Alternative medicine use in patients with localized prostate carcinoma treated with curative intent.

BACKGROUND: Alternative medicine therapies are estimated to be used by 7-64% of cancer patients but up to 72% do not inform their physician. To the authors' knowledge little useful information is available regarding the prevalence of alternative medicine use by patients with prostate carcinoma. Thus, the authors attempted to evaluate the prevalence of alternative medicine use by prostate carcinoma patients treated with curative intent by either radical prostatectomy, brachytherapy alone, or a combination of brachytherapy and external radiation therapy. METHODS: Between January 1997 and May 1998, 234 men with clinically localized prostate carcinoma underwent radical prostatectomy (54 patients) or brachytherapy (180 patients) with (74 patients) or without (106 patients) external beam radiation therapy. In July 1998 a questionnaire was mailed to all patients comprised of multiple questions regarding alternative medicine use to which 190 patients (81%) responded. The overall prevalence and types of alternative medicine therapies used were assessed and the relation between age at procedure, pretreatment prostate specific antigen level, clinical stage, pretreatment Gleason score, and type of treatment with the use of alternative medicine therapies was evaluated using univariate and multivariate analysis. RESULTS: The prevalence of alternative medicine use by prostate carcinoma patients responding to the survey was 43% (81 of 190 patients). No significant differences in alternative medicine use were observed between the patients who received brachytherapy alone (38%), those who underwent radical prostatectomy (40%), and those treated with combined brachytherapy and external beam radiation therapy (51%). Vitamins, prayer or other religious practices, and herbal medicines were the most commonly used therapies in these patients. Higher pretreatment Gleason scores were associated with a greater use of alternative medicine therapies on both multivariate and univariate analyses. Finally, using multivariate analysis, younger prostate carcinoma patients were more likely to use alternative medicine therapies than older patients. CONCLUSIONS: Alternative medicine use is very prevalent among patients treated for localized prostate carcinoma. Because some of these treatments may have a potential biologic impact on tumor behavior and, consequently, on definitive or surrogate therapeutic endpoints, patients should be questioned carefully regarding alternative medicine use during routine tumor follow-up.

Early prostate-specific antigen failure following radical perineal versus retropubic prostatectomy: the importance of seminal vesicle excision.

OBJECTIVES: Because of renewed interest in the radical perineal prostatectomy, we chose to evaluate factors influencing differences in biochemical failure as measured by prostate-specific antigen (PSA) between radical perineal and the radical retropubic prostatectomies. METHODS: We undertook a retrospective review of 87 men with clinically localized prostate cancer who underwent radical retropubic (64%) or radical perineal (36%) prostatectomy, noting age, race, preoperative PSA, Gleason score, clinical stage, capsular penetration, surgical approach, and completeness of seminal vesicle (SV) excision. The two groups were comparable with respect to tumor factors such as preoperative PSA, Gleason score, clinical stage, and capsular penetration. Time to postoperative PSA failure (0.2 ng/mL or greater) was evaluated with univariate and multivariate analysis of multiple contributing factors. RESULTS: Twenty-eight percent of patients had a PSA level rising to 0.2 ng/mL or greater in the follow-up period. Patients who underwent perineal prostatectomy had a higher PSA failure rate (45%) than those treated by the retropubic approach (18%) and patients with incomplete SV excision had a higher failure rate (69%) than patients with bilateral SV excision (20%). When time to PSA failure was examined by multivariate analysis, completeness of SV excision, clinical stage, and Gleason score had a statistically significant impact on this outcome. In perineal prostatectomy patients, bilateral SV excision had a significantly longer time to PSA failure than in patients with incomplete excision. There was no significant difference in time to PSA failure between patients who underwent radical retropubic prostatectomy and the patients who underwent perineal prostatectomy with bilateral SV excision. CONCLUSIONS: Incomplete excision of SVs during a radical perineal prostatectomy contributes to an earlier postoperative biochemical recurrence as measured by a rising PSA, and may explain the higher disease recurrence rate for radical perineal prostatectomies as opposed to radical retropubic prostatectomies in this study.

The Hautmann neobladder with a chimney: a versatile modification.

