[Colony stimulating factors in polychemotherapy of testicular tumors. A comparison between G-CSF and GM-CSF]. / Koloniestimulierende Faktoren bei der Polychemotherapie von Hodentumoren. Ein Vergleich zwischen G-CSF und GM-CSF.

Colony-stimulating factors (CSF) are frequently used in cases of cytostatic therapy of patients with testicular cancer assuming that they support hematopoietic recovery and, thus, shorten duration of neutropenia as well as reduce infections. Currently, G-CSF and GM-CSF are clinically used. In the present study efficacy and toxicity of these two drugs were investigated and compared in patients with testicular cancer treated by standard chemotherapy. Studying 83 chemotherapy cycles applied to 31 patients with advanced germ cell tumors the effectivity and the side effects of the two CSF were examined by questioning, clinical evaluation, and blood chemistry studies. G-CSF (480 micrograms subcutaneously (s.c.)) were used in 55 and GM-CSF (400 micrograms s.c.) in 28 chemotherapeutic cycles. The indications consisted in the treatment of leukocytopenia on the one hand and in the prophylaxis in subsequent cycles on the other hand. No difference between the two CSF could be found either with regard to postponement of the next cycle (G-CSF: 6.8 vs. GM-CSF: 7.3 days), or to the number of injections per cycle (G-CSF: 8 vs. GM-CSF: 12.5), or to the leukocyte (G-CSF: 2.1 vs. GM-CSF: 1.6 x 10(3)/microliter) or platelet nadir (G-CSF: 0.5 vs. GM-CSF: 0.5 x 10(5)/microliter; mean values of all cycles, respectively). Both CSF did not seem to influence the production of platelets. However, a difference between the two CSF was demonstrated with respect to the toxicity. Frequency (G-CSF: 38.5% vs. GM-CSF: 69.3%) as well as intensity of side effects causing a change of the drug (G-CSF: n = 1 vs. GM-CSF: n = 7) were lower in the case of G-CSF. In conclusion, these data demonstrate no difference was seen between G-CSF and GM-CSF with respect to the efficacy in patients with testicular cancer treated by standard chemotherapy. However, the use of G-CSF seems to be associated with lower toxicity.

[Lipoma of the adrenal gland. Case report and review of the literature]. / Lipom der Nebenniere. Fallbericht und Literaturübersicht.

Adrenal lipomas are extremely rarely occurring benign tumors being hormonally inactive. The patient described in this report underwent surgical excision of an adrenal lipoma because of the associated hypertension. The blood pressure decreased postoperatively to normal levels. This case report and the review of the literature consider diagnosis and therapy of the adrenal lipomas.

[Transvaginal closure of vesicovaginal fistulas]. / Transvaginaler Verschluss von vesikovaginalen Fisteln.

The surgical management of vesicovaginal fistulae (VVF) is a matter of controversy. This study deals with our experience with transvaginally treated patients suffering from VVF. Between 1966 and 1996, 64 patients with VVF were treated surgically. The VVF occurred in the course of hysterectomy in 54 patients, was due to radiotherapy in 7, was a result of obstetric complications in 2 patients, and occurred after colporrhaphy in 1 patient. In 60 of these 64 patients closure of the fistula was carried out transvaginally. Fourteen of these 60 patients (23%) had undergone prior surgical attempts to close the VVF (1 to 3 procedures). Transvaginal surgery was successful at first attempt in 55 of these 60 patients (92%). The other 5 patients were successfully treated by a second procedure (again transvaginal: n = 3; transabdominal: n = 2). In conclusion, the transvaginal approach to close VVF is of advantage, avoiding an abdominal incision and reducing postoperative morbidity. In the vast majority of the cases isolated VVF can be treated successfully by transvaginal repair.

[Radical prostatectomy as primary monotherapy in capsule penetrating prostatic carcinoma. 15 years outcome]. / Radikale Prostatektomie als primäre Monotherapie bei kapselüberschreitendem Prostatakarzinom. 15-Jahres-Ergebnisse.

