The problematic nature of metastasized renal cell carcinoma.

The treatment of metastatic renal cell carcinoma presents major unsolved problems. All of the therapeutic options have shown only minimal success rates. In addition to partial clarification of tumour genesis, basic findings regarding the heterogeneity of tumors were made. Options for further therapeutic developments will result from increased knowledge of the pathogenesis of metastatic spread. After the growth of new tumor vessels (angiogenesis) the metastasizing cell must break away from the cell formation (loss of cadherines). By migration it reaches the vessel wall which is made permeable by proteolysis (matrix metaloproteinase). After reaching the target organ, adhesion results (adhesion molecules and integrins) within the vessel system and ex-travasation follows. With stimulation the metastatic cell will grow in the target organ. Growth is subject to the cytokine control mechanism (interleukines). Based on these individual steps, future therapeutic options can be developed. However, the treatment modalities at our disposal today must not be neglected: for example, immuno(chemo)therapy and various radiation therapies as well as metastases surgery.

The behavior of prostate specific antigen (PSA) and free-PSA (f-PSA) under antihormonal therapy.

Within a few weeks, if therapy of the hormone sensitive, advanced prostate cancer (PCa) is sufficient, there will be a PSA-decrease to testify to the regression of the PCa. Free-PSA (f-PSA) is used for the differential diagnosis of the PCa. Values under 25% f-PSA in proportion to complete-PSA show the possibility of the existence of a Pca. The aim of the work was to study the behavior of f-PSA under hormonal ablation. Initial PSA and f-PSA was examined (RIA) in 76 patients (average age = 72.8 yrs. old) with advanced PCa. (metastases) proven by bone scintigraphy and/or computed tomography. During hormonal therapy (LHRH-agonists) monthly PSA and f-PSA abundance were examined. The percent amount of f-PSA was calculated and documented for at least 6 months. The initial PSA-values were 43.6 +/- 17.3, the f-PSA were 13.4% +/- 8.9. Under antihormonal therapy PSA decreased (while f-PSA increased) and after a period of 1 month the values were 27.4 +/- 14.9 (17.4% +/- 12.3), after 3 months 18.1 +/- 11.3 (24.5% +/- 9.9), after 6 months 7.9 +/- 6.8 (26.1 +/- 10.6). During the 6 months of hormonal ablation PSA-values continuously declined, while, after the first 3 months, f-PSA-values showed a behavior similar to benign hyperplasia of prostate. The therapeutic efficiency of the antihormonal therapy is clearly shown through f-PSA and PSA. There are no timely advantages between the two markers. Further investigations will show whether hormone insensitive PCa can be recognized quicker through f-PSA than from an increase in PSA.

Treosulfan in the treatment of metastatic renal cell carcinoma.

BACKGROUND: Treosulfan is a bifunctional alkylating cytostatic agent that has mainly been used in the therapy of advanced ovarian cancer. Lately, a growth inhibiting effect could be detected in human renal cell carcinoma-cell lines as well. In vitro, Treosulfan showed an even higher growth inhibition than Vinblastine. MATERIALS AND METHODS: We performed a small clinical phase II study using Treosulfan as a monotherapy in the treatment of metastatic renal cell carcinoma. Treosulfan was given to 15 patients with bidimensionally measurable metastases. RESULTS: 10 patients were evaluable. Side effects were negligeable. A complete or even partial remission was not seen. 4 patients showed no change, whereas 6 were progressive. The average time to progress was short (4 months, range 1 to 12 months). CONCLUSIONS: Since Treosulfan did not lead to a measurable tumor remission in the given dose regimen, it does not seem to be suitable for the therapy of metastatic renal cell carcinoma.

Marker for renal cell carcinoma (RCC): the dimeric form of pyruvate kinase type M2 (Tu M2-PK).

