Judith E. Robertson

Surgical Management and Prognosis of Renal Cell carcinoma Invading the Vena Cava

A total of 44 patients with renal cell carcinoma and vena caval tumor thrombus underwent surgical resection. Of these patients 27 had primary tumor confined within Gerotas fascia, negative lymph nodes and no distant metastases (stage T3cN0M0). Patients who underwent extraction of a mobile tumor thrombus from the vena cava had a 69% 5-year survival rate (median 9.9 years) but patients with tumor thrombus directly invading the vena cava had a 26% 5-year survival rate (median 1.2 years), which improved to 57% (median 5.3 years) if the involved vena caval side wall was resected successfully. Of these patients 17 had renal cell carcinoma with vena caval thrombus as well as extrafascial extension, regional lymphadenopathy or distant metastases, and the 5-year survival rate was less than 18% in all groups (median survival less than 0.9 years). Prognosis was determined by the pathological stage of the renal cell carcinoma and by the presence or absence of vena caval side wall invasion but not by the level of tumor thrombus extension. Patients with incomplete resection of localized renal cell carcinoma with tumor thrombus do not survive any longer than those with extensive cancer, positive lymph nodes or distant metastases. However, when partial venacavectomy establishes negative surgical margins then survival markedly improves.

Radical Cystectomy for Stages TA, TIS and T1 Transitional Cell Carcinoma of the Bladder

Between January 1969 and January 1990, 531 patients underwent bilateral pelvic lymph node dissection and radical cystectomy for the management of transitional cell carcinoma of the bladder. Of these procedures 220 were performed for clinical stage Ta (31 patients), Tis (23) or T1 (166) disease, which was either high grade or recalcitrant to transurethral resection and/or intravesical chemotherapy. This subgroup of patients was studied to evaluate the outcome of recurrent or chemotherapy resistant superficial transitional cell carcinoma of the bladder after radical cystectomy. The operative mortality rate for the group was 2.3% and the overall complication rate was 20.4%. The pelvic recurrence rate was 5.9%. The 5-year cancer-specific survival rates for patients with pathological stage Ta (11), Tis (19), T0 (43) and T1 (91) disease were 88%, 100%, 80% and 76%, respectively. The 10-year cancer-specific survival rates were 75%, 92%, 66% and 62%, respectively. A total of 74 patients received preoperative radiation therapy (2,000 rad) but they had no better 5-year cancer-specific survival rates than did nonirradiated patients. Transurethral resection and/or preoperative radiation therapy resulted in a pathological status of T0 in 43 patients but this did not confer a survival advantage. Although bladder preservation is preferable, low operative mortality and pelvic recurrence rates, as well as new methods of continent urinary diversion continue to make radical cystectomy the definitive form of therapy for patients with superficial disease recalcitrant to transurethral therapy.

The value of pathologic factors in predicting cancer‐specific survival among patients treated with radical cystectomy for transitional cell carcinoma of the bladder and prostate

Background. A recent consensus conference on bladder carcinoma highlighted the need for pathologic predictors of outcome for patients with transitional cell carcinoma of the bladder. This review was undertaken to determine the pathologic features predictive of cancer‐specific survival after a radical cystectomy and urinary diversion for transitional cell carcinoma of the bladder and prostate.

Complications of Radical Cystectomy and Urinary Diversion: A Retrospective Review of 675 Cases in 2 Decades

A retrospective review was performed on all 675 patients who underwent radical cystectomy and urinary diversion during 2 decades. Of the patients 197 were treated from 1969 to 1979 (group 1) and 478 were treated from 1980 until 1990 (group 2). The mean age of patients in group 1 was 56.7 years versus 64.2 years in group 2 (p < 0.001). The overall operative mortality rate in both groups was 2.5%. A total of 215 patients (31.9%) experienced postoperative complications (within 30 days of surgery). The morbidity rate was nearly identical between the 2 groups (32.0% for group 1 versus 31.8% for group 2, p = 0.962). Of note, however, there was a decreased incidence of wound infections and wound dehiscence among the patients in group 2 compared to group 1. Long-term complications occurred in 198 of the 675 patients (29.3%). At followup group 1 had a 35.5% incidence of long-term complications versus 26.8% in group 2 (p = 0.022). Most notably there was significant improvement in the incidence of ureteroenteric anastomotic strictures when comparing groups 1 (11.2%) and 2 (5.2%) (p = 0.006).

