D. Thüer

[Radical salvage prostatectomy : Treatment of local recurrence of prostate cancer after radiotherapy].

External beam radiation and low- and high-dose interstitial brachytherapy represent therapeutic alternatives to radical prostatectomy for organ-confined and locally advanced prostate cancer. Local recurrences are described in 5-35% of the patients depending on the individual risk profile, and most recurrences are detected due to asymptomatic PSA rise only. According to the most recent data, recurrences are defined by a PSA increase >2 ng/ml above the post-radiation nadir. Radical salvage prostatectomy represents a secondary local treatment with curative intent in patients with organ-confined recurrences. Preoperative risk factors predicting organ-confined disease are initial LDR brachytherapy, preoperative Gleason biopsy score < or =6, < or =50% biopsy cores involved with cancer, and a PSA doubling time >12 months. Metastatic disease should be ruled out preoperatively by skeletal scintigraphy, computed tomography, or magnetic resonance imaging of the abdomen and the small pelvis, and/or choline PET/CT. Functionality of the lower urinary tract is evaluated by urethrocystoscopy and urodynamics. The most appropriate candidates for radical salvage prostatectomy are patients with organ-confined disease or those with symptomatic local recurrences. In experienced hands, morbidity is low with a continence rate of 83-96% depending on the type of previous radiation therapy. Long-term oncological control can be achieved in more than 80% of the patients.

Der Stellenwert der Tageted-Therapie beim Peniskarzinom

With an incidence of 0.1-0.9/100,000 men/year, penile cancer is a rare cancer of the urogenital tract in Western Europe. At the time of initial diagnosis up to 45% of the patients already demonstrate metastatic disease and need some type of systemic treatment. Objective remission rates and 3-year survival rates of 30 and < 10%, respectively, are depressingly low. Identification of molecular targets for the introduction of molecular triggered therapies such as monoclonal antibodies and tyrosine kinase inhibitors might improve the poor prognosis and could replace non-targeted systemic chemotherapies with a less toxic targeted therapy.However, a MEDLINE search does not identify any current clinical trial with regard to targeted therapeutic approaches in penile cancer. Based on a systematic review of the molecular events involved in the metastatic process of penile cancer, therapeutic approaches with bevacizumab or COX-2 inhibitors appear to have the greatest potential to improve the prognosis. In order to perform a prospective clinical phase 2/3 trial in such a low frequency cancer, international cooperative structures have to be established.

Die radikale Salvageprostatektomie

External beam radiation and low- and high-dose interstitial brachytherapy represent therapeutic alternatives to radical prostatectomy for organ-confined and locally advanced prostate cancer. Local recurrences are described in 5-35% of the patients depending on the individual risk profile, and most recurrences are detected due to asymptomatic PSA rise only. According to the most recent data, recurrences are defined by a PSA increase >2 ng/ml above the post-radiation nadir. Radical salvage prostatectomy represents a secondary local treatment with curative intent in patients with organ-confined recurrences. Preoperative risk factors predicting organ-confined disease are initial LDR brachytherapy, preoperative Gleason biopsy score < or =6, < or =50% biopsy cores involved with cancer, and a PSA doubling time >12 months. Metastatic disease should be ruled out preoperatively by skeletal scintigraphy, computed tomography, or magnetic resonance imaging of the abdomen and the small pelvis, and/or choline PET/CT. Functionality of the lower urinary tract is evaluated by urethrocystoscopy and urodynamics. The most appropriate candidates for radical salvage prostatectomy are patients with organ-confined disease or those with symptomatic local recurrences. In experienced hands, morbidity is low with a continence rate of 83-96% depending on the type of previous radiation therapy. Long-term oncological control can be achieved in more than 80% of the patients.

Lokales Prostatakarzinomrezidiv nach Strahlentherapie

Radical salvage prostatectomy represents a secondary local treatment with curative intent in patients with organ-confined prostate cancer (PC) recurrences following radiation therapy. Preoperative risk factors predicting organ-confined disease are initial low dose rate (LDR) brachytherapy, preoperative Gleason biopsy score<or=6, <or=50% biopsy cores involved with cancer, and a prostate-specific antigen (PSA) doubling time>12 months. Metastatic disease should be ruled out preoperatively by skeletal scintigraphy, abdominal computed tomography or magnetic resonance imaging, and/or choline-PET/CT. Functionality of the lower urinary tract needs to be preoperatively evaluated by urethrocystoscopy and urodynamics. With appropriate patient selection, oncological control can be achieved in 80% of patients. A continence rate of 83%-96% depending on the type of previous radiation therapy is achievable.

Value of targeted therapy for penile cancer

With an incidence of 0.1-0.9/100,000 men/year, penile cancer is a rare cancer of the urogenital tract in Western Europe. At the time of initial diagnosis up to 45% of the patients already demonstrate metastatic disease and need some type of systemic treatment. Objective remission rates and 3-year survival rates of 30 and < 10%, respectively, are depressingly low. Identification of molecular targets for the introduction of molecular triggered therapies such as monoclonal antibodies and tyrosine kinase inhibitors might improve the poor prognosis and could replace non-targeted systemic chemotherapies with a less toxic targeted therapy.However, a MEDLINE search does not identify any current clinical trial with regard to targeted therapeutic approaches in penile cancer. Based on a systematic review of the molecular events involved in the metastatic process of penile cancer, therapeutic approaches with bevacizumab or COX-2 inhibitors appear to have the greatest potential to improve the prognosis. In order to perform a prospective clinical phase 2/3 trial in such a low frequency cancer, international cooperative structures have to be established.