PURPOSE: We describe a modification to the popular Hautmann ileal neobladder comprised of a chimney for the ureterointestinal anastomosis in order to enhance its flexibility, reduce its pitfalls and hence make more patients candidates for this type of diversion. MATERIALS AND METHODS: The Hautmann ileal neobladder is prepared in the standard fashion except that an additional 5 to 10 cm. (or more if needed in the case of a short ureter) of small bowel are selected to be added for either a left or right "chimney" (depending on which side the ureter may be shorter or if there is a solitary kidney). The V segment of the W which will be anastomosed to the urethra is made longer than the contralateral V segment. A neobladder neck is created by sewing together the cut edges of a 5 cm. lip in the lowermost W configuration of the neobladder, allowing an end-to-end urethrointestinal anastomosis. RESULTS: Between March and October 1996, 3 patients have undergone this procedure at the University of Virginia. Two had right chimneys and 1 had a left chimney. Followup is short, but there have been no complications except for a transient postoperative partial small bowel obstruction in 1 patient. Two patients have no urinary incontinence, the third has only occasional nocturnal incontinence. CONCLUSIONS: This modification of the Hautmann ileal neobladder provides greater versatility for short ureters, minimizes tension from the mesentery on the urethrointestinal anastomosis, simplifies the ureterointestinal anastomosis and provides easy postoperative access for ureterointestinal anastomosis revision or resection in case of recurrent disease.

Combined analysis of two multicenter studies of finasteride 5 mg in the treatment of symptomatic benign prostatic hyperplasia.

The purpose of this paper is to examine effects of finasteride 5 mg across different age groups in an ethnically diverse population of men with symptomatic benign prostatic hyperplasia (BPH) seen in community urology and primary care practices. Data were combined from two previous placebo-controlled randomised trials of finasteride that evaluated changes in urinary symptoms, blinded global assessments of urologic status, adverse experiences, and effects on dihydrotestosterone (DHT) and prostate-specific antigen (PSA) in over 4500 men. Finasteride showed a favourable efficacy and tolerability profile in this large ethnically diverse population and was similarly effective in middle-aged and older men with BPH and prostate gland enlargement.

Efficacy, tolerability, and effect on health-related quality of life of finasteride versus placebo in men with symptomatic benign prostatic hyperplasia: a community based study. CUSP Investigators. Community based study of Proscar.

This study sought to assess the efficacy, tolerability, and effect of finasteride on health-related quality of life (HRQL) in a diverse population of men with moderate-to-severe symptomatic benign prostatic hyperplasia (BPH). This double-blind study evaluated finasteride and placebo for 12 months in 2342 men with BPH (16.2% black, 14.5% Hispanic, 69.3% Caucasian/other) in a community-based setting. At 3-month intervals, urinary symptoms were measured by use of the American Urologic Association symptom index. HRQL was assessed by use of the BPH impact index (BII), which evaluated degree of bother, worry, physical discomfort, and restriction in activities as a result of urinary symptoms. Additional questions regarding activities of living were administered, and global assessments of change in urologic status were performed by both patients and investigators. Compared with placebo, patients treated with finasteride had a statistically significant decrease in symptom scores when first measured at month 3. Symptom scores continued to improve in finasteride-treated patients throughout the study; at month 12, the mean decrease in symptom scores in the finasteride-treated patients was -4.8 compared with -3.4 for placebo patients ( P = 0.0001). Statistically significant differences in favor of finasteride also were noted at month 12 on the BII (P = 0.0465), and finasteride-treated patients experienced less interference with activities of living (P = 0.0518). Patient and investigator global assessments of urologic status showed that significantly more patients in the finasteride group considered themselves improved and were considered improved by investigators at month 12 (P = 0.000). Finasteride was generally well tolerated. The incidence of drug-related sexual adverse experiences was significantly higher in the finasteride group (P = 0.000), but led to withdrawal in only 1.5% of patients. The demonstrated efficacy and tolerability of finasteride in reducing symptoms and improving quality of life confirm observations of previous trials and make finasteride a highly desirable treatment option for many men with symptomatic BPH.

Computed tomography appearance of the prostatic fossa following radical prostatectomy.

