Roger Paul

ADRENAL SPARING SURGERY DURING RADICAL NEPHRECTOMY IN PATIENTS WITH RENAL CELL CANCER: A NEW ALGORITHM

PURPOSE Ipsilateral adrenalectomy is usually performed during radical nephrectomy because of renal cell cancer. Because renal tumors are detected more often in the earlier stages due to widespread use of ultrasound and computerized tomography, we define a subset of patients who would be eligible for adrenal sparing surgery. In a retrospective analysis we evaluated whether parameters obtained preoperatively are able to predict adrenal metastasis. MATERIALS AND METHODS A total of 866 consecutive patients who underwent nephrectomy and ipsilateral adrenalectomy from 1983 to 1999 were evaluated. Preoperative parameters, including tumor size, location, clinical stage, number of tumors, and patient age and sex, were retrospectively compared with the histological results. Univariate and multivariate analyses were performed. RESULTS A total of 27 (3.1%) adrenal metastases were noted in the 866 patients, and 63% were on the left side and 37% on the right side. Mean tumor size was 10 cm. with versus 6 cm. without adrenal involvement. Of the 27 patients 21 had multiple metastases at diagnosis and only 6 (0.7% of all 866) presented with solitary ipsilateral adrenal metastasis. Univariate and multivariate analyses revealed tumor size and M stage as best preoperative predictors of adrenal involvement. CONCLUSIONS Adrenal sparing surgery is possible, and we suggest a new algorithm. If maximum tumor size measured by computerized tomography is less than 8 cm. and staging examination does not show organ or lymph node metastases, adrenalectomy is not necessary because of oncological reasons. This algorithm has to be validated by a prospective analysis.

Therapeutic Vaccination with an Interleukin-2–Interferon-γ-Secreting Allogeneic Tumor Vaccine in Patients with Progressive Castration-Resistant Prostate Cancer: A Phase I/II Trial

Immunotherapy with whole cell cancer vaccines has been tested in various tumor types. This study investigated the safety profile and antitumor activity of an allogeneic prostate carcinoma cell line, LNCaP, expressing recombinant human interleukin-2 and human interferon-gamma. Thirty HLA-A*0201-matched patients with progressive, castration-resistant prostate cancer received four intradermal injections on days 1, 15, 29, and 92, and then every 90 days, as long as no tumor progression occurred. Three patients received a dose level of 7.5 million cells, and 27 patients received 15 million cells per injection. The primary study criteria were safety and the difference in prostate-specific antigen doubling time (PSA-DT), determined in the pretreatment phase (before the start of vaccination) and in the trial treatment phase (during vaccination). No dose-limiting or autoimmune toxicity was seen. During vaccination there was a significant prolongation of the PSA-DT compared with the prevaccination period (prolongation from 63 to 114 days; p < 0.01; intention to treat). In addition, results showed a period of PSA stabilization of at least 12 weeks, together with stable bone scans in 12 of 30 patients, and 3 patients sustained a >50% decrease in PSA versus baseline. The median overall survival time from first vaccination was 32 months (mean value, 34 months). Immune monitoring revealed T cell stimulation in the majority of patients. This vaccine strategy was found to be safe and well tolerated and was accompanied by prolongation of PSA-DT. The results of this trial warrant clinical development of this vaccine.

Optimization of Prostatic Biopsy: A Prospective Randomized Trial Comparing the Sextant Biopsy with a 10-Core Biopsy

Objective: New prostatic biopsy protocols suggest to increase the core numbers to enhance detection. Additional cores are usually sampled from the lateral part of the p-zone. We direct the sextant biopsy to the most lateral part of the p-zone, therefore we investigated if there is a gain by adding 4 median biopsy cores. Material and Methods: The prospective randomized trial (n = 200) compared our modified sextant biopsy to a 10-core strategy with 2 additional median cores on both sides. Directed biopsies to suspicious areas were allowed in both groups. Morbidity was assessed by a self-administered questionnaire. Results: PC detection was 32% for 6 cores and 40% for 10 cores. Four patients were detected only by median biopsies. Using the binomial distribution table the gain of 4% is statistically significant. There was no statistical difference in morbidity, but a trend towards a higher rate of side effects in the 10-core group. Conclusions: The gain in prostate cancer detection rate by additional median biopsies is low, but statistically significant. There is no difference in morbidity and patient acceptance is high, therefore we favor the 10-core biopsy in our patients.

Rare metastases of signet ring cell carcinomas to the scrotum: report of two cases

Metastases of signet ring cell carcinomas to the scrotum are rare. We present 2 patients with this kind of tumor. In 1 patient, the scrotal pathologic examination helped to detect an adenocarcinoma of the appendix with a signet ring cell component, with an extent that had not been apparent clinically. The other patient was seen at an advanced stage of signet ring cell carcinoma of the sigmoid colon following surgical therapy and palliative chemotherapy. The route of metastases seems to be via seeding along the testicular cord and via lymphatic dissemination.

Prostate-specific antigen density and age-specific prostate-specific antigen values: the solution of prostate cancer screening?

The results of 225 systematic prostate biopsies from 1992 to 1993 were evaluated retrospectively. The parameters prostate-specific antigen (PSA) density and age-specific PSA values were compared with digital rectal examination, transrectal ultrasound, and PSA as single parameters and possible combinations. The PSA density proved to have the highest specificity of all single parameters, but the sensitivity was low. Age-specific PSA values are offering a good compromise of sensitivity and specificity as compared with fixed cutoff levels. Since there is no sufficient screening parameter up to now, a combination of all parameters is recommended for screening of early prostate cancer.

Nebenmilz des Samenstrangs

ZusammenfassungEin 40 jähriger Mann stellte sich mit dem Verdacht eines linksseitigen Samenstrangtumors vor. Dabei ergab sich die Diagnose einer Nebenmilz des linken Samenstrangs.SummaryA 40-year-old man who presented with a tumor of the left spermatic cord was found to have an ectopic accessory spleen located within the left spermatic cord.