Outcome of palliative urinary diversion in the treatment of advanced malignancies

BACKGROUND

It is unclear whether palliative endourologic or percutaneous urinary diversion in the treatment of advanced cancer provides significant improvement in quality or duration of life. The purpose of this study was to evaluate survival and performance status after endourologic palliative urinary diversion in patients with advanced malignancy and to compare the results for different malignancies.

METHODS

One hundred three patients with advanced malignancies underwent palliative urinary diversion (stent or nephrostomy) between 1986 and 1997. Ninety-two patients and 11 patients had bilateral and unilateral obstruction, respectively. Indications, complications, performance status after diversion, and survival for patients with different malignancies were identified and compared. A modified Karnofsky performance scale (KPS) was used for assessment of physical performance. A scale of 0-4 was used: 0) hospitalized until death; 1) bedridden at home, severe pain despite analgesia; 2) moderate disability, moderate pain despite analgesia; 3) mild disability, pain free with medication; and 4) normal.

RESULTS

The mean age of patients was 68 years. The mean pre- and postoperative creatinine levels were 6 mg/dL and 3.3 mg/dL, respectively (P < 0.0001). The median survival and days of hospitalization were 112 and 45, respectively. The median postdiversion KPS score was 2 (range, 0-4), and 15% of patients never left the hospital. Overall, 51% required secondary percutaneous procedures, and 68.4% had complications (minor, 63%; major, 5.4%).

CONCLUSIONS

Most patients with advanced cancers had poor performance status and survival after diversion. Eighty six percent had cancer-related symptoms despite the diversion. The average survival was 5 months, 50% of which was spent in the hospital. Primary endourologic procedures had a high failure rate, and additional procedures were required.

Lymph node size does not correlate with the presence of prostate cancer metastasis

OBJECTIVES

To determine whether lymph node size is a surrogate marker for lymph node metastasis.

METHODS

We reviewed 980 patients who underwent radical retropubic prostatectomy with bilateral pelvic lymph node dissection for clinically localized prostate cancer, of whom 63 had lymph node metastases. A comparable group of patients with prostate cancer undergoing radical prostatectomy who did not have lymph node involvement was identified using the following parameters: serum prostate-specific antigen level, clinical and pathologic stage, and pre- and postoperative Gleason score. The axial and longitudinal dimensions of the nodes from patients with and without metastases were analyzed to assess the significance of lymph node size in predicting the presence of metastases. All patients had negative preoperative computed tomography (CT) and bone scans. Of the 63 patients with lymph node metastases, 48 had tissue available for measuring the dimensions of the lymph nodes.

RESULTS

A total of 76 metastatic and 92 negative lymph nodes were identified from the patients with and without metastatic nodes, respectively. The mean nodal longitudinal size was 1.65 cm (range 0.2 to 6.5) and 3.50 cm (range 0.5 to 9) for positive and negative nodes, respectively (P = 0.0001). The mean axial nodal size was 0.8 cm (range 0.2 to 3.2) and 1.0 cm (range 0.2 to 2.2) for positive and negative lymph nodes, respectively. In 56 metastatic nodes (74%), the axial size was less than 1 cm and in 20 (26%) less than 5 mm.

CONCLUSIONS

Lymph node size should not be used as a surrogate for the presence of lymph node metastases. Although no patient had enlarged lymph nodes by CT scan criteria (greater than 1.5 cm), 6 (8%) of 48 and 19 (12%) of 48 patients with and without lymph node metastases, respectively, had nodes with an axial dimension greater than 1.5 cm.

Should Gleason score 7 prostate cancer be considered a unique grade category?

OBJECTIVES

To evaluate pathologic characteristics and biochemical survival rate differences between patients with Gleason score 6 or less, 7, and 8 or more prostate cancer.

METHODS

A total of 652 patients who underwent a radical prostatectomy for clinically localized prostate cancer between March 1991 and December 1995 were selected for this study. Patients who underwent neoadjuvant or adjuvant hormonal therapy or radiotherapy were excluded. Clinical and pathologic data were obtained from our prostate cancer data base. Serum prostate-specific antigen (PSA) level, pathologic stage, and disease-free survival (DFS) were analyzed between the three Gleason score groups.