OBJECTIVE: The evaluate a potential tumor marker for RCC. Tumor formation is generally linked to an expansion of glycolytic phosphometabolite pools and aerobic glycolyticflux rates. To achieve this, tumor cells generally overexpress a special glycolytic isoenzyme, termed pyruvate kinase type M2. To establish the expansion of phosphometabolite pools pyruvate kinase switches between a tetrameric form with high phosphoenol-pyruvate (PEP) affinity and a dimeric form with a lower PEP affinity. The dimeric form is predominant in all tumors that have been investigated and has been termed TuM2Pk. MATERIALS AND METHODS: We studied: a) the expression of TuM2Pk in RCC by immunohistochemistry using a monoclonal antibody recognizing only the mono- or dimeric form of pyruvate kinase, b) the stability of TuM2Pk in serum by measuring TuM2Pk in 3 patients at different times after taking blood with a two-site immunometric assay, c) the a circadiane rhythm of TuM2Pk in blood by measuring levels every 4 hours in 5 patients, d) TuM2Pk- expression in serum (see 2.) in 5 patients by taking blood from tumor-side vena renalis compared to peripherally blood, e) TuM2Pk (see point 2.) in 40 RCC-patients comparing the results with 39 healthy persons and clinical data of RCC, f) the influence of wound healing to TuM2Pk by measuring serum-levels during a period of more than 12 weeks in 6 patients, g) the individual follow up of 4 patients with RCC stage Robson III for more than 2 years. Comparing TuM2Pk-levels to findings of staging by computed tomography. RESULTS: The isoenzyme TuM2Pk could be demonstrated in RCC and their metastases by immunohistochemistry with a monoclonal antibody specific for pyruvate kinase type M2. In normal kidney cells pyruvate kinase type M2 is not detectable. The stability of TuM2Pk was studied in the serum within 30 minutes. No circadian rhythm was found. Most serum TuM2Pk comes from tumor. Serum evaluation in 39 healthy persons was used to determine normal values, with an upper concentration of 28 U/ml of TuM2Pk (95% percentile of normal healthy persons). Serum evaluation in 40 RCC showed a significant difference to healthy persons and a positive correlation with Robson stage and grading No correlation of TuM2Pk was found with histopathological cell type of tumor diameter. After radical nephrectomy normalization of TuM2Pk level was found within 11 weeks in all localized RCC. Continuously elevated serum levels were seen in metastatic RCC. Individual follow-up seems to be possible. CONCLUSION: Initial discrimination is not possible between localized and metastasized RCC using TuM2PK; however, it is possible to differentiate between benign and malignant renal processes; the specificity under these circumstances is 75%. After successful surgery of localized RCC, an elevated TuM2Pk will be normalized within 11 weeks, and will be remain elevated or will increase again in case of RCC-relapse or metastasis. Thus TuM2Pk would appear to be a useful marker for RCC detection and follow-up.

Immunohistological investigations of carcinoembryonic antigen (CEA) in urothelial carcinomas.

CEA is discussed as a potential tumour marker for carcinomas of the urothelium. However, investigations by means of polyclonal antibodies have shown various cross reactions which are not to be expected with monoclonal antibodies (MAb). Immunohistochemistry was done with the MAb anti-CEA BW 431/26 (Behring), N 1522 (Dako), and C 7292 (Sigma) on 37 carcinomas of the urothelium (grades 1-3). The MAb BW 431/26 showed the best results concerning specificity and sensitivity. In general, immunohistological investigations demonstrated negative or moderate staining reactions. Positive reactions were seen in 32% (12/37) of the carcinomas. Staining intensity for CEA correlated with differentiation grade. On the whole, a maximum of 5% of the tumour cells were CEA positive. Our results indicate that monoclonal anti-CEA antibodies are not usefull as a tumour marker for urothelial carcinomas. For the suitability of CEA for in vitro and for in vivo diagnosis a threshold of CEA positive tumour cells has to be defined.

Pre-analytical problems in the measurement of tumor type pyruvate kinase (tumor M2-PK).

