Quality of life after treatment for localized prostate cancer: differences based on treatment modality.

PURPOSE: Brachytherapy with 103palladium (103Pd) is an increasingly administered treatment modality for localized prostate cancer. We compared general and disease specific health related quality of life after 103Pd treatment, radical prostatectomy and external beam radiation therapy given during the same time frame. MATERIALS AND METHODS: We performed a retrospective cross-sectional survey study of patients treated at a single community medical center between 1995 and 1999. We mailed 5 validated health related quality of life survey instruments to 269, 142 and 222 men who underwent radical prostatectomy, 103Pd treatment and external beam radiation therapy, respectively, with a response rate of greater than 80% in all groups. RESULTS: General health related quality of life assessed by the SF-36 showed the same scores in patients who underwent prostatectomy and 103Pd treatment. The University of California-Los Angeles Prostate Cancer Index was used to assess bowel, urinary and sexual function/bothersomeness. External beam radiation therapy reported was associated with worse bowel function and greater bowel bothersomeness. Prostatectomy was associated with worse urinary function compared to 103Pd and external beam radiation therapy. Prostatectomy was associated with worse sexual function than 103Pd or external beam radiation therapy, although nerve sparing surgery and erectile aids minimized the difference. American Urological Association symptom scores were initially higher for 103Pd but became equal to those in the other groups in patients treated greater than 12 months from survey time. Disease-free men who underwent prostatectomy and 103Pd brachytherapy were equally confident that cancer would not recur in the future. Satisfaction rates were equivalent and biochemical failure significantly decreased satisfaction in all groups. CONCLUSIONS: While general health related quality of life was mostly unaffected by the 3 most common treatments for prostate cancer, there were differences in bowel, urinary and sexual function. This information may aid patients in the decision making process.

Empowering the patient: hypnosis in the management of cancer, surgical disease and chronic pain.

In the past decade, the increasing acceptance of hypnosis as a therapeutic adjunct by physicians and health care professionals both within and outside of the mental health community has resulted in broader use of the technique with patients in both hospital and outpatient settings. In our recent experiences with urologic patients, our staff has found that many bring a surprisingly sophisticated knowledge of clinical hypnosis to the office and often have had experience with some form of therapeutic hypnosis prior to consulting us. Consequently, we find we often encounter a surprising openness to the use of hypnosis as a part of the treatment programs we employ. As a result we have been able to utilize clinical hypnosis successfully in several treatment areas to the benefit of our patients. This paper will describe several programs in place at our practice which utilize clinical hypnosis as an adjunct to treatment.

Serum levels of endothelial and neural cell adhesion molecules in prostate cancer.

BACKGROUND: Tumorigenesis and progression to metastatic disease are accompanied by changes in the expression of cell adhesion molecules (CAMs). Normally expressed CAMs, such as E-cadherin, are lost, while others, i.e., ICAM-1, VCAM-1, NCAM, and E-selectin, are altered and overexpressed in progressive disease and metastases. Abnormal levels of these latter CAMs have been observed in melanoma and carcinomas of the colon and breast, and NCAM is overexpressed in small-cell lung carcinoma (SCLC). The objective of this study was to determine if serum levels of ICAM-1, VCAM-1, NCAM, and E-selectin could differentiate patients with benign prostate hypertrophy (BPH) from those with prostate carcinoma (CaP) and identify prostate cancers with high potential for progression to metastatic disease. METHODS: Serum levels of these CAMs were determined by ELISA in serum from normal males and females and from patients with BPH and CaP before and after treatment. Sera from patients with breast carcinoma, colon carcinoma, melanoma, and small-cell lung carcinoma were also evaluated, as soluble CAMs have been reported to be elevated in these cancer patients. RESULTS: ICAM-1 levels were elevated in sera from patients with breast carcinoma (P = 0.0004) and melanoma (P = 0.0001). VCAM-1 levels were elevated in sera from patients with colon carcinoma (P = 0.0001). NCAM levels were elevated in the sera of patients with SCLC (P = 0.0001). Normal levels of ICAM-1, E-selectin, and NCAM were found in both BPH and pretreatment CaP patients. Median NCAM levels in hormone-refractive CaP patients were significantly greater than in BPH (P = 0.0005) and CaP patients with pathologically determined organ-confined (P = 0.0014) or nonorgan-confined disease (P = 0.0385). VCAM-1 levels were significantly elevated in both BPH patients (P = 0.0002) and CaP patients (P = 0.0002) when compared with levels for normal age-matched donors. None of the CAMs were found to offer an advantage over prostatic-specific antigen (PSA) for monitoring CaP patients following definitive radiotherapy, radical prostatectomy, or hormonal therapy. CONCLUSIONS: The results of this study indicate that serum ICAM-1, VCAM-1, NCAM, and E-selectin are not clinically useful biomarkers for differentiating CaP from BPH, for predicting progression, for identifying metastatic potential, or for monitoring treatment.

Are monotherapy options reasonable for T3 prostate cancer?

