Prognostic factors in metastatic nonseminomatous germ cell tumours.

OBJECTIVE: To determine predictors of prognostic significance for patients with nonseminomatous testicular cancer (NSTC) who have advanced disease at the time of presentation. DESIGN: A chart review with a mean patient follow-up of 5.5 years (range from 0.75 to 13 years). SETTING: University hospitals in Halifax. PATIENTS: All patients with NSTC, stages II-B, II-C and III. Patients were excluded if the follow-up status at the time the study closed could not be determined. Thirty-three patients were included in the study. Current patient status was determined from the clinical charts and personal communication with the patients or their physicians. INTERVENTIONS: All patients received cisplatinum-based chemotherapy. The extent of the disease was assessed by chest radiography or lung tomography, bone scanning, abdominal computed tomography or lymphangiography. MAIN OUTCOME MEASURES: Correlation between levels of beta-human chorionic gonadotropin (BHCG) and alpha-fetoprotein (AFP), comparison of duration of symptoms before initial treatment, response to treatment and survival, and relationship between stage, tumour volume and survival. RESULTS: The 3-year overall survival rate was 76%. Seven of 18 patients with symptoms for more than 16 weeks died of disease (p < 0.01). Overall complete response was seen in 27 of 33 patients. All initial nonresponders died. A survival rate of 93% was seen among initial complete responders (p < 0.01). All seven patients with persistent elevation of BHCG levels (p < 0.001) and the two patients with persistent elevation of AFP levels (p < 0.01) after the second course of chemotherapy died. CONCLUSIONS: A symptomatic interval of more than 16 weeks, poor response to initial treatment, bulky retroperitoneal disease, larger volume lung disease and persistently elevated levels of BHCG and AFP were all indicators of poor prognosis.

Long-term results of combined interstitial gold seed implantation plus external beam irradiation in localised carcinoma of the prostate.

Carcinoma of the prostate is one of the leading causes of death in men. Patients with localised disease can be treated with radiotherapy, but controversy still exists regarding the most effective therapeutic technique. We report 180 patients with surgical stage A2-C prostate cancer treated between 1976 and 1986 by pelvic lymphadenectomy and radioactive gold seed implantation followed by external irradiation. Annual post-treatment biopsies were performed up to 5 years in most patients. Regular follow-up included a digital rectal examination, prostatic acid phosphatase and bone scan. One hundred and sixty-four patients had complete follow-up data at the end-point of data collection (December 1991). The actuarial 10-year cancer-free survival rates were 83.0% and 91.3% for stages A2 and B1 respectively. The incidence of positive biopsy at 2 and 5 years was 13% and 17.1% respectively for the whole series. A firm correlation was defined between biopsy result and subsequent development of local progression, distant metastases and overall survival. Combined interstitial gold seed implantation plus external beam irradiation represent a valid option for the treatment of patients with localised prostatic cancer.

Analysis of imaging modalities, staging systems, and prognostic indicators for renal cell carcinoma.

A retrospective analysis of 314 patients with renal cell carcinoma was done focusing mainly on imaging modalities and prognostic significance of tumor stage using both the Robson and TNM systems. Computerized tomography (CT) scan proved to be the most effective modality for staging. Overall staging accuracy was 62 and 68 percent for TNM and Robson staging, respectively, and understaging was more frequent than overstaging. The actuarial five-year survival using the Robson system was 73 percent for Stage A, 68 percent Stage B, 51 percent Stage C, and 20 percent Stage D. The main limitation of the Robson system is the heterogeneity of the Stage C group which includes patients with renal vein and those with nodal involvement with a significant difference in survival. The survival by the TNM system showed no difference in those with T1, T2, T3a and T3b disease but a significant difference in those with T3c or T4a. One hundred sixteen patients (37%) presented with metastatic disease with a median survival of seventeen months (range 2-204) for those with solitary metastasis and six months (range 1-132) for those with multiple metastases (the difference was not statistically significant). Except for anecdotal cases, nephrectomy with or without treatment of the metastases did not seem to affect survival significantly. The presence of spindle cell, alone or in association with clear or granular cell, affected the prognosis adversely. Thirty-one patients had their tumors identified incidentally. Their stage at diagnosis was earlier than the symptomatic group (Stage T1-T2: 77% vs 34%), and there was a significant difference in the disease-free survival at fifty-four months between the two groups (79% vs 57%, respectively).

