E. Huland

Preoperative Prediction of Tumor Heterogeneity and Recurrence After Radical Prostatectomy for Localized Prostatic Carcinoma with Digital Rectal Examination, Prostate Specific Antigen and the Results of 6 Systematic Biopsies

PURPOSEnDigital rectal examination, preoperative serum prostate specific antigen (PSA) concentration and results of 6 ultrasound guided systematic sextant biopsies in 257 consecutive patients with clinical stages T2 and T1c prostatic carcinoma were evaluated for their use in predicting pathological stage and tumor recurrence.nnnMATERIALS AND METHODSnEach of the 257 consecutive specimens was examined using the 3 mm. step section technique. Results of preoperative digital rectal examination, PSA and 6 systematic sextant biopsies were correlated with pathological stage, margin status and postoperative PSA during a mean followup of 2 years. Patients were considered to have disease progression based on elevated PSA level by a supersensitive assay.nnnRESULTSnDigital rectal examination could not predict pathological stage and tumor recurrence. Preoperative PSA concentration, number of positive biopsies and tumor grade in the biopsy specimens correlated well with pathological stage. The best predictor of tumor recurrence was the biopsy result. However, a precise prediction of outcome (87% probability of being PSA negative versus 0%) was possible only in a third of the patients if the biopsy results were used. Use of preoperative PSA concentration did not improve this probability.nnnCONCLUSIONSnPreoperative PSA concentration and/or biopsy results correlate significantly with pathological stage and margin status. Precise prediction of tumor recurrence is possible in only approximately a third of the patients with clinical stage T2 prostatic carcinoma.

Comparison of Different Schedules of Cytostatic Intravesical Instillations in Patients with Superficial Bladder Carcinoma: Final Evaluation of a Prospective Multicenter Study with 419 Patients

In a prospective multicenter study we compared the value of various protocols of mitomycin C and doxorubicin instillation for the prevention of recurrent tumors in patients whose superficial bladder tumors (stages TA and T1) had been removed by transurethral resection. The 3-year and short-term instillation protocols were compared to each other and to a combination of 2 protocols. Evaluation after a mean followup of 28 months confirmed the value of cytostatic bladder instillation in preventing recurrence and progression of tumor in patients with superficial bladder carcinoma. There was no significant difference between the results of long-term and short-term prophylaxis; their combination achieved the best results. Doxorubicin and mitomycin yielded similar results; mitomycin was better tolerated.

Monoclonal Antibody 486 P 3/12: A Valuable Bladder Carcinoma Marker for Immunocytology

Monoclonal antibodies directed against tumor-associated antigens of bladder carcinoma were used to identify tumor cells in bladder washout specimens of 40 patients with bladder carcinoma (group 1), 41 with no bladder disease or with urinary tract infections (group 2), 41 who received long-term mitomycin C instillation therapy after excision of the tumors (group 3) and 39 who received no prophylaxis after excision of the tumors (group 4). In all groups the same bladder washout specimen was used for standard urinary cytological and immunocytological tests. True positive results were obtained in 90 per cent of the patients in group 1 according to our immunocytological criteria and in 43 per cent according to standard cytology studies. No urine specimens in group 2 (controls) were immunocytologically positive, while 16 of 41 in group 3 and 17 of 39 in group 4 were positive immunocytologically but only 4 and 5, respectively, were positive according to standard cytology studies. Further followup of these patients will show whether cells positive for monoclonal antibody 486 P 3/12 will permit early detection of recurrent bladder cancer and whether one can identify patients who require prophylaxis after removal of the superficial bladder tumors.

Clinical use of Urinary Markers For The Detection And Prognosis Of Bladder Carcinoma: A Comparison Of Immunocytology With Monoclonal Antibodies Against Lewis X And 486p3/12 With The BTA STAT And NMP22 Tests

