatment failure due to the ablative energy inadequately destroying treated tissue is defined as ablation failure. In targeting failure the energy is not adequately applied to the tumor spatially and selection failure occurs when a patient was wrongfully selected for FT. No definition of biochemical recurrence can be recommended based on the current data. Important definitions for outcome measures are potency (minimum IIEF-5 score of 21), incontinence (new need for pads or leakage) and deterioration in urinary function (increase in IPSS >5 points). No agreement on the best quality of life tool was established, but UCLA-EPIC and EORTC-QLQ-30 were most commonly supported by the experts. A complete overview of statements is presented in the text.

CONCLUSION

Focal therapy is an emerging field of PCa therapeutics. Standardization of definitions helps to create comparable research results and facilitate clear communication in clinical practice.

Prognostic outcome in Japanese men with prostate cancer treated with androgen-deprivation therapy (ADT) alone: Data from multi-institutional cooperative study in Kyoto Prostate Cancer Registry (KPCR)

e16106

Background: There is scarce data of ADT alone concerning prognostic outcome in terms of clinical stage, and in comparison with radical treatments specifically in men without metastatic diseases. The aim of this study was to analyze prognostic outcome for ADT alone, and to assess the significant prognostic parameters in Japanese men. Methods: Database in the KPCR, which is a multi-institutional urologic cancer registry, was screened to identify prostate cancer patients who received ADT alone between 1988 and 2008. Clinical data including age, clinical stage, biopsy differentiation, initial prostate-specific antigen (PSA) level and type of ADT: luteinizing hormone-releasing hormone (LH-RH) monotherapy or combined androgen blockade (CAB), were analyzed. Time to prostate cancer relapse as well as cause specific survivals were also analyzed. Results: Of 1167 men with prostate cancer registered in KPCR, 373 patients (32%) received primary ADT and continued ADT alone during the observation period. Of those men, age and PSA level ranged from 52 to 95 y.o (median: 75) and from 2.17 to 8,650 ng/ml (median: 23.5), respectively. The numbers of clinical stage in A to B, C and D were 148 (40%), 127 (34%), and 98 (26%), respectively. The observation period ranged from 1 to 125 months (median: 55). Of the 373 men, 113 men (30%) recurred after the primary ADT. Of the 131men, 36 men (10%) changed from LH-RH monotherapy to CAB, and 46 (12%) and 52 men (14%) underwent anti-androgen alternative therapy and secondary hormonal therapy using estramustine phosphate and/or oral dexamethasone, respectively. There was a significant difference in 5-year cause specific survival between stage A-C (98%) and D (63%, p < 0.0001). Cox proportional hazards multivariate regression analyses revealed that localized cancer (stage A and B) was the most significant prognostic factor in the time to relapse (p < 0.0001) as well as the cause specific survival (p < 0.0001). Conclusions: There was substantial number of men with localized disease who were treated ADT alone. The use of ADT therapy alone appeared to have favor prognosis in the majority of patients without metastatic diseases, at least for an intermediate period.

No significant financial relationships to disclose.

Significance of the expression of thymidylate synthase in prostate cancer

e16163

Background: Thymidylate synthase ( TS ) is an important enzyme in de novo DNA synthesis pathway. 5-Fluorouracil ( 5-FU ), an anticancer chemotherapeutic agent used clinically against a variety of cancers including prostate cancer, inhibits DNA synthesis by binding TS. In the present study, we examined TS expression in prostate cancer and investigated its prognostic significance. Methods: Fifty-two prostate cancer tissue specimens were obtained from patients who underwent radical prostatectomy for prostate cancer without neoadjuvant hormonal therapy. Forty-eight prostate cancer tissue specimens were also obtained from patients who underwent radical prostatectomy for prostate cancer with neoadjuvant hormonal therapy. We examined prostate cancer tissue and normal prostate tissue for TS expression by immunohistochemistry. Results: TS was expressed at higher levels in prostate cancer without neoadjuvant hormonal therapy, compared with normal prostate.TS expression in stage T3 prostate cancer was higher than that in stage T2 prostate cancer. In addition, the level of TS expression in Gleason score 7 or greater prostate cancer was higher than that in Gleason score less than 7 prostate cancer. Patients with prostate cancer with negative TS expression without neoadjuvant hormonal therapy had a longer postoperative recurrence-free rate than those with positive expression in the 5 year follow-up. In addition, patients with Gleason score less than 7 prostate cancer with negative TS expression had a much longer postoperative recurrence-free rate than those with positive expression in the 5-year follow-up. TS expression was significantly decreased in prostate cancer patients who received neoadjuvant hormonal therapy, especially stage T2 prostate cancer patients. Conclusions: The current study has demonstrated for the first time that TS expression may be a prognostic parameterr for prostate cancer patients undergoing radical prostatectomy.