Radical perineal prostatectomy : oncological outcome during a 20-year period

PURPOSE We examined 4 postulates: 1) radical perineal prostatectomy provides a substantial disease control benefit in men with clinically confined prostate cancer, 2) postoperative prostate specific antigen (PSA) levels are an excellent surrogate end point for defining disease control, 3) the biology of primary malignancy defines the interval to death after recurrence and 4) the interval from intervention to death from recurrence is so long that current series of alternative curative therapies have insufficient duration of observation to permit a comparison with the results of surgery. MATERIALS AND METHODS A total of 1,242 men with a median age of 65.2 years who had stage cT1 to 2 N0M0 disease underwent radical perineal prostatectomy. The final pathology specimen was characterized in regard to disease extent, and Gleason grade and score. Patients were followed at 2 weeks, at 2 months and then at 6-month intervals for biochemical, physical and radiographic evidence of disease recurrence. Outcome was evaluated by determining time to biochemical failure (PSA 0.5 ng./ml. or greater) and cancer associated death. RESULTS Median time to noncancer death was 19.3 years. Median cancer associated death end point was not reached by patients with organ and specimen confined disease, while it was 12.7 years for margin positive disease. At 5 years 8, 35 and 65% of the patients with organ confined, specimen confined and margin positive disease, respectively, had PSA failure. This served as an excellent surrogate end point, preceding cancer associated death by 5 to 12 years depending on the biological aggressiveness predicted by Gleason grade or score. Biologically aggressive organ confined disease that had been surgically removed was associated with a high percentage of disease-free survival. CONCLUSIONS Our study confirms our postulates. It also provides guidelines for comparing therapies among institutions and emphasizes that enthusiasm for new treatments may be based on insufficient followup. Patient selection may severely bias outcome independent of treatment when death is used as the end point. Our study establishes the value of PSA as a surrogate end point.

Radical Prostatectomy: the Pros and Cons of the Perineal Versus Retropubic Approach

Radical prostatectomy is frequently recommended for the treatment of localized adenocarcinoma of the prostate. The use of the perineal versus the retropubic approach is mostly dependent upon the experience of the individual surgeon. This study was performed to evaluate the short-term differences between the 2 operations. Between 1988 and 1989, 173 patients were identified with organ confined prostate cancer (stage A or B) who were treated with radical prostatectomy. Of this total population 122 patients underwent radical perineal prostatectomy (group 1) and 51 patients underwent radical retropubic prostatectomy (group 2). The median estimated blood loss for group 1 was 565 cc and for group 2 it was 2,000 cc (p less than 0.001). Group 1 received a median of 0 units of blood during hospitalization, while group 2 received a median of 3 units of blood (p less than 0.001). The total operative time was slightly shorter for group 1 but the anesthesia time was similar for both patient populations. There was no difference in the incidence of positive surgical margins, and in in-hospital and long-term complication rates between the 2 groups. In light of these significant findings it is our belief that the radical perineal prostatectomy is an excellent approach for the treatment of adenocarcinoma of the prostate.

Clinical variables which serve as predictors of cancer-specific survival among patients treated with radical cystectomy for transitional cell carcinoma of the bladder and prostate

Background. Studies have demonstrated conclusively that the stage and grade of transitional cell tumors at presentation are major determinants of survival for those with the disease in the bladder and prostate. The authors initiated a review of 531 patients with transitional cell carcinoma of the bladder and prostate treated with radical cystectomy between 1969 and 1990 to identify other clinical features predictive of cancer‐specific survival.

