Pretherapeutic Extraperitoneal Laparoscopic Staging of Bulky or Locally Advanced Cervical Cancer

Background

To assess the safety, feasibility, and impact on survival of extraperitoneal para-aortic lymphadenectomy in the staging of patients with bulky or locally advanced cervical cancer.

Materials and Methods

Between August 2001 and October 2009, 87 consecutive patients (median age 51 years) with bulky or locally advanced cervical cancer underwent extraperitoneal laparoscopic infrarenal aortic and common iliac dissection as a pretherapeutic staging procedure. Data on pathologic findings, details of surgery, postoperative complications, and disease status at follow-up were collected.

Results

The median operating time was 150 min (range 60–255 min). The mean (± standard deviation) para-aortic nodal yield was 15.5 ± 8.1 (range 4–62). In none of the patients, conversion to the transperitoneal approach or laparotomy was necessary. Histological examination revealed metastasis in 13 patients (macroscopic disease 10, microscopic disease 3). After a median follow-up of 33.4 months (range 13.3–65.9 months), 73.6% of patients were free of disease and 1.1% were alive with disease, 19.5% died from cervical cancer, and 3.3% died from other causes. After a follow-up of 3 years, no deaths or recurrences were documented, with an overall survival rate of 74.8% (95% CI 62.8%–83.4%) and disease-free survival of 86% (95% CI 74.7%–92.5%). There were no significant differences in overall survival and disease-free survival between patients with positive and negative para-aortic lymph nodes.

Conclusion

The extraperitoneal laparoscopic para-aortic lymphadenectomy for pretherapeutic surgical staging in cervical cancer is a safe and feasible procedure that should be considered as a tool to identify lymph node positive patients who require extended-field radiation and/or chemotherapy.     

Laparoscopic extraperitoneal aortic dissection: does single-port surgery offer the same possibilities as conventional laparoscopy?

Background

This study aimed to demonstrate the feasibility of single-port surgery (SPS) for laparoscopic extraperitoneal aortic dissection.

Methods

From December 2010 to April 2011, all patients referred for aortic lymph node staging underwent a laparoscopic extraperitoneal approach with a single-port device. The extraperitoneal approach was performed using only one 3–4?cm incision on the left side. Gelpoint from Applied Medical (Rancho Santa Margarita, CA, USA), a 10-mm 0° laparoscope, and 5-mm standard instruments were used.

Results

The study enrolled 13 patients. Aortic dissection was complete for 11 patients and incomplete for 2 patients. The mean lymph node count was 16 (range, 7–40). The mean blood loss was 40.7?ml (range, 0–100?ml), and no transfusion was necessary. The mean hospital stay was 1.7?days (range, 1–4?days) for this series.

Conclusion

The study results demonstrate the feasibility of single-port-access laparoscopy for extraperitoneal aortic lymphadenectomy. The lymph node count was similar to that described in the published experience of conventional laparoscopic extraperitoneal dissection. This preliminary report shows that SPS is usable for extraperitoneal aortic dissection and that it is possible to perform this procedure using only one skin incision compared with the three or four incisions required for conventional laparoscopy.     

Staging Pelvic Lymphadenectomy for Localized Carcinoma of the Prostate: A Comparison of 3 Surgical Techniques

Purpose

Pelvic lymph node dissection continues to be the most effective method of staging extracapsular adenocarcinoma of the prostate. Three principal methods of pelvic lymph node dissection are currently available: intraperitoneal laparoscopic, minilaparotomy and the standard open modified pelvic lymph node dissection. In the hope of determining some of the relative advantages and disadvantages associated with each technique a comparison of these approaches was made.

Materials and Methods

Of 68 patients with histologically proved clinical stage T3N0M0 adenocarcinoma of the prostate who underwent staging pelvic lymph node dissection 38 underwent modified open, 19 laparoscopic and 11 minilaparotomy procedures. The efficacy of node sampling, resource expenditure and complication rates were compared among the 3 groups.

