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Biomedical subjects

H W Herr

Publications and source records attributed to H W Herr.

At least 55 records · Page 3Linked to original sources
PubMed1998

Paternity in men with stage I testis tumors on surveillance.

PURPOSE: We report long-term paternity in men with stage I testis tumors who were managed initially by surveillance. PATIENTS AND METHODS: One hundred five patients with clinical stage I nonseminomatous germ cell tumors of the testis were entered on a surveillance protocol and followed up for more than 10 years. Actual fertility potential was assessed by pregnancy. RESULTS: Of the 105 patients, 41 (39%) have fathered children, which includes 36 of 78 (46%) patients while on active surveillance and five of 27 (19%) patients after treatment for relapse. Of 63 couples who attempted a pregnancy on surveillance or were presumed capable of impregnation (whether they tried or not), 41 (65%) were successful. CONCLUSION: These results show that the majority of men with stage I testis tumor who are on surveillance after orchiectomy, have a suitable partner, and attempt impregnation achieve a successful pregnancy. Pregnancy rates appear to be less than reported in men who have a nerve-sparing retroperitoneal lymph node dissection (RPLND) because more patients on surveillance require treatment for relapse, which reduces their chances for pregnancy.

Adolescent↗
PubMed1998

Extravesical tumor relapse in patients with superficial bladder tumors.

PURPOSE: To define the incidence of extravesical urothelial tumors among patients with high-risk superficial bladder tumors. PATIENTS AND METHODS: Three hundred seven patients with multiple recurrent papillary and in situ carcinomas of the bladder were treated with transurethral resection and intravesical bacillus Calmette Guérin (BCG) therapy and monitored for a median of 12 years (range, 10 to 18). Extravesical tumors were detected during investigation of a positive urine cytology after no tumor was found in the bladder. RESULTS: Among 307 patients, 78 (25%) developed tumors in the upper urinary tract (UTT). Of 251 men, 61 (24%) had tumors detected in the prostatic urethra or ducts (T4p). The median times to detection of an UTT or prostatic epithelial tumor were 56 months and 11 months, respectively, and 32% of the UTT and 44% of the T4p relapses were lethal. CONCLUSION: Patients with high-risk superficial bladder tumors who are treated successfully by a bladder-sparing strategy are at increased risk for tumor relapse that involves extravesical mucosa.

BCG Vaccine↗
PubMed1998

Neoadjuvant chemotherapy and bladder-sparing surgery for invasive bladder cancer: ten-year outcome.

PURPOSE: To evaluate the 10-year outcome of patients with invasive (T2-3N0M0, staged according to the tumor, node, metastasis system) bladder cancer who responded completely to a combination of methotrexate, vinblastine, adriamycin, and cisplatin (MVAC) chemotherapy followed by bladder-sparing surgery. PATIENTS AND METHODS: Of 111 surgical candidates who received neoadjuvant MVAC, 60 (54%) achieved a complete clinical response (T0) on transurethral resection (TUR) of the primary tumor site. Of these, 28 requested follow-up with TUR alone, 15 had a partial cystectomy, and 17 elected a radical cystectomy. The patients were followed up for a median of 10 years (range, 8 to 13 years). RESULTS: Of 43 patients who had bladder-sparing surgery, 32 (74%) are alive, which includes 25 (58%) with an intact functioning bladder. Twenty-four patients (56%) developed bladder tumor recurrences from 5 to 96 months, which were invasive in 13 (30%) and superficial in 11 (26%). Thirteen patients required a salvage cystectomy, of whom 6 died, which includes 4 (9%) from a new invasive neoplasm. Of the 17 patients who had radical cystectomy, 11 (65%) are alive. CONCLUSION: The majority of patients with invasive bladder tumors who achieve T0 status after neoadjuvant MVAC chemotherapy preserve their bladders for up to 10 years with bladder-sparing surgery. The bladder remains at risk for new invasive tumors. Cystectomy salvages the majority, but not all, of relapsing patients.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1997

Natural history of superficial bladder tumors: 10- to 20-year follow-up of treated patients.

Superficial bladder tumors (Ta, Tl, Tis) account for 80% of primary bladder cancers. Transurethral resection and intravesical therapy are successful in controlling the majority of these tumors for up to 5 years. However, patients with multiple or recurrent Ta, Tl and Tis bladder cancer have a lifelong risk of developing stage progression and upper tract tumors. One-half are at risk of having cystectomy eventually and one-third are at risk over a 15-20 year period of dying of bladder cancer.