RESULTS

The overall mean pretreatment serum PSA level was 12.9 ng/mL, being 8.4, 13.4, and 23 ng/mL for Gleason score 6 or less, 7, and 8 or more prostate cancers, respectively (P = 0.0001). Of patients with specimen Gleason score 6 or less, 7, and 8 or more, pathologic organ-confined disease was present in 69.4%, 43.1 %, and 9.2%, respectively (P = 0.001). Extraprostatic extension was present in 30.6%, 56.9%, and 90.8% (P = 0.0001); positive surgical margins, considered independently from the other pathologic findings, were present in 31 %, 47.6%, and 67.8% of patients with Gleason score 6 or less, 7, and 8 or more, respectively (P = 0.0001). DFS was 34.5% for patients with Gleason score 8 or more, 75% for Gleason score 7, and 91.2% for Gleason score 6 or less prostate cancers, at a median follow-up of 34.2 months (P = 0.0001). On multivariable analysis, after adjusting for serum PSA level (10 or less or more than 10 ng/mL) and pathologic stage, Gleason score (6 or less, 7, 8 or more) remained a statistically significant predictor of DFS (P = 0.0001).

CONCLUSIONS

Patients with Gleason score 7 prostate cancer should be considered a specific prognostic category. We believe that this distinction is critical to obtain more reliable results from prostate cancer analyses about prognosis of patients treated with curative intent.

Population-based study of pelvic lymph node positivity in clinically localized prostate cancer: a study comparing African Americans and whites

OBJECTIVES

To evaluate the correlation between race and lymph node metastasis for prostate cancer by analyzing which preoperative parameters may predict lymph node status in both races.

METHODS

We analyzed a group of patients (552 American white men [AWM] and 423 African-American men [AAM]) who underwent radical prostatectomy plus modified pelvic lymphadenectomy between January 1991 and June 1997. Patients who received neoadjuvant radiation or hormone therapy were excluded. Univariate and multivariate analyses were performed to determine the influence of race on lymph node positivity, as well as to correlate the preoperative parameters (serum prostate-specific antigen [PSA], biopsy Gleason score, and clinical stage) with lymph node metastasis for each race separately.

RESULTS

The AAM presented with significantly higher preoperative Gleason scores and PSA levels than AWM. However, comparing lymph node status by race, the difference of positivity (41 AWM [7.4% and 22 AAM [5.2%]) was not statistically significant (P = 0.16). The percentage of positive nodes was similar in both races for each subset of PSA, Gleason score, and clinical stage. Despite the statistical significance of the three preoperative parameters in univariate analysis, in multivariate analysis only PSA and Gleason score were independent predictors of positive lymph nodes.

CONCLUSIONS

There is no influence of race on lymph node metastasis, despite AAM presenting with higher preoperative Gleason scores and PSA levels. In multivariate analysis, preoperative Gleason score and PSA were independent factors for positive nodes regardless of race.

Matrix metalloproteinase-9 expression in bladder washes from bladder cancer patients predicts pathological stage and grade

The matrix metalloproteinases (MMPs), in particular the gelatinases (MMP-2 and MMP-9) have been associated with tumor cell invasion and metastasis in many human cancers. Here we examined the expression of proMMP-2 (gelatinase A) and proMMP-9 (gelatinase B) proteins in the cellular component of bladder washes obtained from 65 patients. Twenty-six patients had active bladder cancer, 24 had a history of bladder cancer but no evidence of active disease at the time of cystoscopy (recurrence-free), and 15 patients had lesions other than bladder cancer (controls). The results were correlated with the cytological findings of the bladder wash and the histopathological results of the tumor resection when performed. In patients with active transitional cell carcinoma of the bladder, 71 and 38% had expression and overexpression of the latent form of MMP-9 (proMMP-9), respectively. In contrast, neither latent nor active MMP-2 could be detected in any of the samples examined, regardless of tumor status. Overexpression of proMMP-9 correlated with higher grade (P = 0.003) and pathological stage (P = 0.04) of disease in the active bladder cancer group. No significant gelatinase expression was detected in the recurrence-free and control cases. Compared with urine cytology, proMMP-9 expression had an overall higher sensitivity for bladder cancer identification (71 versus 54%, P = 0.11). Detection of proMMP-9 in bladder washes may be a novel approach for the identification of patients with more aggressive forms of bladder cancer.