INTRODUCTION: Tumor M2-PK is an isoform of the glycolytic enzyme pyruvate kinase. This isoform exists in an active tetrameric and less active dimeric form. The dimeric form is expressed by various tumor cells and can be measured in blood by a specific ELISA. MATERIALS AND METHODS: We included 500 healthy persons, 20 patients with an acute rheumatic disease (high CRP) and 30 patients with a nephropathy and proteinuria with more than 20 mg/dl. We measured Tumor M2-PK in each of these groups in different specimens of EDTA-plasma, serum, heparin-, citrate-, fluoride- and oxalate-plasma. RESULTS: We found different concentrations of Tumor M2-PK in healthy persons depending on the kind of specimen. The normal range of Tumor M2-PK concentration was higher in the serum than in the plasma, with 35 U/l compared to 15 U/l. In haemolytic material we found concentrations up to 80 U/l in healthy persons. Lipaemic or icteric serum material showed a higher concentration of Tumor M2-PK as well. In patients with a triglyceride concentration higher than 300 mg/dl, the normal range for Tumor M2-PK was measured between 30-50 U/l. Similar results were found in patients with icteric serum. Patients with an active rheumatic disease and elevated CRP concentration showed a Tumor M2-PK concentration between 40-60 U/l. Patients with a nephropathy and proteinuria over 20 mg/dl had an elevated Tumor M2-PK concentration from 25-60 U/l. CONCLUSION: We conclude that different materials seem to be suitable for the measurement of Tumor M2-PK concentration as long as attention is paid to different normal ranges. Haemolytic material should not be used as it offers false-positive results. Some diseases such as rheumatic disease, hyperlipidaemia and nephropathy have an influence on Tumor M2-PK concentration that should not be neglected.

Serologic angiogenesis factors and microvascular density in renal cell carcinoma: two independent parameters.

Renal Cell Carcinoma (RCC) is characterized by high intratumoral microvascular density (iMVD) and significantly elevated serologic titers of angiogenesis factors, basic fibroblast growth factor (bFGF), vascular endothelial growth factor (vEGF) and angiogenin (Ag). The goal of the present study was to find whether a correlation exists between any of these factors and intratumoral microvascular density (iMVD). Serologic angiogenesis factors were determined directly before nephrectomy of a tumorous kidney in 12 patients (average age: 67.6 years [49-78] with localized clear-cell RCC (Robson I-II) (Quantikine', R&D Systems Europe, Abington, UK). Sections were taken in each case from the microscopically most aggressive area of the tumorous kidney preparations. Staining was carried out with a primary antibody against CD31 (DAKO M 0823, Hamburg, Germany). iMVD was counted at 160x magnification at five "hot spots" 200 x 200 microns in size, and the individual factors were then correlated with the areas of maximum and average iMVD (iMVDmax, iMVD-d). Average concentrations of 38 pg/ml +/- 68 were found for bFGF, 712 pg/ml +/- 791 for vEGF, and 358 ng/ml +/- 97 for Ag. iMVDmax was 20 +/- 11 per area, iMVD-d was 410/mm2 +/- 243. No correlation was found between microvascular density and serologic angiogenesis factors for any parameter. Actual tumor vascularization, expressed as iMVD, was not correlated with the 3 angiogenesis parameters which were studied. On the one hand, this raises the question whether angiogenesis can be measured at all with these parameters; on the other, it remains nuclear whether the continuous process of angiogenesis can be registered at all by chronologic, specific factor analysis.

