Ejaculation in testicular cancer patients after post-chemotherapy retroperitoneal lymph node dissection.

The purpose of this study was to evaluate fertility after different types of post-chemotherapy retroperitoneal lymph node dissection (RPLND). During 1980-1994, 192 patients with metastatic testicular cancer underwent post-chemotherapy RPLND with a gradual shift from modified bilateral template RPLND to nerve-sparing RPLND. Modified bilateral template RPLND was done in 92% of the patients operated during 1980-1984 as compared to 16% during 1989-1994. Pre- and post-treatment fertility was assessed by microscopic sperm analysis, determination of serum FSH and information on ejaculation and paternity. There was no significant difference of the survival rates between the three treatment periods. Antegrade ejaculation was preserved in 11% of the patients after modified bilateral template RPLND as compared to 89% after the nerve-sparing operation technique. The median ejaculatory volume decreased post-operatively, serum FSH increased and sperm density remained unchanged. Fifty-six patients attempted fatherhood after their treatment, and 27 fathered at least one child after an observation-time of 55 months, nine of them by assisted fertilization. Patients with initially advanced testicular cancer but limited residual retroperitoneal masses after induction chemotherapy can safely undergo limited post-chemotherapy RPLND as a part of multimodality treatment. After nerve-sparing RPLND antegrade ejaculation is preserved in 89% of the patients though the ejaculatory volume decreases after RPLND. Post-treatment fatherhood can be achieved in at least 50% of the patients attempting paternity.

Treatment and outcome of patients with extragonadal germ cell tumours--the Norwegian Radium Hospital's experience 1979-94.

This report reviews 48 patients who from 1979 to 1994 were treated at the Norwegian Radium Hospital for newly diagnosed noncerebral extragonadal malignant germ cell tumour (EGGCT). Based on histology and/or serum tumour markers, 12 patients had a seminoma and 36 a non-seminoma. At diagnosis, 33 and 15 patients were classified as having abdominal and mediastinal EGGCT respectively. At the time of diagnosis 13 patients, all with non-seminomatous tumours, had metastases to bone, liver or brain. One patient with abdominal seminoma was cured by radiotherapy alone, whereas cisplatin-based chemotherapy (with or without surgery) was planned in the 47 remaining patients. Twenty-seven out of 42 patients receiving four or more chemotherapy cycles were rendered tumour free by induction chemotherapy, including 5 of the 13 patients with extralymphatic non-pulmonal disease. An additional tumour-free patient died of septicaemia after only two cycles of chemotherapy. Late relapses (after > 2 years) were observed in three patients, and a testicular primary was diagnosed during follow-up in three cases. Seven patients died of treatment-related complications, five of these because of neutropenic septicaemia. The median age of these patients was 52 years compared with 35 years in the remaining 41 patients (P < 0.05). The 5-year overall survival for all 48 patients was 60% (95% CI 46-74%) [cancer-specific 5-year survival 71% (95% CI 50-92%)]. EGGCT is a potentially curable disease, even in patients with very advanced disease. Special attention should, however, be devoted to patients above the age of 40 years because of an increased risk of treatment-related side-effects. Late relapses and the subsequent development of testicular tumours indicate the need for long-term follow-up.

Survival of patients with viable malignant non-seminomatous germ cell tumour persistent after cisplatin-based induction chemotherapy.