Racial differences and prognostic significance of tumor location in radical prostatectomy specimens

BACKGROUND

Our objective was to evaluate radical prostatectomy specimens for possible racial differences in tumor location, as well as to correlate tumor location with pathologic stage and disease-free survival.

METHODS

Between January 1991-December 1997, 1,245 patients underwent radical prostatectomy with bilateral pelvic lymphadenectomy for clinically localized prostate cancer. Seven hundred and eighty-five patients who were treated with surgery as monotherapy were evaluated. Tumor location, defined as mainly anterior, mainly posterior, or both (anterior and posterior), was obtained from review of tumor maps prepared from pathological evaluation of completely embedded, resected specimens.

RESULTS

Overall tumor location was anterior in 107 (14%), posterior in 459 (58%), and both in 219 (28%) cases. The incidence of anterior tumors was higher in African American men compared to Caucasians (16% vs. 11%, P = 0.045). The rate of positive surgical margins in anteriorly and posteriorly located tumors was 60% vs. 38% in African American men (P = 0.001) and 48% vs. 27% in Caucasians (P = 0.001), respectively. African American men were found to have a higher incidence of positive surgical margins (50%; 174/348) compared to Caucasian men (34%; 150/437; P = 0.001).

CONCLUSIONS

Anterior tumors were present in 14% of our patients. African American men have a greater percentage of anterior tumors than do Caucasians. In addition, a higher rate of positive surgical margins was encountered in patients with anterior tumors, especially if they were African American men. In patients with an abnormal serum prostate-specific antigen level and negative sextant prostate biopsies, we recommend biopsy of the anterior zone of the prostate.

Treatment outcome after radical prostatectomy is not adversely affected by a pre-existing penile prosthesis

OBJECTIVES

To report on the safety of radical retropubic prostatectomy (RRP) in patients with a penile prosthesis presenting with clinically localized prostate cancer.

METHODS

From January 1990 to December 1997, 8 consecutive men with a penile prosthesis underwent RRP for clinically localized prostate cancer. Retrospective data regarding patient population, operating time, estimated blood loss, length of hospital stay, and clinical outcome were evaluated.

RESULTS

Mean patient age was 65.4 years (range 57 to 70) at the time of RRP, with a mean preoperative serum prostate-specific antigen level of 11.5 ng/mL. Mean duration of RRP surgery was 183.9 minutes, and the mean estimated blood loss was 1281.8 mL. No complication requiring penile prosthesis removal occurred. In 1 case, the reservoir tubing was punctured during closure of the abdominal fascia wall. This was immediately recognized and fixed. All patients had a functioning penile prosthesis after RRP.

CONCLUSIONS

RRP can be safely and expeditiously performed in patients with a pre-existing penile prosthesis. The risk of prosthesis malfunction after RRP is very low. Patients with a penile prosthesis and prostate cancer should not be denied the option of undergoing RRP.

The influence of race on the efficacy of curative radiation therapy for carcinoma of the prostate

The purpose of this study was to examine the effect of race on the outcome of patients treated curatively with external beam irradiation for carcinoma of the prostate. The study was performed between January 1980 and December 1993 of 1,529 men with prostate cancer. Similar percentages of Caucasian men (CM) and African-American men (AAM) had localized disease (stages T1 and T2) and advanced stage disease (stage T3). There was no difference in crude survival by race (P = .13). At 5 years, crude survival by race was 75% for CM and 73% for AAM. At 10 years, the crude survivals, were 50% and 40%, respectively. Disease-specific survival rates were equivalent for AAM and CM (P = .66). The 5-year disease-specific survival was 83% for CM and 85% for AAM. At 10 years, the disease-specific survival was 65% for CM and 69% for AAM. There was no difference in disease-specific survival by race when stage-for-stage comparisons were made. Among those patients referred for curative radiation therapy, AAM and CM had a similar age, stage, and grade distribution. This study demonstrated that there was no difference in disease-specific survival between CM and AAM treated curatively with radiation for prostate cancer.