In 1997, we believe that either surgery, radiation, or hormonal monotherapy are unlikely to be adequate therapy alone for clinical stage T3 prostate cancer and that primary treatment strategies should use combination therapy. Combination therapies have been investigated in an effort to lessen the impact of monotherapy failure, and combination therapy trials have been shown to diminish the incidence of local failure and increase the time to progression. To gauge the role that irradiation or surgical monotherapy may play in clinical stage T3 disease, this article analyzes series that report local and distant disease control.

Preoperative and postoperative adjuvant chemotherapy using CISCA (cyclophosphamide, doxorubicin, and cisplatin) in the treatment of invasive transitional-cell carcinoma of the bladder.

Fifteen patients with invasive (T2-T4) transitional-cell carcinoma of the bladder were scheduled for three courses of CISCA followed by radical cystectomy and two additional courses of CISCA. Seven patients completed the entire protocol, and 13 completed all the preoperative courses. Seven of 13 patients demonstrated downstaging of their cancers. Of these patients, one has died, one is alive with disease, and five are free of disease at 7 to 38 (mean 17) months. Of the six patients without downstaging, one survives free of disease at 42 months and one is alive with disease 12 months after cystectomy. Downstaging appears to be an important prognostic indicator. Additional studies are being conducted to determine if neoadjuvant chemotherapy improves long-term survival.

Neoadjuvant treatment of stages T2 to T4 bladder cancer with cis-platinum, cyclophosphamide and doxorubicin.

In an ongoing phase II study 17 patients with potentially operable transitional cell carcinoma of the bladder (stages T2 to T4, Nx, Mo) have been treated with intravenous cis-platinum (50 mg.per m.2), cyclophosphamide (400 mg.per m.2) and doxorubicin (40 mg.per m.2). They were to receive 3 treatments at 3-week intervals before cystectomy and 2 treatments at 3-week intervals commencing 5 weeks after cystectomy. Of 17 patients 14 (82 per cent) completed all 3 preoperative treatments but only 7 (41 per cent) continued on to complete the entire 5 treatments. In most cases incomplete therapy was due to patient refusal. Toxicity was low as measured by World Health Organization standards. Of the 17 patients 9 (53 per cent) exhibited objective tumor response (pathological downstaging or greater than 50 per cent reduction of tumor volume determined by either computerized tomography scan and/or endoscopic examination. When the determination was made by endoscopy the changes were dramatic and not borderline.) No patient demonstrated a pathological complete response. All 9 of the responders (100 per cent) remain clinically free of disease at a median follow-up of 19 months (range 4 to 30 months). The 8 nonresponders have done poorly with 5 dead of disease, 1 alive with pelvic recurrence and 2 free of disease at 4 and 12 months. These tumor response rates compare favorably with other cis-platinum-based combination regimens. The response to the chemotherapy appears to be an important prognostic indicator. Phase III trials must be conducted to determine whether this neoadjuvant chemotherapy regimen has a significant effect on long-term patient survival.

State-of-the-art management of renal stone disease in aviators and military special duty personnel.

New developments in the management and evaluation of military aviators, divers, submariners, or other special duty personnel with renal stone disease have simplified surgical management of this difficult problem and markedly reduced recuperation time. Aggressive treatment with newly developed modalities such as ureteroscopy and extracorporeal shock-wave lithotripsy, and careful metabolic evaluation and medical management will often allow the return to full duty of these valuable individuals and allow many who would previously have been permanently disqualified to continue in special duty status.

Myoelectric activity of the small intestine during morphine dependence and withdrawal in rats.

We investigated the effect of morphine dependence on the migrating myoelectric complex (MMC) of the small intestine, whether bacterial overgrowth developed in morphine-dependent rats, and the effect of naloxone, 0.5 mg/kg sc, and methylbromide naltrexone, 1.0 mg/kg sc, a peripheral opioid antagonist, on the MMC in morphine-naive and morphine-dependent rats. We also evaluated intestinal motility during naloxone-induced withdrawal in animals pretreated with clonidine, 100 micrograms/kg sc. Intestinal myoelectric activity was monitored by four indwelling electrodes in unanesthetized, fasted rats. D-[14C]xylose breath tests were performed before and after morphine-pellet implantation to evaluate the presence of bacterial overgrowth of the small intestine. Naloxone had no effect on myoelectric activity of the small intestine in morphine-naive rats. Cycling activity fronts were present in morphine-dependent animals, but there was a significant prolongation of activity front periodicity and slowing of the propagation velocity. No significant increase in 14CO2 excretion was noted in the morphine-dependent rats. After injection of naloxone, the morphine-dependent rats had a marked increase in spike activity with no identifiable activity fronts for 89 +/- 8 min. Similarly, methylbromide naltrexone disrupted activity fronts, but for a significantly shorter period. Clonidine prevented the marked increase in spike activity that occurred during naloxone-induced withdrawal. We conclude from our studies that myoelectric activity of the small intestine develops incomplete tolerance to morphine; bacterial overgrowth is not a feature of morphine dependence in the rat; alterations of intestinal myoelectric activity are a component of the opiate withdrawal syndrome, and they appear at least partially mediated by a peripheral mechanism that can be suppressed by an alpha 2-adrenergic agonist.