Results

No statistically significant difference was observed in terms of the number of nodes harvested with each technique. Resource expenditure analysis revealed significantly increased operative and procedural time requirements for laparoscopic pelvic lymph node dissection compared to modified open and minilaparotomy procedures. Total hospital stay was significantly longer for the modified open pelvic lymph node dissection (mean plus or minus standard deviation 6.5 +/− 0.9 days) compared to the laparoscopic (mean 2.7 +/− 1.1 days) and minilaparotomy (mean 3.3 +/− 0.2 days) groups. Multiple complications, such as ileus, lymphocele and urinary retention, were observed in the modified open pelvic lymph node dissection group. No complications were noted in the other 2 groups.

Conclusions

Comparison of laparoscopic and minilaparotomy procedures to modified open pelvic lymph node dissection revealed similar staging efficacy, and decreased total hospital stay and complications. Laparoscopic pelvic lymph node dissection required increased operative time. Minilaparotomy should become the open surgical procedure of choice for pelvic lymph node dissection, particularly at institutions where the laparoscopy learning curve, equipment expense and time disadvantages cannot be overcome.     

Extraperitoneal endoscopic pelvic lymph node dissection.

Laparoscopic pelvic lymphadenectomy has been found to be efficacious in the staging of genitourinary cancers. Technological advances in endoscopic instrumentation have allowed an extraperitoneal approach to be performed. Presented are two patients who underwent an extraperitoneal endoscopic lymph node dissection as a staging procedure for prostatic carcinoma. Technical aspects of the procedure and advantages relative to the laparoscopic intraperitoneal approach are discussed.     

Hip and Knee Replacement as a Relative Contraindication to Laparoscopic Pelvic Lymph Node Dissection

Purpose

We investigated the effect of lower extremity joint prostheses on subsequent laparoscopic pelvic lymph node dissection.

Materials and Methods

We reviewed the records and pathology studies of 5 patients who underwent laparoscopic pelvic lymph node dissection subsequent to total hip or knee replacement from 1990 through 1995.

Results

Four of the 5 laparoscopic operations were complicated, 3 were unsuccessful in obtaining bilateral pelvic lymph nodes and 2 required conversion to an open procedure. Examination of the lymph nodes revealed sinus histiocytosis in the 4 cases in which nodal tissue was removed.

Conclusions

The increased risk of complications in certain patients with lower extremity joint prostheses may contraindicate attempted laparoscopic pelvic lymph node dissection.     

Lymph node density vs. the American Joint Committee on Cancer TNM nodal staging system in node-positive bladder cancer in patients undergoing extended or super-extended pelvic lymphadenectomy

Purpose

We compared the prognostic value of the American Joint Committee on Cancer (AJCC) TNM nodal staging system with that of lymph node (LN) density in patients with LN-positive bladder cancer who received extended or super-extended pelvic lymphadenectomy.

Anatomical Basis for Pelvic Lymphadenectomy in Prostate Cancer: Results of an Autopsy Study and Implications for the Clinic

Purpose

Pelvic lymphadenectomy remains the most reliable method to prove lymph node metastases in prostate cancer. However, evaluation of lymphadenectomy to be complete and sufficient as judged by the number of removed lymph nodes is hampered by the fact that, in contrast to other malignancies (for example breast or gastric cancer), anatomical studies investigating the regular and average number of pelvic lymph nodes are missing. We established an anatomically based standard for pelvic lymphadenectomy.

Materials and Methods

Standard pelvic lymphadenectomy was performed on 30 human cadavers and 59 consecutive patients with clinically organ confined prostate cancer during radical retropubic prostatectomy. Number, size and topography of the lymph nodes were noted separately for each anatomical region of both iliac fossas.

Results

The mean number of lymph nodes removed in the autopsy series plus or minus standard deviation (22.7 plus/minus 10.2, range 8 to 56) was nearly identical to that from patients with prostate cancer (20.5 plus/minus 6.6, range 10 to 37) but striking interindividual differences were observed. Patients with prostate cancer demonstrated enlarged nodes regardless of whether they did or did not contain tumor. Interestingly, pelvic lymph node metastases were more common on the left side regardless of the primary tumor site.

