Antibody responses to Bacillus Calmette-Guérin during immunotherapy in bladder cancer patients.

Levels of serum antibody to Bacillus Calmette-Guérin (BCG) were determined by solid-phase radioimmunoassays in 48 normal donors and 60 patients with bladder cancer. Of 57 patients enrolled in a randomized prospective controlled trial of BCG immunotherapy, 47 were followed for up to 30 months, thus permitting comparisons of tumor recurrence, delayed cutaneous hypersensitivity responses to purified protein derivative (PPD), and serum BCG antibody levels at specific intervals during the clinical course. Sera from normal donors and cancer patients prior to BCG therapy had equally low levels of BCG antibody. AFter administration of intravesical and percutaneous BCG, significant rises of serum BCG antibody levels were detected in 23 of 24 randomized BCG immunotherapy patients. Skin test responses to PPD and serum BCG antibody levels had a close correlation as immune response indicators in 14 of 24 BCG therapy patients, while rises in serum BCG antibody levels were a better response indicator than PPD skin test reactions in the other 10 patients. Eleven of the 23 patients randomized into the non-BCG treatment group had tumor recurrence, although tumors recurred in only six of the 24 randomized patients in the BCG therapy group. Two additional nonrandomized BCG-treated patients had tumor recurrence. All eight BCG-treated patients with tumor recurrence had documented increases in serum BCG antibody levels after BCG therapy. Only three of these eight patients had conversion of PPD skin test responses from negative to positive; three were positive before immunotherapy and two remained negative after BCG therapy. Levels of antibodies reactive with human adenovirus type 5 and with Escherichia coli antigens were similar in sera from normal donors and from the randomized bladder cancer patients in both the BCG and non-BCG treatment groups. These results suggest that serum BCG antibody responses are as useful as PPD skin tests in identifying immunological responses to the immunoadjuvant BCG during immunotherapy trials in cancer patients.

Leukocyte migration inhibition in vitro in bladder carcinoma.

The leukocyte migration inhibition response in vitro of peripheral blood leukocytes from patients with transitional cell carcinoma of the urinary bladder, other genitourinary diseases, and normal controls was studied. The agarose droplet migration inhibition method was used to determine the cell-mediated immune reactivity of bladder tumor patients to antigens derived from allogeneic bladder tumor cell lines by hypertonic potassium chloride extraction. Sixty-nine bladder tumor patients were tested 131 times and included 68 positive and 63 negative results. A positive assay was shown to correlate strongly with the presence of tumor at the time of testing (p less than 0.001). Five of 24 patients with other genitourinary diseases had positive inhibition assays, but none of the 26 normal controls were positive. These results suggest that this in vitro assay method may prove valuable in monitoring bladder tumor patients for completeness of initial tumor resection and for clinical recurrence as well as for further studies of the tumor-specific immune response in this disease.

Human prostate androgen receptor quantitation: effects of temperature on assay parameters.

When cytoplasmic extracts of human prostatic tissues were split to permit quantitation of total androgen receptor (RCT) content by saturation analysis at 15 degrees and 2 degrees, we observed that 30% (10 of 32) of the specimens yielded statistically increased values for RCT following incubation at 15 degrees as compared to 2 degrees. Considering only those specimens (13 of 32) showing statistically differentiated RCT yield, 77% (10 of 13) yielded greater RCT content following incubation at 15 degrees. The families of association constants (Ka) obtained for RCT determinations at 2 degrees and 15 degrees were not statistically differentiated. The increased yield of RCT content determined at 15 degrees was 95% (mean) and 20 to 350% (range). Nuclear androgen receptor content determined at 15 degrees was greater for 25% (2 of 8) of the patient specimens when compared to split determinations performed at 2 degrees. Incubation of nuclear extracts at 15 degrees resulted in a significant 3-fold reduction in receptor Ka for methyltrienolone (R1881). This did not appear to affect assay precision. These studies showed that incubation at 15 degrees is preferable to incubation at 2 degrees for quantitation of RCT and nuclear androgen receptor content by saturation analysis. Single saturating dose determinations of RCT consistently yielded underestimates. The extent of underestimate was variable from specimen to specimen and was both ligand concentration and assay temperature dependent. Our data suggest that results of single saturating dose determinations of RCT require cautious interpretation.

Inability of cytoplasmic or nuclear androgen receptor content or distribution to distinguish benign from carcinomatous human prostate.

