Comparison of antiemetic efficacy between single and repeat treatment with dexamethasone in patients receiving carboplatin-based combination chemotherapy.

A retrospective study was carried out to compare the preventive effects of single and repeat treatment with dexamethasone (DEX) on delayed nausea and emesis in patients who had received carboplatin (CBDCA)-based combination chemotherapy. Sixty-four patients were evaluated. Efficacy was assessed using the nausea and emesis score, food intake score and the requirement for antiemetic medication. These forward scores were categorized as three-grade during the first 5 days after chemotherapy. Acute nausea and emesis were well controlled in both groups on day 1. Mean values of the nausea and emesis score on day 3 evening and the food intake score on day 4 morning in the repeat-treatment group was 1.31 ± 0.93 and 3.46 ± 1.03, respectively, which were significantly better when compared with the single-treatment group (2.00 ± 1.52; P = 0.028 and 2.79 ± 1.12; P = 0.018, respectively). Multivariate logistic regression analysis revealed that less frequent dispensing of antiemetic medication was significantly associated with the repeat-treatment group (adjusted odds ratio, 0.153; 95% confidence interval, 0.026-0.734; P = 0.018). These results suggest that repeat-dose DEX may be more effective than single-dose DEX for the prevention of delayed nausea and emesis after CBDCA-based combination chemotherapy.

The relationship between the reproducibility of holmium laser enucleation of the prostate and prostate size over the learning curve.

The purpose of this study was to analyze the relationship between the reproducibility of holmium laser enucleation of the prostate (HoLEP) and prostate size over the learning curve. We compared the outcome among three institutions in three subgroups on the basis of the weight of tissue retrieved. There were no significant differences in operating time, efficiency of the procedure, decrease in hemoglobin level and postoperative urinary incontinence among three institutions, only in patients with prostates >or=20 g-<40 g retrieved. Our data indicate that HoLEP is more reproducible in patients with a moderate-sized prostate over the learning curve.

Increased urinary 8-hydroxy-2'-deoxyguanosine excretion after ileal neobladder replacement.

OBJECTIVES: To examine whether orthotopic neobladder replacement using either ileum or colon segments results in increased oxidative stress, by measuring urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG), one of the most commonly used markers for evaluating oxidative DNA damage. PATIENTS, SUBJECTS AND METHODS: Urinary levels of 8-OHdG and creatinine, urine analysis, nutritional status, and acid-base and electrolyte balances, were assessed in 22 patients with an ileal neobladder, 28 with a colon neobladder, 37 with an ileal conduit and 22 healthy volunteers. The results from both types of orthotopic neobladder, the ileal conduit and in the healthy controls were compared. RESULTS: The mean (sd) ratios of urinary 8-OHdG to urinary creatinine in patients with an ileal neobladder, colon neobladder, ileal conduit and in controls were 20.4 (7.8), 15.2 (4.3), 15.9 (5.1) and 15.2 (5.4) ng/mg, respectively. The urinary 8-OHdG ratio in the first group was significantly higher than in the other three groups. Among patients with a neobladder, the urinary 8-OHdG ratio was closely associated with the degree of pyuria, but not age, gender, the interval from surgery, body weight, height, serum creatinine or the degree of metabolic acidosis. CONCLUSIONS: These findings suggest that creating an ileal neobladder caused significantly greater oxidative stress than a colon neobladder, ileal conduit, or that in healthy controls. Therefore, it is recommended to conduct a careful long-term follow-up considering the possible development of malignant disease after urinary diversion, especially by an ileal neobladder.

Significance of prostate-specific antigen--alpha(1)-antichymotrypsin complex for diagnosis and staging of prostate cancer.

