[Idiopathic partial thrombosis of the corpus cavernosum (IPTCC) : A rare urological emergency]. / Die idiopathische partielle Thrombose des Corpus cavernosum (IPTCC) : Ein Kolibri der urologischen Notfallversorgung.

BACKGROUND: Idiopathic partial thrombosis of the corpus cavernosum (IPTCC) is a rare, semi-acute disease in young, healthy men. In addition to an anatomical predisposition, perineal microtrauma is stated as the main risk factor. MATERIALS AND METHODS: A case report and the results of a literature search with descriptive-statistical processing of 57 peer-reviewed publications are presented. A therapy concept was drawn up for clinical practice. RESULTS: Our patient was treated conservatively and was consistent with the 87 cases which have been published since 1976. IPTCC is a disease of young men (33.2 years, range 18-70), which is associated with pain and perineal swelling in 88%. Sonography and contrast-enhanced magnetic resonance imaging (MRI) proved to be the diagnostic modality of choice, demonstrating the thrombus and in 89% a connective tissue membrane inside the corpus cavernosum. Treatment included antithrombotic and analgesic (n = 54, 62.1%), surgical (n = 20, 23%), analgesic (n = 8, 9.2%), via injection (n = 2, 2.3%), as well as radiological interventional (n = 1, 1.1%) options. In 12 cases, erectile dysfunction, mostly temporary, which required phosphodiesterase (PDE)-5 therapy developed. Recurrence and prolonged courses were rare. CONCLUSION: IPTCC is a rare disease in young men. Conservative therapy with antithrombotic and analgesic treatment has shown good chances of full recovery. If relapse occurs or the patient refuses antithrombotic treatment, operative/alternative therapy management should be considered.

[Secondary malignancies in urinary diversions]. / Sekundärmalignome in Harnableitungen.

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

Postoperative acute confusional state in typical urologic population: incidence, risk factors, and strategies for prevention.

OBJECTIVES: To determine the incidence of, and predictors for, the acute confusional state (ACS) in older patients after urologic surgery. ACS is among the most common complications after surgery in older patients. It is associated with increased postoperative morbidity, longer hospital stays, and greater mortality. Agitation caused by ACS might have deleterious consequences in a large proportion of older patients, especially after urologic surgery. Only a few studies, of highly selected urologic procedures, have been reported, and all showed an astonishingly low percentage of patients with this distressing condition. METHODS: We examined 100 consecutive, older patients (age 60 years or older), prospectively, before and after urologic surgery, to determine both the incidence of, and the predictors for, ACS. RESULTS: Only 7 of the 100 patients developed postoperative ACS. The risk factors identified were preoperative cognitive deficits, pre-existing depression, impaired vision, and the operative time. CONCLUSIONS: These results suggest that postoperative ACS is relatively rare after urologic surgical procedures; however, patients who are likely to develop ACS can be identified, prompting consideration for prophylactic antidelirium care.

Schwann cell seeded guidance tubes restore erectile function after ablation of cavernous nerves in rats.

PURPOSE: Dissection of the cavernous nerves eliminates spontaneous erections. We evaluated the ability of Schwann cell seeded nerve guidance tubes to restore erections after bilateral cavernous nerve resection in rats. MATERIALS AND METHODS: Sections (5 mm) of the cavernous nerve were excised bilaterally, followed by immediate bilateral microsurgical reconstruction. In 10 animals per group (20 study nerves) reconstruction was performed by genitofemoral nerve interposition, interposition of silicone tubes or interposition of silicone tubes seeded with homologous Schwann cells. As the control 10 animals (20 study nerves) underwent sham operation (positive control) and bilateral nerve ablation (without reconstruction) was performed in a further 10 (negative control). Erectile function was evaluated 3 months postoperatively by relaparotomy, electrical nerve stimulation and intracavernous pressure recording. RESULTS: After 3 months neurostimulation resulted in an intact erectile response in 90% (18 of 20) of Schwann cell grafts, while treatment with autologous nerves (30% or 6 of 20) or tubes only (50% or 10 of 20) was less successful (p <0.01). Whereas untreated ablated rats showed no inducible erections (0% or 0 of 20), all sham operated animals had an intact erectile response (100% or 20 of 20). Maximum intracavernous pressure upon electrostimulation was significantly elevated using Schwann cell grafts compared to results in the other treatment groups (p <0.001). Morphological evaluation revealed advanced regeneration within Schwann cell grafts. CONCLUSIONS: Schwann cell seeded guidance tubes restore erectile function after the ablation of cavernous nerves in rats and they are superior to autologous nerve grafts.

