Outcome of radical prostatectomy as primary treatment for high-risk prostate cancer patients.

CONTEXT: Recently, there has been considerable interest in the role of radical prostatectomy (RP) in men with high-risk prostate cancer. AIMS: The objective of our study is to report the outcome of upfront RP in our patients with high-risk prostate cancer (Stage ≥ cT2c, a pre-operative serum prostate specific antigen >20 ng/ml or a biopsy Gleason score [GS] 8-10). SUBJECTS AND METHODS: From 1996 to 2010, 208 patients of prostate cancer (high risk category D'Amico's criteria) underwent open RP with bilateral pelvic lymphadenectomy. STATISTICAL ANALYSIS USED: The data was statistically analyzed using Kaplan Meier method and log rank test to calculate progression free, metastasis free survival (MFS) and cancer specific survival (CSS). Furthermore multivariate analysis (MVA) was carried out using SPSS 14 software. (IBM company). RESULTS: At 7 and 10 years, prostate cancer-specific survival (PCSS) was found to be 79.7% and 65%, respectively, biochemical recurrence free survival (BRFS) was 42.4% and 36.7%, respectively and the MFS was 71.1% and 64.4% respectively. High GS was highly predictable of PCSS, BRFS and MFS. Node positivity was the single poor risk factor on MVA whereas biopsy GS, pStage (P = 0.016) and seminal vesicle invasion (P = 0.045) had statistical significance in predicting the MFS. CONCLUSIONS: RP provides accurate pathologic staging of patients with high risk prostate cancer, allows better stratification of patients for further adjuvant therapy and either as an initial approach or part of a multimodal regimen, can provide durable local control and provides excellent CSS.

Staging of transitional cell carcinoma: Has anything changed?

OBJECTIVE: This article is a systematic review of various changes in the evolution of the contemporary clinico-pathological staging of transitional cell carcinoma (TCC). MATERIALS AND METHODS: A thorough search of the literature was done by Medline and other internet references. RESULTS: Accurate staging of TCC is necessary for designing optimal therapy in clinical practice. Further, the current emphasis on bladder conservation and improved long-term disease free survival (DFS) necessitates minimal errors in staging and it's predictability towards recurrence and progression. Traditionally, the staging of TCC revolves around clinical and pathological findings. The staging has evolved through the understanding of various clinico- pathological factors like tumor appearance, number, size, grade, depth of invasion, muscle substratification, lymphovascular invasion and has reached the standard TNM classification. Cystoscopy and transurethral resection still remain the mainstay of staging and noninvasive imaging techniques have further enhanced the accuracy. CONCLUSION: The TNM classification for bladder cancer is currently the gold standard for TCC.

Long-term results of orthotopic neobladder reconstruction after radical cystectomy.

OBJECTIVE: To assess, in a retrospective study, the long-term results of neobladder reconstruction after radical cystectomy, as this is the standard of care for muscle-invasive bladder cancer. PATIENTS AND METHODS: Data were retrieved for all patients with muscle-invasive transitional cell carcinoma of the bladder treated by radical cystectomy and orthotopic neobladder substitution between 1988 and 1998. All perioperative and long-term complications were recorded. The voiding pattern, frequency of micturition and continence were assessed, and a complete urodynamic profile recorded. RESULTS: In all, 102 patients underwent radical cystectomy with orthotopic neobladder reconstruction in the study period; their mean (range) follow-up was 73 (36-144) months. Neobladder substitution was with an ileocaecal segment in 35 patients, sigmoid colon in 34 and ileum in 33. Early complications occurred in 32 patients (31%) although open surgical intervention was required in only nine (9%). The death rate after surgery was 3.9%. Late complications occurred in 31 patients (30%) and were primarily caused by uretero-enteric and vesico-urethral strictures (9% each). Most patients had daytime (89%) and night-time (78%) continence. The mean maximum pouch capacity (mL) and pouch pressure at capacity (cmH2O) were 562.5 and 23 (ileocaecal), 542 and 17.8 (sigmoid) and 504 and 19.1 (ileal), respectively; the mean postvoid residual was 29, 44 and 23 mL, respectively. Nine patients with ileocaecal neobladders, and 20 and seven with sigmoid and ileal neobladders, required clean intermittent catheterization. Twenty-four patients had recurrence of disease, of whom 20 died. CONCLUSIONS: Orthotopic neobladder reconstruction requires complex surgery but has an acceptable early and late complication rate in properly selected patients. It provides satisfactory continence without compromising cure rates.

Metastatic adenocarcinoma in testis presenting as a testicular mass--a case report and review of literature.

