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Diagnostic Urology and Testis Cancer
G022-53£>7 /93/1493-0672$03,00/0 THE JOURNAL OF UROLOGY
Vol, 149, 672-689, Mm-cb 1993
Copyright© 1993 by AMERICAN UROLOGICAL ASSOCJATION, INC
Printed in US,A
ABSTRACTS DIAGNOSTIC UROLOGY AND TESTIS CANCER
gest that there is a true increase in the number of cases diagnosed annually. Jerome P. Richie, M.D.
The Impact of Recent Advances in Diagnostic Teclmology on the Clinical Presentation of Phaeoch:romocytoma G.
A. EDWARDS, G. A. SMYTHE, P. E. GRAHAM AND L. LAZARUS, Department of Chemical Pathology, St. Vincent's
Hospital, Darlinghurst, New South Wales
Solitary Metastases From Renal Cell Carcinoma: A Review H. B. TONGAONKAR, J. N. KULKARNI AND M. R. KAMAT, Department of Ura-Oncology, Tata Memorial Hospital, Parel, Bombay, India
Med. J. Aust., 156: 153-157, 1992
J. Surg. Oncol., 49: 45-48, 1992
Objective: To examine the impact of recent advances in diagnostic technology on the spectrum of clinical and biochemical features of patients presenting with a new diagnosis of phaeochromocytoma. Design: A retrospective review of the clinical and biochemical features of patients diagnosed by our laboratory as having phaeochromocytoma within a 27-month period up to December, 1990. Noradrenaline, adrenaline and dihydroxyphenylglycol were assayed in 24-hour urine specimens (19 patients) or plasma (1 anuric patient) by gas chromatography/mass spectrometry. Setting: A tertiary level chemical pathology department. Patients: Twenty patients with a new diagnosis of phaeochromocytoma. Results: The classic, episodic adrenergic symptoms traditionally associated with phaeochromocytoma were absent in 9 of the 20 patients (45 %) . "Atypical" phaeochromocytoma presented as a mass on computed tomography imaging (6 patients, 30%), "phaeochromocytoma crisis" (4 patients, 20%) or family screening (1 patient, 5% ). Excessive adrenaline production was found in 11 patients (55%) and six (30%) had predominantly adrenaline-secreting tumours. The urinary noradrenaline:dihydroxyphenylglycol ratio was raised in all nine patients with predominantly noradrenaline-secreting tumours but was not raised in nine out of ten patients with adrenaline-secreting phaeochromocytoma. Adrenaline excretion was significantly correlated with tumor size (r = 0.8; P < 0.05). Conclusions: Advances in diagnostic technology, particularly specific adrenaline assays and computed tomography, have made possible the early diagnosis of patients with phaeochromocytoma presenting in ways previously thought to be uncommon. All patients with adrenal masses noted incidentally on CT scan should be investigated for phaeochromocytoma. Adrenaline-secreting tumours are common and both noradrenaline and adrenaline should be assayed in all patients investigated for phaeochromocytoma.
Nineteen patients with solitary metastatic lesions from renal cell carcinoma, 5 synchronous and 14 metachronous, were seen at the Tata Memorial Hospital over a 7 year period between 1981 and 1987. The mean metastatic interval for the metachronous lesions was 31.2 months. The commonest sites of metastases were bone, lung, and liver. The solitary nature of the metastasis was confirmed by appropriate investigations. All patients underwent nephrectomy for the primary kidney lesion. The metastatic lesions were treated with intent of cure. Only 1 patient with synchronous metastasis survived for 2 years and none survived 5 years while in the metachronous metastasis group, the estimated overall survival was 50% at 2 years and 25% at 5 years. The patients with a long metastasis-free interval were found to have a better survival. The patients with liver metastasis did poorly as compared to those with metastases at other sites. The stage of the disease also had a bearing on the survival.
Editorial Comment: The authors report a series of 20 patients that defies the conventional wisdom that most patients with pheochromocytoma present with sig:nificant hypertension and classical symptom complex. Of the patients 45% experienced none of the episodic adrenergic symptoms traditionally associated with pheoch:romocytoma. Although the authors are at a tertiary referral center, they are seeing an increased number of cases of pheochromocytoma, some of which are attributable to advances in diagnostic technology, especially since there are assays for epinephrine. The authors sug672
Editorial Comment: The authors report a 7 .6% incidence of solitary metastases from renal cell carcinoma in 250 patients seen between 1981 and 1987. As expected, patients with synchronous metastases had a poorer survival rate than those with metachronous lesions. The better survival with longer metastasis-free interval suggests a longer doubling time in those tumors and probably reflects the natural history of the disease. The authors recommend nephrectomy and aggressive treatment of an apparent solitary metastatic lesion, especially in good :risk surgical candidates. Jerome P. Richie, M.D. Multimodality Approach to Staging Renal Cell Carcinoma
P. J. FRITZSCHE AND C. MILLAR, Departments of Radiology, Loma Linda University School of Medicine and Loma Linda University Medical Center, Loma Linda, California Urol. Rad., 14 : 3- 7, 1992 Renal imaging has dramatically improved since the introduction of ultrasound (US), computed tomography (CT), and most recently magnetic resonance (MR) imaging. US and MR imaging are ideal for patients with compromised renal function preventing administration of iodinated contrast material or those who have experienced reactions to contrast. Staging errors occur due to limitations in assessing microscopic tumor invasion of the renal capsule and perinephric fat, detecting metastatic deposits in normal sized lymph nodes and differen-
DIAGNOSTIC UROLOGY AND TESTIS CANCER
tiating inflammatory hyperplastic lymph nodes from neoplastic ones. These limitations are shared by US, CT, and MR imaging. Vascular invasion by tumor can be evaluated by all imaging modalities including venography. The advantages and limitations of each examination will be presented.