OBJECTIVES: Review of the outcome in patients with viable residual postchemotherapy malignant germ cell tumour treated at the Norwegian Radium Hospital from 1980 to 1993 and to establish prognostic factors. METHODS: During the years 1980-1993, about 270 patients with malignant non-seminomatous germ cell tumours underwent postchemotherapy surgery at the Norwegian Radium Hospital. In 27 of these patients, residual viable malignant germ cell tumour was found in the operation specimen. These patients were scheduled to receive 3 adjuvant cisplatin-based chemotherapy cycles after surgery, if possible, containing cytostatic agents not given during induction chemotherapy. All patients were followed up until death or January 1st, 1995 (median observation time in surviving patients: 51 months; range: 9-166 months). RESULTS: Sixteen patients developed a relapse after surgery after a median time of 4 weeks (range 1-19 weeks), 12 of them before any adjuvant chemotherapy could be started. Only 2 of these relapsing patients could be salvaged. At the last follow-up, 13 patients were alive, and a 43% 5-year survival was obtained. All deaths occurred within 3 years after surgery. The 9 patients with elevated alpha-fetoprotein and/or human chorionic gonadotropin before surgery have a particularly low survival rate (11%), as compared to the 18 patients with normal markers (62%). The most important prognostic parameter for the postoperative survival was, however, the initial tumour burden: the 14 patients with initially large or very large tumour volume (MRC criteria) had a 9% 5-year survival, whereas the percentage was 84% for the 13 patients with small volume disease. CONCLUSION: Prognosis is poor in patients in whom residual malignant germ cell tumour persists in spite of conventional cisplatin-based induction chemotherapy, especially in patients who initially present with large or very large volume disease and/or pre-operatively elevated tumour markers. More effective treatment modalities have to be developed for these patients. The role of high-dose chemotherapy with stem cell support should be investigated in future trials, especially in the subgroup of patients with poor prognosis.

Survival after curative treatment of muscle-invasive bladder cancer.

This retrospective study includes 534 patients who had curatively intended treatment for T2/T3/T4a bladder cancer at the Norwegian Radium Hospital during the period 1980-1990. Total cystectomy preceded by preoperative radiotherapy represented the treatment of choice in 263 patients (CysGr). High-dose radiotherapy was applied in 271 patients in whom total cystectomy could not be performed (RadGr). From 1985 neo-adjuvant cisplatin-based chemotherapy was increasingly used. The 5-year crude survival rate for all patients was 35% with 40% for CysGr and 22% for RadGr. In CysGr the 5-year survival rate was highest (63%) for patients with

Bladder cancer definitive radiation therapy of muscle-invasive bladder cancer. A retrospective analysis of 317 patients.

BACKGROUND: The role of radiation therapy as curative treatment of muscle-invasive bladder cancer was to be analyzed. METHODS: From 1980-1990, 308 patients with transitional cell carcinoma of the urinary bladder received definitive pelvic radiation therapy (nominal standardized dose greater than or equal to 1700 ret). T categorization was based on clinical examination assessing the palpability of the bladder tumor and its extent (TNM 1978/1982). RESULTS: The cancer-specific 5-year survival rate for all patients was 24% (crude survival, 20%). The 135 patients with T2/T3a tumors lived significantly longer (5-year survival, 38%) than those with greater than or equal to T3b tumors (5-year survival, 14%). In the former group of patients, age (75 years and younger versus older than 75 years) was significantly correlated with a favorable outcome. The cancer-specific 2-year survival was significantly correlated to clinical response assessed 3-4 months after radiation therapy was 72%, 38%, and 10% in cases of complete response, partial response, and no response/inevaluability, respectively. In a multivariate analysis, the T categorization, patient age, serum creatinine level (less than or equal to 150 mumol/l versus greater than 150 mumol/l), and radiation therapy schedule predicted the 5-year survival rate. CONCLUSIONS: The clinical T category (< or = T3a versus > or = T3b), based on bimanual palpation, represents an important prognostic parameter, if done by clinicians experienced in onco-urology. High-dose radiation therapy offers a reasonable chance for long-term survival in patients with T2/T3 tumors confined to the bladder wall, especially in patients younger than 76 years. Greater than or equal to 80% of patients with more extended tumors (greater than or equal to T3b) and those older than 75 years of age are not curable by radiation therapy alone. In these patients palliative treatment modalities should be considered, in particular if cisplatin-based chemotherapy is not feasible.

A bladder cancer multi-institutional experience with total cystectomy for muscle-invasive bladder cancer.