Twenty-five patients with locally advanced prostate cancer (stage pT3pN0) underwent pelvic lymphadenectomy and radical prostatectomy and were followed up thereafter for at least 15 years. No hormonal treatment was given prior to tumor progression. Overall and disease-free 15-year survival rates were observed to be 44 and 24%, respectively. These data suggest that a cure from prostate cancer by radical prostatectomy can be expected in a quarter of patients with capsular penetration. From our results, no justification can be derived to exclude radical prostatectomy from the spectrum of treatment options for patients with capsular penetration of prostate cancer. More detailed analysis of the results depending on the local extent of the tumor and histological grade revealed distinct differences with respect to the risk of progression. Histological grade was the single most predictive parameter of progression. Out of all subgroups of patients with capsular penetration of prostate cancer, those with a poorly differentiated tumor showed the shortest progression-free interval after surgery, the highest level of overall progression and the largest proportion of tumor-related deaths. By contrast, the prognosis was only slightly influenced by the presence or absence of seminal vesicle involvement. The role of adjuvant treatment after radical prostatectomy for patients with stage pT3pN0 prostate cancer or for subgroups of them remains to be determined within the scope of prospective randomized trials.

[Immunochemotherapy of metastatic renal cell carcinoma with interleukin 2, interferon-alpha and 5-fluorouracil]. / Immunchemotherapie des metastasierten Nierenzellkarzinoms mit Interleukin-2, Interferon-alpha und 5-Fluorouracil.

Interleukin-2 (IL-2) and interferon-alpha (IFN-alpha) were both administered subcutaneously (SC) in combination with intravenously (IV) applied 5-fluorouracil (5-FU) for the treatment of patients with metastasized renal cell carcinoma (RCC). The therapy protocol consisted of a treatment cycle of 8 weeks, which could be carried out in an outpatient regimen. The IFN-alpha was given in each of the 8 weeks (6-9 MU/m2 once to three times weekly SC) combined sequentially with IL-2 (5-20 MU/m2 three times weekly SC for 4 weeks) and 5-FU (750 mg/m2 IV weekly for 4 weeks). Among the 30 consecutive patients treated, in 2 cases a complete, and in 9 cases a partial, remission was achieved in patients with mostly lung and skeletal metastases, with an overall objective response rate of 37%. Mean response duration was 8 months (range 3-18 months). A stable state of the disease lasting 3-18 months was observed in 10 cases. The side effects were only slight and corresponded to toxicity grade I (n = 2), grade II (n = 22) and grade III (n = 6), according to the WHO classification. In conclusion, this triple-drug biochemotherapy demonstrated significant clinical effectiveness comparable with that of an aggressive IL-2 treatment regimen (applied IV), but without its high toxicity.

Simultaneous occurrence of urothelial bladder carcinoma and primary retroperitoneal leiomyosarcoma.

A case of primary carcinoma of the urinary bladder associated with a primary retroperitoneal leiomyosarcoma is presented. Due to the lack of early symptoms, diagnosis of the retroperitoneal leiomyosarcoma was late and therefore the prognosis was poor. Twelve months after diagnosis the patient died not of the bladder tumor, but of the recurrent leiomyosarcoma.

Cyclic interferon alpha treatment in metastatic renal cell carcinoma: results of a phase II study and review of the literature.

In a phase II clinical trial 23 patients with metastatic renal cell carcinoma were treated with a cyclic regimen of interferon alpha-2b (IFN-alpha). To these 23 patients IFN-alpha at a dose of 10 MU/m2 body surface was applied subcutaneously on 5 consecutive days every 4 weeks. In 12 out of these 23 patients tumor nephrectomy preceded this treatment. The mean follow-up period was 13.6 (range 2-36) months. No complete remission was achieved in any of the patients. One patient with lung metastases revealed a partial response for 19 months. Stable disease lasting 4 to > 36 (mean: 18.7) months was seen in 7 cases. Progressive disease was observed in 15 patients. Only slight side effects were noted, consisting of a maximum toxicity of grades II (n = 20) and III (n = 3) according to the WHO classification. Five out of 8 patients with partial responses or stable disease showed a long-lasting stabilization (> 12 months) of the disease with a good quality of life. In summary, in advanced renal cell carcinoma patients, the objective response rate of a cyclic treatment with IFN-alpha is rather low. However, a long-lasting stabilization of the disease including a good quality of life can be expected in a modest proportion of the patients.

Ureteroscopic treatment of ureteral stones: only an auxiliary measure of extracorporeal shockwave lithotripsy or a primary therapeutic option?

