Standard of Care Versus Metastases-directed Therapy for PET-detected Nodal Oligorecurrent Prostate Cancer Following Multimodality Treatment: A Multi-institutional Case-control Study

BACKGROUND

Most prostate cancer (PCa) patients with a biochemical failure following primary multimodality treatment (surgery and postoperative radiotherapy) relapse in the nodes.

OBJECTIVE

To perform a matched-case analysis in men with lymph node recurrent PCa comparing standard of care (SOC) with metastasis-directed therapy (MDT).

DESIGN, SETTING, AND PARTICIPANTS

PCa patients with a prostate-specific antigen (PSA) progression following multimodality treatment were included in this retrospective multi-institutional analysis.

INTERVENTION

The SOC cohort (n=1816) received immediate or delayed androgen deprivation therapy administered at PSA progression. The MDT cohort (n=263) received either salvage lymph node dissection (n=166) or stereotactic body radiotherapy (n=97) at PSA progression to a positron emission tomography-detected nodal recurrence.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint, cancer-specific survival (CSS), was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards models, and propensity score-matched analyses.

RESULTS AND LIMITATIONS

At a median follow-up of 70 (interquartile range: 48-98) mo, MDT was associated with an improved CSS on univariate (p=0.029) and multivariate analysis (hazard ratio: 0.33, 95% confidence interval [CI]: 0.17-0.64) adjusted for the year of radical prostatectomy (RP), age at RP, PSA at RP, time from RP to PSA progression, Gleason score, surgical margin status, pT- and pN-stage. In total, 659 men were matched (3:1 ratio). The 5-yr CSS was 98.6% (95% CI: 94.3-99.6) and 95.7% (95% CI: 93.2-97.3) for MDT and SOC, respectively (p=0.005, log-rank). The main limitations of our study are its retrospective design and lack of standardization of systemic treatment in the SOC cohort.

CONCLUSIONS

MDT for nodal oligorecurrent PCa improves CSS as compared with SOC. These retrospective data from a multi-institutional pooled analysis should be considered as hypothesis-generating and inform future randomized trials in this setting.

PATIENT SUMMARY

Prostate cancer patients experiencing a lymph node recurrence might benefit from local treatments directed at these lymph nodes.

[DGFIT: Immune and Targeted Therapy at ASCO 2016 - What will the Future Bring?]

Die Renaissance der spezifischen Immuntherapie eröffnet neue mannigfaltige Behandlungsoptionen in der Uroonkologie. Die Deutsche Gesellschaft für Immun- und Targeted Therapie (DGFIT) gibt einen Überblick über den aktuellen Stand und die neuen wissenschaftlichen Entwicklungen der Immun- und Targeted Therapie, welche dieses Jahr auf den Fachtagungen präsentiert wurden. Neben dem Nierenzellkarzinom, bei welchem bereits ein Immuncheckpoint-Inhibitor zur Therapie des metastasierten Stadiums zugelassen ist, werden beim Blasen- und Prostatakarzinom sowohl die für den Kliniker relevanten Ergebnisse als auch die neuesten, möglicherweise zukünftig relevanten Entwicklungen zusammengefasst.

Adherence of the indication to European Association of Urology guideline recommended pelvic lymph node dissection at a high-volume center: Differences between open and robot-assisted radical prostatectomy

PURPOSE

Contemporary adherence of the indication to European Association of Urology (EAU) guideline recommendation for pelvic lymph node dissection (PLND) at either open (ORP) or robot-assisted radical prostatectomy (RARP) at a high-volume center is unknown. To assess guideline recommended and observed PLND rates in a high-volume center cohort.

METHODS

We relied on the Martini-Clinic database and focused on patients treated with either ORP or RARP, between 2010 and 2013. Actual performed PLND was compared to European Association of Urology (EAU) guideline recommendation defined by nomogram predicted risk of lymph node invasion >5%. Categorical and multivariable logistic regression analyses targeted two endpoints: 1) probability of guideline recommended PLND and 2) probability of no PLND, when not recommended by EAU guideline.

RESULTS

Within 7868 PCa patients, adherence to EAU PLND guideline recommendation was 97.1% at ORP and 96.8% at RARP (p = 0.7). When PLND was not recommended, it was more frequently performed at RARP (71.6%) than at ORP (66.2%) (p = 0.002). Gleason score, PSA and number of positive biopsy cores were independent predictors for both either PLND when recommended, or no PLND when not recommended (all p < 0.05). Clinical tumor stage, age and surgical approach were also independent predictors for no PLND when not recommended (all p < 0.05).

CONCLUSIONS

Adherence of the indication to EAU guideline recommended PLND is high at this high-volume center. Neither ORP nor RARP represent a barrier for PLND, when recommended. However, a high number of patients underwent PLND despite absence of guideline recommendation. Possible staging advantages and PLND related complications needs to be individually considered, especially, when LNI risk is low.