Major rectal complications following interstitial implantation of 125iodine for carcinoma of the prostate.

From April 1975 through April 1983, 152 patients were treated for localized adenocarcinoma of the prostate with interstitial implantation of 125iodine seeds. In each case bilateral pelvic lymph node dissection was performed at implantation. Five rectal complications developed: 2 rectal ulcers and 3 prostatic urethrorectal fistulas. Our method to treat these problems is presented together with our technique of reconstruction in patients with persistent fistulas despite fecal diversion. While urethrorectal fistulas represent potentially devastating complications of the 125iodine implantation procedure, reconstructive techniques can minimize and have reduced their long-term effects.

Ogilvie's syndrome developing after ethanol ablation of renal cell carcinoma.

Urological procedures frequently are implicated as a cause of Ogilvie's syndrome. We report the first case of Ogilvie's syndrome following ethanol ablation of a renal cell carcinoma. The urologist must be alert to the development of this complication. If recognized early and managed correctly long-term morbidity from this complication is minimal.

Pain control following renal infarction/ablation using continuous epidural combined anesthesia/analgesia.

A technique for anesthesia during pre-nephrectomy renal infarction or ablation using standard epidural anesthesia procedures is described. Additionally, post-infarction analgesia using epidural meperidine is discussed. This technique has been used successfully in 8 patients undergoing infarction or ablation of renal adenocarcinoma and shows promise as an adjunct to standard analgesia in other patients undergoing radical surgical procedures.

Relationship of blood group to testicular carcinoma.

The hospital records of 48 patients undergoing retroperitoneal lymphadenectomy for testicular carcinoma between 1971 and 1980 were reviewed with respect to blood group. In contrast to a recent report which suggested an unusually high frequency of blood group A among patients with testicular carcinoma, no correlation between blood type and testicular carcinoma was noted in this group. The blood group frequencies observed in this study group were consistent with the reported blood group frequencies for the general population.

Pseudotorsion of testis.

Unilateral scrotal inflammation was noted in an otherwise asymptomatic three-day-old male and was initially believed to be due to testicular torsion. It proved, however, to be the result of peritonitis from a thermometer-induced rectal perforation presenting via a communicating hydrocele. Treatment included primary closure of the rectal perforation with colostomy diversion combined with parenteral antibiotics. Preoperative evaluation of neonates with acute unilateral inflammation of the scrotum and a known hydrocele or hernia with flat and oblique x-ray films may reveal significant unsuspected intra-abdominal pathology.

Orchiopexy: experiences at two centers.

The results of two series of patients undergoing orchiopexy procedures at different medical centers using different surgical approaches were analyzed. Satisfactory results were obtained in 89 and 91 per cent of patients, and there was no significant difference between centers in the results obtained. The results were further analyzed with respect to the age of the patient at surgery, prior treatment with human chorionic gonadotropin (HCG), and postoperative hospitalization. These were found to have no significant bearing on the outcome of the procedure. Orchiopexy, if meticulously performed according to recognized surgical principles, continues to be an operation of considerable merit in the treatment of cryptorchism.

Radiation-induced sarcoma following radiotherapy for testicular tumor.

We report 4 cases of soft tissue sarcoma following radiation therapy for testicular tumor. The tumors included leiomyosarcoma, fibroxanthosarcoma, reticulum cell sarcoma and spindle cell sarcoma. Each malignancy arose within the irradiated area after a long latent period (mean 12 years) and each was histologically proved. Total radiation doses ranged from 3,500 to 9,000 rad. Three patients died as a result of the second neoplasm. Radiation-induced sarcomas are rare but must be considered in the differential diagnosis of new tumor growth in patients treated previously with radiotherapy. Full evaluation of such new tumor growth, including tissue diagnosis, is necessary before additional therapy is prescribed.

The military aviator with renal stone disease.

Regulations currently in force governing the flight status of military aviators with urinary calculus disease are more restrictive than necessary and result in a substantial loss of aviation manpower. Those regulations and policies currently in force are reviewed, and more liberal guidelines, designed to provide for the safe return to useful flight status of aviation personnel with renal stone episodes, are proposed.

Supraclavicular node biopsy in staging testis tumors.

Supraclavicular node biopsy has been advocated previously as a routine staging procedure for patients with testicular tumors. Of 73 patients with testis tumors the scalene node biopsy revealed metastasis in only 3 of 61 patients with non-seminomatous tumors and in 1 of 12 patients with seminoma. Furthermore, all 4 patients were known to have other metastases; in 3 of the 4 patients a palpable supraclavicular mass was noted as well. The low yield of this procedure, in conjunction with a complication rate of 8%, mitigates against the routine use of supraclavicular node biopsy in patients without a palpable supraclavicular mass.