Both extracorporeal shockwave lithotripsy (ESWL) and ureteroscopy are well-established methods in stone treatment; however, the therapeutic procedure in ureteral calculi, especially in the distal third of the ureter, is still controversially discussed. The aim of the present study was to examine the role of ureteroscopy as an auxiliary measure after ESWL and its importance as an alternative therapeutic option in the treatment of distal ureteral stones. Between 1991 and 1994, 115 ureteroscopic procedures in 104 patients with ureteral stones or stone fragments were carried out at our institution. During the same period of time, 1,595 patients with ureteral calculi (in the proximal two thirds of the ureter: n = 956; in the distal third of the ureter: n = 639) were treated with a Dornier HM-3 lithotriptor. In 77 of those 104 patients treated by ureteroscopy, this procedure was indicated as an auxiliary measure after failure of ESWL including 34 out of the 639 patients (5.3%) with stones in the distal part of the ureter. The overall direct success rate during the ureteroscopic stone treatment (including 11 cases with a second procedure) in the proximal, middle and distal third of the ureter was 74, 81 and 92%, respectively. The success rate of primary ureteroscopic removal of distal-third ureteral stones alone was 100% in 27 of these 104 patients. After 3 months the overall stone-free rate of all patients treated with ureteroscopy was 94%. Ureteroscopy appears to be a safe and effective treatment modality, if used as an auxiliary measure after failure of ESWL as well as a primary treatment modality in the case of stones in the distal third of the ureter. On the other hand, ESWL alone is a noninvasive and also successful procedure in treating stones situated in the distal part of the ureter.

Results of radical prostatectomy in men with locally advanced prostate cancer: multi-institutional pooled analysis.

OBJECTIVE: We investigated the disease-specific and metastasis-free survival rates in men with locally advanced (clinical stage T3) prostate cancer who were treated surgically. METHODS: A retrospective, multi-institutional pooled analysis of the results of surgical treatment in 345 men with clinical stage T3 disease was performed. Survival curves were generated using the Kaplan-Meier method. RESULTS: Among 298 evaluable patients, pelvic lymphadenectomy alone was performed in 56 men (19%), while 242 men (81%) underwent node dissection and radical prostatectomy. In total, 122 of 298 patients (41%) had nodal metastases and/or seminal vesicle tumor spread. Pathologically organ-confined disease was noted in 27 men (9%). The actuarial 10-year disease-specific and metastasis-free survival rates for all patients managed surgically were 57 and 32%, respectively. For patients with well, moderately and poorly differentiated tumors, cancer-specific survival rates at 10 years were 73, 67 and 29%, respectively. CONCLUSIONS: A large number of men with clinical stage T3 prostate cancer have advanced disease and are unlikely to achieve improved long-term survival with surgery alone. Although there may be a role for radical prostatectomy in selected patients with low to intermediate grade tumors, such treatment appears unlikely to result in long-term survival in men with high grade disease. A prospective study is necessary to determine the optimal treatment approach in men with locally advanced prostate cancer.

[Conservative therapy of blunt kidney injuries]. / Konservative Therapie des stumpfen Nierentraumas.

Forty-two patients with blunt renal injuries were treated between 1984 and 1994 at our institution. Twenty-nine patients revealed a contusion (grade I injury), 10 showed lacerations (grade II), 1 a severe fracture (grade III), and 2 presented pedicle injuries (grade IV). All 10 patients with incomplete renal injuries (grade II) were treated conservatively, i.e. without primary surgery. One of these 10 patients required surgical intervention 3 months after the trauma due to a urinary obstruction. Two of the ten patients with grade II injuries suffered late complications, namely a contracted kidney in one case and hypertension in the other. This means that of 10 patients with conservatively treated grade II renal trauma, a loss of the function of the affected kidney occurred in only one. In 9 patients complete function of the kidney could be preserved. In conclusion, conservative management of incomplete blunt renal injuries is an effective treatment option with few complications.

[Surgical treatment of metastases in renal cell carcinoma]. / Metastasenchirurgie beim Nierenzellkarzinom.

The aim of the present study was to investigate the efficacy of surgical excision of metastases in patients with renal cell carcinoma (RCC). Eighteen patients with metastatic RCC underwent resection of metastases between 1988 and 1994 (pulmonary: n = 6; skeletal: n = 6; cerebral: n = 3; local relapse: n = 3). Two patients suffered from synchronous appearance of metastases, whereas in 16 cases a metachronous occurrence was observed. In 12 out of a total of 18 patients metastases were completely resected. These patients survived longer than patients in whom metastases were incompletely resected (30 vs. 12 months). Six out of these 12 patients with a complete resection of metastases are presently free of disease for a mean duration of 24 months (10-34 months). The resection of lung metastases seems to be associated with longer survival times. In conclusion, surgical resection of metastases--solitary or single organ site--especially in the lung appears to be justified in patients with RCC. The surgical excision of skeletal metastases at least improves quality of life.