We used exchange saturation analysis at 15 degrees to quantitate total cytoplasmic and nuclear androgen receptor content of 70 patient specimens. Cytoplasmic androgen receptor contents (fmol/mg DNA) for eight specimens of clinically benign hyperplasia, 14 specimens of histologically hyperplastic prostate obtained at cystoprostatectomy, and carcinomatous and noncarcinomatous prostate obtained at radical prostatectomy for prostatic carcinoma, 48 specimens, respectively, were 830 +/- 165 (mean +/- S.E.), 890 +/- 445, 955 +/- 240, and 750 +/- 95. Nuclear androgen receptor contents of these same specimens, respectively, were 275 +/- 40, 235 +/- 30, 345 +/- 25, and 350 +/- 30; whereas, the values of the cytoplasmic/nuclear receptor content, respectively, were 3.25 +/- 0.55, 3.05 +/- 0.80, 2.50 +/- 0.50, and 2.80 +/- 0.40. Multiway analyses of variance of these cross-sectional data showed that there was no significant difference (p greater than 0.05) between group mean values. This result principally reflects the fact that the families of values for the four tissue groups were highly heterogenous with broad overlap. The results would not appear to be unduly influenced by carcinomatous epithelial cell content of the specimens, because cytoplasmic and nuclear androgen receptor content were not related to specimen carcinomatous epithelial cell content. Paired analyses of receptor content in carcinomatous and noncarcinomatous prostate specimens from the same prostate showed enhanced or unchanged receptor content in 58% (cytoplasmic) and 62% (nuclear) of specimens. Our studies show that cross-sectional analyses of androgen receptor content fail to distinguish carcinomatous prostate from noncarcinomatous prostate. However, paired analyses of these tissues from the same gland identify distinguishing differences. The clinical relevance of these observations remains to be examined.

A diagnostic-prognostic test for bladder cancer using a monoclonal antibody-based enzyme-linked immunoassay for detection of urinary fibrin(ogen) degradation products.

An enzyme-linked immunosorbent assay (ELISA) using a monoclonal antibody was developed to determine the clinical value of urinary fibrinogen/fibrin degradation product levels for the identification and management of patients with bladder cancer. Assays were performed on 286 serial urine specimens from 56 bladder carcinoma patients. Specimens were grouped according to whether the patient had an evident tumor at the time of specimen collection (134 specimens, 41 patients) or was clinically disease-free following treatment (152 specimens, 38 patients). Many patients contributed specimens to both groups as determined by their clinical status at the time of collection. In addition, 45 specimens from 33 patients with inflammation of the urogenital tract and 81 specimens from 19 patients with renal or prostatic cancer were assayed for urinary fibrin degradation products. The ELISA, using a high-sensitivity procedure, identified 83% of the specimens from bladder cancer-positive patients with an overall accuracy with all specimens of 78% and a false-negative rate of 5% for all specimens tested. The high-sensitivity ELISA appeared most appropriate for monitoring bladder cancer patients for recurrence of tumor after surgery. The ELISA using a high-specificity procedure appeared most appropriate for screening. The high-specificity ELISA accurately identified 96% of urine specimens from non-bladder cancer patients with a false-positive rate of only 5%. These results demonstrate that the ELISA is an efficient, reliable, quantitative, and noninvasive immunoassay that can be useful both for the identification of bladder cancer patients and for monitoring the course of the disease.

Therapy of superficial bladder cancer.

Intravesical therapy has been used in the management of superficial transitional cell carcinoma (TCC) of the urinary bladder (Ie, Ta, Tl, and carcinoma in situ [CIS]) with specific objectives that include treating existing/residual tumor, preventing recurrence of tumor, preventing disease progression, and prolonging survival. The initial clinical stage and grade remain the main determinant factors in survival irrespective of the treatment. Intravesical chemotherapy has shown a decrease in short-term tumor recurrence rates, but has had no positive impact on disease progression or prolongation of survival. Presently, bacillus Calmette-Guèrin vaccine (BCG) immunotherapy remains the most effective treatment and prophylaxis for TCC (Ta, Tl, CIS) and has positive outcome on tumor recurrence rate, disease progression, and prolongation of survival. Prostatic urethral mucosal involvement with bladder cancer can also be effectively treated with BCG intravesical immunotherapy. Interferons, keyhole limpet hemocyanin and photofrin-photodynamic therapy are under investigation in the management of TCC and early results are encouraging. This review highlights and summarizes the recent advances in intravesical therapy and prophylaxis of superficial TCC.

Visualization of minute centers of viral infection in unfixed cell cultures by an enzyme-linked antibody assay.

