The results of radiotherapy for isolated elevation of serum PSA levels following radical prostatectomy.

Eleven patients were initially treated for localized prostate cancer with radical retropubic prostatectomy following negative pelvic lymph node dissection. Six or more months after surgery, these patients had elevated serum prostate specific antigen (PSA) levels. No patient had other clinical evidence of disease as determined by history, physical examination, bone scan, computed tomographic scan of the abdomen and pelvis, chest radiograph, complete blood cell count, and serum chemistry profile. These patients received prostate bed irradiation using 10-MV photons and a four-field technique. Doses ranged from 60.0 to 65.8 Gy in 1.8 to 2.0 Gy fractions. Levels of serum PSA were monitored and decreased initially in all treated patients. In two patients, levels of PSA increased after this initial decrease. In 7 of the 11 patients (64%), PSA levels decreased to less than or equal to 0.3 ng/mL at last measurement. Radiotherapy resulted in no severe toxicity. None of the patients had developed clinical evidence of disease at the time of this report. Isolated elevations of serum PSA after prostatectomy reflect residual disease, and radiotherapy appears to effectively decrease the PSA levels in most cases. This effect appears to be accomplished by killing locally residual or recurrent cancer in the postoperative tumor bed.

Transurethral microwave thermotherapy for prostatism: early Mayo Foundation experience.

As part of a multicenter investigative trial, transurethral microwave thermotherapy of the prostate was used in 60 men with symptomatic benign prostatic hypertrophy. A single office treatment on the Prostatron, a device that provides concurrent microwave heating of the prostate and conductive cooling of the urethra, was well tolerated and caused no major adverse events. Symptomatic improvement, especially the decrease in nocturia and urgency, was dramatic, and urinary flow was improved at 6 weeks. Continued follow-up suggests that further improvement will be achieved and that transurethral microwave thermotherapy has a role in the treatment of benign prostatic hypertrophy.

Evaluation of serum prostate-specific antigen levels after postoperative radiation therapy for pathologic stage T3, N0 prostate cancer.

OBJECTIVE: To analyze freedom from progression of serum prostate-specific antigen (PSA) levels in patients who have received radiation therapy after radical prostatectomy for pathologic stage T3, N0 prostate cancer. DESIGN: We assessed the freedom from PSA progression after postoperative radiation therapy and its relationship to several potential prognostic factors during a median follow- up of 43 months. MATERIAL AND METHODS: Thirty Mayo patients received postoperative radiation therapy for pathologic stage T3, N0 prostate cancer between January 1988 and April 1993. Radiation therapy was initiated within 6 months after prostatectomy. Radiation doses ranged from 60 to 67 Gy. RESULTS: "Freedom from PSA failure" was defined as the actuarial risk of maintaining a serum PSA level at 0.3 ng/mL or less. The freedom from failure rate was 66% at 3 and 4 years. Prognostic factors significantly associated with an improved freedom from failure were a pre-radiation PSA level of 1.0 ng/mL or less and no seminal vesicle involvement. A trend toward an improved freedom from failure was noted in patients with low-grade (1 and 2) tumors in comparison with high-grade (3 and 4) tumors. Treatment-related morbidity was minimal. CONCLUSION: Radiation therapy after radical prostatectomy for pathologic stage T3, N0 prostate cancer seems to provide an improved freedom from PSA failure in comparison with that noted in other series of similar patients treated with radical prostatectomy only.

Transurethral microwave thermotherapy v sham treatment: double-blind randomized study.

Transurethral microwave thermotherapy (TUMT) is a single-session, 1-hour office-based treatment for benign prostatic hyperplasia. A randomized, double-blind study has been conducted at our institutions involving 115 patients who, after satisfying the entry criteria, were randomized in a 2:1 fashion to receive TUMT or a sham treatment. Three months' unblinding revealed both statistically and clinically significant improvement in the efficacy measures for the real treatment compared with the sham. The mean Madsen Symptom Score decreased 55% and the mean peak flow rate increased 58% in the TUMT-treated patients v 28% and 27% in the sham-treated patients (P < 0.001). Also, the TUMT-treated patients improved in mean AUA Symptom Score by 43% v 26% for sham-treated patients (P < 0.01). Reclassification of patients after therapy showed a greater shift to the mild category of AUA Symptom Score: 37% for TUMT patients v 6.5% for sham-treated patients. In addition, prostate-specific antigen elevation to >4 times baseline was noted 1 week after TUMT v no statistically significant change for sham-treated patients. This double-blind study demonstrates that thermotherapy's efficacy is not placebo related and that the mechanism of action is related to thermal ablation of transition zone adenoma.

The Tomera technique: high energy transurethral thermotherapy with low energy morbidity.