RATIONALE AND OBJECTIVES: We assessed the value of postsurgical computed tomography (CT) in detecting locally recurrent prostatic carcinoma and determined the most effective CT findings. METHODS: We studied 13 patients with recurrent disease (prostate specific antigen [PSA] > 0.4 ng/ml) and 11 patients with no evidence of recurrence (PSA < 0.3 ng/ml). Pelvic CT scans were independently interpreted by four readers who were unaware of patient status. Readers measured tissue volume in the prostatic fossa and evaluated each scan for the presence of six potentially discriminating criteria. We determined sensitivity and specificity and developed mean and pooled receiver operating characteristic (ROC) curves for each criterion and for overall rating. RESULTS: The respective mean ROC curves, sensitivity, and specificity for each criterion were as follows: irregular tissue margins = .50, .67, and .32; inhomogeneous tissue density = .35, .76, and .11; asymmetric residual seminal vesicles = .68, .86, and .16; fat infiltration around seminal vesicles = .67, .69, and .43; infiltration of perirectal fat = .60, .71, and .40; and margins of the levator ani = .50, .78, and .09. The overall rating of whether a scan was normal or reflected recurrent cancer was .56, .75, and .32. Mean tissue volume in the prostatic fossa was 15.01 cm3 for the positive cases and 11.06 cm3 for the negative cases (p < .05), but because of a large overlap, this difference was not practically significant. CONCLUSION: CT scanning is not an effective technique for detecting recurrent prostate malignancy. Normally, there is a moderate amount of soft tissue in the prostatic fossa postoperatively that should not be confused for malignancy.

Modulation of immunoradiometric and bioactive follicle stimulating hormone secretion and clearance in young and elderly men during treatment with tamoxifen or flutamide.

The secretion and clearance of immunoactive and bioactive follicle-stimulating hormone (FSH) in healthy young men (N = 10) and elderly men (N = 7) during blockade of endogenous sex steroid hormones with tamoxifen, an antiestrogen, and flutamide, an antiandrogen, was investigated. To this end, subjects underwent blood sampling basally every 10 minutes for 24 hours, and then received 2 consecutive intravenous pulses of synthetic gonadotropin releasing hormone (GnRH; 10 micrograms and 100 micrograms) every 2 hours. This paradigm was repeated on two subsequent visits, in which subjects received either flutamide HCl, a specific nonsteroidal competitive antagonist of the androgen receptor (750 mg daily for 3 days), or tamoxifen, a selective antagonist of the estrogen receptor (20 mg daily for 9 days). Serum immunoactive FSH concentrations were measured in each sample by immunoradiometric assay (IRMA). Serum bioactive FSH concentrations were determined by an in vitro bioassay (rat granulosa cell aromatase system) on 24-hour serum pools. Deconvolution analysis was used to analyze both the FSH IRMA 24-hour time series and FSH release after GnRH. Comparisons between young and elderly men of the basal state showed significantly increased 24-hour mean serum immunoactive and bioactive FSH concentrations and significantly decreased free testosterone concentrations in elderly men. By deconvolution analysis, elderly men had a significant decrease in FSH secretory burst duration, and an increase in FSH half-life and FSH secretory burst amplitude compared with younger men. In response to sex steroid receptor blockade in young men, there was a significant increase in mean serum bioactive FSH concentrations during antiandrogen treatment, but not during antiestrogen treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Computerized tomographic appearance of renal cysts after extracorporeal shock wave lithotripsy.

We identified cysts in five kidneys of four patients who had lithotripsy. Three of these kidneys were evaluated with CT scans the day before and the day after lithotripsy and showed no change. The other two kidneys were studied by CT only after extracorporeal shock wave lithotripsy; hemorrhage was shown in one and cyst wall thickening in the other.

Treatment of painful prostatic bone metastases with oral etidronate disodium.

A class of drugs called diphosphonates have been used for several years in benign disorders of ossification such as Paget disease. Recently, these compounds have been applied to treating hypercalcemia of malignancy and painful bone metastases. We have used one of the oral diphosphonates, etidronate disodium, to palliate pain in 12 patients suffering from multiple bone metastases from prostate cancer. All of the patients had progressive metastatic disease following earlier endocrine therapy. Ten of 12 (83%) patients had a positive subjective and clinical response to treatment with oral etidronate disodium. Daily narcotic usage and pain intensity (measured by a zero to 10 pain scale) both decreased significantly on the etidronate protocol. There were no side effects associated with the drug in our patients.

The glycosphingolipids of human prostate tissue.

Neutral glycolipids and gangliosides from surgical samples of benign human prostate tissue were analyzed by chemical, enzymatic and immunostaining procedures. The neutral glycolipids consisted of ceramide mono-, di-, tri- and tetrahexosides of the globo series plus paragloboside. The monosialoganglioside fraction contained GM3 and GM1 plus multiple species of monosialylated lactosamine-containing structures, including sialyl-alpha-2----3paragloboside plus at least two compounds having a non-reducing terminal sialyl alpha 2----6Gal linkage. The disialoganglioside fraction contained GD3 as the major component plus GD1a, GD2 and GD1b. GT1b was the major trisialoganglioside.