Results of radical prostatectomy in men with clinically localized prostate cancer.

OBJECTIVE: To assess the results of radical prostatectomy in men with early prostate cancer. DESIGN: Retrospective, nonrandomized, multi-institutional pooled analysis. SETTING: Eight university medical centers in the United States and Europe. PATIENTS: A total of 2758 men with stage Tl and T2 prostatic cancer. MAIN OUTCOME MEASURES: Disease-specific and metastasis-free survival rates. RESULTS: Tumor grade was the most important preoperative factor in determining outcome. Disease-specific survival 10 years following surgery and associated 95% confidence intervals were 94% (range, 87%-98%), 80% (range, 74%-85%), and 77% (range, 65%-86%) for those men with grade 1, 2, and 3 tumors, respectively. Metastasis-free survival at 10 years was 87% (range, 78%-92%), 68% (range, 62%-73%), and 52% (range, 38%-64%) for patients with grade 1, 2, and 3 cancers, respectively. CONCLUSIONS: Radical prostatectomy leads to high 10-year disease-specific survival rates in men with all tumor grades. However, caution is needed in comparing these results with similar studies of alternative treatment strategies, such as watchful waiting, due to the inherent potential biases in uncontrolled trials. Nevertheless, these results offer the best currently available estimates of 10-year outcome of radical prostatectomy in men with clinically localized prostate cancer and may be useful in counseling patients with early malignancy.

[Cosmetic and functional long-term outcome after operation of Fournier gangrene]. / Kosmetische und funktionelle Langzeitergebnisse nach Operation einer Fournier-Gangrän.

The study documents the long-term cosmetical and functional sequelae in 12 patients treated for Fournier's gangrene after an average of 5 years follow-up. Only 50% of the patients were free of pain. In the majority of cases, the sexual function was impaired by penile deviation or penile torsion as well as by a loss of sensitivity of the penile skin or pain during erection. Two patients suffered from temporary stool incontinence. Despite major complaints due to extensive scarring, most (10 of 12) patients considered their cosmetic result as well as their quality of life to be satisfactory.

Immunochemotherapy for metastatic renal cell carcinoma using a regimen of interleukin-2, interferon-alpha and 5-fluorouracil.

PURPOSE: Promising results of recent clinical trials with a triple drug bio-chemotherapy regimen encouraged its use in patients with renal cell carcinoma. MATERIALS AND METHODS: In a phase II study of patients with metastatic renal cell carcinoma the efficacy and toxicity of a treatment regimen were evaluated using interleukin-2 and interferon-alpha 2 subcutaneously in combination with intravenous 5-fluorouracil. The treatment protocol consisted of an 8-week cycle given on an outpatient basis, with 6 to 9 MU/m2. interferon-alpha given 1 to 3 times a week during the 8 weeks, and sequentially combined with 5 to 20 MU/m2. interleukin-2, 3 times a week for 4 weeks and 750 mg./m.2 5-fluorouracil once a week for 4 weeks. RESULTS: Among 25 consecutive men and 9 women treated 3 (9%) had a complete and 10 (29%) had a partial remission (overall objective response rate 38%). Median response duration (complete plus partial) was 12.5 months (range 3 to 20+). Stable disease lasting 3 to 24+ months was noted in 12 patients (35%). There were only minor side effects, for a maximum toxicity grade of I in 3 patients, II in 25 and III in 6 according to the World Health Organization classification. There were no dose limiting toxicities and no treatment related deaths. CONCLUSIONS: Triple drug immunochemotherapy resulted in a significant clinical effect comparable to an aggressive intravenous interleukin-2 treatment regimen but without significant toxicity.

Atypical findings in a patient with a renal milk-of-calcium cyst.

A case of an atypical renal milk-of-calcium cyst is presented. Although this cyst contained a colloidal suspension of calcium crystals, other signs and findings typical for a milk-of-calcium cyst were lacking. No connection of the cyst to the collecting system could be identified, no "half moon" phenomenon was found on upright and cross-sectional radiography, and the biopsies taken from the wall of the cyst showed sclerosis instead of urothelium. From the present case it was concluded that renal milk-of-calcium cysts may sometimes occur in the absence of findings that are typical of this particular entity. Therefore, this disease should be considered in the differential diagnosis of renal calcifications of unknown origin.