OBJECTIVE: To evaluate the clinical significance of measuring the prostate-specific antigen-alpha(1)-antichymotrypsin (PSA-ACT) for differentiating prostate cancer from benign prostate hypertrophy (BPH) and for the staging of prostate cancer. METHODS: Before treatment, total PSA (tPSA) and PSA-ACT were measured in 120 patients with prostate cancer and in 150 patients with BPH using immunofluorometric techniques with different monoclonal antibodies against PSA and ACT. Furthermore, the tPSA and PSA-ACT densities of the whole prostate (PSAD and ACTD, respectively) were calculated. RESULTS: tPSA, PSAD, PSA-ACT and ACTD levels in patients with prostate cancer paralleled the clinical stage and were significantly higher than those in patients with BPH. Furthermore, these four values were significantly higher in patients with pathologically extraprostatic disease than those with organ-confined disease. Receiver operating characteristics analysis among patients with PSA values of 4.1-10 ng/ml revealed that the areas under the curve for tPSA and ACTD were similar to those for PSA-ACT and ACTD, respectively and that no significant differences in the differentiation between prostate cancer and BPH were observed among these parameters. CONCLUSIONS: Measurement of PSA-ACT provides useful information for the clinical staging of prostate cancer and differential diagnosis between prostate cancer and BPH; however, compared with tPSA, PSA-ACT may not be significantly superior in the diagnosis and staging of prostate cancer.

Value of the serum prostate-specific antigen-alpha 1-antichymotrypsin complex and its density as a predictor for the extent of prostate cancer.

OBJECTIVE: To determine whether serum levels of the prostate-specific antigen-alpha1-antichymotrypsin complex (PSA-ACT) and its density (ACTD) in patients scheduled to undergo radical prostatectomy for clinically localized prostate cancer can predict organ-confined vs extraprostatic disease. PATIENTS AND METHODS: Serum samples were obtained from 62 patients with clinically localized prostate cancer before they underwent radical prostatectomy. PSA and PSA-ACT were measured using immunofluorometric techniques with different monoclonal antibodies against PSA and ACT, respectively. Furthermore, the PSA and PSA-ACT densities of the whole prostate (PSAD and ACTD, respectively) were calculated. The relationships of serum PSA, PSA-ACT, PSAD, ACTD and the pathological stage of the prostatectomy specimens were analysed. RESULTS: The disease was organ-confined or extraprostatic in 30 and 32 men, respectively. In men with organ-confined cancer, the mean PSA and PSA-ACT levels were significantly lower than in those with extraprostatic disease. Furthermore, there were significantly higher mean PSAD and ACTD levels in men with extraprostatic than with organ-confined disease. There were also significant differences in PSA, PSA-ACT, PSAD and ACTD levels at each pathological stage, whereas there was no significant association between these variables and the Gleason score. Receiver-operating characteristic curve analysis for detecting organ-confined disease showed that PSA-ACT and ACTD had a larger area under the curve than PSA and PSAD, respectively, but these differences were not significant. Furthermore, PSA-ACT and ACTD provided significantly better sensitivity for detecting organ-confined disease than PSA and PSAD, respectively. CONCLUSIONS: Measuring PSA-ACT and ACTD may improve the preoperative evaluation of patients scheduled to undergo radical prostatectomy, because these factors better differentiate extraprostatic from organ-confined disease than PSA and PSAD.

Induction of cellular immunity by immunization with novel hybrid peptides complexed to heat shock protein 70.

Heat shock proteins 70 (hsp70) derived from tissues and cells can elicit cytotoxic T lymphocyte (CTL) responses against peptides bound to hsp70. However, peptides can markedly differ in their affinity for hsp, and this potentially limits the repertoire of peptides available to induce CTL by the hsp immunization. Hybrid peptides consisting of a high-affinity ligand for the peptide-binding site of hsp70 joined to T cell epitopes by a glycine-serine-glycine linker were constructed. Immunization with hybrid peptides complexed to mouse hsp70 effectively primed specific CTL responses in mice and were more potent than T cell peptide epitopes alone with hsp70. In vivo immunization with hsp70 and hybrid peptides led to rejection of tumors expressing antigen with greater efficacy than immunization with peptide epitope plus hsp70. Induction of CTL responses occurred independently of CD4(+) T cells, suggesting that immunization directly primed antigen-presenting cells to elicit CD8(+) cytotoxic T cell responses without T cell help. Both peptide/hsp70 complexes and mouse hsp70 alone were able to induce cultures of mouse bone marrow-derived dendritic cells (DC) to release cytokines, including DC from endotoxin-resistant C57BL/10Sc mice. Thus, hsp70/hybrid peptide complexes can activate DC for cytokine release, providing a potential adjuvant effect that could bypass T cell help.