Conclusions

Approximately 20 pelvic lymph nodes may serve as a guideline for a sufficient standard pelvic lymph node dissection. Lymphadenopathy in prostate cancer patients is not always a result of metastases but, rather, hyperplastic or regressive alterations. A preferential distribution of lymph node metastases along the left iliac vessels regardless of the primary tumor site in the prostate warrants further investigation.     

Staging laparoscopic pelvic lymphadenectomy in prostate cancer

OBJECTIVE: To assess the results of transperitoneal laparoscopic pelvic lymphadenectomy as a separate staging procedure in patients with early prostate cancer. PATIENTS AND METHODS: The results were reviewed from the first 27 patients with prostate cancer admitted for laparoscopic lymphadenectomy between January 1994 and March 1998. Initially, all patients with a negative bone scan and either a negative computed tomography or negative magnetic resonance scan were admitted for laparoscopic staging. After several reports detailing ways of reducing the number of negative lymphadenectomy operations, from July 1996 only those patients with a preoperative prostate specific antigen (PSA) serum level of >10 ng/mL were admitted to the study. All procedures were performed by one experienced laparoscopic surgeon. A radical retropubic prostatectomy was performed as a separate procedure by a consultant urologist within 2 weeks. The effectiveness of the staging operation was analysed by assessing the nodal yield, and the results, including operative duration, complications and length of stay, were compared with other published series. Further analysis was provided by reviewing the PSA levels, Gleason grade sum and clinical digital staging. RESULTS: The nodal yield was similar to that published in series from other institutions, with a median (range) of 6.5 (0-12). However, the operation was significantly quicker, at a median (range) of 55 (40-110) min for a bilateral dissection. There were only minor complications, with no detectable reduction in complications with experience; the median (range) postoperative stay was 1 (1-4) days. Two of the 27 patients had metastatic disease within the lymph nodes. If a PSA level of >10 ng/mL had been instituted as an entry criteria at the start of the study, six patients would have been excluded and thus the positive lymphadenectomy rate would have been two of 21 patients (10%). Of 54 patients eligible to enter the study, half did not require a lymphadenectomy. CONCLUSIONS: Laparoscopic transperitoneal lymphadenectomy can be performed expeditiously and safely. A two-stage procedure in some patients with prostate cancer is the management of choice. Attention to carefully closing the peritoneum with sutures minimizes any retropubic adhesions and no problems associated with the staging procedure were encountered during subsequent radical retropubic prostatectomy. In efforts to reduce negative staging lymphadenectomies, the exclusion values for staging should not be set too high (PSA and Gleason grading sum). Such practice, despite a relatively safe staging procedure, would lead to unnecessary radical prostatectomy.     

Technical Feasibility of Laparoscopic Lateral Pelvic Lymph Node Dissection for Patients with Low Rectal Cancer after Concurrent Chemoradiation Therapy

Aim

To test the technical feasibility of laparoscopic lateral pelvic lymph node dissection for patients with clinically positive lateral node(s) after preoperative concurrent chemoradiation therapy for lower rectal cancer.

Methods

The operation procedures are detailed in the attached video.

Results

Forty-five procedures of laparoscopic lateral pelvic lymphadenectomy were performed in 34 patients, with dissection over bilateral lateral node foci in 11 patients and dissection over unilateral lateral node station in 23. There were four procedures in which the metastatic node was very close to or even encased the adjacent iliac vessel and therefore the lymphadenectomy was done with a surgical margin of less than 1 mm. The median (range) number of lymph nodes harvested in each lateral station was 6 (2–14). Lympho-adipose tissues from 32 (71.1%, 32/45) lateral node dissections were confirmed by histopathology to harbor metastatic adenocarcinoma. For unilateral lateral pelvic lymph node dissection, median (range) blood loss was 44 (20–240) ml and median (range) operation time was 58 (42–94) min. There was one (2.9%) operative mortality and seven (20.6%) postoperative complications. Postoperatively, most patients presented with mild postoperative pain and quick convalescence. During follow-up (mean 24 months), nine patients (27.3%) developed recurrent disease. Remarkably, all four patients with surgical margin less than 1 mm developed cancer recurrence.

