Renal artery pseudoaneurysm occurring after partial nephrectomy.

Retroperitoneal hemorrhage resulting from intrarenal pseudoaneurysm formation has been reported after percutaneous renal surgery. However, although hemorrhage is a well-recognized complication of partial nephrectomy, hemorrhage caused by an intrarenal pseudoaneurysm after open partial nephrectomy is rare. We report a case of retroperitoneal hematoma associated with a renal artery pseudoaneurysm occurring in a 56-year-old woman 2.5 weeks after she underwent left partial nephrectomy for renal cell carcinoma. The pseudoaneurysmal branch was successfully identified and selectively embolized using percutaneous renal arterial angiography.

Clinical significance of denuded urothelium in bladder biopsy.

PURPOSE: Although to our knowledge the significance of denuded urothelium in bladder biopsies has not been studied previously, it is thought to be a problem because benign urothelial cells are cohesive and not expected to shed into the urine. We correlated the pertinent clinical features of patients with denuded bladder biopsies and/or specific pathological features of denuded bladder biopsy specimens with patient outcome in regard to bladder lesions to help predict the subsequent likelihood of diagnosing bladder carcinoma in a patient with a nondiagnostic denuded biopsy. MATERIALS AND METHODS: We studied 51 denuded bladder biopsies from 44 patients in which the average extent of epithelial denudation was 90%. RESULTS: Of the 27 male (69%) and 17 female (31%) patients 22 to 86 years old (mean age 62) 34% had no history of bladder neoplasms. In remainder there were flat carcinoma in situ with or without other tumors (26%), high (20%) and low (14%) grade papillary tumors without carcinoma in situ and miscellaneous conditions (6%). Overall 31% of patients were diagnosed with carcinoma in situ within 24 months (median 5.5) after the denuded specimen was obtained. Parameters that did not correlate with the subsequent diagnosis of carcinoma in situ included cystoscopic impression, history of intravesical chemotherapy, sex, age, tissue inflammation, percent of tissue fragments with any denudation, number of denuded tissue fragments and percent of overall denuded epithelium. A history of carcinoma in situ before denuded biopsy predicted a diagnosis of carcinoma in situ within 24 months after denuded biopsy in 54% of patients in contrast to 19% of those without a history of carcinoma in situ (p = 0.03). Factoring in a history of other bladder tumor types in various combinations did not predict carcinoma in situ after denuded biopsy. The other predictive factor was cold cup biopsy. Carcinoma in situ developed within 24 months in 45% of patients in whom the denuded specimen was obtained by cold cup biopsy in contrast to none who underwent hot wire loop biopsy (p = 0.007). Cold cup biopsy and a history of carcinoma in situ were independently predictive. Carcinoma in situ developed within 24 months in 75% of patients with a history of that condition and a subsequent cold cup biopsy showing denuded epithelium. However, only 29% of those who underwent cold cup biopsy and had no history of carcinoma in situ were diagnosed with carcinoma in situ. CONCLUSIONS: In bladder biopsies obtained by a hot wire loop denudation most likely results from thermal injury when there is a low risk of subsequent carcinoma in situ. When the denuded biopsy sample was obtained by cold cup biopsy, particularly when associated with a history of carcinoma in situ, most cases represent neoplastic cell denudation and a high risk for subsequent carcinoma in situ.

Correlation of cystoscopic impression with histologic diagnosis of biopsy specimens of the bladder.