[Pseudoaneurysm of a subsegmental renal artery after percutaneous nephrolitholapaxy]. / Pseudoaneurysma eines Nierenarterienastes nach perkutaner Nephrolitholapaxie.

At postoperative day 10 of a percutaneous nephrolitholapaxy for a large stone in the right renal pelvis of a 78-year-old female patient, persistent gross hematuria, requiring blood transfusions, occurred. Selective renovasography showed a pseudoaneurysm of the branch of a segmental artery close to the lower renal calices. Subsequent selective placement of two "steel-coils" in the feeding artery through a coaxial catheter system resulted in complete and stable occlusion without loss of renal parenchyma. Thereafter, bleeding immediately stopped and the patient suffered no further complications. This tool of interventional radiology should be kept in mind before open surgery is considered.

Significance of random bladder biopsies in superficial bladder cancer.

OBJECTIVES: We investigated to what extent biopsies of normal-appearing urothelium taken from patients with superficial bladder cancer (Ta, T1, Tis) showed malignant disease and whether those findings had impact on therapeutical decisions. PATIENTS AND METHODS: 1033 consecutive patients presenting with Ta, T1 or Tis (carcinoma in situ) superficial bladder tumors at increased risk for recurrence underwent multiple random biopsies from normal-appearing urothelium during transurethral resection (TUR). Patients with small, primary, singular tumors (smaller or equal to 1cm) were excluded from random biopsies. RESULTS: No tumor was found in the random biopsies of 905 patients (87.6%). 128 patients (12.4%) showed urothelial bladder cancer in their random biopsies (Tis: 74, Ta: 41, T1: 12, T2: 1). In 14 patients, where transurethral resection of the primary tumor revealed no signs of malignancy, urothelial bladder cancer was detected in the random biopsy material: Ta 8 patients, Tis 5 patients and T1 one patient. 21 patients with Ta tumors and 29 patients with T1 disease showed concomitant Tis. Upstaging of the primary, resected tumor by histological examination of the random biopsy material occurred in 75 patients (7%). Altogether, due to the random biopsy results therapy was altered in 70 patients (6.8%) of our series: It changed intravesical chemotherapy to BCG in 45, provoked a second TUR in 48 and cystectomy in 15 patients. CONCLUSIONS: While the clinical significance of random biopsies is still controversial, random biopsy results had strong impact on therapeutical decisions in our series. Regarding random bladder biopsies a simple tool for the urologist to identify high risk groups of patients, we recommend them as part of the routine management of superficial bladder cancer.

[Virtual endoscopy of the urinary tract from T(2)-weighted and gadolinium-enhanced T(1)-weighted MR urographic images]. / Virtuelle Endoskopie des Urogenitaltraktes auf der Basis T(2)-gewichteter und kontrastmittelunterstützter T(1)-gewichteter Datensätze.

PURPOSE: To determine the diagnostic performance of T(2)-weighted (T2w) and gadolinium-enhanced T(1)-weighted (T1w-Gd-enhanced) MR urographic images for virtual endoscopy of the urinary tract. MATERIALS AND METHODS: 36 patients underwent MR urography at 1.5 T. In each patient a T2w (3D-TSE, respiration-triggered) and a T1w-Gd-enhanced sequence (T1-FFE, breathhold) were acquired. Data reconstruction was performed as maximum intensity projection (MIP) and virtual endoscopy (VE). RESULTS: Combined analysis of MIP and VE delineated 32 of 36 pathologies; 86 % (19/22) of intraluminal pathologies could be depicted by VE and 15 % (3/22) by MIP (p

Oral intake of poppy seed: a reliable and simple method for diagnosing vesico-enteric fistula.

