Keyhole limpet haemocyanin in experimental bladder cancer: literature review and own results.

OBJECTIVES: Keyhole limpet haemocyanin (KLH) is a high-molecular-weight protein antigen collected from the haemolymph of the sea mollusk Megathura crenulata. It is a powerful non-specific immune response modifier that induces both a cell-mediated and a humoral response in animals and man. Thus, it is commonly used clinically as a measure of immune competence. In 1974, Olson studied the immune competence of bladder cancer patients by intradermal application of KLH. He later observed a significant reduction of recurrent disease in this patient group compared to another not immunized with KLH. This prompted a variety of experimental and clinical studies using KLH as an immunotherapy for recurrent bladder cancer. METHODS: Three different bladder cancer models have been used for experimental studies: intravesical transplantation of tumour cells in syngeneic mouse bladders; subcutaneous transplantation of tumour cells in syngeneic mice; direct chemical induction of bladder tumours by feeding rats with the carcinogen N-butyl-N-(4-hydroxybutyl)nitrosamine. RESULTS: The efficacy of KLH as an immunotherapeutic agent has been compared with different immune response modifiers alone or in combination with these in 11 experimental studies. Most of the studies used different concentration and application schedules for KLH. In addition a pre-immunisation prior to inoculation of the tumour was not performed in all studies. Therefore it is not useful to compare the results of these studies. However, most of the experiments demonstrated a significant effect on tumour appearance and extension after treatment with KLH. Intralesional or systemic application of KLH seemed to be superior to intravesical treatment. Pre-immunisation with KLH several days or weeks before tumour inoculation also seems to be a key point of success. No study reported severe side-effects after application of KLH; additionally performed toxicity studies underlined the good tolerability of KLH. CONCLUSION: Based on all the experimental studies, KLH has to be judged as an effective and safe immunotherapeutic drug for the treatment of experimental bladder cancer. Prospective randomised clinical trials should evaluate the role of KLH as an immunotherapeutic alternative in the prophylaxis of recurrent bladder cancer and should determine whether the efficacy of KLH in man may be improved by systemic application.

Surgical treatment of interstitial cystitis in women.

Interstitial cystitis is a clinical entity that has been known for a century, but its pathophysiology remains largely unknown and the optimal treatment is a matter of ongoing discussion. A successful strategy for treatment relies on precise appraisal of symptoms, clinical findings and histology, as well as on the patient's individual personality. The least invasive treatment possible should be chosen, and only after conservative options have been exhausted should a surgical solution be considered. In this respect, anatomical bladder capacity plays an important role. A large capacity indicates the potential for conservative treatment and may be regarded as a negative predictor for the outcome of orthotopic bladder substitution. In contrast, a small anatomical capacity is unlikely to respond to conservative therapy, but is associated with a high probability of successful orthotopic bladder substitution.

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.

Obstetrical management following incontinence surgery.

OBJECTIVE: To analyze in a retrospective fashion our experiences with obstetrical management following previous incontinence surgery. METHODS: Between 1990 and 1997 4 women presented to our institution in the third trimester of pregnancy with a history of colposuspension performed 3 months to 4 years before onset of pregnancy for second degree stress incontinence. Three of 4 patients experienced recurrent incontinence during the third trimester. RESULTS: A cesarean section was performed before the onset of labor in all 4 patients. Postpartal pelvic floor exercises were prescribed and a follow-up ensued after 6 and 11 months in the form of a questionnaire. While incontinence persisted in 2 patients for 6 months, all 4 patients demonstrated complete continence after one year. CONCLUSIONS: We consider an elective cesarean section to be the optimal mode of delivery in women with a history of incontinence surgery.

Retrovesical mass in men: pitfalls of differential diagnosis.

PURPOSE: We review the differential diagnosis and treatment of retrovesical masses in men. MATERIALS AND METHODS: During the last 8 years 21 male patients 3 to 79 years old (mean age 47.1) presented with symptoms or signs of a retrovesical mass. Clinical features and diagnostic findings were reviewed, and related to surgical and histopathological findings. RESULTS: The retrovesical masses included prostatic utricle cyst in 3 cases, prostatic abscess in 1, seminal vesicle hydrops in 6, seminal vesicle cyst in 2, seminal vesicle empyema in 3, large ectopic ureterocele in 1, myxoid liposarcoma in 1, malignant fibrous histiocytoma in 1, fibrous fossa obturatoria cyst in 1, hemangiopericytoma in 1 and leiomyosarcoma in 1. In 17 patients various symptoms were seen and in 4 the mass was incidentally detected. A mass was palpable on digital rectal examination in 16 cases and visible on sonography in 20. For a cystic mass medial location relative to the bladder neck was suggestive of prostatic abscess or utricle cyst, while lateral location was suggestive of seminal vesicle cyst/hydrops or empyema, ectopic ureter or ureterocele. In 6 patients diagnosis was established only by exploratory laparotomy and histopathological examination. CONCLUSIONS: Digital rectal examination and sonography reliably detect a retrovesical mass. Nevertheless, clinical signs and median or lateral location relative to the bladder neck on ultrasound are diagnostic only for cystic lesions. Computerized tomography and magnetic resonance imaging are useful for staging malignant tumors. However, needle or open biopsy is required in most cases to establish a histopathological diagnosis. Exploratory laparotomy and histopathological examination are the procedures of choice when other findings are equivocal.

The molecular characteristics of bladder cancer in young patients.