No significant financial relationships to disclose.

Enhanced orotate phosphoribosyltransferase activity in renal cell carcinoma and its prognostic significance

15590

Background: 5-Fluorouracil ( 5-FU ) is an anticancer agent clinically used against various cancers including renal cell carcinoma ( RCC ). 5-FU is a prodrug and orotate phosphoribosyltransferase ( OPRT ) is the principal enzyme which directly converts 5-FU to an active anticancer metabolite, 5-fluoro-2’-deoxyuridine 5’-monophosphate. Furthermore, OPRT is the key enzyme in the de novo DNA and RNA synthetic process, which converts orotic acid to orotidine 5’-phosphate. Little is known about the significance of OPRT in a variety of cancers including RCC. We investigated OPRT activity in 83 RCC and evaluated the association between OPRT activity and the stage/grade of RCC. The relationship between OPRT activity in RCC cells and their sensitivity to 5-FU was also examined. Methods: OPRT activity in non-fixed fresh frozen RCC and normal kidney were determined enzymatically by the 5-FU phosphorylation assay. The sensitivity of RCC cells to 5-FU was assessed by the microculture tetrazolium dye assay. Results: OPRT activity was approximately 8.5-fold higher in RCC compared to normal kidney. OPRT activity in T3/4 RCC was 3-fold higher than that in T1/2 RCC. OPRT activity in M1 RCC was 2.5-fold higher than that in M0 RCC. In addition, OPRT activity in Stage III/IV RCC was 3-fold higher than that in Stage I/II RCC. The level of OPRT activity in Grade 3 RCC was 3-fold higher than that in Grade 1/2 cancer. Patients with RCC with low OPRT activity had a longer postoperative disease-specific survival than those with high activity in the 5-year follow-up. OPRT activity in RCC cells positively correlated with their sensitivity to 5-FU. Conclusions: The present study has demonstrated that OPRT activity in RCC was higher than that in normal kidney, and that OPRT activity positively correlated with the stage/grade of RCC. Moreover, higher OPRT activity in RCC predicted worse prognosis and higher sensitivity to 5-FU. These results suggest that OPRT activity may be used as both a prognostic parameter and a predictive indicator for 5-FU efficacy in RCC.

No significant financial relationships to disclose.

Prognostic significance of the level of serum osteoprotegerin in patients with bladder cancer

4581

Background: Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) plays an important role in cytotoxic T lymphocyte-mediated and natural killer cell-mediated apoptosis against cancer cells. Since Osteoprotegerin (OPG) is a soluble decoy receptor for TRAIL, circulating OPG has been implicated in protection from TRAIL-mediated apoptosis. This possibility was examined in patients with bladder cancer. Methods: Serum OPG levels of 185 patients with bladder cancer were determined by using an enzyme-linked immunosorbent assay. Anti-autologous tumor cytotoxic activity of peripheral blood lymphocytes was assessed by the 12-h Cr release assay. Results: The mean serum OPG level in patients with bladder cancer was approximately 3-fold higher than that in normal donors. The serum OPG level in patients with muscle-invasive bladder cancer was higher than that in superficial bladder cancer. Furthermore, serum level of OPG in patients with metastatic bladder cancer was higher than that in muscle-invasive bladder cancer. Serum OPG level in Grade 2 bladder cancer was higher than that in Grade 1 cancer. Moreover, serum OPG level in Grade 3 bladder cancer was higher than that in Grade 2 cancer. Patients with superficial bladder cancer with low serum OPG level had a longer postoperative tumor-free rate than those with high level in the 5-year follow-up. In addition, patients with muscle-invasive bladder cancer with low serum OPG level had a higher disease-specific survival rate when compared with patients with high level in the 5-year follow-up. There was an inverse correlation between serum OPG level and anti-autologous tumor cytotoxic activity. Conclusions: The present study is the first to demonstrate that the serum OPG level correlates with the stage/grade of bladder cancer, and that elevated level serum OPG predicted early recurrence in patient with bladder cancer. These findings suggest that serum OPG level may be used as a prognostic parameter in patients with bladder cancer, and that OPG may be a molecular therapeutic target in bladder cancer.

No significant financial relationships to disclose.