PURPOSE: In up to 50% of patients with vesico-enteric fistula conventional diagnostic methods fail. We report a simple and low cost diagnostic method that involves the oral intake of poppy seed. MATERIALS AND METHODS: From 1994 to 1999, 17 patients in whom vesico-enteric fistula was suspected underwent the poppy seed test. We administered 250 gm. poppy seed orally in the evening and the urinary excretion of poppy seed was evaluated during the next 2 days. RESULTS: Of the 17 patients 11 excreted the black seeds in the urine for 2 days after oral intake of the seeds. The diagnosis was supported by conventional diagnostic methods in 9 of the 11 cases, while in the remaining 2 the poppy seed test was the only preoperative diagnostic procedure that proved the existence of a fistula. The diagnosis was confirmed by surgical exploration in all 11 patients. In the remaining 6 patients with a nonspecific complaint vesico-enteric fistula was excluded by conventional diagnostic techniques and by the success of nonoperative therapy. CONCLUSIONS: The oral intake of poppy seed is a simple and ready available method for diagnosing vesico-enteric fistula. It may support the surgeon decision when conventional diagnostic tools fail.

Erythropoietin in urologic oncology.

OBJECTIVES: The use of erythropoietin (EPO) for the treatment of anemia associated with urological malignancies is not well defined. The rate of anemia is dependent on the type of cancer and on the different types of treatment. Only with a substantial risk for blood transfusion is substitution treatment by EPO justified. Additionally, the long-term risks of blood transfusions have to be balanced against the costs of EPO treatment. METHODS: Different experts have reviewed the literature on anemia and EPO regarding the four main tumor entities. RESULTS/CONCLUSIONS: In prostate cancer, EPO treatment may be justified before radical prostatectomy and in patients with advanced, hormone-refractory disease. In bladder cancer, significant treatment-related anemia mainly occurs in patients who have to undergo radical cystectomy and in patients who will be treated with polychemotherapy for metastatic disease. Patients with renal cell carcinoma rarely suffer from anemia and thus are usually not candidates for EPO treatment. Testis cancer patients only have a substantial risk for blood transfusions if they belong to the intermediate or poor prognosis group according to IGCCCG or if they need salvage chemotherapy or salvage surgery. However, in testis cancer patients EPO treatment should generally be preferred to blood transfusions since cure rates are excellent and thus the potential risks of transfusion-related infections are significant.

Relevance of p53 gene alterations for tumor recurrence in patients with superficial transitional cell carcinoma of the bladder.

PURPOSE: The prognostic relevance of p53 protein accumulation in muscle-invasive bladder carcinoma is well documented, but the prognostic relevance of p53 alterations in superficial bladder tumors remains uncertain. Immunohistochemical data are divergent, possibly because of the use of nonstandardized techniques. We therefore investigated the relevance of p53 gene point mutations and loss of heterozygosity (LOH) for tumor recurrence. The results of this molecular analysis were compared with accumulation of the p53 protein as shown by immunohistochemistry. MATERIAL AND METHODS: Representative tumor tissue was selected and microdissected from 40 patients (pTa, 18 patients; pT1, 22 patients; grade I, 7 patients; grade II, 28 patients; grade III, 5 patients). Polymerase chain reaction (PCR) was carried out with exons 5-8. All PCR products were screened for p53 mutations with temperature-gradient gel electrophoresis (TGGE). When mobility shift was observed, direct nucleotide sequencing was performed. Detection of LOH was performed with nonradioactive microsatellite analysis using three markers (TP 53, D17S513 and D17S786) on chromosome 17p. Immunohistochemistry was performed with the DO 7 antibody. Tumor samples with p53 accumulation of 5% or more positive nuclei were classified as positive. Univariate analysis for disease-free survival was performed using Kaplan-Meier analysis and the log-rank test. RESULTS: TGGE and direct sequencing detected mutations in 10 of 40 patients (2 of 18 pTa and 8 of 22 pT1 patients). LOH was detected in 11 patients. Both a mutation and LOH were detected in 3 patients. p53 immunohistochemistry detected at least 5% positive nuclei in 28 of 40 patients (70%). After a median follow-up of 26 months 14 patients suffered disease recurrence. Whereas disease-free survival did not correlate with a mutation (p = 0.77, log-rank test), LOH (p = 0.2) or a mutation in combination with LOH (p = 0.23), a positive p 53 immunoreaction was significantly associated with short disease-free survival (p = 0.009). CONCLUSION: Despite the relatively high percentage of patients with p53 gene alteration in this population no significant correlation between the detection of molecular alteration and disease recurrence could be found. We conclude that, in contrast to immunohistochemical accumulation, gene alterations play only a minor role in tumor recurrence of p53 in patients with superficial transitional cell carcinoma of the bladder, and that immunohistochemical accumulation of the p53 protein has to be explained by mechanisms other than gene mutations.