Testicular metastasis presenting as a testicular mass is an extremely rare condition. There are only nine previously reported cases where testicular mass was the first clinical manifestation of underlying malignancy. Here we report a case of metastatic mucin secreting adenocarcinoma in testis presenting as a testicular mass with unknown primary. We have given a brief review of literature about the spread of tumor to testes.

Recurrence and progression in stage T1G3 bladder tumour with intravesical bacille Calmette-Guérin (Danish 1331 strain).

OBJECTIVE: To report recurrence and progression rates in patients with T1G3 superficial bladder carcinoma treated with intravesical bacille Calmette-Guérin (BCG, Danish 1331 strain) after complete transurethral resection. PATIENTS AND METHODS: Data from the records of 111 patients with T1G3 bladder carcinoma treated between January 1991 and December 1999 were analysed for recurrence, progression, salvage therapy and survival. RESULTS: Of the 111 patients with T1G3 bladder tumours, 69 had intravesical BCG therapy, 20 radical cystectomy and 22 only transurethral resection (TUR). Of the 69 patients receiving BCG therapy 37 (54%) had no recurrence, and 24 (35%) had a recurrence that was not muscle-invasive (Ta/T1) and were treated with TUR only. The remaining eight (12%) progressed to muscle invasion and had salvage cystectomy. During the follow-up six patients died, four from disease and three from other causes, while the remaining 63 are alive and well. Of the other 42 patients, 15 are alive after radical cystectomy and 18 after TUR. CONCLUSION: This series further confirms the benefits of intravesical BCG (Danish 1331) in an adjuvant setting; furthermore, this treatment facilitates bladder preservation by reducing recurrences and delaying the progression in many patients.

Proliferating cell nuclear antigen and epidermal growth factor receptor (EGFr) status in renal cell carcinoma patients with polysomy of chromosome 7.

We investigated 40 cases of renal cell carcinoma (RCC) to study the polysomy 7 status in papillary and clear-cell types (nonpapillary RCC) and relationship with clinical, pathological, and biological features such as grade, stage, tumor proliferation rate (PCNA expression) and epidermal growth factor receptor (EGFr) expression and thereby to understand the prognostic significance of polysomy 7 and EGFr expression. In a prospective study, chromosome 7 copy number was analyzed in tumor cells by using fluorescence in situ hybridization (FISH) with an alpha-satellite DNA probe for chromosome 7. Both proliferating cell nuclear antigen (PCNA) and EGFr expression were examined in paraffin sections by immunostaining. The relationship between clinicopathological and clinicobiological parameters was evaluated by appropriate statistical methods. Polysomy 7 was present in 100% of papillary and 56.2% of clear-cell types RCC. In clear-cell RCC, in comparison with polysomy 7-dominant (D) category (20-50% polysomy-7 cells), polysomy 7-major (M) category (>50% polysomy 7 cells) was associated with higher tumor grade (P = 0.05). Polysomy 7 was also correlated with stage of the disease (P = 0.006). The PCNA index ranged between 12.8-89.6% and was comparatively high in high-grade tumors (P = 0.001). The PCNA index was also correlated with polysomy 7 (P = 0.002), and the association was stronger in tumors with polysomy M versus polysomy D category (P = 0.02). The EGFr expression did not correlate with either grade, stage, PCNA, or polysomy 7. The correlation of polysomy 7 with less favorable prognostic factors such as higher tumor grade, stage, and higher proliferative index in the present study indicates that polysomy 7 might be used as a prognostic predictor in clear-cell RCC. Evaluation of clinical end points will confirm the prognostic potential of the genetic marker polysomy 7 in our study.

Malignant peritoneal mesothelioma deciduoid or anaplastic variant? Point to ponder.

A case of peritoneal mesothelioma displaying unusual morphology, occurring in a 53 year old woman is described. The role of immunohistochemistry and electron microscopy in the evaluation of this tumor is stressed. The appropriate terminology to be used and possible etiologic factor are also discussed.

Embryonal rhabdomyosarcoma of prostate in an adult--a diagnostic dilemma.

Embryonal rhabdomyosarcoma of the prostate is a rare. Highly malignant tumour. The median age of occurrence is five years, but sporadic cases have been reported in adults' To the best of our knowledge, till date, fewer than ten cases have been reported of which only two are above the age of sixty years. We report a case of embryonal rhabdomyosarcoma of prostate in a patient more than sixty years of age. If one is not aware of this entity, one can make a mistake in the diagnosis as well as treatment.

Malignant peritoneal mesothelioma deciduoid or anaplastic variant? A point to ponder.

A case of peritoneal meosthelioma displaying unusual morphology, occurring in a 53 years old woman is described. The role of immunohistochemistry and electron microscopy in the evaluation of this tumour is stressed. The appropriate terminology to be used and possible etiologic factor are also discussed.