PURPOSEnThe noninvasive detection of urothelial carcinoma remains challenging. We prospectively evaluated urine markers for bladder carcinoma. We compared the NMP22 (Matritech, Cambridge, Massachusetts) and BTA Stat (Bard Diagnostics, Redmond, Washington) tests with immunocytology using mAbs 486p3/12 and BG7 against Lewis X antigen.nnnMATERIALS AND METHODSnThe NMP22 and BTA Stat tests were performed in urine samples and immunocytology with mAbs 486p3/12 and BG7 staining were performed in bladder washing specimens in 146 samples of 115 patients undergoing transurethral resection for suspected bladder carcinoma (70) or 45 undergoing followup cystoscopy for a history of bladder carcinoma (76). Bladder carcinoma was detected in 54 patients, including stages pTa in 25, pT1 in 20, pT2 in 8 and carcinoma in situ in 1, while 61 had no evidence of bladder carcinoma. The cutoff was 10 units per ml. for the NMP22, 30% positive cells for 486p3/12 and 5% positive cells for the Lewis X tests.nnnRESULTSnBTA Stat was positive in 65 samples (44.5%) and NMP22 was positive in 69 (47.3%). Immunocytology with mAbs 486p3/12 and BG7 against Lewis X was positive in 52 (35.6%) and 109 (74.7%) samples, respectively. Sensitivity was 70.3% for BTA Stat, 68.5% for NMP22, 68.5% for 486p3/12 and 94.4% for Lewis X. Specificity was 70.6% for BTA Stat, 65.2% for NMP22, 83.6% for 486p3/12 and 36.9% for Lewis X. Area under the receiver operating characteristics curve was 0.6804 for NMP22, 0.7226 for Lewis X and 0.8002 for 486p3/12. False-positive results on BTA Stat in 2 of 22 patients (9%), on NMP22 in 2 of 25 (8%), on 486p3/12 in 3 of 11 (27%) and on Lewis X in 4 of 43 (9.3%) were associated with tumor recurrence. Furthermore, negative results on BTA Stat in 2 of 39 patients (2%), on NMP22 in 2 of 36 (0.5%), on Lewis X in 0 of 18 (0%) and on 486p3/12 in 1 of 50 (2%) was associated with tumor recurrence during followup.nnnCONCLUSIONSnImmunocytology with mAbs against Lewis X showed higher sensitivity than all commercially available tests evaluated. Because of its high sensitivity and high negative predictive value, it may be useful for screening in a high risk population. Patients with a false-positive 486p3/12 test results are at increased risk for tumor recurrence compared with those with negative results.

Relevance of p53 Gene Alterations for Tumor Recurrence in Patients with Superficial Transitional Cell Carcinoma of the Bladder

Purpose: The prognostic relevance of p53 protein accumulation in muscle–invasive bladder carcinoma is well documented, but the prognostic relevance of p53 alterations in superficial bladder tumors remains uncertain. Immunohistochemical data are divergent, possibly because of the use of nonstandardized techniques. We therefore investigated the relevance of p53 gene point mutations and loss of heterozygosity (LOH) for tumor recurrence. The results of this molecular analysis were compared with accumulation of the p53 protein as shown by immunohistochemistry. Material and Methods: Representative tumor tissue was selected and microdissected from 40 patients (pTa, 18 patients; pT1, 22 patients; grade I, 7 patients; grade II, 28 patients; grade III, 5 patients). Polymerase chain reaction (PCR) was carried out with exons 5–8. All PCR products were screened for p53 mutations with temperature–gradient gel electrophoresis (TGGE). When mobility shift was observed, direct nucleotide sequencing was performed. Detection of LOH was performed with nonradioactive microsatellite analysis using three markers (TP 53, D17S513 and D17S786) on chromosome 17p. Immunohistochemistry was performed with the DO 7 antibody. Tumor samples with p53 accumulation of 5% or more positive nuclei were classified as positive. Univariate analysis for disease–free survival was performed using Kaplan–Meier analysis and the log–rank test. Results: TGGE and direct sequencing detected mutations in 10 of 40 patients (2 of 18 pTa and 8 of 22 pT1 patients). LOH was detected in 11 patients. Both a mutation and LOH were detected in 3 patients. p53 immunohistochemistry detected at least 5% positive nuclei in 28 of 40 patients (70%). After a median follow–up of 26 months 14 patients suffered disease recurrence. Whereas disease–free survival did not correlate with a mutation (p = 0.77, log–rank test), LOH (p = 0.2) or a mutation in combination with LOH (p = 0.23), a positive p 53 immunoreaction was significantly associated with short disease–free survival (p = 0.009). Conclusion: Despite the relatively high percentage of patients with p53 gene alteration in this population no significant correlation between the detection of molecular alteration and disease recurrence could be found. We conclude that, in contrast to immunohistochemical accumulation, gene alterations play only a minor role in tumor recurrence of p53 in patients with superficial transitional cell carcinoma of the bladder, and that immunohistochemical accumulation of the p53 protein has to be explained by mechanisms other than gene mutations.