l
Editorial Comment: The authors provide an overview of modalities for staging renal cell carcinoma, including ultrasound, computerized tomography, magnetic resonance imaging and angiography. Jerome P. Richie, M.D. The Role of Serum Laminin P 1 in the Diagnosis of Transitional Cell Carcinoma of the Bladder K. M. M. ABOU FARHA, P. P. C. A. MENHEERE, J. L. BRUINS, A. D. M. KESTER AND R. JANKNEGT, Departments of Urology, Clinical Chemistry, and Medical Informatics and Statistics, Maastricht University, Maastricht, The Netherlands Eur. Urol., 21: 240-244, 1992 In order to explore the possible role of serum laminin Pl in the diagnosis of transitional cell carcinoma (Tee) of the bladder, the sera of 50 healthy control subjects and of 35 bladdercancerous patients were measured by radioimmunoassay. In 27 patients (77%), the serum level was elevated above the upper limit of normal range. Statistically significant elevation could be determined in all stages and grades of Tee of the bladder compared to those of normal subjects (mean± SD: 1.18 ± 0.16 kU /1). Deterioration of the clinical stages or pathologic grades of the tumor was associated with a progressive increase in the mean values of serum laminin Pl. A longer study with serial determination is planned to assess the prognostic significance of serum laminin in bladder cancer patients.
Editorial Comment: Laminin, a major glycoprotein in the extracellular matrix, is formed of 3 polypeptide chains. Laminin Pl, which is a fragment of laminin that carries most of the antigenic determinants, has been reported in the sera of normal individuals and may be elevated in some tumors. The authors evaluated laminin Pl in control subjects and patients with bladder cancer, and found a statistically significant increase regardless of extent of bladder tumor. This preliminary finding suggests the need for confirmatory studies. Larger series may show a difference in stage of disease that was not obvious in this preliminary study. Jerome P. Richie, M.D. Urethral Diverticular Carcinoma M. CLAYTON, P. SIAMI AND P. GUINAN, Department of Urology, University of Illinois, Chicago, Illinois Cancer, 70: 665-670, 1992 Background. Urethral diverticular carcinoma is an unusual finding in a urologic lesion commonly found in female patients. Methods. This report presents 6 new cases and reviews the other 53 cases in the English literature. Results. Adenocarcinoma occurs more frequently than transitional and squamous cell cancers combined. Conclusion. The prognosis of the former is more favorable. In general, radical therapy is recommended. However, in some instances of localized disease, and with careful follow-up, a more conservative approach might be attempted.
673
Editorial Comment: The authors present 6 detailed case reports and provide an extensive table of the other 53 documented cases of urethral diverticular carcinoma. This uncommon cancer represents only 5% of female urothelial carcinomas and was first reported in 1951. This article details symptoms, location and grade, and provides an overview of treatment approaches to this rare malignancy. Jerome P. Richie, M.D. Monoclonal Antibody 43-9F: An Immunohistochemical Marker of Embryonal Carcinoma of the Testis J. VISFELDT, A. GIWERCMAN AND N. E. SKAKKEBAEK,
University Departments of Pathology, and Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
APMIS, 100: 63-70, 1992 Permission to Publish Abstract Not Granted
Editorial Comment: The authors describe a new monoclonal antibody, 43-9F, which has previously been shown to be a marker for carcinoma in situ. This monoclonal antibody stains reliably for embryonal carcinoma and may help in histological diagnosis. These findings will need to be corroborated in a larger series before routine use of this new monoclonal antibody can be recommended. Jerome P. Richie, M.D. Second Cancer in Patients Treated for Testicular Seminoma M. STEIN, N. LOBERANT, M. LAVIOV, G. RENNERT,J. LACHTER AND A. KUTEN, Department of Radiology, Western Galilee
Regional Hospital, Nahariya, and Northern Israel Oncology Center and Department of Internal Medicine "B," Rambam Medical Center, Department of Community Health, Carmel Hospital and Technion Faculty of Medicine, Haifa, Israel
J. Surg. Oncol., 49: 16-19, 1992 The exact risk of developing a second primary cancer following radiotherapy for testicular seminoma is not known. At the Northern Israel Oncology Center, between the years 1968-1988, 75 patients with early stage (I, IIA) testicular seminoma were treated by orchiectomy followed by radiation therapy. The overall 10- and 20-year survival probability was 95% and 90%, respectively. Eight patients (11%) developed nine second cancers, with a cumulative rate of one case per 1,000 years of follow-up. The second primary cancers were: two bronchogenic carcinomas, one contralateral seminoma, one thymoma, one papillary carcinoma of the thyroid, one carcinoma of the stomach, one transitional cell carcinoma of the urinary bladder, one carcinoma of the colon, and one malignant melanoma. Three of these tumors developed within the irradiated field. Five of these eight patients are alive with no evidence of recurrent cancer. We conclude that patients treated for seminoma have an increased risk of developing a second cancer. There is a need for greater awareness of this possibility. The overall prognosis remains favorable.