Interstitial brachytherapy in carcinoma of the penis.

AIM: Keeping in line with the increasing emphasis on organ preservation, we at the Tata Memorial Hospital have evaluated the role of Ir-192 interstitial implant as regards local control, functional and cosmetic outcome in early as well as locally recurrent carcinoma of the distal penis. PATIENTS AND METHODS: From October 1988 to December 1996, 23 patients with histopathologically proven cancer of the penis were treated with radical radiation therapy using Ir-192 temporary interstitial implant. Our patients were in the age group of 20 to 60 years. The primary lesions were T1 in 7, T2 in 7 and recurrent in 9 patients. Only 7 patients had palpable groin nodes at presentation, all of which were pathologically negative. The median dose of implant was 50 Gy (range 40 to 60 Gy), using the LDR afterloading system and the Paris system of implant rules for dosimetry. Follow-up ranged from 4 to 117 months (median 24 months). RESULTS: At last follow-up 18 of the 23 patients remained locally controlled with implant alone. Three patients failed only locally, 2 locoregionally and 1 only at the groin. Of the 5 patients who failed locally, 4 were successfully salvaged with partial penectomy and remained controlled when last seen. Local control with implant alone at 8 years was 70% by life table analysis. The patients had excellent functional and cosmetic outcome. We did not record any case of skin or soft-tissue necrosis. Only 2 patients developed meatal stenosis, both of which were treated endoscopically. CONCLUSION: Our results lead us to interpret that interstitial brachytherapy with Ir-192 offers excellent local control rates with preservation of organ and function. Penectomy can be reserved as a means for effective salvage.

Radical cystoprostatectomy: an extraperitoneal retrograde approach.

PURPOSE: We describe a new technical approach for the surgical management of bladder cancer. MATERIALS AND METHODS: Patients with invasive bladder cancer underwent radical cystoprostatectomy using a technically different approach than the conventional method. The important features of this modification include a small infraumbilical incision, completely extraperitoneal dissection to maintain the bowel loops away from the operating field, urethral dissection performed earlier in the operation rather than at the end to preserve the striated urethral sphincter with the neurovascular bundles, completely retrograde dissection of the rectovesical plane for increased safety and reperitonealization done at completion to isolate the urinary anastomoses from the bowel anastomosis. RESULTS: More than 50 consecutive patients with early bladder cancer underwent this operation during a 2-year period. The technique was safe and satisfactory. CONCLUSIONS: Radical retrograde extraperitoneal cystoprostatectomy is based on a finer knowledge of anatomy. It requires accurate dissection, making it inherently superior to the conventional method.

Primary carcinoma of fallopian tube--a case study.

Primary carcinoma of fallopian tube is a rare entity. We report an interesting case of primary carcinoma of fallopian tube with contralateral lymph node involvement. The clinicopathological findings and its management is presented.

Improved management of abdominal undescended testicular tumors with bulky confluent retroperitoneal nodal metastases.

PURPOSE: Germ cell tumors of the abdominal undescended testis associated with confluent bulky retroperitoneal metastases are challenging problems. We report the results of neoadjuvant cisplatin based chemotherapy after diagnosis of germ cell tumors by fine needle aspiration cytology of the abdominal testicular mass. After chemotherapy all patients underwent abdominal orchiectomy with retroperitoneal lymph node dissection for residual nonseminomatous germ cell tumors or radiotherapy for pure seminomas. MATERIALS AND METHODS: Between 1980 and 1991, 57 of 425 patients (13.4%) with germ cell tumors of the testicle had malignancy in an undescended testis, while 39 (68.4%) had tumor in an abdominal testis with confluent bulky metastasis. Metastatic evaluation included tumor marker studies, chest x-ray and computerized tomography of the abdomen. Among the tumors 29 (74.4%) were large volume seminomas (stages IIc, III and IV) and 10 (25.6%) were large volume nonseminomas. All 39 patients received 3 cycles of induction chemotherapy, and orchiectomy was deferred until its completion (14 received vinblastine, actinomycin D and bleomycin-6, and 25 received bleomycin, etoposide and cisplatin). After evaluation of response, the testis was excised. Overall followup was 2 to 12 years (median 4.6). RESULTS: Of 29 seminomas 14 (48.3%) showed a complete and 11 (37.9%) showed a partial response. The latter tumors were treated subsequently with radiotherapy. Four patients with progressive disease died, for an actuarial survival rate of 86%. Of the 10 patients with nonseminomatous germ cell tumor 2 (20%) had a complete response and 4 had a partial response. All patients with a partial response underwent retroperitoneal lymph node dissection. Overall, 4 patients with progression and 2 with a partial response died, for an actuarial survival rate of 39%. Of 39 post-chemotherapy orchiectomy specimens 24 (61.5%) showed viable tumor cells. Furthermore, 16 of 39 patients (41%) had additional ilioinguinal metastases requiring adjuvant radiotherapy or surgery. CONCLUSIONS: Surgical removal of the primary tumor in an undescended testis with bulky metastasis is difficult. We believe that initial chemotherapy followed by 1-stage surgical removal of the primary and residual metastasis is a favorable option to improve compliance and decrease the incidence of loss to followup. Atypically altered ilioinguinal metastases may necessitate a change in radiotherapy ports and/or retroperitoneal lymph node dissection boundaries. The significantly poorer survival with nonseminomatous germ cell tumor could be due to the fact that 50% of the lesions were stage IV at presentation. However, multivariate analysis showed only tumor histology to be the significant parameter and not initial stage at presentation.