There is a paucity of information in the contemporary literature that would permit assessment of the urologist's ability to endoscopically discriminate between benign and malignant lesions of the bladder or to predict the grade and stage of papillary neoplasms. This prospective study evaluates the correlation between cystoscopic impression of urothelial lesions and final histologic diagnoses. Sixty-four patients with 68 urothelial abnormalities requiring formal biopsy or endoscopic resection were evaluated prospectively. At the time of endoscopy, treating urologists completed questionnaires documenting the surgeon's endoscopic impression of disease type and extent and performed standard biopsy or resection of all suspicious lesions. Specimens were submitted for routine histopathologic analysis, and the results were correlated with the questionnaire data. Endoscopic evaluation correctly discriminated between dysplastic/malignant and benign/reactive lesions in this study with a sensitivity of 100%, specificity of 100%, and positive and negative predictive values of 100%. Urologists could not readily distinguish between low- and high-grade papillary urothelial lesions and were frequently unable to determine if a tumor was invasive, particularly if the degree of invasion was microscopic. Endoscopic impression at the time of bladder biopsy or resection is accurate and discriminates between the presence and absence of cancer. Endoscopic impression alone is a relatively poor staging tool with respect to extent of invasive disease and must be coupled with careful histopathologic analysis of biopsy material, bimanual examination when appropriate, and axial imaging for complete assessment of a given tumor.

Absence of karyotype abnormalities in patients with familial urothelial cell carcinoma.

OBJECTIVES: In a previous pilot study, a constitutional balanced translocation t(5;20)(p15;q11) was identified in a family with urothelial cell carcinoma (UCC). The purpose of this study was to find (additional) constitutional chromosomal abnormalities in selected families to obtain an indication for genome location(s) of UCC susceptibility gene(s). METHODS: UCC families were selected through an ongoing study on familial clustering of UCC, the largest study on this subject ever performed. This study included 1193 new patients with UCC of the bladder, ureter, and renal pelvis, identified from the population-based cancer registries of the Dutch Comprehensive Cancer Centers East and South. Information on demographic factors, smoking habits, and family history of UCC was collected by postal questionnaires. UCC in the families was verified with pathology reports. Thirty families were selected in which 2 or 3 individuals were affected, preferably diagnosed at a relatively young age. Blood samples were obtained from all probands, and routine cytogenetic analysis was performed on 23 male and 7 female UCC patients. Subsequent spectral karyotyping was performed in 4 patients from families, which were most suggestive for an inherited etiology. RESULTS: No aberrant chromosomal features were found by either classical or spectral karyotype analyses. CONCLUSIONS: It is conceivable that genetic germline abnormalities do exist in the patients in our study but are below the detection limit of the explorative methods used in this study.

Papillary urothelial hyperplasia is a clonal precursor to papillary transitional cell bladder cancer.

Papilloma and papillary hyperplasia (PH) have been proposed to be the putative precursor lesions of papillary transitional-cell carcinoma of the urinary bladder. We examined 15 PH lesions and 4 papillomas for loss of heterozygosity (LOH) at 17 microsatellite markers on 9 chromosomal arms. Eight of 15 (53%) PHs were clonal, demonstrating LOH of at least 1 microsatellite marker. In contrast, none of the papillomas showed any genetic changes among the markers tested. In PH, chromosomal arm 9q was the most frequently lost (4/15), followed by 9p and 18q (n = 2) and, less frequently, 8p, 10q, 11p and 17p (n = 1). Furthermore, 2 hyperplastic lesions demonstrated LOH at 9q only, confirming the notion that allelic loss on chromosomal arm 9q is among the earliest events in bladder-cancer progression. In 1 patient, identical LOH patterns were observed between PH and a recurrent transitional-cell carcinoma. Our molecular data demonstrate that at least a proportion of PHs represent pre-cancerous lesions of the bladder that subsequently progress to papillary bladder cancer. Moreover, chromosomal arm 9q may harbor a tumor-suppressor gene(s) inactivated in the earliest stages of human bladder tumorigenesis.

Biological pathways to bladder carcinogenesis.

The transformation of normal urothelium into histologically different neoplastic states has been well characterized, and current clinical management of both superficial and invasive bladder cancer has benefited from recent scientific discoveries. The ability to define novel treatment strategies including surgical, chemotherapeutic, and gene therapies relies on our understanding of the basic mechanisms underlying human bladder carcinogenesis. Many in vitro culture systems and in vivo animal models have been developed over recent years, which have been used to define key molecular events that are associated with the development of bladder cancer. The biological pathways through which normal urothelium may progress to superficial or invasive disease will be discussed in the framework of recent advances in the field.