Quality of life in patients undergoing salvage procedures for locally recurrent prostate cancer

BACKGROUND AND OBJECTIVES

As patients are being treated for prostate cancer at a younger age, a significant number of them will ultimately fail the primary treatment and will be candidates for potentially curative salvage therapy. The purpose of this study was to evaluate the impact of salvage therapy for locally recurrent prostate cancer upon the patients' quality of life.

METHODS

A cohort of 68 men with locally recurrent prostate cancer undergoing salvage treatment was included in this analysis. Data were collected for the study by mailing the subjects a self-administered questionnaire that included a General Functional Assessment of Cancer Therapy (FACT-G) and a Prostate Cancer Treatment Outcome Questionnaire (FACT-P). Group comparisons were conducted using one-way analysis of variance (ANOVA).

RESULTS

Overall, 50% and 88.6% of patients were free of biochemical recurrence in the salvage surgery (SS) and salvage radiotherapy (SRt) group, respectively (P=0.4). The physical well-being (PWB) subscale of FACT-G was significantly higher for the SRt patients (P=0.008). Using the Trial Outcome Index Prostate subscale, the Trial Outcome Index Incontinence Urinary scores, and the Functional Assessment of Incontinence Therapy-Urinary score group comparisons, patients in the SRt group had a higher quality of life than patients in the SS group (P=0.038, P=0.001, and P=0.001, respectively).

CONCLUSIONS

In the current study, patients with clinically localized prostate cancer who are at high risk for local disease recurrence may have a trend toward better disease-free survival and a better urinary continence rates if the primary treatment is radical prostatectomy rather than radiation therapy.

Limited role of radionuclide bone scintigraphy in patients with prostate specific antigen elevations after radical prostatectomy

PURPOSE

Bone scintigrams of patients with increasing serum prostate specific antigen (PSA) after radical prostatectomy are only rarely positive. We identify clinical parameters that would improve our ability to select patients for this imaging study.

MATERIALS AND METHODS

We reviewed all bone scintigrams done at our institution between 1991 and 1996 in patients with persistently increasing serum PSA after radical prostatectomy. What prompted the clinician to obtain the bone scintigram was trigger PSA (tPSA). The rate of increase in PSA to tPSA was measured by tPSA/time from radical prostatectomy (slope 1) and tPSA/time from last undetectable PSA (slope 2). These parameters were evaluated together with standard clinicopathological data in univariate and multivariate analyses to determine the ability to predict the bone scintigram result.

RESULTS

In univariate analysis tPSA (p = 0.003), slope 1 (p = 0.005) and slope 2 (p = 0.004) were useful in predicting the bone scintigram result but pathological stage, Gleason score, preoperative PSA and time to recurrence were not. In multivariate analysis the single most useful parameter in predicting the bone scintigram result was tPSA (p = 0.01). Based on a logistic regression model the probability of a positive bone scintigram was less than 5% until tPSA increased to 40 to 45 ng./ml.

CONCLUSIONS

In patients with increasing serum PSA after radical prostatectomy current serum PSA is the best predictor of the bone scintigram result. Furthermore, there is limited usefulness of bone scintigraphy until PSA increases above 30 to 40 ng./ml.

Angiographic arterial occlusion and extra-anatomical vascular bypass for the management of a ureteral-iliac fistula: case report and review of the literature

Ureteroarterial fistulas related to nonvascular etiology are rare clinical entities that are difficult to diagnose and manage. Diagnosis is best made by a combination of studies, including digital subtraction angiography. Low morbidity and mortality rates have been described with either percutaneous thrombosis of the iliac artery and extra-anatomic bypass, or by placement of a stented graft in the involved artery. We report on a well-documented case of a ureteroarterial fistula managed successfully with interventional radiologic embolization of the common iliac artery and immediate femoral-femoral arterial bypass. A review of the literature supports this approach.

Management of primary urethral cancer

OBJECTIVES

To determine the best therapeutic approach for treatment of patients with urethral cancer according to tumor location and clinical-pathologic stage.

