David C. Utz

The Treatment of Renal Cell Carcinoma with Solitary Metastasis

Between 1950 and 1970, 44 patients (2.5 per cent) with renal cell carcinoma and a solitary metastatic lesion were treated at our clinic. Generally, treatment was aggressive, involving nephrectomy and excision of the metastatic lesion when possible. Patients presenting with the primary and metastatic lesion at the same time did not do as well as patients who presented with metastasis after nephrectomy. An operation for the metastatic lesion seemed to offer the best results in patients who presented with the solitary metastatic lesion after nephrectomy. The prognosis was uniformly poor in patients presenting with the primary and secondary lesion together, regardless of the mode of therapy. However, an operation seemed to be better marginally and did produce an occasional long-term survival.

Renal angiomyolipoma. A clinicopathologic study of 32 cases

The data from 32 cases of angiomyolipoma (renal hamartoma) are presented: 23 of the tumors were removed at surgery and nine at autopsy. The histopathologic findings are reviewed and the spectrum of gross renal involvement is emphasized. On the basis of the duration of symptoms and findings and the subsequent course of patients subjected to surgical resection, the clinical behavior of the tumor is assessed. Of particular interest is the relationship of this tumor to the tuberous sclerosis complex. Data presented indicate that many of the patients have various components of the syndrome, which in some patients have familial manifestations. It is inferred from this study that the tuberous sclerosis complex may vary in expression from a solitary renal tumor to the fully developed clinical syndrome.

Influence of thiotepa and doxorubicin instillation at time of transurethral surgical treatment of bladder cancer on tumor recurrence: a prospective, randomized, double-blind, controlled trial.

The influence of the instillation of thiotepa or doxorubicin hydrochloride into the bladder at the end of transurethral surgical treatment on the recurrence of bladder cancer was evaluated. We studied in a randomized, double-blind, controlled fashion 89 patients with transitional cell epithelioma (carcinoma in situ or papillary carcinoma) whose tumors were considered to have been completely removed. Of these patients 28 (the control group) received a placebo (sterile water), 30 received thiotepa and 31 received doxorubicin. By 3 to 4 months postoperatively 71 per cent of the control group, and 30 and 32 per cent, respectively, of the patients treated with thiotepa and doxorubicin had recurrences (p less than 0.01). Additional treatment during the followup interval was ineffective in all groups. Patients studied also were classified according to grade, histological findings, multiplicity of tumors and history of bladder tumor. Treatment was most effective in reducing recurrence in patients with low grade, papillary or multiple tumors and in patients with a history of bladder cancer. No effect was observed in patients with single tumors and only modest effects were found in those with high grade tumors, carcinoma in situ or new tumors. The results support the concept that recurrences may arise from tumor cell implantation at the time of transurethral management of bladder tumors and may be reduced effectively by concomitant intravesical chemotherapy.

Treatment of Transitional Cell Carcinoma of the Bladder with Hematoporphyrin Derivative Phototherapy

The demonstration that intravenously administered hematoporphyrin derivative concentrates preferentially in dysplastic and neoplastic transitional cells in the human bladder prompted a trial of hematoporphyrin derivative phototherapy in patients with transitional cell cancer of the bladder. A dose of 2.5 mg. per kg. was given intravenously 3 to 48 hours before treatment with light of a wavelength of 630 nm. from an argon ion pumped dye laser. Total light dose approximated 150 joules per cm.2. Four patients with resistant carcinoma in situ have been treated and all have had disappearance of the tumors proved by biopsy. Although there are many technical problems we believe that hematoporphyrin derivative phototherapy holds promise as an effective treatment modality, primarily for patients with resistant, recurrent in situ transitional cell carcinoma of the bladder.

Bilateral Pelvic Lymphadenectomy and Radical Prostatectomy for Clinical Stage C Prostatic Cancer: Role of Adjuvant Treatment for Residual Cancer and in Disease Progression

A total of 101 patients with limited but unequivocal clinical stage C adenocarcinoma of the prostate underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy. At operation 49 patients had pathological stage C and 52 had stage D1 disease. Followup ranged from 0.5 to 17 years (mean 4.9 years). The 5 and 10-year observed survival rates for patients with stages C and D1 disease were similar to the expected survival. Sixteen patients had residual cancer postoperatively but only 2 had local progression: 1 had received no adjuvant therapy, and 1 had received diethylstilbestrol and radiation. None of the others, having received adjuvant radiation and/or orchiectomy, suffered local recurrence. Over-all, local progression occurred in 17 patients, only 4 of whom had received adjuvant treatment initially (diethylstilbestrol, 1 also received radiation). Local progression occurred in 13 of 47 patients (28 per cent) without adjuvant treatment. Thus, in all patients immediate adjuvant bilateral orchiectomy or radiation (except for 1 patient) prevented local progression. In patients with pathological stage D1 disease bilateral orchiectomy significantly reduced disease progression (p less than 0.0001). Therefore, limited clinical stage C adenocarcinoma of the prostate can be successfully treated surgically (with low morbidity) when supplemented with appropriate immediate adjuvant treatment.