Deletion of antigens of the Lewis a/b blood group family in human prostatic carcinoma.

The expression of antigens of the blood group Lewis a/b family were studied in a series of 42 prostatectomy specimens from patients with adenocarcinoma clinically confined to the prostate; 19 of these were later reclassified as pathologic Stage C. Staining of normal or hyperplastic versus neoplastic epithelium was assessed in routinely processed, paraffin-embedded tissue using murine monoclonal antibodies and an avidin-biotin immunoperoxidase technique. Antigens screened and the antibodies used to recognize them were Lewis a (CF4C4), Lewis b and Type 1 H (NS10), monosialosyl Lewis a I (19.9), and disialosyl Lewis a and monosialosyl Lewis a II (FH7). FH7 strongly stained the benign epithelium of all 39 Lewis positive cases, suggesting that the sialyltransferase responsible for synthesis of FH7-reactive determinants is highly active in benign prostatic tissue. When compared to the reactivity of benign epithelium in Lewis positive cases, the staining of the carcinomas was markedly reduced in 18 cases (46%) and absent in 16 cases (41%). This reduction or loss of staining of the malignant epithelium was observed for all antibodies that stained the corresponding benign epithelium of each case. In only five of the cases (13%) was the intensity of staining in the carcinoma equal to that of the surrounding benign epithelium. No cases in this latter group had recurrence of disease, whereas in the other staining groups 25-33% of the cases had recurrences; median follow-up for the entire group was 78 months. No correlation was apparent between Gleason score and the staining pattern with these antigens. In summary, antigens of the Lewis a/b family are deleted in a high percentage of cases of prostatic adenocarcinoma.

Combined gold seed implantation and external radiotherapy for stage B2 or C prostate cancer.

Patients with clinical stage B2 or C prostatic carcinoma represent a group for which there are several treatment options. We followed the course and outcome of 72 patients with clinical stages B and C prostate cancer who were treated with surgical staging, insertion of gold grains and external radiation at our institutions between 1975 and 1984. Of the patients 44 (61 per cent) had clinical stage B disease and the majority (89 per cent) of these were stage B2 lesions. The remaining 28 patients (39 per cent) had clinical stage C tumors. In our series 27 per cent of the clinical stage B and 68 per cent of the clinical stage C cancer patients had positive lymph nodes. The 5-year survival free of disease was 52 per cent for patients with both stages of disease. The 7-year survival free of disease was 47 per cent for patients with clinical stage B and 14 per cent for those with clinical stage C cancer. Lymph node status did not have a statistically significant effect on total survival but survival free of disease correlated significantly with node status. Local treatment failures were defined as patients who required transurethral prostatic resection or orchiectomy for palliation of obstructive symptoms related to local tumor regrowth. By these criteria we prevented local progression in 78 per cent of the patients at 5 years.

The role of radiology in extracorporeal shock wave therapy.

Extracorporeal shock wave lithotripsy was used for the treatment of 1,252 kidneys and ureters with calculi during a 10-month period at the authors' medical center. Before lithotripsy was performed, excretory urography, radiography, renography, computed tomography, and ultrasound studies were done, when necessary, to locate the calculi. Nine calculi in five kidneys could not be fragmented with lithotripsy. Of 895 patients with calculi less than 2.5 cm in diameter, only 13 (1.5%) required interventional procedures to clear the calculi, whereas of 161 patients with calculi greater than or equal to 2.5 cm, 36 (22.4%) required nephrostomies. A column of calculous debris in the mid and distal portions of the ureter (steinstrasse) was seen in 171 instances (13.6%) after lithotripsy; 62% required interventions. The most common intervention required for successful lithotripsy was retrograde ureteral catheterization. Evaluation and treatment of patients with urolithiasis were largely dependent on radiography and excretory urography.

Late recurrence of a seminoma.

We report a case of an extragonadal mediastinal seminoma that recurred almost 19 years after successful initial remission had been achieved with actinomycin D and chlorambucil. Treatment of the recurrence consisted of excision of a single involved supraclavicular lymph node followed by combination chemotherapy with cis-platinum, vinblastine and bleomycin. The patient has remained free of residual disease for 3 years. To our knowledge this case represents the longest reported interval to recurrence for a germ cell neoplasm.

Prostate adenocarcinoma: effects of castration on in situ androgen uptake by individual cell types.

