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J E Altwein

Publications and source records attributed to J E Altwein.

At least 37 records · Page 2Linked to original sources
PubMed2000

[Early detection of prostatic carcinoma in urologic practice with digital rectal examination and prostate-specific antigen. Early Detection Project Group].

For the early detection of prostate cancer, a patient should undergo digital rectal examination (DRE) and PSA investigation. Follow-up of increased PSA levels detects nearly 80% of cancers. Positive predictive value of suspicious DRE and PSA is about 50%. Whereas in the first evaluation of this case-finding trial about 70% of the patients had organ-confined cancers, nearly all of the detected cancers in the follow-up investigation were organ confined. The increased number of organ-confined cancers detected in early periodical examinations can lead to a reduction of mortality and morbidity from prostate cancer.

Adult↗
PubMed2000

Comparison of an LH-RH analogue (Goeserelin acetate, 'Zoladex') with combined androgen blockade in advanced prostate cancer: final survival results of an international multicentre randomized-trial. International Prostate Cancer Study Group.

OBJECTIVE: The aim of this study was to compare the effects of the nonsteroidal antiandrogen flutamide plus the LH-RH analogue goserelin acetate (combined androgen blockade [CAB]) with goserelin acetate alone in patients with advanced prostate cancer. The original analyses at 25 and 56 months of follow-up have been reported previously, and here we report the final survival analysis after 10 years of follow-up. METHODS: 589 patients with advanced prostate cancer (55% with metastatic [M1] and 45% with locally advanced [M0] disease) were randomized to receive goserelin acetate 3.6 mg either alone or in combination with flutamide (250 mg three times daily). RESULTS: A total of 583 patients were included in the analysis. There was a small, but nonsignificant, benefit for CAB compared with goserelin acetate alone in all patients with respect to survival (hazard ratio 0.88, 95% CI 0.73, 1.06). Subgroup analysis of M0 and M1 patients showed similar results (M0: hazard ratio 0.92, 95% CI 0.68, 1.25; M1: hazard ratio 0.85, 95% CI 0.66, 1. 08). The treatment effect was not significantly different for M0 and M1 patients (p = 0.685). CONCLUSIONS: In this large randomized trial containing significant numbers of M0 patients, after 10 years there was a small but nonsignificant benefit for CAB over castration alone.

Aged↗
PubMed1999

[Early recognition of prostate carcinoma. Initial results of a prospective multicenter study in Germany. Project Group for Early Detection DGU-BDU Laboratory diagnosis Professional Circle].

To compare the efficacy of digital rectal examination (DRE) and serum prostate specific antigen (PSA) in early detection of prostate cancer, we initiated a prospective multicenter screening trial. In 12,542 men choosen at random with a mean age of 62 (+/- 7.5) a suspect DRE or a PSA level > 4.0 ng/ml was found in 2343 (20%). Of the presently performed 744 biopsies, 157 revealed diagnosis of prostate cancer. Although further biopsies as well as the follow up of the 12,542 men are still missing, combination of DRE and PSA value > 4.0 ng/ml appears to be superior to DRE alone with a positive predictive value of 50% versus 19% in early detection of prostate cancer.

Aged↗
PubMed1999

[Lymph node positive prostate carcinoma. A case for primary hormone therapy].

At the present time, lymph node metastases may be nomographically predicted or histologically proven. As a rule, this indicates a systemic disease. Unimodal local therapy (radical prostatectomy/irradiation) does not alter the outcome. Occasionally, this appeared to be the case, if lymph nodes were diagnosed in a very early stage (diagnostic lead-time). This phenomenon disappears, when the follow-up time is long. A comparable situation is encountered, if one relies on the bimodal local therapy, i.e. radical prostatectomy plus adjuvant irradiation. Similarly, there is a diagnostic lead-time effective. However, patients with minimal lymph node metastases (also known as pN1.1) may probably not need immediate endocrine therapy. The combination of tele- and brachy-therapy in the presence of positive nodes appears to be not useful. Unimodal systemic therapy following radical prostatectomy has never been tested in a phase III-trial. If one weighs the arguments pro immediate versus delayed hormone therapy, the following trends can be found: The time-to-progression is prolonged, however, that does not translate in a longer cause-specific survival. In the results of a phase III-trial of irradiation plus primary versus delayed androgen deprivation in stage N1/pN1 prostate cancer the above trends were noticed. Neoadjuvant hormone therapy in N1 prostate cancer has not been tested in a phase III-trial, however, it is very unlikely that patients benefit more than from a similar treatment in the presence of locally advanced, but node-negative prostate cancer. An interesting concept in these potentially long surviving patients is the intermittent hormone therapy, among the benefits is the reduced number of side-effects.

Androgen Antagonists↗
PubMed1999

Prostate and sexuality: An overview.