Biomodulatory Treatment of Patients with Castration-Resistant Prostate Cancer: A Phase II Study of Imatinib with Pioglitazone, Etoricoxib, Dexamethasone and Low-Dose Treosulfan

Therapeutic options for patients with castration-resistant prostate cancer (CRPC) remain limited. In a multicenter, Phase II study, 65 patients with histologically confirmed CRPC received a biomodulatory regimen during the six-month core study. Treatment comprised daily doses of imatinib mesylate, pioglitazone, etoricoxib, treosulfan and dexamethasone. The primary endpoint was prostate-specific antigen (PSA) response. Responders could enter an extension phase until disease progression or intolerable toxicity occurred. Mean PSA was 45.3 ng/mL at baseline, and 77 % of patients had a PSA doubling time <3 months. Of the 61 evaluable patients, 37 patients (60.6 %) responded or had stable disease and 23 of them (37.7 % of 61 patients) were PSA responders. Among the 23 responders mean PSA decreased from 278.9 ± 784.1 ng/mL at baseline to 8.8 ± 11.6 ng/mL at the final visit (week 24). The progression-free survival (PFS) was 467 days in the ITT population. Of the 947 adverse events, 57.6 % were suspected to be drug-related, 13.8 % led to dose adjustment or permanent discontinuation and 40.2 % required concomitant medication. This novel combination approach led to an impressive PSA response rate of 37.7 % in CRPC patients. The good PSA response and PFS rate combined with the manageable toxicity profile suggest an alternative treatment option.

[DGFIT: Immune and targeted therapy in urologic oncology – what can be expected?]

Immune and targeted therapy represent innovative therapy options in oncology. An overview of novel immune and targeted therapy options in urologic oncology presented at the most recent scientific urological and oncological meetings is given by representatives of the German Association of Immune and Targeted Therapy (DGFIT). Besides renal cell cancer, where targeted therapy is well established, new immune and targeted approaches in prostate and bladder cancer are discussed, summarizing current results and new developments with relevant impact for the treating physician.

[Metastatic renal cell cancer in Germany in 2010. Impact of different target therapies]

BACKGROUND

Since 2006 in Germany six different target drugs for therapy in metastatic renal cell cancer (mRCC) have been used. Comparative studies for the application with the same indication are absent, and the order of potential sequential therapy is up to now unclear. The aim of the study was to collect data on therapy decisions in Germany regarding mRCC in the age of "targeted therapy". At the same time the study addressed the central question of sequencing of the different therapy options. In addition, the data of this study were to be compared to a study already published in 2008.

PATIENTS AND METHODS

In 2010, four groups of doctors specialized in the therapy of patients with mRCC were asked for their behaviour in the first-, second- and third-line or sequential therapy. Those questioned included urologists in private practice (n=40), oncologists in private practice (n=40), hospital urologists (n=35) and hospital oncologists (n=35). Further the reasons for a therapy decision should be stated or weighted.

RESULTS

Altogether 92% of all patients with mRCC were treated. Urologists in private practice treat only 30% of their patients themselves. The earlier used immune therapies (IFN, IL-2) no longer play a role. Sunitinib is used most often in first-line therapy by urologists in private practice (50.4%) and oncologists in private practice (47.1%). In second- and third-line therapy everolimus is used by urologists in private practice (27.1%, 26.3%) and sorafenib (28.6%) or everolimus (26.4%) by oncologists in private practice. Hospital oncologists use primarily sunitinib (56.1%), in second-line sorafenib (45.5%) and in third-line above all everolimus (19.4%). Hospital urologists use sunitinib most often for first-line therapy (57.6%) and sorafenib for second-line treatment (37.3%), while in third-line therapy temsirolimus (49.6%) and also everolimus (30.4%) were used.

CONCLUSIONS

The therapy of mRCC is determined very strongly by the substances sunitinib and sorafenib. The mTOR inhibitors have recently been increasingly included in the second- and third-line therapy. With the introduction of the new targeted therapies, the treatment of these special patients is performed less by urologists and increasingly more by oncologists. This trend is strengthened in comparison to the DGFIT study from 2008.

[Impact of immunotherapy in metastatic kidney cancer in Germany after introduction of new target therapy--results of a telephone survey of the German Society of Immuno- and Targeted Therapy (DGFIT)]

INTRODUCTION

Until recently, the standard therapy for metastatic renal cell carcinoma (mRCC) in Germany consisted of interleukin-2 (IL-2), interferon-alfa (IFN) as single agents or in combination, with or without chemotherapy. Since 2005, new drugs (target drugs) in the therapy for mRCC are available. The aim of this study was to analyse the current therapy standard in Germany.

METHODS

By representative telephone interviews (GFK-Nürnberg by order of DGFIT) the following colleagues were contacted A: urologists in private practice (n = 40), B: oncologists in private practice (n = 40), C: hospital urologists (n = 35) and D: hospital oncologists (n = 35). Screening criteria were 1) responsibility for therapy in mRCC; 2) therapy of at least 10 patients with mRCC per year.

RESULTS

Patients/year: A: n = 19, B: n = 17, C: n = 43, D: n = 21. 98% of patients with mRCC were treated: A: the most frequent therapy was sunitinib (43%, 42%, 33% as first-, second-, third-line), B: the most frequent therapy was sunitinib (45% as first-line, 37% as second-line), the most frequent third-line therapy was sorafenib (35%); C: the most frequent therapy were sorafenib and sunitinib (first-line 26% vs. 27%, second-line 46% vs. 42%), in third-line therapy additionally temsirolimus 24%; D: primary sorafenib and sunitinib (first-line 33% vs. 40%, second-line 46% vs. 42%), in third-line therapy additionally temsirolimus 23%. Immunotherapy (IL-2, IFN with or without chemotherapy) in mRCC plays in Germany for the second- and third-line therapy in A-D no major role (less than 10%). Otherwise, for first-line therapy immunotherapy has some relevance: A: 25%, B: 37%, C: 33%, D: 16%. The most important criteria for therapy decision making in A-D were: efficacy, toxicity, drug approval status.