Clinical outcome of high-dose chemotherapy combined with peripheral blood stem cell transplantation for male germ cell tumors.

Peripheral blood stem cell transplantation (PBSCT) is widely performed currently instead of bone marrow transplantation (BMT) because bone marrow reconstruction is better and the procedure is less invasive. We applied 26 courses of high-dose chemotherapy (1250 mg/m2 of carboplatin, 1500 mg/m2 of etoposide and 7.5 g/m2 of ifosfamide) to 14 male patients with germ cell tumors. Eleven patients underwent high-dose chemotherapy as induction after two to three courses of conventional BEP therapy. The remaining three patients had recurrent disease after conventional chemotherapies. Peripheral blood stem cells were harvested during previous chemotherapy and sufficient CD34+ cells were harvested for transplantation. Although all patients had grade 4 hematotoxicity, the white blood cell count recovered to more than 1000/microl within 8-11 days after PBSCT. No treatment-related death was found. Nine of 14 patients (64.3%) remain disease free at 18 months of median follow up time (range 12-60). We conclude that high-dose chemotherapy is a safe and effective means of treating advanced or refractory germ cell tumors in male patients.

Clinical study of renal cell carcinoma with brain metastasis.

BACKGROUND: The clinical outcome of patients with renal cell carcinoma with brain metastasis was analyzed. METHODS: Nine patients (median age, 60 years) with primary renal cell carcinoma and distant metastasis, including brain metastasis, were treated. The median time to the development of brain metastasis was 15 months after the initial visit. Patients with poor performance status or progressive disease were treated with interferon or conservative therapy alone. Patients with good performance status and other well-controlled metastatic foci were treated either with radiotherapy, or by tumorectomy of brain metastasis, or both. The median follow-up was 26 months after the initial visit. RESULTS: The 1-year, cause-specific survival rate was 17%. Of the 5 patients treated with alpha-interferon alone, all died of disease after the treatments, without improvement of performance status, 1 to 4 months after the diagnosis of brain metastasis. Two of 4 patients who underwent radiotherapy were treated with a combination of gamma-knife and tumorectomy of brain metastasis. They remained alive 10 and 22 months after diagnosis of brain metastasis. The 2 patients who underwent the combination treatment of gamma-knife and tumorectomy showed improvement of their performance status after these treatments for brain metastasis. CONCLUSION: Brain metastasis is an unfavorable prognostic factor in renal cell carcinoma. Although a larger number of patients would be necessary to demonstrate the definitive effects of gamma-knife treatment, our results suggest that the combination of gamma-knife and tumorectomy of brain metastases may be recommended for selected patients with good performance status and other well-controlled metastatic foci.

Fc receptors are required in passive and active immunity to melanoma.

Effective tumor immunity requires recognition of tumor cells coupled with the activation of host effector responses. Fc receptor (FcR) gamma-/- mice, which lack the activating Fc gamma R types I and III, did not demonstrate protective tumor immunity in models of passive and active immunization against a relevant tumor differentiation antigen, the brown locus protein gp75. In wild-type mice, passive immunization with mAb against gp75 or active immunization against gp75 prevented the development of lung metastases. This protective response was completely abolished in FcR gamma-deficient mice. Immune responses were intact in gamma-/- mice because IgG titers against gp75 develop normally in gamma-/- mice immunized with gp75. However, uncoupling of the Fc gamma R effector pathway from antibody recognition of tumor antigens resulted in a loss of protection against tumor challenge. These data demonstrate an unexpected and critical role for FcRs in mediating tumor cytotoxicity in vivo and suggest that enhancement of Fc gamma R-mediated antibody-dependent cellular cytotoxicity by inflammatory cells is a key step in the development of effective tumor immunotherapeutics.