Editorial Comment: The authors review a series of patients treated with low dose radiation averaging 25 to 30 Gy at a mean fractionation of 200 cGy. Second cancers developed in 8 patients, of whom 1 had a con-
674
DIAGNOSTIC UROLOGY AND TESTIS CANCER
tralateral seminoma. Three of the second tumors developed within the radiation field. None of the patients had post-radiation sarcoma, which usually is associated with doses greater than 35 Gy. The authors conclude that there is considerable risk for development of a second primary cancer in this cohort of patients. Jerome P. Richie, M.D. Management of Testicular Seminoma Following Organ Transplantation M. A. VILLALONA-CALERO, T. DUCKER, M. HOLASEK, J. NAJARIAN AND B. J. KENNEDY, Division of Oncology, Department of Medicine, and Departments of Therapeutic Radiology and Surgery, University of Minnesota Medical School, University Hospital, Minneapolis, Minnesota Med. Ped. Oncol., 20: 338-340, 1992 An increased incidence of malignancies has occurred in recipients of organ transplantation who are immunosuppressed. Although testicular cancers have been uncommon, seminomas are extremely rare. Two patients with long-standing diabetes mellitus and renal transplants developed clinical stage I seminoma of the testis. These patients posed a therapeutic problem with respect to the use of radiation therapy. In one, none was given because of a combination of kidney rejection and antibiotic-induced renal damage. The second patient received radiation therapy with shielding of the transplanted kidney. The surgical distortion of lymph node architecture increases the problems in the use of radiation therapy. Individual factors need to be considered in the use of postorchiectomy radiation therapy for seminoma in transplant patients. Editorial Comment: The authors report 2 cases of pure seminoma in an older age group following organ transplantation. Radiation therapy is problematic because of the transplant kidney. One patient was treated with the transplant kidney shielded. The authors discuss the factors that need to be considered with radiation therapy or chemotherapy in the transplant population. Jerome P. Richie, M.D.
Retroperitoneal Surgery in Patients With Nonseminomatous Testicular Cancer and Minimal Residual Tumor H. QVIST, S. D. FOSSA, s. Ous, H. H. LIEN, A. E. STENWIG AND K.-E. GIERCKSKY, Departments of Surgical Oncology, Medical Oncology and Radiotherapy, Diagnostic Radiology and Pathology, The Norwegian Radium Hospital, Oslo, Norway J. Surg. Oncol., 50: 220-223, 1992 In the period 1980-1991, 78 patients with advanced nonseminomatous testicular cancer underwent retroperitoneal lymphadenectomy for postchemotherapy residual masses <2 cm. To decrease the frequency of "dry ejaculation" in these patients with no or limited residual disease, the extent of dissection was reduced during the period, with bilateral dissections (49 cases, 1980-1986) being initially replaced by unilateral procedures (19 cases, 1983-1990) and subsequently by nerve-sparing techniques (10 cases, 1990-1991). As expected, a higher total number of lymph nodes was found in the retroperitoneal specimens after bilateral (44 (13-100)) than after unilateral (21 (7-35)) and nerve-sparing (18 (7-60)) procedures. The number of lymph nodes with pathological changes was low, with 3 (1-16)
after bilateral, 2 (1-9) after unilateral, and 2 (1-4) after nervesparing operations. Histological examination revealed only necrosis/fibrosis in 65% of the patients, elements of mature teratoma in 28%, and remnants of viable malignant tumor in 6%. There were no major postoperative complications. "Dry ejaculation" was reported by 84 % of the patients with bilateral operations, but was generally avoided after the unilateral (16%) and nerve-sparing (nil) procedures. After a mean follow-up of 83 (5-138) months, 6 patients have developed a recurrence, only one of them primarily in the retroperitoneal space. It is concluded that in patients with minimal residual retroperitoneal tumor, post chemotherapy lymphadenectomy using a unilateral or nerve-sparing technique seems to offer an effective therapeutic alternative with acceptable postoperative morbidity and preserved ejaculation. Editorial Comment: The authors report on 78 patients who during an 11-year period underwent surgical removal of post-chemotherapy retroperitoneal residual masses less than 2 cm. in diameter. Diameters of the lesions were perpendicular as measured on transverse computerized tomography before and after chemotherapy. The authors advocate a modified technique, either unilateral or nerve sparing, which has decreased the incidence of failure to ejaculate. This study adds to the growing body of evidence that unilateral or nerve sparing techniques can be effective therapeutic alternatives in select patients. Jerome P. Richie, M.D. Vascular Injury and Repair Associated With Retroperitoneal Lymphadenectomy for N onseminomatous Germinal Cell Tumours of the Testis J. F. MORIN, J. L. PROVAN, M.A. S. JEWETT AND F. M. AMELI, Divisions of Vascular Surgery and Urology, Department of Surgery, The Wellesley Hospital, University of Toronto, Toronto, Ontario Canad. J. Surg., 35: 253-256, 1992 Metastatic disease adjacent to major vascular structures in the retroperitoneum sometimes necessitates planned removal of portions of these vessels, or the vessels may inadvertently be injured when retroperitoneal lymphadenectomy is performed. In 78 patients who underwent retroperitoneal lymphadenectomy, 17 (22%) required vascular repair intraoperatively. The vena cava was most frequently involved (eight cases) followed by inadvertent injury to the renal arteries (five cases) or the infrarenal aorta (three cases). Resection of the infrarenal aorta was planned in two cases without postoperative complication. In six cases a resection of either the whole inferior vena cava or a portion of it was needed to remove all of the tumour. There were nine cases of inadvertent injury to the aorta, vena cava or a renal artery. The outcome after arterial repair was satisfactory with the exception of the inadvertent renal artery injuries, which required nephrectomy in three cases. Leg swelling was not a longterm sequela of either caval repair or resection. Editorial Comment: The authors discuss management of vascular injuries, including aortic, inferior vena caval and visceral vessel repairs, in 17 patients who required vascular procedures at retroperitoneal lymph node dissection. This article adds to the growing body of literature recognizing the need for knowledge and experience
ADRENAL, HYPERTENSI01"~~ REJ'.'.JA.L PHYSIOLGC\-Y AN.D RENAL PAILURE
in ,u1.dersta,uiing re1tr{m~,r1t01lle:H anatomical re:lationships, and fhe ability to deal with inadvertent injury to major vessels and :retroperitoneal structures at :ret:rope:ritoneal lymph node dis§ection. Jerome P. Richie, M.D.
potentially curative therapeutic even for heavily pretreated or cisplatin-refractory patients. Some degree of disease resistance to cisplatin can be overcome with dose escalation of platinum compounds. Patients with multiple recurrences of relapsed or refractory primary mediastinal germ cell tumors were not helped by this approach.