BACKGROUND: The role of total cystectomy was to be assessed in the curative treatment of muscle-invasive bladder cancer. METHODS: Two hundred and fifty-three patients with T2-T4a transitional cell carcinoma of the urinary bladder were referred to precystectomy radiation therapy (46 Gy, 66 patients; 20 Gy, 187 patients). These patients represented approximately 20% of all patients developing muscle-invasive bladder cancer in Southern Norway from 1980-1990. The clinical T categorization was generally based on palpability and extent of the palpable bladder tumor assessed by the referring urologist. Twenty-six patients (10%) did not have total cystectomy, most often due to peroperatively demonstrated locoregional inoperability. Two or three cycles of cisplatin-based combination chemotherapy were given to 68 patients. RESULTS: For the 227 patients who underwent cystectomy, the cancer-specific 5-year survival rate was 58% (T2 [104 patients], 63%; greater than or equal to T3 [123 patients], 54%) (P = 0.022). The comparable figure for patients with histologically proven regional lymph node metastases was 22%. The 97 stage-reduced cases (less than or equal to pT1) survived significantly longer than the 130 patients without stage reduction (74% versus 46%) (P < 0.0001). Neoadjuvant chemotherapy was correlated with a more favorable survival in patients with greater than or equal to T3 tumors but did not seem to influence survival of patients with T2 bladder cancer. CONCLUSIONS: In a multicenter setting, prognostically relevant T categorization of operable muscle-infiltrating bladder cancer can be based on the palpability of the primary tumor. Approximately 50% of favorably selected patients with operable T2-T4 bladder cancer survived for at least 5 years independent of whether the operation was done at a large uro-oncologic unit or a smaller urologic section. In this retrospective review, chemotherapy seemed to improve the survival in patients with deeply infiltrating (greater than or equal to T3) bladder cancer but appeared to represent an overtreatment in patients with T2 tumors.

Salvage treatment in male patients with germ cell tumours.

The outcome of salvage treatment was reviewed in 55 patients relapsing during or after their primary chemotherapy for advanced malignant germ cell tumours. Fifty-two patients had been given cisplatin-based chemotherapy as their primary treatment, whereas three patients had received carboplatin-based chemotherapy. The median time to relapse was 2 months (range: 0-96 months) from discontinuation of the primary treatment. Two patients underwent radical surgery only, and one patient had radiotherapy to a brain metastasis as his only curatively intended salvage treatment. Six patients did not receive any treatment for their recurrent malignancy (refusal, terminal condition) except for purely palliative measures. The disease-free survival for the total group was 27% at 5 years. Complete response to primary treatment lasting for > or = 6 months was the only parameter which significantly predicted a favourable outcome (45% 5 year disease-free survival in 12 eligible patients).

Semen quality after treatment for testicular cancer.

During the last 14 years repeated sperm cell analyses and serum hormone analysis were done regularly in patients with testicular cancer before and after treatment. The summarized results are hereby reported. The sperm cell count was highly impaired in 60-70% of testicular cancer patients evaluated 1-4 weeks after unilateral orchidectomy before further treatment. However, improvement of the exocrine gonadal function was regularly observed during the following 2-3 years, provided there were normal or only slightly elevated pre-treatment FSH levels. Standard irradiation and cytotoxic treatment (abdominal radiotherapy 30-40 Gy; < or = 4 cycles of cisplatin-based chemotherapy) delayed this recovery by about one year. Higher doses of chemotherapy or combined irradiation/chemotherapy reduced the chances of rapid improvement of the exocrine gonadal function. Unilateral retroperitoneal lymph node dissection resulted in a slight reduction of the post-treatment ejaculatory volume, even in patients with preserved antegrade ejaculation.

Retroperitoneal surgery in patients with nonseminomatous testicular cancer and minimal residual tumor.