The cellular distribution of androgen uptake was investigated in normal prostate and in Dunning R3327H prostate tumors in Copenhagen rats in vivo at different time intervals after castration. Quantitative dry-autoradiography was used to demonstrate which cell types have androgen binding, and to quantify the amount of androgen binding per cell type during initial castration-induced tumor regression and subsequent tumor relapse. Regardless of time after castration, tumor stromal nuclei had significantly more 3H-dihydrotestosterone (DHT) labelling than did tumor epithelial nuclei (p less than .001). On the other hand, prostate gland epithelial nuclei showed more 3H-DHT binding than prostate gland stromal nuclei. Tumor stromal nuclei had greater DHT uptake than any other cell type measured in the tumor or in secondary sex organs at all times after castration. Different cell types responded differently to castration. The 3H-DHT uptake measured in tumor stromal nuclei after castration showed that one day after castration 14.6 +/- 2.1 silver grains were present, 14 days after castration 9.3 +/- 2.4 were seen, and 50 days after castration 18.9 +/- 1.8 were present. This significant increase from 14 days to 50 days is not seen in the other cell types. This study gives insight into the cellular androgen receptor distribution in normal and malignant rat prostate tissue.

Extracorporeal shock wave lithotripsy: interventional radiologic solutions to associated problems.

Among 1,500 patients treated with extracorporeal shock wave lithotripsy, 1,300 had calculi less than 2.5 cm in diameter and 200 had calculi of 2.5 cm or larger. Although most patients did well and required no further radiologic intervention, 178 interventional radiologic procedures were performed. Urinary tract obstruction often developed in patients with large stones when the collecting system filled with stone fragments (steinstrasse). Nephrostomy was performed in 5.3% of the total patient population and in 29% of the patients with stones measuring 2.5 cm or more. Only 1.8% of the patients with calculi smaller than 2.5 cm required radiologic intervention. When the obstructed collecting system could not be crossed with conventional angiographic techniques, the stone fragments were removed through a percutaneous nephrostomy tract either by flushing or by suctioning with a pulsating water jet.

Detection of enteric-urinary fistulas with a noninvasive quantitative method.

The 51chromium test is an inexpensive, noninvasive test to evaluate patients for enteric-urinary fistulas. Of 11 patients studied the 51chromium test demonstrated correctly a fistula in 5 of 6 patients with fistulas and showed no lesion in all 5 without fistulas. Excretory urography, barium enemas, visible contrast medium, cystograms and upper gastrointestinal series failed to demonstrate the fistulas with similar accuracy. Cystoscopy suggested a possible lesion in 4 patients but was definite for a fistula in only 2 of those patients.

Immunoperoxidase staining of acid phosphatase in human prostatic tissue.

The introduction of immunoperoxidase and the indirect immunoperoxidase technique made important contributions in histopathologic diagnosis of prostatic cancer. This staining can be performed on formalin-fixed paraffin-embedded tissue which is usually available. We have used this histopathologic staining technique in 56 patients. The tissues include primary and metastatic prostatic cancer tissue in addition to normal renal pelvis and bladder tissue from other patients. Our data indicate that acid phosphatase can be localized in prostatic cells but not in transitional cells. Therefore, immunohistochemical staining of prostatic acid phosphatase seems most useful to identify metastatic prostate adenocarcinoma or primary tumor and to differentiate them from intraductal prostatic transitional carcinoma or other transitional cell carcinomas.

Lactic dehydrogenase in the monitoring and prognosis of testicular cancer.

In a prospective study of 80 patients with germinal testicular cancer, serial determinations of lactic dehydrogenase (LDH), alpha-fetoprotein (AFP) and human chorionic gonadotrophin (HCG) were followed for a mean of 18.1 months. Serum LDH was found to be elevated more frequently with increasing tumor bulk. LDH was elevated in 78.0% of the patients with Stage III disease but only 26.3% of the Stage II patients and 20.0% of the pre-orchiectomy Stage I patients. In this study, serum HCG and AFP levels were always elevated in the presence of elevated serum LDH levels except in one patient when LDH was the only elevated marker, in which case it correlated with clinical disease. Correlation of these three serum markers is shown by elevation of LDH in 78.0% of the Stage III patients, AFP in 78.6%, and HCG in 76.2%. In addition, of the 43 patients who had normal LDH levels on initial presentation, their mean survival time (MST) at the end of the study was 15.5 months while the 26 patients who had elevated LDH levels on initial presentation had an MST of 9.2 months. Serum LDH, therefore, may be useful in evaluating patient prognosis as well as an adjunct in monitoring the treatment of patients with bulky testicular cancer. The combination of LDH and HCG has been utilized to monitor the treatment of seminoma.