Mark S. Austenfeld

Overexpression of Her-2/Neu may be an Indicator of Poor Prognosis in Prostate Cancer

Previous reports have shown that Her-2/neu oncogene expression in human breast cancer and ovarian cancer may be associated with poorer prognosis. We report the expression of Her-2/neu on fresh samples of known prostatic adenocarcinoma but not on those of benign prostatic hypertrophy. Using a monoclonal antibody (TA1) directed against human Her-2/neu oncogene product and an immunohistochemical staining method, no Her-2/neu expression was noted with benign prostatic hypertrophy (15 samples). With prostatic adenocarcinoma samples, a subset (9 of 25) showed overexpression of Her-2/neu. Such overexpression is correlated with higher histological grade, higher stage of disease, and high S phase and aneuploidy on flow cytometric analysis. These findings suggest that Her-2/neu may be a prognostic marker in prostate cancer as well.

Transitional cell carcinoma of the renal pelvis or ureter: Patterns of failure

OBJECTIVES To identify recurrence patterns and possible indications for adjuvant treatment. METHODS Ninety-four patients with transitional cell carcinoma of the renal pelvis or ureter were reviewed to determine their pattern of failure. Factors including gender and age, tumor stage and grade, and extent of surgical procedure and adjuvant radiation therapy (RT) were analyzed with respect to local and distant recurrence and survival. RESULTS Seventy-seven patients had resections without residual. On multivariate analysis, grade (P = 0.01) and adjuvant RT (P = 0.02) had significant effects on local control. Metastases were solely dependent on stage (P = 0.0001). Survival was dependent on stage (P = 0.0059) and age (P = 0.036), with the use of adjuvant RT of borderline significance (P = 0.07). Twenty-seven patients were excluded from local failure and survival analysis; of these, 3 died within 1 month of surgery, 5 had metastasis at presentation, and 19 had local disease that was unresectable. Eleven of these 19 were treated by RT, resulting in 2 long-term disease-free survivors after receiving doses of 45 and 50.4 Gy. CONCLUSIONS In patients with adverse factors, such as high grade or stage, close margins, or positive nodes, local control can be improved with adjuvant radiation. Improvement in survival is of borderline significance on multivariate analysis, with approximately 50% of high stage or grade patients developing metastasis.

Adjuvant radiotherapy in high stage transitional cell carcinoma of the renal pelvis and ureter

This review was undertaken to assess the influence of adjuvant radiation therapy on failure patterns and survival in high stage transitional cell carcinoma of the renal pelvis or ureter. Ninety-four patients with transitional cell carcinoma of the renal pelvis or ureter were retrospectively reviewed. Twenty-six had American Joint Commission stage T3 or T4 N0/+, M0 disease and underwent curative resections (median follow-up 13.5 months, range 3-311). Local failure was defined as recurrence in the tumor bed, regional nodes, or ureteral stump. Time to recurrence and survival were calculated from the time of pathologic diagnosis. Variables associated with local failure, distant metastasis, and survival were analyzed using univariate and multivariate analysis. Seventeen received surgery only, nine received adjuvant radiation therapy (median dose 50 Gy). Local failure occurred in 9 of 17 without and 1 of 9 with adjuvant radiation therapy (p = 0.07). Actuarial 5-year local control was 34% without and 88% with adjuvant radiation therapy. Cox step-wise regression confirmed adjuvant radiation therapy (p = 0.006) and grade (p = 0.006) as significantly associated with local failure. No patients with low grade lesions suffered local failure either with or without adjuvant radiation therapy. High grade lesions had an local failure rate of 15% with and 71% without adjuvant radiation therapy. Metastatic disease occurred in 4 of 9 and 8 of 17 with and without radiation therapy. No significant factors influencing distant failure were identified. Five-year actuarial survival was 44% with and 24% without adjuvant radiation therapy. The survival differences were not statistically significant on univariate or multivariate analysis. High staged transitional cell carcinoma of the renal pelvis or ureter has a substantial local failure risk after surgery alone. Adjuvant radiation therapy markedly reduces this risk but has no impact on distant disease which occurs in approximately 50%. Effective adjuvant therapy will require effective systemic therapy in addition to adjuvant radiation therapy.

Meta-analysis of the literature : guideline development for prostate cancer treatment

Medical interventions are identified to be in need of practice guidelines based on several criteria, including uncertainty of therapeutic benefit, economic impact, variation in practice patterns and lack of objective data for new developments. Treatment of localized adenocarcinoma of the prostate meets these criteria and has been identified as an issue in need of practice guideline development. The American Urological Association began working toward establishing prostate cancer treatment guidelines in 1989. An explicit method based on collection of scientific data was adopted, which requires complete review of the literature and analysis of the evidence collected. An update on the progress toward this data analysis and guideline document is presented.

