DNA demethylation and histone deacetylation inhibition co-operate to re-express estrogen receptor beta and induce apoptosis in prostate cancer cell-lines.

INTRODUCTION: Epigenetic silencing mechanisms are increasingly thought to play a major role in the development of human cancers, including prostate cancer. Promoter CpG island hypermethylation and histone hypoacetylation, catalyzed by DNA methyltransferase (DNMT) and histone deacetylase (HDAC), respectively, are associated with transcriptional repression in a number of cancers. Evidence is accumulating the two mechanisms are dynamically linked, yet few studies have examined a potential interaction in prostate cancer. METHODS: LNCaP, DU-145, and PC-3 prostate cancer cells were co-treated with a DNMT inhibitor, 5'-aza-2'-deoxycytidine (5-AZAC), and an HDAC inhibitor, trichostatin A (TSA). Following treatment cells were processed for cell proliferation/apoptosis assays, or harvested for real-time RT-PCR. Assessed target genes were estrogen receptor beta (ERbeta), estrogen receptor alpha (ERalpha), androgen receptor (AR), progesterone receptor (PGR), and prostate specific antigen (PSA). RESULTS: In all cell-lines, co-treatment was associated with reduced cell proliferation compared with control groups (P<0.05). A reciprocal rise in caspase activation was identified, indicating apoptosis was the major mechanism of cell death. Most marked effects were seen in the androgen-dependent, AR-positive LNCaP cell-line. In all cell-lines, an additive re-expression of ERbeta was identified in the co-treatment group, a finding not seen for either AR or PSA. CONCLUSION: At concentrations associated with gene re-expression, the DNA demethylating agent 5-AZAC and the HDAC inhibitor TSA co-operate to induce apoptosis in prostate cancer cell-lines. Increased apoptosis in the co-treatment group was associated with marked re-expression of ERbeta, raising the possibility of further targeting of prostate cancer cells with ERbeta-selective agents.

Bird's nest filter causing symptomatic hydronephrosis following transmural penetration of the inferior vena cava.

We report a case of symptomatic hydronephrosis caused by transcaval penetration of a Bird's Nest filter. Perforation of the wall of the inferior vena cava (IVC) following insertion of a caval filter is a well-recognized complication. Whilst two cases of hydronephrosis have been described with Greenfield filters, no case involving a Bird's Nest filter has been reported previously.

A vaccination strategy for the long-term suppression of androgens in advanced prostate cancer.

OBJECTIVES: We have previously reported the ability of D17DT (formerly GnRH-DT) vaccination to produce castrate levels of androgens in men with advanced prostate cancer. This study examines the efficacy and tolerability of 3 and 15 micrograms of D17DT in 12 patients with advanced prostate cancer to establish a dose-response relationship. METHODS: 12 patients received either 3 or 15 micrograms of D17DT as 3 deep intramuscular injections over 6 weeks. Outcome was assessed in terms of physical and biochemical evaluations of clinical progression and antibody titres. RESULTS: Significant titres of anti-GnRH antibodies were detected in 2 out of 6 subjects who received 15 micrograms of D17DT; suppression of testosterone to castrate levels accompanied by a significant and prolonged reduction in PSA was also demonstrated. No responses were seen following treatment with 3 micrograms of D17DT. CONCLUSION: The induction of anti-GnRH antibodies through vaccination with 15 micrograms D17DT can produce and sustain castrate levels of testosterone in men with advanced prostate cancer.

EAU guidelines for the management of urinary and male genital tract infections. Urinary Tract Infection (UTI) Working Group of the Health Care Office (HCO) of the European Association of Urology (EAU).

A short version of the UTI Guidelines elaborated by the Urinary Tract Infection Working Group of the Health Care Office of the European Association of Urology is presented. The topics include classification, diagnosis, treatment and follow-up of uncomplicated UTI, UTI in children, UTI in diabetes mellitus, renal insufficiency, renal transplant recipients and immunosuppression, complicated UTI due to urological disorders, sepsis syndrome, urosepsis, urethritis, prostatitis, epididymitis, orchitis and principles of perioperative prophylaxis in urology.

Production and characterization of 188Re-C595 antibody for radioimmunotherapy of transitional cell bladder cancer.

