[Recent Therapy of Organ-confined Testis Cancer]. / Aktuelle Therapie organbegrenzter Hodentumoren.

BACKGROUND: In Germany, testicular cancer accounts for about 1-2% of all malignant tumours. Although, therefore, this is a rare tumour, it assumes an exceptional position among malignant tumours in several respects. In male patients aged 20-35 years it is the most common tumour, which directly affects the family and life planning of young men, a matter of prime importance at this age. Another aspect of testicular cancer is its excellent prognosis since the introduction of platinum-based chemotherapy into the armamentarium of testicular cancer therapy. Therefore, therapeutic innovations increasingly focus on reducing the radicality of treatment, even more so since this therapy, in addition to acute toxicity, can cause severe long-term consequences up to and including secondary malignancies. OBJECTIVES: This article gives an overview of the present therapeutic standard of stage I testicular cancer treatment. MATERIAL AND METHODS: Selective PubMed research Results and Discussion: Besides potential implications for organ-sparing surgery, the article elucidates the benefits of a risk-adapted therapeutic approach and indications for a surveillance strategy for patients with localised testicular cancer.

[Secondary prevention in patients with superficial urothelial carcinoma]. / Sekundäre Prävention bei Patienten mit oberflächlichem Urothelkarzinom.

BACKGROUND: Urothelial cancer is the 4th most common cancer in men and the 7th most common malignancy in women in Germany. 95 % of all tumors of the urinary bladder are urothelial carcinomas. At the time of diagnosis approximately 80 % of these carcinomas are not invasive. The affection is often multicentric. Approximately 10-15 % of the tumors develop into muscle-invasive growth. In this prospective study, we analyzed measures patients independently took to reduce their risk of bladder cancer recurrence. MATERIALS AND METHODS: During the period January 2012 to December 2013, we surveyed a total of 97 patients with superficial transitional cell carcinoma (pTa). The question was how far the diagnosis of urothelial cancer has changed their lives, eating and drinking habits or whether follow-up consultations had been carried out regularly. Furthermore, we recorded whether they accepted psychological care or had autonomously adopted prophylactic measures, as well as changed their smoking habits, if they had smoked. RESULTS: Of the 97 patients questioned, there were 79 men and 18 women (56 smokers and 41 nonsmokers). The median age was 71 years (range 36-96 years). For 22 patients (22.7 %), the diagnosis resulted in no changes. In 33 patients the changes were small (44 %), moderate in 20 (26.7 %), in 14 (18.6 %) strong and very strong in 8 (10.7 %). A total of 25 patients (25.8 %) changed their eating habits. In all, 49 patients changed their drinking habits; 48 patients claimed to drink more (> 2.0 L/day). One patient reduced his drinking amount. Regarding smoking, 40 patients (71.4 %) had stopped and 7 (12.5 %) reduced consumption, while 6 patients (10.7 %) had not changed their smoking habits. Overall, 44 patients (45.4 %) changed their physical activity: 11 (25 %) exercised more, 8 (18.1 %) less. Only 3 patients (3.1 %) used psycho-oncological care and 39 (40.2 %) patients used supportive/complementary medicine measures of favorablly influence their disease (mistletoe therapy, vitamin supplements). In addition, 22 patients (22.7 %) sought advice from their physician. However, 45.4 % of all patients did not believe in the success of their measures taken. CONCLUSION: Of all patients diagnosed with urothelial carcinoma, 77.3 % reported a change in their living habits and they were willing to take specific steps, such as giving up smoking, being more physically active, changing drinking and eating habits in order to positively influence their disease. However, almost half of the patients (45.4 %) did not believe in a resounding success of their measures taken.

Management of muscle-invasive bladder cancer.

The incidence of muscle-invasive bladder cancer (MIBC) is increasing. Many different and multimodal novel treatment options were brought on the way since the beginning of a new era in the early 1980s, when the neobladder as a common option for urinary diversion had been induced. In addition to open radical cystectomy and urinary diversion, recently, minimal invasive surgery has been implemented in experienced centers and led to promising results in short term follow-up, awaiting confirmation in larger cohorts. Pelvic lymphnode dissection can cure patients with low metastatic load. Expansion of pelvic lymphonodal dissection and its influence on survival was discussed intensively with trends to a moderate enlargement of the standard field. Outcome in nodal positive disease is remaining poor, while 90% of patients with multiple lymphnode metastases will suffer from systemic progress 5 years after diagnosis. In the last decade, treatment regimens based on neoajuvant or adjuvant chemotherapy were published with different results on efficiency. To decide whether to treat with surgery alone, or to offer perioperative systemic cytostatic therapy, is one of the unanswered questions. Furthermore, bladder preserving techniques are still optional for patients with small unifocal lesions or the medically unfit cohort. This review summarizes current data and aims to help guiding through several available recommendations on therapy and management of MIBC.

