Arie Lindner

The Treatment of Renal Cell Carcinoma with Human Leukocyte Alpha-Interferon

An extended phase II trial of human leukocyte (alpha) interferon was done in 48 patients with measurable metastatic renal cell carcinoma, 43 of whom were evaluable. Of these patients 1 (2.5 per cent) had a complete response that was maintained after 19 months, 6 (14 per cent) had a partial response and an additional 23 per cent had either a minimal response or stabilization of previously growing metastases for greater than 3 months. Toxicity caused termination of treatment in only 1 patient and generally was tolerable. Major toxicity consisted of fever (80 per cent), fatigue (80 per cent) and hematologic toxicity (42 per cent), which was severe in only 2 patients. Characteristics of patients responding to therapy were good performance status, previous nephrectomy and metastases limited to the lungs. The results achieved with human leukocyte interferon were superior to those achieved by immunotherapy or chemotherapy at this and other institutions, and further trials are warranted.

Prognostic Implications of Vena Caval Extension of Renal Cell Carcinoma

Vena caval extension of renal cell carcinoma occurs in 4 to 10 per cent of the patients and usually is considered a poor prognostic sign. To ascertain the true effect of vena caval extension on survival a retrospective analysis was done of 27 patients who had undergone radical nephrectomy and removal of vena caval thrombus between 1970 and 1980. An additional 46 cases were collected from series in the literature and composite statistics were compiled. Extension to the vena cava alone had a limited impact on prognosis (survival for 2 years--81 per cent, 5 years--53 per cent, median--81 months). Capsular invasion negatively influenced survival (2-year survival 66 per cent). Disease in the regional lymph nodes had a much greater impact on survival, with a 2-year survival rate of 35 per cent and no patient survived 5 years (median survival 24 months). Only 5 per cent of the patients with distant metastases survived 2 years and none survived 5 years (median survival 8.5 months). In conclusion, the prognosis of patients with vena caval tumor thrombus is influenced primarily by known adverse prognostic factors: capsular invasion, nodal disease and distant metastases. Aggressive surgery in patients with gross nodal involvement or distant metastases is unwarranted since it contributes nothing to survival and only 7 per cent of the patients had significant signs or symptoms secondary to the vena caval thrombus itself. Patients with vena caval extension alone have a cure rate approaching that of patients with stage I renal carcinoma following radical nephrectomy and complete removal of the vena caval thrombus.

Complications of penile prosthesis surgery for impotence.

Complications and their management in 1,207 cases of semirigid rod prosthesis for erectile failure are presented. Major complications occurred in 7.8 per cent of the cases. Complications and management of 84 cases of impotence treated with inflatable penile prostheses also are discussed. Mechanical problems occurred in 44 per cent of the cases and medical complications occurred in 10 per cent.

The use of collagenase in the treatment of Peyronie's disease

Purified clostridial collagenase was administered intralesionally in 31 men with Peyronies disease. Within 4 weeks of treatment 20 patients showed an objective improvement. Pain was eliminated in 13 of 14 patients with this complaint at presentation within the same 4-week period. The ability to have intercourse was restored in 3 of 4 patients with this problem. Except for a small corporeal rupture at the site of injection in 1 patient, no significant untoward effects were noted. During the mean 9.8-month followup 1 recurrence of bending was noted.

The Management of Superficial Bladder Tumors and Carcinoma in situ with Intravesical Bacillus Calmette-Guerin

A phase II study was performed to assess the role of bacillus Calmette-Guerin as a prophylaxis against recurrent stages O and A bladder tumors, and in the treatment of existing superficial bladder tumors and carcinoma in situ. Tice strain bacillus Calmette-Guerin (1 vial, 2 to 8 times 10(8) organisms in 60 cc saline) was instilled intravesically without cutaneous inoculation. Instillations were given weekly for 6 weeks and then monthly or until recurrence in 22 patients with a history of recurrent tumors, while 22 with existing stages O and A transitional cell carcinoma, and 19 with carcinoma in situ were treated weekly for 8 weeks and then monthly for 12 months or until failure. Complications included cystitis in 88 per cent of the patients (severe in 20 per cent), fever in 15 per cent, a flu-like syndrome in 13 per cent, edema and pruritus in 1.5 per cent, and ureteral stenosis in 1.5 per cent. Twelve patients (19 per cent) did not complete the study owing to toxicity. Of the patients in the prophylaxis group 67 per cent have had no tumor recurrence 10 to 26 months (mean 15 months) after therapy. Of the patients with existing tumors 36 per cent had complete regression following bacillus Calmette-Guerin therapy and 23 per cent had a partial response. Among the patients with carcinoma in situ 13 (68 per cent) had reversal to normal urothelium and 3 (16 per cent) had marked improvement. None of the patients had recurrence at 11 to 20 months. Intravesical Tice strain bacillus Calmette-Guerin is effective as a prophylaxis against recurrent superficial bladder tumors and in the treatment of carcinoma in situ.

Risk of Urinary Incontinence following Radical Prostatectomy

Of 143 prostatic cancer patients treated with radical prostatectomy 38 had undergone transurethral resection of the prostate before the prostatectomy. After radical prostatectomy 5 per cent of the patients who did not have a resection and 8.1 per cent of those who did were severely incontinent. This difference is not statistically significant.

Cost effective analysis of prenephrectomy radioisotope scans in renal cell carcinoma ARIE LINDNER, M.D.

To evaluate the cost-effectiveness of liver and bone isotope scans, results of scans were reviewed in 60 patients with renal cell carcinoma. In no patient did the results of the scans influence or change the treatment plan. Routine utilization of radioisotope scans as part of the preoperative evaluation of patients with renal cell carcinoma should be discouraged.

TRANSITIONAL CELL CARCINOMA OF BLADDER IN FIRST FOUR DECADES OF LIFE

A retrospective analysis of 27 patients seen at UCLA in whom transitional cell carcinoma of the bladder developed at age forty or younger was conducted. Forty-one per cent had tumors manifesting known characteristics of aggressive and lethal potential: high histologic grade, muscular invasion, severe epithelial atypia, and frequent multifocal recurrence. One of these patients had extensive pelvic node metastases. The time from the first symptom, usually hematuria, to endoscopic diagnosis exceeded six months in 8 patients. The results of segmental cystectomy were very poor, in the absence of narrowly defined criteria for selection of this mode of therapy. No evidence was found to suggest that transitional cell carcinoma of the bladder in patients forty years of age and under differs clinically or morphologically from that of older patients. Treatment should be determined by the stage of the tumor and other indices of potential lethality.

Cost-Effective Analysis of Pre-Cystectomy Radioisotope Scans

To evaluate the cost-effectiveness of liver and bone isotope scans results were reviewed in 114 patients with invasive transitional cell carcinoma of the bladder. In 100 patients cystectomy was performed. In no patient has the results of the scans influenced or changed treatment. Routine use of isotope scans is not warranted for the preoperative evaluation of bladder cancer patients.

Topical Beta-Aminopropionitrile in the Treatment of Peyronie’s Disease

We treated 9 patients with Peyronies disease for 1 to 8 years in duration with a 4-week course of beta-aminopropionitrile free base as the pure liquid. The drug was applied topically to the plaques twice daily. Patients were followed with ultrasound imaging of the plaques and saline inflations of the corpora cavernosa with photographic documentation of the deformity. No significant adverse effect was noted. Three patients experienced a subjective response but did not demonstrate objective change on the aforementioned studies. It was concluded that topical beta-aminopropionitrile was not effective in reversing the deformity of Peyronies disease. Further investigation into specific anti-collagen drugs for the treatment of this condition may be warranted.