OBJECTIVE: Diseases of the prostate, prostatitis, prostatodynia, benign prostatic hyperplasia (BPH), and carcinoma of the prostate interfere with sexual function. Since the American Urological Association have issued their position statement in 1990 that male sexual dysfunction is a recognized disease entity, studies examined the interrelation between sexuality and the prostate. These studies were identified in our review. METHOD: A computer- and hand-based search of the literature was conducted with the key words health-related quality of life, sexual function and the various disease states of the prostate, the drawback being that validated quality-of-life instruments have just recently and mostly nationally been validated. RESULTS: Sexual function is a dimension of quality-of-life questionnaires with 1 up to 11 questions addressing sexuality. The effect of aging on male sexuality as determined in Sweden serves as an important background information. Whereas prostadynia and sexual dysfunction aggravate each other, BPH and its treatment influence only certain sexual functions. Carcinoma of the prostate, untreated or under observation, has the greatest impact on sexuality which is tolerated differently from country to country and depends upon the expectation of survival. CONCLUSION: The impact of treatment of prostatic diseases on sexuality can now be studied easier in utilizing validated questionnaires. This update may serve as a base for these upcoming studies.

Aging↗
PubMed1999

Prognostic factors for carcinoma of the prostate.

Prognostic factors for prostatic carcinoma should be significant, independent and clinically important. They should be of practical use, and their determination should be affordable in everyday practice. Prognostic factors may be grouped into patient-related, tumor-related and treatment-related. They should meet certain requirements, such as possession of a clear biological significance, an adequate sample size (possibly more than 150 patients), no patient population bias, an adequate statistical test, such as Cox regression analysis, as well as optimized cut-off values and reproducibility. From a pathologist's view, prognostic factors with established values are grade, margin involvement, capsular penetration, seminal vesical involvement, metastases and invasion of fat in needle biopsies. In contrast to this, factors with little value are, among others, zone location or nuclear shape. If these guidelines for assessment of prognostic factors are not met, the prognostic factors grow exponentially, as an individual patient can only belong to one prognostic group. If one considers all three categories of prognostic factors together, the clinical stage matters most despite all uncertainties. The same holds true for grading; particularly, the well-differentiated grades on biopsy cores have the drawback of being reflected in the specimen only infrequently. The use of biomarkers to give a better prognostic information is also disappointing, as only PSA and PAP have a reliable value among 28 biomarkers. It is of note that new biomarkers are continuously being discovered and examined, such as cyclin A or D. Due to these deficiencies in all three categories of prognostic factors for prostatic carcinoma, prognostic indices in the form of nomograms were constructed. But, if these indices are employed to answer the most important question at the time of diagnosis, i.e., 'is this man a candidate for surveillance?', neoadjuvant treatment plus irradiation, neoadjuvant treatment plus radical prostatectomy, perineal radical prostatectomy, because of a low probability of extracapsular extension or positive lymph nodes, adjuvant therapy after local treatment with curative intent as opposed to progression-based treatment or immediate systemic treatment, let alone intermittent endocrine manipulation, are not reliably possible. The outcomes of the few available studies based on prognostic factors should be studied carefully. If considered, a valuable new way of estimating artificial neural networks is a possibility to come to practical terms.

Biomarkers, Tumor↗
PubMed1999

Therapeutic options in locally defined or advanced prostate cancer.

OBJECTIVE: Critical discussion of the available therapeutic options in locally defined or advanced prostate cancer (PCa) in the absence of standards or guidelines. METHODS: Medline-based survey of the pertinent literature. The therapeutic options are presented stage-by-stage. RESULTS: Intracapsular PCa (T1a-T2bN0M0) is preferably managed by radical prostatectomy; 'insignificant' cancers may be treated expectantly. The outcome of irradiation is not as predictable as radical surgery. The following points regarding treatment of locally advanced PCa are still under debate: neoadjuvant treatment is probably not as efficient as believed; technical refinements of radical prostatectomy may be helpful; in some instances, the value of adjuvant treatment is undecided. The efficacy of irradiation in conjunction with androgen deprivation probably equals the efficacy of surgery. No consensus can be found in the presence of positive lymph nodes, although single institutions achieve remarkable results with surgery plus androgen deprivation. CONCLUSION: Prognostic factors beside the clinical stages and grades should be incorporated in the treatment decision, and quality-of-life measurement should gain more importance when the treatment outcome is assessed.

Combined Modality Therapy↗
PubMed1998

[Complete androgen blockade versus monotherapy].

