Telomerase enzyme inhibition (TEI) and cytolytic therapy in the management of androgen independent osseous metastatic prostate cancer.

BACKGROUND: Recurrent prostate cancer can be osseous, androgen independent and lethal. The purpose is to discern the efficacy of synthetic small molecule telomerase enzyme inhibitors (TEI) alone or in combination with other cytotoxic therapies in controlling metastatic osseous prostate cancer. METHODS: C4-2B was pre-treated with a match or mismatch TEI for 6 weeks and then inoculated into nude mice subcutaneously or intraosseously. In a separate experiment, untreated C4-2B was injected into femur of nude mice. The mice were divided into seven systemic "combination" treatment groups of control, Ad-BSP-E1a virus, docetaxel, mismatch and match TEI. Serum PSA was followed longitudinally. Histology analyses and histomorphometry were performed. Repeated measure analysis was applied for statistical analysis and Bonferroni method was used in multiple comparisons. RESULTS: In the pre-treated study, the PSA of match treated cells in subcutaneous or intraosseous model was significantly lower than mismatch TEI or PBS treated group (P < 0.05). Histology revealed increased fibrosis, apoptosis and decreased PSA staining in the match TEI treated subcutaneous xenografts. In the combination treatment study, the PSA was significantly lower in single/double treatment and triple treatment than control (P < 0.05). Histology revealed that triple therapy mice had normal femur architecture. Histomorphometrics revealed that the area of femur tumor and woven bone was significantly positively correlated (P = 0.007). CONCLUSIONS: Multiple lines of data point toward the efficacy of systemically administered telomerase inhibitors. Combining cytotoxic regimens with telomerase inhibitors could be beneficial in controlling prostate cancer. Clinical trials are warranted to explore the efficacy of TEI in prostate cancer.

Robotic surgical education: a collaborative approach to training postgraduate urologists and endourology fellows.

OBJECTIVE: Currently, robotic training for inexperienced, practicing surgeons is primarily done vis-à-vis industry and/or society-sponsored day or weekend courses, with limited proctorship opportunities. The objective of this study was to assess the impact of an extended-proctorship program at up to 32 months of follow-up. METHODS: An extended-proctorship program for robotic-assisted laparoscopic radical prostatectomy was established at our institution. The curriculum consisted of 3 phases: (1) completing an Intuitive Surgical 2-day robotic training course with company representatives; (2) serving as assistant to a trained proctor on 5 to 6 cases; and (3) performing proctored cases up to 1 year until confidence was achieved. Participants were surveyed and asked to evaluate on a 5-point Likert scale their operative experience in robotics and satisfaction regarding their training. RESULTS: Nine of 9 participants are currently performing robotic-assisted laparoscopic radical prostatectomy (RALP) independently. Graduates of our program have performed 477 RALP cases. The mean number of cases performed within phase 3 was 20.1 (range, 5 to 40) prior to independent practice. The program received a rating of 4.2/5 for effectiveness in teaching robotic surgery skills. CONCLUSION: Our robotic program, with extended proctoring, has led to an outstanding take-rate for disseminating robotic skills in a metropolitan community.

Local-regional prostate cancer.

Historically, locally advanced prostate cancer was defined clinically with the digital rectal exam (DRE). With the introduction of screening prostate specific antigen (PSA), further pretreatment stratification of locally advanced prostate cancer was possible. Tables and nomograms have been developed to predict pathologic staging prior to therapy. By combining DRE, PSA, Gleason score, and clinical staging, a patient's probability of treatment failure is estimated, thereby stratifying the risk of locally advanced disease. Pretreatment PSA velocity (PSAV) and PSA doubling time (PSADT) will likely continue to play a role in defining locally advanced prostate cancer. Imaging studies, especially high-field strength pelvic MRI, may provide additional information regarding the presence of locally advanced prostate cancer. In the future, molecular or genetic testing may permit further stratification of patients with locally advanced disease, who are at variable risk for recurrence and death after treatment. Future trials will need to assess the utility of multimodality treatments for patients in the diverse classification of locally advanced prostate cancer.