CONCLUSIONS

Most patients with mRCC in Germany were seen by hospital urologists. Sunitinib (in first-line) and sorafenib (in second-line) are currently the most frequent prescribed drugs in mRCC. Temsirolimus is used mostly for third-line therapy (followed by sunitinib/sorafenib). Treatment of mRCC in Germany is increasingly being performed by oncologists.

Therapeutic approaches in metastatic renal cell carcinoma: local immunotherapy

Since 1990, aerosol interleukin (IL)-2 has been used to treat pulmonary metastatic renal cell carcinoma (pmRCC). Inhalation therapy deposits a drug into the airways to achieve a high, local, clinical effect while avoiding serious systemic side effects. We report three studies to describe safety and efficacy of aerosol IL-2 in patients with pmRCC. In a multicenter study, 24 patients received exclusive inhalation (study I) of natural IL-2 (three dose levels, 48 weeks) and response and toxicity were evaluated. The survival of high-risk patients (study II) with mainly inhaled IL-2 (n=94) was compared with that of patients receiving systemic IL-2 (n=103). In ten patients we analyzed in detail lung function and markers of airway inflammation before and during inhalational IL-2 therapy (study III). Study I: The response of exclusive inhalation was 33.3% at 3 months and 16.7% at 6 months. Treatment was well tolerated, cough being the most frequent adverse event. Study II: The probabilities of survival at 5 years were 21% for the inhalational group and 0% for the systemic group. Study III: Inhaled IL-2 induced a moderate decline of forced expiratory volume (FEV), while exhaled nitric oxide (NO) and sputum eosinophils rose accompanied by moderate cough and dyspnea. In conclusion, inhalational IL-2 combines good efficacy and improves tolerability. This is especially important for patients who are not able to benefit from systemic IL-2 therapy. Whether the local eosinophilic response additionally supports the antitumor effect remains a challenging question.

Interleukin-2 inhalation therapy temporarily induces asthma-like airway inflammation

BACKGROUND

Inhaled interleukin-2 (IL-2) is an effective and safe treatment in metastasing renal cell carcinoma (mRCC) but known to potentially elicit respiratory symptoms.

OBJECTIVES

The present study analyses the effects of IL-2 using a panel of measures including markers of airway inflammation.

METHODS

Ten patients with mRCC (7m/3f; mean age, 63 yrs) were measured at baseline, 6-10 days after start of therapy (n = 5, inhaled IL-2 only; n = 5, inhaled IL-2 plus 1/11th of daily dose subcutaneously), and 16-29 days later under continuous combined (inhaled plus subcutaneous) therapy, including additional subcutaneous IFN-alpha in 8 patients.

RESULTS

After start of therapy median FEV1 declined from 108 to 85 to 90 % predicted and the provocative concentration of methacholine eliciting a 20 % fall in FEV1 (PC20 FEV1) from 16 to 8 to 3 mg/mL, while the level of exhaled nitric oxide (FENO) rose from 27 to 79 to 60 ppb and the percentage of sputum eosinophils from 2 to 18 to 37 % (p<0.01, each), accompanied by cough and dyspnoea (p<0.05). One patient who stopped therapy, was back to baseline values when measured 2 months later. Cytokine production by blood or sputum T lymphocytes was not markedly altered by IL-2 inhalation.

CONCLUSIONS

IL-2 inhalation therapy in patients with metastasing renal cell carcinoma is capable of temporarily inducing symptomatic, functional and inflammatory alterations similar to those of bronchial asthma.

[Technical aspects of nerve sparing during retropubic prostatectomy]

Retropubic radical prostatectomy is the most commonly used therapeutic option for the treatment of clinically localized prostate cancer. An ongoing stage migration towards organ-confined cancers allows performing a nerve-sparing procedure in a growing number of patients. Key elements for achieving convincing functional results are a sphincter preserving Ligation of the distal part of Santorini's plexus and the subtle preparation of the neurovascular bundle. This article gives a detailed description of the operative technique. Furthermore, a strategy for patient selection and tumour selection for the indication of nerve-sparing radical prostatectomy (NSRP) is suggested.

Interleukin-2/interferon-alpha2a/13-retinoic acid-based chemoimmunotherapy in advanced renal cell carcinoma: results of a prospectively randomised trial of the German Cooperative Renal Carcinoma Chemoimmunotherapy Group (DGCIN)

We performed a prospectively randomised clinical trial to compare the efficacy of four subcutaneous interleukin-2-(sc-IL-2) and sc interferon-alpha2a (sc-IFN-alpha2a)-based outpatient regimens in 379 patients with progressive metastatic renal cell carcinoma. Patients with lung metastases, an erythrocyte sedimentation rate < or =70 mm h(-1) and neutrophil counts < or =6000 microl(-1) (group I) were randomised to arm A: sc-IL-2, sc-IFN-alpha2a, peroral 13-cis-retinoic acid (po-13cRA) (n=78), or arm B: arm A plus inhaled-IL-2 (n=65). All others (group II) were randomised to arm C: arm A plus intravenous 5-fluorouracil (iv-5-FU) (n=116), or arm D: arm A plus po-Capecitabine (n=120). Median overall survival (OS) was 22 months (arm A; 3-year OS: 29.7%) and 18 months (arm B; 3-year OS: 29.2%) in group I, and 18 months (arm C; 3-year OS: 25.7%) and 16 months (arm D; 3-year OS: 32.6%) in group II. There were no statistically significant differences in OS, progression-free survival, and objective response between arms A and B, and between arms C and D, respectively. Given the known therapeutic efficacy of sc-IL-2/sc-INF-alpha2a/po-13cRA-based outpatient chemoimmunotherapies, our results did not establish survival advantages in favour of po-Capecitabine vs iv-5-FU, and in favour of short-term inhaled-IL-2 in patients with advanced renal cell carcinoma receiving systemic cytokines.