Salvage Therapy in Recurrent Testicular Cancer
Edito:rial Comment: This study evaluates high dose carboplatin and etoposide treatment in 40 consecutive patients, of whom 3 also received ifosfamide. AH patients underwent autologous bone marrow rescue. These were high risk patients, with primary media,stinal germ cell tumor or extensive disease. The authors achieved a 65% objective response rate, which is impressive for this heavily pretreated group. Toxicity is high with this type of aggressive therapy. Jerome P. Richie, M.D.
S.
Department of Medicine, Indiana University, Indianapolis, Indiana SAXMAN,
Sem. Oncol., 19: 143-147, 1992 No Abstract
Editorial Comment: This timely article reviews second and third line chemotherapy with ifosfamide and autologous bone marrow transplantation in cases that fail first line chemotherapy for nonseminomatous germ cell testicular cancer. The author discusses salvage chemotherapy, single agent activity, combination activity and dose intensive chemotherapy with rescue by autologous bone marrow t:ransplantation. Jerome P. Richie, M.D. Long-Term Outcome of Patients With Relapsed and Refractory Ge:rm Cell Tumors Treated With High-Dose Chemotherapy and Autologous Bone Marrow Rescue
E. R. BROUN, C.R. NICHOLS, P. KNEEBONE, §. D. WILLIAMS, P. J. LOEHRER, L. H. EINHORN AND G. J. K. TRICOT, Indiana University Hospital, Indianapolis, Indiana Ann. Intern. Med., 117: 124-128, 1992 Objective: To review the long-term outcome of patients with recurrent and refractory germ cell tumors treated with highdose chemotherapy and autologous bone marrow rescue. Design: Cohort study. Setting: A university hospital. Patients: Forty consecutive patients with recurrent or refractory germ cell tumors treated at Indiana University between September 1986 and June 1989. Interventions: Patients were treated with high-dose carboplatin (900 to 2000 mg/m 2 body surface area) and etoposide (1200 mg/m 2 ). Three patients also received ifosfamide (10 g/ m 2 ). All patients had autologous bone marrow rescue. Of the 40 study patients, 26 received two full courses of therapy. Measurements: Patient charts were reviewed to determine the rate and duration of complete and partial remission and the number of long-term, disease-free survivors. The influence of cisplatin-refractory disease and the site of the primary tumor on the incidence of remission and survival were also investigated. Results: Of the 40 study patients, 26 (65%) responded to treatment; 12 (30%) achieved a complete response, and 14 (35%) achieved a partial response. Of the 12 complete responders, 5 relapsed, and 1 died of treatment-related acute leukemia 27.5 months after treatment without evidence of germ cell cancer. Six (15%) of the original 40 patients, of whom 3 were refractory to cisplatin, remained in complete remission after at least 24 months of follow-up. Eight of 40 patients had primary mediastinal germ cell tumors with no complete remissions and a median survival of 2 months (range, 0.5 to 9.0 months). Conclusions: Treatment with high-dose carboplatin and etoposide in conjunction with autologous bone marrow rescue in patients with relapsed or refractory germ cell tumors is a
ADRENAL, HYPERTENSION, RENAL PHYSIOLOGY AND RENAL FAILURE Multiple Myeloma and Contrast Media C. S. McCARTHY AND J. A. BECKER, Department of Radiology,
State University of New York, Health Science Center at Brooklyn, Brooklyn, New York Radiology, 183: 519-521, 1992 Contrast media administered intravenously are still thought by many to be a major cause of acute renal failure (ARF) in myeloma patients. Recently, several authors found that the predominant risk factors of ARF in myeloma patients are hypercalcemia, dehydration, infection, and Bence Jones proteinuria rather than contrast media. In a review of seven retrospective studies of myeloma patients receiving contrast media, 4 76 patients were noted to have undergone 568 contrast media studies, with an ARF prevalence of 0.6%-1.25%. One large series showed the incidence of ARF after administration of contrast media to be 0.15% in the general population. Although the administration of contrast media to myeloma patients is not totally risk free, it may be performed if the clinical need arises and the patient is well hydrated.
Editorial Comment: This interesting article suggest§ that the incidence of acute :renal failu:re following administration of contrast material in patients with multiple myeloma has been overexaggeratect Indeed, if such a patient is not dehydrated o:r hype:rcalcemic and does not have massive Bence Jones proteinu:rfa he o:r she is unlikely to experience any untoward effects from the contrast medium. Proper preparation of the patient and appropriate use of the contrast material should allow the clinician to perform contrast studies in patients with multiple myeloma with low morbidity resulting. W. Scott McDougal, M.D. Clinical Profiles of Gross Hematuria in Autosomal Dominant Polycystic Kidney Disease
P. A. GABOW, I. DULEY AND A. M. JOHNSON, Department of Medicine, University of Colorado Health Sciences Center, Denver, Colorado Amer. J. Kidney Dis., 20: 140-143, 1992
Vol, 149, 672-689, Mm-cb 1993
Copyright© 1993 by AMERICAN UROLOGICAL ASSOCJATION, INC
Printed in US,A
ABSTRACTS DIAGNOSTIC UROLOGY AND TESTIS CANCER
gest that there is a true increase in the number of cases diagnosed annually. Jerome P. Richie, M.D.
