Cyclophosphamide Associated Bladder Cancer--A Highly Aggressive Disease: Analysis of 12 Cases

Purpose

We gained knowledge of the etiology, treatment and prevention of cyclophosphamide associated urothelial cancer.

Materials and Methods

The medical records of 6 men and 6 women (mean age 55 years) with cyclophosphamide associated bladder cancer were reviewed.

Results

All tumors were grade 3 or 4 transitional cell carcinoma. Of the 5 patients initially treated with endoscopic resection alone only 1 is alive without disease. Of The 6 patients who underwent early cystectomy 4 were alive at 24 to 111 months. The remaining patient with extensive cancer underwent partial cystectomy for palliation and died 3 months later.

Conclusions

Cyclophosphamide associated bladder tumor is an aggressive disease. However, long-term survival is possible when radical cystectomy is performed for bladder tumors with any sign of invasion and for recurrent high grade disease, even when noninvasive.     

Incidence and Risk Factors for Postoperative Urinary Retention in Total Hip Arthroplasty Performed Under Spinal Anesthesia

Background

The objective of this study is to determine the risk factors for postoperative urinary retention (POUR) following total hip arthroplasty (THA) under spinal anesthesia.

THE FATE OF PATIENTS WITH LOCALLY ADVANCED BLADDER CANCER TREATED CONSERVATIVELY WITH NEOADJUVANT CHEMOTHERAPY, EXTENSIVE TRANSURETHRAL RESECTION AND RADIOTHERAPY: 10-YEAR EXPERIENCE

Purpose

We asses the results of bladder preservation for infiltrating cancer. The potential for neoadjuvant chemotherapy followed by extensive transurethral resection and radiotherapy was evaluated in 40 patients with T2-T4a G2-G3 bladder carcinoma.

Materials and Methods

From 1983 to 1995, 40 patients with bladder cancer underwent bladder sparing treatment, consisting of neoadjuvant chemotherapy, extensive transurethral resection and radiotherapy. Most patients had T3G3 cancer. A deep transurethral resection biopsy was performed before and after chemotherapy, and an extensive transurethral resection was repeated at the end of radiotherapy. Of the patients 30 received cisplatin and methotrexate and 10 also received vinblastine. Total dose of radiotherapy was 60 to 65 Gy. Recurrent superficial tumors were treated transurethrally. Radical cystectomy was considered for persistent or recurrent invasive disease.

Results

Complete response occurred in 19 patients (47.5%) after chemotherapy, and in 8 patients after transurethral resection and radiotherapy (67.5%). Within 10 years 8 responding patients (30%) had local recurrences and 3 underwent cystectomy. Of the patients 14 (35%) are alive, including 13 with no evidence of disease (mean survival 65 months), 5 died of unrelated disease and 21 (52.5%) died of distant metastases (mean survival 28 months). Of the 21 patients 14 had residual tumor after radiotherapy, 3 presented with distant metastases after vesical infiltrating recurrence and 4 had distant metastases in the absence of locoregional recurrence. In 22 patients (55%) the bladder was salvaged. Patients with complete response to chemotherapy had a low risk for recurrent infiltrating tumors and metastases.

Conclusions

Complete tumor control was maintained at 5 years in more than 50% of the patients treated conservatively. Bladder salvage is feasible in select patients.     

TRANSVERSE RETUBULARIZED ILEUM: EARLY CLINICAL EXPERIENCE WITH A NEW SECOND LINE MITROFANOFF TUBE

Purpose

Transverse retubularization of small ileal segments has been described as a new time and labor saving variation of the Mitrofanoff principle in a dog model with good functional results. We report our initial clinical experience with this technique.