Prostate cancer disease-free survival after radical retropubic prostatectomy in patients older than 70 years compared to younger cohorts.

OBJECTIVES: To evaluate the feasibility of radical retropubic prostatectomy (RRP) as an option for treating men older than 70 years with organ confined prostate cancer and to compare biochemical progression-free survival with younger cohorts. MATERIALS AND METHODS: A total of 689 consecutive patients who were treated with RRP from 1994 to 2002 for clinically localized prostate cancer were categorized into 3 different age groups: younger than 50 years (n = 49), 50-70 years (n = 601), and older than 70 years (n = 39). Patients older than 70 years were healthy individuals for their age. Preoperative and postoperative cancer-specific characteristics were compared among these 3 groups. RESULTS: There was no statistical significant difference among the 3 age strata in terms of clinical parameters (prostate-specific antigen, Gleason score, clinical stage, percent and number of positive biopsy cores) and pathologic findings (surgical margin, lymph node status, extracapsular extension, lymphovascular invasion, and pathologic Gleason score). The rate of seminal vesicle invasion and prostate volume increased with advancing age (P = 0.034 and P < 0.001). In multivariate logistic regression analysis, age was not associated with seminal vesicle invasion. The 5-year prostate-specific antigen progression-free estimates for patients younger than 50, 50-70, and older than 70 years were 82% (95% confidence interval [CI] 69% to 96%), 82% (95% CI 78% to 86%), and 65% (95% CI 43% to 86%), respectively (P = 0.349). The overall and cause-specific mortalities were not different. CONCLUSIONS: RRP could be considered a standard treatment option in men older than 70 years with localized prostate cancer. Further studies are necessary to assess the survival benefit and health-related quality of life after radical prostatectomy versus watchful waiting in patients older than 70 years.

Prostate cancer stem cells, telomerase biology, epigenetic modifiers, and molecular systemic therapy for the androgen-independent lethal phenotype.

Numerous, relatively well-characterized androgen-independent osteotropic prostate cancer cell lines are now available to interrogate clinically relevant fundamental questions of prostate cancer metastasis and lethal progression systematically. Mounting basic and translational science efforts reveal that, very likely, the currently incurable form of androgen independent osseous prostate cancer originates from a more undifferentiated or "stem cell" like component, coexisting within a heterogeneous tumor mass containing more differentiated epithelial cancer subtypes. Current therapeutic preclinical investigations point toward the use of epigenetic modifiers, such as histone deacetylase inhibitors, to abrogate the continued survival of prostate cancer cells and likely can be used relatively chronically, with little morbidity. Telomere maintenance is critical in the immortalization of prostate cancer cells, and all known androgen independent cell line variants invariably express telomerase, and, thus, an argument can be made that these aggressive cells are likened to immature, progenitor variants. The arena of telomere biology has evolved enough to provide precise, nontoxic small molecule inhibitors of telomerase that limit viability of androgen-independent cell lines, yielding apoptosis. Both epigenetic modifiers and telomerase-directed small molecule inhibitors have enhanced efficacy when given in combination with conventional and novel cytotoxic drugs. Better knowledge of the "stem cell" nature of prostate cancer will help direct the molecularly targeted therapies of the near future.

Strategies for targeted tumor assessment and elimination: the physician-scientist and the blossoming of molecular medicine in urologic oncology.

To realize its full potential in treating urologic malignancies, molecular medicine in the post-genomic era requires the science of molecular biology to become a great force of change directed to the critical health questions confronting the clinician. The clinician-scientist is the linchpin to convert an exploratory, reactive stance to a predictive and efficacious paradigm in treating urologic malignancies. The explosion of basic and translational discoveries will demand a "systems biology" approach at the fingertips of the future clinician, and realize the dream of proactive and highly adaptable "engineered" response to the very complex "survival" biology of urologic tumors. To arm our clinicians of tomorrow, the physician-scientists of today need resources, time, and a nurturing environment to ask great questions, and, thus, to solve the problem of cancer.

Bladder cancer: toward state of the art multidisciplinary molecular medicine.

