Validity of predictions of residual retroperitoneal mass histology in nonseminomatous testicular cancer.

PURPOSE: To validate predictions of the histology (necrosis, mature teratoma, or cancer) of residual retroperitoneal masses in patients treated with chemotherapy for metastatic nonseminomatous testicular germ cell tumor. PATIENTS AND METHODS: We studied 172 testicular cancer patients who underwent resection while tumor markers were normal. Predictive characteristics for the residual histology were registered, including the presence of teratoma elements in the primary tumor, the prechemotherapy level of tumor markers (alpha-fetaprotein [AFP], human chorionic gonadotropin [HCG], lactate dehydrogenase [LDH]), the size of the residual mass, and the percentage of shrinkage in mass diameter. We calculated the predicted probability of necrosis and the ratio of cancer and mature teratoma with previously published logistic regression formulas. RESULTS: The distribution of the residual histology was necrosis in 77 (45%), mature teratoma in 72 (42%), and cancer in 23 (13%). Necrosis could be well distinguished from other tissue, with an area under the receiver operating characteristic (ROC) curve of 82%. No tumor was found in 15 patients with a predicted probability of necrosis over 90%. The predicted probabilities corresponded reliably with the observed probabilities (goodness-of-fit tests, P > .20), although a somewhat higher probability of necrosis was observed in patients treated with chemotherapy containing etoposide. Conversely, cancer could not reliably be predicted or adequately discriminated from mature teratoma. CONCLUSION: The predicted probabilities of necrosis have adequate reliability and discriminative power. These predictions may validly support the decision-making process regarding the need and extent of retroperitoneal lymph node dissection.

Paraureteral calculi caused by ureteroscopic perforation.

OBJECTIVES: Ureteroscopy has become an effective and safe procedure for treatment of ureteral calculi. Formation of strictures are considered long-term complications with a low incidence. This report focuses on the incidence of strictures in cases of calculi pushed or flushed retroperitoneally alongside the ureter because of iatrogenic ureteral perforation. METHODS: Fifteen consecutive patients with paraureteral calculi caused by ureteroscopic perforation were observed. An excretory urogram was performed after a mean of 22.5 months, with a range of 9 to 54 months. In all patients, a stent was placed for 3 to 41 days (mean, 13.5 days) and antibiotics were administered between 3 and 5 days postoperatively. RESULTS: Only 1 patient of 15 with a short stricture of the distal ureter was observed. The stricture was successfully treated by endoscopic ureterotomy, balloon dilation, and transient placement of a ureteral stent. CONCLUSIONS: Paraureteral calculi caused by ureteral perforation are a minor complication of ureteroscopy, which rarely lead to formation of strictures. Removal of paraureteral calculi by enhanced endoscopic procedures or open surgery is not required.

Clinical assessment of solid phase immunoadsorbent assay of human prostatic acid phosphatase.

A new solid phase immunoenzyme assay for human prostatic acid phosphatase was tested in clinical practice. Clearly elevated levels of prostatic acid phosphatase (PAP) were found with advancing age and even more so in patients with benign prostatic hyperplasia (BPH). In patients with localized carcinoma of the prostate there was no elevation of levels above those observed in patients with BPH. When lymph node metastases were found at staging lymphadenectomy, the preoperative level of prostatic acid phosphatase was elevated in 7 of 12 cases. Good response to hormone treatment of metastatic carcinoma of the prostate was indicated by decrease of PAP-levels to normal. Rising levels often preceded the clinical manifestation of progression.

Methodological and clinical comparison of the ACS prostate-specific antigen assay and the Tandem-E prostate-specific antigen assay in prostate cancer.

