Scandinavian journal of urology and nephrology. Supplementum最新文献

This paper, based on the activity of the Morphology-Based Prognostic Factors Committee of the 2004 World Health Organization-sponsored International Consultation, describes various methods of handling radical prostatectomy specimens for both routine clinical use and research purposes. The correlation between radical prostatectomy findings and postoperative failure is discussed in detail. This includes issues relating to pelvic lymph node involvement, detected both at the time of frozen section and in permanent sections. Issues of seminal vesicle invasion, including its definition, routes of invasion and relationship to prognosis, are covered in detail. The definition, terminology and incidence of extra-prostatic extension are elucidated, along with its prognostic significance relating to location and extent. Margins of resection are covered in terms of their definition, the etiology, incidence and sites of positive margins, the use of frozen sections to assess the margins and the relationship between margin positivity and prognosis. Issues relating to grade within the radical prostatectomy specimen are covered in depth, including novel ways of reporting Gleason grade and the concept of tertiary Gleason patterns. Tumor volume, tumor location, vascular invasion and perineural invasion are the final variables discussed relating to the prognosis of radical prostatectomy specimens. The use of multivariate analysis to predict progression is discussed, together with proposed modifications to the TNM system. Finally, biomarkers to predict progression following radical prostatectomy are described, including DNA ploidy, microvessel density, Ki-67, neuroendocrine differentiation, p53, p21, p27, Bcl-2, Her-2/neu, E-cadherin, CD44, retinoblastoma proteins, apoptotic index, androgen receptor status, expression of prostate-specific antigen and prostatic-specific acid phosphatase and nuclear morphometry.

An understanding of prognosis in cancer medicine is important for patient care, research and cancer control programs. In prostate cancer, prognostic (predictive) factors are particularly important given the marked heterogeneity of this disease at clinical, morphologic and biomolecular levels. Clinical stage and histologic grade have historically played major roles in defining heterogeneity in prostate cancer. More recently, serum prostate-specific antigen measurement has assumed a significant prognostic role. Over the last two decades there has been an explosion of research into biomarkers, many of which have been purported to have prognostic significance. In this paper we present an overview of the various consensus initiatives that have transpired over the last dozen years. Criteria for evaluating prognostic factors and classifications of predictive factors have emerged that have proven useful and advanced our understanding of the biology of prostate cancer. The results of these consensus initiatives form a foundation on which the current international consultation on prognosis (prediction) in prostate cancer is built. Advances in our understanding of the new and promising prognostic factors will require a more rigorous evidence-based approach to the analysis of published studies. Furthermore, appropriate mathematical models for the analysis of the multiple factors that influence a prognostic system will have to be employed.

Recent developments in the field of molecular techniques have provided new tools that have led to the discovery of many new promising biomarkers for prostate cancer. These biomarkers may be instrumental in the development of new tests that will have a high specificity for the diagnosis and prognosis of prostate cancer. A biomarker is defined as a molecular test that provides additional information to currently available clinical and pathological tests. Biomarkers should be reproducible (both within and between institutes) and have an impact on clinical management. For diagnostic purposes it is important that potential biomarkers are tested in terms of tissue specificity and their discrimination potential between prostate cancer, normal prostate and benign prostatic hyperplasia. The results of (multiple) biomarker-based assays may enhance the specificity of cancer detection. There is an urgent need for molecular prognostic biomarkers for predicting the biological behavior and outcome of cancer.

Substantial gaps exist in the data of the assessment of risk and prognosis that limit our understanding of the complex mechanisms that contribute to the greatest cancer epidemic, prostate cancer, of our time. This report was prepared by an international multidisciplinary committee of the World Health Organization to address contemporary issues of epidemiology and statistical methods in prostate cancer, including a summary of current risk assessment methods and prognostic factors. Emphasis was placed on the relative merits of each of the statistical methods available. We concluded that: 1. An international committee should be created to guide the assessment and validation of molecular biomarkers. The goal is to achieve more precise identification of those who would benefit from treatment. 2. Prostate cancer is a predictable disease despite its biologic heterogeneity. However, the accuracy of predicting it must be improved. We expect that more precise statistical methods will supplant the current staging system. The simplicity and intuitive ease of using the current staging system must be balanced against the serious compromise in accuracy for the individual patient. 3. The most useful new statistical approaches will integrate molecular biomarkers with existing prognostic factors to predict conditional life expectancy (i.e. the expected remaining years of a patient's life) and take into account all-cause mortality.

The information provided in the surgical pathology report of a prostate needle biopsy of carcinoma has become critical in the subsequent management and prognostication of the cancer. The surgical pathology report should thus be comprehensive and yet succinct in providing relevant information consistently to urologists, radiation oncologists and oncologists and, thereby, to the patient. This paper reflects the current recommendations of the 2004 World Health Organization-sponsored International Consultation, which was co-sponsored by the College of American Pathologists. It builds on the existing work of several organizations, including the College of American Pathologists, the Association of Directors of Anatomic and Surgical Pathologists, the Royal Society of Pathologists, the European Society of Urologic Pathology and the European Randomized Study of Screening for Prostate Cancer.