The Impact of Recent Advances in Diagnostic Teclmology on the Clinical Presentation of Phaeoch:romocytoma G.
A. EDWARDS, G. A. SMYTHE, P. E. GRAHAM AND L. LAZARUS, Department of Chemical Pathology, St. Vincent's
Hospital, Darlinghurst, New South Wales
Solitary Metastases From Renal Cell Carcinoma: A Review H. B. TONGAONKAR, J. N. KULKARNI AND M. R. KAMAT, Department of Ura-Oncology, Tata Memorial Hospital, Parel, Bombay, India
Med. J. Aust., 156: 153-157, 1992
J. Surg. Oncol., 49: 45-48, 1992
Objective: To examine the impact of recent advances in diagnostic technology on the spectrum of clinical and biochemical features of patients presenting with a new diagnosis of phaeochromocytoma. Design: A retrospective review of the clinical and biochemical features of patients diagnosed by our laboratory as having phaeochromocytoma within a 27-month period up to December, 1990. Noradrenaline, adrenaline and dihydroxyphenylglycol were assayed in 24-hour urine specimens (19 patients) or plasma (1 anuric patient) by gas chromatography/mass spectrometry. Setting: A tertiary level chemical pathology department. Patients: Twenty patients with a new diagnosis of phaeochromocytoma. Results: The classic, episodic adrenergic symptoms traditionally associated with phaeochromocytoma were absent in 9 of the 20 patients (45 %) . "Atypical" phaeochromocytoma presented as a mass on computed tomography imaging (6 patients, 30%), "phaeochromocytoma crisis" (4 patients, 20%) or family screening (1 patient, 5% ). Excessive adrenaline production was found in 11 patients (55%) and six (30%) had predominantly adrenaline-secreting tumours. The urinary noradrenaline:dihydroxyphenylglycol ratio was raised in all nine patients with predominantly noradrenaline-secreting tumours but was not raised in nine out of ten patients with adrenaline-secreting phaeochromocytoma. Adrenaline excretion was significantly correlated with tumor size (r = 0.8; P < 0.05). Conclusions: Advances in diagnostic technology, particularly specific adrenaline assays and computed tomography, have made possible the early diagnosis of patients with phaeochromocytoma presenting in ways previously thought to be uncommon. All patients with adrenal masses noted incidentally on CT scan should be investigated for phaeochromocytoma. Adrenaline-secreting tumours are common and both noradrenaline and adrenaline should be assayed in all patients investigated for phaeochromocytoma.
Nineteen patients with solitary metastatic lesions from renal cell carcinoma, 5 synchronous and 14 metachronous, were seen at the Tata Memorial Hospital over a 7 year period between 1981 and 1987. The mean metastatic interval for the metachronous lesions was 31.2 months. The commonest sites of metastases were bone, lung, and liver. The solitary nature of the metastasis was confirmed by appropriate investigations. All patients underwent nephrectomy for the primary kidney lesion. The metastatic lesions were treated with intent of cure. Only 1 patient with synchronous metastasis survived for 2 years and none survived 5 years while in the metachronous metastasis group, the estimated overall survival was 50% at 2 years and 25% at 5 years. The patients with a long metastasis-free interval were found to have a better survival. The patients with liver metastasis did poorly as compared to those with metastases at other sites. The stage of the disease also had a bearing on the survival.
Editorial Comment: The authors report a series of 20 patients that defies the conventional wisdom that most patients with pheochromocytoma present with sig:nificant hypertension and classical symptom complex. Of the patients 45% experienced none of the episodic adrenergic symptoms traditionally associated with pheoch:romocytoma. Although the authors are at a tertiary referral center, they are seeing an increased number of cases of pheochromocytoma, some of which are attributable to advances in diagnostic technology, especially since there are assays for epinephrine. The authors sug672
Editorial Comment: The authors report a 7 .6% incidence of solitary metastases from renal cell carcinoma in 250 patients seen between 1981 and 1987. As expected, patients with synchronous metastases had a poorer survival rate than those with metachronous lesions. The better survival with longer metastasis-free interval suggests a longer doubling time in those tumors and probably reflects the natural history of the disease. The authors recommend nephrectomy and aggressive treatment of an apparent solitary metastatic lesion, especially in good :risk surgical candidates. Jerome P. Richie, M.D. Multimodality Approach to Staging Renal Cell Carcinoma
P. J. FRITZSCHE AND C. MILLAR, Departments of Radiology, Loma Linda University School of Medicine and Loma Linda University Medical Center, Loma Linda, California Urol. Rad., 14 : 3- 7, 1992 Renal imaging has dramatically improved since the introduction of ultrasound (US), computed tomography (CT), and most recently magnetic resonance (MR) imaging. US and MR imaging are ideal for patients with compromised renal function preventing administration of iodinated contrast material or those who have experienced reactions to contrast. Staging errors occur due to limitations in assessing microscopic tumor invasion of the renal capsule and perinephric fat, detecting metastatic deposits in normal sized lymph nodes and differen-
DIAGNOSTIC UROLOGY AND TESTIS CANCER
tiating inflammatory hyperplastic lymph nodes from neoplastic ones. These limitations are shared by US, CT, and MR imaging. Vascular invasion by tumor can be evaluated by all imaging modalities including venography. The advantages and limitations of each examination will be presented.