UNLABELLED: Bladder cancer was responsible for >12,000 deaths in the United States in 1999. The high-molecular-weight glycoprotein MUC1 mucin is overexpressed on bladder tumors and represents a useful target for radioimmunoscintigraphy and radioimmunotherapy. We report on the production and initial tracer studies of a 188Re-antibody complex directed against this target and intended for intravesical radioimmunotherapy of superficial bladder cancer. METHODS: 188Re perrhenate was eluted from a 188W/188Re generator. C595 antibody was reduced with 2-mercaptoethanol and was labeled in the presence of stannous tartrate. The final reaction mixture contained high-molecular-weight contamination, which was removed from the complex using an affinity separation technique. The specificity and integrity of the antibody complex were tested by radioimmunoassay and size exclusion chromatography. Tumor localization was investigated using an ex vivo model in human cystectomy specimens. Tracer amounts of the complex were also administered intravesically to three patients with bladder cancer, who were then imaged by gamma scintigraphy. RESULTS: The complex was immunoreactive (70% +/- 17%) and specific for MUC1 antigens. A peak corresponding to a protein of 150 kDa was observed on size exclusion chromatography, showing that the complex was homogeneous. Binding to bladder tumors was observed in an ex vivo model in which tumors were successfully imaged in four specimens. The mean tumor-to-normal tissue ratio in ex vivo bladders was 7:1. Tumor uptake after intravesical administration was confirmed in three patients with bladder cancer (mean tumor-to-normal tissue ratio, 4:1). CONCLUSION: The C595 antibody was labeled with 188Re, providing a radioimmunoconjugate with high immunoreactivity and specificity. Its ability to localize in tumors both in an ex vivo model and after intravesical administration to patients has been shown. This approach will now be extended for the therapy of superficial bladder cancer.

Production and characterisation of a C595 antibody-99mTc conjugate for immunoscintigraphy of bladder cancer.

Current radiological techniques for staging bladder cancer are inaccurate, especially in the identification of pelvic lymph node metastases. Immunoscintigraphy has the potential to offer improved staging for bladder cancer. The aim of this study was to label the anti-MUC1 monoclonal antibody C595 with 99mtechnetium (Tc), the most widely used diagnostic radionuclide, and assess the potential of the resultant conjugate for intravenous immunoscintigraphy of bladder cancer. A direct, reduction-mediated technique was used to label the antibody. The resultant conjugate was shown to be highly immunoreactive, stable and bound specifically to MUC1. The ability of the conjugate to bind to bladder tumours was demonstrated in an ex vivo model where the mean tumour:normal urothelial uptake was 5.7:1 and by intravesical administration in patients with bladder cancer where the mean tumour:normal urothelial uptake was 20.4:1. The ability of the conjugate to localise MUC1-expressing tumours was demonstrated in a nude mouse xenograft model. A conjugate of 99mTc-C595 has been produced and characterised, and it may be suitable for intravenous immunoscintigraphy, a potential novel staging tool for bladder cancer.

Infections associated with dialysis and transplantation.

Infection within the abdominal wall and peritonitis are still important causes of morbidity which ultimately limit the use of peritoneal dialysis in end-stage renal failure. Similarly disastrous complications resulting in loss of access can follow infection in venous cannulae and artificial arteriovenous fistulae, particularly in synthetic vascular grafts. Important publications continue to underline the mechanism of reduced resistance to infection by uraemic patients. After renal transplantation bacterial infection is common and predictable. However, immunosuppressed recipients are particularly susceptible to viral and fungal infection. Arguably infection of all types can induce organ rejection.

Imaging for staging bladder cancer: a clinical study of intravenous 111indium-labelled anti-MUC1 mucin monoclonal antibody C595.

OBJECTIVE: To investigate the clinical application of an 111In-labelled anti-MUC1 mucin monoclonal antibody (mAb) imaging for staging invasive bladder cancer. PATIENTS AND METHODS: Indirect immunohistochemistry was used to confirm the expression of the MUC1 target antigen by metastatic tumours. Twelve patients with bladder cancer (two with superficial and 10 with locally invasive/metastatic disease) underwent planar gamma-scintigraphy 48 h after an intravenous injection with 111In-labelled anti-MUC1 mucin mAb C595. RESULTS: No bladder uptake was detected in the two patients with superficial disease, but scintigraphy showed primary and recurrent bladder tumours and metastases in nine of the remaining 10 patients with invasive disease. In three patients additional staging information was obtained from the mAb imaging which would have altered patient management. There were no reported side-effects. CONCLUSION: This study confirmed the ability of the mAb technique to detect both primary and recurrent invasive bladder tumours and distant metastases. Some lesions shown by mAb imaging were not detected by other methods. The use of mAb imaging has the potential to improve clinical staging and assist in selecting those patients most likely to benefit from radical therapy.