Conclusions

Laparoscopic lateral pelvic lymphadenectomy is technically feasible for some selected patients. To date, laparoscopic approach is still underdeveloped to treat the complex clinical condition in which the metastatic node involves the iliac vessel and combined resection of the vessel is required to obtain sufficient margin.     

The Gasless Laparoscopic Burch Bladder Neck Suspension: Early Experience

Purpose

We evaluated the gasless extraperitoneal laparoscopic Burch bladder neck suspension.

Materials and Methods

This retrospective study included 47 patients with type II stress urinary incontinence treated sequentially with this technique between September 1994 and September 1995. Balloon dissection was used to develop the extraperitoneal space. A mechanical retraction system was used with conventional laparotomy instruments to perform laparoscopic Burch bladder neck suspension.

Results

Of the 47 patients who underwent this procedure 3 (6 percent) required conversion to an open operation. Obesity and previous pelvic surgery were not contraindications to this technique. The only major complication involved blood loss necessitating conversion to an open operation. Average operative time was 96.4 minutes and average hospital stay was 3.5 days. Followup at 2 to 15 months (mean 8.2) indicated successful results (that is no pads were required) in 44 patients (90 percent).

Conclusions

Gasless laparoscopic bladder neck suspension has a lower open surgery rate, and may be performed more rapidly than conventional carbon dioxide laparoscopic Burch bladder neck suspension. Previous multiple operations and obesity are not contraindications to the technique.     

Endoscopic mucosal resection as a staging technique to determine the depth of invasion of esophageal adenocarcinoma

Background

Endoscopic ablation and vagal-sparing esophagectomy offer the potential for reduced morbidity in patients with high-grade dysplasia or early esophageal adenocarcinoma, but neither includes a lymphadenectomy. Although adequate for intramucosal tumors, both are potentially inadequate for patients with submucosal tumor invasion given the high prevalence of nodal metastases with these lesions. Currently there is no test including endoscopic ultrasound that can accurately determine whether a small tumor is confined to the mucosa or has penetrated into the submucosa. The aim of this study was to compare the pathologic depth of invasion by endoscopic mucosal resection with findings and outcome after surgical resection to assess the accuracy and reliability of endoscopic mucosal resection for staging early esophageal adenocarcinoma.

Methods

From 2001 to 2003, 7 patients presented with small, endoscopically visible adenocarcinomas. All underwent endoscopic mucosal resection followed by surgical resection.

Results

Analysis of the resected specimens confirmed that the endoscopic mucosal resection had accurately determined the depth of tumor invasion in all patients, and had completely excised the lesion in all but 1 patient (86%). Lymph node dissection was included as part of the resection in 2 patients with submucosal invasion by endoscopic mucosal resection, and a vagal-sparing esophagectomy was used in the 5 patients with only intramucosal tumors. All patients are alive and disease-free at a median follow-up of 7 months.

Conclusions

Endoscopic mucosal resection accurately determines the depth of tumor invasion, and should be used as a staging procedure in patients with early esophageal cancer when therapies that do not include a lymphadenectomy are considered.     

Sentinel lymph node dissection combined with meticulous histology increases the detection rate of nodal metastases in prostate cancer

Purpose

To evaluate benefits of sentinel lymph node (SLN) biopsy for staging accuracy in prostate cancer. Extended pelvic lymph node dissection (ePLND) is a preferred staging tool; however, it may underestimate the incidence of nodal involvement.

Methods

Eighty patients with estimated risk of lymphadenopathy above 5 % based on Briganti nomogram had Tc-99m-labeled nanocolloid injected into the prostate. Planar lymphoscintigraphy and single-photon emission computed tomography/CT were performed to localize SLNs. Radioguided SLN dissection was followed by backup ePLND comprising external iliac, obturator and internal iliac regions. All SLNs were serially sectioned every 150 μm and examined using hematoxylin and eosin; immunohistochemical staining was applied every 300 μm.

Results

A total of 335 SLNs were detected, and 17 % were located outside ePLND template. Nodal metastases were diagnosed in 32 patients (40 %). Without radioguided SLN localization, solitary metastases posteriorly to the branches of the internal ilaic vessels, in pararectal and common iliac regions would not have been removed in five of 32 patients (16 %). Using standard histology protocol, we would have diagnosed metastases in 23 patients with median size of 2.8 mm. Serial sectioning of SLN and immunohistochemistry led to the detection of metastases in additional nine patients (28 %) with median size of 0.2 mm.