l
Editorial Comment: The authors provide an overview of modalities for staging renal cell carcinoma, including ultrasound, computerized tomography, magnetic resonance imaging and angiography. Jerome P. Richie, M.D. The Role of Serum Laminin P 1 in the Diagnosis of Transitional Cell Carcinoma of the Bladder K. M. M. ABOU FARHA, P. P. C. A. MENHEERE, J. L. BRUINS, A. D. M. KESTER AND R. JANKNEGT, Departments of Urology, Clinical Chemistry, and Medical Informatics and Statistics, Maastricht University, Maastricht, The Netherlands Eur. Urol., 21: 240-244, 1992 In order to explore the possible role of serum laminin Pl in the diagnosis of transitional cell carcinoma (Tee) of the bladder, the sera of 50 healthy control subjects and of 35 bladdercancerous patients were measured by radioimmunoassay. In 27 patients (77%), the serum level was elevated above the upper limit of normal range. Statistically significant elevation could be determined in all stages and grades of Tee of the bladder compared to those of normal subjects (mean± SD: 1.18 ± 0.16 kU /1). Deterioration of the clinical stages or pathologic grades of the tumor was associated with a progressive increase in the mean values of serum laminin Pl. A longer study with serial determination is planned to assess the prognostic significance of serum laminin in bladder cancer patients.
Editorial Comment: Laminin, a major glycoprotein in the extracellular matrix, is formed of 3 polypeptide chains. Laminin Pl, which is a fragment of laminin that carries most of the antigenic determinants, has been reported in the sera of normal individuals and may be elevated in some tumors. The authors evaluated laminin Pl in control subjects and patients with bladder cancer, and found a statistically significant increase regardless of extent of bladder tumor. This preliminary finding suggests the need for confirmatory studies. Larger series may show a difference in stage of disease that was not obvious in this preliminary study. Jerome P. Richie, M.D. Urethral Diverticular Carcinoma M. CLAYTON, P. SIAMI AND P. GUINAN, Department of Urology, University of Illinois, Chicago, Illinois Cancer, 70: 665-670, 1992 Background. Urethral diverticular carcinoma is an unusual finding in a urologic lesion commonly found in female patients. Methods. This report presents 6 new cases and reviews the other 53 cases in the English literature. Results. Adenocarcinoma occurs more frequently than transitional and squamous cell cancers combined. Conclusion. The prognosis of the former is more favorable. In general, radical therapy is recommended. However, in some instances of localized disease, and with careful follow-up, a more conservative approach might be attempted.
673
Editorial Comment: The authors present 6 detailed case reports and provide an extensive table of the other 53 documented cases of urethral diverticular carcinoma. This uncommon cancer represents only 5% of female urothelial carcinomas and was first reported in 1951. This article details symptoms, location and grade, and provides an overview of treatment approaches to this rare malignancy. Jerome P. Richie, M.D. Monoclonal Antibody 43-9F: An Immunohistochemical Marker of Embryonal Carcinoma of the Testis J. VISFELDT, A. GIWERCMAN AND N. E. SKAKKEBAEK,
University Departments of Pathology, and Growth and Reproduction, Rigshospitalet, Copenhagen, Denmark
APMIS, 100: 63-70, 1992 Permission to Publish Abstract Not Granted
Editorial Comment: The authors describe a new monoclonal antibody, 43-9F, which has previously been shown to be a marker for carcinoma in situ. This monoclonal antibody stains reliably for embryonal carcinoma and may help in histological diagnosis. These findings will need to be corroborated in a larger series before routine use of this new monoclonal antibody can be recommended. Jerome P. Richie, M.D. Second Cancer in Patients Treated for Testicular Seminoma M. STEIN, N. LOBERANT, M. LAVIOV, G. RENNERT,J. LACHTER AND A. KUTEN, Department of Radiology, Western Galilee
Regional Hospital, Nahariya, and Northern Israel Oncology Center and Department of Internal Medicine "B," Rambam Medical Center, Department of Community Health, Carmel Hospital and Technion Faculty of Medicine, Haifa, Israel
J. Surg. Oncol., 49: 16-19, 1992 The exact risk of developing a second primary cancer following radiotherapy for testicular seminoma is not known. At the Northern Israel Oncology Center, between the years 1968-1988, 75 patients with early stage (I, IIA) testicular seminoma were treated by orchiectomy followed by radiation therapy. The overall 10- and 20-year survival probability was 95% and 90%, respectively. Eight patients (11%) developed nine second cancers, with a cumulative rate of one case per 1,000 years of follow-up. The second primary cancers were: two bronchogenic carcinomas, one contralateral seminoma, one thymoma, one papillary carcinoma of the thyroid, one carcinoma of the stomach, one transitional cell carcinoma of the urinary bladder, one carcinoma of the colon, and one malignant melanoma. Three of these tumors developed within the irradiated field. Five of these eight patients are alive with no evidence of recurrent cancer. We conclude that patients treated for seminoma have an increased risk of developing a second cancer. There is a need for greater awareness of this possibility. The overall prognosis remains favorable.