99mTechnetium-C595 radioimmunoscintigraphy: a potential staging tool for bladder cancer.

OBJECTIVES: To assess whether immunoscintigraphy using a conjugate of the anti-MUC1 monoclonal antibody C595 and 99mTc could be used to target transitional cell bladder cancer after intravenous administration to patients. PATIENTS AND METHODS: Twenty-one patients with invasive or metastatic transitional cell carcinoma were recruited. Patients received 1 mg of C595 labelled with 800 MBq 99mTc followed by imaging at 0.5, 6 and 24 h using a combination of planar and single-photon emission computed tomography. Of these patients, 14 subsequently underwent cystectomy, four underwent radiotherapy and the remaining three had histologically confirmed metastatic disease. The results of immunoscintigraphy were compared with surgical findings and conventional radiology. RESULTS: There were no adverse reactions in any patient. Of the 20 patients who were found to have tumour at the time of the study, positive localization of antibody in tumour was apparent in 16. Of the remaining four patients, false-positive localization of antibody in presumed nodal tissue was detected in two. The remaining scan results were equivocal. In three patients, histologically confirmed pelvic nodal metastases that had not been detected on preoperative computed tomography were identified. CONCLUSION: These early results show the potential of 99mTc-C595 immunoscintigraphy for staging bladder cancer. A larger study is needed to fully evaluate the technique.

Anti-GnRH antibodies can induce castrate levels of testosterone in patients with advanced prostate cancer.

D17DT consists of the GnRH decapeptide linked to diphtheria toxoid. The aim of this pilot study was to assess the tolerance of D17DT and the production of anti-GnRH antibodies from two doses, 30 and 100 microg, in patients with locally advanced prostate cancer. Twelve patients with histologically proven prostate cancer in whom hormonal therapy was indicated were recruited. Patients received either 30 or 100 microg given intramuscularly on three separate occasions over six weeks. Patients were followed up and blood was taken for estimation of serum testosterone, PSA and anti-GnRH antibody titre. Overall the drug was well tolerated. In 5 patients a significant reduction in serum testosterone and PSA was seen. Castrate levels of testosterone were achieved in 4 and maintained for up to 9 months. Patients with the highest antibody titre had the best response in terms of testosterone suppression. This study shows that it is possible to immunize a patient with prostate cancer against GnRH to induce castrate levels of testosterone. This state appears to be reversible. This novel form of immunotherapy may have advantages over conventional forms of hormonal therapy and further studies are warranted in order to try and increase the proportion of responders.

Targeting superficial bladder cancer by the intravesical administration of copper-67-labeled anti-MUC1 mucin monoclonal antibody C595.

PURPOSE: More effective intravesical agents are required to limit the recurrence and progression of superficial bladder cancer. This study assessed the ability of copper-67 ((67)Cu)-C595 murine antimucin monoclonal antibody to bind selectively to superficial bladder tumors when administered intravesically, with a view to its development for therapy. PATIENTS AND METHODS: Approximately 20 MBq of (67)Cu-C595 monoclonal antibody was administered intravesically to 16 patients with a clinical indication of superficial bladder cancer. After 1 hour, the bladder was drained and irrigated. Tissue uptake was assessed by imaging and by the assay of tumor and normal tissues obtained by endoscopic resection. RESULTS: Tumor was correctly identified in the images of 12 of 15 patients who were subsequently found to have tumors. Assay of biopsy samples at 2 hours showed a mean tumor uptake of 59.4% of the injected dose per kilogram (SD = 48.0), with a tumor-to-normal tissue ratio of 14.6:1 (SD = 20). After 24 hours (n = 5), this decreased to 4.3% of the injected dose per kilogram (SD = 2.9), with a tumor-to-normal tissue ratio of 1.8:1 (SD = 0.8). CONCLUSION: This study indicates a promising method for the treatment of superficial bladder cancer. Although the mean initial tumor uptake was high, effective therapy of bladder tumors will require an increased retention of the cytotoxic radionuclide in tumor tissue.