Gender differences in stage-adjusted bladder cancer survival.

OBJECTIVES: Gender differences have been observed in the prognosis of patients with bladder cancer. It has also been suggested that these differences are caused by a worse stage distribution at diagnosis among women. The purpose of this study was to evaluate whether women with bladder cancer have a worse prognosis even after adjustment for disease stage at first presentation. METHODS: Data on patients with bladder cancer diagnosed between 1973 and 1996 and registered by one of the nine population-based Surveillance, Epidemiology, and End Results (SEER) cancer registries in the United States (n = 80,305) were obtained from the National Cancer Institute public domain SEER*Stat 2.0 package. Similar data on patients with bladder cancer diagnosed between 1987 and 1994 and registered by two population-based registries in the Netherlands (n = 1722) were obtained through the Comprehensive Cancer Centers, Amsterdam and South. Survival rates adjusted for mortality owing to other causes (ie, relative survival) were calculated for men and women within each category of the American Joint Committee on Cancer (SEER data) and TNM (Netherlands data) stage groupings.Results. In the United States, the 5-year relative survival rate of male patients with bladder cancer was calculated to be 79.5% (95% confidence interval 79.0% to 80.0%). Among women, the 5-year relative survival rate was significantly worse: 73.1% (95% confidence interval 72.2% to 74.0%). The male versus female 5-year survival rate among stage groups I, II, III, and IV was 96.5% versus 93.7%, 65.5% versus 59.6%, 58.8% versus 49.6%, and 27.1% versus 15.2%, respectively. The (sparser) data from the Netherlands were less conclusive. Women with Stage II and Stage IV disease fared worse than men but the reverse seemed to be true in Stage I disease. CONCLUSIONS: Female patients with bladder cancer have a worse prognosis than male patients. It is unlikely that the difference can explained entirely by the more frequent diagnosis of higher stages at first presentation among women.

Genetic alterations in urinary bladder carcinosarcoma: evidence of a common clonal origin.

The cellular origin of carcinosarcoma of the bladder is unknown. We addressed this issue by using microsatellite analysis for loss of heterozygosity (LOH) in both the carcinomatous and sarcomatous components of 6 bladder tumors. We tested 40 microsatellite markers from 19 human chromosomes and compared the genetic alterations between the two separately isolated components. The potential relevance of the E-cadherin pathway was also evaluated by immunohistochemistry. All 6 cases revealed identical LOH on chromosomal arms 9p, 9q, 8p, and 8q, corresponding to relatively early events in bladder carcinogenesis. Discordant losses between two alleles in the remaining chromosomes, associated with progression, were seen in all tumors with a trend toward a higher incidence in the more advanced tumors (N1M1 and N1Mx). E-cadherin was strongly expressed in the carcinomatous components (5 of 6), whereas most of sarcomatous elements displayed absence of the protein product (4 of 6). These results indicate that both the carcinomatous and sarcomatous components of carcinosarcoma are derived from a common stem cell. Downregulation of E-cadherin may define one of the pathways responsible for conversion of epithelial cells to the sarcomatous phenotype.

Paclitaxel-induced stomal neuropathy: a unique cause of pain in a patient with ileal conduit.

We present a case of unusual chemotherapy-induced neurotoxicity in a patient who had undergone radical cystoprostatectomy and ileal conduit diversion for invasive bladder cancer. On routine computed tomography scan several years later, he was diagnosed with metastatic transitional cell carcinoma involving the retroperitoneal lymph nodes. The patient received systemic chemotherapy, including a combination of paclitaxel (Taxol) and gemcitabine (Gemzar). During this treatment, the patient developed spasmodic pain and dysesthesia in the stoma area, with no apparent skin irritation or any other local finding. These symptoms resolved about 3 months after completion of the therapy.

Detection of bladder cancer recurrence by microsatellite analysis of urine.