[Fast-track surgery in radical retropubic prostatectomy. First experiences with a comprehensive program to enhance postoperative convalescence]

Fast-track surgery is a comprehensive program for the optimization of perioperative care in elective surgery reducing potential postoperative complications and speeding up convalescence. Recent data from randomized colon resection trials emphasize that fast-track surgery is possible in most major operations. Our initial results in radical retropubic prostatectomy fast-track surgery have been encouraging. Fast-track surgery in major urological operations needs validation using randomized trials.

[Success rates of two-layer, microsurgical vasovasostomy. Results from a patient questionnaire and comparison with one-layer technique]

Vasovasostomy is the most commonly performed procedures in the therapy for occlusive azoospermia after vasectomy. In our clinic the two-layer microsurgical technique (DL VVST) is considered to be the gold standard. We have examined the results of DL VVST by means of a questionnaire and compared them with those of the monolayer technique (ML VVST).

MATERIALS AND METHOD

In the period from 1996 to 2001, a microsurgical DL VVST with 10 x 0 Prolene sutures under the operation microscope was performed in 141 patient. Aspects of the operation, social aspects and postoperative results (results of spermiogram, birth rates) were assessed by means of a questionnaire. The results were compared with those of a historical patient collective who had undergone a modified monolayer VVST with 7 x 0 Prolene (n = 64).

RESULTS

The questionnaire could be sent to 90/141 patients, the response rate was 63/90 (70 %). The time interval between vasectomy and VVST was on average 9.5 years. The patency rate was 86 %, the birth rate 24 %. Severe or moderately sever complications did not occur. In the historical patient collective, the average occlusion interval was 6.9 years. The patency rate in these patients in whom the VVST was performed merely under the loupe and in a monolayer technique was 87 %, the pregnancy rate 48 %.

CONCLUSION

The highly positive results of VVST with pregnancy rates > 80 % from earlier publications could not be reproduced. According to our results, the two-layer VVST does not afford better results than the monolayer technique.

[Immunotherapy of renal cell carcinoma. With special emphasis on therapy of the elderly patient]

Interleukin-2 (IL-2) and/or interferon-alpha (IFN-alpha) induce remissions and prolong life in patients with metastatic renal cell carcinoma when carefully selected for a possibly toxic treatment. However, better-tolerated and more effective therapies are needed, especially in the elderly and patients with comorbidities. Recent achievements in the treatment of advanced renal cell carcinoma highlight potentially significant improvements. Immune cells within the tumor correlate with response and survival indicating the importance of local immune modulation. Such modulation has allowed introducing well-tolerated treatments such as inhalation of IL-2 to control lung metastases, which results in a significant survival benefit for high-risk patients as suggested by a recent cohort study in 200 patients. Antibody-based tumor targeting against cG250, specifically expressed on RCC, seems to stabilize progressive metastatic disease and does not induce toxicity. Vaccination strategies are also well tolerated, but have not shown convincing results in advanced disease so far. Other approaches have not fulfilled expectations. Stem cell transplantation still has significant toxicity and cannot be recommended for the elderly.

Efficacy and safety of inhaled recombinant interleukin-2 in high-risk renal cell cancer patients compared with systemic interleukin-2: an outcome study

Systemic IL-2 is an effective treatment for low to intermediate risk mRCC patients, its efficacy is marginal in high-risk cases. Therefore, other treatment approaches are required for this population. Ninety-four high-risk patients with RCC and pulmonary metastases were treated with inhaled plus concomitant low-dose subcutaneous rhIL-2. Clinical response, survival and safety were compared with those from IL-2 given systemically at the registered dose and schedule in 103 comparable historical controls. In the rhIL-2 INH group, treatment consisted of 6.5 MIU rhIL-2 nebulized 5x/day and 3.3 MIU rhIL-2 SC once daily. The rhIL-2 SYS group received treatment which consisted of intravenous infusion of 18.0 MIU/m2/day rhIL-2 or SC injection of 3.6-18.0 MIU rhIL-2. Some patients in both groups also received IFNalpha. Mean treatment durations were 43 weeks rhIL-2 INH and 15 weeks rhIL-2 SYS. Significantly longer overall survival and progression-free survival durations were observed in the rhIL-2 INH group. The probability of survival at 5 years was 21% for the rhIL-2 INH group. No patients survived 5 years in the rhIL-2 SYS group. A multivariate analysis of overall survival adjusting for differences in baseline characteristics between the two treatment groups resulted in a risk ratio of 0.43 (95% CI 0.30-0.63; P < 0.0001). The data suggested an association between the response (SD or better) and survival, especially in the rhIL-2 INH group. The inhalation regimen was well tolerated. This outcome study suggests that administration of rhIL-2 by inhalation is efficacious and safe in high-risk mRCC patients with pulmonary metastases, who have no other treatment option available.