OBJECTIVES: The new ACS prostate-specific antigen (PSA) assay was methodologically and clinically compared with the established Tandem-E PSA assay. We intended to find a possible advantage in primary diagnosis and monitoring the recurrence of prostate cancer due to the additional better recognition of the free PSA form by the ACS PSA assay. METHODS: sera of 51 healthy men, 127 patients with hyperplasia, and 82 untreated patients with prostate cancer were analyzed by means of the Tandem-E PSA assay (Hybritech) and the ACS PSA assay (Ciba Corning). Follow-up was done on 12 cancer patients with recurrences. RESULTS: Both assays correlated very well (r = .98 for all studied men or hyperplasia patients or cancer patients). However, both assays did not yield comparable values: The ACS assay was characterized by nearly doubled values compared with the Tandem-E assay. At 95% specificity versus patients with benign hyperplasia, cutoff values were obtained as follows: 28.8 ng/mL for the ACS PSA assay and 15.2 ng/mL for the Tandem-E assay. At 95% specificity versus hyperplasia patients, we calculated sensitivities of 60% (ACS PSA) and 63% (Tandem-E PSA). Our longitudinal study revealed more prominent slopes for the ACS assay in patients with recurrent cancer disease. However, using either the ACS assay or the Tandem-E assay, the PSA increase started at the same time. In 1 patient, the increasing ACS PSA accelerated 3 months earlier than the increasing Tandem-E PSA did. CONCLUSIONS: The ACS assay has obviously higher PSA levels. The clinician is not familiar with such high PSA levels. The specificity-sensitivity profile nonetheless remains unchanged. If the PSA concentration is measured by the ACS assay, patients who relapse will reveal a more rapid PSA increase. Then, recurrent cancer disease may be detected earlier in some cases.

Alpha 1-antichymotrypsin-PSA (ACT-PSA): a useful marker in the differential diagnosis of benign hyperplasia and cancer of the prostate?

UNLABELLED: This study examined the clinical relevance of the determination of alpha 1-antichymotrypsin complexed PSA (ACT-PSA) in addition to total PSA antigen (t-PSA). PATIENTS AND METHODS: Both total PSA- and ACT-PSA-values of frozen sera obtained pretherapeutically from 93 patients with carcinoma (PC) and 132 patients with benign hyperplasia of the prostate (BPH) were analyzed by means of PSA sandwich-ELISA (Dianova GmbH) and ACT-PSA sandwich-ELISA (Dianova GmbH). RESULTS: At 95% specificity (true negative test results), a cutoff value of 18.9 [micrograms/L] was obtained for total PSA (7 patients with BPH [5%] were above this value). For this cutoff value we calculated a sensitivity (true positive test results) of 41%. Using the same criteria for the ratio Q = ACT-PSA: t-PSA (percentage of ACT-PSA) a cutoff of 6.0 was found again at a specificity of 95%. In a second step only patients with total PSA values below the cutoff level of 18.9 [micrograms/L]) were considered. Out of these patients 119 of 125 with BPH and 3 of 54 with PC were below the above mentioned ratio (Q = 6.0). Considering both steps (total PSA and Q) 42 patients with PC were detected correctly and 15 patients with BPH would have been biopsied unnecessarily. CONCLUSION: High total PSA levels are a very good indicator for the presence of prostate cancer. There is still concern to improve the differentiation of the diagnosis between BPH and PC, when an intermediate or low value (< or = 95% specificity) is observed. The determination of Q = ACT-PSA: t-PSA is not to be recommended because it might not be helpful for the clinicians decision to perform biopsy.

Screening for prostatic carcinoma with prostate specific antigen.

The usefulness of prostate specific antigen (PSA) in screening for prostatic carcinoma was studied in 262 inpatients of the department of internal medicine. All patients underwent a rectal digital examination and determination of PSA by the Tandem-E method (Hybritech). The plan was to perform biopsies if there were suspicious findings on the rectal examination or if the PSA value was more than 10 ng/ml. The PSA values were < or = 4 ng/ml in 219 patients (83.6%), > 4 to 10 ng/ml in 27 patients (10.3%) and > 10 ng/ml in 16 men (6.1%). In consideration of the severity of disease which limited life expectancy we did not perform a biopsy on 37.5% of the patients with PSA > 10 ng/ml. 7 patients with prostatic carcinoma were found. Their PSA values varied between 11.2 and 875 ng/ml. The cancer detection rate was highest for the combination of a suspicious rectal examination and a PSA value > 10 ng/ml (70%).