METHODS

A retrospective review of 21 consecutive patients diagnosed with primary urethral carcinoma was performed. Clinical-pathologic staging, treatment modality, and outcome were analyzed.

RESULTS

The overall survival rate was 62%. In patients with clinical Stage Ta-2N0M0 tumors, 8 of 9 patients (89%) are free of disease compared to 5 of 12 patients (42%) with Stage T3-4N0-2M0 tumors (P = 0.03). Best treatment outcome for patients with Stage T3 disease or higher was obtained when multimodality therapy (neoadjuvant chemotherapy and radiation therapy with or without surgery) was administered, with a disease-free survival rate of 60%.

CONCLUSIONS

Clinical-pathologic stage was a strong predictor of disease-free survival rate. For patients with Ta-2N0M0 tumors, multimodality therapy may not be required. Conversely, best treatment outcomes in patients with T3-4N0-2M0 tumors are obtained by administering a multimodal therapy combining chemotherapy and radiation therapy with surgical resection.

Prognostic indicators in patients with seminal vesicle involvement following radical prostatectomy for clinically localized prostate cancer

PURPOSE

We identify prognostic factors in patients with seminal vesicle involvement and negative lymph nodes following radical prostatectomy for clinically localized prostate cancer.

MATERIALS AND METHODS

A total of 93 patients who underwent radical prostatectomy and had seminal vesicle invasion without lymph node metastasis were evaluated. Patients who underwent neoadjuvant/adjuvant hormonal or radiation therapy were excluded from study. Preoperative serum prostate specific antigen (PSA), biopsy and radical prostatectomy specimen Gleason score, surgical margin status, presence of extraprostatic extension and evidence of biochemical disease progression were determined prospectively. Biochemical failure was defined as a single serum PSA elevation greater than 0.4 ng./ml.

RESULTS

The presence of positive surgical margins (p = 0.001), and Gleason score 7 or higher from preoperative biopsies (p = 0.03) and from the radical prostatectomy specimen (p = 0.01) were significant predictors of disease progression at a median followup of 43.3 months. Patients with preoperative PSA less than 10 ng./ml. had a better disease-free survival (p = 0.07). On multivariate analysis, after adjusting for biopsy Gleason score, prostatectomy Gleason score and serum PSA, positive surgical margins remained a statistically significant predictor of disease progression (p = 0.002).

CONCLUSIONS

Surgical margin status is an independent predictor of disease recurrence in patients with seminal vesicle involvement and negative lymph nodes following radical prostatectomy. Serum PSA 10 ng./ml. or greater and specimen Gleason score 7 or greater also were adverse prognostic factors in these patients. Conversely, patients with negative surgical margins and lymph nodes have a better prognosis than previously expected, despite seminal vesicle invasion.

Prognostic indicators in patients with seminal vesicle involvement following radical prostatectomy for clinically localized prostate cancer

PURPOSE

We identify prognostic factors in patients with seminal vesicle involvement and negative lymph nodes following radical prostatectomy for clinically localized prostate cancer.

MATERIALS AND METHODS

A total of 93 patients who underwent radical prostatectomy and had seminal vesicle invasion without lymph node metastasis were evaluated. Patients who underwent neoadjuvant/adjuvant hormonal or radiation therapy were excluded from study. Preoperative serum prostate specific antigen (PSA), biopsy and radical prostatectomy specimen Gleason score, surgical margin status, presence of extraprostatic extension and evidence of biochemical disease progression were determined prospectively. Biochemical failure was defined as a single serum PSA elevation greater than 0.4 ng./ml.

RESULTS

The presence of positive surgical margins (p = 0.001), and Gleason score 7 or higher from preoperative biopsies (p = 0.03) and from the radical prostatectomy specimen (p = 0.01) were significant predictors of disease progression at a median followup of 43.3 months. Patients with preoperative PSA less than 10 ng./ml. had a better disease-free survival (p = 0.07). On multivariate analysis, after adjusting for biopsy Gleason score, prostatectomy Gleason score and serum PSA, positive surgical margins remained a statistically significant predictor of disease progression (p = 0.002).