Recent advances in bladder cancer research, and clinical diagnosis and therapy are explored. Major advances in biologic understanding are applied toward better early diagnosis and staging. Using molecular medicine to help informed clinical trial design and implementation will lead to more effective therapeutic intervention in transitional cell carcinoma. Interdisciplinary care and multimodal approach will allow better outcomes, stage for stage and grade for grade. The challenge is for clinician-scientists to integrate basic and translational advances efficiently and rapidly into the clinic, recognizing the value of a multifaceted paradigm.

Conditionally replicating adenovirus-mediated gene therapy in bladder cancer: an orthotopic in vivo model.

INTRODUCTION: The effects of a conditionally replicating adenovirus on various bladder cancer lines were explored, a truncated bone sialoprotein (BSP) promoter controlling the E1a/b lytic-regulating sequence was used, since BSP protein is found in many osteotropic neoplasms, including bladder cancer. METHODS: Reverse transcriptase polymerase chain reaction analysis was used to determine expression patterns of BSP and Coxsackie adenovirus receptor, a receptor known to interact with adenovirus, on multiple lines of bladder cancer (253J, 253J B-V, RT4, transitional cell carcinoma, T24, UMUC3, and WH). Ad-BSP-E1a was tested in vitro for lytic activity on 4 of these cell lines. The 253J B-V cell line was used and inoculated into female nude mice either subcutaneously in the flank or orthotopically into the bladder, and treated with control or Ad-BSP-E1a virus. RESULTS: BSP is expressed in RT4, transitional cell carcinoma, and WH. Meanwhile, Coxsackie adenovirus receptor was expressed in all lines except T24. Ad-BSP-E1a had the most impact on 253J and 253J B-V cells; cell density declined significantly when compared to phosphate-buffered saline and Ad-BSP-TK "dummy" virus-treatment groups. The 253J B-V tumors treated with Ad-BSP-E1a revealed a decreased percent change of size in the subcutaneous model when compared to controls at week 3. The orthotopic murine model showed decreased end tumor mass in the Ad-BSP-E1a treated group over controls. Histologic examination of in vivo tumors showed evidence of fibrosis and apoptosis in the Ad-BSP-E1a treated groups using hematoxylin-eosin, trichrome, and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) staining. Control groups only had viable tumor in in vivo models. CONCLUSION: Adenovirus therapy of orthotopic murine bladder tumors is feasible. Ad-BSP-E1a is effective in treating very aggressive yet sensitive bladder tumor cells. Further study of this conditionally replicating adenovirus treatment (Ad-BSP-E1a) with chemotherapeutic combination is warranted, and future translation of such combination therapy into human beings is a possibility.

Small molecule, oligonucleotide-based telomerase template inhibition in combination with cytolytic therapy in an in vitro androgen-independent prostate cancer model.

PURPOSE: Determine the efficacy and timing of small molecule oligonucleotide-based inhibitors to the enzyme telomerase in an in vitro model of androgen-independent, osseous prostate cancer. MATERIALS AND METHODS: Telomerase was inhibited in prostate cancer cell lines C4-2/C4-2B and in controls by using small molecule antisense oligonucleotide-based inhibitors alone or in various combinations of small-dose Taxotere (sanofi-aventis, Bridgewater, NJ) and/or conditionally replication competent adenovirus (AD-BSP-E1a). After transfection and proliferation, telomerase telomeric repeat amplification protocol and telomere restriction fragment assays were performed, with specific times for evaluating telomere length. Specimens were stained for analysis with hematoxylin and eosin (H&E), terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL), and prostate-specific antigen (PSA). RESULTS: C4-2/C4-2B cell lines had the shortest initial mean telomere length (approximately 2.5 kilobase [kb]) compared to PC-3 (approximately 5.5 kb). Dose-dependent inhibition of telomerase activity was seen using match oligonucleotide-based inhibitors to telomerase (50% inhibitory concentration 3-5 nm), whereas mismatch compound showed no telomerase inhibition. Significant growth delay and apoptosis in cell lines occurred after > 50 days of treatment. Cells treated with combination "triple therapy" (i.e., telomerase inhibitors, adenovirus, and Taxotere) had the highest amount of apoptosis. Compared to controls, all combination treatment groups had statistically significant reductions in prostate-specific antigen in the conditioned media. CONCLUSIONS: Combining cytotoxic regimens with small molecule inhibitors to telomerase with oligonucleotide-based agents could be beneficial in controlling osseous hormone refractory prostate cancer, as evidenced by these in vitro, preclinical investigations. Telomerase inhibition needs to move into in vivo models and human studies.