Materials and Methods

From May 1996 through January 1997 a new technique of channel formation for intermittent catheterization was applied in 9 children (1 to 16 years old) and 7 adults (18 to 56) with various abnormalities of the lower urinary tract. The new method was used in primary reconstruction of the lower urinary tract and in revision procedures. An ileal segment 2 cm. long was excised. The bowel wall was opened longitudinally about 1 cm. from the mesentery. The resulting rectangle was retubularized over a 14F catheter in transverse direction. The longer portion of the tube was implanted submucosally into the native bladder, the augmented bladder or an intestinal reservoir. The shorter portion was used to form the stoma. In 4 patients we created a double tube.

Results

Of the patients 13 (81%) are completely continent day and night with easy catheterization postoperatively. In 2 cases of tunnel failure continuous leakage required reimplantation of the intact ileal tube to achieve continence. Minor leakage with bladder fullness in an 11-year-old boy could be obviated by adjusting the interval of catheterization.

Conclusions

With the advantage of constant availability, minimal loss of bowel, relative simplicity (no mesentery interfering with implantation, high tube mobility), minimized risk of stone formation (no staples), reliable continence (no leak point) and easy catheterization (longitudinal folds), this straightforward technique is an excellent second choice use of the Mitrofanoff principle.     

INTRAVESICAL CAPSAICIN AS A TREATMENT FOR REFRACTORY DETRUSOR HYPERREFLEXIA: A DUAL CENTER STUDY WITH LONG-TERM FOLLOWUP

Purpose

We described the long-term outcome of intravesical capsaicin instillations in patients with urinary incontinence and compared its efficacy in 2 similar populations of patients with multiple sclerosis in a dual center study.

Materials and Methods

During 5 years 79 patients with intractable urinary incontinence have been treated with intravesical capsaicin. The majority of patients had spinal cord disease due to multiple sclerosis but 4 were neurologically normal. Cystometry was performed before and 4 to 6 weeks after intravesical instillation of 1 to 2 mmol./l. of capsaicin in 30% ethanol in saline. Instillations of vehicle (30% ethanol in saline) alone were carried out in 5 patients.

Results

In patients with phasic detrusor hyperreflexia complete continence was achieved in 44%, satisfactory improvement occurred in 36% and treatment failed in 20%. Clinical benefit from a single instillation lasted 3 to 6 months and was repeated in some patients with similar improvement. Capsaicin was ineffective in patients with poor bladder compliance and in neurologically normal patients with sensory urgency and detrusor instability. There was no clinical or urodynamic improvement in patients treated with vehicle alone. There have been no long-term complications.

Conclusions

Our study shows that repeated instillations of intravesical capsaicin are effective in treatment of patients with detrusor hyperreflexia due to spinal cord disease and that effectiveness of the treatment persists at least 3 to 5 years.     

BLADDER CARCINOMA WITH LYMPHOEPITHELIOMA-LIKE DIFFERENTIATION: A REPORT OF 9 CASES

Purpose

Lymphoepithelioma-like carcinoma of the bladder is rare with only 14 cases reported to date. We report 9 additional cases with long-term followup.

Materials and Methods

All 713 patients with an initial diagnosis of bladder tumor in western Sweden from 1987 through 1988 were prospectively registered and followed. A clinical and histopathological review was performed on 816 bladder tumors from the files of the oncology department treated between 1962 and 1989.

Results

Of 9 patients with stages T2M0-T3M0 cancer treated with locoregional therapy 6 with either pure or predominant lymphoepithelioma-like carcinoma pattern had no evidence of disease after a median observation of 4 years (range 1 to 18) and 3 with focal lymphoepithelioma-like carcinoma pattern died of disease after 9 to 68 months.

Conclusions

Lymphoepithelioma-like carcinoma is diagnosed in less advanced stages and has a more favorable long-term prognosis than other types of undifferentiated invasive carcinomas of the bladder. Our data and review of the literature suggest that lymphoepithelioma-like carcinoma should be treated stage by stage like other bladder carcinomas.     

DESMOPRESSIN FOR NOCTURNAL INCONTINENCE IN THE SPINA BIFIDA POPULATION

Purpose

We report our experience with the use of desmopressin in the spina bifida population that is dry during the day but wet at night.