Conclusion

ePLND comprised 83 % of SLNs, at least one SLN laid outside its template in 28 % of patients. ePLND and SLN dissection combined with nodal serial sectioning and immunohistochemistry increased the detection rate of nodal metastases by 68 % in comparison with ePLND alone and standard histology protocol.     

Pelvic Lymph Node Dissection During Robot-assisted Radical Prostatectomy: Efficacy,Limitations, and Complications—A Systematic Review of the Literature

Context

Pelvic lymph node dissection (PLND) in prostate cancer is the most effective method for detecting lymph node metastases. However, a decline in the rate of PLND during radical prostatectomy (RP) has been noted. This is likely the result of prostate cancer stage migration in the prostate-specific antigen-screening era, and the introduction of minimally invasive approaches such as robot-assisted radical prostatectomy (RARP).

Objective

To assess the efficacy, limitations, and complications of PLND during RARP.

Evidence acquisition

A review of the literature was performed using the Medline, Scopus, and Web of Science databases with no restriction of language from January 1990 to December 2012. The literature search used the following terms: prostate cancer, radical prostatectomy, robot-assisted, and lymph node dissection.

Evidence synthesis

The median value of nodal yield at PLND during RARP ranged from 3 to 24 nodes. As seen in open and laparoscopic RP series, the lymph node positivity rate increased with the extent of dissection during RARP. Overall, PLND-only related complications are rare. The most frequent complication after PLND is symptomatic pelvic lymphocele, with occurrence ranging from 0% to 8% of cases. The rate of PLND-associated grade 3–4 complications ranged from 0% to 5%. PLND is associated with increased operative time. Available data suggest equivalence of PLND between RARP and other surgical approaches in terms of nodal yield, node positivity, and intraoperative and postoperative complications.

Conclusions

PLND during RARP can be performed effectively and safely. The overall number of nodes removed, the likelihood of node positivity, and the types and rates of complications of PLND are similar to pure laparoscopic and open retropubic procedures.     

A New N Staging System for Colorectal Cancer in the Era of Extended Lymphadenectomy

Background

Complete mesocolic excision is becoming popular in colon cancer surgery in Western countries, and in the tumor-node-metastasis (TNM) classification of rectal cancer, a part of the lateral pelvic lymph nodes is classified as regional. However, the appropriateness of TNM staging according to the assessment of nodal status exclusively by extended lymphadenectomy remains unclear.

Patients and Methods

Using a nationwide multicenter database in Japan, we retrospectively analyzed 6866 patients with stage III colorectal cancer (CRC) treated with extended (D3) dissection. First, the best cutoff values for the number of metastatic nodes were explored. Second, the utility of the metastatic status of the main lymph nodes (i.e., at the origin of the feeding artery) and the lateral pelvic lymph nodes (“jN3” category in the Japanese staging system) as N staging criteria was evaluated. The modified N staging system that had the best risk stratification power was determined according to the Akaike information criterion (AIC).

Results

Excellent performance was noted when the number of metastatic nodes was categorized by cutoff values of “3/4” and “6/7.” Categorization of nodal metastasis was proven the most clinically efficacious when classified as modified-N1 (N1 and jN3-negative), modified-N2a (N2a and jN3-negative), and modified-N2b (N2b and/or jN3-positive; AIC, 22,810.8), rather than the classification based on the TNM (AIC, 22,849.2) or Japanese staging system (AIC, 22,811.1).

Conclusions

We structured a modified N staging system according to the number and extent of lymph node metastases. The modified system may be used in stage III cases for precise risk stratification.