Sorting and secretion of a melanosome membrane protein, gp75/TRP1.

The melanosome is an organelle specialized for melanin synthesis that is derived from the endocytic pathway. Several melanosome membrane proteins have been identified, forming a family of proteins known as tyrosinase-related proteins. Two members of this family, tyrosinase and gp75, are well-characterized melanocyte differentiation antigens. Our previous studies have shown that gp75, the mouse brown locus protein, is sorted to melanosomes along the endocytic pathway, directed by a hexapeptide sorting signal located in the cytoplasmic tail. In this study, we report the unexpected finding that a portion of gp75 is secreted. Substantial levels of secretory gp75 were detected in melanocytic cells. Cell surface expression of gp75 was also detected, representing 2% of cellular gp75. Characterization of secretory gp75 cells showed that it is: (i) a truncated form that lacks the transmembrane region, the cytoplasmic tail where the endosomal sorting signal is located, and a small portion of the lumenal domain; (ii) more extensively glycosylated than endocytic/melanosomal gp75, containing trans-Golgi processed sugar residues; and (iii) generated post-translationally in an acid sensitive compartment after processing in the trans-Golgi, and secreted rapidly after generation. Thus, these endocytic/melanosomal membrane proteins can be processed to abundant secretory forms, probably in an endocytic compartment through a potentially novel secretory pathway.

Priming for T-cell-mediated rejection of established tumors by cutaneous DNA immunization.

DNA immunization has been shown to elicit both antibody and CTL responses against antigens expressed by infectious organisms. Because CTL responses have been implicated in rejection of cancer, we investigated whether DNA immunization by particle bombardment using a gene gun could induce CTL responses that were capable of rejecting tumors in mice. DNA immunization by particle bombardment using genes encoding beta-galactosidase and ovalbumin primed mice to generate CTLs in two genetic backgrounds (DBA/2 and C57BL/6 strains, respectively). DNA immunization was more potent in inducing CTLs than immunization with an optimized regimen of ovalbumin peptide plus immune adjuvant. Immunity induced by DNA immunization protected mice against s.c. challenge with tumors expressing the beta-galactosidase antigen. Tumors were rejected even when DNA immunization was started 3 or 7 days after tumor challenge as tumors were becoming established. Tumor rejection required CD8(+) T cells, confirming a role for CTLs in vivo. These studies show that DNA immunization by particle bombardment can efficiently induce CTL responses that are capable of rejecting even established tumors.

Immune response to a differentiation antigen induced by altered antigen: a study of tumor rejection and autoimmunity.

Recognition of self is emerging as a theme for the immune recognition of human cancer. One question is whether the immune system can actively respond to normal tissue autoantigens expressed by cancer cells. A second but related question is whether immune recognition of tissue autoantigens can actually induce tumor rejection. To address these issues, a mouse model was developed to investigate immune responses to a melanocyte differentiation antigen, tyrosinase-related protein 1 (or gp75), which is the product of the brown locus. In mice, immunization with purified syngeneic gp75 or syngeneic cells expressing gp75 failed to elicit antibody or cytotoxic T-cell responses to gp75, even when different immune adjuvants and cytokines were included. However, immunization with altered sources of gp75 antigen, in the form of either syngeneic gp75 expressed in insect cells or human gp75, elicited autoantibodies to gp75. Immunized mice rejected metastatic melanomas and developed patchy depigmentation in their coats. These studies support a model of tolerance maintained to a melanocyte differentiation antigen where tolerance can be broken by presenting sources of altered antigen (e.g., homologous xenogeneic protein or protein expressed in insect cells). Immune responses induced with these sources of altered antigen reacted with various processed forms of native, syngeneic protein and could induce both tumor rejection and autoimmunity.