In the period 1980-1991, 78 patients with advanced nonseminomatous testicular cancer underwent retroperitoneal lymphadenectomy for post-chemotherapy residual masses less than 2 cm. To decrease the frequency of "dry ejaculation" in these patients with no or limited residual disease, the extent of dissection was reduced during the period, with bilateral dissections (49 cases, 1980-1986) being initially replaced by unilateral procedures (19 cases, 1983-1990) and subsequently by nerve-sparing techniques (10 cases, 1990-1991). As expected, a higher total number of lymph nodes was found in the retroperitoneal specimens after bilateral (44 (13-100)) than after unilateral (21 (7-35)) and nerve-sparing (18 (7-60)) procedures. The number of lymph nodes with pathological changes was low, with 3 (1-16) after bilateral, 2 (1-9) after unilateral, and 2 (1-4) after nerve-sparing operations. Histological examination revealed only necrosis/fibrosis in 65% of the patients, elements of mature teratoma in 28%, and remnants of viable malignant tumor in 6%. There were no major postoperative complications. "Dry ejaculation" was reported by 84% of the patients with bilateral operations, but was generally avoided after the unilateral (16%) and nerve-sparing (nil) procedures. After a mean follow-up of 83 (5-138) months, 6 patients have developed a recurrence, only one of them primarily in the retroperitoneal space. It is concluded that in patients with minimal residual retroperitoneal tumor, postchemotherapy lymphadenectomy using a unilateral or nerve-sparing technique seems to offer an effective therapeutic alternative with acceptable postoperative morbidity and preserved ejaculation.

Is postchemotherapy retroperitoneal surgery necessary in patients with nonseminomatous testicular cancer and minimal residual tumor masses?

PURPOSE: At least one third of the patients with metastatic testicular cancer are rendered tumor-free by cisplatin-based chemotherapy. One may question, therefore, the routine use of postchemotherapy retroperitoneal lymph node dissection (RLND), especially if the residual masses are less than 20 mm in diameter. To define the role of such surgery, we analyzed the postchemotherapy histology in testicular cancer patients with minimal residual disease. PATIENTS AND METHODS: Seventy-eight patients with advanced nonseminomatous testicular cancer underwent RLND after three to four cycles of cisplatin- or carboplatin-based chemotherapy. In all patients, the largest diameter of the residual retroperitoneal mass was less than 20 mm. RESULTS: Complete fibrosis/necrosis was found in 51 patients, mature teratoma in 22, and vital malignant germ cell tumor in five. In two of the latter five patients, alphafetoprotein (AFP) had increased immediately before RLND. In the 76 patients with normal pre-RLND tumor markers, the presence of undifferentiated malignant teratoma (MTU) in the primary tumor and normal prechemotherapy tumor markers were independent parameters predicting complete fibrosis/necrosis, which was demonstrated in all 15 patients with these two pretreatment parameters. CONCLUSIONS: Postchemotherapy RLND can be omitted in patients with MTU in the primary tumor who have normal AFP/human chorionic gonadotropin (AFP/HCG) before chemotherapy and whose residual retroperitoneal mass is less than 20 mm in diameter. If the pre-RLND tumor markers are normal, RLND should be performed in all other patients with small residual masses, even in the presence of a normal computed tomography (CT) and particularly if regular follow-up of the patients is not guaranteed.

Cisplatin and 5-fluorouracil in advanced cancer of the penis.

A total of 8 patients with advanced squamous cell carcinoma of the penis (Jackson stages III and IV) received chemotherapy with 100 mg./m2. cisplatin intravenously on day 1 and a 24-hour infusion of 1,000 mg./m.2 5-fluorouracil on days 1 to 5. Of the patients 2 (25%) achieved a partial response: 1 required a further operation and 1 required surgery with radiotherapy to achieve a complete response. These 2 patients were disease-free at 32+ and 57+ months. Nonresponders had a survival range of 2+ to 28 months after chemotherapy. Nausea and vomiting were the most frequent side effects of chemotherapy. Chemotherapy-related increase in serum creatinine occurred in 3 patients. Two patients had septicemia and 1 complained of tinnitus. Poor tolerability especially in the elderly was the main reason for discontinuing chemotherapy. The combination of cisplatin and 5-fluorouracil may have a role in the management of advanced penile cancer together with surgery and radiotherapy.