A reliable, noninvasive method for monitoring patients with transitional cell carcinoma (TCC) of the bladder would be of great clinical benefit. Cystoscopy is currently the "gold standard," but it is invasive, expensive and uncomfortable for the patient. Recently, we demonstrated a novel approach for the detection of primary bladder cancer based on microsatellite analysis of urine DNA. To determine the feasibility of this technique for following-up patients with TCC, we tested serial urine samples from 21 patients who had been treated for bladder cancer with 20 polymorphic microsatellite markers in a blinded fashion. We detected recurrent lesions in 10 out of 11 patients and correctly predicted the existence of a neoplastic cell population in the urine of two patients, 4 and 6 months before cystoscopic evidence of the tumor. The assay was negative in 10 of 10 patients who had no evident cancer. Microsatellite analysis of urine sediment represents a novel and potentially powerful clinical tool for the detection of recurrent bladder cancer.

Familial transitional cell carcinoma among the population of Iceland.

PURPOSE: Several case reports have described familial aggregation of transitional cell carcinoma of the urinary tract but to our knowledge only 1 epidemiological study specifically addressed the issue of familial bladder cancer. We evaluated the extent of familial aggregation of transitional cell carcinoma among the population of Iceland. MATERIALS AND METHODS: The first to third degree relatives of 190 patients with bladder, ureter or renal pelvis transitional cell carcinoma diagnosed between 1983 and 1992 in Iceland were identified through the Icelandic Cancer Family Resource. The records of these 12,328 relatives were subsequently linked to the 1965 to 1994 cancer registry. The observed occurrence of transitional cell carcinoma of the urinary tract was compared to the expected occurrence based on age, gender and calendar specific incidence rates. Observed-to-expected ratios and 95% confidence intervals were calculated. RESULTS: In 41 of the 190 pedigrees at least 1 relative had transitional cell carcinoma of the urinary tract. Of the probands 38 had only 1 and 3 had 2 affected relatives. The prevalence of family history of transitional cell carcinoma was 3% in first degree and 10% in first or second degree relatives. The risk of transitional cell carcinoma among all relatives was slightly elevated (observed-to-expected ratio 1.24, 95% confidence interval 0.90 to 1.67). The observed-to-expected ratio was greater among second and third degree relatives than among first degree relatives. CONCLUSIONS: The risk of transitional cell carcinoma among relatives of patients is somewhat increased. However, the greater risk for more distant relatives argues against the existence of a hereditary subtype of bladder transitional cell carcinoma, at least in the founder population of Iceland.

Androgen receptor variants with short glutamine or glycine repeats may identify unique subpopulations of men with prostate cancer.

The androgen receptor (AR) contains glutamine (CAG) and glycine (GGC) repeats that are each polymorphic in length. We screened clinically localized prostate cancers for somatic mutations in the length of the CAG and GGC repeats in the AR gene and characterized the length of these repeats in the germ-line AR gene. Somatic mutations were rare, and the range of germ-line repeat lengths in men with prostate cancer was within the range of normal in the general population. Most allele frequencies in Caucasian men with clinical prostate cancer were remarkably comparable to those in the general Caucasian population. However, a subpopulation of the men with clinical prostate cancer had a substantially higher frequency of AR alleles with 16 or 17 CAGs (6 of 59 men, 10%) than did the general population (6 of 370 alleles, 1.6%), and a different subpopulation of the men with prostate cancer had a higher frequency of AR alleles with 12 or 13 GGCs (7 of 54 men, 13%) than did the general population (1 of 110 alleles, 0.9%). Of the men with prostate cancer who had an AR gene with 16 or 17 CAGs, 83% had lymph node-positive disease, despite the lack of clinical evidence of metastatic spread. This suggests that a short AR CAG allele may be a risk factor for the development of clinically unsuspected lymph node-positive prostate cancer among men undergoing radical prostatectomy and raises the question of whether this short repeat length played an active role in the development of aggressive prostate cancer. The odds of having a germ-line AR gene with a short CAG repeat (

Microsatellite analysis and telomerase activity in archived tissue and urine samples of bladder cancer patients.