[The use of Surgisis® optimizes and simplifies partial nephrectomy for large renal tumors]. / Anwendung von Surgisis® zur Optimierung und Vereinfachung der Nierenteilresektion bei größeren renalen Neoplasmen.

BACKGROUND: With lower rates of postoperative renal failure, diabetes and cardiovascular disease, partial nephrectomy achieves longer overall survival and equally long tumor-specific survival. It is thus the current gold standard treatment for renal tumors and now also for those ≥ 4 cm in size. The main complications of nephron-sparing surgery, particularly for large and centrally located tumors, are postoperative parenchymal bleeding and urinary fistulas after opening the urinary collecting system (UCS). MATERIAL AND METHODS: Between August 2003 and April 2012, 76 partial nephrectomies for tumors ≥ 4 cm in size were performed using porcine small intestinal submucosa (SIS, Surgisis®) to close the capsular, renal and in some cases, UCS defects. RESULTS: The median tumor size was 5.0 cm (range 4.0-13.0 cm) and the intervention was performed with warm ischemia in 25 cases (32.8 %), with cold perfusion in 16 cases (21.2 %) and without ischemia in 35 cases (46.0 %). A total of 4 patients (5.5 %) developed postoperative urinary fistulas and 4 (5.5 %) required revision surgery because of significant postoperative bleeding. There were no local infections or allergic reactions to the foreign material. CONCLUSIONS: Surgisis® enables a quick and technically uncomplicated closure of the renal defect after partial nephrectomy for tumors. It has the potential to further minimize postoperative bleeding and urinary fistulas and to facilitate the intervention to the extent that nephron-sparing surgery will gain broader acceptance even in patients with tumors ≥4 cm in size.

[Palliative care and medicamentous therapy during the final episode of life]. / Palliativmedizin und medikamentöse Therapie in der Sterbephase.

The idea of modern palliative care goes back to the times of Dame Cicely Mary Strode Saunders in 1967, a British nurse and physician. Modern palliative care is a multimodal therapeutic and supportive concept for the patient, when curative care has failed or seems to be not reasonable. In this article we review the basics of current palliative care and focus in particular on specific medicamentous therapy during the final episode of life.

[Radical cystectomy and ileal neobladder reconstruction in elderly female patients over 70 years old: morbidity, functional and oncological long-term results]. / Zystektomie mit Anlage einer Ileumneoblase bei der über 70-jährigen Frau : Morbidität, funktionelle und onkologische Ergebnisse.

BACKGROUND: As life expectancy is increasing the incidence and therefore the number of elderly female patients with bladder cancer is also increasing. The aim of this study was to assess long-term clinical, functional and oncological outcome in elderly women (≥70 years) who were treated by radical cystectomy and ileal neobladder reconstruction for invasive bladder cancer. MATERIAL AND METHODS: A total of 121 women with clinically organ-confined invasive urothelial carcinoma underwent radical cystecomy with an orthotopic ileal neobladder in Ulm between 1995 and 2010. The clinical course, functional, pathological, and oncological outcome of these women were analyzed retrospectively and compared between patients ≥70 (n=24) and <70 years of age (n=97). All complications which occurred during the first 90 days after surgery were analyzed in detail, defined and classified according to the modified Clavien system. RESULTS: The overall 90 day complication rates were 66.7 % and 62.5 % for patients ≥70 and <70 years, respectively. Of these 54.2% and 44.8% were minor complications and 12.5 % and 17.7 % were major complications, respectively. Infections were the most frequent cause of complications with 36.7 %. Univariate analyses revealed that neither age nor comorbidity (ASA score) were significant predictors of perioperative complications. The daytime continence rates were comparable in both age groups (71% versus 82%, p=0.64); however, younger patients showed significantly higher night time urinary continence rates (43% versus 89%, p=0.013). Neither univariable nor multivariable analyses indicated that age ≥70 years had a significant impact on tumor-specific survival. CONCLUSIONS: Chronological age per se does not seem to be a contraindication for the creation of an orthotopic ileal neobladder; however, the risk of postoperative incontinence seems to increase with age.