Materials and Methods

From 1994 to 1996, 18 patients with myelodysplasia were treated with desmopressin for persistent nocturnal enuresis. Initial dose was 40 mcg. before bedtime, decreased by intervals of 10 mcg. every 3 weeks. Patients were kept on the minimum dose required to keep them dry. We reviewed morning catheterized volumes, side effects and dosages needed to stay dry, and compared augmented patients with nonaugmented patients.

Results

Of 18 patients 14 (78%) reported marked improvement in nocturnal enuresis. Of 6 augmented patients 5 (83%) are dry compared to 9 of 12 nonaugmented patients (75%). There were no adverse side effects from the use of desmopressin. Average dose to stay dry was 20 mcg. for augmented and 30 mcg. for nonaugmented patients. Of the 4 patients who had persistent nocturnal incontinence despite desmopressin 3 (75%) became dry with a single catheterization in the middle of the night.

Conclusions

Desmopressin is successful in treating nocturnal enuresis in the spina bifida patient with diurnal continence.     

Coincidence of Bladder and Prostate Cancer

Purpose

Diagnostic bias can be a problem when determining the coincidence of prostate and bladder cancer. The objective of this study was to calculate the coincidence of bladder and prostate cancer after correcting for diagnostic bias.

Materials and Methods

The cancer registry at 1 medical institution provided the number of patients diagnosed with prostate or bladder cancer between 1989 and 1994. The expected incidences of bladder and prostate cancer were calculated using 1987 to 1991 Surveillance, Epidemiology and End Results data. Diagnostic bias was determined by reviewing the charts of all patients with both types of cancer.

Results

Of 100 patients with a diagnosis of bladder cancer 25 (25%) also had prostate cancer and 25 of 651 (3.8%) with prostate cancer also had bladder cancer. Diagnostic bias was involved in diagnosing bladder cancer in 3 of 25 patients and prostate cancer in 7 of 25. When these patients are eliminated from the incidence data, the rate of prostate cancer in those with bladder cancer is 17% and the rate of bladder cancer in those patients with prostate cancer is 3.2%. In an age, sex and race matched general population the expected rates of prostate and bladder cancer were 0.9 and 0.18%, respectively.

Conclusions

The rate of bladder cancer in patients with prostate cancer is 18 times higher (p <0.01) and the rate of prostate cancer in those with bladder cancer is 19 times higher (p <0.01) than expected. These rates do not include cases involving diagnostic bias.     

Neurogenic Bladder Dysfunction Due to Myelomeningocele: Neonatal Versus Childhood Treatment

Purpose

We sought to determine whether the neonatal institution of treatment of neurogenic bladder dysfunction in myelomeningocele patients at high risk of urinary tract deterioration improves renal and bladder outcome.

Materials and Methods

We reviewed the records of patients with bladder dysfunction believed to be at high risk for renal deterioration based on urodynamic studies. All patients were treated with clean intermittent catheterization. We compared rates of urinary infection, hydronephrosis, reflux, continence and surgical intervention in 46 patients in whom treatment was started in year 1 of life and 52 treated after age 4 years.

Results

Renal outcome was similar in both groups with persistent hydronephrosis in 6 of 46 patients (13%) and 7 of 52 (14%), respectively. However, significantly fewer bladder augmentation procedures were required in patients started on treatment during year 1 of life (5 of 46, 11% versus 14 of 52, 27%, p <0.05).

Conclusions

In addition to any psychological benefit, early intervention with clean intermittent catheterization in children with neurogenic bladder dysfunction may help to prevent irreversible bladder dysfunction and limit the need for bladder augmentation.     

The Use of Urine Cytology for Diagnosing Bladder Cancer in Spinal Cord Injured Patients

Purpose

The diagnosis of bladder cancer in spinal cord injured patients is complicated by inflammatory changes caused by long-term indwelling catheters, which make cystoscopic followup difficult. We evaluated cytology as an aid in diagnosing bladder cancer in spinal cord injured patients.