The incidence of prostate cancer has increased dramatically during the last 10-15 years and it is now the commonest cancer in males in developed countries. The increase is mainly caused by the increasing use of opportunistic screening or case-finding based on the use of prostate-specific antigen (PSA) testing in serum. With this approach, prostate cancer is detected 5-10 years before giving rise to symptoms and on average 17 years before causing the death of the patient. While this has led to detection of prostate cancer at a potentially curable stage, it has also led to substantial overdiagnosis, i.e. detection of cancers that would not surface clinically in the absence of screening. A major challenge is thus to identify the cases that need to be treated while avoiding diagnosing patients who will not benefit from being diagnosed and who will only suffer from the stigma of being a cancer patient. It would be useful to have prognostic markers that could predict which patients need to be diagnosed and which do not. Ideally, it should be possible to measure these markers using non-invasive techniques, i.e. by means of serum or urine tests. As it is very useful for both early diagnosis and monitoring of prostate cancer, PSA is considered the most valuable marker available for any tumor. Although the prognostic value of PSA is limited, measurement of the proportion of free PSA has improved the identification of patients with aggressive disease. Furthermore, the rate of increase in serum PSA reflects tumor growth rate and prognosis but, due to substantial physiological variation in serum PSA, reliable estimation of the rate of PSA increase requires follow-up for at least 2 years. Algorithms based on the combined use of free and total PSA and prostate volume in logistic regression and neural networks can improve the diagnostic accuracy for prostate cancer, and assays for minor subfractions of PSA and other new markers may provide additional prognostic information. Markers of neuroendocrine differentiation are useful for the monitoring of androgen-independent disease and various bone markers are useful in patients with metastatic disease.

Objective: Detrusor muscle is sensitive, in vitro, to changes in the chemistry of its environment. However, the extent to which the intravesical environment influences bladder function is unclear. This study was designed to assess the impact of changes to the intravesical biochemical environment on urodynamic testing, compared with a normal saline control.

Material and methods: Ninety-four women were studied with repeat fill urodynamics, using a normal saline control and test solutions (hyperosmolar, a solution intended to cause extracellular alkalosis and solutions designed to affect both intracellular and extracellular pH, and high potassium solution).

Results: There were no significant effects of any changes in filling solution.

Conclusions: Urodynamic testing was unaffected by changes to intravesical chemistry that are known to affect detrusor cells in vitro. This suggests that the homoeostatic mechanisms of the bladder are able to maintain a stable microenvironment for detrusor cells despite changes to bladder contents.

Objective: This paper comprises a critical assessment of the many competing ways of assessing detrusor contractility in the urodynamic clinic. It is based on measurements made in a group of elderly women, and the conclusions apply, strictly speaking, only to that population. Detrusor contractility has two aspects, which appear to be independent of each other: the strength of the detrusor contraction and whether the contraction is adequately sustained. The second of these can be assessed quite simply from postvoid residual urine. The main aim of the paper therefore is to identify and recommend one or two best methods of measuring detrusor contraction strength.

Conclusions: For research, the isovolumetric detrusor pressure should be measured during a continuous occlusion test or a mechanical stop test, effected by blocking the outlet with a balloon catheter. For routine clinical use, where ease of performance and minimization of repeat catheterization are important considerations, the isovolumetric detrusor pressure may be estimated from a simple contractility index PIP (=pdet.qmax + Qmax, in the usual urodynamic units). The older indices detrusor coefficient, projected isovolumetric pressure and bladder contractility index, the detrusor power and the well-known contractility nomogram, are not recommended for use in older women. Except for specialized research purposes, the Watts factor does not offer enough advantages to offset the complex calculation required. These conclusions may require modification for male patients.

Stimulation of muscarinic receptors is a main mechanism for contractile activation of the detrusor from both animals and humans. Muscarinic receptors are coupled to G-proteins, but the signal transduction systems may vary. In general, M, M and M receptors are considered to couple preferentially to Gq/11, activating phosphoinositide hydrolysis, in turn leading to mobilization of intracellular calcium through inositol trisphosphate generation. M2 and M4 receptors couple to pertussis toxin-sensitive Gi/o, resulting in inhibition of adenylyl cyclase activity. However, in the detrusor smooth muscle, other signalling pathways may be involved. Recent investigations revealed that a main pathway for muscarinic receptor activation of the detrusor may be calcium influx via L-type calcium channels, and increased sensitivity to calcium of the contractile machinery via inhibition of myosin light chain phosphatase through activation of Rho-kinase. The importance of these findings for treatment of voiding dysfunction remains to be established.

This paper reviews the contractility and the expression of contractile and regulatory proteins in the detrusor smooth muscle (DSM) following partial bladder outlet obstruction (PBOO) in rabbits. PBOO was surgically induced by partial ligation of the urethra in adult male New Zealand White rabbits. The force generated by DSM strips from normal and obstructed bladders which showed bladder dysfunction, despite detrusor hypertrophy (decompensated bladder, DB) was measured. The expression of contractile and regulatory proteins was analyzed by reverse transcriptase-polymerase chain reaction and Western blotting. The DSM from obstructed DB revealed an overexpression of SM-A myosin heavy chain isoform (associated with decreased maximum velocity of shortening). DSM from sham-operated rabbits showed phasic contractions, whereas the detrusor from DB was tonic, exhibiting slow development of force, a longer duration of force maintenance, and slow relaxation. Rho-kinase inhibitor Y-27632 enhanced the relaxation of precontracted (with 125 mM KCl) DSM strips from DB. The enhancement of relaxation of DB by Y-27632 was associated with dephosphorylation of myosin light chain. The detrusor from normal bladders expresses predominantly the smooth muscle caldesmon (h-CaD), a thin filament-associated protein. However, the DSM from DB shows an overexpression of l-CaD, the non-muscle isoform of CaD. The l-CaD colocalizes with myosin in the cytoplasmic filaments in myocytes. These results show that the alteration of contractility of the detrusor following PBOO is associated with changes in the expression of proteins that form the contractile apparatus and regulate the actomyosin ATPase activity and contraction.