CONCLUSIONS

Surgical margin status is an independent predictor of disease recurrence in patients with seminal vesicle involvement and negative lymph nodes following radical prostatectomy. Serum PSA 10 ng./ml. or greater and specimen Gleason score 7 or greater also were adverse prognostic factors in these patients. Conversely, patients with negative surgical margins and lymph nodes have a better prognosis than previously expected, despite seminal vesicle invasion.

Primary adenocarcinoma of the urethra with metastasis to the glans penis: successful treatment with chemotherapy and radiation therapy

Primary carcinoma of the male urethra accounts for less than 1% of malignancies in males. A 54-year-old man with primary adenocarcinoma of the urethra with metastasis to the glans penis and lymphadenopathy in the right groin was treated successfully by combined chemotherapy (5-fluorouracil and cis-platinum) and external beam radiotherapy (total dose of 75 Gy). Short-term remission using multimodal approach with penile preservation was achieved in the present case.

Systemic interleukin 2 therapy for human prostate tumors in a nude mouse model

Once the regional lymph nodes become involved in prostate carcinoma, 85% of patients develop distant metastases within 5 years, and metastatic disease is difficult to treat. We have investigated the effect of systemic interleukin 2 (IL-2) treatment on metastatic prostate carcinoma using a xenograft tumor model. Cells from a PC-3/IF cell line, produced by intrafemoral injection of human PC-3 prostate carcinoma cells, were injected in the prostate of Balb/c nude mice. Prostate tumors and para-aortic lymph nodes were resected, and tumor cells were recultured and passaged in the prostate in vivo to produce new cell lines. On day 6 following prostatic injection of these cell lines, mice were treated with i.p. injections of IL-2 at 25,000-50,000 units/ day for 5 consecutive days. The effect of IL-2 on tumor progression was assessed, and histological studies were performed on prostate tumor and lymph node sections. The tumor cell lines generated by serial prostate injection were tumorigenic and metastasized to regional para-aortic lymph nodes. Tumors of 0.4 cm were obtained by day 16 and grew to 1-1.5 cm by day 40 with metastasis to para-aortic lymph nodes. Following two to three weekly courses of 5 days of 25,000-40,000 units/day of IL-2, the growth of prostate tumors was inhibited by 94%. Higher doses of 50,000 units/ day were toxic. Histologically, prostate sections showed vascular damage manifested by multifocal hemorrhages and an influx of lymphocytes and polymorphonuclear cells into disintegrating tumors and areas of necrosis containing numerous apoptotic cells. In contrast to control mice, para-aortic lymph nodes were not enlarged in responding mice. These findings suggest that systemic IL-2 therapy can induce an antitumor response in prostate tumors and control their growth and metastasis.

Salvage surgery or salvage radiotherapy for locally recurrent prostate cancer

OBJECTIVES

To evaluate the efficacy and toxicity of salvage radiation or surgery for locally recurrent tumor after initial treatment for clinically localized prostate cancer.

METHODS

The treatment records of 70 patients with local treatment failure after definitive therapy for clinically localized prostate cancer were reviewed. Initial treatment consisted of external beam radiation therapy (RT) in 27 patients and radical retropubic prostatectomy (RP) in 43 patients.

RESULTS

The mean serum PSA levels were similar in both groups before initial treatment: 8.5 and 10.5 ng/mL for the salvage RP and salvage RT groups, respectively (P = 0.09). However, at the time of salvage treatment, the mean serum PSA levels were 9.1 and 1.1 ng/mL for the salvage RP and salvage RT groups, respectively (P = 0.0001). The mean time from tumor recurrence to salvage treatment was 15.6 months for the salvage RP group and 4.9 months for the salvage RT group (P = 0.0001 ). Although there was no statistical difference in the disease-free survival rate (P = 0.38), a trend for better disease control in the salvage RT group was evident (74.4% versus 44.4%). Patients treated with salvage RP had a higher rate of urinary incontinence than those undergoing salvage RT: 63% and 32.6%, respectively (P = 0.01).

CONCLUSIONS

The disease-free survival rate was similar between patients receiving salvage RP or RT, despite the significantly higher serum PSA levels at the time of treatment and the delay in time to treatment for the salvage RP patients. Salvage RP is associated with a high rate of urinary incontinence. Earlier identification of tumor recurrence after RT may improve the efficacy and safety of salvage RP.