[Diagnostic relevance of choline-PET / CT in patients with prostate cancer]. / Diagnostische Wertigkeit der Cholin-PET / CT bei Patienten mit Prostatakarzinom.

The choline-positron emissiontomography / computed tomography (choline-PET / CT) is a widely used imaging method for prostate cancer. This review concentrates on the relevance of choline-PET / CT for primary diagnosis, staging and re-staging of prostate cancer and highlights possible -applications in clinical practice. Therefore, we performed a systematic literature research via Pubmed and Medline database for original articles, reviews and editorials on choline-PET / CT and prostate cancer. Choline-PET / CT should not be routinely used for primary diagnosis of prostate cancer due to a lack of data. With regard to the definition of the local tumour extent (T-stag-ing) choline-PET / CT plays only a minor role, in contrast, for the evaluation of lymph node involvement it has a high positive predictive value and is equal to conventional scintigraphy in detecting bone metastases. Moreover, in cases of biochemical relapse following local therapy, choline-PET / CT seems to be appropriate for differentiating between local recurrence and systemic prostate cancer metastasis, particularly when patients are selected by defined criteria (PSA value > 1.0  ng / mL and / or PSAdt < 6  months and / or Gleason score > 7 and / or primary radiotherapy). The non-critical routine use of choline-PET / CT for patients with prostate cancer cannot be recommended, and this not only because of its high costs. It should be applied to definite clinical questions after thorough selection of appropriate patients.

[Renal masses in pregnancy. Diagnostics and therapeutic management]. / Nierentumore in der Schwangerschaft. Diagnostik und therapeutisches Management.

Cancer is the second most common cause of death in women of childbearing age. However, renal cell carcinoma (RCC) is a rare tumor in this collective with an incidence far below 5/100,000 cases per year. Therefore, medical experience with respect to diagnostics and therapeutic management of newly diagnosed RCC in pregnant women is scarce and the number of published cases low. However, recent studies indicated that higher estrogen levels and multigravidity could be associated with a higher risk of RCC. The aim of this article is to summarize the clinical experience in treating pregnant women with renal cancer against the background of those cases published in the literature.

[Overweight is an advantageous prognostic marker in patients with clear cell kidney cancer]. / Übergewicht ist ein günstiger Prognosefaktor für Patienten mit Nierenzellkarzinom.

OBJECTIVES: Obesity increases the risk of developing renal cell carcinoma (RCC). We assessed whether different body mass index (BMI) levels and the body surface area (BSA) at the time of surgery had an effect on aggressiveness and long-term prognosis of RCC. METHODS: The study included 1,595 RCC patients with complete information about their BMI who had undergone surgery for renal cell cancer at the University Hospitals in Hannover (MHH) and Marburg between 1990 and 2005. The mean follow-up was 5.0 years. RESULTS: A higher BMI and a higher than average BSA were significantly associated with younger age. A high BMI value was additionally related to a lower tumor grade, the clear cell histological subtype, and metastasis at the time of diagnosis. Overweight patients had a significantly lower risk of cancer-related death; their median 5-year tumor-specific survival rate was 76.9% (BMI>30) and 72.6% (BMI 25-30) as opposed to 63.5% for patients with a BMI below 25 (p<0.001). However, the positive correlation between a high BMI and tumor-specific survival could be confirmed in multivariable analyses for localized clear cell RCC only. CONCLUSION: We identified BMI as an independent prognostic marker of improved cancer-specific survival in patients with RCC, particularly with organ-confined clear cell cancer.

[Benefits and risks of orthotopic neobladder reconstruction in female patients]. / Nutzen und Risiko des orthotopen Harnblasenersatzes bei Frauen.