Significant decrease of the International Index of Erectile Function in male renal failure patients treated with hemodialysis

In order to evaluate the erectile function in male renal failure patients treated with hemodialysis (HD), we investigated the International Index of Erectile Function (IIEF) in patients and healthy controls. The subjects were 174 male patients treated with HD, of whom 43 had diabetes mellitus (DM) and the remaining 131 patients did not have DM. The controls were 1133 healthy males. We evaluated the prevalence of erectile dysfunction (ED) using the erectile function (EF) score, which is one of the five domains of the IIEF, in each age group (upto 39 y old, 40-49 y old, 50-59 y old, 60-69 y old). The severity of ED was classified into five categories using EF in each age group. The univariate logistic regression analysis and multiple variate analysis of IIEF in HD patients were performed. The prevalence of ED in HD patients was significantly higher than that in the controls in each age group. The severity of ED in HD patients was also significantly higher than that in the controls in each age group. In the logistic regression analysis and multiple variate analysis of IIEF in HD patients, DM and age were significant risk factors on sexual dysfunction. ED was more prevalent in male renal failure patients treated with HD than in the controls. In the patient group, ED was more prevalent in older DM patients.

Possible use of ultrasound estimated bladder weight in evaluating vesicoureteral reflux in children

The present study was designed to reveal the possible use of ultrasound estimated bladder weight (UEBW) in evaluating vesicoureteral reflux (VUR) in children in terms of possible implication of bladder hypertrophy in VUR. In 27 children with VUR, UEBW was measured by transabdominal ultrasound. The UEBW in an individual patient was evaluated quantitatively using the percent deviation from age matched UEBW. There was a significant difference noted in the percent deviation from age-matched UEBW between patients (n = 17) with primary VUR and those (n = 10) with secondary VUR (p <.05). When analyzed together in 27 patients, a significant positive correlation (p <.05) was recognized between the percent deviation from age-matched UEBW and VUR grade. This was also the case in ten patients with secondary VUR (p <.01), but not for 17 patients with primary VUR. The measurement of UEBW might be of clinical use in evaluating the pathogenesis as well as the severity of VUR in children.

Follow-up study of bedwetting from 3 to 5 years of age

OBJECTIVES

To evaluate the relationship between bedwetting and development in infancy.

METHODS

Questionnaires concerning micturition habits and development at 3 and 5 years of age were completed by the parents of 157 children who had had their health checked by pediatricians at a group checkup at 3 years of age.

RESULTS

The percentage of bedwetters in whom the frequency of bedwetting was at least once a month was 53% at 3 years of age and 21% at 5 years of age. The prevalent resolution period of bedwetting in infants was 2.5 to 3.5 years of age. The head circumference for boys at birth differed significantly between the bedwetters and nonbedwetters at both ages. Daytime symptoms were more frequent among bedwetters at both ages. Earlier toilet training had no influence on bedwetting at 5 years of age, although it led to earlier control at night at a younger age. Delays in speaking and walking might be factors connected to bedwetting. The prevalence of bedwetting in boys was higher than that in girls. Multiple logistic regression analysis revealed that daytime incontinence and sex were significant factors for bedwetting at 5 years of age.

CONCLUSIONS

Daytime incontinence and sex were the significant factors for bedwetting in infancy. Head circumference for boys and developmental delays in speaking and walking might also be important factors.

Possible use of transrectal power Doppler imaging as an indicator of microvascular density of prostate cancer

OBJECTIVES

To reveal the possible use of transrectal power Doppler imaging (PDI) of the prostate in the assessment of the microvascular density (MVD) of cancer lesions.

METHODS

In 22 patients with clinically organ-confined prostate cancer, PDI was performed before radical prostatectomy and the degree of vascularity of the cancer lesions as evaluated by PDI was compared with the MVD determined on the surgical specimens. The vascularity by PDI of each cancer lesion was graded on a scale of DS0 to DS2, according to the degree of Doppler signal accumulation. MVD was obtained using factor VIII immunohistochemistry.

RESULTS

The vascularity of the PDI of 46 cancer lesions categorized 23 (50%), 10 (22%), and 13 (28%) cancer lesions as DS0, DS1, and DS2, respectively. Significant differences were found in the MVD between DS0 (46.6 +/- 26.8) and DS2 (89.0 +/- 18.1, P <0.005) lesions and between DS1 (50.9 +/- 25.4) and DS2 (P <0.001) lesions. The MVD of 30 cancer lesions in 13 patients without neoadjuvant therapy was significantly higher than that of the 16 lesions in 9 patients with therapy (70.2 +/- 28.2 versus 39.5 +/- 23.9, P <0.001). In the 13 patients without neoadjuvant therapy, the MVD of the DS2 lesions (89.1 +/- 18.9) was significantly higher than that of the DS0 lesions (59.3 +/- 32.5, P <0.01) and DS1 lesions (55.9 +/- 20.9, P <0.005).