In a comparative analysis of 29 studies, maximal androgen deprivation (MAD) was not found to be superior to partial androgen deprivation. Thus, MAD cannot be regarded as the new gold standard. Most trials focus on quality of life which--given the palliative aim of the treatment--deserves special attention. This aspect has not yet been evaluated, however, in the largest multicenter study, intergroup study 0105. In patients with advanced bone metastasis or severe pain, MAD treatment should be begun because of the flare phenomenon. The synergistic effects of LHRH agonists on the prostate are currently being investigated. Since no clear prognostic factors exist and reduction of serum-PSA levels under MAD does not delay progression, the patient must help to make the decision of whether or not MAD should be begun.

Androgen Antagonists↗
PubMed1998

Obstructive benign prostatic hyperplasia: therapeutical aspects.

OBJECTIVE: Once benign prostatic obstruction (BPO) is diagnosed, the urologist is confronted with an array of therapeutic modalities, from which he has to choose. The decision can be based on the patient's desire, deobstructing efficacy, durability, cost and on the physician's experience as well as availability of modalities. METHODS: A therapeutic spectrum is constructed for individualization of therapeutic options in evaluation of the relevant factors based on the published studies. RESULTS: In treating BPO the surgical treatment (TURP, TUIP) is still the most reliable in experienced hands, and its cost-efficacy has to be weighed against durability. If LUTS without intravesical obstruction dominates, alpha-blocker or finasteride (prostates >40 g) are useful and more efficient than watchful waiting when symptom relief and uroflow improvement are outcome parameters. Interventional treatment modalities remain a moving target, since even high-energy TUMT does not overcome obstruction. Ablation techniques (Holmium laser, TEVAP) have not been used with regard to durability. CONCLUSION: Picking an inappropriate modality or selecting the wrong patient may lead to a cascade of therapies. One can obtain a change in paradigms to measure the outcome putting emphasis on cost, need to retreat and, last but not least, quality of life.

Adrenergic alpha-Antagonists↗
PubMed1998

Enhancing the efficacy of radical prostatectomy in locally advanced prostate cancer.

Locally advanced prostate cancer patients comprise those with iatrogenic capsular injury, extracapsular extension resulting in positive surgical margins following radical prostatectomy, and tumors with lymph node metastases, thus representing stage T3,N0,M0 or T1-4,N1-2,M0 disease. Parameters can be combined, as shown below, in a nomogram to predict advanced prostate cancer: if, for example, stage T2c is coupled with a PSA of 16 ng/ml and a high Gleason grade, the patient will have an approximately 70% likelihood of having extracapsular extension; then again, if the Gleason score is known from biopsies and a PSA of 10-20 ng/ml is given, then a stage T2c prostate cancer patient with a Gleason of 7 will have a 39% probability of having positive lymph nodes. The following therapeutic considerations may be used to enhance the chance of eradicating advanced disease through radical prostatectomy: (1) Neoadjuvant hormonal therapy helps downsize the tumor and may eventually reduce the number of positive margins by almost 50%. However, it is a moot point if this will lead to a prolonged survival period. (2) Technical refinements on radical prostatectomy may be achieved through the principle of wide extension excision, a modification of current apical dissection procedures, which involves the use of panoramic magnifying loupes, and an examination of resection margins during surgery using repetitive frozen sections. (3) If positive (not simply 'equivocal' as defined by Epstein) margins are found, radical prostatectomy alone is not curative. Among the various options available is postoperative irradiation with or without adjuvant hormonal therapy. The latter should probably be reserved for patients with extracapsular extension, a high Gleason score or positive lymph nodes. Hormonal therapy may be used continuously or intermittently. The value of adjuvant treatment is currently being tested in phase-III trials. (4) Hormonal therapy may be commenced at the time of biochemical or clinical progression, although it is not clear whether this modality is inferior to adjuvant forms of treatment. Technical expertise in radical prostatectomy accumulated at major institutions can be used to the advantage of patients with locally advanced prostate cancer. In this regard, results of ongoing phase-III trials testing various options including this procedure are eagerly awaited.

Biopsy↗
PubMed1997

Cost-effective monotherapy of concomitant benign prostatic hyperplasia and hypertension.

Increasing longevity in the developed world means an increasing prevalence of age-related disorders such as hypertension and benign prostatic hyperplasia (BPH). In the case of BPH there are additional factors contributing to the increasing number of patients requiring treatment. This review illustrates the potential economic and effectiveness benefits of using one drug to treat two disorders.

Adrenergic alpha-Antagonists↗
PubMed1997

[Prognostic parameters of locally confined prostate carcinoma].