Materials and Methods

The charts of 208 spinal cord injured patients were reviewed retrospectively from January 1988 to July 1995 to define the value of cytology in the diagnosis of bladder cancer in this population. In all patients at least 1 urine cytology study was done less than 3 months before bladder biopsy. We examined 272 bladder biopsies (several patients underwent more than 1 biopsy at least 1 year apart) with 1 to 6 cytology studies done before biopsy.

Results

Cytology results were classified as negative-no malignant cells, inflammation or benign urothelial cells, reactive-atypia or atypical reactive and suspicious-atypical suspicious, keratinizing squamous metaplasia, suspicious for cancer, cancer of dysplastic. A total of 960 cytology specimens was obtained before the 272 biopsies (average 3 before each biopsy). Of 17 patients with cancer 12 had at least 1 prior suspicious urine cytology result. The sensitivity and specificity of cytology were 71 and 97%, respectively, when evaluating only patients with suspicious findings.

Conclusions

The high sensitivity and specificity of multiple cytology studies in this population suggest that cytology is a useful adjunct to improve the detection of bladder cancer in spinal cord injured patients with chronic (longer than 5 years) indwelling catheters. We recommend a minimum of yearly cytology in all high risk spinal cord injured patients with subsequent biopsies in all patients with any suspicious finding.     

Combined Modified Rectus Fascial Sling and Augmentation Ileocystoplasty for Neurogenic Incontinence in Women

Purpose

We assessed results of a combined modified rectus fascial sling procedure and augmentation ileocystoplasty in women with neurogenic urinary incontinence.

Materials and Methods

We prospectively evaluated 21 patients (mean followup 28.6 months).

Results

A total of 20 patients (95.2%) was dry during the day on intermittent catheterization and none had difficulty with catheterization. Subsequently surgery was necessary in 1 case for perforation of the augmented bladder.

Conclusions

A combined modified rectus fascial sling procedure and augmentation ileocystoplasty are safe and effective when all available pharmacological treatments and clean intermittent catheterization have failed.     

Morphological and Functional Factors Predicting Bladder Deterioration After Spinal Cord Injury

Purpose

We investigated factors predictive of morphological and functional deterioration of the bladder in patients with spinal cord injury.

Materials and Methods

Urological evaluation, including excretory urography and urodynamic studies, was performed once a year in 66 patients. Bladder compliance was used as an index of bladder function.

Results

Mean age of the patients with worsening bladder form and function was significantly greater than that of those with no change. In patients with worsening bladder function intermittent catheterization was performed less frequently and mean catheterization volume was greater compared to those with improvement and no change. Catheterization was less frequent and at long intervals in patients with a high urethral closure pressure.

Conclusions

High storage pressure due to a high urethral closure pressure is believed to cause deterioration of bladder form and function.     

Holmium laser enucleation of the prostate is an effective treatment in patients with concomitant bladder diverticula and outlet obstruction

Introduction

Bladder diverticula can be congenital or secondary to benign prostatic hyperplasia with bladder outlet obstruction, and be a source of high postvoid residuals prompting surgical intervention. We sought to evaluate the outcomes of patients with bladder diverticula undergoing holmium laser enucleation of the prostate (HoLEP) for bladder outlet obstruction.

Methods

We retrospectively reviewed HoLEP patients with at least one bladder diverticulum at two high volume institutions. All cases were performed in similar fashion. Preoperative, perioperative, and postoperative patient variables were obtained and assessed.