Serummarker in der Früherkennung und dem Staging des Prostatakarzinoms

ZusammenfassungDie Entwicklung des prostataspezifischen Antigens (PSA) erfolgte nach bescheidenem Beginn durch Extraktion aus Seminalplasma als potentieller Marker in der Forensik über die Identifizierung in Prostatagewebe und nachfolgend im Serum. Jedoch konnte erst die Entwicklung von Immunoassays zur Bestimmung der PSA-Konzentration im Serum das einzigartige Potential des PSA in der Behandlung des Prostatakarzinoms offenbaren. Heute ist das PSA der mit Abstand wichtigste Tumormarker in der Urologie, wenn nicht in der gesamten Onkologie und hat Früherkennung, Staging, Behandlung und Nachsorge des Prostatakarzinoms in jeder Beziehung revolutioniert.Trotz dieser Verdienste des PSA treten dessen Unzulänglichkeiten immer deutlicher zutage, die dem PSA das Charakteristikum eines perfekten Tumormarkers verbieten. Erstens ist PSA—trotz hoher Organspezifität—kein Marker für Prostatakarzinome: benigne Prostatahyperplasie, Prostatitis oder prostatische Manipulation beeinflussen die PSA-Serumkonzentration und führen zu einer hohen Anzahl kostspieliger und potentiell morbiditätsbehafteten Biopsien. Weiterhin ist im Gesamt-PSA-Bereich zwischen 4 und 10xa0ng/ml bei einer erforderlichen Sensitivität von 95% die Spezifität des PSA nicht zufriedenstellend. Darüber hinaus—ein einmaliges Charakteristikum des Prostata-Ca—entwickeln zwar 30–40% aller Männer ein Prostatakarzinom, jedoch nur 9–11% eine klinisch signifikante Tumorlast und noch weniger (2,5–4,3% aller Männer) versterben an einem Prostatakarzinom. Mit anderen Worten sind der überwiegende Teil aller Karzinome für die Lebenserwartung des Betroffenen ohne Bedeutung und müssen daher u.xa0U. weder diagnostiziert, noch behandelt werden. Das PSA ist nicht in der Lage, diese sog. klinisch nichtsignifikanten von den signifikanten Karzinomen zu unterscheiden. Schließlich steigt die Prävalenz des Prostatakarzinoms durch die höhere Lebenserwartung jenseits der 7. Dekade an. Andererseits sind es v.xa0a. die Patienten im Alter von 50–70xa0Jahren, die ein aggressiv wachsendes Karzinom entwickeln und von früh eingeleiteter invasiver Diagnostik und Therapie profitieren werden.Was generell unter dem Oberbegriff Gesamt-PSA subsummiert wird, ist in Wirklichkeit eine komplexe, in der Zusammensetzung der einzelnen Subformen heterogene Mischung aus gebundenen und freien molekularen PSA-Formen. Komplexiertes PSA (cPSA) stellt die dominierende Variante des Gesamt-PSA dar, hiervon besteht wiederum der größte Teil (ca 98%) aus PSA in 1/1 molarem Verhältnis kovalent an α1-Antichymotrypsin gebunden (ACT-PSA). Der kleinere Anteil, das freie PSA (fPSA) im Serum, ist enzymatisch inaktiv ohne mit dem Überschuss an Antiproteasen im Serum zu reagieren. Darüber hinaus existieren verschiedene Isoformen des fPSA, die spezifisch im Serum bestimmt werden können. Neuere Studien unterstützen die Hypothese einer klinischen Verwendung dieser Isoformen des fPSA in der Früherkennung des Prostatakarzinoms.Die klinische Evaluierung des humanen glandulären Kallikreinxa02 (hK2) unterstützt eine dem PSA komplementäre Rolle in der Früherkennung des Prostatakarzinoms und als Stagingserummarker für das klinisch lokalisierte Prostatakarzinom eine signifikante Verbesserung gegenüber dem PSA.In dieser Übersicht werden die etablierten und potentiell neuen PSA-Varianten und das hK2 für Diagnostik und Staging des Prostatakarzinoms zusammengefasst.AbstractIt was a modest beginning of the unique career of PSA when Hara et al. extracted a protein from human seminal fluid and proposed it to serve as a forensic tool followed by purification from prostate tissue, and subsequently in serum. However, only due to the development of immunoassays for detection of PSA in blood has the unique potential of PSA as a marker for prostate cancer become evident. Today, as a tumor marker, PSA has outperformed any other urologic marker and, as enthusiastically stated by others, any other tumor marker in oncology.Nowadays, we are challenged by limitations of PSA, which fail to make it an ideal marker for the detection of prostate cancer. First, despite a high degree of organ specificity, PSA is not a true prostate cancer marker. Benign prostatic hyperplasia, inflammation, and other conditions also increase serum concentrations of PSA leading to a substantial number of unnecessary and costly invasive diagnostic procedures. Second, unique to prostate cancer, about 9–11% of men will develop clinically manifest disease in their lifetime and about 2.6–4.3% will actually die of the disease. In other words, about 30–40% of cancers have direct impact on the life span of the affected men, hence may not need to be detected. PSA fails to discriminate between these clinically insignificant and significant cancers. Finally, the prevalence of prostate cancer is increasing due to a demographic shift to longevity; however, typically younger men carry aggressive prostate cancer with a high potential for progression to metastases and an urgent need for treatment.What is generally summarized under the global term total immunoreactive PSA or simply PSA is in fact a heterogeneous blend of different complexed and free molecular forms of PSA. Complexed PSA contributes the major proportion of total PSA, a stable covalent complex of PSA linked to alpha-1-antichymotrypsin (PSA-ACT) and constitutes the vast majority (≥98%) of the immunodetected PSA complexes, whereas free PSA is inert and unable to interact with the large excess of antiproteases in blood. Moreover, there is evidence that the free PSA forms consist of several subfractions and there are now increasing data reported that selective measurements of at least some of these free PSA subfractions may further enhance discrimination of benign from malignant prostatic diseases.Clinical evaluation of hK2 showed promising results as a complementary marker to PSA to improve sensitivity and specificity of PCA detection and preliminary superior results as a staging marker for clinically localized PCA. It may be concluded that further evaluation of hK2 might improve the armamentarium for better management of prostate cancer.In this chapter, we will describe clinically established and potentially valuable forms of PSA and human glandular kallikrein 2 for early detection and staging of prostate cancer.

