Fluorescence in situ hybridization analysis of CCND3 gene as marker of progression in bladder carcinoma.

The aim of this study was to assess patterns of CCND3 gene amplification in bladder cancer and correlate gene status with recurrence-free and progression-free survival. A sequential cohort series of 102 primary bladder tumor samples in which there was enough tissue material to assess CCND3 gene status by fluorescent in situ hybridization (FISH) was the study group. CCND3 gene FISH amplification present in 31.4 percent of bladder carcinomas, was related to tumor progression (p=0.021) and lower time to progression (mean+-SD; 25.75+-15.25 months) as compared to 33.29+-11.0 months in the CCND3 not amplified group (p=0.05). By immunohistochemistry, Cyclin D3 labeling index was higher in the CCND3 amplified group (mean+-SD, 76.69+-27.51) than in not amplified (mean+-SD, 21.57+-7.02) (p less than 0.0001). The univariate survival analysis showed CCND3 gene amplification to be associated to a shorter progression-free survival (p=0.020) together with WHO histological grade (p=0.001) and pT stage category (p less than 0.0001). Cox’s regression analysis selected CCND3 amplification as an independent predictor of progression-free survival (p= 0.030, RR3.561, 95 percent CI 1.128-11.236) together with pT category (p less than 0.0001, RR5.834, 95 percent CI 2.364-14.395). Our FISH analysis suggests that CCND3 gene amplification is a marker of aggressiveness and might be a predictor of tumor progression in bladder urothelial carcinoma.

Multigene methylation analysis of conventional renal cell carcinoma.

Renal cell carcinoma (RCC) is the most common malignancy of the kidney. Since RCC is curable when it is confined to the renal capsule, early diagnosis is extremely important. Promoter hypermethylation is the most common mechanism for the inactivation of the tumor suppressor genes (TSG) in the development of human cancer. This study aimed to investigate the methylation profiles of 7 TSG (RASSF1A, ECAD, TIMP3, APC, MGMT, p16 and RARbeta2) in 3 different tissue samples (normal, premalign, malign) of patients with RCC. Twenty-one patients diagnosed with RCC were included in the study. Methylation-specific polymerase chain reaction was performed to detect the methylation patterns of the 7 TSG. High methylation rates for the genes RASSF1A (76%), p16 (80%), ECAD (42%), TIMP3 (33%) and MGMT (33%) were observed in the patients with RCC. The APC (14%) and RARbeta2 (19%) genes showed low methylation rates. In conclusion, 5 TSG (RASSF1A, ECAD, TIMP3, MGMT and p16) showed high methylation rates in RCC patients. A methylation-based gene test including these genes may be useful in the early detection of RCC.

Significance of heat shock protein-27 expression in patients with renal cell carcinoma.

OBJECTIVES: To investigate heat shock protein (HSP)-27 expression in patients with renal cell carcinoma (RCC) and examine its biologic significance. HSPs were first defined as proteins induced by heat shock and other environmental and pathophysiologic stresses. They are implicated in protein-protein interactions and are thought to play an important role in cancer. The expression of HSP-27 has been demonstrated in some human tumors. METHODS: The expression of HSP-27 was studied in tumor and normal parenchyma tissue specimens from 76 patients with RCC by immunohistochemistry. The findings were correlated with clinical stage, lymph node metastasis, histologic grade, and survival. RESULTS: Of the 76 RCC tissue specimens studied, the presence of HSP-27 was demonstrated in 73 (96%). The expression was low in 10 patients (14%), intermediate in 38 (50%), and high in 25 (33%). HSP-27 expression was greater in RCC tissue compared with adjacent noncancerous renal tissue (P <0.001). An inverse relationship was found between tumor stage and HSP-27 expression (r = -0.281, P = 0.016). However, no statistically significant difference was observed in progression-free survival with respect to HSP-27 expression. No relationship was found between HSP-27 expression and tumor grade, lymph node metastasis, distant metastasis, or cause-specific survival. CONCLUSIONS: Our data suggest that HSP-27 expression is not a powerful and statistically significant prognostic indicator for disease-free survival for patients with RCC.