Detection of loss of heterozygosity in the p53 tumor-suppressor gene with PCR in the urine of patients with bladder cancer.

PURPOSE: Detection of loss of heterozygosity (LOH) has been described in various carcinomas on the basis of meticulous molecular techniques. Because of lack of simple and rapid techniques, LOH has not achieved common use in routine tumor diagnosis. A recently found variable number of tandem repeats (VNTR) segment in intron 1 of the p53 gene was described as highly polymorphic and therefore useful in detecting LOH. We used a rapid technique for detection of LOH in the p53 gene of patients with transitional cell carcinoma (TCC) of the bladder. The technique was based on the polymerase chain reaction (PCR) and agarose gel electrophoresis as described for other carcinomas previously. We evaluated whether TCC screening and surveillance could be performed detecting LOH in the urinary sediment. MATERIALS AND METHODS: We investigated 29 patients with TCC of the bladder (pTa 12 patients; pT1 10 patients; pT2 - pT4 seven patients; grade 1 one patient; grade 2 19 patients; grade 3 nine patients). DNA was prepared by standard methods from white blood cells, tumor tissue, normal bladder mucosa, and urinary sediments. The amplification of the VNTR region was performed with PCR. PCR products were run in parallel lanes on 4.5% agarose gels. RESULTS: Of the 29 patients, 23 (79.3%) were found to have two different alleles ("informative cases") for the VNTR region. Of the 23 informative cases LOH was detected in the tumor tissue of 10 patients (43.5%). Referring to the total population 10 of 29 patients (34.4%) revealed LOH. In all patients with LOH in the tumor, LOH was also detected in the urinary sediment. LOH was not detected in the histologically benign bladder mucosa. CONCLUSION: We present a simple and rapid technique based on PCR and agarose gel electrophoresis for the detection of LOH in tumor and urinary sediment of patients with TCC of the bladder. The ability to detect LOH not only in tumor tissue but also in urinary sediment offers an attractive approach for noninvasive diagnosis and surveillance of bladder cancer patients.

Improvement of ureteroileal anastomosis in continent urinary diversion with modified Le Duc procedure.

PURPOSE: Ureteroileal stricture after urinary diversion often has deleterious effects on the upper ureteral tract. A common ureteral implantation technique described by Le Duc et al has recently been criticized for a high rate of ureteral stricture. We assessed the rate of upper urinary tract dilatation and deterioration in 60 consecutive patients who underwent continent urinary diversion and ureteroileal anastomosis with a modified Le Duc procedure. MATERIALS AND METHODS: A total of 60 patients underwent continent urinary diversion with an ileal neobladder (Hautmann). Ureteroileal implantation was performed using a modified Le Duc technique. Followup was performed prospectively for a median of 32 months. The clinical end point was postoperative development of upper urinary tract dilatation, or an increase in preoperative dilatation confirmed by excretory urography or furosemide isotope nephrography. RESULTS: Nonneoplastic deterioration of the upper urinary tract was noted in 4 of 117 renoureteral units (3.4%). No permanent decrease in renal function or increase in pyelonephritic episodes was noted. CONCLUSIONS: The modified Le Duc technique is simple and safe for ureteroileal anastomosis and has a low complication rate.