Asymmetrical autonomic dysfunction of the feet after retroperitoneal surgery in patients with testicular cancer: 2 case reports.

We report on 2 patients with hyperhidrosis and decreased temperature of the leg on the unoperated side after unilateral retroperitoneal lymph node dissection. Both patients had a 4 to 5C difference in skin temperature of the feet, with the operated side being warm and dry compared to the nonoperated side. This condition is most likely due to a lesion of sympathetic fibers or ganglia located in close proximity to the retroperitoneal lymph nodes, resembling a unilateral lumbar sympathectomy. In addition, both patients had profuse sweating and a subjective feeling of coldness of the leg on the nonoperated side, which caused considerable discomfort. This latter phenomenon most likely represents a compensatory sympathetic hyperfunction due to the decreased sympathetic function in the other leg.

DNA flow cytometry and neo-adjuvant chemotherapy/radiotherapy in operable muscle-invasive bladder carcinoma. A preliminary report.

Fifty-five patients with muscle-invasive transitional cell carcinoma of the bladder were treated with preoperative cisplatin-based chemotherapy followed by radiotherapy (20 Gy within 1 week) and cystectomy. DNA flow cytometry (FCM) was performed in paraffin-embedded tissue obtained by transurethral resection immediately before therapy. Together with the T-category and histological grade, DNA ploidy and S-phase fraction (SPF) were evaluated for the ability to predict the response to chemotherapy/radiotherapy and survival: a low T-category, but neither DNA ploidy nor SPF, was predictive for the response to neo-adjuvant treatment. The T-category was not related to the patients' survival. In the Cox regression analysis, SPF was an independent prognostic parameter together with response to the precystectomy therapy. We concluded that, in spite of remaining technical problems, paraffin-embedded tissue from bladder carcinoma is suitable for DNA FCM. Contrary to the situation in superficial bladder cancer, DNA ploidy is not related to the clinical outcome in muscle-invasive bladder carcinoma treated by neo-adjuvant chemo-/radiotherapy and cystectomy. SPF seems to be a clinically worthwhile parameter with significance that has to be further studied in larger series.

The prognostic significance of deoxyribonucleic acid flow cytometry in muscle invasive bladder carcinoma treated with preoperative irradiation and cystectomy.

Deoxyribonucleic acid (DNA) flow cytometry measurements were performed in nuclear suspensions obtained from paraffin-embedded biopsies from 83 patients with stages T2, T3 and T4a bladder carcinoma. All patients were treated with preoperative radiotherapy and cystectomy from 1976 through 1985. Of the tumors 13 (16%) were diploid, 18 (22%) tetraploid and 52 (63%) aneuploid. A total of 19 tumors (23%) had 2 or 3 stemlines in addition to the diploid cells. Post-radiotherapy stage reduction (absence of muscle infiltration in the cystectomy specimen) occurred more often in tumors with only 1 nondiploid stemline than in diploid tumors or nondiploid tumors with multiple stemlines. The 5-year survival rate was significantly poorer for patients with a diploid (33%) than for those with a nondiploid (66%) tumor (p = 0.05), although this was only marginally retained in a multivariate analysis (p = 0.11). The clinical significance of DNA ploidy in muscle infiltrating bladder cancer seems not to be as evident as has been shown for superficial bladder tumors but it may be of value in selecting patients for preoperative radiotherapy.

Patterns of primary care and survival in 336 consecutive unselected Norwegian patients with bladder cancer.