Editorial Comment: The authors review a series of patients treated with low dose radiation averaging 25 to 30 Gy at a mean fractionation of 200 cGy. Second cancers developed in 8 patients, of whom 1 had a con-
674
DIAGNOSTIC UROLOGY AND TESTIS CANCER
tralateral seminoma. Three of the second tumors developed within the radiation field. None of the patients had post-radiation sarcoma, which usually is associated with doses greater than 35 Gy. The authors conclude that there is considerable risk for development of a second primary cancer in this cohort of patients. Jerome P. Richie, M.D. Management of Testicular Seminoma Following Organ Transplantation M. A. VILLALONA-CALERO, T. DUCKER, M. HOLASEK, J. NAJARIAN AND B. J. KENNEDY, Division of Oncology, Department of Medicine, and Departments of Therapeutic Radiology and Surgery, University of Minnesota Medical School, University Hospital, Minneapolis, Minnesota Med. Ped. Oncol., 20: 338-340, 1992 An increased incidence of malignancies has occurred in recipients of organ transplantation who are immunosuppressed. Although testicular cancers have been uncommon, seminomas are extremely rare. Two patients with long-standing diabetes mellitus and renal transplants developed clinical stage I seminoma of the testis. These patients posed a therapeutic problem with respect to the use of radiation therapy. In one, none was given because of a combination of kidney rejection and antibiotic-induced renal damage. The second patient received radiation therapy with shielding of the transplanted kidney. The surgical distortion of lymph node architecture increases the problems in the use of radiation therapy. Individual factors need to be considered in the use of postorchiectomy radiation therapy for seminoma in transplant patients. Editorial Comment: The authors report 2 cases of pure seminoma in an older age group following organ transplantation. Radiation therapy is problematic because of the transplant kidney. One patient was treated with the transplant kidney shielded. The authors discuss the factors that need to be considered with radiation therapy or chemotherapy in the transplant population. Jerome P. Richie, M.D.
Retroperitoneal Surgery in Patients With Nonseminomatous Testicular Cancer and Minimal Residual Tumor H. QVIST, S. D. FOSSA, s. Ous, H. H. LIEN, A. E. STENWIG AND K.-E. GIERCKSKY, Departments of Surgical Oncology, Medical Oncology and Radiotherapy, Diagnostic Radiology and Pathology, The Norwegian Radium Hospital, Oslo, Norway J. Surg. Oncol., 50: 220-223, 1992 In the period 1980-1991, 78 patients with advanced nonseminomatous testicular cancer underwent retroperitoneal lymphadenectomy for postchemotherapy residual masses <2 cm. To decrease the frequency of "dry ejaculation" in these patients with no or limited residual disease, the extent of dissection was reduced during the period, with bilateral dissections (49 cases, 1980-1986) being initially replaced by unilateral procedures (19 cases, 1983-1990) and subsequently by nerve-sparing techniques (10 cases, 1990-1991). As expected, a higher total number of lymph nodes was found in the retroperitoneal specimens after bilateral (44 (13-100)) than after unilateral (21 (7-35)) and nerve-sparing (18 (7-60)) procedures. The number of lymph nodes with pathological changes was low, with 3 (1-16)
after bilateral, 2 (1-9) after unilateral, and 2 (1-4) after nervesparing operations. Histological examination revealed only necrosis/fibrosis in 65% of the patients, elements of mature teratoma in 28%, and remnants of viable malignant tumor in 6%. There were no major postoperative complications. "Dry ejaculation" was reported by 84 % of the patients with bilateral operations, but was generally avoided after the unilateral (16%) and nerve-sparing (nil) procedures. After a mean follow-up of 83 (5-138) months, 6 patients have developed a recurrence, only one of them primarily in the retroperitoneal space. It is concluded that in patients with minimal residual retroperitoneal tumor, post chemotherapy lymphadenectomy using a unilateral or nerve-sparing technique seems to offer an effective therapeutic alternative with acceptable postoperative morbidity and preserved ejaculation. Editorial Comment: The authors report on 78 patients who during an 11-year period underwent surgical removal of post-chemotherapy retroperitoneal residual masses less than 2 cm. in diameter. Diameters of the lesions were perpendicular as measured on transverse computerized tomography before and after chemotherapy. The authors advocate a modified technique, either unilateral or nerve sparing, which has decreased the incidence of failure to ejaculate. This study adds to the growing body of evidence that unilateral or nerve sparing techniques can be effective therapeutic alternatives in select patients. Jerome P. Richie, M.D. Vascular Injury and Repair Associated With Retroperitoneal Lymphadenectomy for N onseminomatous Germinal Cell Tumours of the Testis J. F. MORIN, J. L. PROVAN, M.A. S. JEWETT AND F. M. AMELI, Divisions of Vascular Surgery and Urology, Department of Surgery, The Wellesley Hospital, University of Toronto, Toronto, Ontario Canad. J. Surg., 35: 253-256, 1992 Metastatic disease adjacent to major vascular structures in the retroperitoneum sometimes necessitates planned removal of portions of these vessels, or the vessels may inadvertently be injured when retroperitoneal lymphadenectomy is performed. In 78 patients who underwent retroperitoneal lymphadenectomy, 17 (22%) required vascular repair intraoperatively. The vena cava was most frequently involved (eight cases) followed by inadvertent injury to the renal arteries (five cases) or the infrarenal aorta (three cases). Resection of the infrarenal aorta was planned in two cases without postoperative complication. In six cases a resection of either the whole inferior vena cava or a portion of it was needed to remove all of the tumour. There were nine cases of inadvertent injury to the aorta, vena cava or a renal artery. The outcome after arterial repair was satisfactory with the exception of the inadvertent renal artery injuries, which required nephrectomy in three cases. Leg swelling was not a longterm sequela of either caval repair or resection. Editorial Comment: The authors discuss management of vascular injuries, including aortic, inferior vena caval and visceral vessel repairs, in 17 patients who required vascular procedures at retroperitoneal lymph node dissection. This article adds to the growing body of literature recognizing the need for knowledge and experience
ADRENAL, HYPERTENSI01"~~ REJ'.'.JA.L PHYSIOLGC\-Y AN.D RENAL PAILURE
in ,u1.dersta,uiing re1tr{m~,r1t01lle:H anatomical re:lationships, and fhe ability to deal with inadvertent injury to major vessels and :retroperitoneal structures at :ret:rope:ritoneal lymph node dis§ection. Jerome P. Richie, M.D.
potentially curative therapeutic even for heavily pretreated or cisplatin-refractory patients. Some degree of disease resistance to cisplatin can be overcome with dose escalation of platinum compounds. Patients with multiple recurrences of relapsed or refractory primary mediastinal germ cell tumors were not helped by this approach.