Disease Progression↗
PubMed1997

Radical cystectomy in the octogenarian.

PURPOSE: We evaluated the morbidity and outcome of cystectomy and urinary diversion in patients 80 years old or older with invasive bladder cancer. MATERIALS AND METHODS: We reviewed the records of all patients older than 80 years who underwent cystectomy during the last 15 years. Of 1,186 cystectomies 44 patients (4%) were identified. Patients were evaluated for complications, mortality and functional status after surgery. RESULTS: The 44 patients had a median age of 81 years (range 80 to 87). Of the patients 78% had significant co-morbidity, including 41% with 2 or more medical problems. Median hospital stay was 14 days, with 20% of the patients requiring intensive care for 24 hours. There was a 51% complication rate including 25% due to surgical complications and 26% from underlying medical illness. Operative mortality was 4.5%. Within 6 months of surgery 66% were rehospitalized for medical or surgical reasons. Median survival time was 25 months. Median performance status before and after surgery decreased slightly from 70 to 65. CONCLUSIONS: The results of this study support the use of cystectomy in octogenarians with invasive bladder cancer. Surgery can be accomplished with acceptable morbidity and mortality. Radical cystectomy in this population offers the best opportunity for sustained disease-free quality survival.

Age Factors↗
PubMed1997

Does necrosis on frozen-section analysis of a mass after chemotherapy justify a limited retroperitoneal resection in patients with advanced testis cancer?

OBJECTIVE: To evaluate morbidity and relapse in patients with advanced testis cancer who underwent a post-chemotherapy resection of a residual mass and a limited retroperitoneal lymph node dissection. PATIENTS AND METHODS: A total of 62 patients underwent complete resection of retroperitoneal masses after chemotherapy and a limited lymph node dissection if frozen sections of the mass showed necrosis (37 patients) or a bilateral dissection if the frozen section indicated viable germ cell tumour or teratoma (25 patients). RESULTS: With a median follow-up of 6 years, 14 (23%) patients relapsed, but only one within the retroperitoneum (teratoma) after a limited lymphadenectomy. There was a concordance of 89% between the frozen section of the post-chemotherapy mass and the permanent-section histological diagnosis of the entire lymphadenectomy specimen. Of the 37 patients whose masses showed necrosis on frozen section, three had viable germ cell tumour and one had teratoma on final histology. In all four false-negative cases, residual tumour was confined to the resected mass. Six patients (10%) had surgical complications (one after limited and five after bilateral lymph node dissection). CONCLUSION: The surgical resection of all residual masses after chemotherapy, followed by limited retroperitoneal lymphadenectomy if frozen-section analysis shows necrosis, is a safe approach in selected patients with advanced testicular cancer.

Adult↗
PubMed1997

Tumour progression and survival in patients with T1G3 bladder tumours: 15-year outcome.

OBJECTIVE: To evaluate tumour progression and survival of patients with T1G3 bladder tumours who were followed for 15 years. PATIENTS AND METHODS: A subset of 48 patients with T1G3 bladder tumours was entered into a randomized trial of transurethral resection (TUR) or TUR plus bacille Calmette-Guèrin (BCG) therapy and followed for a minimum of 15 years. Thirty-nine (81%) patients received one or more courses of BCG. The endpoints of the study were stage progression (defined as muscle invasion of metastasis) and disease-specific survival. RESULTS: Of the 48 patients, 25 (52%) progressed and 15 (31%) died from the disease; 33 patients (69%) survived, including 24 (50%) with an intact bladder. The median progression-free survival time was 151 months. Tumour progression occurred in 35% of the patients within the first 5 years, in 16% after 5-10 years and in 12% of those followed for 10-15 years. Deaths from cancer occurred in 25% of the patients in the first 5 years and in 10% of patients at risk from 5 to 15 years. CONCLUSIONS: Patients with T1G3 bladder tumours who are treated conservatively are at life-long risk of having a muscle-invasive tumour and dying from bladder cancer.

Adult↗
PubMed1997

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 (28) or refractory carcinoma in situ (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.

Disease Progression↗
PubMed1997

Ureteral carcinoma in situ at radical cystectomy: does the margin matter?

