DNA in situ sensitivity to denaturation in bladder cancer and its correlation with tumor stage.

DNA content and sensitivity of DNA in situ to denaturation by acid were analyzed by flow cytometry of cell nuclei freshly isolated from the bladder tumors of 32 patients and were compared with normal urothelium of 8 subjects. DNA sensitivity to denaturation was assessed in RNase treated cells by acridine orange metachromasia following partial denaturation with hydrochloric acid; the extent of denatured DNA is given as an index (alpha t), representing the ratio of single stranded to total DNA per nucleus. Of the low stage tumors (papillomas, Ta, Tis, T1) 11 of 18 (61%) were aneuploid. Of the high stage tumors (T2 and T3a) 11 of 14 (79%) were aneuploid. DNA in nuclei of normal transitional epithelium was very sensitive to denaturation, as was papilloma, characterized by nuclear alpha t indices of 0.73 +/- 0.01 (SD) and 0.73 +/- 0.04, respectively. Nuclear DNA of noninvasive carcinomas (Ta, Tis) was significantly more resistant to denaturation (alpha t = 0.69), and DNA of invasive carcinomas was most resistant, ranging from alpha t = 0.61 (T1 tumors) to alpha t = 0.59 (T2 tumors) to alpha t = 0.57 (T3 tumors). High stage tumors as a group (T2, T3) had significantly different (lower) alpha t values than low stage tumors (Ta, Tis, T1). In model cell culture systems it is known that a decrease in alpha t index, i.e., greater resistance to denaturability, occurs as cells transit from resting phase into the cell cycle. Whether the alpha t index can be used to estimate resting vesus cycling cells of human tumors is still speculative; changes in DNA denaturability also are known to occur with changes in chromatin structure during cell differentiation and in transformation. However, the empirical relationship between alpha t index and tumor stage, of itself, may prove clinically useful in identifying more advanced and perhaps more aggressive tumors.

Preoperative prostate-specific antigen in predicting pathologic stage and grade after radical prostatectomy.

Preoperative serum prostate-specific antigen (PSA) was measured in 63 men who had clinically localized, previously untreated adenocarcinoma of the prostate and underwent subsequent radical prostatectomy and bilateral pelvic lymph node dissection. Pathologic stage and grade were correlated to the serum PSA value. Patients with organ-confined (P1, P2) and extracapsular (P3, P3N +) prostate cancer had elevated preoperative serum PSA levels (greater than 4 ng/mL) in 61 and 90 percent of cases, respectively. Patients with low-grade and high-grade tumor histology had elevated preoperative PSA levels in 62 and 80 percent of cases, respectively. In distinguishing between organ-confined and extracapsular disease with a preoperative serum PSA of 10 ng/mL as a cutoff value, the sensitivity was 68 percent, the specificity was 66 percent, the positive predictive value was 46 percent, and the negative predictive value was 83 percent. Although there was a trend of increasing preoperative serum PSA levels with higher pathologic stage or grade, there was no significant difference in preoperative serum PSA values with pathologic stage and/or grade considered as a group or in determining stage and/or grade preoperatively on an individual basis.

Prostate-specific antigen and digital rectal examination in screening for prostate cancer: a community-based study.

In this study, 1,027 healthy men over age 40 were screened for prostate cancer with digital rectal examinations (DRE) and prostate-specific antigen (PSA) levels. Findings were abnormal in 189 (18%). PSA levels alone were abnormal (> 4.0 ng/mL) in 111 men (12%), 60 men (8%) had abnormal DRE and normal PSA, and 18 men had abnormal results of both examinations. Of the 189 men, 176 (93%) were referred for follow-up studies, and 39 cases of prostate cancer were detected. Of the 60 men with abnormal findings on DRE and normal PSA levels, only 2 men (3%) were found to have prostate cancer. Twenty-two of the 107 men (21%) with PSA levels between 4.0 and 9.9 ng/mL and 14 of 22 men (64%) with a PSA level greater than 10 ng/mL had prostate cancer. Conversely, 36 of the 39 men (92%) with prostate cancer had a PSA level greater than 4.0 ng/mL. Of 18 men with both abnormal DRE and elevated PSA, 9 (50%) were found to have prostate cancer. Overall, the 39 men found to have prostate cancer constituted 3.8% of the population screened; 25 of them (64%) had disease clinically confined to the prostate. PSA in combination with DRE appears to be useful in detecting prostate cancer in its early stages. Prospective randomized trials must be completed to determine whether early detection will have an impact on overall mortality from prostate cancer.

The use of prostate specific antigen density to improve the sensitivity of prostate specific antigen in detecting prostate carcinoma.

