Douglas E. Johnson

Metastases from transitional cell carcinoma of urinary bladder

In 107 patients who died of metastatic transitional cell carcinoma, the most common sites for metastases at necropsy were the lymph nodes, liver, lung, bone, and adrenal gland. Metastases first were documented clinically in multiple-organ sites in one third of the patients; solitary metastases were present in only 9 patients at necropsy. The mean duration of survival for patients was thirteen months from the diagnosis of the primary tumor. The metastatic lesion(s) generally were evident clinically within eleven months of the primary diagnosis; death ensued usually within three months. Our finding that the majority of patients presented initially with high-grade tumors suggests that a high-grade lesion, regardless of its clinical stage, warrants early aggressive therapy.

Bleomycin combination chemotherapy in the management of testicular neoplasia.

Eighty‐three patients with Stage II or Stage III germinal neoplasia of the testis and 7 patients with extragonadal primary tumors were treated with bleomycin plus vinblastine, or a five‐drug program, bleomycin plus cyclophosphamide, vincristine, methotrexate, and 5‐fluorouracil. Of the 70 Stage III patients, there were 53 responses (75%), 22 complete and 31 partial. The mean survival of the complete responders is 100+ weeks, with 3 dead. The mean survival of the partial responders and nonresponders is 38 weeks and 33 weeks, respectively. There is a highly significant difference between complete responders vs. partial and nonresponders (p < 0.01). Thirteen patients with nonmeasurable disease (Stage II and Stage III postresectional status) but at great risk to develop widespread metastasis were treated prophylactically after conventional therapy. Nine continue in complete response to 36 months. The 7 extragonadal primary patients showed 4 partial responses, none complete. Major toxicity was myelosuppression and also bleomycin pneumonitis in 5 of the 90 evaluable patients.

Histologic grading study of prostate adenocarcinoma: The development of a new system and comparison with other methods—A preliminary study

A new grading system for adenocarcinoma of the prostate (MDAH System) and its simplified version, both based on the percentage of tumor that is differentiated (gland‐forming) or undifferentiated (non‐gland‐forming), were compared with the grading systems of Mostofi and Gleason. In a study group of 182 patients with Stage C adenocarcinoma of the prostate, the MDAH system identified 84 patients (46%) as Grade 1, 75 (41%) as Grade 2–3, and 23 (13%) as Grade 4. Kaplan‐Meier survival curves predicted a 91% five‐year survival for Grade 1 patients, a 60% 5‐year survival for Grade 2–3 patients, and a 15% five‐year survival for Grade 4 patients. Wilcoxon (Gehan modification) tests showed that the survival was significantly different among Grades 1, 2–3, and 4. The MDAH System is an improvement over other grading systems in that it is a simple, low‐power microscopic method that depends only on the percentage of gland formation in the tumor and further reflects the biologic behavior of the tumor as measured by the patients survival.

Metastases from testicular carcinoma Study of 78 autopsied cases

The necropsy records of 78 patients with histologically proved germ cell tumors of the testis, who died as a direct result of their malignant disease, were reviewed to determine the usual modes of spread, distribution of metastasis, the histologic characteristics of the metastatic foci as compared with the morphology of the primary tumor and the specific cause of death. The sites of metastases in order of decreasing frequency for all cases were lung, retroperitoneal lymph nodes, liver, mediastinal lymph nodes, brain, kidney, gastrointestinal tract, bones, adrenals, peritoneum and spleen. The absence of metastases solely in the anterior mediastinum without involvement of other mediastinal nodes (middle/posterior) strongly supports the premise for a primary extragonadal origin whenever the anterior mediastinum alone is involved with malignant disease having the histologic appearance of a primary germ cell tumor. The histologic features of the metastatic lesions were usually similar in nature to those of the primary tumor except for seminoma in which the metastatic lesions proved to be of a different histologic pattern in almost one third of the patients dying from the disease. It should be axiomatic that whenever a patient with seminoma fails to respond appropriately to radiotherapy that his treatment be immediately discontinued and that appropriate biopsies be obtained to substantiate the histologic pattern present.