Microsatellite alterations at chromosomes 9p, 13q, and 17p in nonmuscle-invasive transitional cell carcinomas of the urinary bladder.

The clinical behavior of bladder cancer is difficult to predict and prognostic markers applicable to routinely processed tumor specimens clearly are needed. We screened 40 primary Ta and T1 bladder cancers for microsatellite alterations at 9p, 13q, and 17p with PCR, using nine polymorphic microsatellite markers. DNA was prepared after microdissection of paraffin-embedded transurethral resection specimens. PCR products were separated on sequencing gels, and allelic loss as well as band shifts was assessed by comparing alleles of control and tumor tissue. The results were correlated with grade, stage, and clinically documented tumor recurrence. Overall, allelic loss at 9p, 13q, and 17p was present in 35.1%, 25%, and 27.5% of cases, respectively. Whereas the frequency of allelic loss at 9p was nearly equally distributed throughout all tumor grades and stages, the occurrence of allelic loss at 13q and 17p correlated statistically significantly with higher grades and stage. Band shifts were observed in three cases. Of the 40 patients, 16 had tumor recurrence during a follow-up period of 3-49 months (median, 23 months). Kaplan-Meier analysis did not show any statistically significant correlation between allelic loss at either locus and tumor recurrence. The results confirm the role of alterations at 13q and 17p in the progression of bladder cancer. Allelic loss at 9p seems to be an early event in tumor development. However, the detection of alterations at the three chromosomal loci studied did not have any prognostic value regarding tumor recurrence in this group of patients.

Tumor-associated antigens in normal mucosa of patients with superficial transitional cell carcinoma of the bladder.

PURPOSE: We identified premalignant lesions in tumor-surrounding histologically normal bladder mucosa from patients with superficial and muscle-invasive bladder cancer to look for "premalignant" lesions as the source of tumor recurrence. MATERIALS AND METHODS: Tumor-associated antigen expression in histologically normal bladder mucosa in 23 patients with superficial bladder cancer was studied. Histologically normal bladder specimens from 21 patients with muscle-invasive bladder cancer and from 30 prostatic cancer patients served as controls. Tumor-related antigens 486p 3/12, LBS8, 19A211 and M344 were mapped quantitatively with monoclonal antibodies and immunohistological techniques. RESULTS: Expression of all four bladder tumor-associated antigens was significantly enhanced and more than two antigens were expressed simultaneously in histologically normal mucosa from both bladder-cancer groups, compared with histologically normal bladder mucosa of prostatic carcinoma patients (p < 0.05). CONCLUSIONS: The results suggest the existence of early malignantly transformed cells in the benign-looking and morphologically normal bladder mucosa of superficial bladder carcinoma patients, which possibly is the source of recurrent bladder cancer. This approach models the mapping of histopathologic premalignant lesions of the bladder to predict risk.

Long-term follow-up of cytostatic intravesical instillation in patients with superficial bladder carcinoma. Is short-term, intensive instillation better than maintenance therapy?

OBJECTIVES: Comparisons of two 3-year protocols, one 20-week protocol of mitomycin C instillation and one 3-year protocol of doxorubicin instillation for the prevention of recurrent tumors and progression in patients whose superficial bladder tumors had been removed by transurethral resection. METHODS: A prospective, randomized parallel group multicenter trial was conducted. 419 patients were evaluated after a median follow-up of 57 months. Cox proportional hazards analysis was performed. RESULTS: An overall recurrence rate of 22.7% and an overall progression rate of 9.8% was found. For time to progression a significant overall treatment effect was detected dependent on the recurrence status before entry into the study (p = 0.0059). Pairwise comparisons showed the mitomycin protocol with short-term intensive (weekly) combined with long-term maintenance instillation to have a highly beneficial effect compared to long-term maintenance instillation only especially for patients entering the study with recurrent tumors (RR = 0.06, 95% CI: [0.008, 0.506]. CONCLUSION: These results show that intensive therapeutic instillation may have an advantage over less intensive, prophylactic regimens.