BACKGROUND: Prostate specific antigen (PSA) is useful as a tumor marker for monitoring patients with prostate cancer after definitive therapy. Limitations have been noted when PSA was used for the early detection of prostate cancer. The use of prostate specific antigen density [PSAD = PSA (ng/ml)/prostate volume (cc)] has been suggested to differentiate benign from malignant prostate disease. METHODS: A retrospective analysis of 559 men who underwent transrectal prostate ultrasound and biopsy for an abnormal PSA value (> 4.0 ng/ml) and/or an abnormal prostate gland by digital rectal examination (DRE) was performed. Prostate specific antigen density evaluation was performed on all men, and its utility for diagnosing prostate cancer was compared with those of PSA and DRE. RESULTS: Two hundred, sixty seven (47%) of the 559 men had positive biopsies for prostate cancer. Sixty-one men had PSA levels of less than 4.0 ng/ml, and 17 (27.8%) of these men had positive biopsies for prostate cancer. No patient with a normal DRE had a positive biopsy regardless of the prostate specific antigen density (PSAD) value. PSAD was not more useful than PSA alone in detecting prostate cancer in this group. Two hundred, seventy-seven men had PSA values between 4.1 and 10.0 ng/ml, and 110 (40.0%) had positive biopsies for prostate cancer. For this group as a whole, the mean PSA values of the positive and negative biopsy groups showed no significant difference. The mean PSAD was significantly different (P < 0.0001) between the positive and negative biopsy groups. Two hundred, twenty-one men had PSA values of greater than 10.0 ng/ml, and 140 (63%) had positive biopsies for prostate cancer. Prostate specific antigen density was no more useful than PSA alone in distinguishing men with positive or negative biopsies for prostate cancer in the entire group. In the subset of patients with a normal DRE, (including no benign prostatic hyperplasia) the mean PSAD appeared useful (P < 0.004) in distinguishing the positive from the negative biopsy groups, whereas the mean PSA was not. CONCLUSION: These results suggest that PSAD is useful in discriminating prostate cancer in men with normal DRE and PSA levels between 4.1 and 10.0 ng/ml.

Detection of occult micrometastases in the bone marrow of patients with prostate carcinoma.

A panel of three monoclonal antibodies that recognize membrane and cytoskeletal antigens expressed by epithelial cells (T16, C26, and AE-1) was used in a sensitive immunohistochemical assay to detect tumor cells in bone marrow aspirates from 20 patients with prostate cancer. Bone marrow aspirates from 2/9 (22%) patients with localized prostate cancer (stage B, 0/5; Stage C, 2/4), and 4/11 (36%) patients with metastatic prostate cancer (Stage D1, 0/7 patients; Stage D2, 4/4 patients) had antigen-positive cells in their bone marrow. The patients with localized disease had conventional examinations for metastases, including radioisotope bone scans and examination of bone marrow cytology, which were negative. The serum prostatic specific antigen (PSA) level appeared to correlate with the presence of micrometastases. Those patients with localized disease and antigen-positive cells in the bone marrow had an average serum PSA level of 26.6 ng/ml, while the average serum PSA level in patients without antigen-positive cells was 12.3 ng/ml. In addition, the number of antigen-positive cells detected appeared to correlate with the stage of disease; patients with Stage C prostate cancer had an average of 10 antigen-positive cells per one million bone marrow elements, while patients with Stage D2 disease had an average of 25 antigen-positive cells per one million bone marrow elements. We have demonstrated that immunohistochemical staining of bone marrow aspirates can detect occult bone marrow metastases in patients with apparently localized prostate cancer. Further follow-up of these and a larger number of patients will be require to determine the potential clinical significance of this finding.

Initial evaluation of a new epithelial antigen (T16) for bivariate flow cytometry of bladder irrigation specimens.

Bivariate flow cytometry (FCM) was used to study immunofluorescent T16 mouse monoclonal antibody (Mab) binding simultaneously with propidium iodide DNA measurements in bladder irrigation specimens from 30 patients with a history of bladder cancer. Aliquots of the same samples were stained with acridine orange (AO) and examined by conventional FCM. T16 Mab is believed to be specific for epithelial cells in this type of specimen and stained from 13% of the cells in a patient with cystitis to 95% of the cells in a patient with an atypical papilloma. In combination with DNA measurements, this antibody increased the sensitivity of FCM in patients with severe cystitis and relatively small numbers of tumor cells, but the diagnostic specificity may be decreased and the criteria established for interpreting univariate flow cytometry may have to be re-evaluated and modified.

Flow cytometry as a predictor of response and progression in patients with superficial bladder cancer treated with bacillus Calmette-Guerin.