Radical retropubic prostatectomy and pelvic lymphadenectomy for high-stage cancer of the prostate

A series of 340 patients with adenocarcinoma of the prostate treated by bilateral pelvic lymphadenectomy and radical retropubic prostatectomy was reviewed to determine the factors that influence survival and time to progression of disease. Follow‐up ranged from 1–12½ years. Factors evaluated were grade, stage, and bulk of tumor; influence of seminal vesical involvement and number of pelvic nodes involved; age of patient; and year of surgery. Tumor grade was the only factor related significantly to patient survival. However, grade, stage, and bulk of tumor were all significantly associated with interval between surgery and disease progression. Furthermore, in Stage C disease, seminal vesical involvement (C+) was an adverse factor for disease progression, particularly among patients with low‐grade tumor. This is in contrast to the finding that, among patients with Stage D1 disease, those with seminal vesical involvement experienced more favorable survival times and times to progression of disease when compared with patients without seminal vesical involvement. Overall, patient survival compared favorably with an age‐matched control group for all stages, A through D1. Patients with few pelvic nodes involved had a survival experience nearly comparable with that of an age‐matched control group. This suggests that pelvic lymphadenectomy might have a therapeutic value and that patients with pelvic nodal disease only, without evidence for metastatic disease, should not be denied radical surgery. The influence of concomitant hormonal manipulation or radiotherapy (or both) on patient survival and disease progression is not conclusively answered in this report.

Relationship Between Grade and Stage of adenocarcinoma of the Prostate and Regional Pelvic Lymph Node Metastases

The relationship of grade and local tumor extent to pelvic nodal involvement was assessed surgically in 469 patients who underwent pelvic lymphadenectomy and radical retropubic prostatectomy for adenocarcinoma of the prostate. Grade and local stage alone and combined score were associated in a linear fashion with nodal involvement. Gleason sum and Mayo grade alone were not predictive of nodal metastases. Some patients with a Gleason score of 4 had positive nodes and some with a score of 8 to 10 had negative nodes. Mayo sum (grade plus stage) consistently was related to negative nodal involvement.

Inverted papillomas of the urinary bladder

Study of 20 patients with inverted papilloma of the urinary bladder and urethra revealed that the lesion is a true neoplasm, benign in its histologic morphology and clinical behavior. The lesion is believed to arise from the trigone and bladder outlet as a result of chronic proliferative cystitis. It occurs predominantly in men who are past middle age. The most commonly associated clinical symptoms are hematuria and those of urinary obstruction. The lesion may be easily mistaken for a low‐grade papillary transitional cell carcinoma, although the histologic appearance is distinctly different, as is its subsequent behavior.

A clinicopathologic evaluation of partial cystectomy for carcinoma of the urinary bladder

Segmental resection of the bladder was performed on 199 patients as definitive therapy for cancer. Six patients were lost to followup and there were 6 hospital deaths. Followup of the other 187 patients showed that 43% lived 5 years or longer. Survival rates for patients with lesions of Stage B2 and C were 40% and 29%, respectively; those for patients with cancers of Grade 3 and Grade 4 were 46% and 21%, respectively. Partial cystectomy may not appeal to every urologist as the paragon of procedures for vesical neoplasm. On reflection of this reported experience, however, this time‐honored operation represents the best available treatment for specific varieties of cancer of the bladder.

Significance of Urinary Cytology in the Early Detection of Transitional Cell Cancer of the Upper Urinary Tract

Cytologic study of urine from 100 patients with transitional cell cancer of the upper urinary tract revealed that findings on the voided and catheterized specimens correlated well with grade and stage of the tumor. However, there was a significantly greater positive yield with urine specimens obtained by ureteral catheterization than by voiding. Consequently, because concomitant bladder tumors, diagnosed or not, can give questionable positive results ureteral catheterization specimens should be used for cytologic study.