Handling and pathology reporting of adrenal gland specimens.

Proper treatment of resection specimens by the urologist and pathologist is critical in accurately reporting tumors and tumor-like nodules of the adrenal gland. Clinically inapparent adrenal masses are discovered, with increasing frequency, in the course of diagnostic testing or treatment for conditions that are not related to adrenal diseases. As a consequence an increasing number of relatively small tumors lacking the characteristic gross features of malignancy is detected. There is a need for identification of pathological findings that can improve the diagnostic accuracy and predict patient outcome. The aim of this paper is to review the handling and pathology reporting of adrenal gland specimens in the light of recent advances in this field of pathology.

Handling and pathology reporting of renal tumor specimens.

The gold standard in the treatment of renal tumors is radical or partial nephrectomy. The surgical specimen handling is important since the pathologic features result in clinico-pathologic knowledge that determines prognosis, additional treatment and scientific studies. The correct handling of the specimen by urologists and pathologists becomes very basic in order to enable retrieval of a maximum of information. This protocol aims at standardization of the minimal criteria for handling, cellular subtyping, grading, staging and margin evaluation that must allow the comparison among the different scientific groups.

Gemcitabine-induced vasculitis in advanced transitional cell carcinoma of the bladder.

BACKGROUND: Gemcitabine (GEM) is an alternative chemotherapeutic agent for patients with metastatic bladder cancer. It is believed to be a well-balanced agent, having acceptable toxicity and enhanced antitumor activity. The integration of GEM into the initial chemotherapy plan for these patients is still being developed. CASE REPORT: The patient, male, aged 56 years, was suffering from a transitional cell carcinoma of the bladder. Due to frequent local superficial recurrences, radical cystectomy with pelvic lymphadenectomy and continent ileal diversion was performed. Four years after the operation a left inguinal lymphadenopathy was noted and metastatic bladder carcinoma was confirmed on biopsy. Cytotoxic therapy combining GEM and cisplatin and local external irradiation therapy was initiated. The patient developed extensive necrotising vasculitis with muscle damage after the second course of therapy. Chemotherapy was stopped immediately but this was not enough to relieve the symptoms of severe myalgia and swelling, and additional treatment consisting of cyclophosphamide and prednisolone was initiated. CONCLUSION: Although GEM seems to be relatively safe, some unexpected complications may occur during treatment. This case is not common, but it reinforces the need for careful attention to any new symptoms that seem to be unassociated with the primary disease. Prompt evaluation of such symptoms should be carried out in patients receiving GEM therapy.

Premalignant lesions of the kidney share the same genetics changes as conventional renal cell carcinoma.

This study investigated the frequency of allelic imbalance (AI) in particular loci in conventional renal cell carcinoma tissue and premalignant lesions of the kidney. DNA from the tumor tissue, premalignant lesions and normal kidney tissue of radical nephrectomy specimens from 33 patients was obtained. It was amplified with a set of eight microsatellite markers, which are located on chromosomes 2, 3, 5, 8, 9, 11, 16, 17. AI in DNA samples was determined by analysis of the alteration in (CA)n repeats. The rates of AI in tumor tissue were found to be between 22.2% and 53.3% and in premalignant lesions between 11.1% and 40.0%. Premalignant lesions and tumor tissues in conventional renal cell carcinoma have the same genotypic changes in 50.0-87.8% (informative cases). These results suggest that the progressive accumulation of AI in areas of premalignant lesions may contribute to the development of renal cell carcinoma, representing an important molecular event in the multistep renal carcinogenesis cascade.

Prognostic significance of nuclear morphometry in renal cell carcinoma.