Total and free PSA: a methodical and clinical evaluation of five assays.

UNLABELLED: We studied the methodical and clinical relevance of five determination assays for free PSA (f-PSA) in addition to the corresponding total PSA antigen (t-PSA). METHODS: Both the total PSA- and free-PSA-values of frozen sera obtained pretherapeutically from 80 patients with carcinoma (PC) and 171 patients with benign hyperplasia of the prostate (BPH) were analysed by means of Enzymun-Test PSA/BM, PSA-RIACT/ CIS, CanAg PSA EIA/ Dia, Tandem-E PSA/Hyb, PSA IRMA/ IBL and Enzymun-Test PSA free/BM, F PSA-RIACT/CIS, CanAg Anti Free PSA/Dia, Tandem-R free PSA/Hyb, FREE PSA IRMA/IBL. RESULTS: The coefficient of correlation between Hybritech PSA assay and the other assays was determined in patients with benign and malignant prostatic diseases. There was a strong overall correlation with all assays measuring total or free PSA, respectively. A satisfying correlation is also shown using a limited scale up to 50 ng/mL for total PSA and 5 ng/mL for free PSA. At 95% specificity sensitivities of total PSA between 40% and 50% of the ratio (Q) = free PSA/total PSA between 4% and 28% were calculated. In a second step only patients with total PSA values below the cutoff level of 16.5 [micrograms/l] (BM), 13.9 [micrograms/l] (CIS), 14.7 [micrograms/l] (Dia), 15.7 [micrograms/l] (Hyb) and 16.8 [micrograms/l] (IBL) were considered. Using the BM assays, of these patients 9 of 162 with BPH and 14 of 47 with PC [CIS: 14 of 162 with BPH and 4 of 48 with PC/Dia: 13 of 162 with BPH and 11 of 48 with PC/Hyb: 6 of 156 with BPH (missing values = 6) and 11 of 40 with PC/IBL: 11 of 160 with BPH (missing values = 1) and 13 of 33 with PC (missing values = 2)] were below the ratio Q = free PSA/total PSA. Considering both steps (total PSA and Q) using the BM assay 47 patlents with PC were detected correctly and 18 patients with BPH would have been biopsied unnecessarily (positive biopsy rate = pos. br.: 72%) [CIS: 38 patients with PC and 23 patients with BPH (pos. br.: 62%)/Dia: 43 patients with PC and 22 patients with BPH (pos. br.: 66%)/Hyb: 51 patients with PC and 15 patients with BPH (pos. br.: 77%)/IBL: 46 patients with PC and 20 patients with BPH (pos. br.: 70%)] CONCLUSIONS: High total PSA levels of all assays are a very good indicator for the presence of prostate cancer. There is still concern to improve the differentiation between BPH and PC, when an intermediate or low value (< 95% specificity) is observed. The determination of Q is only useful in this range and it might be helpful for the clinicians decision to apply or avoid biopsy.

Clinical relevance of CYFRA 21-1, TPA-IRMA and TPA-LIA-mat in urinary bladder cancer.

The sera of 154 cancer patients were analyzed at primary diagnosis before any therapy to find out the clinical importance of CYFRA 21-1 (detecting cytokeratin 19-fragments) compared with the polyclonal TPA-IRMA and the monoclonal TPA-LIA-mat-assay (both measuring fragments of cytokeratin 8, 18 and 19). The reference group consisted of 100 healthy persons as well as 78 patients with exclusively benign urological diseases. We defined the cut-off values based on 95% specificity versus benign urological disorders. For CYFRA 21-1 the cut-off value was found to be 2.5 ng/ml, for TPA-IRMA 165 U/L, and for TPA-LIA-mat 136 U/L. Taking into account all stages CYFRA 21-1 showed a sensitivity of 31% versus 20% and 16% for TPA-IRMA and TPA-LIA-mat, respectively. Considering only the muscle invasive carcinomas 52% sensitivity for CYFRA 21-1 vs. 39% and 33% for TPA-IRMA and TPA-LIA-mat could be found. All three markers correlate with the stage of disease, CYFRA 21-1 to the highest degree (stage O: 16%, stage IV: 71%). CYFRA 21-1 shows the best sensitivity-specificity-profile and seems to be a recommendable marker for the follow-up of urinary bladder cancers except for the Ta-tumors which only rarely develop into muscle invasive cancers.