Simultaneous bladder wash flow cytometry, voided urinary cytology and cystoscopic examinations were performed at 3-month intervals during a median of 18 months (range 5.5 to 50 months) in 65 patients receiving intravesical bacillus Calmette-Guerin treatment for superficial bladder cancer. Of the 65 patients treated 36 (56 per cent) had a complete response, 12 (18 per cent) had no response and 17 (26 per cent) had progression. Results of examinations at 6 months suggested that a negative bladder wash flow cytometry (29 of 36 patients, r equals 0.73, p less than 10(-7) is a strong predictor of response to bacillus Calmette-Guerin, comparable with cytological (r equals 0.60, p less than 10(-7) or cystoscopic (r equals 0.38, p less than 0.005) examinations alone or combined with cytology (r equals 0.74, p less than 10(-7)). At 6 months a positive bladder wash flow cytometry (r equals 0.44, p less than 0.0005) is as strong a predictor of disease progression as a positive cystoscopic examination (r equals 0.43, p less than 0.0005). The combination of bladder wash flow cytometry and voided urinary cytology is not superior to positive bladder wash flow cytometry alone. Median estimated interval to progression for these patients treated with bacillus Calmette-Guerin was 38 months. In the subgroup with positive bladder wash flow cytometry at 6 months the median interval to progression was 30 months. With a negative bladder wash flow cytometry at 6 months the probability of survival free of progression at 30 months was 85 per cent (p less than 0.01). Thus, negative bladder wash flow cytometry at 6 months is a strong predictor of response to bacillus Calmette-Guerin and also survival free of progression.

Intravesical bacillus Calmette-Guerin therapy for in situ transitional cell carcinoma involving the prostatic urethra.

A total of 23 patients presenting with multifocal superficial bladder cancer and concomitant in situ transitional cell carcinoma of the prostatic urethra (mucosal in 19 and ductal in 4) underwent transurethral resection and intravesical bacillus Calmette-Guerin therapy. Median followup was 51.6 months (range 6 to 105 months). Of the 23 patients 13 (48 per cent) had a complete response with a median followup of 43.7 months without recurrence. Progression of some type (local, muscle invasion or metastasis) occurred in 10 patients (44 per cent); none occurred in the prostatic urethra. Median interval free of progression was 55.7 months; 7 of 10 patients required cystectomy for progression or refractory disease in the bladder (prostate negative for transitional cell carcinoma). A trial of complete transurethral resection plus intravesical bacillus Calmette-Guerin is a viable alternative to immediate radical cystectomy for patients with mucosal and/or ductal involvement of the prostatic urethra with in situ transitional cell carcinoma.

The response of patients with superficial bladder cancer to a second course of intravesical bacillus Calmette-Guerin.

Of 347 patients who received an initial 6-week course of intravesical bacillus Calmette-Guerin for superficial transitional cell carcinoma of the bladder 28 (8%) were treated with another course. Subsequent progression of disease (muscle infiltration, metastasis or local progression) occurred in 13 patients (46%). Of the 15 patients (54%) without progression 10 (36%) had a complete response and 5 (33%) had new tumors, and they were rendered free of disease after transurethral resection. The median duration of response to course 1 of bacillus Calmette-Guerin was shorter for patients with disease progression after course 2 than for those with no progression (15 and 27 months, respectively, p equals 0.05). The median followup after course 2 was 31.2 months (range 15.6 to 56.4 months). The median interval between courses 1 and 2 of intravesical bacillus Calmette-Guerin was 21.6 months (range 3.6 to 78.8 months). The interval from course 2 of bacillus Calmette-Guerin to progression correlated with the duration of response to course 1 of treatment (p equals 0.01). It appears that a subsequent treatment with bacillus Calmette-Guerin is most likely to be useful in patients who have a sustained response to the initial treatment.

Voided urine flow cytometry in screening high-risk patients for the presence of bladder cancer.

Fifty-nine patients with a history of bladder cancer were evaluated with three serially voided urines for flow cytometry and cytology within the 24 hours preceding cystoscopy, bladder wash, and biopsy. Evaluation of the 32 patients with biopsy proven cancer revealed that for one, two, and three voided urine specimens, the sensitivity of flow cytometry in detecting bladder cancer was 29%, 35%, and 41%, respectively, whereas the sensitivity of voided urine cytology was 44%, 53%, and 57%, respectively. Bladder wash flow cytometry had a sensitivity of 76%. Interpretation of the voided urine flow cytometry was based on a control group of 80 volunteers with negative voided urine cytology. The control group demonstrated that a minimum of 1500 analyzable cells was necessary for a reliable histogram. Considering all 59 patients, voided urine flow cytometry, bladder wash flow cytometry, and voided urine cytology were acceptable for analysis in 53%, 93%, and 100% of the specimens, respectively. Voided urine specimens appear less suitable than bladder irrigation specimens for evaluation by flow cytometry. Voided urine flow cytometry is less sensitive in detecting bladder cancer than voided urinary cytology or bladder wash flow cytometry and is not effective for use as a bladder cancer screening test.