OBJECTIVE: To assess nuclear morphometry as a predictor of prognosis in patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: The study included 65 consecutive patients with RCC who underwent radical nephrectomy and were followed up for a median (range) of 80 (27-138) months. Nuclear morphometry was assessed using a computer-assisted image analysis system on histological sections and characterized by five nuclear variables (area, perimeter, major and minor diameter, and form factor). From the patients' records and pathology specimens, the clinicopathological prognostic variables (histological type, Fuhrman grade and pathological stage) were recorded. The proliferative activity was assessed using immunohistochemical staining with Ki-67 antibody. RESULTS: Higher values of mean nuclear area, perimeter, and major and minor diameter were significantly related to higher nuclear grade, proliferative activity and advanced tumour stage. They were significant predictors of disease progression and survival, together with grade, stage, sarcomatoid histology and proliferative activity. Of all significant prognostic factors predicting progression-free survival, only stage was independent (T4 vs T1, hazard ratio 6.55, 95% CI 1.63-26.13, P=0.008). CONCLUSION: Although the significance of these preliminary results must not be overstated, nuclear morphometry might provide significant prognostic information in predicting survival and tumours at high risk of progression in RCC.

Vertebral fracture associated with shockwave lithotripsy in a patient with granulomatous spondylitis.

Extracorporeal shockwave lithotripsy (SWL) is an accepted treatment modality in the treatment of urinary stone disease. Many complications have been reported secondary to high-energy shockwaves, but the effects of SWL on the skeletal system have rarely been investigated. We represent the first case of a burst-type vertebral fracture after SWL in an elderly osteoporotic patient with granulomatous spondylitis.

Prognostic significance of nuclear morphometry in superficial bladder cancer.

OBJECTIVE: To evaluate the significance of nuclear morphometry in predicting the clinical course in superficial (pTa and pT1) bladder cancer. STUDY DESIGN: The study included 73 patients with superficial transitional cell carcinoma of the bladder who were followed for a median of 21 months (range, 1-90). Nuclear morphometry was performed by a computer-assisted image analyzer system on hematoxylineosin-stained histologic sections and characterized by five nuclear variables: area, perimeter, major and minor diameter, and form factor. Patient charts and microscopic slides were reviewed to record tumor stage, grade and size. Tumor proliferative activity was assessed by immunohistochemical staining with Ki-67 antibody. RESULTS: None of the morphometric variables showed a significant relation to tumor progression and recurrence. Higher values of mean nuclear area, perimeter, and major and minor diameter were significantly related to higher grade and proliferative activity. Mean nuclear area and minor diameter were associated with advanced stage. Of established prognostic factors, only histologic grade was significant in predicting progression. CONCLUSION: The results suggest that nuclear morphometry may be valuable in determining proliferative activity and may be well correlated with histologic grade in superficial bladder cancer. However, like many other potential prognostic factors, it seems to be unreliable in predicting clinical behavior.

Expression of pS2 protein and its relation with the Ki-67 proliferative indices and tumor recurrence in superficial bladder carcinomas.

OBJECTIVE: To investigate the expression and possible role of pS2 protein as a predictor of tumor recurrence in superficial transitional cell carcinoma of the bladder and to determine its relation with tumor stage, grade, size, number, recurrence and proliferative activity. METHODS: Paraffin sections of transurethral resection material from 80 patients with superficial transitional cell bladder carcinoma were stained with pS2 and Ki-67 antibodies using the standard streptavidin biotin immunoperoxidase method. Cytoplasmic pS2 staining was scored on a scale of 1-3 and the Ki-67-labelling index was determined as a percentage of positively staining tumor cells. RESULTS: An inverse relationship was found between pS2 expression and Ki-67 index (p<0.001). pS2 expression showed no relation with any clinicopathological prognostic parameters as well as the recurrence rate. The recurrence rate was only associated with increased tumor number (p = 0.05), while the time to first recurrence was significantly related to tumor size, proliferative activity and tumor grade (p = 0.04, p<0.001, and p = 0.03, respectively). On the other hand, higher tumor grade was correlated with increased tumor number, Ki-67 index and tumor stage (p = 0.016, p = 0.006, and p<0.001, respectively). CONCLUSION: pS2 expression is associated with a low proliferative potential of superficial transitional cell carcinoma of the bladder, while it does not seem to be related to the recurrence rate of the tumor and other prognostic factors. Tumor size and proliferative activity may aid in the estimation of the time to the first recurrence.

Does angiogenesis predict recurrence in superficial transitional cell carcinoma of the bladder?

