How safe is surveillance in patients with histologically low-risk non-seminomatous testicular cancer in a geographically extended country with limited computerised tomographic resources?

In patients with clinical stage I non-seminomatous testicular cancer only limited information is available about the administrative problems with the surveillance programme, in particular if this policy is to be implemented in a geographically extended country with limited computerised tomography (CT) resources. One hundred and two patients with non-seminomatous testicular cancer clinical stage I and low-risk histology (MRC criteria, UK) were followed by the surveillance policy for at least 1 year after orchiectomy (median 47 months, range 21-81 months). Twenty-two patients (22%) relapsed after a median time of 5 months (range 2-18 months), 14 of them in the retroperitoneal space. Serum alpha-fetoprotein and/or human chorionic gonadotrophin were elevated in eight of the 22 relapsing patients. The progression-free and cancer-corrected survival rates were 78% and 99% respectively. Patient non-compliance did not represent a major problem, whereas the regular and adequate performance of necessary CT examinations yielded some administrative difficulties. One and 3 years after orchiectomy about 50% of the relapse-free patients had no psychological problems and were satisfied with the surveillance programme, whereas 46% reported minor and 4% major psychological distress. Despite non-negligible administrative difficulties in geographically extended countries, surveillance is feasible and safe in compliant patients with low-risk non-seminomatous testicular cancer stage I. The responsible cancer centre and the local hospitals should establish a high degree of cooperation and enable adequate follow-up examinations in these patients.

Prognostic factors in disseminated prostatic cancer, with special emphasis on extent of disease.

Current clinical trials in disseminated prostatic cancer mostly use M0 or M1 to identify two prognostically different groups of patients. Soloway et al. [Cancer 1988;61:195-202] have shown a significant difference in survival depending on the extent of disease (EOD) on bone scan in M1 disease. Seventy-three prostatic cancer patients with bone-scan-proven metastases (T0-4 Nx M1 G1-3) from the Aust-Agder County in Norway with observation time 2-9 years were followed. The impact of T stage, grade, serum acid phosphatase status and EOD on survival was analyzed. EOD was assessed according to Soloway et al. No statistically significant difference could be demonstrated according to T stage or histological grade. A statistically significant difference in survival could be demonstrated both for normal versus elevated serum acid phosphatase and for EOD. EOD I/II had a better prognosis than EOD III/IV. Stratification of patients in EOD categories seems relevant, but the relative importance of the different EOD categories is not yet established.

Prognosis of localised prostatic cancer managed by "watch and wait" policy.

Progression (within 2-7 years) and cancer-specific mortality (within 4-9 years) were examined in 94 patients with localised (T0-T2 NXM0) prostatic cancer. The patients received no initial anti-cancer treatment. A significant difference was found according to the initial T category both in progression (T0 focal 1/13, T0 diffuse 9/53, T1-2 13/28) and in cancer-related death (T0 focal 0/13, T0 diffuse 3/53, T1-2 6/28). Progression (G1 4/48, G2 17/42, G3 2/4) and cancer-related deaths (G1 1/48, G2 7/42, G3 1/4) also showed significant differences according to histological differentiation. No difference could be demonstrated according to age.

Prostatic cancer in Aust-Agder County, Norway. Age, stage, grade and mode of presentation.

Two hundred and five patients (89 per 100,000 men) with newly diagnosed prostatic cancer comprises all cases in the Aust-Agder County in Norway over a 5-year period. There were 36% stage T0 M0, 19% T1-2 M0, 16% T3-4 M0 and 29% T0-4 M1. In patients with well differentiated disease (G1), 8% had distant metastases on presentation, whereas in the moderately differentiated tumors (G2) and the poorly differentiated tumors (G3) distant metastases occurred in 30% and 62%, respectively. A statistically significantly higher proportion of well differentiated (G1) tumors were observed in the younger age groups (less than 70 years). On presentation diagnosis was suspected on routine digital rectal examination in 9% of the patients, while 12% had symptoms on disseminated disease as mode of presentation. Of patients operated upon for apparently benign hyperplasia 13% had prostatic cancer.

Prognosis of incidental prostatic cancer in Aust-Agder County, Norway.

The clinical significance of dividing incidental prostatic cancer into T0 focal (A1) and T0 diffuse (A2) is well documented, but criteria for the distinction vary considerably. Eighty-four patients with incidental prostatic cancer over a 5-year period comprise all newly diagnosed cases from an area of 94,000 inhabitants in the Aust-Agder County in Norway. This represents 13% of the patients operated upon for apparently benign prostatic hyperplasia. Of these patients, 80 with a mean age of 73.9 years did not receive any additional treatment after prostatectomy until progression (deferred treatment) and were followed up for 2-7 years. Three chips or less of well-differentiated cancer were defined as T0 focal (n = 18), all other cases were T0 diffuse (n = 62). Sixty-nine patients (86%) were free of progression. Eighteen patients died of causes unrelated to prostatic cancer. Progression occurred in 11 patients (14%) at a mean time interval of 39 months after diagnosis, and 3 patients died of prostatic cancer. Related to grade, progression occurred in 2% of the G1 tumors, in 25% of G2, and in 40% of the G3 tumors. When a tumor volume of 25% was chosen as level of distinction between T0 focal and T0 diffuse, 25 patients (31%) changed the stage to T0 focal without any impact on prognosis.

Digital rectal examination to screen for prostatic cancer.

In a prospectively designed study 480 men, aged 45-67 years of age having routine medical examinations as part of the Occupational Health Service Program, underwent digital rectal examination to screen for early prostatic cancer. 26 men were referred to the Urology Service of the Aust-Agder Central Hospital for repeat examinations and further diagnostic procedures. Biopsies were performed on 16 patients, and transrectal ultrasound examination on 9. One patient was found to have prostate cancer. The value of an organized screening program for the detection of early prostatic cancer still seems to be under discussion.

Idiopathic retroperitoneal fibrosis.

Two out of five patients with idiopathic retroperitoneal fibrosis treated at the Aker Hospital, and the Department of Urology, Ullevål Hospital, Oslo, Norway, are reported. They had pronounced early symptoms, similar to collagen disease, and were therefore treated with corticosteroids long before the correct diagnosis was established. The effect of this treatment was immmediate with prompt and striking improvement. Some pathological and immunological considerations are discussed. Serological and histopathological methods, including a mixed agglutination test, were used in order to find an immunological activity, but no such activity could be demonstrated in the present material. Still, the clinical course, the histological appearance, and the excellent therapeutic effect of corticosteroids seem to show a resemblance to connective tissue disorders.