CONCLUSIONS

The semiquantitative assessment of Doppler flow signals using PDI appears to be of clinical value as an indicator of MVD.

Immunohistochemical studies on the distribution of nerve fibers in the human prostate with special reference to the anterior fibromuscular stroma

BACKGROUND

Although the anterior fibromuscular stroma (AFMS) comprises up to one third of the total bulk of the prostate, its physiological function remains unknown. We recently reported the possible contribution of the AFMS to micturition. The aim of this study is to reveal the differences in the distribution of innervation between the AFMS and the other regions of the prostate.

METHODS

We performed immunohistochemical stainings using antibodies such as protein gene product (PGP) 9.5, tyrosine hydroxylase(TH), neuropeptide Y (NPY), and vasoactive intestinal peptide (VIP). Morphometric analysis was made to examine the density of peripheral nerve fibers containing PGP 9.5, TH, NPY, and VIP by using a computer-assisted imaging system.

RESULTS

The number of PGP 9.5-immunoreactive (IR) nerve fibers and the smooth muscle in the AFMS decreased from the base to the apex of the prostate. TH-IR nerve fibers were more abundant in the AFMS than in the transition zone. NPY- and VIP-IR nerve fibers were less numerous in the AFMS than in the peripheral zone.

CONCLUSIONS

This study is the first to demonstrate that the AFMS has peculiar neuronal innervation. We observed significantly different innervation in the AFMS compared with the other regions of the prostate.

Alternative splicing isoforms of hippostasin (PRSS20/KLK11) in prostate cancer cell lines

BACKGROUND

Hippostasin is a kallikrein-like protease (PRSS20/KLK11), which is expressed preferentially in the hippocampus and prostate. We have reported that alternative splicing variants of human hippostasin are regulated in a tissue-specific manner. Brain-type hippostasin consists of 250 amino acids including a typical signal sequence, and is expressed in the brain and prostate. The prostate-type hippostasin, which has 32 extra amino acids at the N-terminal end, is expressed only in the prostate.

METHODS

We analyzed the expression and localization of hippostasin in normal prostate tissue, BPH tissue, and prostate cancer cell lines. We performed northern blotting, in situ hybridization, immunohistochemistry, and RT-PCR.

RESULTS

Hippostasin mRNA is expressed preferentially in the normal prostate and weakly in the testis. It was detected in prostate secretory epithelium. Hippostasin protein was localized in the prostate secretory epithelium, and western blotting showed that hippostasin was present in semen. All tested prostate cancer cell lines, including PSA-negative cell lines, expressed hippostasin. Interestingly, all the prostate cancer cell lines expressed only brain-type but not prostate-type hippostasin, while normal prostate and BPH expressed both types of hippostasin

CONCLUSIONS

Our results suggest the possibility that hippostasin may be a useful marker by which prostate cancer and BPH can be distinguished.

EVALUATION OF REFLUX KIDNEY USING RENAL RESISTIVE INDEX

PURPOSE

We clarified the relationships of the renal resistive index, reflux and renal scarring.

MATERIALS AND METHODS

The resistive index in the interlobar artery was measured using power Doppler ultrasonography in 22 patients with reflux (reflux group), 13 with postoperative or resolved reflux (previous reflux group) and 20 who served as controls.

RESULTS

Resistive index values in 11 kidneys with mid or high grade reflux were significantly higher than in 22 with low grade reflux and in the 40 normal kidneys. The resistive index in the 11 kidneys with reflux and scarring was significantly higher than in the 22 with reflux and without scarring, and in the 40 normal kidneys. The resistive index in the 14 kidneys with previous reflux and scarring was significantly higher than in 12 with previous reflux and without scarring, and in the 40 normal kidneys. Receiver operating characteristics curve analysis in 25 kidneys with and 34 without scarring revealed that a discriminatory resistive index value of 0.71 was optimal for detecting renal scarring. When the resistive index cutoff value was 0.71, there was 76% sensitivity for diagnosing renal scarring, 91% specificity and 85% overall accuracy.

CONCLUSIONS

Our results show the possibility that an increased resistive index in kidneys with reflux predicts renal scarring. The resistive index measured with power Doppler ultrasonography may be a noninvasive and useful alternative for screening and following renal scarring.