[Immunotherapy of metastatic renal cell carcinoma in Germany. An assessment of the current status]

This survey was established to evaluate everyday use of interferon-alpha (IFN-alpha) and interleukin-2 (IL-2) in metastatic renal-cell carcinoma (mRCC). Of 186 centers (with 2200 patients per year) that responded, 182 support immunotherapy by using it themselves (147 centers) or by referring patients (35 centers). Effectiveness and tolerance are the main reasons for use. 133 centers use IL-2 subcutaneously, 64 by inhalation, 24 use it locally or intratumorally. Continuous intravenous IL-2 is used in 13 centers only. Most centers use subcutaneous combinations of IL-2 and IFN-alpha, either alone or with 5-fluorouracil and/or isotretinoin; IFN-alpha/Vinblastin combinations, IFN-alpha-monotherapy, and IL-2 s.c.-monotherapy are used with similar frequency. Average treatment duration is 3-6 months. Maintenance therapy is used in responding patients in 118 centers. Subcutaneous and local application of IL-2 is standard treatment for mRCC in Germany and subcutaneous IL-2 and IFN-alpha represents the most frequently used combination.

[Regional immunotherapy of metastatic renal cell carcinoma]

We summarized the current literature concerning regional immunotherapy of pulmonary metastases in metastatic renal cell carcinoma and other malignancies using inhaled interleukin-2 (IL-2). Inhaled IL-2 therapy is associated with minimal toxicity and is effective in preventing progression in metastatic renal cell carcinoma, melanoma, and possibly other diseases such as breast cancer. Local (physiologic) use and systemic (pharmacologic) use of IL-2 are not mutually exclusive; a combination may be very appropriate in metastatic cancer. Local physiologic therapy intensifies treatment without intensifying toxicity.

Systemic chemotherapy and chemoimmunotherapy for metastatic renal cell cancer

We review the current literature on systemic therapy for patients with metastatic renal cell carcinoma. Metastatic renal cell carcinoma remains highly resistant to chemotherapy and hormonal agents not justifying its use as a single agent. Interleukin-2 immunotherapy is the most effective treatment for metastatic renal cell carcinoma available today. There is evidence that interleukin-2 improves survival and yields long-lasting remissions in selected patients; the optimal dose and schedule still need to be defined. Response rates in patients treated with subcutaneous interleukin-2 are similar to those achieved with high-dose bolus intravenous applications. Questions remain concerning quality of life and benefit-to-risk ratio with respect to immunotherapy in individual patients. Different routes of administration of interleukin-2 such as local application, promise to improve quality of life and survival times.

A comparison of systemic versus inhaled recombinant IL-2 administration for the treatment of metastatic renal cell carcinoma

The aim of the current study was to compare the objective response and survival rates of patients with mRCC treated with IL-2 administered either systemically (SYST, subcutaneously) or via inhalation (INH), using relatively large sample sizes to afford a more meaningful comparison. We used univariate and multivariate analyses to retrospectively evaluate the data from two different databases generated from 277 patients treated with IL-2 during the 1993-1997 period, one developed at the University Hospital Hamburg-Eppendorf, and the other at Chiron-Amsterdam. Patients treated with INH IL-2 tended to have a poorer ECOG performance status than patients receiving SYST IL-2. Of 75 patients receiving INH IL-2, eight (10.7%) achieved an objective response; of 202 patients administered SYST IL-2, 45 (22.2%) achieved an objective response. The median survival time was 13.8 months for patients receiving INH IL-2 and 13.1 months for patients treated with SYST IL-2. One- and two-year survival rates were also comparable for the two treatment modalities (one-year: INH, 55%; SYST, 56%; two-year: INH, 28%; SYST, 26%). There was no significant difference in the likelihood of survival for patients receiving INH IL-2 versus SYST IL-2 (risk ratio = 0.82, P = 0.27). Patients administered INH IL-2 experienced considerably less toxicity and complications than patients administered SYST IL-2. We conclude that INH IL-2 treatment is at least as effective as SYST IL-2 treatment in promoting the survival of patients with mRCC. Given that INH IL-2 treatment of patients with a poorer ECOG performance status elicited a survival rate comparable to that seen with SYST IL-2 treatment of patients with a superior performance status, the potential exists for INH IL-2 treatment to be even more effective for patients having a better performance status. Additionally, INH IL-2 treatment is considerably less toxic and associated with fewer complications than SYST IL-2 treatment, thus providing a therapeutic option for otherwise untreatable patients, offering patients a relatively good quality of life, and requiring fewer co-medications. Nonetheless, selection of an IL-2 treatment modality should be based on several patient-related considerations. Moreover, these two IL-2 treatment modalities need not be mutually exclusive.

[Side-fire laser coagulation of the prostate with the neodymium:YAG-laser. Long-term outcome]

Transurethral laser prostatectomy has been widely used in patients with benign prostatic obstruction (BPO) with good short-term results and an excellent safety profile. We investigated how stable the results of side-firing visual laser coagulation of the prostate are during long-term follow-up to evaluate whether laser prostatectomy can really be an alternative to transurethral resection of the prostate (TURP). Between January 1993 and December 1995 a total of 59 patients underwent visual transurethral side-firing laser coagulation of the prostate (Urolase, Bard Inc., Murray Hill, NJ, USA). The patients were monitored at 1, 3, 6, and 12 months and then reevaluated after a mean of 33 months. As expected, at the 1-year follow-up there was a significant improvement in peak flow rate, post-void residual urine, international prostate symptom score (IPSS) and quality of life index (QoL). After a mean of 33 months, 15% of the patients required reoperation due to persistent BPO. In the remaining patients, peak flow rate and post-void residual urine were stable. However, the QoL index increased during long-term follow-up and no longer differed from the preoperative value after 33 months. The side-firing laser coagulation of the prostate does not seem to be a sufficient therapeutic alternative to TURP in the treatment of BPO.

