Laparoscopic pelvic lymph node dissection: a review of 103 consecutive cases

Laparoscopic pelvic lymph node dissection is a recently introduced technique for the surgical evaluation of the regional pelvic lymph nodes in genitourinary malignancies. We report the results of a laparoscopic pelvic lymph node dissection performed on 103 consecutive patients for staging of clinically localized prostatic, bladder and penile carcinomas. In 20 patients (group 1) the adequacy of the laparoscopic pelvic lymph node dissection was evaluated with a subsequent open dissection. In this group 87 to 95% of the lymph nodes within a modified template could be reliably removed laparoscopically. In 73 patients (group 2) laparoscopic pelvic lymph node dissection was performed as a solitary operation. Mean hospitalization was 1.6 +/- 2.4 days, while postoperative narcotic requirements were minimal. Mean operative time for bilateral laparoscopic pelvic lymph node dissection was 156 +/- 41.2 minutes. The overall complication rate in these 2 groups was 13.5%. Group 3 includes 10 patients (9.7% of the total) in whom laparoscopic pelvic lymph node dissection was unsuccessful. The minimally invasive surgical techniques of laparoscopic pelvic lymph node dissection seem to provide adequate staging accuracy in patients with genitourinary neoplasms. The complication rate and recovery period appear to be decreased relative to those for open surgical lymphadenectomy.

High levels of nm23 expression are related to cell proliferation in human prostate cancer

Reduced expression of the nm23 gene has been correlated with high metastatic potential in rodent mammary tumors and human breast cancer. The expression of this gene was studied in human prostate cancer tissue from 43 patients by immunohistochemistry using anti-nm23-H1 antibodies. Intense immunostaining was observed in 71.4% of the patients with clinical stage D disease as compared to 23.1% in clinical stage B and 18.7% in stage C disease (P < 0.05). Similarly intense immunostaining was present in 75% of poorly differentiated cancers versus only 28.6% in men with moderately differentiated cancer. nm23-H1 mRNA expression was measured by Northern blot analysis during phases of the cell cycle in DU 145, PC-3, LNCaP, and TSU-Prl human prostate cancer cell lines. Cells were synchronized in G0-G1 phases by serum deprivation and at the G1-S boundary by aphidicolin. nm23-H1 mRNA levels declined during serum deprivation and increased rapidly following serum addition. Although nm23-H1 was expressed continuously throughout the cell cycle, higher expression was observed in late G1, early S, and G2-M phases. These results indicate that nm23-H1 gene expression is related to the proliferative phase of cell growth.

Results of conservative management of clinically localized prostate cancer

BACKGROUND

The selection of treatment for patients with localized prostate cancer requires reliable information about the outcome of conservative management. Previous studies of this question are generally considered unreliable because they were uncontrolled and nonrandomized.

METHODS

We performed a pooled analysis of 828 case records from six nonrandomized studies, published since 1985, of men treated conservatively (with observation and delayed hormone therapy but no radical surgery or irradiation) for clinically localized prostate cancer. A Cox regression analysis was performed to determine which factors influenced survival among patients who did not die of causes other than prostate cancer (disease-specific survival). Kaplan-Meier curves for overall and metastasis-free survival among such patients were compared with use of the log-rank method and the Mantel-Haenszel test.

RESULTS

Factors that had a significant effect on disease-specific survival were grade 3 tumors (risk ratio, 10.04), residence in Israel (risk ratio, 2.48) or New York (risk ratio, 0.37), and age under 61 years (risk ratio, 0.32). Ten years after diagnosis, disease-specific survival (with data on men who died from causes other than prostate cancer censored) was 87 percent for men with grade 1 or 2 tumors and 34 percent for those with grade 3 tumors; metastasis-free survival among men who had not died of other causes was 81 percent for grade 1, 58 percent for grade 2, and 26 percent for grade 3 disease. These findings were not affected by the inclusion of men who had early-stage cancer, were older, had worse-than-average health, or underwent delayed radiation therapy or radical prostatectomy.