Consequences of telomerase inhibition and combination treatments for the proliferation of cancer cells.

Telomerase is expressed in most types of tumor cells but not in most somatic cells, suggesting that telomerase inhibitors may be a powerful new approach to cancer chemotherapy. Here we explore this hypothesis by treating cultured human tumor cells with a 2'-O-methoxyethyl oligonucleotide that binds the telomerase RNA template and acts as a potent inhibitor. Treatment of DU145 (Rb(-), p53(-)) and LNCaP (Rb(+), p53(+)) cells causes telomeres to shorten and cell proliferation to stop. Decreased cell proliferation in culture is not observed immediately but occurs after several weeks and is accompanied by telomere shortening. Antiproliferative effects are more profound for cells growing in soft agar or in colony formation assays, with 90% reduction in the colony-forming ability of LNCaP cells after less than 2 weeks of exposure to the inhibitor. Decreased growth of DU145 and LNCaP tumors and large reductions in prostate-specific antigen levels are also observed in vivo in xenograft models. Short-term treatment of cells with telomerase inhibitors does not increase the effects of standard antiproliferative agents paclitaxel, doxorubicin, etoposide, cisplatin, or carboplatin. Long-term inhibition and telomere shortening sensitize DU145 cells, but not LNCaP cells, to cisplatin or carboplatin. These results demonstrate that methoxyethyl oligomers directed against the template region of telomerase are potent agents and that significant antiproliferative effects can be observed after 2-3 weeks of treatment. Reduced cell proliferation and tumor growth support the hypothesis that telomerase inhibition can make a useful contribution to chemotherapy and should encourage broad testing of telomerase inhibitors.

Hand-assisted laparoscopic nephrectomy for renal masses >9.5 cm: series comparison with open radical nephrectomy.

OBJECTIVE: To assess the feasibility of hand-assisted laparoscopic nephrectomy (HALN) for large renal masses (stage T2, mean size 9.7 cm) and compare outcomes with a similar cohort undergoing open radical nephrectomy (ORN). METHODS: A nonrandomized comparison of 19 consecutive patients who underwent nephrectomy for renal masses >or=7 cm was performed. The HALN group was compared to the ORN group regarding demographic parameters and perioperative data, including blood loss, operating time, narcotic usage, hematocrit change, return to standard oral intake, length of hospital stay, and complications. Data collected prospectively and statistics used 2-tailed t-test analysis. RESULTS: Patients underwent either ORN (mean tumor size 12.3 cm) or HALN (mean tumor size 9.7cm). Tumors up to 14 cm (n = 2) and pT3b, with renal vein thrombosis (n = 2), could be safely excised with HALN. There were no differences between the HALN and ORN groups regarding any demographic parameter. Blood loss, operating time, length of stay, parenteral narcotic use, and time to tolerating regular diet were all less statistically significant in the HALN group as compared to the ORN group (P < 0.05). Tumors >15 cm necessitated ORN. CONCLUSIONS: HALN is technically feasible even for tumors with mean size >9.5 cm. There is a significant advantage to HALN over ORN regarding the intraoperative and postoperative morbidity. Tumors >or=15 cm should, in most cases, be performed with an open approach.

Synthesis and evaluation of a novel gene reporter molecule: detection of beta-galactosidase activity using 19F NMR of a fluorinated vitamin B6 conjugate+.