A melanosomal membrane protein is a cell surface target for melanoma therapy.

Differentiation antigens on cancer cells are recognized by the immune system. A prototype set of these autoantigens in melanoma cells are the melanosomal glycoproteins, expressed in both melanomas and normal melanocytes. These are intracellular proteins that can be recognized by both antibodies and T lymphocytes. While one can understand how T cells can respond to intracellular proteins, based on cellular requirements for antigen processing and presentation, it is more difficult to understand how antibody responses to melanosomal proteins could lead to tumor rejection. We demonstrate that gp75 is expressed on the cell surface as well as intracellularly in human and mouse melanomas. The surface expression of gp75 can be augmented by IFN-gamma and during tumor growth in vivo. Surface expression of gp75 on mouse melanoma cells correlates with the ability of a monoclonal antibody (mAb) against gp75 to reject melanomas in syngeneic mice. Antibody-mediated rejection seems to require the Fc portion of the antibody, suggesting a role for Fc receptor-positive effector cells such as natural killer cells. However, although NK1.1(+) cells have been implicated in antibody-induced rejection in vivo, cell surface expression of gp75(+) on melanoma does not lead to susceptibility to antibody-dependent cellular cytotoxicity in vitro. The mAb to gp75 induced tumor rejection in mice carrying both scid and bg/bg traits, showing that neither thymus-dependent T cells nor natural killer cytotoxic activity was required in vivo. Long-term treatment of mice with mAb led to patchy depigmentation in the coat. In summary, an intracellular organellar protein can be expressed at the cell surface and provide an antigenic target for antibody therapy and autoimmunity.

The significance of E-cadherin in transitional-cell carcinoma of the human urinary bladder.

E-cadherin is a Ca(2+)-dependent intracellular adhesion molecule in the epithelial tissue. The urothelium also expresses E-cadherin molecules. We determined E-cadherin expression in bladder carcinoma immunohistochemically and investigated its relationship with pathological and clinical data. The percentage of cases showing pattern B, less than 50% of which cancer cells expressed the same intensity of E-cadherin as did the normal epithelium, was higher in cases of high-grade or high-stage tumors as compared with those of low grade or low stage. Heterogeneous staining was observed in the same specimens, which suggested changes in the cell phenotype. Immunoblotting demonstrated no evidence of gross alteration of E-cadherin molecules. The decrease in E-cadherin expression was associated with the invasiveness of bladder carcinoma, as has been reported in other carcinomas.

Implicating a role for immune recognition of self in tumor rejection: passive immunization against the brown locus protein.

The immune system can recognize differentiation antigens that are selectively expressed on malignant cells and their normal cell counterparts. However, it is uncertain whether immunity to differentiation antigens can effectively lead to tumor rejection. The mouse brown locus protein, gp75 or tyrosinase-related protein 1, is a melanocyte differentiation antigen expressed by melanomas and normal melanocytes. The gp75 antigen is recognized by autoantibodies and autoreactive T cells in persons with melanoma. To model autoimmunity against a melanocyte differentiation antigen, mouse antibodies against gp75 were passively transferred into tumor-bearing mice. Passive immunization with a mouse monoclonal antibody against gp75 induced protection and rejection of both subcutaneous tumors and lung metastases in syngeneic C57BL/6 mice, including established tumors. Passive immunity produced coat color alterations but only in regenerating hairs. This system provides a model for autoimmune vitiligo and shows that immune responses to melanocyte differentiation antigens can influence mouse coat color. Immune recognition of a melanocyte differentiation antigen can reject tumors, providing a basis for targeting tissue autoantigens expressed on cancer.

Rejection of mouse melanoma elicited by local secretion of interleukin-2: implicating macrophages without T cells or natural killer cells in tumor rejection.