The significance of dihydropyrimidine dehydrogenase (DPD) activity in bladder cancer

Dihydropyrimidine dehydrogenase (DPD) is the rate-limiting enzyme in the pathway of uracil and thymine catabolism. DPD is also the principal enzyme involved in the degradation of 5-fluorouracil (5-FU), which is one of the anticancer chemotherapeutic agents currently used in the treatment of bladder cancer. Little is known about the significance of DPD activity in human cancers. We investigated the activity of DPD in 74 bladder cancers and the relationship between the DPD activity and the sensitivity to 5-FU. The levels of DPD activity in bladder cancer and normal bladder tissues were determined by the 5-FU degradation assay. The sensitivity to 5-FU was assessed by the microculture tetrazolium dye (dimethylthiazolyl-2-5-diphenyltetrazolium bromide; MTT) assay. The activity of DPD was approximately 2-fold higher in bladder cancer tissues compared with normal bladder tissues. DPD activity in invasive bladder cancers was approximately 2-fold higher than that in superficial cancers. In addition, the levels of DPD activity in grade 2 and grade 3 bladder cancers were approximately 3-fold and 4-fold higher than that in grade 1 cancers, respectively. Patients with superficial bladder cancer with a low DPD activity had a slightly longer postoperative tumour-free period than those with a high DPD activity over a 2-year follow-up period, but this was not significant. There was an inverse correlation between DPD activity in bladder cancer cells and their sensitivity to 5-FU. Furthermore, 5-chloro-2,4-dihydroxypyridine (CDHP), a potent DPD inhibitor, enhanced the sensitivity to 5-FU. The present study has demonstrated that the level of DPD activity correlated with the progression of the stage and an increase in the grade of the bladder cancer. These results suggest that an elevated DPD activity might be associated with the malignant potential of the bladder cancer. In addition, it might be possible to overcome 5-FU insensitivity by using DPD inhibitors in the treatment protocols of 5-FU-based chemotherapy for bladder cancers.

Acupuncture on clinical symptoms and urodynamic measurements in spinal-cord-injured patients with detrusor hyperreflexia

OBJECTIVES

We investigated the possible use of acupuncture for the treatment of urinary incontinence caused by detrusor hyperreflexia in patients with chronic spinal cord injuries.

METHODS

A total of 13 patients (11 males, 2 females) suffering from urinary incontinence due to spinal cord injuries were treated by acupuncture, which was carried out with disposable stainless steel needles inserted into the bilateral BL-33 (Zhongliao) points on the skin of the third posterior sacral foramina. Urodynamic studies were also performed before acupuncture, immediately after the 1st acupuncture and 1 week after the 4th acupuncture. In 6 patients, these urodynamic studies were performed again 1 month after the 4th acupuncture.

RESULTS

No side effects were recognized throughout the treatment period. Of the 13 patients, incontinence disappeared in 2 (15%) and decreased to 50% or less compared to baseline in a further 6 (46%). Maximum cystometric bladder capacity increased significantly from 76.2 +/- 62.3 to 148.1 +/- 81.5 ml 1 week after the 4th acupuncture (p < 0.01). In the 6 patients in whom cystometry was repeated 1 month after the 4th acupuncture, bladder capacity decreased from 187.5 +/- 90.4 ml 1 week after the 4th acupuncture to 128.3 +/- 93.4 ml.

CONCLUSION

In spinal cord injury patients acupuncture could represent another valuable therapeutic alternative to the treatment of urinary incontinence caused by detrusor hyperreflexia.

Immunohistochemical localization of platelet-derived endothelial cell growth factor expression and its relation to angiogenesis in prostate

OBJECTIVES

Tumor angiogenesis has been reported as a predictor for prognosis in patients with prostate cancer. The aim of this study was to determine the localization of one angiogenic factor, platelet-derived endothelial cell growth factor (PD-ECGF), in benign and malignant prostatic tissues and the correlation between PD-ECGF expression and microvessel density (MVD) in prostate cancer.

METHODS

Forty cases of prostate cancer, 3 cases of benign prostatic hyperplasia, and 5 young autopsy cases without prostatic disease were processed with immunohistochemistry, using an anti-PD-ECGF antibody and anti-factor VIII-related antigen antibody. The PD-ECGF expression intensity and MVD were evaluated in each case.