Gene therapy has emerged as a promising strategy for treatment of various diseases. However, widespread implementation is hampered by difficulties in assessing the success of transfection, in particular, the spatial extent of expression in the target tissue and the longevity of expression. Thus, the development of non-invasive reporter techniques based on appropriate molecules and imaging modalities may help to assay gene expression. We now report the design, synthesis and evaluation of a novel in vivo gene transfection reporter molecule 3-O-(beta-D-galactopyranosyl)-6-fluoropyridoxol (GFPOL) using fluorinated vitamin B(6) as the (19)F NMR sensitive aglycone. GFPOL exhibits the following strengths as an in vivo (19)F NMR gene expression reporter: (a) large chemical shift response to enzyme cleavage (Deltadelta=8.00 ppm); (b) minimal toxicity for substrate or aglycone; (c) good water solubility; (d) good blood stability; (e) pH responsiveness of aglycone.

Phase I dose escalation clinical trial of adenovirus vector carrying osteocalcin promoter-driven herpes simplex virus thymidine kinase in localized and metastatic hormone-refractory prostate cancer.

Osteocalcin (OC), a major noncollagenous bone matrix protein, is expressed prevalently in prostate cancer epithelial cells, adjacent fibromuscular stromal cells, and osteoblasts in locally recurrent prostate cancer and prostate cancer bone metastasis [Matsubara, S., Wada, Y., Gardner, T.A., Egawa, M., Park, M.S., Hsieh, C.L., Zhau, H.E., Kao, C., Kamidono, S., Gillenwater, J.Y., and Chung, L.W. (2001). Cancer Res. 61, 6012-6019]. We constructed an adenovirus vector carrying osteocalcin promoter-driven herpes simplex virus thymidine kinase (Ad-OC-hsv-TK) to cotarget prostate cancer cells and their surrounding stromal cells. A phase I dose escalation clinical trial of the intralesional administration of Ad-OC-hsv-TK followed by oral valacyclovir was conducted at the University of Virginia (Charlottesville, VA) in 11 men with localized recurrent and metastatic hormone-refractory prostate cancer (2 local recurrent, 5 osseous metastasis, and 4 lymph node metastasis) in order to determine the usefulness of this vector for the palliation of androgen-independent prostate cancer metastasis. This is the first clinical trial in which therapeutic adenoviruses are injected directly into prostate cancer lymph node and bone metastasis. Results show that (1). all patients tolerated this therapy with no serious adverse events; (2). local cell death was observed in treated lesions in seven patients (63.6%) as assessed by TUNEL assay, and histomorphological change (mediation of fibrosis) was detected in all posttreated specimens; (3). one patient showed stabilization of the treated lesion for 317 days with no alternative therapy. Of the two patients who complained of tumor-associated symptoms before the treatment, one patient with bone pain had resolution of pain, although significant remission of treated lesions was not observed by image examination; (4). CD8-positive T cells were predominant compared with CD4-positive T cells, B cells (L26 positive), and natural killer cells (CD56 positive) in posttreated tissue specimens; (5). levels of HSV TK gene transduction correlated well with coxsackie-adenovirus receptor expression but less well with the titers of adenovirus injected; and (6). intrinsic OC expression and the efficiency of HSV TK gene transduction affected the levels of HSV TK protein expression in clinical specimens. Our data suggest that this form of gene therapy requires further development for the treatment of androgen-independent prostate cancer metastasis although histopathological and immunohistochemical evidence of apoptosis was observed in the specimens treated. Further studies including the development of viral delivery will enhance the efficacy of Ad-OC-hsv-TK.

Changing management of organ-confined renal masses.

BACKGROUND AND PURPOSE: Rapid evolution of laparoscopic and ablative techniques is changing the approach to renal masses. We evaluated our approach to managing renal masses in light of newly available technology. PATIENTS AND METHODS: The records for all patients who underwent treatment for a renal mass between January 2000 and July 2002 at UT Southwestern Medical Center were reviewed for patient demographics, operative details, and pathology results. There were 180 patients with 190 masses. Of the 190 masses, 97 were <4 cm, 47 were between 4 and 7 cm, and 46 were >7 cm. RESULTS: Most tumors >7 cm were managed with open radical nephrectomy (RN). For patients with masses between 4 and 7 cm, the majority were treated with laparoscopic RN, while 21% were treated by open partial nephrectomy (PN). Tumors <4 cm were treated with the widest variety of approaches. Open PN was the most commonly utilized, followed by laparoscopic RN and percutaneous ablation. The number of laparoscopic and percutaneous ablative procedures increased significantly with time, from none in the first year to 13% (7/55) and 29% (16/55) in the last year, respectively. Benign pathology was found in 20%, 17%, and none of lesions <4, 4 to 7, and >7 cm, respectively. CONCLUSIONS: The addition of laparoscopy and ablative technologies has increased the treatment options for patients with renal masses. We propose a treatment algorithm that incorporates ablative technologies and favors parenchyma-sparing approaches for small lesions.