CONCLUSIONS

The strategy of initial conservative management and delayed hormone therapy is a reasonable choice for some men with grade 1 or 2 clinically localized prostate cancer, particularly for those who have an average life expectancy of 10 years or less. New treatment strategies are needed for men with grade 3 prostate cancer.

Buschke-Lowenstein tumor: therapeutic options including systemic chemotherapy

Verrucous carcinoma of the penis (Buschke-Lowenstein tumor) is a rare variant of squamous cell carcinoma which has been reported to have limited potential for metastatic disease. We report on 2 patients who presented with locally advanced disease after prolonged intervals of neglect. In both cases, the disease was locally aggressive with extensive tissue destruction. In 1 patient, after failure to achieve tumor control with repeated aggressive surgical excision, systemic chemotherapy using bleomycin, cisplatin, methotrexate, and leucovorin led to a complete pathologic response. We believe this is the first reported case in which systemic chemotherapy has been used to successfully treat verrucous carcinoma of the penis. Surgical excision alone was successful in achieving local disease control in the second patient.

The application of laparoscopy to retroperitoneal surgery in urology

The application of minimally invasive laparoscopic surgical techniques has provided the urologist with access to retroperitoneal structures previously available only through an abdominal incision. The enhanced visualization provided by video-imaging as well as the ease of access to the retroperitoneum through an incision in the posterior peritoneal envelope has facilitated the manipulation of many retroperitoneal organs. In particular these techniques have been applied to the clinical management of several urologic malignancies, such as adenocarcinoma of the prostate, transitional cell carcinoma of the bladder, and squamous cell carcinoma of the penis. A transperitoneal laparoscopic pelvic lymphadenectomy appears to provide adequate surgical staging of regional pelvic lymph nodes in these malignancies, while providing the patients with reduced morbidity. Additionally, transperitoneal access may be accomplished for an internal spermatic vein ligation, as well as approaches to the kidney, ureter and retroperitoneal lymph nodes. The surgical options are limited only by the availability of the instrumentation and the creativity of the surgeon. However, the indications for these procedures remain unclear and must await further information regarding actual benefits in the form of reduced patient morbidity and cost. The challenge for the future is to more completely define the indications and selection criteria for laparoscopic surgery.

Blindness secondary to prostate cancer

We report a case of blindness, secondary to hormone-refractory prostate cancer, occurring 7 years after the diagnosis of metastatic prostate cancer and 3.5 years after the clinical onset of the hormone-refractory state. Prolonged suppression of the disease with chemotherapy may have contributed to the unusual clinical findings. We discuss the role of supportive care in the management of prostate cancer.

Screening for prostate cancer in 1993: is it appropriate, or not?

Screening for prostate cancer is a complex problem with scientific, medicolegal, and socioeconomic consequences. Recommendations regarding screening should be based on scientific studies rather than on personal biases. At present, the value of screening is unknown, and hopefully proper studies will provide adequate information in the future. Until then, patients should be educated about the advantages and disadvantages of screening and should participate in the decision.

Methotrexate, vinblastine, doxorubicin and cisplatin followed by radiotherapy or surgery for muscle invasive bladder cancer: the University of Chicago experience

A total of 29 patients with muscle invasive bladder cancer, clinical stage T2N0 (12), T3aN0 (9), T3bN0 (5), T3N2 (2) or T4N2 (1), underwent 2 to 4 cycles of neoadjuvant methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) chemotherapy followed by either radiotherapy (15), radical cystectomy (11) or no local therapy (3). The overall response rate to M-VAC chemotherapy was 69%, with 31% clinical complete responses and 38% clinical partial responses. A functioning bladder was maintained in 55% of the responding patients, although bladder wall calcifications were observed in 4 of 15 irradiated patients. Overall survival was 71% and disease-free survival was 55% at a median followup of 57 months. For the 12 stage T2N0 cancer patients overall survival was 100% at a median followup of 52 months. For the stages T3a and T3bN0 cancer patients overall survival was 63%, while all 3 node positive patients died. Neoadjuvant chemotherapy with a modified M-VAC regimen is well tolerated and may result in bladder preservation.