RESULTS

In the 40 cases with prostate cancer, the expression of PD-ECGF was noted in the stromal cells within cancer tissues in 80% of cases. Additionally, noncancerous glands next to cancer lesions were positive for PD-ECGF in 85% of cases. However, cancer cells were negative for PD-ECGF in all cases. In the 8 cases without cancer, both the prostatic glands and their surrounding stroma were positive for PD-ECGF only when they were accompanied by inflammation. There was a significant positive correlation (r = 0.636, P <0.001) between the intensity of PD-ECGF expression and MVD. MVD was significantly different when comparing the intensity of PD-ECGF expression of grade 0 versus grade 1 (P <0.05), grade 1 versus grade 2 (P <0.05), and grade 0 versus grade 2 (P <0.01).

CONCLUSIONS

This study suggested that PD-ECGF expression in the stromal cells within cancer tissues might play an important role in tumor angiogenesis in prostate cancer.

Low doses of oral dexamethasone for hormone-refractory prostate carcinoma

BACKGROUND

Although glucocorticoids have been used to treat patients with hormone-refractory prostate carcinoma (HRPC), reports have varied regarding the types and doses of glucocorticoids used as well as their clinical benefits. In the current study, low doses of dexamethasone were investigated for their specific beneficial effects and the feasibility of long term treatment.

METHODS

Thirty-seven patients diagnosed with HRPC were treated with oral dexamethasone (0.5-2 mg/day). The patients ranged in age from 53-89 years (median, 74 years). Thirty-two patients, including 6 with lymph node metastases, had bone involvement whereas only 5 patients were found to have elevated serum prostate specific antigen (PSA) levels.

RESULTS

Twenty-three patients (62%) who received no other concomitant therapy demonstrated a decline in their serum PSA level of > or = 50%, which was confirmed by a second PSA value obtained > or = 4 weeks later. The median time to PSA progression was 9 months. Among 18 patients with bone pain, 11 (61%) had improvement and in 5 patients (28%) the pain became stable. Among 21 patients with interpretable bone scans, 4 (19%) showed improvement and 8 (38%) achieved stable disease. Both symptomatic and objective responses of bone metastases were correlated with declines in the serum PSA level of > or = 50%. Ten patients achieved an increase in their hemoglobin level of at least 2 g/dL. Patients whose PSA level declined by > or = 50% with therapy had significantly prolonged survival (median, 22 months). As pretreatment markers, a longer interval before the initial evidence of disease progression appeared was found to correlate significantly with posttherapy PSA declines of > or = 75%. All side effects of the glucocorticoids were reported to be mild.

CONCLUSIONS

Low doses of dexamethasone were found to be beneficial in the treatment of HRPC, decreasing the severity of anemia and osseous disease as well as reducing serum PSA levels. A posttherapy serum PSA decline of > or = 50% appears to be a reliable marker of improved survival with this therapy.

[Ultrasound in urodynamics]

Recent developments of ultrasound imaging have contributed much to the understanding of urodynamics in patients with lower urinary tract symptoms (LUTS). These include ultrasound estimated bladder weight (UEBW), transrectal power Doppler imaging of the prostate and transrectal ultrasonography during voiding (voiding TRUS). UEBW, which is obtained by measuring the thickness of the anterior bladder wall using a 7.5 MHz probe, represents well the degree of bladder hypertrophy caused by obstruction. This parameter is, accordingly, of clinical use in the evaluation of obstruction. The UEBW predicted the presence of obstruction as determined by pressure-flow study with a diagnostic accuracy of 73%. Transrectal power Doppler imaging of the prostate has made it easy to detect prostatic vessels and furthermore to obtain their resistive index (RI). Accumulating data suggest strongly that RI reflects the intraprostatic pressure. More interestingly, RI decreases significantly during voiding in normal subjects but not in patients with benign prostatic hyperplasia. Thus, this method is of particular use in monitoring noninvasively the dynamic change in intraprostatic pressure during voiding. Voiding TRUS makes it possible to monitor the movement of not only the posterior urethra but also the prostate during voiding. Based on our recent study, the anterior fibromuscular stroma (AFMS) seems to contract to open the urethra. Although the physiological function of the AFMS in the prostate remains unknown, AFMS may play a significant role in normal micturition. Due to its noninvasiveness and ease of application, ultrasound imaging would play a vital role in the diagnostic process for patients with LUTS in future.

Doppler resistive index in benign prostatic hyperplasia: correlation with ultrasonic appearance of the prostate and infravesical obstruction

OBJECTIVE

This study was designed to characterize the resistive index (RI) of prostatic blood flows obtained by transrectal power Doppler sonography (TRPDS) in benign prostatic hyperplasia (BPH).

METHOD

In 140 patients with lower urinary tract symptoms, the RI was measured using TRPDS and compared with age and planimetric parameters of the prostate obtained by conventional transrectal sonography. In addition, the RI was related with pressure flow studies.