Thromboembolic complication rate after radical retropubic prostatectomy. Impact of routine ultrasonography for the detection of pelvic lymphoceles and hematomas

OBJECTIVES

The impact of routine ultrasonography for diagnosis and rapid treatment of pelvic lymphoceles and hematomas on the rate of thromboembolic complications was studied.

METHODS

From June 1987 to December 1995, 508 patients underwent radical retropubic prostatectomy with low-dose heparin prophylaxis at our medical institution. Beginning with patient 321, routine pelvic ultrasonography was started on each patient on postoperative day 1 for diagnosis of lymphoceles and hematomas. The rate of thromboembolic complications in patients 321-508 was compared with that in patients 1-320 (without routine ultrasonography).

RESULTS

In patients 1-320, a total of 20 (6.2%) symptomatic thromboembolic complications occurred: five (1.6%) pulmonary emboli and 15 (4.7%) cases of deep venous thrombosis. In patients 321-508, the total rate of thromboembolic complications was significantly reduced (p = 0.049): only 4 patients (2.1%) had thromboembolic events (1 pulmonary embolism and 3 cases of deep venous thrombosis): all but 1 of the complications were associated with small hematomas, which were first negative on routine pelvic ultrasonography but positive on CT scan only done when clinical suspicion of symptoms occurred or during open surgery and showed compression of the iliac vein.

CONCLUSIONS

Pelvic lymphoceles and hematomas seem to be important cofactors in the pathophysiology of thromboembolic complications after radical retropubic prostatectomy. Most lymphoceles and hematomas can be diagnosed with pelvic ultrasonography although small hematomas can be overseen with pelvic ultrasonography Surgeons should become more aware of these postoperative complications particularly in patients on heparin prophylaxis.

[Treatment of metastatic renal cell carcinoma. Value of immunotherapy compared with surgery of metastases]

The prognosis for patients in whom metastatic renal cell carcinoma (RCC) is not treated is unfavorable, with a reported 5-year survival of 0-18%. Before the era of immunotherapy and in the absence of effective nonsurgical therapy, resection of metastases was the accepted way to prolong survival, giving a 5-year survival of 7-69%. Retrospective studies have shown that several clinical factors are associated with a relatively good prognosis. Some patients will benefit from resection of metastases, but most patients with metastatic RCC are not candidates for such aggressive surgery. The use of interleukin-2 has demonstrated that immunotherapy can produce durable remissions. Without randomized trials, it is difficult to know whether survival is longer than that in untreated patients, but there is clear evidence that immunotherapy improves survival and yields long-lasting remissions in selected patients. Many questions remain concerning quality of life and the benefit-to-risk ratio of immunotherapy, but it is the most effective treatment for metastatic RCC.

Overview of interleukin-2 inhalation therapy

PURPOSE

Locoregional administration of interleukin (IL)-2, which acts physiologically as a local hormone, is an effective therapeutic modality. Diverse preclinical and clinical models have described methods of administration that expose tumor tissues to continuously high levels of cytokines. Regional administration of IL-2 that does not raise intravascular IL-2 levels induces local and systemic immunomodulation and produces objective local tumor responses. Most importantly, regional therapy is much less toxic than systemic IL-2 therapy.

PATIENTS AND METHODS

We review clinical experiences using inhaled IL-2 therapy for the treatment of pulmonary metastases in roughly 300 patients with a variety of primary tumors. This includes our own 10-year single-institution experience with inhaled IL-2 therapy in the treatment of 188 metastatic renal cell carcinoma patients with progressive pulmonary metastases. Patients in our clinic are treated with 18 to 36 million IU of recombinant IL-2, administered 90% by inhalation and 10% subcutaneously, until disease progression. A variety of doses and schedules of inhaled IL-2 have been investigated alone and in combination with systemic therapies.

RESULTS

Inhalation of IL-2 has been reported to prevent progression of pulmonary and mediastinal metastases of metastatic renal cell carcinoma, breast and ovarian carcinoma, and melanoma. Inhaled IL-2 alone is well tolerated; a dose-dependent cough is the major adverse event. A significant dose-dependent increase in lymphocytes and eosinophils has been observed in bronchoalveolar lavage in patients and animals. Dose and schedule can influence outcome. In a phase I trial using inhaled IL-2 alone in patients with a variety of primary malignancies, once-daily inhalation of IL-2 at doses up to 15 million IU/m2 was well tolerated but did not result in prolonged stabilization of pulmonary disease. In a multidose phase I trial, using 5-times-daily inhalation of natural IL-2, pulmonary lesions in three of 14 (21%) metastatic renal cell carcinoma patients responded, and a similar multicenter trial demonstrated a 29% response rate. Among 188 metastatic renal cell carcinoma patients treated with inhaled recombinant IL-2 at the Clinic Eppendorf, progression of pulmonary metastases was prevented in 68% of patients for a median duration of 7 months, and overall survival was significantly improved compared with expected survival (Elson's risk analysis; 17.2 vs 5.3 mo). All patients, including high-risk patients, appeared to benefit. Encouraging results have also been reported in patients with metastatic melanoma and gynecologic tumors when inhaled IL-2 was used as second-line therapy to treat pulmonary metastases.