Current methods for patient selection lack the necessary sensitivity and specificity for selecting those for whom cure is required and possible. Prognostic factors must be understood in the light of the nature of prostatic carcinoma and the actual direct benefit of the information to the patient. The absolute impact of prostate cancer at different ages and in all grades varies substantially as indicated by loss of life expectancy. Diagnostic tests are able to distinguish clinically unimportant cancers. Quantitative analysis of systematic biopsy specimens combined with PSA density provides valuable staging information and helps to identify cancers of low biological potential i.e. small (0.5 cm3 or less), well or moderately differentiated and confined to the prostate. The majority of the patients with a maximum cancer length of 2 mm or less and a PSA density of less than 0.1, do not need curative treatment. Multivariate analysis studies identified pathological grade and preoperative serum PSA concentration as independent predictors of clinical progression in up to 1/4 of patients with pathologically organ-confined prostate cancer after radical prostatectomy. Prognostic scoring systems are reported using the regression coefficients from the Cox multivariate model to classify patients further according to risk of progression.

Biomarkers, Tumor↗
PubMed1997

Simultaneous radical prostatectomy and partial rectum resection without colostomy.

The simultaneous occurrence of carcinoma of the rectum and prostate is observed in 6%. Ablative surgery in two sessions is technically more difficult than in a single session. This is demonstrated by the successful outcome of a patient treated for such a double carcinoma without colostomy. In contrast to an accidental rectal injury, the thorough bowel preparation in this planned procedure enabled a single-session resection of the two cancers.

Anastomosis, Surgical↗
PubMed1996

Organ-sparing treatment for ureteral carcinoma?

OBJECTIVE: Nephroureterectomy (NUE) with a bladder cuff is the standard therapy for ureteral cancer. Based on an analysis of the literature and a retrospective study, this concept is questioned. METHODS: Between 1980 and 1991, 40 patients with ureteral tumors underwent surgery at the Krankenhaus der Barmherzigen Brüder in Munich. Tumoral stages were pTa and pTl in 62% of the patients; 37% showed an invasive carcinoma. Radical surgery (NUE with bladder cuff) was performed in 22 patients and conservative treatment (ureterocystoneostomy or end-to-end-anastomosis) in 13 patients. RESULTS: The median follow-up was 42 months in the conservative group and 59 months in the radical surgery group. A recurrence in the conservatively operated patients was observed only in primary invasive tumors (4/13), whereas none of the remaining patients had a recurrent tumor. In terms of time to progression and tumor-specific survival, there was a good correlation of the ureteral carcinoma according to grading and staging. In terms of survival, patients with superficial tumors run a similar course whether treated by conservative or radical surgery. CONCLUSION: The conservative treatment of patients presenting with superficial ureteral lesions seems to be a good alternative to radical surgery.

Aged↗
PubMed1995

The changing therapy of benign prostatic hyperplasia.

The diagnosis and treatment of benign prostatic hyperplasia (BPH) is increasingly under review and discussion. The diagnosis of BPH can be based on microscopic, clinical, or urodynamic criteria, and has important implications for treatment. Recommendations for treatment regimens are regularly updated, as new therapies enter the market and the cost effectiveness of new and established regimens are reviewed. Surgery, the mainstay of treatment for BPH, is declining, and medical therapy is assuming a greater role. Pharmacological regimens, for example alpha adrenoceptor blockers and 5-alpha reductase inhibitors, are becoming established for the treatment of mild and moderate symptoms of BPH. This paper will review the spectrum of BPH treatment modalities facing the urologist, and the factors that influence individual treatment choice.

5-alpha Reductase Inhibitors↗
PubMed1994

Stage T1A carcinoma of prostate.

When presented with a post-TURP patient with pathologically confirmed Stage T1a disease, several points should be considered (Fig. 1). Is the patient's anticipated longevity and quality-of-life likely to be affected by the confirmed diagnosis? From current knowledge, men over the age of seventy or with co-morbid risk factors probably will not be adversely affected, and no treatment is required apart from expectant follow-up with semiannual DRE and serum PSA determinations. The group at risk seems to be the young patient with a Stage T1a tumor who is likely to survive more than ten years after the diagnosis. Data showing progression rates without treatment as high as 16-25 percent at eight to ten years seem to indicate the need for additional therapy. If the patient belongs to this category and is ready to pursue more aggressive treatment, reestablishing the diagnosis might be suggested, as well as an evaluation of the pre- and post-TUR PSA levels. This can be done by TRUS-guided biopsies of the prostate (or repeat TURP, which we regard as less preferable). If residual tumor is not found, we would counsel a "wait and see" approach. If subsequent tissue sampling identifies other than well-differentiated cancer or indicates the likelihood of more extensive cancer than the T1a staging, treatment would be suggested. If the restaging reveals some residual well-differentiated disease that would not alter the initial staging of T1a, the patient should be offered the alternatives of close monitoring, radical prostatectomy, or radiation therapy. Until prognostic factors such as DNA ploidy and nuclear roundness are better studied, we are unable to counsel the patient on the biologic significance/aggressiveness of his Stage T1a disease.

Adenocarcinoma↗