Renal cell carcinoma: immunohistological investigation of expression of the integrin alpha v beta 3.

alpha v beta 3 Integrin has been shown in various tumor entities to promote binding to superficial structures of the basement membrane during metastasis. The goal of the present paper was a structural demonstration of this Integrin in renal cell carcinoma (RCC). After removal of paraffin from formalin-fixed tissue, the cells were labelled with the antibody (VNR 147, H. Biermann, Bad Nauheim) using the peroxidase-antiperoxidase method (DAKO Diagnostical GmbH, Hamburg). Evaluation was carried out microscopically and semiquantitatively from missing (-) through moderate (+) to strong (+2) staining. A total of n = 79 RCCs and n = 53 healthy areas were examined. Semiquantitative staining results: there was a grading-dependent increase (+2) of stainability and thus alpha v beta 3 expression. Two of 53 benign specimens showed strong staining, 11 of 53, only weak staining. Four of 18 G1 RCCs showed strong staining, 11 of 18 only weak staining. Results for G2-RCCs: 11 with strong staining, 21 of 40 with weak staining. G3-RCCs: 4 with strong staining, 2 of 7 with weak staining. Of the metastases, on the other hand, 2 of 14 showed strong staining, another 8 of 14 only weak staining. There were no deviations within the histologic (clear-cell, chromophil, or chromophobe) subpopulations. This grading-dependent expression permits the conclusion that the probability of binding to the human basement membrane mediated by alpha v beta 3 Integrin rises with increasing grading, but the already metastatic cell exhibited this Integrin less strongly, since a basement membrane adhesion is no longer necessary for this cell group.

Renal cell carcinoma: relevance of angiogenetic factors.

Angiogenesis is essential for tumour growth. Mostly hypervasculariced renal cell carcinoma (RCC) usually express angiogenic factors, e.g. basic fibroblast factor (bFGF), vascular endothelial growth factor, and angiogenin (ag). This study was designed to evaluate the improvement of serological angiogenesis-factors, their prognostic relevance and correlation to tumour-grade, -stage and -volume. Measurement of bFGF, vEGF and ag was done with ELISA (Quantikine), R and D-Systems Europe Abbington, United Kingdom. The control group comprised 39 healthy blood donors, RCC-group were 35 patients with different RCC. Survival dates were presented with Kaplan-Meyer-curves, significance was tested with students-t-test. For all angiogenic factors a highly significant difference between the healthy and RCC-group was found. A strong correlation between angiogenic factors and tumor grade, -stage and -volume, was not found, but a trend for each of the angiogenic factors to correlate with grade was seen. No survival benefit was seen between patients with normal angiogenic factor over those with elevated angiogenic levels.

Control of hepatic parameters in renal cell carcinoma (RCC) by interleukin-6 (IL-6)?

RCC can go hand-in-hand with an elevation of various hepatic proteins. An interrelationship between the IL-6 titer, C-reactive protein (CRP) and the blood sedimentation rate (BSR) has already been proven. The aim of the present study was to study 1) the possibility of differentiating between healthy and RCC patients via IL-6 in the serum and 2) the relationship of IL-6 to hepatic parameters {alkaline phosphatase (AP), gamma-glutamyltransferase (gGT), serum proteins (E'p)} and the usual clinical prognostic parameters (tumor grading, staging). Serum analysis of 38 healthy patients via ELISA (DPC-Biermann, Germany) showed normal values of 1.2 ng/ml for IL-6, with a standards deviation of +/- 1.7 and a peak concentration of 3 ng/ml (specificity: 95%). In 20 RCCs there were IL-6 titers of 10.7 ng/ml +/- 6.56 in the pre-operative serum. The sensitivity of IL-6 was about 90%. The difference was statistically significant (p < 0.0001, Wilcoxon test). For IL-6 there was a positive correlation with the BSR (1-hour value: r = 0.7; 2-hour value: r = 0.6), CRP (r = 0.85), E'p (r = 0.6), and gGT (r = 0.6). No correlation was found between AP, the Robson stage, grading, and IL-6. IL-6 is potentially suitable for differentiating between healthy and RCC patients but is not tumor specific. IL-6 has a strong correlation with all laboratory values which were analyzed except AP thus there is considerable evidence for a cytokine (IL-6) control of the hepatic changes. Since some of the above-named laboratory parameters have prognostic relevance, IL-6 can be regarded as a cumulative prognostic parameter.