     

Lymphadenectomy in minimally invasive urologic oncology

PURPOSE OF REVIEW: Standardization of pelvic lymphadenectomy in the urologic community is strongly needed. The definition of limited versus extended pelvic lymphadenectomy in the literature is variable, and the indications and extent of dissection is often surgeon dependent. RECENT FINDINGS: Laparoscopic prostatectomy with extended lymphadenectomy can be performed safely, retrieves a higher node count, and yields positive nodes more frequently than a limited lymphadenectomy. Lymphadenectomy remains the best method to stage prostate cancer; further studies are needed, however, to assess the potential therapeutic benefits. SUMMARY: Laparoscopic radical cystectomy with extended lymphadenectomy provides short-term functional and oncologic outcomes that compare favorably to data published in large open series. Renal cell cancer with nodal metastases is an independent predictor of prognosis in patients with clinical M0 disease. In experienced hands, laparoscopic retroperitoneal lymphadenectomy for renal cell cancer is safe and allows for adequate staging of nodal status or tumor debulking before secondary therapy. The therapeutic benefits of lymph node dissection are still controversial.     

Chromosomal Anomalies in Stage D1 Prostate Adenocarcinoma Primary Tumors and Lymph Node Metastases Detected by Fluorescence in Situ Hybridization

Purpose

We determined if characteristic chromosomal anomalies exist within the primary tumors and lymph node metastases in patients with stage D1 prostate cancer, and compared the patterns of chromosomal alterations between primary tumors and nodal metastases.

Materials and Methods

Fluorescence in situ hybridization analysis using peri-centromeric probes for chromosomes 6, 7, 8, 17, X and Y was performed on 5 micro. sections from paraffin embedded tissue blocks obtained from 23 consecutive patients who underwent radical prostatectomy and bilateral pelvic lymphadenectomy in 1990 for stage D1 prostate cancer.

Results

The dominant focus of primary tumor was compared to matched nodal metastases in 12 cases. Five of 12 primary tumor foci (41.7%) had similar chromosomal gains and the same fluorescence in situ hybridization ploidy result as the corresponding nodal metastases. Chromosomes 7 and X (73.2% of cases) were most frequently gained in the primary tumors, and chromosomes X and Y (81.2% of cases) were most frequently gained in the metastases. No primary tumor or metastasis demonstrated chromosomal loss. Three of 19 primary tumors (15.7%) were diploid, while 16 of 19 (84.3%) were nondiploid. Chromosomal aneusomy was inversely correlated with increasing Gleason summary score.

Conclusions

These data indicate that the dominant primary tumor foci may not give rise to nodal metastases, gains of chromosomes 7, X and Y may be associated with metastatic behavior, and patients with stage D1 disease have a greater rate of aneuploidy than those with lower stage cancer.     

Videomediastinoskopie und videoassistierte mediastinoskopische Lymphadenektomie

Background

Mediastinal lymphadenectomy is a prerequisite for accurate nodal staging and has an impact on survival. It is usually performed during thoracotomy together with lung resection. All available pretherapy options of mediastinal staging, e.g., videomediastinoscopy, fine needle aspiration techniques, and PET-CT, are far less accurate.

Methods

VAMLA (video-assisted mediastinoscopic lymphadenectomy) dissection is guided by anatomical landmarks. It includes en bloc resection of the right (3, 2+4R) and central (7, 8) compartments, and dissection and lymphadenectomy of the left-sided compartment (2+4L) of the middle mediastinum. In addition, intraoperative mediastinoscopic ultrasound (MUS) is applied to cT4 tumors.

Results

During VAMLA, significantly more mediastinal lymph nodes are harvested than during open lymphadenectomy (p<0.001). Mean duration was 54 min, the complication rate 4.6%, conversion rate and mortality 0%, sensitivity 93.8%, specificity 100%, and the false negative rate 0.9%. Of the 24 cT4 tumors, 16 were correctly predicted to be resectable. For minimally invasive oncological lung resections, combined VATS + VAMLA harvested significantly (p<0.05) more lymph nodes than VATS alone without impact on operation time or complication rate.

Conclusion

VAMLA is a well–tolerated, minimally invasive method for accurate mediastinal staging and radical mediastinal dissection. VAMLA can be carried out independent of tumor resection. Based on well-documented clinical studies and experience with VAMLA, we suggest its application together with neoadjuvant strategies, trials, VATS lobectomy, and radiation therapy with curative intent. In addition, MUS can help identify resectable cT4 cases and offer curative treatment.     

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.