Partial cystectomy for invasive bladder cancer.

Thirty two patients--23 males and 9 females with a mean age of 52.5 years--underwent planned partial cystectomy for histologically proved muscle invasive bladder cancer. Twenty patients had transitional cell carcinoma and 12 had adenocarcinoma of the bladder. One patient had well-differentiated, 18 had moderately differentiated, and 13 had poorly differentiated tumours. The tumour size was < 2 cm in 7 patients, 2-4 cm in 19 patients, and > 4 cm in 6 patients. Patients with single primary muscle invasive tumours situated in the upper half of the bladder were considered eligible for partial cystectomy. The presence of multicentric urothelial disease, of dysplasia, or carcinoma-in-situ in bladder mucosa away from the tumour on multiple random punch biopsies was considered contraindications to partial cystectomy. All patients underwent partial cystectomy with bilateral pelvic lymphadenectomy. The tumour-free margins of resection were confirmed by intraoperative frozen section examination. The bladder was closed primarily in all patients, although three patients required re-implantation of the ureter. No patient received adjuvant radiation or chemotherapy. Five patients had pathological stage B1 (T2), 18 had B2 (T3A), and 9 had C (T3B) disease. No patient had metastatic pelvic lymph nodes. There was one postoperative death due to unrelated medical cause. Five patients had minor complications that resolved with conservative measures. All patients had adequate bladder capacity of > 250 cc at 6 months after surgery, and none had symptoms attributable to reduced bladder capacity. The overall actuarial survival was 80.1% at 5 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Superficial bladder cancer. A 10 year experience.

A total of 236 patients - 198 males and 38 females with superficial bladder cancer (stage A(TaT1)) were treated with transurethral resection of the tumours. Intravesical chemotherapy (84 patients) or immunotherapy (27 patients) was added in those patients considered to be at high risk of developing local recurrences or stage progression. The five and ten years survival in the single tumour group (117 patients) were 86 percent and 72.9 percent as compared to 72.5 percent and 70.7 percent respectively in the multiple tumour group (119 patients). The five and ten year survival rates for grade I tumours were 88.3 percent and 86 percent respectively, for grade II tumours 80.8 percent and 64 percent and for grade III tumours 56.9 percent and 46 percent respectively. The impact of tumour grade on survival was found to be independent of the number of tumours. The response rates to intravesical thiotepa was 54.9 percent mitomycin 60 percent and with BCG 71.5 percent. All the three reduced the local recurrence rates and increase the mean interval to recurrence but the stage progression rate was significantly lowered only with intravesical BCG. In our study, we have used the Danish strain of BCG available to us and have found it to yield response rates comparable to other centres using Tice or Pasteur strains.

Renal cell carcinoma extending to the renal vein and inferior vena cava: results of surgical treatment and prognostic factors.

Forty-seven patients with renal cell carcinoma with tumor thrombus extension to the renal vein or inferior vena cava (IVC) were treated surgically over a 10-year period. There were 41 males and 6 females with a mean age of 45.7 years. Thirty-three patients had right-sided and 14 had left-sided tumors. Patients with renal vein or infrahepatic IVC thrombus were treated with radical nephrectomy with tumor thrombus excision after achieving conventional vascular control over the IVC and the opposite renal vein. Four patients with retrohepatic IVC thrombus were treated with venacavotomy and thrombectomy after achieving vascular control above the thrombus but below the hepatic veins while two other patients with retrohepatic and one with suprahepatic thrombus required a bifemoroatrial partial venous bypass prior to tumor thrombectomy. There was one postoperative death due to pulmonary embolism. The actuarial 5-year survival for all patients with venous extension was 50% and the median survival was 4.35 years. Perinephric spread and lymph node metastases were significant prognostic factors affecting survival. This suggests that it is the locoregional spread of renal cell carcinoma rather than the level of the thrombus which governs the prognosis of patients with tumor thrombus extension to the renal vein or IVC.