The ratio of free to total prostate specific antigen: an advantageous addition in the differential diagnosis of benign hyperplasia and cancer of the prostate?

UNLABELLED: This study examined the clinical relevance of the determination of free PSA (f-PSA) in addition to total PSA (t-PSA). PATIENTS AND METHODS: Both total PSA- and free PSA-values of frozen sera obtained pretherapeutically from 80 patients with carcinoma (PC) and 171 patients with benign hyperplasia of the prostate (BPH) were analysed by means of PSA IRMA and FREE PSA IRMA (IMMUNOCORP/IBL). RESULTS: At 95% specificity (true negative test results), a cut-off value of 16.8 [micrograms/L] was obtained for total PSA (9 patients with BPH [5%] were above this value). For this cut-off value we calculated a sensitivity (true positive test results) of 41%. Using the same criteria for the ratio Q = f-PSA:t-PSA a cut-off of 0.083 was found again at a specificity of 95%. In a second step only patients with total PSA values below the cut-off level of 16.8 [micrograms/L]) were considered. Of these patients 11 of 160 with BPH (missing values = 1) and 13 of 33 with PC (missing values = 2) were below the above mentioned ratio (Q = 0.083). Considering both steps (total PSA and Q) 46 patients with PC were detected correctly and 20 patients with BPH would have been biopsied unnecessarily (positive biopsy rate: 70%). CONCLUSION: High total PSA levels are a very good indicator for the presence of prostate cancer. There is still concern to improve the differentiation between the diagnosis between BPH and PC, when an intermediate or low value (< or = 95% specificity) is observed. The determination of Q is only useful in this range and might be helpful for the clinician's decision to apply or avoid biopsy.

Nuclear mitotic apparatus protein (NuMA) in benign and malignant diseases.

Nuclear mitotic apparatus protein (NuMA) is a 239 kDa internal nuclear matrix protein described to be elevated in cancer patients, especially in colorectal carcinoma and early colorectal cancers. We tested the significance of NuMA as tumour marker in colorectal cancer and also the sensitivity/specificity profile in general. Therefore, we investigated in a retrospective clinical study 507 sera from patients suffering from solid tumours, with the main emphasis on colorectal carcinoma, and 418 sera from patients with benign diseases and healthy individuals. Testing was done with a double monoclonal enzyme immunoassay detecting head and rod domain of NuMA and results were compared to the established tumour associated antigens. Based on a specificity of 95% versus the benign reference group of gastrointestinal diseases, we found--at the time of primary diagnosis--a sensitivity for colorectal cancer of 8% for NuMA, 36% for CEA and 17% for CA 19-9. Regarding T-stages of colorectal cancer no marker detected T1 when regarding 95% specificity-cut-off value but NuMA showed little more sensitivity when based on a 95% specificity cut off value versus healthy. This could not be shown in Dukes' stages. Regarding all other solid tumours tested--all based on a specificity of 95% for the corresponding benign reference groups--no advantage of NuMA in sensitivity for all other solid tumours investigated was found. No additional sensitivity could be observed. Based on our results, the NuMA-assay in its present form has no clinical relevance.

BTA-TRAK--a useful diagnostic tool in urinary bladder cancer?

During recent years the BTA-TRAK-assay (Bard Diagnostics, Redmont, USA) has been described in several investigations to be of clinical utility for patients suffering from bladder cancer. In a prospective study we investigated over four months the voided urine samples of all consecutive patients undergoing cystoscopy independent of their clinical background (n = 244) with the BTA-TRAK-assay. With a specificity of 95% for benign urological diseases (cut off: 1300 U/mL) we found a sensitivity of 13% for active bladder tumours. Using healthy individuals as a reference group (cut off: 40 U/mL) we found a sensitivity of 56% (specificity 67%). Using the cut off value recommended by the manufacturer (14 U/mL) a specificity of 54% and a sensitivity of 62% was found. For patients without relapse (NED) versus patients with active bladder tumours we got a specificity of 55% and a sensitivity of 62%. Due to an insufficient specificity and sensitivity the BTA-TRAK-test is not able to replace cystoscopy nor to improve existing diagnostic strategies in bladder cancer.