We performed microsatellite analysis and tested telomerase activity in paired tissue and urine of bladder cancer patients from frozen archived samples. DNA obtained from microdissected tumor and urine sediment was analyzed and compared to peripheral lymphocytes for microsatellite alterations (loss of heterozygosity [LOH] or instability) using a panel of 20 microsatellite markers in 15 patients with transitional or squamous cell carcinoma of the urinary tract. Additionally, telomerase activity was determined in 12 microdissected tumor specimens and corresponding frozen urine pellets. Tumor cell DNA was detected by microsatellite analysis (LOH or shift) in at least one marker in 14/15 microdissected tumor specimens and in 13/15 DNA samples obtained from urine sediments. Telomerase activity was present in 11/12 tumor samples but could not be detected in any of the corresponding urine sediments. Frozen archived urine samples are useful for retrospective studies utilizing microsatellite analysis or other PCR-based approaches after DNA extraction. However, the evaluation of telomerase protein activity in stored urine samples appears to be unsuitable.

Ureteral frozen section analysis during cystectomy: a reassessment.

PURPOSE: Frozen section analysis of the distal ureteral margins is commonly performed at cystectomy to exclude involvement of tumor in retained ureter. We reviewed our experience with 101 consecutive cystectomies to determine the contemporary incidence and clinical significance of the urothelial abnormalities detected by frozen section analysis performed at operation. METHODS AND MATERIALS: The pathology reports for 101 patients treated with nerve sparing cystectomy between 1982 and 1989 were reviewed. Frozen section and final ureteral analyses were compared. RESULTS: Of the patients 8% had evidence of a urothelial abnormality ranging from mild atypia to frank carcinoma in situ involving the distal ureters on frozen section. Only 4 patients had documented carcinoma in situ at the final margin and all 4 ultimately died of disease. The frozen section false-positive and false-negative rates were 2 and 6%, respectively. In 6 patients with ureteral urothelial abnormalities documented on frozen section ureterointestinal anastomosis was performed despite persistent abnormalities at the ureteral margins, frequently after multiple frozen analyses failed to clear the margins definitively. None of the 6 patients in this group experienced upper tract recurrence during a mean followup of 41 months. CONCLUSIONS: These data suggest that routine frozen section analysis of the ureteral margins at cystectomy may not be necessary for most patinets undergoing cystectomy.

Molecular detection of primary bladder cancer by microsatellite analysis.

Microsatellite DNA markers have been widely used as a tool for the detection of loss of heterozygosity and genomic instability in primary tumors. In a blinded study, urine samples from 25 patients with suspicious bladder lesions that had been identified cystoscopically were analyzed by this molecular method and by conventional cytology. Microsatellite changes matching those in the tumor were detected in the urine sediment of 19 of the 20 patients (95 percent) who were diagnosed with bladder cancer, whereas urine cytology detected cancer cells in 9 of 18 (50 percent) of the samples. These results suggest that microsatellite analysis, which in principle can be performed at about one-third the cost of cytology, may be a useful addition to current screening methods for detecting bladder cancer.

Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10-year followup.

PURPOSE: The efficacy of nerve sparing radical cystoprostatectomy for the treatment of bladder cancer has been evaluated. We reviewed our 10-year experience with this technique to ascertain survival and local recurrence rates. MATERIALS AND METHODS: The charts of 101 patients treated with nerve sparing cystoprostatectomy between March 1982 and November 1989 were reviewed and updated. RESULTS: The disease-specific 10-year survival rate for all stages of bladder cancer treated was 69% and the 10-year survival rate free of local recurrence was 94%. Recovery of sexual function following nerve sparing cystectomy correlated with patient age: 62% in men 40 to 49 years old, 47% in men 50 to 59 years old, 43% in men 60 to 69 years old and 20% in men 70 to 79 years old. CONCLUSIONS: Nerve sparing radical cystoprostatectomy does not compromise cancer control and provides improved postoperative quality of life.