Salvage Therapy in Recurrent Testicular Cancer
Edito:rial Comment: This study evaluates high dose carboplatin and etoposide treatment in 40 consecutive patients, of whom 3 also received ifosfamide. AH patients underwent autologous bone marrow rescue. These were high risk patients, with primary media,stinal germ cell tumor or extensive disease. The authors achieved a 65% objective response rate, which is impressive for this heavily pretreated group. Toxicity is high with this type of aggressive therapy. Jerome P. Richie, M.D.
S.
Department of Medicine, Indiana University, Indianapolis, Indiana SAXMAN,
Sem. Oncol., 19: 143-147, 1992 No Abstract
Editorial Comment: This timely article reviews second and third line chemotherapy with ifosfamide and autologous bone marrow transplantation in cases that fail first line chemotherapy for nonseminomatous germ cell testicular cancer. The author discusses salvage chemotherapy, single agent activity, combination activity and dose intensive chemotherapy with rescue by autologous bone marrow t:ransplantation. Jerome P. Richie, M.D. Long-Term Outcome of Patients With Relapsed and Refractory Ge:rm Cell Tumors Treated With High-Dose Chemotherapy and Autologous Bone Marrow Rescue
E. R. BROUN, C.R. NICHOLS, P. KNEEBONE, §. D. WILLIAMS, P. J. LOEHRER, L. H. EINHORN AND G. J. K. TRICOT, Indiana University Hospital, Indianapolis, Indiana Ann. Intern. Med., 117: 124-128, 1992 Objective: To review the long-term outcome of patients with recurrent and refractory germ cell tumors treated with highdose chemotherapy and autologous bone marrow rescue. Design: Cohort study. Setting: A university hospital. Patients: Forty consecutive patients with recurrent or refractory germ cell tumors treated at Indiana University between September 1986 and June 1989. Interventions: Patients were treated with high-dose carboplatin (900 to 2000 mg/m 2 body surface area) and etoposide (1200 mg/m 2 ). Three patients also received ifosfamide (10 g/ m 2 ). All patients had autologous bone marrow rescue. Of the 40 study patients, 26 received two full courses of therapy. Measurements: Patient charts were reviewed to determine the rate and duration of complete and partial remission and the number of long-term, disease-free survivors. The influence of cisplatin-refractory disease and the site of the primary tumor on the incidence of remission and survival were also investigated. Results: Of the 40 study patients, 26 (65%) responded to treatment; 12 (30%) achieved a complete response, and 14 (35%) achieved a partial response. Of the 12 complete responders, 5 relapsed, and 1 died of treatment-related acute leukemia 27.5 months after treatment without evidence of germ cell cancer. Six (15%) of the original 40 patients, of whom 3 were refractory to cisplatin, remained in complete remission after at least 24 months of follow-up. Eight of 40 patients had primary mediastinal germ cell tumors with no complete remissions and a median survival of 2 months (range, 0.5 to 9.0 months). Conclusions: Treatment with high-dose carboplatin and etoposide in conjunction with autologous bone marrow rescue in patients with relapsed or refractory germ cell tumors is a
ADRENAL, HYPERTENSION, RENAL PHYSIOLOGY AND RENAL FAILURE Multiple Myeloma and Contrast Media C. S. McCARTHY AND J. A. BECKER, Department of Radiology,
State University of New York, Health Science Center at Brooklyn, Brooklyn, New York Radiology, 183: 519-521, 1992 Contrast media administered intravenously are still thought by many to be a major cause of acute renal failure (ARF) in myeloma patients. Recently, several authors found that the predominant risk factors of ARF in myeloma patients are hypercalcemia, dehydration, infection, and Bence Jones proteinuria rather than contrast media. In a review of seven retrospective studies of myeloma patients receiving contrast media, 4 76 patients were noted to have undergone 568 contrast media studies, with an ARF prevalence of 0.6%-1.25%. One large series showed the incidence of ARF after administration of contrast media to be 0.15% in the general population. Although the administration of contrast media to myeloma patients is not totally risk free, it may be performed if the clinical need arises and the patient is well hydrated.
Editorial Comment: This interesting article suggest§ that the incidence of acute :renal failu:re following administration of contrast material in patients with multiple myeloma has been overexaggeratect Indeed, if such a patient is not dehydrated o:r hype:rcalcemic and does not have massive Bence Jones proteinu:rfa he o:r she is unlikely to experience any untoward effects from the contrast medium. Proper preparation of the patient and appropriate use of the contrast material should allow the clinician to perform contrast studies in patients with multiple myeloma with low morbidity resulting. W. Scott McDougal, M.D. Clinical Profiles of Gross Hematuria in Autosomal Dominant Polycystic Kidney Disease
P. A. GABOW, I. DULEY AND A. M. JOHNSON, Department of Medicine, University of Colorado Health Sciences Center, Denver, Colorado Amer. J. Kidney Dis., 20: 140-143, 1992