OBJECTIVES: To investigate the role of angiogenesis in predicting tumor recurrence and its correlation with established clinicopathologic prognostic factors in superficial transitional cell carcinoma of the bladder. METHODS: The paraffin sections of 80 superficial papillary transitional cell bladder carcinoma specimens were stained with CD31 antibody to label the vascular endothelium using the standard streptavidin-biotin-immunoperoxidase method. The vascular surface density (VSD) equivalent to the vascular surface area per unit of tissue volume and number of vessels per square millimeter of stroma (NVES) were assessed by means of stereology, and these morphometric parameters of angiogenesis were statistically analyzed to interpret the relation to tumor recurrence in addition to tumor stage, grade, size, and number and the presence of carcinoma in situ. RESULTS: VSD and NVES values showed no statistically significant difference between pTa and pT1 tumors or patients with and without recurrence. In contrast, VSD and NVES values were found to increase in higher grade tumors (P = 0.019). VSD values were also higher in patients with coexisting carcinoma in situ in pTa tumors (P <0.001). Tumor number and size and recurrence number and time to the first recurrence did not correlate with any vascular parameters. CONCLUSIONS: Stereologic assessment of angiogenesis does not help to predict recurrence in superficial bladder cancer. Angiogenic parameters appeared to be well correlated with the conventional histologic grading system. Otherwise, the present study did not show any correlation of angiogenesis with any potential prognostic factors. This may be due to the diverse angiogenic pathways occurring in invasive and superficial tumors.

Metallothionein expression in renal cell carcinoma: subcellular localization and prognostic significance.

PURPOSE: We investigated the immunohistochemical localization of metallothionein (MT) in renal cell carcinoma and determined the potential role of MT expression as a possible prognostic variable for tumor proliferation and progression. MATERIALS AND METHODS: Tumor tissue blocks from 70 patients with renal cell carcinoma who underwent radical or partial nephrectomy were investigated. Mean followup plus or minus standard error was 36 +/- 3 months. Immunohistochemical testing was performed by the avidin-streptavidin method using a monoclonal mouse antiMT antibody. MT staining intensity in samples was evaluated semiquantitatively. The subcellular distribution of MT was also determined. Staining characteristics were compared with the clinicopathological results. RESULTS: MT immunostaining was found in 39 of 70 tumors (55.7%) and subcellulary MT was localized in the cytoplasm, nucleus and cell membrane. The survival of patients with MT immunostaining was significantly worse than that of those with MT negative results (p = 0.02). A significant relationship of higher tumor grade and MT staining intensity was observed in grades I and III (p = 0.01), and grades II and III (p = 0.02) tumors. No association was found of MT expression and pathological stage. Sarcomatoid tumors showed significantly higher MT expression than clear cell, papillary, granular or chromophobe tumors (p = 0.02, 0.001, 0.01 and 0.01, respectively). MT expression was not an independent prognostic variable. CONCLUSIONS: MT over expression seems to be associated with malignant behavior and poor prognosis in renal cell carcinoma. Therefore, MT expression may be considered a useful marker of less differentiated and more aggressive renal cell carcinoma.

Quality control of radical prostatectomy: a feasibility study.

The aim of this study was to assess whether the quality of the surgical act could be an important prognostic factor for patients undergoing radical prostatectomy. This study also aims to investigate whether the surgical quality can be assessed by any means. Questionnaires were collected from 23 different institutes including 232 radical prostatectomies (RPr) performed for T1T2 prostate cancer. Blood loss, duration of surgery, margin status, postoperative prostate specific antigen (PSA) and urinary incontinence were analysed and correlated with the yearly number of RPr performed. The mean values obtained for each parameter were very different in the various centres. The outcome in terms of tumour control and incontinence could not be related to a higher or lower number of RPr performed. Quality control of RPr is feasible on the basis of an analysis of a few parameters, such as surgical margins, postoperative PSA and incontinence, that might recognise urologists that perform better or poorer than a proposed average.

Significance of tissue laminin P(1) elastase and fibronectin levels in transitional cell carcinoma of the bladder.