DETECTION OF LOSS OF HETEROZYGOSITY IN THE P53 TUMOR-SUPPRESSOR GENE WITH PCR IN THE URINE OF PATIENTS WITH BLADDER CANCER

PURPOSEnDetection of loss of heterozygosity (LOH) has been described in various carcinomas on the basis of meticulous molecular techniques. Because of lack of simple and rapid techniques, LOH has not achieved common use in routine tumor diagnosis. A recently found variable number of tandem repeats (VNTR) segment in intron 1 of the p53 gene was described as highly polymorphic and therefore useful in detecting LOH. We used a rapid technique for detection of LOH in the p53 gene of patients with transitional cell carcinoma (TCC) of the bladder. The technique was based on the polymerase chain reaction (PCR) and agarose gel electrophoresis as described for other carcinomas previously. We evaluated whether TCC screening and surveillance could be performed detecting LOH in the urinary sediment.nnnMATERIALS AND METHODSnWe investigated 29 patients with TCC of the bladder (pTa 12 patients; pT1 10 patients; pT2 - pT4 seven patients; grade 1 one patient; grade 2 19 patients; grade 3 nine patients). DNA was prepared by standard methods from white blood cells, tumor tissue, normal bladder mucosa, and urinary sediments. The amplification of the VNTR region was performed with PCR. PCR products were run in parallel lanes on 4.5% agarose gels.nnnRESULTSnOf the 29 patients, 23 (79.3%) were found to have two different alleles (informative cases) for the VNTR region. Of the 23 informative cases LOH was detected in the tumor tissue of 10 patients (43.5%). Referring to the total population 10 of 29 patients (34.4%) revealed LOH. In all patients with LOH in the tumor, LOH was also detected in the urinary sediment. LOH was not detected in the histologically benign bladder mucosa.nnnCONCLUSIONnWe present a simple and rapid technique based on PCR and agarose gel electrophoresis for the detection of LOH in tumor and urinary sediment of patients with TCC of the bladder. The ability to detect LOH not only in tumor tissue but also in urinary sediment offers an attractive approach for noninvasive diagnosis and surveillance of bladder cancer patients.

Regionale Immuntherapie beim metastasierten Nierenzellkarzinom

ZusammenfassungDie vorliegende Arbeit gibt einen Überblick über die bisherigen Erfahrungen lokoregionärer Immuntherapie in der Behandlung pulmonaler Metastasen beim metastasierten Nierenzellkarzinom und anderer Tumoren durch die inhalative Gabe von Interleukin-2 (IL-2). Der lokoregionärer Einsatz von IL-2 zeigt eine therapeutische Effektivität gegen die lokalen Metastasen ohne Erhöhung der systemischen Toxizität und erlaubt den Einsatz von Zytokinen in ihrem physiologischem Spektrum. Eine therapeutische Wirksamkeit scheint nicht nur beim metastasierten Nierenzellkarzinom und malignen Melanom vorhanden zu sein, den Tumoridentitäten mit nachgewiesenem Ansprechen auf eine Immuntherapie, sondern auch bei anderen pulmonal metastasierten Tumoren wie Mammakarzinom und Ovarialkarzinom.Wir sehen die lokoregionäre (physiologische) IL-2-Gabe und die systemische (pharmakologische) Gabe nicht als sich ausschließende Therapieverfahren. Beide Applikationen können sich in der Immuntherapie metastasierter Tumorerkrankungen ergänzen und zu einer individuellen Therapieplanung beitragen.AbstractWe summarized the current literature concerning regional immunotherapy of pulmonary metastases in metastatic renal cell carcinoma and other malignancies using inhaled interleukin-2 (IL-2). Inhaled IL-2 therapy is associated with minimal toxicity and is effective in preventing progression in metastatic renal cell carcinoma, melanoma, and possibly other diseases such as breast cancer. Local (physiologic) use and systemic (pharmacologic) use of IL-2 are not mutually exclusive; a combination may be very appropriate in metastatic cancer. Local physiologic therapy intensifies treatment without intensifying toxicity.