The role of laparoscopic lymphadenectomy in staging and treatment of urological tumours

Laparoscopic lymphadenectomy for managing a variety of urological malignancies is likely to continue to increase in popularity. It is essential that the role of these procedures be critically evaluated to ensure that they offer significant benefit without added morbidity as compared with standard techniques. The challenge for the future is to better define selection criteria for laparoscopic surgery, particularly in men with clinically localized prostate cancer, so that both staging methods and therapy can be tailored to the individual patient.

Screening and early detection of prostate cancer

BACKGROUND

The value of routine screening for prostate cancer remains unknown because of the lack of randomized studies. Until such studies are completed, a sensible approach to screening is needed.

METHODS

One approach is to use the method of decision analysis to model the outcome of alternative screening strategies.

CONCLUSIONS

By assessing the results in terms of their effect on life expectancy and prostate cancer mortality, it may be possible to select the policy that has the greatest potential benefit for the least cost.

Disease-specific survival following routine prostate cancer screening by digital rectal examination

OBJECTIVE

To assess prostate cancer mortality in men undergoing routine screening by routine digital rectal examination.

DESIGN

Cohort study with a median follow-up period of 75 months.

SETTING

Population consisted of volunteers at a university clinic and men in an institutional health maintenance clinic.

PATIENTS

Fifty-six men with a mean age of 65 years (range, 52 to 79 years) diagnosed with prostate cancer.

INTERVENTIONS

Patients treated initially by observation, external or interstitial radiotherapy, radical prostatectomy, hormone therapy, or combination.

MAIN OUTCOME MEASURES

Kaplan-Meier analysis of time to local progression, distant metastases, death from all causes, and death from prostate cancer. Mantel-Haenszel log-rank statistic was used to compare outcome in men diagnosed on initial examination with those diagnosed on subsequent examinations.

RESULTS

Clinically localized prostate cancer was diagnosed in 73% during an initial examination and 83% on subsequent examinations and (P.35). Grade distribution of tumors was similar in both groups. Overall 5 and 10 year survival of all cancer patients was 85% and 67%, respectively. Death from prostate cancer was 8% (3/38) in men diagnosed on initial examination and 33% (6/18) during subsequent examinations. Five- and 10-year disease-specific survival was 97% and 86%, respectively, for men diagnosed during the first rectal examination compared with only 81% and 57%, respectively, for men diagnosed on subsequent rectal examinations (P = .02).

CONCLUSION

Routine screening for prostate cancer by annual digital rectal examination alone may be insufficiently frequent and/or sensitive to prevent significant mortality from this disease [corrected].

Workshop summary: screening policies and procedures

The question of screening for prostate cancer has, since the advent of prostate-specific antigen testing, become a major source of contention. Important issues include: (1) should such screening become part of routine health checks for men; (2) if routine screening is implemented, at what age should it be started, and (3) can the early detection of prostate cancer facilitated by such screening actually benefit the patient in the long run? These were some of the topics put to the audience and debated by the panel of experts in the discussion forum on screening.

Current and future roles of laparoscopic surgery in urology

There is little doubt that laparoscopy will gain an increasing role in urologic surgery. Pelvic node dissection, varicocelectomy, and evaluation of nonpalpable undescended testes are already widely performed. As improved instrumentation is developed expressly designed for urologic applications, there will be even greater interest and wider applicability of laparoscopic techniques. However, as this occurs, it is essential that each new procedure be critically evaluated to be certain that it offers significant benefit without added morbidity as compared with standard techniques.

Screening for prostate cancer

Early-stage prostate cancer is usually asymptomatic and therefore, in the past, has often gone undetected, unless diagnosed by a digital rectal examination. More recently, new tests have been introduced, namely prostate-specific antigen and transrectal ultrasound, in order to improve the detection of early-stage disease. Considerable debate exists about the routine use of these screening tests. This article addresses issues such as which tests are the most predictable, the outcome of screening in terms of benefits (or not) to the patient and the advantages and disadvantages of screening itself.

