Akos Pytel

New aspect of photodynamic diagnosis of bladder tumors: fluorescence cytology

OBJECTIVES To establish a new diagnostic method for the detection and follow-up of bladder cancer that combines the principles of photodynamic diagnosis and urinary cytology. METHODS We investigated 46 patients scheduled for transurethral resection of a bladder tumor immediately before the resection was carried out. After intravesical instillation of either 5-aminolevulinic acid (ALA) or hypericin, urinary cytology specimens were obtained. Induced fluorescence of urothelial cells was detected by fluorescence microscopy. The results were compared with the conventional cytologic and histologic findings. RESULTS In the 46 patients, 42 cases of urothelial carcinoma and 4 cases of nonspecific inflammation were diagnosed. Of the 42 patients with cancer, 19 had Stage Ta, 9 had T1, 3 had carcinoma in situ, and 11 had invasive bladder cancer. The grading was G1 in 17 patients, G2 in 6 patients, and G3 in 19 patients. In 38 cases we instilled ALA and in 8 hypericin. All 4 patients diagnosed with nonspecific inflammation had received ALA. We detected ALA-induced fluorescence in 34 of 38 cases. One of the four histologically negative cases had a false-positive finding and 1 case of urothelial carcinoma did not show fluorescence. After instillation of hypericin we could detect induced fluorescence in all cases. CONCLUSIONS Our first results suggest that fluorescence cytology is more sensitive than other noninvasive tests. After additional investigation, it may become a valuable diagnostic method and may reduce the number of cystoscopies in the follow-up of bladder tumors.

Fluorescence Diagnosis of Bladder Cancer with New Water Soluble Hypericin Bound to Polyvinylpyrrolidone : PVP-Hypericin

Although conventional white light endoscopy (WLE) is currently the gold standard for diagnosing bladder tumors, rates of false negative results and residual tumors after transurethral resection are relatively high. The goal of the present clinical study is to investigate whether using new water soluble hypericin (PVP‐hypericin) as a fluorescent dye improves bladder cancer detection and diagnosis. Following instillation of PVP‐hypericin (total amount of 0.25 mg hypericin bound to 25 mg polyvinylpoyrrolidone [PVP], reconstituted in 50 mL phys. sodium chloride solution), WLE and fluorescence cystoscopy (photodynamic diagnosis; PDD) were performed on patients with suspected primary or recurrent bladder malignancies (n = 57). Incubation time was 1–2 h and biopsies (n = 163) were taken from fluorescing regions and/or from regions which were suspicious under WLE. Histological investigations of the biopsies provided the final proof of malignancy (or the counterevidence). Results indicated that overall sensitivity with PVP‐hypericin and PDD is significantly higher (95%) than with WLE (85%). The sensitivity of PDD in the diagnosis of carcinoma in situ (n = 12) was 100% compared with 33% for WLE. In the diagnosis of dysplasia, the sensitivity of PDD was 85% compared with 31% for WLE. PDD has a positive predictive value (PPV) of 0.75% and a negative predictive value (NPV) of 0.86%, in comparison to WLE PPV = 0.66% NPV = 0.58%. Biopsies were not taken from healthy tissues, thus specificity was markedly lower in our study (53%) than that reported in other studies (98–100%). As a conclusion, PDD using PVP‐hypericin is superior to WLE in terms of sensitivity in the diagnosis of malignancies of the bladder. Results suggest that PVP‐hypericin is a promising formulation for various diagnostic and therapeutic applications.