PURPOSE: The clinical impact of ureteral carcinoma in situ identified at the time of radical cystectomy for bladder cancer has been poorly studied. We discuss our experience with this clinical problem in the context of published reports. MATERIALS AND METHODS: A total of 31 patients with concomitant ureteral carcinoma in situ was retrospectively identified among 401 consecutive radical cystectomies. End points analyzed included positive urinary cytology, upper tract recurrence of carcinoma and cancer specific survival. RESULTS: Ureteral margins were positive in 21 patients and negative in 10. Among 30 patients in whom it was performed frozen section failed to detect carcinoma in situ in 5 (16.6%) and sequential ureteral resection did not result in a negative margin in 15 (50%). In 3 patients upper tract carcinoma recurred at the anastomosis (1) and renal pelvis/ureter (2) at a median of 51 months (mean 49, range 36 to 59) following cystectomy. Positive cytology and upper tract carcinoma recurrence were not significantly associated with ureteral margin status, clinical or pathological bladder tumor stage or prior bacillus Calmette Guerin treatment. Median followup was 22.9 months (mean 31.8, range 2.0 to 74.2), during which 7 of the 31 patients died of metastatic bladder cancer. CONCLUSIONS: Concomitant ureteral carcinoma in situ is uncommon, and is rarely associated with local morbidity. It appears to confer increased risk for upper tract carcinoma recurrence, irrespective of margin status. In our experience upper tract carcinoma recurrence is heralded by positive cytology and generally appears only with protracted followup. Prognosis appears to be determined by the bladder tumor. Given the lack of morbidity and mortality attributable to concomitant ureteral carcinoma in situ, and the limited ability of frozen section examination to assist in its extirpation, the value of intraoperative identification of concomitant ureteral carcinoma in situ is questionable and expectant management is advised.

Adult↗
PubMed1997

CT detection of retroperitoneal lymph node metastases in patients with clinical stage I testicular nonseminomatous germ cell cancer: assessment of size and distribution criteria.

OBJECTIVE: Patients with nonseminomatous germ cell cancer of the testis with no evidence of metastatic disease after orchiectomy may be managed with either retroperitoneal lymph node dissection or surveillance. The present retrospective study was undertaken to determine the accuracy of CT for revealing retroperitoneal lymph node metastases in patients with newly diagnosed clinical stage 1 testicular nonseminomatous germ cell cancer of the testis when smaller size criteria (smaller than 10 mm) are applied and to test the hypothesis that CT-revealed anterior retroperitoneal lymph nodes are more likely to correlate with metastases than are posterior lymph nodes. MATERIALS AND METHODS: Abdominal CT scans obtained before surgery in 70 patients were reviewed by three observers who were unaware of the results of retroperitoneal lymphadenectomy. The sizes and sites of all lymph nodes measuring larger than or equal to 4 mm were recorded. Each CT scan was judged as positive or negative for retroperitoneal metastasis on the basis of the size of the largest measured lymph node at the expected metastatic site. Diameters of 4, 6, 8, and 10 mm were successively applied to each case as the criteria for a positive scan. RESULTS: Using a criterion of 10 mm or larger for metastases, we calculated a sensitivity of 37% and a specificity of 100%; with a 4-mm criterion, the sensitivity was 93% and the specificity was 58%. Receiver operating characteristic curves comparing the accuracy of CT for revealing similar-sized lymph nodes located anterior or posterior to a line bisecting the aorta differed significantly (p = .04) when the same criteria were applied to lymph nodes in both regions. CONCLUSION: False-negative rates were decreased from 63% using a size criterion of 10 mm to as low as 7% using a size criterion of 4 mm, with a corresponding decrease in specificity. Lymph nodes measuring larger than or equal to 4 mm, especially those located anterior to the mid portion of the aorta, should raise a suspicion of metastases.

Germinoma↗
PubMed1997

Surgery for a post-chemotherapy residual mass in seminoma.