Results

Of 2746 HoLEP patients, 51 were diagnosed with bladder diverticula before surgery. Mean prostate size was 80.8 ± 50.0 g and mean diverticulum size (largest if multiple) was 5.5 ± 2.6 cm. Preoperatively, urinary retention requiring catheterization was present in 28 (55%) patients. In the remainder, mean preoperative AUASI was 19.7, peak flow 7.2 ml/s, and post-void residual (PVR) 365 ml. At most recent follow-up (mean 12.2 months), mean total AUASI was 8.6, peak flow 27.1 ml/s, and PVR 145 ml with 71, 276, and 221% improvement, respectively. All patients were voiding and none required catheterization. Only three (6%) patients required diverticulectomy at a mean of 15.2 months after HoLEP for the following indications: hematuria (one patient) and urinary retention (two patients).

Conclusions

HoLEP is an effective method of outlet obstruction treatment in patients with bladder diverticula. Most patients, even with large diverticula, do not require further treatment after the outlet obstruction has been relieved and can avoid more invasive surgical interventions.

     

Urinary microbes and postoperative urinary tract infection risk in urogynecologic surgical patients

Introduction and hypothesis

Women have a 20% risk of developing a urinary tract infection (UTI) following urogynecologic surgery. This study assessed the association of postoperative UTI with bacteria in preoperative samples of catheterized urine.

Methods

Immediately before surgery, vaginal swabs, perineal swabs, and catheterized urine samples were collected, and the V4 region of the 16S ribosomal RNA (rRNA) gene was sequenced. The cohort was dichotomized in two ways: (1) standard day-of-surgery urine culture result (positive/negative), and (2) occurrence of postoperative UTI (positive/negative). Characteristics of bladder, vaginal, and perineal microbiomes were assessed to identify factors associated with postoperative UTI.

Results

Eighty-seven percent of the 104 surgical patients with pelvic organ prolapse/urinary incontinence (POP/UI) were white; mean age was 57 years. The most common genus was Lactobacillus, with a mean relative abundance of 39.91% in catheterized urine, 53.88% in vaginal swabs, and 30.28% in perineal swabs. Two distinct clusters, based on dispersion of catheterized urine (i.e., bladder) microbiomes, had highly significant (p?<?2.2–16) differences in age, microbes, and postoperative UTI risk. Postoperative UTI was most frequently associated with the bladder microbiome; microbes in adjacent pelvic floor niches also contributed to UTI risk. UTI risk was associated with depletion of Lactobacillus iners and enrichment of a diverse mixture of uropathogens.

Conclusions

Postoperative UTI risk appears to be associated with preoperative bladder microbiome composition, where an abundance of L. iners appears to protect against postoperative UTI.

     

Accuracy and precision of a new portable ultrasound scanner,the Biocon-700, in residual urine volume measurement

Introduction and hypothesis

The aim of this study was to examine the accuracy of a new portable abdominal ultrasound (US) machine (Biocon-700, Mcube Technology, Seoul, Korea) for measuring postvoid residual (PVR) urine.

Method

One-hundred and twenty-five patients with voiding problems underwent PVR measurements, which were compared with the postvoid bladder volume measurements obtained by catheterization within 5 min in the same patients. Accuracy was assessed by comparing the two methods, and correlation coefficients were obtained.

Result

The Pearson’s correlation coefficient between PVR volume as measured by US and by catheterization was 0.872 (R ² ?=?0.76). The mean difference was 23.59?±?37.32 ml (95% confidence interval, 17.5–30.65 ml), and the absolute scan error tended to increase with a greater amount of catheterized residual urine volume (R ²?=?0.49).

Conclusions

Accuracy of the Biocon-700 scanner is as good as catheter assessments of residual volume and is therefore a sufficient alternative to catheterization for determining residual urine volume.

     

PHOTODYNAMIC THERAPY USING PORFIMER SODIUM AS AN ALTERNATIVE TO CYSTECTOMY IN PATIENTS WITH REFRACTORY TRANSITIONAL CELL CARCINOMA IN SITU OF THE BLADDER

Purpose

Photodynamic therapy combines a photosensitizer, such as porfimer sodium (Photofrin), with red laser light (630 nm.) to destroy cancer cells. Investigators have reported the effectiveness of photodynamic therapy in the treatment of patients with recurrent superficial bladder cancer. We assess the safety and efficacy of 1 or 2 photodynamic treatments using porfimer sodium and controlled uniform laser light (630 nm.) as an alternative to cystectomy in patients with refractory vesical carcinoma in situ of the bladder.

