European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG).

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Management of prostate-specific antigen relapse in prostate cancer: a European Consensus.

A European Consensus on the management of prostate-specific antigen (PSA) relapse in patients with prostate cancer has been formulated. The key recommendations proposed are that total PSA is the best detection tool for prostate cancer, with free and complexed PSA having a role in the PSA range 1-4 ng/ml. PSA relapse after radical prostatectomy (RP) has been defined as a value of 0.2 ng/ml with one subsequent rise, while the ASTRO definition should be used after radiotherapy. A PSA level of less than 0.4 ng/ml after hormonal therapy can be considered an indicator of a positive response. Continuous assessment using nomograms or artificial neural networks will help to determine whether progression after local therapy is distant or local, which is the basis for treatment decisions. Secondary treatment after local failure of RP should be initiated when PSA levels reach 1.0-1.5 ng/ml and salvage radiotherapy can be considered with or without hormonal therapy. Local failure after radiotherapy can be treated with a choice of high-intensity-focused ultrasound, salvage RP (only in highly selected patients), cryotherapy or external beam radiation. Treatment of distant failure involves hormonal manipulation, the type and the timing of which is based on both physician and patient preferences.

Prospective, randomized trial to evaluate high-versus low-dose interferon-alpha 2b versus conventional chemotherapy in prevention of the recurrence of superficial transitional cell carcinoma of the urinary bladder.

Forty-four patients with superficial bladder cancer were randomized to receive 10 MU (14 patients) or 100 MU (14 patients) of interferon (IFN)-alpha 2b or 1.3 g ethoglucid (16 patients) instilled into the bladder once weekly for 10 weeks and then monthly for 1 year. Efficacy (evaluated in 34 patients who completed the course of treatment), based on recurrence rate and time to first recurrence, was similar in the three groups. No systemic toxicity of treatment was seen. Severe chemocystitis occurred in some patients who received ethoglucid (three had to discontinue treatment), while no local toxicity was seen with IFN-alpha 2b treatment.

Treatment decision for stage I non-seminomatous germ cell tumours based on the risk factor "vascular invasion".

Surveillance has become an alternative treatment modality for stage I non-seminomatous germ cell tumours with reported relapse rates of up to 30% in retrospective studies. Results obtained in our retrospective study showed vascular invasion in primary tumours to be the risk factor with the highest negative predictive value. Since January 1985 patients with stage I non-seminomatous germ cell tumours have been stratified by the presence or absence of vascular invasion in the primary tumour: those without vascular invasion (n = 26; group A) were subjected to a rigorous surveillance programme, while those with vascular invasion (n = 22; group B) were given 2 chemotherapy courses of bleomycin, etoposide and platinum in the hope of preventing progression. Relapse rates were 3.8% and 9% in groups A and B, respectively. The pooled relapse rate for both groups A and B (n = 48) was 6.2% (3/48). After a mean follow-up time of 36 months 95.8% (46/48) of the patients were without evidence of disease.

How effective is topical alpha-2b interferon in preventing recurrence of superficial bladder cancer?

A total of 44 patients with low and intermediate grade superficial urothelial bladder cancer Ta and T1 were randomised into a controlled, long-term, phase III trial on topical instillation therapy with high dose alpha-2b interferon (100 x 10(6) IU versus low dose alpha-2b interferon (10 x 10(6) IU) versus ethoglucid. Thirteen patients in the low dose group, 11 in the high dose group and 10 in the ethoglucid group completing the trial were evaluable (median follow-up 36.5 months) and were followed up for 3 years. They were treated weekly for 10 weeks and then monthly for a total of 1 year. The aim of the trial was to establish the prophylactic efficacy and the toxic side effects, if any, of alpha-2b interferon in the topical treatment of superficial bladder cancer. Recurrence rate and disease-free survival were chosen as study end-points. The recurrence rate was 4.4 in the low dose interferon group, 2.76 in the high dose interferon group and 3.08 in the ethoglucid group. In the low dose interferon group the time to the first recurrence was 22.23 months versus 22.36 in the high dose group and 21.76 months in the ethoglucid group. No differences of statistical significance were noted between the 3 groups. Progression occurred in 5 patients on interferon but was not seen in those on ethoglucid. Neither systemic nor local side effects were seen in the interferon groups, but 3 patients had to be taken off ethoglucid because of severe chemocystitis. In superficial bladder cancer, topical instillation therapy with interferon is as effective as conventional chemotherapy and has no side effects.

Surgical approach to the retrocrural lymph nodes.

Removal of retrocrural lymph nodes requires an approach other than the infradiaphragmatic retroperitoneal access generally used in the surgical management of testicular tumours. The transperitoneal route given access, at best, to the origin of the superior mesenteric artery, but advanced testicular tumours occasionally require retrocrural node dissection. We describe a useful surgical approach to these nodes and the underlying anatomy.

Renal vein anatomy and its implications for retroperitoneal surgery.

Because of its complicated embryological development, the anatomy of the renal veins shows extensive variability. A full understanding of the potential anatomical variations is imperative for retroperitoneal operations. Based on 4,520 retroperitoneal computerized tomography scans, anatomical studies of autopsy material of 354 unselected cases and intraoperative observations made during 215 major retroperitoneal procedures, an attempt was made to define the most common renal vein variants and retrace their development during embryogenesis. Awareness of rare anomalies in urological and general surgery is crucial to prevent severe damage to the venous drainage of the left kidney, and because troublesome bleeding may occur during vascular and retroperitoneal oncological procedures in patients with unknown venous anomalies. We found the incidence of these variants to be 0.8 versus 1.7 versus 3.7%, respectively.

Testicular cancer: prognostic implications of vascular invasion.

In a retrospective study the primary tumors of 33 patients with seminomas and 53 with nonseminomatous germ cell tumors were re-evaluated for vascular invasion. The significance of vascular invasion was analyzed in respect to the appearance of visceral metastases and the effect of adjuvant chemotherapy. Vascular invasion was demonstrated in 27 per cent of the patients with seminomas and 53 per cent with nonseminomatous germ cell testis tumors, while visceral metastases appeared in 9 and 32 per cent, respectively. Without adjuvant chemotherapy all 13 patients with nonseminomatous germ cell testis tumors and vascular invasion had metastases, compared to only 3 of 13 without vascular invasion (p less than 0.0005). Of 9 patients with seminoma and vascular invasion 3 had tumor progression, compared to 1 of 24 without vascular invasion (p greater than 0.05). With adjuvant chemotherapy only 1 of 15 patients (7 per cent) with nonseminomatous germ cell testis tumors and vascular invasion had metastases, compared to 100 per cent of 13 without this treatment. No significant correlation was noted between pT stage versus vascular invasion and pT stage versus tumor progression. The results demonstrate the importance of vascular invasion in the staging of and choice of treatment for early nonseminomatous germ cell testis tumors.