Radical prostatectomy in the management of localized prostate cancer.

No data from prospective randomized studies comparing radical prostatectomy, radiotherapy and deferred treatment for localized prostatic cancer are currently available. Comparison of retrospective series, however, strongly suggests a clear superiority of radical prostatectomy over other attempts to cure prostate cancer, and especially over the 'watchful waiting' strategy. This concerns survival data as well as quality of life and psychological aspects. In 1994, the Department of Veterans Affairs and The National Cancer Institute in the United States initiated a randomized controlled study comparing radical prostatectomy vs expectant management for the treatment of localized prostate cancer, the 'Prostate Cancer Intervention vs Observation Trial (PIVOT)'. Until the results of this study become available, the decision on how to manage a patient with a newly-diagnosed clinically localized prostate cancer has to be based on current knowledge. The current knowledge is that localized prostate cancer can be cured by radical prostatectomy with acceptable treatment-related morbidity. Therefore, the chance of receiving curative treatment should be offered to every man with localized prostate cancer and a life expectancy of 10 or more years.

Prognostic significance of capsular invasion and capsular penetration in patients with clinically localized prostate cancer undergoing radical prostatectomy.

One hundred thirty patients with an observed follow-up of more than 10 years after radical prostatectomy were restaged with regard to local extent of the tumor in relation to the prostate capsule. Of 112 patients with surgically staged negative pelvic lymph nodes, 62 had a tumor-free prostate capsule, 24 had capsular invasion without penetration, and 26 had tumors extending through the capsule of the prostate. Observed overall and disease-free 10-year-survival rates were 79% and 69.4%, respectively, in patients with absence of capsular involvement and 70.8% and 66.7%, respectively, in patients with capsular invasion alone. In patients with capsular penetration, however, the survival rates significantly decreased to 57.7% (P = 0.018) and to 38.5 (P = 0.017), respectively. The overall progression rate was found to be significantly higher in patients with tumors extending through the prostatic capsule (46.2%), as compared to those with absence of capsular involvement (21%; P = 0.014) as well as to those with capsular invasion alone without penetration (25%; P = 0.034). Thus, in contrast to capsular invasion alone, capsular penetration means a poor prognostic indicator, which accounts for a reduced survival expectancy and a higher progression rate following radical prostatectomy. Therefore, tumors with capsular invasion and those with capsular penetration should not be grouped together in the same tumor stage as done in the 1987 edition of the TNM tumor classification system.

Significance of conventional and new prognostic factors for locally confined renal cell carcinoma.

BACKGROUND: The prognosis of patients with locally confined renal cell carcinoma is variable. To improve the prognostic knowledge and select patients at high risk, additional prognostic parameters are needed. METHODS: The significance with respect to survival and tumor recurrence of "classic" and "new" prognostic parameters has been examined by following 41 patients with locally confined renal cell carcinoma after nephrectomy (mean follow-up, 5.2 years). The significance of histologic grade, tumor stage, Ki-67 index, proliferating cell nuclear antigen index, 3H-thymidine labeling index, tumor ploidy status, and tumor growth after xenotransplantation into nude mice (GAX range) was tested using the Kaplan-Meier plots by the log rank test or Tarone's test and also by the Cox multiple hazard regression analysis. RESULTS: Tumor stage (P < 0.0025), histologic grade (P < 0.005), Ki-67 index (P < 0.006), and GAX range (P < 0.00004) were found to be significant prognostic parameters for survival and tumor recurrence using single-factor analysis. Applying the multivariate analysis, the combination of the "new" factors, GAX range and Ki-67 index, resulted in even a higher prognostic relevance than the combination of the "classic" prognostic factors, tumor stage and histologic grade. The calculated prognostic index based on the results of the Cox analysis, which, except for stage and grade, included the Ki-67 index, was shown to be highly correlated with survival (P = 0.00002) and tumor recurrence (P = 0.0004). Its prognostic validity was studied with the receiver operating characteristics procedure and was found to be considerably superior to that of the two conventional prognosticators. CONCLUSIONS: The additional determination of the Ki-67 labeling index increases the prognostic assessment of patients with locally confined renal cell carcinoma.