Expanding indications for conservative renal surgery in renal cell carcinoma.

OBJECTIVE To more clearly define the selection criteria for conservative renal surgery in renal cell carcinoma. METHOD The survival experience of 42 patients who underwent in situ partial nephrectomy (21), enucleation (18), or both (3) over an eighteen-year period was examined. The presence or a history of contralateral cancer, type of surgery, gender, grade, diameter of tumor, age at diagnosis, presenting symptoms, positive surgical margins, smoking history, and stage were examined with regard to prognostic significance. RESULTS The five-year cancer-specific survival rates were 100 percent for those patients undergoing partial nephrectomy and 84 percent for those undergoing enucleation. The local recurrence rate was 4.8 percent (2/42) for the group, with both recurrences occurring in patients with von Hippel-Lindau disease. The mean diameter of tumor resected was 4.2 cm. Those patients found to have a positive surgical margin (6) had a significantly shorter disease-specific survival than those who did not (37) (p = 0.004), and those with a smoking history (23) had a significantly shorter survival than non-smokers (19) (p = 0.038). CONCLUSIONS We conclude that both partial nephrectomy and enucleation are acceptable approaches to renal cell carcinoma in select cases, with survival rates that closely approximate those found in radical nephrectomy series. Renal carcinomas that are peripherally located and small in diameter (< or = 5 cm) are most appropriate for these procedures, and given the excellent results noted to date, the expanded use of these approaches to include very young patients and those with any disease process that may affect renal function is warranted. A positive surgical margin is an ominous pathologic finding and should be avoided by frozen section biopsy at surgery or possibly intraoperative ultrasonography. Additionally, smokers with renal cell carcinoma have a poorer disease-specific survival than non-smokers, further questioning a carcinogenic etiology in this disease.

Does radical prostatectomy in the presence of positive pelvic lymph nodes enhance survival

SummaryA retrospective review was performed on all patients with stage D1 prostate cancer treated at Duke University Medical Center between 1975 and 1989. A total of 156 patients underwent staging pelvic lymph-node dissection for clinically organ-confined prostate cancer (stage A or B) but were found to have disease metastatic to the pelvic lymph nodes (stage D1). Of this population, 42 patients also underwent radical prostatectomy (group 1), leaving 114 who did not have their prostate removed (group 2). The median cancer-specific survival was 11.2 years for group 1 versus 5.8 years for group 2 (P=0.005). In patients with one or two positive lymph nodes the median cancer-specific survival was 10.2 years for group 1 versus 5.9 years for group 2 (P=0.015). There was no difference in survival if three or more lymph nodes were positive. Adjuvant treatment with immediate androgen deprivation and/or postoperative radiation therapy failed to improve the survival experience. The incidence of local problems, including stricture formation, bleeding, or regrowth of cancer requiring dilation or surgical intervention (transurethral prostatectomy) averaged 9.5% in group 1 and 24.6% in group 2. These data show that patients with limited node-positive disease selected for radical prostatectomy experience a survival advantage over those denied such therapy and that this advantage is independent of adjunctive therapy.

Postoperative Radiotherapy of the Prostate for Patients Undergoing Radical Prostatectomy With Positive Margins, Seminal Vesicle Involvement and/or Penetration through the Capsule

A group of 159 patients previously reported as having margins positive for disease after radical prostatectomy with or without adjunctive postoperative radiation was reanalyzed to determine whether the reported benefit did indeed exist. Upon re-examination of the 159 patients 15 were identified who did not receive radical prostatectomy but who were analyzed as if they had received this therapy. An updated review of the total pool of 159 patients with analysis as to failure, death of any cause or death of prostatic cancer demonstrated no benefit of postoperative radiation therapy for margin positive disease. Exclusion of patients who did not receive radical prostatectomy and analysis as described also failed to identify any benefit of postoperative adjunctive radiation therapy.