RESULTS

The RI was significantly higher in patients with BPH (0.72+/-0.06, p<0.0001) than those with a normal prostate (0. 64+/-0.04). Although the RI correlated significantly with age and all prostatic planimetric parameters, multiple regression analysis revealed that age and presumed circle area ratio were independent predictors for RI. The RI was also higher in patients with infravesical obstruction than those without (0.74+/-0.06 vs. 0. 70+/-0.05, p<0.005). There was a significant correlation between RI and urodynamic parameters obtained in pressure flow studies. Out of 33 patients with obstruction, 28 (85%) had an RI of 0.7 or more, while 11 out of 24 patients (46%) without obstruction had an RI less than 0.7.

CONCLUSION

The RI is promising as a new parameter to estimate the intraprostatic pressure to investigate BPH. Its value to represent urodynamic information during voiding remains to be studied.

Causes of nocturnal urinary frequency and reasons for its increase with age in healthy older men

PURPOSE

We investigate the causes of nocturnal urinary frequency and reasons for its increase with age.

MATERIALS AND METHODS

All voided volumes and times were recorded for 3 days in 188 healthy older men without prostatic diseases during a mass screening program for prostatic diseases in Japan. Nocturnal urinary frequency for each night was defined as the frequency during sleep not counting the morning void. Relationships between nocturnal urinary frequency and functional bladder capacity, nocturnal bladder capacity, nocturnal urinary volume and sleep time were analyzed. Age related changes in functional and nocturnal bladder capacity, and nocturnal and diurnal urinary volume were evaluated.

RESULTS

Multiple regression analysis demonstrated nocturnal bladder capacity and urinary volume to be significant independent determinants of nocturnal frequency. In age related analysis nocturnal bladder capacity and diurnal urinary volume decreased with age, while nocturnal urinary volume did not change.

CONCLUSIONS

Nocturnal urinary volume and nocturnal bladder capacity were the significant determinants of nocturnal urinary frequency in healthy older men. The increase of nocturnal frequency with age was thought to be due to a decrease in nocturnal bladder capacity, since urinary volume did not change. In older men a decrease in water intake might influence age related changes in urinary volume.

Significant changes in transrectal ultrasonic measurements of the prostate in relation to the degree of rectal wall distension

The present study was conducted to reveal the possible changes in transrectal ultrasonic measurements of the prostate in relation to the degree of rectal wall distension. When analyzed together for 51 men, all measurements but area changed statistically significantly as the rectal wall was distended by a balloon covering a probe. Ultrasonic measurements concerning the prostatic shape changed more remarkably than those concerning its size. More importantly, changes in ultrasonic measurements were much more remarkable in patients with a healthy prostate than in those with an advanced BPH. These results suggest that possible changes in prostatic shape with the rectal wall distension has to be taken into account when evaluating transrectal prostatic ultrasonograms in terms of changes in shape, especially in patients with a healthy prostate. This is also the case when the diagnosis of BPH is made based on the change in shape, such as presumed circle area ratio, which is a parameter representing the roundness of the horizontal sonogram of the prostate.

[Renal angiomyolipoma with marked extrarenal development: a case report]

A 28-year-old female complained of minimal fever elevation. Computed tomography (CT) revealed a left renal tumor of 10 cm in diameter. Ultrasonogram and CT, magnetic resonance imaging and angiography suggested a renal angiomyolipoma (AML) with marked extrarenal development. Partial nephrectomy was performed using a microwave tissue coagulater without clamping of the renal artery. The tumor weight was 800 g and the pathological diagnosis was AML. The management of large AML is reviewed in the literature. Nephron sparing surgery should be performed even in patients who have a larger tumor with extrarenal development.

Adrenal hemorrhage diagnosed by ultrasonically-guided biopsy

Adrenal hemorrhage in adults is an uncommon disease and is usually associated with systemic diseases, trauma or anticoagulation. When adrenal hemorrhage is discovered in chronic course without any suggestive clinical settings, it is difficult to distinguish adrenal hemorrhage correctly before surgical resection. We present a case of adrenal hemorrhage which was incidentally detected as an adrenal mass and was successfully treated in a conservative way based upon histopathological findings obtained by ultrasonically guided biopsy.

Comparative morphometric study of bladder detrusor between patients with benign prostatic hyperplasia and controls

PURPOSE

We determined the change in the amount of connective tissue of the detrusor in patients with benign prostatic hyperplasia (BPH) in relation to the degree of bladder hypertrophy by ultrasound estimated bladder weight. The ratio of connective tissue-to-smooth muscle between controls and BPH cases was compared.