Materials and Methods

A total of 36 patients with carcinoma in situ were treated with whole bladder photodynamic therapy as an alternative to cystectomy. In all patients at least 1 course of bacillus Calmette-Guerin (BCG) had failed. Each patient received a single whole bladder photodynamic therapy treatment, consisting of 2 mg./kg. porfimer sodium intravenously followed 40 to 50 hours later by intravesical red light (630 nm.) at 15 J./cm.². Post-photodynamic therapy evaluations included weekly telephone contact to assess acute adverse reactions, and assessment of efficacy and bladder toxicity at 3 months and quarterly thereafter.

Results

At initial clinical evaluation at 3 months 58% of the patients had a complete response as indicated by negative cystoscopy, bladder biopsy and urine cytology but in 42% treatment failed. At a mean followup of 12 months (range 9 to 48) 10 of the 21 complete responders had recurrence for an overall durable response rate of 31%. Fourteen patients subsequently underwent cystectomy for persistent carcinoma in situ (12) and carcinoma in situ recurrence (2). Of the 36 patients 7 experienced bladder contracture.

Conclusions

The initial results are encouraging for a single whole bladder photodynamic treatment of patients in whom prior intravesical therapy for carcinoma in situ has failed. While followup is short, porfimer sodium photodynamic therapy appears potentially promising as an alternative to cystectomy in patients with refractory carcinoma in situ.     

PREDICTIVE VALUE OF p53 AND pRb IMMUNOSTAINING IN LOCALLY ADVANCED BLADDER CANCER TREATED WITH CYSTECTOMY

Purpose

We elucidate the association between altered immunostaining for retinoblastoma gene protein (pRb) and p53 nuclear proteins, and cancer specific death in patients treated with cystectomy for locally advanced bladder cancer.

Materials and Methods

The hospital records of 173 patients treated with cystectomy for advanced urothelial bladder cancer between 1967 and 1992 were retrospectively reviewed. Representative biopsies obtained before treatment were sectioned and stained using the standard immunohistochemical technique with antibody DO-7 (p53) and antibody PMG3-245 (pRb). A tumor was considered to have an altered p53 expression if 20% or more of tumor cells exhibited nuclear staining. Similarly, if no tumor cell had nuclear immunostaining the tumor was considered to have an altered pRb expression.

Results

An altered expression was observed for p53 in 98 tumors (57%) and for pRb in 60 (35%). In a proportional hazards analysis no association was found between an altered expression of pRb or p53 and cancer specific death. This finding was also true in another analysis when the results of immunostaining for pRb and p53 were combined.

Conclusions

An altered expression for pRb and/or p53 was not correlated to cancer specific death. Thus, these parameters could not be used as predictors of treatment outcome after cystectomy for locally advanced bladder cancer.     

VESICOURETHRAL DYSFUNCTION ASSOCIATED WITH MULTIPLE SCLEROSIS: CLINICAL AND URODYNAMIC PERSPECTIVES

Purpose

We investigate the association of clinical and urodynamic findings with corresponding clinical grade and possible predictors of clinical grade of multiple sclerosis (MS).

Materials and Methods

A total of 90 patients, 28 to 62 years old (mean age 45.8 +/− 12.1), with the clinical syndrome of MS were consecutively and prospectively studied. All patients were subjected to detailed video urodynamic evaluation and electromyography of the external urethral sphincter.