Tumor cells transduced with cytokine genes provide a model to study host-effector mechanisms involved in tumor rejection. Local IL-2 production within a tumor site mimics a specific helper-T-cell response, bypassing an immunization phase. Growth of mouse B16F10 melanomas transduced with interleukin-2 (IL-2) in syngeneic hosts were significantly delayed. IL-2-producing B16F10 cells were super-transduced with interferon-gamma to up-regulate expression of major-histocompatibility-complex (MHC) antigens. Expression of class-I- or class-II-MHC molecules did not augment tumor rejection of IL-2-secreting tumor cells. Rejection of IL-2-transduced B16F10 cells in syngeneic mice was unaffected by depletion of CD8+ T-cell and NK1.1+ natural-killer (NK) cell populations. Tumor rejection occurred in SCID mice even after depletion of NK1.1+ cells, confirming that T cells and NK cells were not required for tumor rejection. Histologic examination of sites of tumor rejection showed inflammation, characterized by infiltrates of macrophages, occasional neutrophils, and areas of necrosis. When mice were treated systemically with macrophage-colony-stimulating factor to expand monocyte pools, tumor rejection was significantly augmented further. This study shows that in situ IL-2 production can result in tumor rejection mediated by inflammatory events, possibly involving macrophages, and mimicking a delayed-type hypersensitivity (DTH) response even in the absence of T cells and NK cells. Furthermore, tumor rejection can be enhanced by systemic administration of a cytokine to expand potential inflammatory cell populations.

Esophagoaortic fistula caused by esophageal tuberculosis: report of a case.

We report herein the case of a 73-year-old woman who was urgently admitted to hospital with severe hematemesis. An emergency endoscopy revealed a protruding lesion 36 cm from the incisors; however, respiratory insufficiency precluded surgery and despite aggressive medical treatment, the patient's respiratory status continued to deteriorate, leading to death on the 36th hospital day. An autopsy revealed the source of the hemorrhage to be a fistula connecting the esophagus and the descending aorta. Histopathologic studies showed that this fistula was caused by esophageal tuberculosis.

Right common iliac arterio-intestinal fistula caused by tubercular peritonitis: report of a case.

A 59-year-old female was admitted with massive hematemesis and melena. A hematological examination revealed that the red blood cell count was 1.31 x 10(6)/mm3, Hb 3.4 g/dl, and Hct 12%. No source of bleeding was found by an emergency endoscopic examination of the esophagus, stomach and duodenum, or by superior mesenteric angiography. At laparotomy a right common iliac arterio-intestinal fistula was found. The microscopic examination of this part of the ileum, including the fistula, revealed the presence of tubercular peritonitis. An extra-anatomic bypass graft using a prosthetic graft was performed between the left and right femoral arteries because reconstruction of the right common iliac artery was impossible.

[Statistics on operations at Hara Genitourinary Hospital (1971-1991)].

The statistical analysis of the inpatients and operations in our department from April, 1971 to March, 1991 revealed a total of 9,170 operations. One of the biggest changes in treatment is a marked increase in closed surgery. This includes endourological surgeries; transurethral resections of prostate and bladder tumor (TUR-P, TUR-Bt), percutaneous nephrolithotripsy (PNL), transurethral uretero-lithotripsy (TUL) and extracorporeal shock-wave lithotripsy (ESWL). From 1976 to 1980 there were 721 open surgical procedures (71.0% of cases) and 295 closed procedures (21.0% of cases). This ratio has now been reversed completely. From 1986-1991, there were 342 open procedures (8.2% of cases) and 3808 closed procedures (91.8% of cases). The main reason for this change was the introduction of the new techniques PNL, TUL and ESWL. Other important observations include: The incidence of emergency operations was higher in this private institution than that seen in non-private hospitals. From 1986, there was an increase in the use of PNL and TUL for the management of urinary calculi, and from 1988, ESWL has overtaken PNL and TUL in the treatment of this condition. Recently the limitations of ESWL have been appreciated and the value of a combined approach to therapy, for selected cases, is being recognized. A total of 238 ileal or ileocecal conduits were created with good results. A low complication rate has been observed with preservation of renal function.