Predictors for maximal outcome in patients undergoing salvage surgery for radio-recurrent prostate cancer

OBJECTIVES

To determine preradiation and preoperative clinical staging and postoperative pathologic factors that can predict disease-free survival in patients undergoing salvage surgery for radio-recurrent prostate cancer.

METHODS

A retrospective review was performed on 40 patients who underwent salvage surgery for radio-recurrent prostate cancer. Preradiation and preoperative clinical staging factors, as well as pathologic stage were analyzed as predictors of disease-free survival. Biochemical failure was defined as a persistent serum prostate-specific antigen (PSA) elevation greater than 0.4 ng/mL.

RESULTS

As a group, salvage surgery provided excellent clinical disease control in 35 of 40 patients (87.5%). Overall, 18 of 38 (47.4%) patients analyzed had no evidence of biochemical progression. Preradiation clinical stage and pathologically organ-confined disease were statistically significant predictors of disease-free survival (P = 0.03 and P = 0.02, respectively). Seminal vesicle invasion and positive lymph nodes were the worst pathologic prognostic factors. Preoperative clinical T1c disease approached statistical significance in predicting pathologically organ-confined disease and disease-free survival (P = 0.08 and P = 0.07, respectively).

CONCLUSIONS

Ideal candidates for salvage surgery should have preradiation and preoperative clinically organ-confined disease. All patients with pathologically organ-confined disease following salvage prostatectomy were disease free at a mean follow-up of 36.1 months. Salvage surgery, although technically feasible, should not be widely advocated as an effective curative treatment in patients with locally advanced disease at the time of diagnosis.

High flow malignant priapism with isolated metastasis to the corpora cavernosa

Malignant priapism is a rare disease with only 88 reported cases. We present a case of a patient with priapism secondary to isolated metastasis to corpora cavernosa from bladder tumor. Metastasis to penis usually represents evidence of a more widespread disease in 80% to 90% of the patients. Rarely, as in this case, the metastasis is solitary.

Prognostic implications of a positive apical margin in radical prostatectomy specimens

PURPOSE

We evaluated the prognostic implication of a positive surgical margin at the prostatic apex to define the risk of failure after radical prostatectomy.

MATERIALS AND METHODS

Radical prostatectomy specimens of 590 patients operated on between 1990 and 1994 were reviewed by 2 uropathologists (D. G. and W. S.) to determine the percentage of patients with a positive margin at the apex in the absence of positive margins, extraprostatic extension or involvement of seminal vesicles and pelvic lymph nodes. In this group of 33 patients, the significance of a positive apex could be determined without the influence of any other stage related prognostic factors. Treatment failure was defined as prostate specific antigen greater than 0.4. All 33 patients have been followed between 3.5 and 65.5 months (median 38.7).

RESULTS

Among 590 patients 236 (40%) had disease completely confined to the prostate. A total of 217 patients (37%) had either positive surgical margins (M+) or extraprostatic extension and of these, only 33 (5.5%) had an apical positive margin in an otherwise prostate confined tumor. Of 33 apical positive margin patients only 3 in whom surgery failed had progressively detectable prostate specific antigen 3.5 to 65.5 months after surgery.

CONCLUSIONS

A positive surgical margin at the prostatic apex in the absence of positive margins or extraprostatic extension elsewhere does not confer a worse prognosis than organ confined disease. In this study the recurrence rate for patients with positive apical margins was the same as for those with confined disease.