CONCLUSIONS

The efficacy of inhaled IL-2, alone or in combination with systemic immunotherapy, immunochemotherapy, or chemotherapy, has been documented in a variety of malignancies. All reports confirm low toxicity, thus providing important quality-of-life benefits. Moreover, patients not eligible for systemic IL-2 therapy may be treated with inhalation therapy.

Subjective and objective prospective, long-term analysis of quality of life during inhaled interleukin-2 immunotherapy

PURPOSE

We conducted both a subjective and objective, prospective quality-of-life analysis during high-dose (36 x 10(6) immunizing units/d) inhalational interleukin (IL)-2 treatment (mean treatment time, 13.4 months) of 15 patients with metastatic renal cell carcinoma (mRCC). Additionally, quality of life for 10 patients with mRCC receiving low-dose (9 x 10(6) IU/m(2)/d for 5 days) intravenous IL-2 treatment also was evaluated.

PATIENTS AND METHODS

Patients responded to the European Organization for Research and Treatment of Cancer quality-of-life questionnaire QLQ-C30 before and during inhalational IL-2 treatment at 1, 3, 6, 9, and 12 months and before and once during intravenous IL-2 treatment. A clinician assessed patient well-being using the Quality of Well-Being scale to calculate once weekly quality-adjusted life-years (QALYs) during inhalational IL-2 treatment.

RESULTS

Patients completed 103 questionnaires and clinicians performed 892 QALY calculations. For patients treated with inhalational IL-2, the mean quality-of-life score deteriorated modestly but significantly 1 month after treatment initiation (15.1%, P =.01) but did not differ significantly from pretreatment scores after 3, 6, 9, and 12 months of treatment. Inhalational IL-2 therapy stabilized patient quality of life for a mean of 13.4 months. The resulting QALY calculation for patients on inhalation IL-2 was 70.1% of 13.4 months, representing 9.4 months of QALY. In comparison, patients who received intravenous IL-2 showed a more marked, statistically significant deterioration in mean quality-of-life score during treatment (27%, P =.006); moreover, three of these 10 patients experienced treatment-related toxicity that prevented questionnaire completion.

CONCLUSION

Quality-of-life analysis during immunotherapy provides valuable information regarding cancer treatment outcomes.

[Treatment of pulmonary metastases from kidney cell carcinoma with inhalational interleukin-2. 10-year experience Hamburger Unicenter]

Systemic immunotherapy, notably with interleukin-2 (IL-2) and interferon-alpha (IFNalpha), has yielded a response rate of 10 % to 30 % in metastatic renal cell carcinoma. However, systemic immunotherapy is limited by severe side effects, and long-lasting response is rare. Tumor palliation and quality-of-life are important end points for evaluating the clinical benefits of immunotherapy. Experimental and clinical treatment models have proved that local IL-2 application is less toxic than systemic treatment and is therapeutically effective. Here we report long-term experience with inhalation IL-2 therapy in 188 patients who had progressive pulmonary metastatic renal cell carcinoma. High-dose inhalation of IL-2 was used with low-dose systemic IL-2 or IFNalpha. Maximal toxicity over the total treatment time was mild, and the low incidence of WHO grade 3 toxicity (24 %) allowed social activities and performance of social roles. Comedication for systemic side effects was required only in half of the patients. Inhaled IL-2 prevented progress of pulmonary metastases in 68 % of patients for a median period of 9.8 months. Median survival was 12.4 months compared with the expected 5.3 months and quality-of-life did not differ substantially from pretreatment status. Local treatment can be applied alone or in combination with systemic therapy and can increase therapeutic efficacy.

Treatment of pulmonary metastatic renal-cell carcinoma in 116 patients using inhaled interleukin-2 (IL-2)

BACKGROUND

We report 6 years of experience in 116 patients who used inhaled interleukin-2 (IL-2) and were treated in different protocols with natural, recombinant glycosylated and recombinant nonglycosylated IL-2.

MATERIALS AND METHODS

All protocols had in common high-dose inhalation of IL-2, either exclusively (11%), with low-dose systemic IL-2 (33%), or with low-dose systemic IL-2 and interferon-alpha (56%). Maximal toxicity per total treatment time (median treatment time, 7.2 months) was mild and at a low incidence (16%) of WHO grade 3 toxicity. Treatment was allowed in patients for whom systemic IL-2 was not suitable.

RESULTS

Progressive pulmonary metastases responded in 15% of patients for a median of 15.5 months (range 4.1-33) and were stabilized in 55% for a median of 6.6 months (range, 3-51.7). Overall response rate was 16%, 49%, and 35%, respectively. Median overall response duration was 9.6 mo. Median achieved survival was 11.8 months (range 1.7-68.8).

CONCLUSIONS

Inhaled IL-2 prevents progress of pulmonary metastases effectively in 70% of patients. Local use of IL-2 allows the use of the full potential of cytokines with little or no toxicity.

Immunotherapy of pulmonary metastatic renal cell carcinoma: success dependant on risk factors?

BACKGROUND/AIMS

Risk factors may influence not only prognosis in metastic renal cell carcinoma but also probability of response to immunotherapy. Response of patients treated with inhalation of interleukin-2 (IL-2), which can be offered to those not suitable for systemic therapy, was compared to risk factors. We report on 116 patients who used inhaled IL-2 and were treated in different protocols with natural, recombinant glycosylated and recombinant non-glycosylated.

