Katja Lipsky

Impact of tumor-associated symptoms on the prognosis of patients with renal cell carcinoma: a single-center experience of 683 patients

OBJECTIVES To evaluate the impact of cancer-associated symptoms present at the diagnosis of renal cell carcinoma (RCC) on the prognosis of patients. Increasing numbers of RCC are currently detected incidentally by routine ultrasonography. METHODS From January 1994 to December 2000, 693 operations for RCC in 683 consecutive patients have been performed at our institution. Overall, tumor-specific, and progression-free survival were investigated using the Kaplan-Meier method. For multivariate analysis regarding tumor-specific survival, the Cox regression model, including risk ratios, was used. A receiver operating characteristics curve regarding the sensitivity and specificity for the association between tumor size and symptoms was used. RESULTS Of the 683 patients, 417 patients were male and 266 female. The mean patient age was 62 years (range 16 to 88). Of the 683 patients, 141 (20.8%) presented with symptoms suspicious for cancer. The 5-year overall, progression-free, and cancer-specific survival rates were 82%, 79%, and 86%, respectively, for asymptomatic patients compared with 60%, 55%, and 65%, respectively, for patients with symptoms at diagnosis (P <0.0001, log-rank test). The cutoff value of 5 cm for the tumor diameter to result in symptoms was chosen on the receiver operating characteristic curve. Multivariate analysis found tumor grade (P = 0.001), tumor stage (P = 0.001), presence of symptoms (P = 0.013), and tumor diameter (P = 0.005) to be independent prognostic parameters for cancer-specific survival. CONCLUSIONS Tumors larger than 5 cm were significantly more likely to cause symptoms compared with smaller tumors in our series. In multivariate analysis, patients presenting with symptoms suspicious for cancer at the diagnosis of RCC had a 1.8-fold greater risk of dying of cancer compared with patients without symptoms.

Did the rate of incidental prostate cancer change in the era of PSA testing? A retrospective study of 1127 patients

OBJECTIVES To evaluate, in a retrospective study, the impact of routine prostate-specific antigen (PSA) testing on the rate of incidental prostate cancer in patients undergoing surgery for obstructive symptoms caused by presumed benign prostatic enlargement (BPE) and to investigate the indication of a routine biopsy before alternative treatment procedures for BPE. In the pre-PSA era, the diagnosis of incidental carcinoma was exclusively based on normal digital rectal examination (DRE) findings. METHODS Since January 1993, 2422 operations (2283 transurethral resection of the prostate, 139 retropubic adenoma enucleations) for BPE were performed at our institution. The preoperative DRE findings and PSA level were evaluated, and patients with any suspicion for cancer were excluded. The pathologic reports of all patients were reviewed. A diagnosis of incidental carcinoma of the prostate required histologic evidence of cancer and negative DRE findings and a PSA level within age-specific reference ranges preoperatively. RESULTS Of 2422 patients, 1127 (46.5%) had both negative DRE findings and an age-specific PSA level and were evaluated for our study. Overall, prostate cancer was diagnosed by surgery in 314 (13%) of 2422 patients. The rate of incidental prostate cancer in patients with both negative age-specific PSA levels and negative DRE findings was 6.4% (72 of 1127). CONCLUSIONS In our series, the likelihood of detecting incidental prostate cancer by surgery was 6.4%. In the PSA era, the rate of incidental prostate cancer has been decreased by more than 50%. Today, the low rate of incidental carcinoma does not warrant routine histologic evaluation of the prostate if PSA testing and DRE are negative when alternative treatment modalities without tissue sampling are offered for the treatment of BPE.

Detection of prostate cancer by TURP or open surgery in patients with previously negative transrectal prostate biopsies

OBJECTIVES To evaluate retrospectively the effectiveness of transurethral resection of the prostate (TURP) in diagnosing prostate cancer in patients with obstructive voiding symptoms and a history of negative transrectal prostate biopsy but elevated prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE). METHODS In 1189 consecutive patients undergoing TURP or open prostatectomy between 1994 and 2000 for obstructive voiding symptoms, we identified 445 patients (37.4%) with at least one previous set of transrectal prostate biopsies because of an elevated PSA level and/or abnormal DRE findings. The probability to detect prostate cancer by TURP (n = 423; 95%) or open surgery (n = 22; 5%) was investigated overall, as well as related to patient age, PSA level, DRE findings, number of previous biopsies, time from biopsy to surgery, and weight of resected tissue. RESULTS The mean number of preoperative negative biopsies per patient was 1.6 (range 1 to 8). The mean patient age was 69 years (range 48 to 89). The median PSA level and resection weight was 8.64 ng/mL and 32 g, respectively. Ninety-seven patients (21.8%) had abnormal DRE findings. Overall, prostate cancer was detected in 35 patients (7.9%). The cancer incidence was 5.5% (19 of 348) in patients with a normal DRE compared with 16.5% (16 of 97) in patients with an abnormal DRE (P <0.001; Fishers exact test). The cancer rate was also related to age; other subgroups showed no statistically significant differences regarding cancer incidence. CONCLUSIONS In patients with previously negative biopsies, the diagnostic yield of TURP is low. Therefore, TURP for diagnostic purposes only cannot be recommended. However, in patients with an abnormal DRE and obstructive symptoms, surgery should be preferred over alternative treatment options.

Do patients with a higher body mass index have a greater risk of advanced-stage renal cell carcinoma?

OBJECTIVES To evaluate whether patients with a higher body mass index (BMI) are at elevated risk of an advanced tumor stage for renal cell carcinoma at diagnosis. A high BMI has recently been proved to be associated with advanced tumor stages for some malignant diseases. METHODS From January 1994 to December 2000, 693 operations for renal cell carcinoma were performed in 683 patients at our institution. Ten patients underwent surgery twice for bilateral tumors. Of the 683 patients, 417 were men and 266 women. The mean age at surgery was 62.2 years, and the mean tumor diameter was 5.2 cm. Seventy-eight percent of the patients were asymptomatic at tumor diagnosis. The following parameters were evaluated with regard to a possible correlation to tumor stage and/or tumor diameter: BMI, presence of symptoms, age, sex, hemoglobin, lactate dehydrogenase, erythrocyte sedimentation rate, serum cholesterol, and triglycerides. For statistical analysis, the Spearman rank correlation test was used. RESULTS The mean BMI was 26.8 +/- 4.4 (range 16.9 to 44.3). Statistical analysis showed a significant positive correlation between advanced T stage and the presence of symptoms (P <0.0001), erythrocyte sedimentation rate (P <0.0001), lactate dehydrogenase (P = 0.0015), and age (P = 0.046), and an inverse correlation with hemoglobin (P <0.0001) and serum cholesterol (P <0.0001). For all other investigated parameters, including BMI, no significant correlation could be proved. CONCLUSIONS Our data indicate that obese patients are not at greater risk of advanced tumor stages of renal cell carcinoma at the time of diagnosis compared with a population of normal weight.

Testicular tumor with gastrointestinal hemorrhage

Abstract We report a case of a 37-year-old man who presented with signs of gastrointestinal hemorrhage. Emergency endoscopy revealed a bleeding tumor in the duodenum. The history and physical investigation showed a tumor in the right testis. Computed tomography demonstrated multiple metastases, including retroperitoneal bulk infiltrating the duodenum. The histologic evaluation proved a germ cell tumor. After testicular ablation, immediate chemotherapy was started. After a partial remission, the patient died of progressive metastatic disease 11 months later. This is only the second published case of a metastatic germ cell tumor diagnosed by severe anemia resulting from gastrointestinal hemorrhage.