Results

Urodynamic evaluation revealed detrusor hyperreflexia in 52 patients (57.7%), detrusor external sphincter dyssynergia in 27 (30%) and hypocontractility or areflexia of the detrusor in 15 (16.6%). Residual urine varied widely from 50 to 900 ml. Decreased compliance with areflexia was seen in 5 patients (5.5%) and nonrelaxing sphincter (but not contracting) with bladder hypercontractility was noted in 9 (10%). Statistical analysis followed comparison of 2 proportions. When patients with a less severe form (grades 1 and 2) were differentiated from those with a more severe form of MS (grade 3), we observed a significant difference only in incontinence, high post-void residual, leg spasticity, urinary stones, hydronephrosis, type 3 detrusor external sphincter dyssynergia, no electromyography activity and positive sharp waves. The variables with the highest predictive value between the groups were urinary stones, sepsis, type 3 detrusor external sphincter dyssynergia and no electromyography activity of the external urethral sphincter (100%).

Conclusions

Proper identification of the bladder and external urethral sphincter status, especially exclusion of detrusor overactivity or a dyssynergic response of the external urethral sphincter, will prevent complications that may result in deterioration of quality of life.     

The Treated Natural History of High Risk Superficial Bladder Cancer: 15-year Outcome

Purpose

The long-term outcome of patients with high risk superficial bladder cancer is unknown. We report the results of 15 years of followup of high risk patients treated initially with aggressive local therapy, including transurethral resection alone or combined with intravesical bacillus Calmette-Guerin.

Materials and Methods

Between 1978 and 1981, 86 high risk patients enrolled in a randomized study of transurethral resection alone or with intravesical bacillus Calmette-Guerin for superficial bladder cancer. Of these patients 81% had diffuse carcinoma in situ and 44% had stage T1 tumors before entry into the study. Patients were followed until death (61%) or until the present time (median followup 184 months).

Results

Disease stage progressed in 46 patients (53%) and 31 (36%) eventually underwent cystectomy for progression reference 28 or refractory carcinoma in situ reference 3, while 18 (21%) had upper tract tumors at a median of 7.3 years. The 10 and 15-year disease specific survival rates were 70 and 63%, respectively. At 15 years 34% of patients overall were dead of bladder cancer, 27% were dead of other causes and 37% were alive, including 27% with an intact functioning bladder.

Conclusions

Despite aggressive local therapy patients with high risk superficial bladder cancer are at lifelong risk for development of stage progression and upper tract tumors. A third of patients are at risk for death from bladder cancer, justifying careful and vigilant long-term followup. These results support the use of initial aggressive local therapy in patients with high risk superficial bladder cancer.     

SECOND PRIMARY MALIGNANCIES IN T1-3N0 PROSTATE CANCER PATIENTS TREATED WITH RADIATION THERAPY WITH 10-YEAR FOLLOWUP

Purpose

The risk of patients with prostate cancer to have second primary malignancies is unclear. Population and autopsy based studies have shown no increased risk, which is at variance with several institutional analyses. A retrospective review was performed with comparison to expected cancer data from the Connecticut Tumor Registry.

Materials and Methods

Records of a cohort of prostate cancer patients treated with staging pelvic lymphadenectomy and definitive radiotherapy between November 1, 1974 and July 7, 1987 were reviewed. Median potential followup from date of diagnosis was 10.9 years.

Results

Of the 164 patients 150 (91.5%) had followup to death or to August 1995, with data available in part on 4 of the remaining patients. In 43 patients 51 second primary malignancies developed. Increased frequency of lymphomas, and kidney, bladder and rectal lesions (all p <0.001) was observed concurrently with diagnosis of prostate cancer, although this may be due to bias since full staging for the prostate cancer may have led to their diagnosis. An increased frequency of renal lesions in the 1 to 4-year followup period (p = 0.032) also was observed. Two sarcomas and a leukemia were putatively radiation induced but their frequency was not significantly different from the comparison baseline.

Conclusions

Much of the apparent increase in second primary malignancies associated with prostate cancer noted by some authors may be attributed to bias in the staging process. Renal cancers may occur more frequently in patients with prostate cancer but the distribution of these lesions is inconsistent with a field defect mechanism of cancer induction.