METHODOLOGY

All protocols had in common a high-dose inhalation of IL-2, either exclusively (11%), with low-dose systemic IL-2 (33%), or with low-dose systemic IL-2 and interferon-alpha (56%). Maximal toxicity per total treatment time (median treatment time: 7.2 months) was mild and there was a low incidence (16%) of WHO grade 3 toxicity. Treatment response was analyzed in a subgroup of patients having at least one given risk factor and treated with recombinant IL-2 (n=86). In all patients having risk factors the following distribution was found: more than 1 metastic location (86%), diagnosis to treatment interval (DTI) <12 months (62%), weight loss prior to therapy (41%), and ECOG performance status > or =2 (13%). In comparison, a group of patients having no risk factors at all was analyzed accordingly.

RESULTS

Response to immunotherapy is dependant on risk factors, the most prominent one being the ECOG. Patients with an ECOG > or =2 achieved no overall response compared to patients with no risk factors who responded to immunotherapy (33%). Progressive pulmonary metastases responded in 15% of patients for a median of 15.5 months (range: 4.133) and were stabilized in 55% for a median of 6.6 months (range: 3-51.7). Overall response rate was 16%, 49%, and 35%, respectively. Median overall response duration was 9.6 months. Median achieved survival was 11.8 months (range: 1.7-68.8).

CONCLUSIONS

We conclude that risk factors have to be considered in the interpretation of response to immunotherapy. Exclusion of patients because of risk factors alone does not seem to be justified according to our data. Responses, including long-term stabilization, can be achieved in 27-57% of such patients. IL-2 immunotherapy can also be considered as useful antitumor therapy in patients with risk factors, especially if given without major toxicity.

Inhaled interleukin-2 therapy in pulmonary metastatic renal cell carcinoma: six years of experience

PURPOSE

Patients with advanced metastatic renal cell carcinoma often cannot or do not want to tolerate high-dose systemic interleukin-2 (IL-2) therapy and the toxicity associated with it. To reduce toxicity and still maintain or even increase effectiveness, we developed a method to deliver IL-2 locally for the treatment of pulmonary and mediastinal metastases in metastatic renal cell carcinoma patients.

PATIENTS AND METHODS

We report here 6 years of experience treating 116 metastatic renal cell carcinoma patients who had pulmonary or mediastinal metastases with inhaled IL-2. We have utilized three different IL-2 preparations (natural human IL-2 purified from the supernatants of mitogen-activated peripheral blood lymphocytes, glycosylated recombinant IL-2 produced by Chinese hamster ovary cells, and non-glycosylated recombinant IL-2 produced by bacteria). All protocols used high-dose inhalation of IL-2, either exclusively (11%), with coadministration of low-dose systemic IL-2 (33%), or with coadministration of low-dose systemic IL-2 and interferon-alpha (56%).

RESULTS

Maximal toxicity per total treatment time was mild (median treatment time, 7.2 months); there was a low incidence (16%) of World Health Organization grade 3 toxicity. Toxicity associated with exclusive inhalation of IL-2 was local and consisted mainly of cough. Thus, patients who could not tolerate high-dose systemic IL-2 were able to tolerate inhalation IL-2 therapy. Progressive pulmonary metastases responded in 15% of patients for a median of 15.5 months (range, 4.1-33 months) and were stabilized in 55% of patients for a median of 6.6 months (range, 3-51.7 months). The overall response rate was 16%; disease was stabilized in 49% of patients and disease progressed in 35% of patients. The overall median response duration was 9.6 months. Median survival was 11.8 months (range, 1.7-68.8 months); expected survival according to risk analysis was 5.3 months.

CONCLUSIONS

Inhalation of IL-2 is a nontoxic and effective treatment for patients with progressive pulmonary and mediastinal metastases. Inhaled IL-2 effectively prevented progress of pulmonary metastases in 70% of patients. Furthermore, patients could be treated as outpatients and remain employed. Local administration of IL-2 increases therapeutic effectiveness with little or no toxicity.

Early complication of anatomical radical retropubic prostatectomy: lessons from a single-center experience

OBJECTIVES

The purpose of this study is to report the rate of early complications in 316 of 600 patients who underwent anatomical radical retropubic prostatectomy for localized prostatic cancer from June 1988 to July 1996 and to measure the effect of increasing experience in a single institution.

METHODS

From January 1992 to August 1995, 316 patients with prostatic cancer underwent anatomical radical retropubic prostatectomy at our medical institution. Early complications were recorded prospectively and the rate of complications of the first 166 patients was compared with the rate in the next 150 patients.

RESULTS

Comparison of the 2 groups showed a significant decrease in blood loss with time (mean 1,397 vs. 967 cm3, p = 0.0011). The rates of anastomotic urinary leakage (21.7 vs. 10%, p = 0.0056), lymphoceles (22.3 vs. 2%, p < 0.0001), rectal injury (7.8 vs. 2%, p = 0.02), reoperation (10.2 vs. 4%, p = 0.049), and thromboembolic complications (7.8 vs. 2.7%, p = 0.0479) also decreased significantly. Only ureteral transsection showed an increase in the later group (0 vs. 4.7%, p = 0.005).

CONCLUSIONS

The low percentage of early complications suggests that anatomical retropubic radical prostatectomy is a safe approach. Our single-center study showed a learning pattern that appears unavoidable when this operation is as radical as possible so as to keep the percentage of positive margins low especially in patients with advanced tumors (> pT2).