Mircea Golimbu

Renal cell carcinoma: Survival and prognostic factors

Three hundred twenty-six patients treated at New York University from 1970 to 1982 were studied for survival in relationship to surgical stage, type of therapy, and pathologic characterization of the primary tumor. At the time of diagnosis 25.5 per cent of tumors were Stage I, 15 per cent Stage II, 28.5 per cent Stage III, and 31 per cent Stage IV. The retrospective study showed that patients with tumor confined within the capsule achieved the highest five- and ten-year survivals of 88 per cent and 66 per cent, respectively. Survivals decreased as tumor invaded perirenal fat (67% and 35%) or regional lymph nodes (17% and 5%). Tumor invasion into the renal vein alone did not significantly change five-year survival (84%) but lowered ten-year survival to 45 per cent. Patients with metastases at the time of nephrectomy did poorly regardless of site of metastases or kind of adjuvant therapy, except for those managed by surgical extirpation of the secondary lesion. Certain tumor characteristics were associated with a better prognosis, e.g., size below 5 cm in diameter, lack of invasion of collecting system, perirenal fat or regional lymph nodes, and predominance of clear or granular cells growing into a recognizable histologic pattern.

Extended Pelvic Lymphadenectomy for Prostatic Cancer

Thirty patients with clinically localized prostatic carcinoma underwent extended pelvic lymph-adenectomy, including the presacral and presciatic (lateral sacral) areas. The first echelon of pelvic nodes to be involved by metastases was the external iliac, obturator, presacral and presciatic. The deep presacral-presciatic nodes were involved almost as often as the more superficial external iliac-obturator group. Metastases limited only to the deep pelvic nodes were found in 14 per cent of the cases.

Partial Nephrectomy for Renal Cell Carcinoma: Indications, Results and Implications

Of 52 patients who underwent partial nephrectomy for tumor 44 were found to have renal cell carcinoma. The indications for this parenchyma-sparing procedure were categorized according to the initial status of the contralateral kidney and included bilateral tumors or tumor in a solitary kidney in 16 patients (mandatory indications), unilateral carcinoma with compromise of the contralateral kidney by a benign disease process in 9 (relative indications) and small peripheral tumor with a normal contralateral kidney in 19 (elective indications). There were 4 recurrences that accounted for 3 deaths, all in patients with mandatory indications. All patients who underwent partial nephrectomy for relative or elective indications were without definite evidence of recurrent disease at last followup (over-all mean 36 months). Our results suggest that conservative surgery can often provide effective and advantageous therapy for renal cancer and we encourage further consideration of the role of partial nephrectomy as an alternative to radical nephrectomy in selected patients with small peripheral tumors and normal contralateral kidneys.

Cat scanning in staging of prostatic cancer

Forty-six patients with histologically proved adenocarcinoma of the prostate underwent pelvic lymphadenectomy after CAT scanning. The accuracy, specificity, and sensitivity of the CAT scan in detecting nodal metastasis were 70, 93 and 30 per cent, respectively; this compares favorably with pedal lymphangiography. Seventeen of the patients had radical prostatectomy. The accuracy, specificity, and sensitivity of the CAT scan in depicting local extent of the tumor were 47, 100, and 18 per cent, respectively; although low, no other clinical or biochemical method provides a better result.

Differences in Pathological Characteristics and Prognosis of Clinical A2 Prostatic Cancer from A1 and B Disease

A retrospective study was done of 53 cases of clinical stages A1 to B2 prostatic carcinomas staged by pelvic lymphadenectomy. The study compared the histologic differentiation, degree of lymphocytic infiltration, incidence of lymph node metastases and type of cellular response of clinical stage A2 to stages A1 and B disease. The available data pertaining to the incidence and survival of patients with stage A2 prostatic carcinoma were analyzed. Our study indicates that 1 of every 3 unsuspected carcinomas is of clinical stage A2. The stage A2 tumors are diffused, with a higher degree of undifferentiation and a higher incidence of lymph node metastases than tumors classified clinically as stages A1 and B1. Also the survival of patients with clinical stage A2 tumors is lower than the survival of patients with clinical stage B1 disease. Clinical stage A2 tumors are more advanced biologically than clinical stage B1 tumors.