OBJECTIVE: Elastase is a serine protease which hydrolyses connective tissue components. Laminin and fibronectin also play an important role in progression and invasion of cancer. The purpose of this study is to investigate the relation between tissue elastase, laminin P(1) and fibronectin levels and tumor characteristics, and analyze the potential of these as prognostic factors in transitional cell carcinoma (TCC) of the bladder. METHODS: Thirty-four patients with TCC of the bladder and 11 controls were included in this study. Elastase and fibronectin levels in tissue homogenates were determined using an enzyme immunoassay and laminin P(1) by radioimmunoassay. Mean follow-up was 43 months. RESULTS: The mean elastase level in bladder carcinoma tissue was 120+/-11.42 ng/homogenate protein, while normal tissue level was 12.36+/-2.70 (p<0.01). The carcinoma and normal tissue mean laminin P(1) levels were 7.02+/-0.37 U and 0.65+/-0.10 U/mg homogenate protein, respectively (p<0.01). The mean fibronectin level was 19.97+/-1.45 ng/mg homogenate protein in the carcinoma tissue and 2.16+/-0.40 in normal tissue (p<0.01). There was no correlation between tumor stage, grade, size, multiplicity and elastase, laminin P(1) and fibronectin levels. CONCLUSION: These results provide evidence that tissue elastase, laminin P(1) and fibronectin levels increase in TCC of the human bladder. Further studies including serum and urine levels should be performed in order to analyze their value as tumor markers in a larger group of patients.

Ondansetron versus diclofenac sodium in the treatment of acute ureteral colic: a double blind controlled trial.

The aim of this study is to compare the effectiveness of the 5-HT3 antagonist, ondansetron and a non-steroidal anti-inflammatory agent, diclofenac sodium, as a pain reliever in the treatment of acute ureteral colic. Sixty four patients with severe or moderate pain who were clinically diagnosed as having ureteral colic associated with microscopic or gross hematuria were included in the study. Thirty three patients were administered ondansetron and 31 patients were administered diclofenac sodium. Exclusion critera were known kidney or liver disease causing dysfunction, known hypersensitivity to ondansetron or diclofenac sodium, pregnancy, lactation, duodenal ulcer or bleeding. After pain assessment with a verbal scale and a visual analog scale (VAS), we randomized patients and administered 8 mg ondansetron intravenously to 33 patients and 75 mg diclofenac sodium intramuscularly to 31 patients and pain scores were recorded every 15 minutes. If significant pain relief was not achieved within 60 minutes, i.v. meperidine was given as rescue pain medication. Ondansetron was effective as a primary pain reliever in 14 (42.4%) patients, whereas 19 patients required additional medication. Diclofenac sodium was effective as a primary pain reliever in 24 (77.4%) patients, whereas 7 patients required additional medication. Ondansetron was not superior to diclofenac sodium in relieving pain in patients with acute ureteral colic.

Premalignant lesions in the kidney.

Renal cell carcinoma (RCC) is the most malignant urologic disease. Different lesions, such as dysplasia in the tubules adjacent to RCC, atypical hyperplasia in the cyst epithelium of von Hippel-Lindau syndrome, and adenoma have been described for a number of years as possible premalignant changes or precursor lesions of RCC. In two recent papers, kidneys adjacent to RCC or removed from other causes were analyzed, and dysplastic lesions were identified and defined in detail. Currently renal intraepithelial neoplasia (RIN) is the proposed term for classification. The criteria for a lesion to be defined as premalignant are (1) morphological similarity; (2) spatial association; (3) development of microinvasive carcinoma; (4) higher frequency, severity, and extent then invasive carcinoma; (5) progression to invasive cancer; and (6) similar genetic alterations. RIN resembles the neoplastic cells of RCC. There is spatial association. Progression to invasive carcinoma is described in experimental cancer models, and in some human renal tumors. Similar molecular alterations are found in some putative premalignant changes. The treatment for RCC is radical or partial nephrectomy. Preneoplastic lesions may remain in the renal remnant in patients treated by partial nephrectomy and may be the source of local recurrences. RIN seems to be a biologic precursor of some RCCs and warrants further investigation. Interpretation and reporting of these lesions would reveal important resources for the biological nature and clinical significance. The management of RIN diagnosed in a renal biopsy and partial nephrectomy needs to be answered.