Elwin E. Fraley

The Value of Serum Prostate Specific Antigen Determinations Before and after Radical Prostatectomy

We evaluated serum prostate specific antigen before and after radical prostatectomy. In 100 consecutive patients who underwent radical prostatectomy, preoperative prostate specific antigen levels tended to increase with the increasing severity of pathological stage. However, even at levels of greater than 10 ng. per ml. the positive and negative predictive values (78 and 61 per cent, respectively) of prostate specific antigen to predict extracapsular disease were not sufficient to make this test useful alone for staging. In theory, after radical prostatectomy prostate specific antigen should be zero if no remaining prostatic tissue is present. Tests of precision and analytical sensitivity in our laboratory using a commercial prostate specific antigen assay revealed that a value of 0.4 ng. per ml. or more is different from zero at a greater than 95 per cent confidence level. With this guideline we evaluated the meaning of prostate specific antigen levels 3 to 6 months after radical prostatectomy in 59 men. Among men whose prostate specific antigen level was less than 0.4 ng. per ml. only 9 per cent demonstrated recurrence as evidenced by the development of positive bone scan or progressively elevated prostate specific antigen levels within 6 to 50 months. Alternatively, in men whose 3 to 6-month prostate specific antigen level was 0.4 ng per ml. or more there was evidence of recurrence in 100 per cent within 6 to 49 months (p less than 0.0001). Progressively elevated (more than 0.4 ng. per ml.) prostate specific antigen levels preceded recurrence from 12 to 43 months in all 6 patients who had positive bone scans, while increasing prostate specific antigen levels since radical prostatectomy have continued from 9 to 65 months in the 11 patients who have no radiological evidence of recurrent disease to date. Prostatic acid phosphatase serum values after radical prostatectomy were not useful to predict persistent disease. Prostate specific antigen values 3 to 6 months after radical prostatectomy are a sensitive indicator of persistent disease after radical prostatectomy and often precede other evidence of this occurrence by many years. This fact may alter concepts about surgical results, and possibly shorten and sharpen clinical studies involving adjuvant therapy after radical prostatectomy.

Malignant Urachal Lesions

Urachal cancers are uncommon malignancies with a location that often permits considerable local extension before they are discovered. The most common histological type is adenocarcinoma, which may produce mucus that is a valuable aid in diagnosis. The presence of stippled calcification in a midline abdominal wall mass is almost pathognomonic for urachal carcinoma. More commonly, however, the symptoms are less specific, such as hematuria and an abdominal mass. Many lesions are visible endoscopically and, thus, the diagnosis can be made preoperatively from a biopsy. Most treatment failures occur because the tumor is not controlled locally by the initial operation and, therefore, we recommend en bloc cystectomy with umbilectomy and pelvic lymphadenectomy unless the tumor is known to be a sarcoma or early stage (I) carcinoma. If these patients are undertreated and there is a local recurrence then the patient usually is not salvageable. Because of the difficulty in identifying the origin of a bladder adenocarcinoma, any tumor on the dome or anterior wall should be approached initially as if it were a urachal tumor.

Incidental Carcinoma of the Prostate: a Review of the Literature and Critical Reappraisal of Classification

The problem in treating incidental carcinoma of the prostate is that of distinguishing between tumors that will have a long, benign natural history and those that will progress rapidly. A review of the English literature concerning incidental prostatic carcinoma reveals that patients with focal low grade tumors have a good prognosis, while patients with high grade lesions often suffer rapid tumor progression. By contrast, the clinical significance of high volume, low grade tumor is unknown. A method has been developed to evaluate the distribution of prostatic cancer using 4-quadrant transurethral prostatic resection. A detailed method for staging these cancers based on a comprehensive, segmental histopathological analysis also is presented. A precise definition of the stages of prostatic cancer should eventually improve our understanding of the natural history of this disease.

Tissue Blood-Group Antigens and Prognosis in Low Stage Transitional Cell Carcinoma of the Bladder

The loss of A, B or H blood-group antigens from the surface of neoplastic epithelial cells has been correlated with aggressive tumor behavior. We examined this phenomenon in low stage transitional cell carcinoma of the bladder. In an analysis of biopsy material from 37 patients the absence of these antigens on the original or recurrent tumors correlated with the subsequent development of invasive disease (stage B or greater), while the presence of antigens correlated with failure to develop invasive disease. Analysis of transitional cell surface antigens may help improve the therapy of bladder cancer.