Enzyme-linked antibody was used to treat unfixed herpesvirus-infected human fetal lung cell cultures in a mode which permitted the visualizing of local sites of infection. Foci containing as few as 20 herpesvirus-infected cells produced sufficient viral mass to be easily detectable by this method. 'Clouds' or 'plumes' of colored reaction product diffused into the substrate overlay, accumulated above and around each focus of infection and allowed quantitation of the number of foci in a culture. The number of minute centers of viral infection determined by the enzyme-linked antibody method corresponded almost exactly with values obtained by fluorescence microscopy. Quantitation of herpes simplex infectivity by focus assay was possible within only 17 h after culture inoculation, well before cytopathic effects were visible macroscopically. The technique was also applied to demonstrate measles and mumpsvirus plaques (infectious centers) in Vero cell cultures.

Metallothionein isoform 3 as a potential biomarker for human bladder cancer.

The goal of the present study was to determine if the expression of metallothionein isoform 3 (MT-3) might serve as a biomarker for human bladder cancer. To accomplish this goal, we defined the localization and expression of MT-3 protein and mRNA using fresh and archival biopsy specimens obtained from patients undergoing differential diagnosis for a variety of bladder disorders. We used immunohistochemistry, immunoblot, and RT-PCR analysis to define the localization and expression of MT-3 protein and mRNA. Immunohistochemical analysis disclosed no immunoreactivity for MT-3 in normal bladder cells. The absence of MT-3 expression in the normal bladder was further confirmed by demonstrating that MT-3 mRNA could not be detected using reverse transcriptase-polymerase chain reaction (RT-PCR) or MT-3 protein using immunoblot. Immunohistochemistry also disclosed no immunoreactivity for MT-3 in archival biopsy specimens from patients with interstitial cystitis and related disorders. Immunohistochemical analysis demonstrated that MT-3 was expressed in carcinoma in situ (CIS), high-grade bladder cancer, low-grade bladder cancer, and dysplastic lesions. MT-3 immunostaining was intense in both CIS and high-grade bladder cancer, and low to moderate in low-grade bladder cancer and dysplastic lesions. We determined MT-3 mRNA expression in a subset of these bladder cancer specimens; expression was elevated as compared to that of the housekeeping gene, ss-actin. The cDNA from the RT-PCR reaction primed for MT-3 contained a FokI restriction site, a site unique for MT-3 as compared to other MT family members. In conclusion, this study demonstrates that MT-3 is up-regulated in human bladder cancer and that this up-regulation increases with increasing tumor grade. The finding that MT-3 expression is minimal in normal bladder suggests that MT-3 might be developed into an effective biomarker for bladder cancer.

Accessory and ectopic scrota.

Two cases of ectopic scrotum are presented, and 12 previously reported cases are reviewed. This anomaly presumably develops secondary to faulty division or abnormal migration of the embryonic labioscrotal swellings.

Serum and bone marrow radioimmunoassay of acid phosphatase in prostatic cancer.

Use of radioimmunoassay (RIA) for determinations of prostatic acid phosphatase has recently received considerable attention because of reported higher sensitivity and specificity than previous enzymatic assays. We have compared the sensitivity and specificity of a commercially available RIA to a highly specific enzymatic assay (thymolphthalein monophosphate) using 37 patients with prostatic cancer and 34 patients with surgically proved benign prostatic hyperplasia. Seventeen of the cancer patients and all 34 of the BPH patients were studied prospectively. We further evaluated specificity by performing the RIA on 25 specimens of bone marrow from patients with nonprostatic disease. Our results indicate the radioimmunoassay is not, at this time, an adequate screening tool, and we question its accuracy in staging patients anymore reliably than by enzymatic assay.

Preventing warm ischemia with a polyurethane bag during renal transplantation.

We have developed a technique that reduces the rewarm time during renal transplant vascular anastomoses by supporting the kidney in a slush-filled sterile polyurethane bag. There were no complications related to the use of this technique.

Perioperative management in undiagnosed pheochromocytoma.

Pheochromocytoma which is diagnosed intraoperatively carries a high morbidity and mortality. Successful management of the patient with unsuspected pheochromocytoma requires a high index of suspicion and aggressive pharmacologic intervention.

Medical therapy of experimental infection stones.

Struvite bladder calculi were induced in rats with an intrarenal injection of urease-producing human T mycoplasma strain T960. Acetohydroxamic acid was effective in inhibiting calculous formation. Methylene blue, tetracycline, orthophosphate, diphosphonate, and hydrochlorothiazide had no inhibitory effect.

Automatic spring-loaded biopsy gun with ultrasonic control for renal transplant biopsy.