Laparoscopic retroperitoneal lymph node dissection in the extremely obese patient: technical insight into access and port placement.

PURPOSE: We report on laparoscopic retroperitoneal lymph node dissection (RPLND) in a morbidly obese patient to discuss the associated technical steps for satisfactory completion of staging lymphadenectomy. METHODS: A laparoscopic RPLND was performed using a modified template on the left side. Initially, 4 ports were placed with the patient in the supine position. Three were placed 3 cm to the left of midline and one in the anterior axillary line, at the level of the umbilicus. During the operation, successful bowel retraction necessitated placement of 2 additional ports in the anterior axillary line (just above the pelvis and off the tip of the 12th rib). Using these 6 trocar sites, the dissection was completed, and 44 lymph nodes were obtained. RESULTS: Laparoscopic retroperitoneal lymph node dissection was accomplished in an extremely obese patient with acceptable morbidity by using prudent modification of standard techniques. CONCLUSION: If access and port placement limitations are overcome, the benefits of laparoscopy in the obese are clear. This report serves as a signpost that laparoscopic retroperitoneal lymph node dissection for testes cancer can also be accomplished using modification of standard techniques.

Conditionally replicating adenovirus therapy utilizing bone sialoprotein promoter (Ad-BSP-E1a) in an in vivo study of treating androgen-independent intraosseous prostate cancer.

BACKGROUND: Adenoviral based gene therapy has been used in clinical trials in control of advanced prostate cancer. In this study, a promising conditionally replicating adenovirus (CRAd) driven by a tissue specific bone sialoprotein promoter in controlling prostate cancer both in vitro and in vivo is demonstrated. METHODS: C4-2B, an androgen-independent prostate cancer cell line, was treated with PBS, Ad-BSP-TK, or the Ad-BSP-E1a in vitro, and in subcutaneous and intraosseous xenographs. Cell proliferation, PSA level in condition medium, tumor volume, and/or serum PSA were followed. RESULTS: The growth of C4-2B and the PSA production was dramatically suppressed by Ad-BSP-E1a at very low dosage (0.3 MOI) compared with PBS and Ad-BSP-TK treatment in vitro. In the subcutaneous model, the tumor volume was significantly lower statistically in the Ad-BSP-E1a treated group than the Ad-BSP-TK control group (P = 0.02). In the intraosseous model, the mice treated in the Ad-BSP-E1a treatment group demonstrated a significant lower PSA compared to that in the control group (P < 0.01) at week 8 and week 16 post-treatment. CONCLUSIONS: The CRAd Ad-BSP-E1a revealed potential in treating prostate cancer in this model system. Using viral or none-viral mediated gene therapy to treat prostate carcinoma continues to be a potential avenue to treat afflicted men with prostate cancer.

Osteoblasts can stimulate prostate cancer growth and transcriptionally down-regulate PSA expression in cell line models.

INTRODUCTION: To investigate the effect of bone environment on cellular proliferation, mature prostate-specific antigen (PSA) production and secretion, and PSA transcriptional regulation of prostate cancer cells. MATERIALS AND METHODS: Androgen-independent C4-2 prostate cancer cells were co-cultured with various osteoblastic cells in a transwell system. Proliferation was measured via cell counting and MTT assay. Lactate and PSA were determined in the conditioned media (CM). Transcriptional activity of the full-length PSA promoter (6.1 kilobases) and of 3 deletion constructs was determined via luciferase reporter assay upon exposure to CM from various osteoblastic cell lines. RESULTS: Osteoblastic bone cells and CM, but not control cells (fibroblast) or CM, reproducibly stimulated the proliferation of C4-2 cells. The co-culture system, PSA production by C4-2 cells transiently decreased when in co-culture with osteoblastic, but not with control cells. After abundant prostate cell proliferation, the secreted PSA levels rose exponentially. Addition of CM from osteoblastic cells, but not control cells, consistently decreased (about 3-fold) the transcriptional activity of the PSA promoter in C4-2 cells. Deletion construct analysis of the PSA promoter revealed that the transcriptional down-regulation is dually controlled by elements close to the TATA and upstream androgen responsive (ARE(III)) components. CONCLUSIONS: The osteoblastic environment stimulates prostate cancer cell proliferation but reduces PSA production initially. The mechanism of PSA down-regulation is transcriptional, most likely in response to soluble factors present in the osteoblastic bone stromal cell CM. Transcriptional down-regulation appears to be mediated by elements near both the TATA box and the ARE(III) component.