The Role of Ilioinguinal Lymphadenectomy and Significance of Histological Differentiation in Treatment of Carcinoma of the Penis

We reviewed retrospectively the medical records of 58 patients treated for squamous cell carcinoma of the penis who were followed for more than 3 years or until they died. Tissue sections from all patients were reviewed. Of 15 patients with stage I disease 11 underwent partial penectomy, and 4 underwent partial penectomy and immediate ilioinguinal lymphadenectomy; none died of cancer. Nine patients with stage II and 9 with stage III disease underwent partial or total penectomy and immediate ilioinguinal lymphadenectomy, and 5-year survival was 100 and 75%, respectively. Of 20 patients with clinical stage II disease who did not undergo immediate ilioinguinal lymphadenectomy 18 had metastasis to the groin. Of these 18 patients 12 underwent delayed ilioinguinal lymphadenectomy but only 1 survived more than 5 years. We evaluated the possible significance of the degree of histological differentiation of the primary tumor to the course of the disease. Of the 23 cases of carcinoma in situ or well differentiated disease only 1 became metastatic, while of the 35 cases of moderately to poorly differentiated disease 31 metastasized to the groin. Vascular invasion of cancer cells in the primary tumor was another indicator for poor prognosis.

IMPACT OF DELAY IN DIAGNOSIS ON CLINICAL STAGE OF TESTICULAR CANCER

Abstract Of 335 patients with germ-cell testicular cancer, 87·5% of the patients had symptoms related to the testis. Only 40% of the patients saw a physician within 2 weeks. Similarly, testicular signs were present in more than 90% of patients, but in only 61% of patients was a correct diagnosis made within 2 weeks of the initial physician visit. The length of the patient-related and physician-related delay was directly related to the clinical stage of the cancer at diagnosis. The median patient-plus-physician delay for stage I was 75 days, for stage II, 101 days, and for stage III, 134 days (p=0·017). Education programmes for the public and for physicians are needed to reduce delay in diagnosing testicular cancer.

Renal Cell Cancer Invading the Inferior Vena Cava: Clinical Review and Anatomical Approach

Renal cell carcinoma invades the inferior vena cava in approximately 5 per cent of the patients. The only effective therapy for intravascular renal cell carcinoma is radical nephrectomy and complete removal of the tumor thrombus. To formulate a reasonable operative approach to intracaval renal cell carcinoma we have reviewed our experience with 6 cases as well as the experience of other investigators. In addition, we studied the collateral circulation of the renal veins as described by various anatomists, and to this information we have added our experience with inferior venacavography and with intraoperative and autopsy dissections. Herein we describe a new preoperative staging system for intravascular renal cell carcinoma. The operative approach to each stage is discussed in detail beneficial intraoperative maneuvers are described and illustrated.

Ejaculation and Fertility After Extended Retroperitoneal Lymph Node Dissection for Testicular Cancer

We studied ejaculation and fertility in 55 men who had undergone suprahilar extended retroperitoneal lymphadenectomy for nonseminomatous testicular cancer between 1972 and 1980. Antegrade ejaculation had returned spontaneously in 25 patients, with sperm counts of 35 to 190 million per ml., and normal morphology and motility in 20. The other 5 men either refused to provide semen for analysis or had had vasectomies but all had fathered children postoperatively. Ten men in whom antegrade ejaculation had not returned spontaneously were treated wih sympathomimetic drugs. Antegrade ejaculation was induced in 5 patients, 1 of whom fathered a child while taking the drugs. Two other patients who had only small volumes of ejaculate also responded well to sympathomimetic drugs. A therapeutically sound retroperitoneal node dissection can be performed for testicular cancer without impairing fertility permanently in a significant number of patients.

A, B, H antigens in transitional cell tumors of the urinary bladder: correlation with the clinical course.

The A, B, H blood group antigens can be detected in normal transitional epithelium of the urinary bladder by the red cell adherence (RCA) test. We examined the possibility that the reactivity for these antigens is lost or decreased in transitional cell carcinomas and that such a change may reflect the future evolution of these tumors. We studied several bladder biopsies from 60 patients who presented with noninvasive transitional cell carcinomas and were followed for at least 5 years or until muscle invasion was histologically demonstrated. Eighty‐one percent of patients whose tumors were RCA positive in the initial biopsy did not subsequently develop invasive tumors and 27% of these patients had no recurrences. All 34 patients whose tumors were negative in the initial biopsy experienced recurrences and 62% of them developed invasive lesions. In 81% of patients, the recurrent tumors retained the same pattern of RCA reactivity for blood group antigens on serial biopsies. These results suggest that the presence of readily detectable A, B, H antigens correlates with a favorable prognosis whereas their absence denotes an aggressive potential.

Germ-Cell Testicular Cancer in Adults

(First of Two Parts) THIS review is warranted by the recent progress in understanding and treating testicular cancer. For example, it has been established that nearly all these cancers originate in...