Clinicopathologic and interphase cytogenetic analysis of papillary (chromophilic) renal cell carcinoma

Trisomy 7 and 17 with deletion of Y is typical of papillary renal cell adenoma (PRCA), and additional alterations occur in the putative genetic progression toward papillary renal cell carcinoma (PRCC). Our study correlated aneuploidy with clinicopathologic features in PRCCs. We used fluorescence in situ hybridization to assess copy number for chromosomes 7, 8, 10, 12, 16, 17, and Y in 16 PRCCs and surrounding benign tubular parenchyma from 15 patients by use of alpha satellite (centromere) probes on deparaffinized tissue sections. We then compared the pattern of monosomy/nullisomy or trisomy/polysomy/hemidisomy to clinicopathologic parameters. Nine tumors (58% Group 1) showed the numeric aberrations typical of PRCAs and PRCCs, with gains of 7 and 17 and loss of Y. We also identified four trisomies of 12 and 16 and one of 8 in Group 1. The remaining seven cases (Group 2) were cytogenetically atypical. Two displayed borderline loss of chromosome 7, although trisomy 17 was present in both. Five had trisomy 7, but none exhibited chromosome 17 alterations, and two exhibited a gain of Y. Neoplasms in Group 2 were less often multicentric than were Group 1 tumors, and they contained foamy macrophage infiltrates less often. One chromophilic carcinoma with abundant clear cells and another with oncocytic features exhibited Group 2 chromosomal profiles. One patient (nuclear grade 4) died from disease, and 14 had no evidence of carcinoma at the last follow-up. We concluded that PRCCs represent a histologically and genotypically heterogeneous group of tumors. If PRCAs consistently exhibit +7, +17, and -Y, it is uncertain whether PRCCs always evolve directly from such lesions. The presence of genotypic heterogeneity might reflect histologic variants of PRCCs, which overlap with other types of RCC. PRCC is generally an indolent neoplasm, despite a high frequency of chromosomal aneuploidy.

Orthotopic urinary diversion is a viable option in patients undergoing salvage cystoprostatectomy for recurrent prostate cancer after definitive radiation therapy

OBJECTIVES

To evaluate whether orthotopic urinary diversion is a viable option for patients undergoing cystoprostatectomy for radio-recurrent prostate cancer (RRPC).

METHODS

Between 1990 and 1996, we performed 34 salvage surgeries for RRPC, including 26 radical retropubic prostatectomies and 8 cystoprostatectomies. We determined the operative and postoperative complication rates and pathologic stage for the 8 patients undergoing cystoprostatectomy.

RESULTS

Of the 8 patients in whom cystoprostatectomy was performed, 5 underwent ileal conduit diversion and 3 underwent orthotopic neobladder reconstruction. There were no intraoperative complications or perioperative mortalities. In the group with orthotopic neobladder, postoperative complications included pyelonephritis in 1 patient and prolonged ileus in another. In the group with ileal conduit, no short-term complications occurred; 1 patient developed an incisional hernia on long-term follow-up. All patients with neobladder reconstruction are continent during the day. One patient wears one pad at night. The other 2 are continent at night.

CONCLUSIONS

Orthotopic urinary diversion is a valid option for selected patients with RRPC who require a cystoprostatectomy. This procedure can be performed with minimal complications, resulting in good continence and good quality of life.

Incidence of urethral involvement in female bladder cancer: an anatomic pathologic study

OBJECTIVES

To evaluate risk factors for urethral involvement in female patients undergoing cystectomy for bladder cancer and to define potential candidates for orthotopic continent urinary diversion.

METHODS

From 1990 to 1996, 43 female patients underwent cystectomy for primary bladder malignancy. Bladder mapping studies were performed with special attention to tumor location, multifocality, pathologic stage and grade, presence of carcinoma in situ (CIS), and the relationship of these factors to urethral involvement.

RESULTS

Of the 43 patients evaluated, 7 (16.3%) had urethral involvement by tumor. Two patterns of urethral invasion were identified: 5 patients had tumors in the vascular or lymphatic channels of the periurethral tissue, and 2 had tumors in the mucosa or submucosa. Three of the 12 patients with tumors located at the trigone and 4 of the 26 with CIS of the bladder had tumor in the urethra. Three of the 5 patients with vaginal involvement had tumor in the urethra. Only vaginal involvement was significantly associated with urethral involvement (P = 0.02).

CONCLUSIONS

Vaginal involvement was the only preoperative factor that was associated with presence of tumor in the urethra. Five patients with urethral involvement had submucosal tumors without concomitant CIS of the urethra. Before the performance of orthotopic urinary diversions, intraoperative full-thickness bladder neck biopsies are needed to accurately evaluate the female urethra.