Elevated activated partial thromboplastin time during administration of first-generation adenoviral vectors for gene therapy for prostate cancer: identification of lupus anticoagulants.

OBJECTIVES: To evaluate the cause and significance of elevated activated partial thromboplastin time (aPTT) in a group of patients who received a first-generation adenoviral vector (Ad-OC-TK) delivering a toxic gene to prostate cancer cells as part of a Phase I clinical trial at the University of Virginia. METHODS: Eleven subjects were injected intratumorally to metastatic lesions of prostate cancer in the prostatic fossa, retroperitoneal lymph nodes, or bone (iliac, ischium, or vertebrae). After the initial laboratory evaluation, patients with elevated aPTT underwent a series of additional tests, including mixing studies, coagulation factor, prekallikrein, and high-molecular-weight kininogen, and lupus anticoagulant studies (modified Russell viper venom time) with phospholipid correction, and a Staclot LA assay. RESULTS: Of the 11 subjects who were enrolled in the trial, 6 had elevated aPTT values. Of the 6 patients, 3 had aPTT elevation of more than 10 seconds above normal. Two of the subjects with higher values demonstrated an inhibitory pattern with the factor VIII and XI assays, and the lupus anticoagulant studies were positive. No clinical sequelae to the elevated aPTT values were observed. CONCLUSIONS: This is, to our knowledge, the first formal report of a first-generation adenoviral vector causing a slight transient elevation of the aPTT through the induction of an antiphospholipid antibody. No clinical sequelae related to elevated aPTT values were observed. The adenoviral protocol was safe; similar protocols should be aware of this phenomenon.

The utility of screening renal ultrasonography: identifying renal cell carcinoma in an elderly asymptomatic population.

OBJECTIVE: To evaluate the efficacy and utility of screening renal ultrasonography (RUS) in older patients with a high prevalence of risk factors for renal cell carcinoma (RCC), as with the widespread use of advanced imaging techniques the identification of incidental RCC has increased, and although previous studies in low-risk groups reported little use for screening RUS, its utility in high-risk groups is unknown. PATIENTS AND METHODS: From 1993 to 1997, screening RUS was completed for 6678 consecutive patients in conjunction with the Aneurysm Detection and Management study. Patient demographics, medical and social history were recorded for each patient. Screening RUS was completed by one ultrasonographer using a 3.5-MHz sector scanner. A urologist verified any abnormalities identified by RUS during consultation. Additional imaging tests were obtained selectively and intervention was recommended based on the results of the genitourinary evaluation. RESULTS: From the screened population of 6678 patients, 817 (12.3%) renal anomalies were found, including a solid renal mass in 22 (0.32%), simple renal cysts in 627 (9.4%), hydronephrosis in 21 (0.31%), renal calculi in 121 (1.8%), or other abnormalities in 24 (0.36%). Treatment was completed for 15 renal cancers; 13 were organ-confined on pathological review. At a mean follow-up of >55 months, 12 of the 15 patients with RCC survived. CONCLUSIONS: In this older cohort, retroperitoneal RUS was an effective tool for case-finding by detecting significant findings in an asymptomatic population. The prevalence of solid renal masses (0.32%) was higher than reported with other screening protocols. Although probably not the best method for generalized primary screening, the use of RUS may still be beneficial for 'secondary' screening in a more selected patient population.