The outcome of 336 unselected patients diagnosed as having bladder cancer in 1985 in a southern health region of Norway was studied. Two hundred and forty patients had superficial bladder cancer (Tis, Ta and T1). Seventy-four had T2-3 and 17 had T4 bladder tumours at the time of diagnosis (the T-category was unknown in five cases). In 46 of 248 evaluable cases (19%) 12 or more months had elapsed between the onset of symptoms and the histological confirmation of the diagnosis. The information received from the initial routine histology report was inadequate in 51 of 240 (21%) of the patients with superficial bladder cancer. Among the 91 patients with muscle-infiltrating tumours the primary treatment varied considerably, and only 15 patients underwent total cystectomy as the initial treatment. Only 46 in whom muscle-infiltrating tumours were diagnosed initially were referred to the regional uro-oncological unit during the course of the disease. The cancer-corrected, four-year survival was 86% and 42% for superficial and muscle infiltrating bladder cancer, respectively. The comparable figures for crude survival were 64% and 34%, respectively. The lack of optimal standard treatment of muscle-infiltrating bladder cancer warrants the introduction of clinical trials to assess both curative and palliative regimens as well as to study prognostic factors such as proliferation and immunohistochemical parameters by uro-oncological units. Scandinavian Cancer Registries should consider the optional recording of the T category on the case record forms for newly diagnosed cases of bladder cancer.

Colony formation in urinary bladder carcinoma. Relationship to DNA flow cytometry, stage and histopathology.

Tumour cells from 74 biopsies from human urinary bladder carcinomas were cultivated in a semisolid system (Courtenay and Mills method). In 51 cases DNA flow cytometry (FCM) was performed. Significant growth was obtained in 53 of 74 cases (71.6%), and good quality DNA histograms from FCM were obtained in all 51 attempts. No correlations between clinical or histopathological data and plating efficiency (PE) were found, nor between ploidy and PE. However, a very high S-phase (greater than 15%) correlated with a low PE. This work shows that bladder carcinoma cells can be studied in a semisolid agar system. It also suggests that there exists no correlation between PE and DNA FCM data or clinical or histopathological data.

Post-chemotherapy tumor residuals in patients with advanced nonseminomatous testicular cancer. Is it necessary to resect all residual masses?

A total of 15 patients with advanced nonseminomatous testicular cancer underwent 2 sequential operations (4 in 1 patient) to remove residual masses after cisplatin-based combination chemotherapy. All patients had normal human chorionic gonadotropin and alpha-fetoprotein levels but persistent radiographic masses after chemotherapy. The operations included retroperitoneal lymph node dissection in 13 patients, thoracotomy in 15, hepatic resection in 3 and craniotomy in 1. Histological comparison of the specimens resected during post-chemotherapy operations 1 and 2 demonstrated different patterns in 7 of 15 patients. Of these 7 patients 4 had less favorable pathological features in the specimen removed during the second procedure. Residual malignant tumor or mature teratoma was found in at least 1 site in 12 of the 15 patients and only 3 had complete necrosis or fibrosis in both specimens examined. These data indicate the favorable impact of excising all post-chemotherapy tumor residuals in patients with advanced nonseminomatous testicular cancer. However, in patients with no teratomatous elements in the testicular tumor and complete necrosis or fibrosis in the initial post-chemotherapy operation specimen the probability of complete necrosis or fibrosis in remaining tumors appears to be high.

Long-term morbidity and quality of life in testicular cancer patients.