PURPOSE: We attempted to select patients for surgery of post-chemotherapy residual mass in advanced seminoma. MATERIALS AND METHODS: A total of 55 patients with advanced seminoma underwent surgical exploration of a mass seen on computerized tomography (CT) after chemotherapy. Residual masses were defined radiographically as smaller or larger than 3 cm. and as well defined or poorly defined. Surgery consisted of complete resection of the mass and surrounding lymph nodes or multiple biopsies at sites of disease. RESULTS: Of the 55 patients 32 (58%) had masses resected and 23 (42%) underwent multiple biopsies. Of 27 patients with a post-chemotherapy 3 cm. or larger mass on CT 8 (30%) had residual tumor (seminoma in 6 and teratoma in 2), whereas necrotic tissue was found in the other 28 patients having a mass smaller than 3 cm. Well defined masses on CT were resected in 78% of patients and poorly defined masses could be resected in only 44%. Of the 8 patients with positive histology 6 remain alive and disease-free after complete resection of a well defined, larger than 3 cm. mass containing viable tumor, and 2 with a poorly defined mass died after biopsy only of residual seminoma despite salvage therapy. Three other patients who underwent complete resection of necrotic masses subsequently had relapse at distant sites and died. Median followup was 47 months (range 5 +/- 153+ months). CONCLUSIONS: Patients with advanced seminoma who have a residual mass smaller than 3 cm. after chemotherapy do not benefit from surgery. For patients with a residual mass 3 cm. or larger we prefer surgery to define response, resect viable tumor when possible and direct further treatment.

Follow-Up Studies↗
PubMed1997

Is biopsy of the contralateral testis necessary in patients with germ cell tumors?

PURPOSE: Carcinoma in situ is present in the contralateral testis in up to 5% of patients with a primary germ cell tumor and will progress in the majority of cases to a second primary invasive cancer. We address the question of whether the other testis should be biopsied in patients with testis tumors. MATERIALS AND METHODS: The literature on carcinoma in situ of the testis from 1972 to the present was critically evaluated in an attempt to address the issue of carcinoma in situ in the opposite testis. RESULTS: Carcinoma in situ of the opposite testis in patients with a primary germ cell tumor is easily diagnosed by biopsy and cured by orchiectomy or radiation. The problem is that biopsy is unnecessary in the majority of patients, and treatment of carcinoma in situ may have undesirable physical and emotional consequences. The rare patient who has an asynchronous second primary cancer can be cured with current treatment regimens. CONCLUSIONS: We do not advocate nor does the literature support routine biopsy of the opposite testis in patients with unilateral testis tumor. Patient education and close followup are rational alternatives to intervention in all cases to diagnose a small subset who are risk for bilateral tumors.

Biopsy↗
PubMed1997

Adjuvant and neoadjuvant chemotherapy for urothelial carcinoma.

Transitional cell carcinoma of the bladder is associated with a high relapse rate, locally and systemically, particularly in patients with nodal or soft-tissue involvement, despite radical cystectomy. The responsiveness of the disease to chemotherapy in the metastatic setting has stimulated the use of systemic therapy in earlier stage disease, either before (neoadjuvant) or after (adjuvant) definitive local therapy. Interpretation of the data is hampered by low patient accrual to randomized trials, lack of standardization of local treatment modalities, and the use of a variety of chemotherapy agents and regimens pointing to the difficulty in reaching a consensus as to what constitutes standard therapy. In this article, we review the use of adjuvant and neoadjuvant chemotherapy, the advantages and disadvantages of both approaches, and the recommendations that can be made based on available data. New approaches to improving survival, potentially with organ preservation, include the development of more effective chemotherapy, and the identification of prognostic features-clinical or biologic-that might be a better guide to patient selection.

Antineoplastic Agents↗
PubMed1996

The National Cancer Data Base report on bladder carcinoma. The American College of Surgeons Commission on Cancer and the American Cancer Society.

BACKGROUND: Previous Commission on Cancer Data from the National Cancer Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. The most current (1993) data relating to patients with bladder carcinoma are described here. METHODS: Five calls for data have yielded a total of 3,700,000 cases for the years 1985 through 1993, including 447,679 cases for 1988 and 608,593 cases for 1993, from hospital cancer registries across the U.S. Data were received on 18,053 bladder carcinoma cases in 1988 and 22,606 cases in 1993. RESULTS: Interesting trends are 1) younger patients (49 years of age and younger) present with earlier stages of disease than do older patients; 2) women are slightly more likely to be diagnosed with later stages (II, III, and IV) of bladder carcinoma than men; 3) African Americans are less likely to be diagnosed with Stage 0 or Stage I disease than either Hispanic or non-Hispanic whites; and 4) National Cancer Institute designated centers treat more patients with advanced disease than do other types of hospitals. CONCLUSIONS: The NCDB data are important for analyzing what cancer treatments and outcomes are used and occurring in the country. The data suggest that African Americans are diagnosed at later stages of disease progression. The relative survival rates among African Americans are lower than among Hispanics or non-Hispanic whites. Also, the decreasing utility of adjuvant chemotherapy is being recognized.

Adult↗