[Long-term results of Stamey bladder neck suspension. Effect of data analysis technique on surgical result]. / Langzeitergebnisse der Blasenhalssuspension nach Stamey. Einfluss der Erhebungstechnik auf das operative Resultat.

The methodology used to assess postoperative continence has a significant effect on the outcome of incontinence surgery. Retrospective chart review studies consistently report higher success rates than patient questionnaire-based outcome analyses. The purpose of this study was to evaluate the true long-term results of the Stamey bladder neck suspension procedure using an anonymous patient questionnaire. Of 172 consecutive patients, 138 (80.2%) returned a questionnaire on long-term continence, complications and subjective satisfaction with the operative result. With a mean follow-up of 66 months, 65 of 130 evaluable patients (50.0%) remained completely continent while 15 (11.5%) never became continent and 50 (38.5%) had recurrent incontinence 6-90 months postoperatively. Almost two-thirds of the patients felt either cured or substantially improved more than 5 years after surgery. Stamey bladder neck suspension leads to a persistently improved quality of life despite a considerable failure rate. Our study demonstrates the advantages of patient questionnaires for outcome analyses and emphasizes the need for standardisation and validation to allow comparisons between the results of different incontinence procedure in the future.

p53 in noncancerous bladder mucosa as a marker of disease recurrence in patients with superficial transitional cell carcinoma of the bladder.

We investigated the prevalence and clinical relevance of p53 nuclear overexpression in histologically benign bladder mucosa in patients with superficial transitional cell cancer (TCC) of the bladder to look for "premalignant" lesions as the source of tumor recurrence. p53 Accumulation in representative tumor and normal-looking bladder mucosa was studied in 53 patients with Ta and T1 TCC. Histologically normal bladder specimens from 20 prostate cancer patients served as controls. We used a biotin streptavidine-peroxidase system to stain deparaffinized tissue sections with the p53 monoclonal antibody DO7. Specimens from 42 (79%) of the 53 TCC patients stained for p53 in the tumor area. There was no statistically significant difference between pTa and pT1 lesions (pTa, 71.4%; pT1, 87.5%), and staining correlated weakly with tumor grade (G1, 62%; G2, 82%; G3, 100%). Evaluation of histologically normal bladder mucosa showed positive p53 staining in 13 (24.5%) of the 53 patients. Disease recurred in 20 patients. Among them, 12 had positive staining in the normal bladder mucosa. Although p53 expression in tumor areas showed only slight correlation with tumor recurrence (p = 0.043, Cochran-Armitage test), p53 accumulation in healthy bladder mucosa correlated strongly with disease recurrence (p < 0.0001, Fisher's exact test). p53 Overexpression in histologically normal bladder mucosa in patients with TCC might identify premalignant alterations in tumor-surrounding areas. Our data suggest that p53 accumulation in histologically benign bladder mucosa of TCC patients is a possible marker of disease recurrence.

Immunocytologic staining of cytokeratin in bone marrow aspirates to detect micrometastatic cells fails in patients with metastatic urologic carcinoma.

The detection of cytokeratin-positive cells in bone marrow of patients with various carcinomas is considered an adverse marker. To establish a routine diagnostic procedure to detect these cells in patients with urologic carcinoma, we evaluated different immunocytological techniques in parallel. The study included 50 patients with urologic carcinoma (16 with metastatic disease) and 10 healthy volunteers. Bone marrow was aspirated from the iliac crest; after density centrifugation, cytocentrifuged specimens were stained according to optimized modifications of conventional immunocytologic techniques. Overall only 3% of patients with locally restricted carcinoma and only 19% with metastatic disease showed cytokeratin-positive bone marrow cells. Nonspecific labeling of bone marrow cells in the immunoglobulin isotype controls was a major problem, demonstrating the need for numerous detailed controls. If all nonspecific reactions were excluded, up to 20% of the healthy controls yielded positive results as well. The presence of cytokeratin-positive cells in bone marrow aspirates shows only slight correlation with systemic metastasis. The biologic and clinical relevance of this immunocytologic marker must be judged cautiously.