Edward C. Parkhurst

Prognostic Factors in Carcinoma of the Ureter

The records and pathological slides of 60 patients with ureteral cancer were reviewed with particular attention being paid to the tumor-adjacent mucosa. Mucosal abnormalities increased as grade and stage increased but their presence did not correlate with survival nor with the presence of urothelial tumors elsewhere, that is previous, concomitant and subsequent tumors. Patients with papillary and solid tumors survived equally well. Survival among patients with stage B tumors was better than that reported previously (82 per cent survived 5 years).

Megavoltage irradiation for pure testicular seminoma: Results and patterns of failure

The survival, patterns, and mechanisms of failure in 171 patients with pure testicular seminoma treated with megavoltage irradiation from 1950 to 1976 were analyzed. The survival of the entire group was 93% at five and ten years post‐irradiation. Survival at five years was significantly less for Stages III and IV (45%) when compared with Stages I and II (95%, P < 0.001). Extranodal relapses were more common in early stages, and abdominal recurrences occurred in more advanced stages. Salvage treatment, management of HCG‐producing seminomas, and second testicular seminomas are analyzed. The need for aggressive and appropriate radiation technique is emphasized.

Preliminary Results in Invasive Bladder Cancer with Transurethral Resection, Neoadjuvant Chemotherapy and Combined Pelvic Irradiation Plus Cisplatin Chemotherapy

Preliminary data are presented of a clinically feasible pilot study to select a significant subgroup of patients among those with muscle-invading bladder tumors for local cure and bladder preservation, while also to offer all patients the possibility of preventing the development of distant metastases. Transurethral debulking surgical resection was combined with neoadjuvant methotrexate, cisplatin and vinblastine chemotherapy plus 2 additional courses of cisplatin and 4,000 cGy. If tumor was found on cystoscopic re-evaluation by biopsy and for cytology after cisplatin and partial irradiation (4,000 cGy.) immediate cystectomy was advised. If tumor was not found consolidation by a radiotherapy boost to a total of 6,480 cGy. plus 1 additional course of cisplatin was given. Of 53 consecutive patients the planned treatment was completed in 42 (79%). With a median followup of 26 months (range 15 to 42 months), 72% of all entered patients were alive, 70% have not required cystectomy and 74% have not had distant metastases. Among the 42 patients who completed the planned protocol chemotherapy dose reductions were required in 39% for stomatitis, bone marrow depression and/or renal dysfunction. There were 2 serious complications but no treatment-related sepsis, deaths or significant renal dysfunction. Eight patients underwent immediate radical cystectomy because of positive biopsy and/or cytology results after 4,000 cGy., while 34 completed full chemotherapy and radiotherapy without any significant bladder or bowel injury. Of 42 patients 22 (52%) have maintained the bladder without any recurrence, and of those selected for full chemotherapy and radiotherapy this number increased to 65%. To date 12 patients have persistent or recurrent bladder tumors: 5 (15%) had invasive tumors treated by cystectomy and 7 (21%) had carcinoma in situ treated by intravesical therapy. The true success of this or other selective bladder-preserving treatments will require 3 to 5 years of followup to be confident that such treatment has sterilized the bladder of cancer. This feasibility study has been clinically practical, modestly well tolerated and encouraging for the significant proportion of patients with a sustained complete response and for the 70% over-all survival rate at 2 years. To evaluate critically the efficacy of methotrexate, cisplatin and vinblastine chemotherapy in the prevention of occult distant micrometastases and in increasing the rate of successful bladder preservation, in May 1988 we began a randomized phase 3 trial with and without neoadjuvant methotrexate, cisplatin and vinblastine chemotherapy.