DNA cytophotometry in renal cell carcinoma: a significant prognostic factor?

We report on a prospective DNA cytophotometric study of 66 patients with renal tumors, 61 of whom had renal cell carcinoma (RCC) (pT1-pT4, G1-G3). 16 of the patients had a metastasis at the time of diagnosis. Cell material from 1-5 specimens of each tumor was analyzed for intratumoral heterogeneity. The aim of the study was to evaluate the prognostic value of the following DNA parameters: DNA ploidy, DNA grade of malignancy (DNA MG), mean DNA, DNA index, 2c deviation index (2cDI), and 5c exceeding rate (5cER). In this study 21% of the tumors were non-aneuploid, 79% were aneuploid; however, it proved possible to diagnose 38% of the total collective as aneuploid only by analyzing several tumor areas. In five of 61 RCC patients who died during an observation period of 42 months, at least one area of the primary tumor was aneuploid. Aneuploid primary tumors also accompanied the development of metastases and recurrent tumors in four of the 61 RCC patients. Only DNA 2cDI was found to have a significantly positive clinical correlation with metastasis (r = 0.261) during the clinical course. This was not true, however, for the histopathologic parameters. Significantly positive correlations were found between the tumor stages and the following DNA parameters: mean DNA, DNA index, and 5cER. Histopathologic tumor grading showed a significantly positive correlation with DNA MG, mean DNA, and 5cER. Statistically, the mean values of all evaluated parameters were significantly higher in metastasizing and recurrent RCCs than in non-metastasizing carcinomas (p < 0.05; t-test). DNA cytophotometry cannot substitute histopathologic prognosis. However, the analysis of various DNA parameters helps considerably in evaluating both the malignant potential of kidney tumors and the benign parenchyma of tumor-bearing kidneys.

Loss of chromosomes in clear cell renal cell carcinoma and in corresponding renal parenchyma.

Chromosome studies were done on six renal cell carcinomas (RCC) and on the corresponding renal parenchymas of the tumor bearing kidneys. Histopathologically, all tumors belonged to the clear cell subtype. All examined parenchymas were pathologically benign. None of the tumor cells showed the typical chromosomal aberrations described for (nonpapillary) RCC, i.e. deletions in the short arm of chromosome #3, or gains in the long arm of chromosome #5. In our series both the tumor and the benign kidney tissues were characterized by loss of chromosomes, especially of the chromosomes #6, #9, #16, #20, and of the Y chromosome. Trisomy of chromosome #7 was found frequently in benign parenchyma cells. The identical chromosomal changes in the tumor and in the parenchyma tissues might reflect rather in vivo mosaics rather than primary chromosomal aberrations in the oncogenetic process of clear cell RCC.

[Primary malignant melanoma of the distal urogenital tract. Case report and review of the literature]. / Das primäre maligne Melanom des distalen Urogenitaltraktes. Fallbericht und Literaturübersicht.

The primary manifestation of a malignant melanoma is rarely found in the female urethra and considerably less in urinary bladder. This article is based on a case report of a female patient who had to undergo numerous transurethral resections and died of such an escalating tumor. Malignant melanoma in the form of metastases are relevant to the urologist, because they are discovered frequently in the genitourinary tract. The symptoms and diagnostic procedures correspond to those of other urological carcinomas. Radical surgery is of major importance as therapy.

[Is bladder wall resection in cancer of the urinary bladder obsolete?]. / Ist die Blasenwandresektion beim Harnblasenkarzinom überholt?

This is a report on 32 partial cystectomies. From our experience and the review of the literature we come to the conclusion, that in selected cases it may be considered an alternative to cystectomy.

[Results of color-coded duplex ultrasound diagnosis (angiodynography) after intraurethral administration of PgE1 in erectile dysfunction]. / Ergebnisse der Color-coded-duplex-Sonographie (Angiodynographie) nach intraurethraler Applikation von Pg E1 bei ED.