Value of prostate cancer screening

The challenge for the future is to establish whether screening will lead to a decrease in prostate cancer mortality. This issue can only be settled by the performance of a properly controlled, randomized, prospective study. Due to the generally slow progression rate of prostate cancer, such a study will require an at least 15-year follow-up of a large number of men. Because of the increasing widespread use of prostate-specific antigen in the United States, finding a large control population who will not be screened for an extended period of time may no longer be possible. Nevertheless, such a study is clearly needed and is being undertaken by the National Institutes of Health. In the meantime, it is important that physicians counsel patients regarding the relative benefits and risks of screening so that they can make their own judgments regarding the aggressiveness with which the diagnosis of prostate cancer should be pursued.

Laparoscopic retroperitoneal lymph node dissection in a patient with stage 1 testicular carcinoma

Minimally invasive laparoscopic surgical techniques are being increasingly applied to the treatment of urological diseases. We report a case of a laparoscopically performed modified bilateral retroperitoneal lymph node dissection for clinical stage 1 testicular cancer. The laparoscopic surgical approach to the retroperitoneal nodes is a technically feasible procedure that can remove lymph node tissue from all primary landing sites for testicular cancer metastases with potentially decreased morbidity.

Local staging of prostate cancer by tumor volume, prostate-specific antigen, and transrectal ultrasound

Conventional methods of staging prostate tumors are highly inaccurate. To improve clinical staging, prostate-specific antigen (PSA) levels (> 10 ng/mL), sonographic tumor volume (> 3 cc), maximum tumor diameter, length of capsular tumor abutment, and overall impression of capsular irregularity suggesting periprostatic tumor spread were assessed in 29 men prior to undergoing radical prostatectomy for clinically localized tumor. After surgery, 18 men had tumor confined to the prostate, while 11 men had histologic evidence of extracapsular disease. Analysis of the parameters measured showed these were the most helpful factors in predicting the presence of extracapsular disease. However, the positive and negative predictive values were only 70 to 90 percent. Therefore, the clinical usefulness of any one measurement alone in determining treatment for the individual patient is limited. However, combining these parameters yields an improved prediction of extracapsular disease. All 6 patients with PSA < 10 ng/mL, tumor volume < 3 cc, and no capsular irregularity on ultrasound had localized disease (neg. predictive value = 100%), while all 7 patients who had more than one of these parameters had extracapsular disease (pos. predictive value = 100%). Thus, using the factors in combination may provide more accurate staging and thereby help in counseling patients regarding therapy.

The effect of digital rectal examination on prostate-specific antigen levels

OBJECTIVE--To identify the effect of digital rectal examination (DRE) on serum prostate-specific antigen (PSA) levels. DESIGN--A prospective trial before and after DRE. SETTING--Multicenter outpatient screening program. PATIENTS--A total of 2754 healthy men aged 40 years and older who presented to a prostate cancer screening program and consented to two phlebotomies. MAIN OUTCOME MEASURE--Changes in serum PSA levels after DRE. RESULTS--Patients were divided into four groups based on their initial serum PSA levels. The levels were chosen based on previous studies that showed different incidences of prostate cancer within these groups. The two groups with the lowest initial PSA values (0.1 through 4 micrograms/L and 4.1 through 10 micrograms/L) were found to have statistically insignificant changes in the serum PSA levels after DRE. The group with initial PSA levels of 10.1 through 20 micrograms/L had increases in serum PSA values that showed a trend toward statistical significance. The group with initial PSA levels of greater than 20 micrograms/L had statistically significant increases in serum PSA values after DRE. The alterations in serum PSA levels in the two groups with the highest PSA values were not clinically important as the patients' clinical treatment was not altered. CONCLUSIONS--No clinically important effects on serum PSA levels were noted after DRE.