Protons or megavoltage X‐rays as boost therapy for patients irradiated for localized prostatic carcinoma an early phase I/II comparison

A total of 180 patients with carcinoma of the prostate limited to the pelvis were treated with one of two external beam irradiation techniques between 1972 and 1979. One hundred and sixteen patients were treated with conventional pelvic megavoltage x‐ray therapy. Sixty‐four patients were treated with combined pelvic x‐ray therapy plus a perineal proton beam boost to a carefully defined prostatic tumor volume. A 160 MeV proton beam has been modified to irradiate patients with localized tumors by using conventional treatment schedules. This proton beam has the physical advantage over megavoltage x‐rays of reducing the dose to normal tissues adjacent to the tumor volume. By using the proton beam boost we have delivered an increased prostatic tumor dose of 500 to 700 cGy without increasing treatment morbidity at all. The two groups are actuarially analyzed for patient survival, disease‐free survival and local recurrence‐free survival, and thus far, no significant differences have been noted. Because of the minimal complications observed in the proton group despite a 10% increase in dose, a randomized clinical trial comparing these two treatment techniques is studied.

Mucinous adenocarcinoma of bladder: Case associated with extensive intestinal metaplasia of urothelium in patient with nonfunctioning bladder for twelve years

A mucin-secreting adenocarcinoma of the bladder arose in a fifty-one-year-old man twelve years after he had an ileal conduit and urinary diversion for a neurogenic bladder which was due to a myelomeningocele. The patient presented with a mucinous penile discharge, and cystoscopy showed several papillary tumors with mucoid material coating the intervening mucosa. Examination of the resected bladder showed almost total intestinal metaplasia of the urothelium with numerous foci of dysplasia, adenocarcinoma in situ, papillary and invasive adenocarcinoma. The clinical and pathologic features of this case and the risk of carcinoma developing in a nonfunctioning bladder are discussed.

Insular Carcinoid Arising in a Mature Teratoma of the Testis

AbstractWe report a case of an insular carcinoid tumor arising in a mature teratoma. These are rare entities and present as asymptomatic testicular masses in the older age group without signs of a carcinoid syndrome. Treatment consisted of radical orchiectomy and prognosis appears to be benign.

Ileal Conduit Undiversi0N: Experience with Tunneled Vesical Implantation of Tapered Conduit

Reconstruction of the urinary tract after ileal conduit diversion was done in 9 patients by antirefluxing vesical implantation of the tapered conduit. Of the patients 5 required prior operative rehabilitation of the lower tracts, while 4 had urodynamically normal lower tracts. Reoperation for post-undiversion reflux was necessary in 2 patients; reimplantation was satisfactory in 1 but ileocecocystoplasty was required in the other. Followup showed a stable or improved upper tracts and renal function in the remaining patients.

Successful management of ileal conduit-enteric fistula: the case against loopograms.

The second reported case of ileal conduit-enteric fistula successfully managed with long-tube decompression and intravenous hyperalimentation is presented. Loopograms are not indicated unless excretory urography is contraindicated or intraperitoneal leakage is suspected.

The Long-Term Success of Local Radiation Therapy in Preventing Tumor Regrowth in the Treated Field

The local tumor regrowth rate for patients irradiated at the Massachusetts General Hospital from 1973 to 1979 was evaluated by the cumulative frequency of local tumor regrowth. The results indicate that following 6,800–7,500 cGy of external beam irradiation, the absence of tumor regrowth in the treated field for patients with Stage T2 (B) tumors occurs in 85 to 90 percent. This curve, relating the cumulative incidence of local tumor regrowth against time, approached an asymptote after 5 to 7 years, suggesting there may be no further instances of local tumor regrowth with “infinite” time of follow up. In contradistinction were the 122 patients with clinical Stage T3 and T4 (C) tumors whose cumulative incidence of regrowth curve appears to be still rising from 6 to 10 years, suggesting that 35 percent of patients will have had regrowth by 10 years, and that this may increase with further time of follow up. The incidence of local tumor regrowth rate for patients with Stage T2 tumors (less than 10 percent at 8 years) is significantly lower than that for patients with Stage T3 and T4 tumors (35 percent at 8 years) at the p = 0.0024 level.

Sipple's syndrome A urologist's viewpoint

A case of Sipples syndrome, a triad of medullary carcinoma of the thyroid, pheochromocytoma, and parathyroid hyperplasia is presented. The cause, laboratory diagnosis, and operative management of the syndrome are discussed. The need for thorough endocrine screening of patients with pheochromocytoma and family screening of patients with the full syndrome is stressed.