The automatic spring-loaded biopsy gun with 18-gauge needle was used to perform 20 renal transplant biopsies. A total of 35 needle passes were used during the 20 biopsies to obtain 31 cores of renal tissue (ratio of successful cores to passes 0.88). Nineteen of 20 biopsies (95%) resulted in renal tissue sufficient for diagnosis. One patient experienced gross hematuria that required blood transfusion and resulted in temporary ureteral clot obstruction. We believe the automatic spring-loaded biopsy gun with ultrasonic control allows rapid, accurate, and safe histologic assessment of the renal allograft, and we recommend this system for routine use.

Treatment of renal cell carcinoma with 5-fluorouracil and alfa-interferon.

OBJECTIVES: Renal cell carcinoma is relatively resistant to both chemotherapy and immunotherapy. Response, survival, duration of response, and toxicity of treatment were evaluated in patients with advanced renal cell carcinoma receiving a continuous intravenous infusion of 5-fluorouracil (5-FU) and low dose subcutaneous alfa-2b-interferon. METHODS: Between 1989 and 1994, 21 patients with advanced renal cell carcinoma underwent treatment with continuous intravenous infusion of 5-FU, 200 mg/m2/day, and subcutaneous injections of recombinant interferon alfa-2b (IFN-alpha), 1 x 10(6) U/day. RESULTS: Objective response was observed in 9 patients (43%). Complete response occurred in 4 patients (19%): 2 with lung, 1 with bone, and 1 with liver metastasis. Partial response occurred in 5 patients (24%). Three of 4 complete responders remain alive without recurrence. Mean survival rate was 195 weeks among complete responders, 184 weeks among partial responders, and 88 weeks among nonresponders. The overall mean duration of response was 101 weeks. Responders developed progression of disease a mean of 62 weeks after the initial response to therapy. Mild dose-dependent toxicity was related to 5-FU infusion. Nearly all toxicities subsided with the temporary cessation of 5-FU infusion and/or decreasing the dose of the infusion. Few if any of the toxicities appear to be directly related to the low dose interferon injections. CONCLUSIONS: Although this study is based on a small sample size, we believe that the encouraging complete and partial responses, apparent prolongation of survival, and manageable toxicity of this combination therapy warrant further investigation with larger randomized trials.

Bropirimine immunotherapy of upper urinary tract carcinoma in situ.

OBJECTIVES: Bropirimine has been shown to be effective in treating approximately 50% of patients with carcinoma in situ (CIS) of the bladder in recent clinical trials. Patients with upper tract CIS were treated with bropirimine to determine whether this oral drug might be effective in that setting. METHODS: Twenty-four patients with negative radiographic findings and positive cytologic evidence for upper tract CIS in one or both ureters received bropirimine (3.0 g/day orally) for 3 consecutive days each week for up to 1 year. Ureteral collection of urine or barbotage for cytologic analysis was performed quarterly thereafter. RESULTS: Ten (48%) of 21 evaluable patients had a negative ureteral cytologic analysis after 12 weeks (5 patients) or 24 weeks (5 patients). Of these 10 patients, 8 continue to have negative cytology for a period of 3 to 30 months (median, more than 9 months). In 2 patients, negative cytology reverted to positive at 6 and 9 months, respectively, during therapy. Twelve (50%) of the 24 patients reported no toxicity. Three patients stopped treatment at 2, 3, and 3 weeks due to pruritic rash, nausea and vomiting, and severe bone pain, respectively. Therapy was stopped in 1 additional patient between 4 and 5 months because of transient liver enzyme elevations, yet this patient has had a continuous negative cytologic analysis for more than 9 months. CONCLUSIONS: Orally administered bropirimine may be effective therapy for CIS of the ureter or renal pelvis, with acceptable toxicity in most patients. Further efforts to better define this activity as well as the possible need for maintenance or intermittent long-term therapy are warranted.

Oral bropirimine immunotherapy of carcinoma in situ of the bladder: results of a phase II trial.