Resection of hypernephromas with vena caval or right atrial tumor extension using extracorporeal circulation and deep hypothermic circulatory arrest: a multidisciplinary approach.

OBJECTIVE: Among retroperitoneal tumors, renal cell carcinoma most often invades the retrohepatic inferior vena cava or the right atrium. Even in these cases, radical nephrectomy may be performed with curative intention. The aim of this retrospective study was to elucidate the impact of cardiopulmonary bypass and hypothermic circulatory arrest on surgical complications, primary mortality, and long-term survival. PATIENTS AND METHODS: From Jan. 1981 till Aug. 1996, 44 patients were operated upon for renal cell carcinoma with advanced vena caval extension. The patients were divided into two groups. In 19 cases (Cardiopulmonary Bypass Group), extracorporeal circulation and deep hypothermic circulatory arrest was used. The Conventional Technique Group comprised 25 patients who had radical nephrectomy, paraaortic lymphadenectomy and extirpation of the intracaval tumor thrombus applying common principles in vascular surgery. The median age was 59 years with a range from 42 to 78 years in the Cardiopulmonary Bypass Group, and 60 years, ranging from 22 to 72 years, in the Conventional Technique Group. In addition, both groups did not differ in gender, UICC TNMG staging classification, and perioperative risk factors. A review of the patient charts was done and surveys were sent to survivors or nearest of kin. Wilcoxon test and log-rank test were used as appropriate. RESULTS: A lower intraoperative complication rate was found in patients who had surgery using cardiopulmonary bypass. This was especially true with embolization of the tumor thrombus into the pulmonary arteries: 0.0% in Cardiopulmonary Bypass Group and 16.0% in Conventional Technique Group (P < 0.05). Severe hemorrhage occurred in 10.5% (Cardiopulmonary Bypass Group) and 16.0% (Conventional Technique Group). This translated into a significantly lower perioperative mortality in the Cardiopulmonary Bypass Group when compared to the Conventional Technique Group (5.6 and 16.0%, respectively). In spite of these results, differences in long-term survival did not reach statistical significance. But, a trend to superior long-term survival was apparent. The mean survival was 1289 +/- 278 days in the Cardiopulmonary Bypass Group and 746 +/- 166 days in the Conventional Technique Group. CONCLUSIONS: Due to acceptable long-term results, the resection of hypernephromas showing extensive vena caval invasion seems to be justified. The use of cardiopulmonary bypass and hypothermic circulatory arrest is able to decrease primary morbidity and mortality. However, the influence on long-term survival remains to be proven.

[The technic and value of the 3-dimensional imaging of renal calyx staghorn calculi with spiral CT]. / Technik und Stellenwert der dreidimensionalen Darstellung von Nierenbeckenkelch-Ausgusssteinen mit Spiral-CT.

5 patients with staghorn calculi in the renal pelvis were examined by spiral CT. From the raw data three dimensional reconstructions of the stones were obtained. In all patients it was possible to compare the three dimensional model with the stone following performance of percutaneous litholapaxy and endoscopic removal of the fragments. In all cases the three dimensional reconstruction provided a realistic image of the stones and was of practical value for the urologist for preoperative diagnosis and intraoperative control.

[Adjuvant therapy in lymph node positive prostate carcinoma?]. / Adjuvante Therapie bei lymphknotenpositivem Prostatakarzinom?