PURPOSE: The molecular characteristics of bladder cancer in children and young adults remain largely undefined. We sought to identify common molecular changes in bladder tumors in young patients using standard immunohistochemical and interphase cytogenetic methods. MATERIALS AND METHODS: We retrospectively evaluated 73 bladder tumors removed from patients younger than 30 years for the p53 tumor suppressor gene product using immunohistochemical techniques and numerical aberrations of chromosomes 9, 17, X and Y. RESULTS: Regardless of stage, immunohistochemical evidence of p53 gene product over expression was found in the majority of tumors studied. Numerical aberrations (monosomy) of chromosome 9 were rare. Aneuploidy of chromosome 17 was common, particularly in carcinoma in situ and invasive bladder cancer. CONCLUSIONS: These data suggest that immunohistochemical evidence of p53 gene product over expression is common in bladder cancer in young patients. Further prospective analysis of lesions in this population may help to establish a comprehensive molecular progression model for urothelial neoplasms.

Treatment of interstitial cystitis: comparison of subtrigonal and supratrigonal cystectomy combined with orthotopic bladder substitution.

PURPOSE: We retrospectively evaluate the outcome of interstitial cystitis treated with subtrigonal or supratrigonal cystectomy and orthotopic bladder substitution. MATERIALS AND METHODS: Of 22 women and 1 man a mean of 51 years old with interstitial cystitis refractory to conservative therapy 17 were treated with subtrigonal cystectomy and ureteral reimplantation (group 1), and 6 were treated with supratrigonal cystectomy directly above the ureteral orifices (group 2). Both groups underwent orthotopic bladder substitution with an ileocecal pouch (Mainz pouch I). RESULTS: Postoperatively functional capacity significantly increased from a mean plus or minus standard error of mean 46 +/- 5 to 346 +/- 57 ml. in group 1 and 34 +/- 61 to 319 +/- 29 ml. in group 2 (p < 0.001). Daytime and nighttime urinary frequency significantly decreased from 24 +/- 2 to 8 +/- 1 and 7 +/- 1 to 2 +/- 1 ml., respectively, in group 1 and 28 +/- 2 to 6 +/- 1 and 6 +/- 1 to 1 +/- 1 ml., respectively, in group 2 (p < 0.001). At a mean followup of 93.9 months 14 patients in group 1 (82%) are completely symptom-free, and 1 has tolerable residual urinary urgency and suprapubic pain. At a mean followup of 31.5 months all group 2 patients are symptom-free and void spontaneously, whereas 41% of the group 1 patients require self-catheterization after subtrigonal cystectomy. CONCLUSIONS: For interstitial cystitis refractory to conservative treatment subtotal cystectomy with orthotopic bladder substitution with the ileocecal pouch (Mainz pouch I) is a valid therapeutic option. In this series supratrigonal and subtrigonal cystectomy resulted in similar relief of symptoms but the former appears to provide better functional bladder rehabilitation.

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.

Microsatellite-based cancer detection using capillary array electrophoresis and energy-transfer fluorescent primers.

The development of sensitive, rapid, and accurate methods and apparatus for high-throughput short tandem repeat (STR) analysis will be critical for the use of microsatellite alteration in cancer screening. Here we show that STR-based bladder cancer diagnosis can be performed using capillary array electrophoresis and two-color labeling with energy-transfer (ET) fluorescent primers. Rapid (< or = 35 min) separations are achieved on capillary arrays using replaceable separation matrices and the allelic ratios are quantitatively determined with a precision of +/- 10%. With this precision, a variation of 20% was considered diagnostically significant. These methods provide a significant improvement in the speed, ease, and precision of STR analyses compared to slab gel electrophoresis.

Detailed deletion mapping at chromosome 9p21 in non-small cell lung cancer by microsatellite analysis and fluorescence in situ hybridization.

We examined 82 cases of primary non-small cell lung cancer (NSCLC) for loss of heterozygosity (LOH) at the chromosome 9p21-24 region using 16 microsatellite markers. A total of 52 tumors (63%) displayed LOH, and 25 of these cases displayed LOH for all markers. Two cases had small hemizygous losses confined to the p16 gene and more distal markers, whereas 3 cases had loss proximal to p16 and extended through marker D9S126. This latter region has recently been described as another minimal region of loss at 9p21 in lung cancer. However, homozygous deletion of the p16 gene was observed in 18 of 85 cases, with only 5 cases having large deletions extended into the D9S126 region. Furthermore, we did not observe homozygous deletion at the 9p21 region that excluded the p16 gene. Fluorescence in situ hybridization (FISH) analysis using genomic probes spanning either the p16 or Hel-N1 (located at D9S126) gene was performed in 14 tumors. The results from FISH correlated with the chromosomal mapping data, suggesting that the p16 region is the major target of deletion at chromosome 9p21 in primary NSCLC.

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.

Continent reconstruction of detrusor hyperreflexia by sacral bladder denervation combined with continent vesicostomy.

We describe a two-stage surgical procedure for complex hyperreflexic detrusor dysfunction refractory to conservative therapy. First, ventral and dorsal sacral rhizotomies (S2 to S4/5) are performed to restore vesical storage function and abolish autonomic dysreflexia. Then, after an interval of several weeks to allow for detrusor relaxation, continent vesicostomy is performed for suprapubic clean intermittent catheterization. The procedure is effective both objectively and subjectively, is only moderately invasive, and requires neither sophisticated nor expensive medical equipment.