Colonic Urinary Diversion: 10 Years of Experience

Experience with 46 colon urinary conduits is summarized. The transverse colon was used in 39 patients and the sigmoid in 7. Initially, we considered widened uretercolic anastomosis with free reflux desirable but later, upon realizing the dangers of reflux, antireflux procedures were incorporated into the operation. Among the advantages of the colon conduit are minimal stomal stenosis, little residuum, less electrolyte disturbance and availability for high and low diversions.

Radical prostatectomy for stage D1 prostate cancer: Prognostic variables and results of treatment

Surgical extirpation of the primary tumor together with the involved regional nodes has been considered ineffective treatment for locally disseminated prostatic carcinoma. We retrospectively reviewed our experience with 42 patients with Stage D1 disease who underwent radical prostatectomy and bilateral pelvic lymphadenectomy and who had a follow-up of one to thirteen years (mean 5 years). The following variables affecting survival and tumor progression were analyzed: (1) tumor grade and local extent; (2) number of positive lymph nodes, and (3) adjuvant therapy. The overall five- and ten-year survival was 79.5 per cent and 28 per cent compared with the expected survival of an age-matched control group of 88 per cent and 28 per cent, respectively. The degree of tumor differentiation had no effect on prognosis, but local tumor bulk and the number of involved lymph nodes significantly changed the disease progression and survival rate. Patients with low local tumor bulk and one positive node survived as long as the age-matched male population group. Our data suggest that radical prostatectomy may represent a valuable treatment in selected patients with Stage D1 prostate carcinoma.

Radical prostatectomy for stage D1 prostate cancer

Abstract Surgical extirpation of the primary tumor together with the involved regional nodes has been considered ineffective treatment for locally disseminated prostatic carcinoma. We retrospectively reviewed our experience with 42 patients with Stage D1 disease who underwent radical prostatectomy and bilateral pelvic lymphadenectomy and who had a follow-up of one to thirteen years (mean 5 years). The following variables affecting survival and tumor progression were analyzed: (1) tumor grade and local extent; (2) number of positive lymph nodes, and (3) adjuvant therapy. The overall five- and ten-year survival was 79.5 per cent and 28 per cent compared with the expected survival of an age-matched control group of 88 per cent and 68 per cent, respectively. The degree of tumor differentiation had no effect on prognosis, but local tumor bulk and the number of involved lymph nodes significantly changed the disease progression and survival rate. Patients with low local tumor bulk and one positive node survived as long as the age-matched male population group. Our data suggest that radical prostatectomy may represent a valuable treatment in selected patients with Stage DI prostate carcinoma.

Aggressive Treatment of Metastatic Renal Cancer

Radical nephrectomy and excision of metastases were performed in 21 patients with metastatic renal cell carcinoma. Followup was 12 years. Eight patients had metastases at the time of diagnosis and survived an average of 54 months, with 50 per cent alive 5 years postoperatively. Metastases developed after nephrectomy for localized disease in 13 patients. After extirpation of the secondary lesions these 13 patients survived an average of 38 months and 25 per cent were alive at 5 years. Survival varied with the length of time free of disease. Patients in whom metastases developed later than 2 years after nephrectomy survived 55 months compared to only 22 months for those in whom metastases developed earlier. Survival also was influenced by tumor aggressiveness (reflected by prognostic index number) and completeness of surgical excision of the secondary lesion.

Jejunal Conduits: Technique and Complications

Thirty patients underwent jejunal urinary diversion: 27 bilateral cutaneous ureterojejunostomies, 2 cutaneous pyeloureterojejunostomies and 1 bilateral pyelocutaneous jejunostomy. In the majority of the cases this high diversion was indicated for malignant disease with preoperative and postoperative irradiation of the pelvis. Postoperative morbidity in these cases is not different from thatin cases of ileal conduit operation, except for a high incidence of reversible hypochloremic acidosis with hyponatremia, hyperkalemia and uremia. This electrolytic syndrome is the consequence of a continuous exchange of ions between the jejunal content and the extracellular fluid with resultant loss of sodium chloride and absorption of potassium and urea. An important link in the pathophysiology of the jejunal syndrome is the hypersecretion of renin-aldosterone, which aggravates the disturbance. Limited renal function (glomerular filtration rate less than 50 cc per minute), long loop and inadequate salt intake are among contributing factors. The syndrome is correctable by administration of salt. Some patients must be placed on salt supplement indefinitely. The jejunum is not recommended for urinary diversion in patients with limited renal function, those on low salt diet or those in whom a long intestinal loop would be required for diversion.