Evaluation of transition zone and lateral sextant biopsies for prostate cancer detection after initial sextant biopsy

OBJECTIVES To assess the value of transition zone and lateral sextant biopsies for the detection of prostate cancer after a previous sextant biopsy was negative. METHODS A total of 74 prostates after radical prostatectomy were used to perform biopsies ex vivo. First, a sextant biopsy was taken, then two different rebiopsy techniques were performed. Rebiopsy technique A consisted of a laterally placed sextant biopsy and two cores per side of the transition zones only. Rebiopsy technique B included a standard sextant biopsy and two cores per side from the lateral areas of the prostate. The biopsies were taken using ultrasound guidance to sample the areas of interest precisely. RESULTS The initial sextant biopsy found 39 prostate cancers. Rebiopsy technique A found 12 cancers (34%). In this group, a laterally placed sextant biopsy found 12 cancers; transition zone biopsies revealed cancer in 5 cases, but no additional tumor was found. Rebiopsy technique B detected 23 prostate cancers (66%). Fourteen tumors were found after a second standard sextant biopsy, and nine additional tumors were found in the lateral areas. CONCLUSIONS Sextant biopsy has a low sensitivity of only 53%. A biopsy including the transition zones is not the ideal technique for detecting the remaining tumors. Therefore, transition zone biopsies should be reserved for patients with multiple previous negative biopsies of the peripheral zone. A subsequent sextant biopsy with additional cores from the lateral areas of the prostate is favorable if rebiopsy is necessary after a negative sextant biopsy.

Prevalence and Type Diversity of Human Papillomaviruses in Penile Cancers in Hungary

To the editor Penile cancers are one of the rare forms of oncological diseases as in developed countries their prevalence is less than 1 %. Epidemiological studies suggested the role of oncogenic HPV-types as a causative agent of penile tumors [1, 2]. Around 40 % of patients with penile cancer had also been affected by HPV with type 16 being the most prevalent [3]. Currently available literature data explain HPV-induced tumors with the integration of virus into the epithelial cells’ genome, and its genetic manipulation of the host DNA. Another interesting fact is that HPV infection is much more frequently associated with certain types of penile cancers, than other malignant manifestations [3]. Clinical course and prognosis of patients with penile cancer is unequivocally determined by the lymphatic node status. Five year survival rate of pathologically negative lymph nodes (pN0) is 85–100 %, whereas the involvement of pathologically verified metastatic lymph nodes in the inguinal region dramatically reduces this rate [4]. A retrospective study including 145 male patients describes: tumor thickness and lymphatic or vascular invasion as prognostic factors for lymph node involvement. Interestingly, no statistical correlations can be indicated in lymphatic involvement in connection with T status and the grade of cancer [5]. The aims of the present study were i) to identify and estimate the prevalence of high-risk HPV (hrHPV) genotypes in both primary penile tumors and metastatic lymph nodes, ii) to analyse the potential correlation between the hrHPV positivity and the severity and progression of the cancer. Tissue samples were taken from both the primary tumor and the regional lymph nodes, in over the course of operations of penile cancers in the Department of Urology, University of Pécs, Hungary, between 2002 and 2012. Samples were forwarded to histopathological processing where tissues were fixed in formalin and embedded into paraffin for histological processing. For retrospective molecular studies, 10 μm sections of the paraffin blocks were deparaffinated. Subsequently, DNAwas extracted for the purpose of HPV-identification. Cells were disintegrated using TissueLyser (Qiagen), and subcellular structures were digested enzymatically using Proteinase-K. DNA was purified from tissues using QIAmp DNA FFPE Tissue Kit (Qiagen), according to the manufacturer’s recommendations. HPV DNA was detected by virus-specific TaqMan PCR (DIAGON Ltd., Hungay). In case of HPV positive samples Linear Array HPV Genotyping Test (Roche) was further used for genotyping. A total of 35 patients were involved in the current clinical study. High-risk HPV was identified from primary tumors in 17 cases (48.5 %), regional (inguinal) lymph nodes were positive in 3 cases. The average age of hrHPV positive males was 55 years (range: 44–87 years) while HPV negative patients were slightly older, averaging 66 years of age (range: 50– 82 years). Genotyping using high-sensitivity molecular assays was available for 14 cases out of the 17 hrHPV-positive patients. HPV 16 was identified in 11 of 14 samples (78.5 %), HPV 59 and 82 were detected in two separate cases, while * Ferenc Jakab jakabf@gamma.ttk.pte.hu