OBJECTIVES: Bropirimine is an orally administered immunostimulant that has been shown to have activity against carcinoma in situ (CIS) of the bladder. To further assess this potential activity, bropirimine was administered to 42 patients for bladder CIS in a Phase II trial. METHODS: Patients were treated with bropirimine 3.0 g/day by mouth for 3 consecutive days each week up to 1 year. Cystoscopy with biopsies and bladder wash cytology were performed quarterly. RESULTS: Twenty (61%) of 33 evaluable patients converted malignant biopsies and bladder wash cytology to negative, including 6 (50%) of 12 who failed prior bacillus Calmette-Guérin (BCG) immunotherapy, 14 (67%) of 21 who had not received prior BCG therapy, and 12 (80%) of 15 with primary CIS. Median response duration exceeds 21 months. Four of the 20 responders did have a papillary tumor recurrence at 3 to 15 months, all Stage Ta or T1. Mild toxicity (grade I or II) suggestive to interferon induction or administration occurred in one third of patients. Headache, transient hepatic enzyme elevations, skin rash, and arthralgias each occurred in 5% to 14% of the patients, with nausea or emesis in 21%. Grade 1 tachycardia/palpitations or chest pain each were noted in 5%. CONCLUSIONS: Oral bropirimine can induce remission of bladder CIS with acceptable toxicity at 3.0 g/day. Bropirimine may be a valuable alternative to cystectomy for some failures of BCG therapy and may have the potential to replace BCG as front-line therapy because of its ease of administration.

Improved detection of recurrent bladder cancer using the Bard BTA stat Test.

OBJECTIVES: To evaluate the BTA stat Test in the detection of recurrent bladder cancer. METHODS: Sensitivity and specificity were determined using frozen voided urine samples from patients with recurrent bladder cancer, volunteers, patients with nonurologic conditions, and patients with a history of bladder cancer but free of disease. Results of cytology and the original BTA Test were compared with the sensitivity of the BTA stat Test in a large subgroup of the patients with cancer. RESULTS: The BTA stat Test detected 147 (67%) of 220 recurrent cancers. For those urine samples with previous cytologic and BTA Test results available, cytology had a sensitivity of 23%, the BTA Test 44%, and the BTA stat Test 58% for detection of recurrent cancer (P < 0.001, stat versus cytology). The specificity of the BTA stat Test was 72% for benign genitourinary disease and 95% in healthy volunteers. CONCLUSIONS: The BTA stat Test has high sensitivity and is significantly superior to voided urine cytologic analysis in the detection of recurrent bladder cancer.

Androgen priming and cytotoxic chemotherapy in advanced prostatic cancer.

Hormone manipulation has been standard therapy for metastatic adenocarcinoma of the prostate for many years. Recently cytotoxic drugs have been studied, but their effectiveness has been limited, indicating the need for new therapeutic approaches. Based upon the hypothesis that cytotoxic drugs are most effective against actively proliferating cells, we have designed a clinical pilot study employing cyclical androgen priming to transiently stimulate tumor cells followed by cytotoxic chemotherapy with cyclophosphamide and methotrexate. There were nine responders (43%) out of 21 patients entered in the study, with a median duration of response that has not been reached at 9+ months. Survival was significantly better in responders than in non-responding patients. These results are similar to those of other studies in which chemotherapy was used alone. Chemotherapy toxicity with this schedule was mild. However, the androgen priming frequently resulted in increased bone pain, and there was one episode of spinal cord compression, suggesting that tumor stimulation was achieved. These results demonstrate the need for additional basic studies of the effects of testosterone on tumor cell kinetics before further clinical trials of this approach are initiated.

Management of patients with Bacilli Calmette-Guérin-refractory carcinoma in situ of the urinary bladder: cost implications of a clinical trial for valrubicin.

OBJECTIVE: This study was undertaken to identify the expected first- and second-year clinical costs associated with intravesical valrubicin therapy, using a decision analytic model, for patients with Bacilli Calmette-Guérin (BCG)-refractory carcinoma in situ (CIS) of the urinary bladder. BACKGROUND: Cancer of the urinary bladder is the fourth most common malignancy in men and the sixth most common noncutaneous carcinoma overall. One histopathologic stage of bladder cancer is CIS, for which BCG intravesical immunotherapy is the first-line therapy. Radical cystectomy has been recommended for patients with CIS who do not respond to or become refractory to therapy with BCG. Surgery, however, may not be appropriate for all patients, especially those who are ineligible for the lengthy procedure because of advanced age or comorbidities and those who prefer alternative nonsurgical management. For these groups, intravesical valrubicin therapy is a plausible alternative. METHODS: Models were developed and populated with data from 1 open-label study of 90 patients, information from the medical literature, and input from clinical experts. The analysis was conducted from the payor perspective for direct costs only. RESULTS: Our data indicate that first- and second-year expected costs for valrubicin therapy are $19,912 and $23,496, respectively. Expected cost for radical cystectomy was also evaluated, since some patients may have no other option if drug therapy fails. CONCLUSION: Our cost-consequence analysis and clinical data provide decision-makers with tools to aid in global budgetary projections of fractional and total expected health care costs associated with the management BCG-refractory CIS of the urinary bladder.