Nuclear localization of androgen receptor in heterogeneous samples of normal, hyperplastic and neoplastic human prostate

To facilitate an understanding of how androgens participate in the genesis of human benign hyperplasia and carcinoma we assayed androgen receptor in the epithelium and stroma of human prostatic tissue from 57 patients. Immunohistochemical staining of human androgen receptor was performed on 106 sections of normal prostate, benign prostatic hyperplasia (BPH) and prostate cancer. To determine variability of androgen receptor staining sections taken from different portions of the gland were studied. Frozen tissue sections were incubated with monoclonal antiandrogen receptor antibodies and staining was completed by the indirect avidin-biotin peroxidase method. Antibody staining was found mainly in the nucleus of prostatic epithelial cells, although some stromal cells also showed positive staining. Unlike normal prostate, there was a heterogeneous distribution of androgen receptor in BPH and prostate cancer. The androgen receptor content in well differentiated adenocarcinoma epithelium was significantly higher compared to moderately (p less than 0.05) and poorly (p less than 0.05) differentiated adenocarcinoma. Regardless of the origin of stromal tissue, some staining was observed. In each specimen studied the androgen receptor staining was consistent qualitatively and quantitatively for each pathological component throughout the specimen. These data confirm that androgen receptor is a nuclear receptor protein. Furthermore, they show the ability of monoclonal antibodies to reveal cellular/subcellular distribution of androgen receptor, and demonstrate a correlation between the degree of tumor differentiation and androgen receptor content in epithelial but not in stromal cells. These observations may have important implications for understanding the variable tumor response to hormone therapy.

Basic fibroblast growth factor in human prostate cancer cells

To increase our understanding of the potential role of basic fibroblast growth factor (bFGF) in malignant progression of prostate cancer, we determined the production of bFGF, the expression of FGF receptor (flg), and the response to exogenous bFGF in LNCaP, DU 145, and PC 3 cells. We observed that these three prostate cancer cell lines, which differed in their dependence on androgens for growth in vitro and in their in vivo behavior in nude mice, could be distinguished as follows: (a) androgen-sensitive LNCaP cells, which do not metastasize in nude mice, did not produce measurable amounts of bFGF, expressed small but measurable amounts of FGF receptor mRNA, and did respond to exogeneous bFGF; (b) androgen-insensitive, moderately metastatic DU 145 cells did produce measurable amounts of biologically active bFGF, expressed large amounts of FGF receptor mRNA, and responded to exogeneous bFGF and the heparin-binding fractions from DU 145 cell extracts; (c) androgen-insensitive and highly metastatic PC3 cells also produced measurable amounts of bFGF but did not demonstrate a growth response to either the heparin-binding fractions from PC3 cell extracts or exogenous bFGF, even though large amounts of FGF receptor mRNA were expressed in PC 3 cells. These results suggest the possibility that differences in production of, and response to, bFGF may be associated with different biological behavior.

The natural history of adenocarcinoma of the prostate

All analyses of the efficacy of therapy for prostate cancer must control for the natural history of the disease. Over the past years, several long-term series involving several hundred patients have helped to describe the results of untreated disease. In general, most patients will not die of their disease, although approximately half of the patients will develop disease progression within 10 years. Predictors of progression include tumor stage, grade, and ploidy status.

Autoregulation of androgen receptor expression in rodent prostate: immunohistochemical and in situ hybridization analysis

Autoregulation of androgen receptor mRNA and protein was investigated by immunohistochemical and in situ hybridization techniques. In both mouse and rat prostate, the epithelial cell nuclei were stained with the monoclonal or polyclonal antibodies raised against human androgen receptor. It was observed that 3 days after castration, nuclear staining of the epithelium was greatly reduced, while androgen treatment restored the staining intensity to a normal level. In situ hybridization using an androgen receptor cDNA fragment as probe demonstrated that the change in androgen receptor mRNA level correlated with the change in antibody staining intensity. These data suggested an up-regulation of androgen receptor expression by androgen.