Optimizing treatment of advanced testicular germ cell tumors

Testicular germ cell cancer represents the most frequent solid neoplasm in young men aged 20-40 years. Depending on the prognosis according to the IGCCCG classification, the treatment of choice for advanced germ cell tumors consists in three to four cycles of bleomycin, etoposide, and cisplatin (BEP) in accordance with the current European Consensus Guidelines. Although residual tumor resection (RTR) adheres to guidelines as the treatment for residual metastatic lesions, numerous questions remain unresolved, which we intend to systematically answer within the scope of our research group by conducting prospective/retrospective and clinical/molecular investigations in cooperation with national and international project groups.

Behandlungsoptimierung fortgeschrittener testikulärer Keimzelltumoren

Testicular germ cell cancer represents the most frequent solid neoplasm in young men aged 20-40 years. Depending on the prognosis according to the IGCCCG classification, the treatment of choice for advanced germ cell tumors consists in three to four cycles of bleomycin, etoposide, and cisplatin (BEP) in accordance with the current European Consensus Guidelines. Although residual tumor resection (RTR) adheres to guidelines as the treatment for residual metastatic lesions, numerous questions remain unresolved, which we intend to systematically answer within the scope of our research group by conducting prospective/retrospective and clinical/molecular investigations in cooperation with national and international project groups.

[Locally recurrent prostate cancer following radiation therapy: radical salvage prostatectomy].

Radical salvage prostatectomy represents a secondary local treatment with curative intent in patients with organ-confined prostate cancer (PC) recurrences following radiation therapy. Preoperative risk factors predicting organ-confined disease are initial low dose rate (LDR) brachytherapy, preoperative Gleason biopsy score<or=6, <or=50% biopsy cores involved with cancer, and a prostate-specific antigen (PSA) doubling time>12 months. Metastatic disease should be ruled out preoperatively by skeletal scintigraphy, abdominal computed tomography or magnetic resonance imaging, and/or choline-PET/CT. Functionality of the lower urinary tract needs to be preoperatively evaluated by urethrocystoscopy and urodynamics. With appropriate patient selection, oncological control can be achieved in 80% of patients. A continence rate of 83%-96% depending on the type of previous radiation therapy is achievable.

[Pitfalls and outcome of nephrectomy for patients with polycystic kidney disease: Peri- and postoperative results].

BACKGROUND There are several indications to perform nephrectomy in patients with polycystic kidney disease (PCKD), including pain, hematuria, hypertension, and infections. Operative access and time to surgery are discussed controversially in the literature. We retrospectively reviewed our peri- and postoperative experiences in the surgical management of patients with PCKD and compared them to minimally invasive procedures. MATERIAL AND METHOD Between January 2003 and January 2010, 40 patients with PCKD underwent simple (n=25) or radical nephrectomy (n=4). In 11 patients a bilateral nephrectomy was performed. The mean patient age was 59 (45-69) years. Indications for nephrectomy were flank/abdominal pain (n=19); gross recurrent hematuria (n=9), septic constellation (n=8), and suspected malignancy (n=4). There were 26 male and 14 female patients. All procedures were performed with a retroperitoneal approach or a chevron incision. RESULTS A total of 51 nephrectomies were performed on 40 patients with a mean surgical time of 115 (60-310) min. There was one significant intraoperative complication. The mean length of the specimens was 45 (20-87) cm and mean weight was 3.5 (0.8-22.3) kg. Histological examination of the specimens identified renal cell carcinoma (RCC) in three of the four cases. In the other kidneys the pathologists described a polycystic kidney disease. Two significant complications (5%) occurred in the postoperative period: bleeding from an intercostal artery and nonocclusive mesenteric ischemia (NOMI). CONCLUSION Although technically demanding due to size and weight, retroperitoneal nephrectomy can be performed safely in patients with PCKD. However, surgery might be associated with unusual complications such as NOMI due to nephrectomy. Compared to minimally invasive procedures there is reduced morbidity, so at least in larger specimens we recommend open surgery.

Retroperitoneale Nephrektomie bei Patienten mit polyzystischer Nephropathie

BACKGROUND There are several indications to perform nephrectomy in patients with polycystic kidney disease (PCKD), including pain, hematuria, hypertension, and infections. Operative access and time to surgery are discussed controversially in the literature. We retrospectively reviewed our peri- and postoperative experiences in the surgical management of patients with PCKD and compared them to minimally invasive procedures. MATERIAL AND METHOD Between January 2003 and January 2010, 40 patients with PCKD underwent simple (n=25) or radical nephrectomy (n=4). In 11 patients a bilateral nephrectomy was performed. The mean patient age was 59 (45-69) years. Indications for nephrectomy were flank/abdominal pain (n=19); gross recurrent hematuria (n=9), septic constellation (n=8), and suspected malignancy (n=4). There were 26 male and 14 female patients. All procedures were performed with a retroperitoneal approach or a chevron incision. RESULTS A total of 51 nephrectomies were performed on 40 patients with a mean surgical time of 115 (60-310) min. There was one significant intraoperative complication. The mean length of the specimens was 45 (20-87) cm and mean weight was 3.5 (0.8-22.3) kg. Histological examination of the specimens identified renal cell carcinoma (RCC) in three of the four cases. In the other kidneys the pathologists described a polycystic kidney disease. Two significant complications (5%) occurred in the postoperative period: bleeding from an intercostal artery and nonocclusive mesenteric ischemia (NOMI). CONCLUSION Although technically demanding due to size and weight, retroperitoneal nephrectomy can be performed safely in patients with PCKD. However, surgery might be associated with unusual complications such as NOMI due to nephrectomy. Compared to minimally invasive procedures there is reduced morbidity, so at least in larger specimens we recommend open surgery.