Orthotopic neobladder reconstruction is an established treatment option in female patients undergoing radical cystectomy for invasive bladder cancer. Long-term results have proven its oncological safety and functional efficacy in both organ-confined and locally advanced disease. The use of nerve-sparing procedures has the potential to further improve the functional results in terms of postoperative continence and sexual function as long as we adhere to basic oncological principles. One important contraindication for performing neobladder reconstruction in female patients with bladder cancer is a positive urethral margin at radical cystectomy. In this respect, frozen section analysis is associated with a high sensitivity and specificity for the detection of positive urethral margins. The risk of urethral recurrence at 5 years in patients with negative urethral margins at cystectomy is ≤ 1 % and may become clinically apparent as inguinal lymphadenopathy due to changes of the lymphatic drainge after neobladder reconstruction. The 5-year recurrence-free survival after neobladder reconstruction in female patients with organ-confined bladder cancer ranges between 63 and 75 %. In female patients with locally advanced node-negative disease (≥ pT3a-4a, pN0) who underwent an orthotopic neobladder the recurrence free survival at 5 years is 71 % and so does not significantly differ from that of female patients with node-positive disease treated with an cutaneous diversion. Whether robotic cystectomy has the potential to further improve the functional outcome after neobladder reconstruction in female patients and achieve oncological long-term results comparable to those of open series is still under investigation should further be evaluated in prospective trials.

[Assessment of residual tumours after systemic treatment of metastatic seminoma: ¹8F-2-fluoro-2-deoxy-D-glucose positron emission tomography - meta-analysis of diagnostic value]. / Beurteilung von Residualtumoren nach Systemtherapie des metastasierten Seminoms : (18)F-2-Fluor-2-Deoxy-D-Glucose-Positronenemissionstomographie - Metaanalyse zur diagnostischen Wertigkeit.

BACKGROUND: Meta-analysis evaluating the accuracy and sensitivity of FDG (2-[(18)F]-fluoro-2-deoxy-D-glucose) positron emission tomography (PET) to predict viable residual tumours in patients with metastatic seminoma. MATERIAL AND METHODS: Altogether 5 studies with 130 patients were identified. Both FDG PET and the size of the residual lesions on conventional computed tomography (CT; lesions either ≤ or > 3 cm) were correlated with the presence or absence of viable residual tumour. RESULTS: The specificity (92 vs 59%), sensitivity (72 vs 63%), positive (70 vs 28%) and negative (93 vs 86%) predictive value of FDG PET were superior to data obtained by assessing residual tumour size (either ≤ or > 3 cm) applying CT scans alone. CONCLUSION: In view of the data currently available, FDG PET seems to be a clinically useful predictor of viable tumour in post-chemotherapy residuals of pure seminoma.

[Postoperative and adjuvant intravesical therapy of superficial bladder tumours. Clinical practice and applied therapeutic agents]. / Intravesikale Instillationstherapie beim oberflächlichen Harnblasenkarzinom, Leitlinien und Wirklichkeit: Versorgungsstudie.

BACKGROUND: The aim of this questionnaire was to obtain an impression of the practice and applied therapeutic agents in postoperative and adjuvant intravesical therapy of superficial bladder tumours. PATIENTS AND METHODS: Standardised questionnaires answered by urologists about instillation therapy in 351 patients were analysed. RESULTS: Results showed a discrepancy between the clinical practice and the guidelines in respect of the postoperative instillations and the use of BCG immunotherapy, respectively. CONCLUSION: It does not seem to be standard practice to treat every patient with one immediate post-operative instillation. Only a minority of high-risk patients received intravesical BCG instillations. Substances mainly used for instillation therapy were mitomycin C and doxorubicin.

[New biomarkers and application of multivariate models for detection of prostate cancer]. / Neue Biomarker und Anwendung multivariater Modelle zur Detektion des Prostatakarzinoms.

The specificity of PSA has been enhanced by using molecular forms of PSA and free PSA (fPSA) such as percent free PSA (%fPSA), proPSA, intact PSA or BPHA and / or new serum markers. Most of these promising new serum markers like EPCA2 or ANXA3 still lack confirmation of the outstanding initial results or show only marginally enhanced specificity at high sensitivity levels. PCA3, TMPRSS2-ERG, and other analytes in urine collected after digital rectal examination with application of mild digital pressure have the potential to preferentially detect aggressive PCa and to decrease the number of unnecessary repeat biopsies. The combination of these new urinary markers with new and established serum markers seems to be most promising to further increase specificity of tPSA. Multivariate models, e. g., artificial neural networks (ANN) or logistic regression (LR) based nomograms have recently been performed by incorporating these new markers in several studies. There is generally an advantage to include the new markers and clinical data as additional parameters to PSA and %fPSA within ANN and LR models. Results of these studies and also unexpected pitfalls are discussed in this review.