Few patients with prostate cancer metastatic to the lymphnodes can be cured by radiotherapy, radical prostatectomy or androgen deprivation. Inevitably serum PSA levels will rise after a few years whereas the clinical recurrence appears after 5 to 10 years. Prospective trials regarding adjuvant treatment of lymphnode positive prostate cancer do not exist. Retrospective studies involving adjuvant endocrine treatment reveal a prolonged disease free survival time. Scientific proof of the best treatment for prostate cancer with lymphnode metastasis does not exist. The decision how to treat is based on our personal experience and philosophy as well as on our knowledge and interpretation of the available literature. The art of medicine is the feeling for the best treatment of each individual patient.

[Endoscopic removal of a fibroepithelial ureteral polyp]. / Endoskopische Entfernung eines fibroepithelialen Harnleiterpolypen.

Fibroepithelial polyps are rare benign ureteral neoplasms of mesodermal origin, found mostly in the proximal ureter. Precisely in these cases, ureteroscopy is extremely important in diagnosis and therapy. We report on a case of a distal fibroepithelial polyp that was removed endoscopically. The base of the tumour was coagulated by laser.

[Crossed dystopia of the kidney and an ectopic ureteral orifice]. / Gekreuzte Dystopie der Niere und ektope Harnleitermündung.

We report on a case of crossed renal ectopia with fusion and a refluxing single ectopic ureteral orifice in the prostatic urethra in a renal transplant recipient. The diagnosis was made on the basis of a chronic urinary tract infection and a refluxing ectopic ureteral stump. Crossed ectopia with fusion was found intraoperatively. Nephroureterectomy cured the urinary tract infection.

[Complications following external radiotherapy of prostate cancer. Case reports and overview of the literature]. / Komplikationen nach externer Strahlentherapie des Prostatakarzinoms. Fallberichte und Literaturübersicht.

Complications after definitive radiotherapy of prostatic cancer occur in 3 to 30% of cases. Most common is radiation injury of the urethra, the bladder or the rectum. Definitive radiation therapy of carcinoma of the prostata after staging lymphadenectomy has a considerable risk of lymphedema of the lower extremities. Two typical cases are used to illustrate the permanent damage done to the quality of life of the particular patient. The complication rate is decreased if only the prostate is irradiated without radiation of the regional lymphnodes. Interstitial radiation therapy using 125-Iodine-seeds yields comparable results with a tenfold decrease in the complication rate.

[Fusion of an ectopic spleen with the left kidney. Preoperative diagnosis: adenocarcinoma of the kidney]. / Fusion einer ektopen Milz mit der linken Niere. Präoperative Diagnose: Adenokarzinom der Niere.

We report on the case of a left retroperitoneal accessory spleen with splenorenal fusion. Computed tomography demonstrated a solid mass arising from the left kidney and angiography revealed no abnormality, leading to the preoperative diagnosis of a poorly vascularized carcinoma of the kidney.

[Aminoglutethimide in the treatment of advanced prostatic cancer]. / Aminoglutethimid zur Behandlung des fortgeschrittenen Prostatakarzinoms.

A total of ten previously castrated men with stage D carcinoma received 1000 mg aminoglutethimide and 50 mg/die cortisoneacetate. The patients were evaluated using the criteria of the National Prostate Cancer Project. No patients showed objective response, three patients had reduction of bone pain and subjective improvement. Pretreatment testosterone, prolactine and estradiol levels were measured. Three patients had a statistically significant elevation of testosterone levels.

[Percutaneous nephrostomy as primary therapy of ureterovaginal fistula]. / Perkutane Nephrostomie als primäre Therapie der Harnleiter-Scheidenfistel.

We report on our experience with 11 cases of ureterovaginal fistula primarily treated with percutaneous nephrostomy drainage. In 6 patients the fistula persisted and ureteral reimplantation with psoas hitch was performed. In 5 patients the ureterovaginal fistula closed during nephrostomy drainage. In 2 of these 5 cases a distal ureteral stricture developed and was in 1 case successfully treated by ureteral dilation under systemic corticosteroid treatment. In the second case of a ureteral stricture reimplantation was necessary. All 4 patients, that were managed without open surgery had IVP's more than a year after treatment with normal upper tracts. When ureteral reimplantation had to be performed this was an elective procedure with minimal risk and optimal preparation of the patient due to percutaneous nephrostomy drainage.