Multicentric renal angiomyolipoma associated with pulmonary lymphangioleiomyomatosis : Case report, with histologic, immunohistochemical, and DNA content analyses

A 26-year-old pregnant woman presented with pulmonary lymphangioleiomyomatosis (LAM) and multicentric angiomyolipoma (AML) involving the left kidney and perirenal lymph nodes. In both tumors, smooth muscle cells were the predominant component. Immunohistochemically, these cells stained for vimentin, smooth muscle actin, desmin, and HMB-45. Estrogen receptors were weakly positive in LAM and negative in AML. Progesterone receptors were negative for both lesions. DNA content analysis studies showed the renal AML to be diploid with a minor aneuploid component, the lymph node AML aneuploid, and the LAM diploid. The diagnostic and prognostic significance of hormonal studies and DNA content analysis are discussed.

Histologic confirmation of lesions identified by Prostascint® scan following definitive treatment

The purpose of the study was to determine the accuracy of the monoclonal antibody (Mab) [Prostascint, Cytogen, Inc.] scan for the detection of nodal metastases using histologic examination of surgical lymphadenectomy specimens as the standard of reference. We reviewed the records of 31 patients who had undergone biopsy after monoclonal antibody scan. Histologic evaluation was obtained for a total of 31 patients and 43 pathology samples. When analyzed by surgical site, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the Mab scan were 94%, 42%, 53%, 92% and 65%, respectively. When analyzed by individual patient, the same data for the Mab scan were 100%, 33%, 62%, 100% and 68%, respectively. Current noninvasive studies are not sufficiently accurate to reliably determine the presence of metastatic nodal disease from prostate cancer. This series illustrates the importance of rigorous clinical evaluation of future methods that are designed to detect microscopic metastatic disease of any neoplasm.

Comparison of Patient-Controlled Analgesia Versus Intramuscular Narcotics in Resolution of Postoperative Ileus after Radical Retropubic Prostatectomy

Patient-controlled analgesia has become standard practice after major abdominal operations. The benefits of patient-controlled analgesia have been well documented. However, its possible effect of prolonging postoperative ileus has not been well examined. To determine if patient-controlled analgesia prolongs postoperative ileus when compared to conventional intramuscular narcotics, a retrospective review of length of postoperative ileus in 98 consecutive patients (62 using patient-controlled analgesia and 36 using intramuscular narcotics) undergoing bilateral pelvic lymphadenectomy and radical retropubic prostatectomy was done. The patients receiving patient-controlled analgesia resolved the postoperative ileus an average of 1.0 day later than the intramuscular injection group (5.2 days versus 4.2 days p < 0.0001). Overall hospital stay was not significantly affected. Our results show that patient-controlled analgesia use prolongs postoperative ileus.

Combined cholecystectomy and radical genitourinary cancer surgery

We have routinely performed simultaneous cholecystectomy in patients with cholelithiasis undergoing selected radical genitourinary cancer surgery. A total of 31 patients have undergone cholecystectomy at the time of radical nephrectomy (25), radical cystectomy (5), and radical prostatectomy (1). Operative time was increased twenty-five to forty-five minutes. There was no significant increase in blood loss, postoperative total bilirubin, or number of complications. No complications were directly attributable to the cholecystectomy except for 1 patient who had prolonged drainage from a closed suction drain in the gallbladder fossa. We conclude that concomitant cholecystectomy at the time of radical genitourinary cancer surgery does not significantly increase morbidity and recommend that it be performed in the presence of cholelithiasis.

Fatal Pulmonary Embolus from Ischemic Necrosis of Intracaval Tumor Thrombus: A Case Report

Angioinfarction of renal tumors has been proposed as a preoperative adjunct and as palliative therapy. Most side effects of angioinfarction are transient and are well tolerated by the patient. We report a case of fatal pulmonary embolus resulting from migration of an intracaval tumor thrombus following renal arterial embolization.

Quantitative Effects of Antiandrogen Therapy on High-Grade Prostatic Intraepithelial Neoplasia in Radical Prostatectomy Specimens

High-grade prostatic intraepithelial neoplasia (HGPIN) is considered to be the premalignant lesion of prostatic adenocarcinoma. This study was performed to evaluate the quantitative effects of antiandrogen (AA) therapy on HGPIN. Glass slides from totally embedded radical prostatectomy specimens from ten patients treated with leuprolidine and/or flutamide prior to surgery were examined for area of HGPIN, and compared with those of ten patients who had received no therapy. Patients from each group had comparable serum PSA levels, age, and histologic tumor grades. Only HGPIN located one half low-power field or more from the tumor were measured. The total area of HGPIN from each case was then expressed as the percentage of the total area of prostate examined. Our results showed that, in the treated group (n = 10), the mean area involved by HGPIN was 0.034 ± 0.028% of the total area examined, and 0.087 ± 0.061%, p < 0.038, in the untreated group (n = 10). This retrospective study suggests that HGPIN may be reversed with AA therapy.