Transurethral Microwave Thermotherapy (TUMT) is a unique and promising method of treating benign prostatic hyperplasia. Clinical outcomes after high energy protocol TUMT 2.5 are comparable to transurethral resection of the prostate. Previously this increased efficacy has had greater morbidity than lower energy protocol TUMT 2.0 with catheterization required in all patients. A technique of careful preoperative patient teaching, intravenous ketorolac and remifentanyl; patient discomfort is minimized, bladder spasms avoided, and requirement for catheterization infrequent. In 16 consecutive patients, only four required catheters despite an average energy of 155 KJ and a maximum energy of 208 KJ.

Transurethral microwave thermotherapy: strategies to ensure successful outcomes with Prostasoft 2.0.

Transurethral microwave thermotherapy (TUMT) is a unique and promising method of treating benign prostatic hyperplasia. Clinical outcomes are related to thermal dose delivered. In 359 consecutive patients, strategies to increase thermal dose using the FDA-approved Prostasoft 2.0 delivered a mean of 148 kJ, which was almost 50 kJ more than the U.S. FDA trials. These strategies include careful preoperative patient teaching, exclusion of very small prostates, ketorolac, prewarming of the prostaprobe, antitorque of the rectal probe, use of urethral cooling adjustment during power ramping, and no manual power interruptions. Clinical outcomes improved without any significant adverse events. Peak urinary flow increased in 4 months by 5.5 mL/sec.

Renal oncocytoma.

Review of the Mayo Clinic tissue registry for the years 1950 to 1979 identified 90 cases of pure, well differentiated eosinophilic granular cell renal tumors. The clinical, laboratory, pathologic and survival features of these patients were analyzed. Fifty-nine per cent of these tumors were discovered incidentally during an examination for other problems and 91 per cent were confined within the renal capsule, with no evidence of local invasion. Sixty-two patients had grade 1 and 28 had graded 2 tumors. None of the patients with grade 1 tumors developed metastases. Four of the patients with grade 2 tumors died of metastatic disease. Survival curves show no difference in survival between patients with these renal tumors, and an age and sex matched cohort. If the term renal oncocytoma is used to signify a very well differentiated (grade 1) eosinophilic granular cell renal parenchymal tumor then this study demonstrates that renal oncocytomas are non-aggressive tumors with a highly favorable prognosis.

Pyeloscopy in urothelial tumors.

Intraoperative pyeloscopy was performed on 18 consecutive patients with indeterminate pelvic of caliceal filling defects, subsequently proved to be transitional cell carcinomas. After nephroureterectomy local tumor recurrence in the region of the renal fossa developed in 2 patients. Intraoperative pyeloscopy entails significant risks and the seeding of transitional cell carcinoma is possible.

Sarcomatoid renal carcinoma.

Sarcomatoid renal carcinoma made up 1 per cent of renal parenchymal tumors resected from 1967 to 1980. The majority of patients with this aggressive type of renal carcinoma were symptomatic and had a palpable renal mass at the time of diagnosis. Only 2 of 13 patients had tumor confined within the renal capsule at the time of operation. One of these patients survived and 12 of 13 died rapidly of metastatic renal carcinoma, with a median survival of 6.3 months from the time of diagnosis. This distinctive histologic variant of renal carcinoma has a highly malignant biological behavior and, as effective adjuvant treatment for renal carcinoma becomes available, should be one of the tumor types treated vigorously.

Well differentiated (grade 1) clear cell renal carcinoma.

We reviewed the experience at this clinic from 1950 to 1980 with cases of grade 1 clear cell renal carcinoma. We wanted to determine whether patients with well differentiated clear cell renal tumors had the favorable clinical course that has been demonstrated for those with well differentiated oncocytic renal tumors. Of the 46 patients identified with pure grade 1 clear cell renal carcinoma two-thirds were discovered incidentally during diagnostic tests for unrelated complaints. These tumors generally were small, with 67 per cent being 6 cm. in diameter or smaller. Of all tumors 83 per cent were pathologic stage 1 (confined within the renal capsule). However, 10 patients have died of metastatic renal carcinoma and 3 are alive with disease. Actuarial survival curves show a significantly poorer prognosis for patients with grade 1 clear cell renal tumors compared to patients with grade 1 oncocytic renal tumors or to an age and sex-matched control group. We conclude that whereas well differentiated oncocytic renal tumors behave like benign renal tumors, well differentiated clear cell renal tumors can behave like aggressively malignant renal carcinomas and should be treated as such.

Transitional cell carcinoma of the bladder in children and adolescents.

A review of our records between 1950 and 1980 identified 12 patients with transitional cell carcinoma of the bladder who were less than 21 years old. The tumors were low grade and low stage, and were associated with an excellent prognosis. Only 1 patient had a solitary recurrence. This study supports the contention that transitional cell carcinoma of the bladder is a less aggressive disease in patients who are in the first 2 decades of life than in older patients.