A collaborative end-of-life care curriculum.

Death and dying in America has received limited attention in medical education. The Southern Arizona VA Health Care System and the University of Arizona have collaborated with three nonprofit community hospice programs to develop an end-of-life care curriculum. This formal and comprehensive program is offered as a one-month elective to senior medical students, residents and fellows. The goal of the program is to improve clinical skills in caring for the dying patient and foster research in palliative and supportive care.

Combined transurethral prostatectomy and inguinal hernia repair: a retrospective audit and literature review.

OBJECTIVE: To audit the results of combined transurethral resection of the prostate (TURP) and inguinal hernia repair, often carried out under the same anaesthetic (because bladder outlet obstruction from prostatic disease and inguinal hernia are both common conditions in elderly men), to avoid two separate operations. PATIENTS AND METHODS: The study included 85 patients who underwent primary inguinal hernia repair with TURP in the urology unit of Nottingham City hospital between 1989 and 1995, and who were recalled to a special clinic. The type of hernia and repair carried out were recorded and complications audited with specific reference to recurrence of hernia and wound infection. RESULTS: The 85 patients underwent 88 primary inguinal hernia repairs with TURP (three were bilateral). Maloney's darn repair was used on 55 and a Bassini repair on 33 occasions, respectively. Two patients developed mild wound infection after surgery, but only two patients (2%) had recurrence of hernia. CONCLUSIONS: The recurrence rate after primary inguinal herniorraphy with conventional methods of repair, performed with TURP, was comparable with published results of hernia repairs alone, before the introduction of Lichtenstein's mesh repair.

MUC1 mucin as a tumour marker in bladder cancer.

OBJECTIVE: To evaluate serum MUC1 levels (a high molecular weight glycoprotein which is upregulated and abnormally glycosylated in bladder cancer and other carcinomas) in patients with a variety of stages and grades of transitional cell carcinoma (TCC) of the bladder, to assess its potential as a tumour marker. PATIENTS AND METHODS: Blood samples were taken before treatment in 87 patients with TCC of the bladder and in 31 controls undergoing cystoscopy for benign conditions. Serum MUC1 levels were estimated with an enzyme-linked immunosorbent assay using the C595 monoclonal antibody. RESULTS: Of patients with T4 tumours, 47% had MUC1 levels above the normal range (P<0.001); patients with T3 tumours also had significantly higher MUC1 levels than controls. The overall sensitivity was only 24% for all tumours when the upper limit of normal was defined as 4.8 U/mL; the specificity was 97%. CONCLUSION: Serum MUC1 is not as useful tumour marker for screening, as it has a low sensitivity. However, MUC1 levels are high in advanced disease and serum MUC1 levels may be useful for disease monitoring.

Metal mesh stents for ureteral obstruction caused by hormone-resistant carcinoma of prostate.

BACKGROUND: Long-segment ureteral obstruction by hormone-refractory carcinoma of the prostate is a difficult problem to manage. J-Stents often obstruct by compression. Metal mesh stents have been used successfully in the management of extrinsic ureteral obstruction caused by malignant disease. In this paper, we review our results in three patients in terms of the defined objective of palliation. PATIENTS AND METHODS: All three patients presented with painful obstructed kidneys and renal failure from long (7-10-cm) distal ureteral strictures responding to nephrostomy drainage. Endoluminal metal mesh stents of 7 to 8-mm diameter of various lengths (depending on the size of the stricture) were implanted after antegrade balloon dilatation of the stricture by a standard technique. The case notes were reviewed for technical success, preservation of the renal units, complications, and the impact on the overall quality of life. RESULTS: All three stents were placed without any complication and showed patency on contrast study. In one patient, the stent obstructed after 5 months, necessitating placement of a nephrostomy tube. In the remaining two patients, the stents obstructed within 3 months. During these 3 months, both patients had multiple admissions for stent-related complications and other symptoms of their disease. Overall quality of life was poor for these patients. CONCLUSION: Metal mesh ureteral stents give poor palliation in distal strictures caused by hormone-refractory carcinoma of the prostate. Permanent nephrostomy may be a more acceptable alternative in these patients with short life expectancies.