When the pathomechanism of erectile dysfunction is obscure, intraurethral administration of prostaglandin E1 is followed by a marked increase in blood flow velocity in the penile arteries as measured by color-coded Duplex sonography. This increase compares to that following intracavernous administration of half the dose of prostaglandin E1. The difference in the effects after intraurethral and intracavernous administration is the missing rigidity after intraurethral application; there must be a loss of pharmacological efficacy to the smooth penile muscles. Clinical efficacy is to be expected with higher intraurethral dosage.

[Renal cell carcinoma. Immunohistological study to the expression of the inactive form of the pyruvate kinase]. / Nierenzellkarzinom. Immunhistologische Untersuchungen zur Expression der inaktiven Form der Pyruvatkinass.

PURPOSE: The inactive form of pyruvatekinase could be established in different tumours. Purpose of this study was to demonstrate the presence or absence of the inactive form of pyruvatekinase in renal cell carcinoma, metastases and benign renal tissue by immunohistology. METHOD: After deparaffinization of formaline-fixed tissue (5 original tumours, 2 metastases and 5 benign renal tissues) cells were stained (APAAP-method) with Clon DF4 (ScheBo Tech). RESULTS: All malign tissue showed a positive reaction, inside benign tissue we saw a positive reaction of endothelial cells however we saw no reaction with benign renal cells. CONCLUSION: Renal cell carcinoma and metastatic cells show a strong immunohistological reaction against the inactive form of pyruvatekinase, no reaction of benign renal cells. It should be possible to develop a serological tumour marker for renal cell carcinoma.

Skeletal alkaline phosphatase: a marker for individual follow-up in patients with advanced prostatic cancer.

Skeletal alkaline phosphatase (sAP) is a tumor marker indicating osseous metastases, e.g. of prostate cancer. Sera of healthy men and patients with benign prostatic hyperplasia (BPH), localized and advanced prostatic cancer (PCa) were analyzed with Tandem-R-Ostase and prostate-specific antigen (PSA). No significant differences were found in sAP levels between healthy men and patients with BPH and localized PCa, but there was a significant difference with the group of patients with advanced PCa. In some cases, the individual follow-up was better and earlier with sAP compared to PSA. It is possible to discriminate between localized and advanced PCa with sAP. The individual follow-up shows in 30% of patients with advanced PCa an earlier increase in sAP, compared to PSA, during progression of disease.

Randomized open labelled comparative study of the efficacy, safety and tolerability of leuprorelin acetate 1M and 3M depot in patients with advanced prostatic cancer.

OBJECTIVES: In a European, prospective, 1:2 randomized phase II multicentre study, 237 patients with advanced or metastatic prostate cancer were treated with either the 1M- (80 patients) or 3M-depot formulation (157 patients) of leuprorelin acetate for 9 months to compare efficacy and safety. METHODS: Standard clinical investigations and methods were employed in the study. Leuprorelin levels were determined using a specially modified RIA. RESULTS: The two formulations produced virtually identical effects with a pronounced fall in testosterone and gonadotropin serum levels and a marked reduction in PSA levels. After 9 months' treatment, PSA was normalized (< or = 4 ng/ml) in 65.2 and 66.1% of the 1M and 3M depot patients, respectively. The best response to 1M vs. 3M depot during the study was as follows: complete remission in 5 vs. 5.7%, partial remission in 36.3 vs. 33.8% and stabilization in 40.0 vs. 40.8%. The main side effects of both formulations were related to androgen deprivation. CONCLUSIONS: Comparable results were recorded for the two formulations of leuprorelin acetate in terms of clinical response, endocrine effects and tolerability. The newly developed leuprorelin acetate 3M depot, as a refinement of the established 1M depot, offers an opportunity to improve patient compliance and provides individualized and optimized, patient-orientated treatment by reducing the number of injections to four per year.