MEGAVOLTAGE RADIATION THERAPY FOR CARCINOMA OF THE PROSTATE

Abstract Between July 1966 and December 1972, 154 patients with prostatic cancer that was localized to the pelvis were treated with megavoltage radiation therapy. At the time of analysis, the disease was controlled locally in 86.4% of patients, 68.2% were alive, and 58.4% had no evidence of disease (NED) (mean follow-up time=4 years 7 months). The majority of treatment failures resulted from hematogenous metastases. There was no improvement in the local control or survival rates with adjunctive hormonal therapy, since 74.7% of the patients treated with radiation therapy alone were alive as compared to 61.3% of those treated with radiation therapy plus hormones. There was no difference in the local control and survival rates between patients receiving ∼6500 rad in 6.5 weeks and those receiving ∼7000 rad in 7 weeks. Although the majority of patients were treated through relatively small portals, a significant failure rate in the regional nodes was not observed clinically. Whether the survival rate could have been improved with larger fields covering the common and external iliac lymph nodes is not known.

Is Nephrectomy Justified in Patients with Metastatic Renal Carcinoma

The survival data of 93 patients with metastatic renal carcinoma are discussed with respect to the site of metastasis and whether nephrectomy was performed as part of the initial treatment. Analysis of the cumulative survival rates revealed that nephrectomy significantly increased survival only for those patients pesenting exclusively with osseous metastases. Nephrectomy did not alter survival for patients with pulmonary and/or soft tissue metastases.

Squamous Cell Carcinoma of the Bladder

Clinical and morphological features of 90 cases of squamous cell carcinoma of the bladder have been reviewed. The lesions were solitary in 90 per cent of the patients, developed without a history of vesical malignant disease in 82 per cent and were invasive at the time of diagnosis in all cases. Ureteral obstruction was demonstrated in 42 per cent of the group. The over-all survival rate at 5 years was only 10.6 per cent. There were 17 patients who received no therapy, all of whom were dead before 2 years. Unassisted supervoltage radiation therapy for patients with stages B2 and C lesions yielded a 5-year survival rate only 17.7 per cent. However, preoperative radiotherapy followed by simple total cystectomy and urinary diversion in a small number of patients with stages B2 and C lesions resulted in a 5-year survival rate in excess of 34 per cent. We are encouraged by this finding and believe that combination therapy warrants further clinical trial.

Complications of a Single Stage Radical Cystectomy and Ileal Conduit Diversion: Review of 214 Cases

Single stage radical cystectomy and ileal conduit diversion were performed on 214 patients for treatment of bladder carcinoma. The over-all operative mortality rate was only 3.3 per cent. Early complications occurred in 27.6 per cent of the patients and late complications were noted in 41.1 per cent of the patients followed 6 months or longer. We refute recent arguments for staged procedures as a necessity for reducing operative mortality and morbidity.

Role of intravesical mitomycin c in management of superficial bladder tumors

Forty-three patients with biopsy-proved Stage O or A transitional cell carcinomas of the bladder, whose tumors were not amenable to transurethral resection, received mitomycin C intravesically at weekly intervals for eight treatments. Five different drug doses were used (20, 25, 30, 40, and 60 mg). Best response rates occurred at doses of 30 mg. or higher. Complete responses occurred in 49% of patients, partial responses in 30%, and improvement in 5%, for an over-all effective rate of 84%. Responses were achieved regardless of tumor extent as long as individual tumors were 1 cm. or less in diameter. Toxicity was minimal. The necessary for maintenance therapy in complete responders remains to be proved.

Cystectomy for superficial bladder cancer

One hundred nine patients with Stage O or A bladder cancer unmanageable transurethrally underwent radical cystectomy and ileal conduit urinary diversion without lymphadenectomy. Fifty-six were also given planned preoperative radiation therapy. Five-year survival rate was 76 per cent for the entire group. Irradiation eradicated all of the tumor (Po) in 36 per cent of patients, no patient Po after irradiation had recurrent disease, and local recurrence was noted in only 3.5 per cent of the irradiated patients compared with 9.4 per cent of those not irradiated. Urethral cancer was present in 9 per cent of our patients, a finding that does not support our previous impression that patients with multifocal bladder cancer or tumors involving the prostatic urethra had a higher than average incidence of urethral carcinoma.