Conservative management of renal lacerations in blunt trauma.

Controversy in the treatment of blunt renal trauma is largely focused on immediate surgery versus conservative management for parenchymal lacerations. A retrospective analysis of 133 cases of blunt renal trauma at the Victoria General Hospital in Halifax over a 10-year period revealed 26 cases of renal laceration. The conservative approach to radiologic diagnosis and treatment options is discussed. Our experience confirms a low rate of both nephrectomy and secondary complications using conservative management.

Conversion from cyclosporine to azathioprine in renal graft recipients.

Only one of six patients in whom a clinical diagnosis of rejection was confirmed by both biopsy and FNA benefited from a switch from cyclosporine to azathioprine. Nine patients, in whom nephrotoxicity and rejection could not be separated and in whom the biopsy was positive but the FNA negative, improved when converted to cyclosporine. This improvement was, however, followed by subsequent rejection episodes in four of these patients. This study suggests caution in changing from CsA therapy in patients with unstable function.

Carcinoma of the penis: an 11-year review.

Management of primary carcinoma of the penis in 37 men by local excision or radiotherapy was associated with a high risk of recurrence. The authors in this review recommend partial penectomy as the minimum surgical procedure for the primary lesion. Clinical assessment of the inguinal lymph nodes was often inaccurate and the value of early sentinel node biopsy is discussed. All patients who underwent ilioinguinal node dissection had complications and only one of six men with histologic stage III disease was cured. The overall 2-year survival rate was 51%.

Pneumonia in renal transplant patients.

Between January 1976 and March 1982, 28 episodes of pneumonia occurred in 26 renal transplant patients. The overall mortality rate was 46%. Of the 16 patients with nosocomial pneumonia 9 (56%) died, whereas of the 12 patients with community-acquired pneumonia 4 (33%) died. In all 9 cases of unknown cause the response to empiric treatment was prompt, whereas in 4 of the 10 cases of monomicrobial pneumonia and 8 of the 9 cases of polymicrobial pneumonia the patient died. Cytomegalovirus was the sole cause of the pneumonia in two patients and a contributing cause, along with aerobic gram-negative bacteria, in another five, four of whom also had a fungal infection. Two patients, both of whom survived, had nosocomial Legionnaires' disease.

Antithymocyte globulin in cadaver renal grafts: prophylaxis and antirejection therapy with three different preparations.

Three different preparations of antithymocyte globulin were used to treat recipients of cadaver kidney transplants. Twenty patients received Connaught Institute/Armand-Frappier ATG prophylactically beginning on the day of grafting and achieved superior graft and patient survival compared to 18 concurrent controls. Pressimmune as a 5-day course was able to reverse steroid resistant rejections in 20 of 31 recipients as was ATGAM in three of six treated patients receiving it for 10 days. These short courses were associated with a 16% early and a 10% late relapse rate. The combination of high steroid therapy, maintenance azathioprine and ATG was associated with an infection rate of 22%.

Acute renal failure secondary to bilateral ureteric obstruction: review of 50 cases.

The records of 50 patients with acute renal failure secondary to bilateral ureteric obstruction were reviewed. An underlying malignant disorder was the cause of the obstruction in 38 of the patients and had not previously been diagnosed in almost half of them. Carcinomas of the cervix and prostate were the most frequent malignant disorders, and aggressive management resulted in good survival rates. Similarly, the outcome for patients with benign bilateral ureteric obstruction, usually caused by retroperitoneal fibrosis, was good with proper management.

Failure to correct the metabolic defect by renal allotransplantion in Fabry's disease.

Plasma neutral glycolipid levels and plasma and leukocyte alpha-galactosidase activities were measured serially before and after renal allotransplantation in two men, aged 47 and 45 years, with renal failure due to Fabry's disease. The patients were followed posttransplantation for 92 and 64 weeks, respectively. No significant elevation of plasma or leukocyte alpha-galactosidase activities above levels in untreated men with Fabry's disease or decrease in the levels of trihexosyl ceramide was observed in either patient. The results do not support the use of renal allotransplantation for enzyme replacement in Fabry's disease.