Today about 90% of patients with testicular cancer can be cured. The consideration of treatment-related long-term morbidity has, therefore, become an important issue. Cisplatin-based chemotherapy induces long-lasting Raynaud-like phenomena and/or peripheral sensoric, usually mild, neuropathy in 30-40% of the patients. Irreversible reduction of renal function is a frequent finding after chemotherapy, especially if high doses of cisplatin are given. Abdominal radiotherapy is generally well tolerated but may lead to slight chronic meteorism and dyspepsia. 'Dry ejaculation' represents the principal sequelae after retroperitoneal surgery. The frequency of this side effect can be reduced by nerve-sparing surgery. Both chemotherapy and radiotherapy reduce spermatogenesis transiently. About 2 years after discontinuation of treatment, sperm production has recovered in most of the patients with normal pretreatment gonadal function. At least half of the patients with a desire for post-treatment paternity are able to father a child after their treatment. Assisted fertilization may reduce post-treatment infertility problems for individual couples. In general, cured testicular cancer patients are more satisfied with life than an age-matched control group, but may present a greater fluctuation of their mood and affect. In conclusion, most cured testicular cancer patients enjoy a normal life if precaution is taken to reduce therapy-related side effects to a minimum. However, reduction of the complication rate would not lead to a decrease of the present high cure rate of this malignancy.

Early clinical stages of nonseminomatous testis cancer. Evaluation of the primary treatment and follow-up procedures of the SWENOTECA project.

During a 5-year period, 588 consecutive patients with nonseminomatous testicular germ cell cancer were included by 16 hospitals into the Swedish-Norwegian Testicular Cancer Project (SWENOTECA). A total of 370 (63%) had early clinical stages (CS1, CS1Mk+ and CS2A), and 345 (93%) of these patients underwent pathological staging (PS) by retroperitoneal lymph node dissection (RPLND). The overall clinical staging accuracy was 75%, with no significant difference between hospitals with low, medium or high patient accrual rate. Addition of bipedal lymphography did not improve the clinical staging accuracy compared to evaluation of the retroperitoneum by CT alone. Tumor serum markers before and close monitoring of the levels after orchiectomy gave valuable information regarding risk of retroperitoneal metastases. After a median follow-up period of 5 years 30 (13.8%) of 217 patients with PS1 disease relapsed, only 3 of them later than 18 months from the RPLND. Short orchiectomy to RPLND time interval, vascular invasion and absence of teratoma elements in the primary tumour were significant predictors of relapse in PS1 cases according to multivariate analysis. Unilateral RPLND was not associated with higher relapse rate than a bilateral procedure, but significantly reduced the risk of dry ejaculation after RPLND. None out of 122 PS2 patients who received adjuvant cisplatin-based chemotherapy after RPLND relapsed, despite the fact that 37 of them had only undergone a unilateral RPLND. Repeated CT examinations and most routine blood tests except serum alpha foeto protein (AFP), beta subunit of human chorionic gonadotropin (HCG) and lactate dehydrogenase (LD) may safely be omitted in the follow-up period for patients who have been pathologically staged with RPLND, provided that effective adjuvant chemotherapy has been given to the PS2 patients.

Clinical significance of the "palpable mass" in patients with muscle-infiltrating bladder cancer undergoing cystectomy after pre-operative radiotherapy.

Between 1976 and 1985, 132 patients with T2/T3/T4a bladder cancer underwent cystectomy after pre-operative radiotherapy (46 Gy: 67 patients; 20 Gy: 65 patients). After a median time of 41 months, 62 patients were alive; 51 had died from recurrent bladder cancer and 19 from intercurrent disease without recurrence of their malignancy. Distant metastases developed in 40 patients, accompanied in 5 cases by local recurrence. Local recurrence was the first sign of relapse in 11 patients. In 3 patients the localisation of the relapse remained unknown. The corrected 5-year survival rate was 60%. T category and a palpable bladder tumour were independent pre-treatment prognostic factors in a Cox regression analysis, together with the interval between initial diagnosis and cystectomy. The presence of a palpable tumour before the start of treatment was associated with a particularly poor prognosis in T3/T4a tumours, whereas the survival of patients with non-palpable T3/T4a tumours was similar to that of patients with T2 bladder cancer. Another important prognostic factor was post-irradiation stage reduction (no residual muscle infiltration in the cystectomy specimen). Significantly more patients with non-palpable bladder tumours experienced post-radiation stage reduction than did those with a palpable tumour. However, the prognostic value of stage reduction was statistically significant only in patients with palpable bladder tumours.