MATERIALS AND METHODS

For normal controls we used cadaver bladders excised at autopsy from 13 men with no urinary tract diseases. Bladder wall samples were also obtained at subcapsular prostatectomy for BPH in 26 patients. On thin sections stained with Masson trichrome, the ratio of connective tissue-to-smooth muscle was measured using a computer assisted color image analysis. This ratio was compared in BPH cases with estimated bladder weight, which was measured preoperatively using transabdominal ultrasonography.

RESULTS

A connective tissue-to-smooth muscle ratio ranged from 19.8 to 28.2% (mean plus or minus standard deviation 24.7+/-2.4) and from 12.9 to 53.3% (27.3+/-9.9) in control and BPH cases, respectively. In BPH cases a significant correlation was noted between estimated bladder weight and connective tissue-to-smooth muscle ratio (r=0.788, p <0.0001). Interestingly, in BPH cases with an estimated bladder weight of less than 60 gm. the ratio ranged from 12.9 to 30.4% (22.8+/-4.9), which was not significantly different compared to control cases. In contrast, in all BPH cases with an estimated bladder weight of 60 gm. or more connective tissue-to-smooth muscle ratio increased significantly to more than 30% (range 33.4 to 53.3%, mean 42.2+/-13.6%).

CONCLUSIONS

These results suggest that abnormal increase of connective tissue in addition to smooth muscle hypertrophy and/or hyperplasia could contribute to advanced bladder hypertrophy caused by infravesical obstruction.

Noninvasive evaluation of bladder compliance in children using ultrasound estimated bladder weight

PURPOSE

In healthy children as well as those with urinary disturbance we determined ultrasound estimated bladder weight with the aim of revealing its possible usefulness as a measure of bladder compliance.

MATERIALS AND METHODS

We measured ultrasound estimated bladder weight in 71 healthy children with a mean age of 10.3 years, and determined a standard value. A total of 82 patients with a mean age of 9.6 years with urinary disturbance also underwent ultrasound estimated bladder weight measurement as well as conventional urological examinations, including filling cystometry.

RESULTS

In healthy children ultrasound estimated bladder weight increased with age, showing a significant linear correlation (r = 0.80, p < 0.0001). Using the formula for linear correlation, 0.86 x patient age + 6.9 gm., we obtained an age matched estimated weight. In 82 patients the percent deviation of the estimate from age matched values was calculated using the formula, (measured ultrasound estimated bladder weight -age matched ultrasound estimated bladder weight)/age matched ultrasound estimated bladder weight x 100, and then correlated with bladder compliance. In 75 of 77 patients (97%) with compliance of 10 ml./cm. water or more the estimate was within 100% deviation. In contrast, 4 of 5 patients (80%) with a low compliant bladder (less than 10 ml./cm. water) had an ultrasound estimated bladder weight greater than 100% deviation. When the estimate was within 100% deviation, all but 1 patient (75 of 76, 98.7%) had compliance of 10 ml./cm. water or more compared to 33.3% (2 of 6) of those with an estimate greater than 100% deviation. As a result, with the use of a cutoff value of 100% deviation ultrasound estimated bladder weight predicted a low compliant bladder with a diagnostic accuracy as high as 96.3% (79 of 82 cases).

CONCLUSIONS

Ultrasound estimated bladder weight may be used to evaluate bladder compliance in children. It seems to be a suitable noninvasive urodynamic test in children with suspected urodynamic abnormalities.

Intraobserver and interobserver variance in the measurement of ultrasound-estimated bladder weight

Recently, we reported that ultrasound-estimated bladder weight (UEBW) could be used as a noninvasive tool in evaluating the degree of bladder hypertrophy. This study was designed to test the reproducibility of its measurement. The overall mean UEBW of the initial measurement and that of the second one by one observer in 36 cases was 42.8 +/- 22.6 g and 42.9 +/- 22.6 g, respectively. The paired differences between two measurements ranged from -3.4 to 2.7 g, with a mean difference of only -0.1 g. The interobserver variance was also slight. The paired differences between UEBW measurements derived from the two observers in 32 cases ranged from -6.0 to 7.9 g, with a mean difference of only 0.1 g. The Cochran's test statistic of the measurements of UEBW was 0.142 for one observer and 0.130 for two, which were less than its 5% critical value. Due to these favorable characteristics, UEBW could be reliable tool for the investigation of bladder hypertrophy with a sufficient reproducibility.