Tumor-Associated Antigens in Normal Mucosa of Patients With Superficial Transitional Cell Carcinoma of the Bladder

PURPOSEnWe identified premalignant lesions in tumor-surrounding histologically normal bladder mucosa from patients with superficial and muscle-invasive bladder cancer to look for premalignant lesions as the source of tumor recurrence.nnnMATERIALS AND METHODSnTumor-associated antigen expression in histologically normal bladder mucosa in 23 patients with superficial bladder cancer was studied. Histologically normal bladder specimens from 21 patients with muscle-invasive bladder cancer and from 30 prostatic cancer patients served as controls. Tumor-related antigens 486p 3/12, LBS8, 19A211 and M344 were mapped quantitatively with monoclonal antibodies and immunohistological techniques.nnnRESULTSnExpression of all four bladder tumor-associated antigens was significantly enhanced and more than two antigens were expressed simultaneously in histologically normal mucosa from both bladder-cancer groups, compared with histologically normal bladder mucosa of prostatic carcinoma patients (p < 0.05).nnnCONCLUSIONSnThe results suggest the existence of early malignantly transformed cells in the benign-looking and morphologically normal bladder mucosa of superficial bladder carcinoma patients, which possibly is the source of recurrent bladder cancer. This approach models the mapping of histopathologic premalignant lesions of the bladder to predict risk.

Immuntherapie des metastasierten Nierenzellkarzinoms in DeutschlandEine Standortbestimmung

ZusammenfassungDie Umfrage untersucht den Einsatz von Interferon-α (IFN-α) und Interleukin-2 (IL-2) beim metastasierten Nierenzellkarzinom.186 Zentren mit 2200 Patienten jährlich antworteten. 182 Zentren befürworten die Immuntherapie, 147 führen sie durch, 35 überweisen gezielt. Effektivität und Verträglichkeit sind hierfür häufig genannte Gründe. Die Therapiezeiten liegen bei 3–6 Monaten. Eine Erhaltungstherapie bei klinischem Ansprechen verwenden 118 Zentren. Kombinationen von subkutanem IL-2 und IFN-α, ohne oder mit 5-Fluorouracil und/oder Isotretinoin sind das häufigste Schema.Darauf folgen IFN-α mit Vinblastin, IFN-α-Monotherapie und IL-2-s.c.-Monotherapie. IL-2 wird überwiegend subkutan, inhalativ und manchmal lokal bzw. intratumoral eingesetzt. Kontinuierlich intravenös wird IL-2 selten gegeben, dies ist nie einzige oder wichtigste Applikationsart.Die Kombination von IFN-α und IL-2 sowie die subkutane und lokale IL-2-Applikation sind Standardbehandlung bei der Immuntherapie des metastasierten Nierenzellkarzinoms in Deutschland.AbstractThis survey was established to evaluate everyday use of interferon-α (IFN-a) and interleukin-2 (IL-2) in metastatic renal-cell carcinoma (mRCC).Of 186 centers (with 2200 patients per year) that responded, 182 support immunotherapy by using it themselves (147 centers) or by referring patients (35 centers). Effectiveness and tolerance are the main reasons for use. 133 centers use IL-2 subcutaneously, 64 by inhalation, 24 use it locally or intratumorally. Continuous intravenous IL-2 is used in 13 centers only. Most centers use subcutaneous combinations of IL-2 and IFN-a, either alone or with 5-fluorouracil and/or isotretinoin; IFN-α/Vinblastin combinations, IFN-α-monotherapy, and IL-2 sc-monotherapy are used with similar frequency. Average treatment duration is 3–6 months. Maintenance therapy is used in responding patients in 118 centers.Subcutaneous and local application of IL-2 is standard treatment for mRCC in Germany and subcutaneous IL-2 and IFN-α represents the most frequently used combination.