Initial and superior experience with 30 minute TUMT.

Transurethral microwave thermotherapy (TUMT) is an evolving technique with different machines, protocols, intraprostatic temperatures, marketing claims, and clinical outcomes that can be confusing to the clinician. We report our initial and superior results with 30 Minute TUMT over previous treatment protocols in 16 patients. Patient discomfort and acceptance are greatly improved, with reduced analgesic requirements (11 vs. 24 mL of remifentanil), visual analogue pain scores of 0-2, and no power interruption required in any patients. All four patients in urinary retention are catheter-free 1 week after therapy. Post-treatment catheterization was required in only one patient who was voiding spontaneously before the procedure. Urinary flow rates and postvoid residuals improved in all patients. Prostatic cavities were found in all patients having prostate ultrasound 3 months after TUMT. 30 Minute TUMT is not simply a shortened 30-minute TUMT treatment. Rather it is a very different TUMT with an initial power of 80 W and initial urethral cooling water of 48 degrees F/8 degrees C. Mean maximum intraprostatic temperatures achieved are 154 degrees F/68 degrees C or 43 degrees F/24 degrees C greater than previous versions of microwave thermotherapy. 30 Minute TUMT s increased cooling and shorter times result in minimal discomfort and elimination of routine catheterization, but the initial 80-W energy and avoidance of power interruption provide higher intraprostatic temperatures and prostatic cavities in almost all patients in this office-based treatment.

Bilateral pelvic lymphadenectomy and radical retropubic prostatectomy for adenocarcinoma confined to the prostate.

A total of 519 patients with clinical stage B disease underwent radical prostatectomy from 1966 to 1981: 65 (12.5 per cent) had pathologic stage D1, 72 (14.0 per cent) pathologic stage C and 382 (73.5 per cent) pathologic stage B disease. Of the 519 patients 320 with pathologic stage B1 (239) or B2 (81) adenocarcinoma of the prostate and no prior hormonal or radiation therapy underwent complete pelvic lymphadenectomy and radical retropubic prostatectomy. Stage, grade and size of tumor were associated significantly with interval to disease progression but not with survival. The probable explanation for this observation is that only 2 per cent of 186 patients who were followed for 5 years and 2 per cent of 46 who were followed for 10 years died of prostatic carcinoma within these intervals. The over-all survival of patients who had intracapsular prostatic carcinoma was not different from that of an age-matched surgical control group (men undergoing total hip arthroplasty during the same interval). These observations suggest that although morbidity from alternative therapies may vary no other treatment modality offers survival superior to that observed for pelvic lymphadenectomy and radical retropubic prostatectomy in patients with pathologic intracapsular prostatic cancer.

Transurethral microwave thermotherapy for management of benign prostatic hyperplasia: results of the United States Prostatron Cooperative Study.

The primary objective of the study was to determine the safety and efficacy of transurethral microwave thermotherapy for the treatment of symptomatic benign prostatic hyperplasia. From March to August 1991, 150 patients were entered into a multi-site study and treated with transurethral microwave thermotherapy under a Food and Drug Administration approved protocol. Only patients with symmetrical trilobar or bilobar prostatic hypertrophy, peak flow rate of less than 15 cc per second (on 2 voided volumes of 150 cc or greater) and a total Madsen symptom score of more than 8 were treated. Transurethral microwave thermotherapy was performed with a 20F catheter and 1,296 MHz. microwave antenna for 60 minutes. The mean power achieved for this single session was 32.1 watts, with a mean power at maximum urethral temperature of 41.1 watts. Mean urethral temperature was 44.3C and the mean rectal temperature was 42.2C. The rectal and urethral temperatures were continuously monitored. Mean peak urinary flow rates, Madsen symptom score, post-void residual volume and improvement in motivating symptom to seek treatment were measured at 6 weeks, and 3, 6 and 12 months. Mean peak urinary flow rates improved 33% at 12 months (p < 0.0001). Overall, the mean Madsen symptom score improved 61% (p < 0.0001). The obstructive score and the irritative score improved 67% and 43%, respectively. Of 17 patients 12 (71%) reported improvement in weak stream when that was the motivating symptom to seek treatment. Of 28 men 18 (64%) reported improvement in nocturia, while 11 of 30 (37%) reported improvement in daytime frequency and 12 of 17 (71%) reported improvement in urgency. There was no statistically significant difference in post-void residual volume at 12 months from baseline. The treatment was well tolerated by all patients, and side effects were considered mild and transitory. Our study demonstrates the safety, effectiveness, patient tolerability and durability of transurethral microwave thermotherapy.