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Biomedical subjects

R S Foster

Publications and source records attributed to R S Foster.

At least 109 records · Page 6Linked to original sources
PubMed1994

Predictive parameters of biologic behavior of early stage nonseminomatous testicular germ cell tumors.

BACKGROUND: Thirty percent of patients presenting with clinical stage A nonseminomatous testicular germ cell tumors in fact have pathologic stage B disease. This pilot study was performed to determine whether DNA content and cell cycle analysis by flow cytometry and single-cell cytophotometry can improve clinical staging in these patients. METHODS: The orchiectomy specimens of 102 patients with clinical stage A disease were analyzed retrospectively using histopathologic classification, flow cytometry, and single-cell cytophotometry. All patients had undergone retroperitoneal lymph node dissection. RESULTS: The multivariate analysis in this group of patients resulted in the following model: If the primary tumor consisted of 100% embryonal carcinoma, the patient was classified as high risk for retroperitoneal metastasis. If the patient was found to have less than 100% embryonal carcinoma in the primary tumor, the percent of aneuploid tumor cells in S-phase as identified by flow cytometry was most predictive for pathologic stage. Using this approach, 91% of all patients with pathologic stage B, and 77% of the patients with pathologic stage A were correctly classified; test efficiency was 82%. CONCLUSIONS: These results demonstrate an improvement in clinical staging in this group of patients. This paradigm, developed from retrospective analysis, will be tested prospectively in consecutive patients to determine if it is clinically useful.

Aneuploidy↗
PubMed1994

Flow-cytometric and quantitative histologic parameters as prognostic indicators for occult retroperitoneal disease in clinical-stage-I non-seminomatous testicular germ-cell tumors.

Our study was performed to clarify whether the combination of DNA flow-cytometric and quantitative histopathological parameters improves the prediction of occult metastatic disease in clinical stage-I non-seminomatous testicular germ-cell tumors (NSGCT). We used archival paraffin primary-tumor tissue of 67 clinical stage-I NSGCT patients who had undergone retroperitoneal lymph-node dissection (RPLND). According to the RPLND specimens, 24 patients were at pathological stage I and 43 at pathological stage II. Archival blocks were redissected for histological re-evaluation. In addition, 50 microns sections were prepared according to the Hedley technique in order to obtain nuclear suspensions which were processed for flow cytometry (FC). In univariate analysis, the percentage of embryonal carcinoma, the percentage of immature teratoma and vascular invasion were the most accurate predictive histopathological parameters. The percentage of aneuploid cells in S-phase was the best predictive FC parameter. In multivariate analysis, the percentage of embryonal carcinoma and the S-phase fraction of aneuploid cells were the only independent markers for occult metastatic disease. According to this statistical approach, 91.0% of pathological stage-I and stage-II cases were correctly classified. Sensitivity was 95.3% and specificity was 83.3%. Using histopathological criteria alone, only 56.7% NSGCT patients were correctly classified.

Aneuploidy↗
PubMed1994

Stage I nonseminomatous germ-cell testicular cancer--management options and risk-benefit considerations.

The results obtained with primary retroperitoneal lymph-node dissection (RPLND) in 464 patients with clinical stage A nonseminomatous germ-cell (NSGC) testicular cancer over a period of 25 years (1965-1989) were reviewed. Results were analyzed in clinical terms and subdivided into early (1965-1978) and contemporary (1979-1989) findings so as to be comparable with series using radiotherapy or surveillance. Between 1965 and 1978 (86 clinical stage A patients), the overall relapse rate of 15% (n = 13) was similar to that obtained in radiotherapy series but the survival (98.8% after RPLND) was superior to that achieved with irradiation (87%). From 1979 to 1989, 378 clinical stage A cases had primary RPLND, of whom 29% (n = 111) had cancerous nodes. The relapse rate for pathological stage A patients (n = 267) was 11% and two patients died. The rate of relapse for pathological stage B patients who did not receive adjuvant chemotherapy was 32%. No relapse was seen among 46 pathological stage B patients given postoperative adjuvant chemotherapy. The mortality of 0.7% observed among 378 clinical stage A RPLND cases was lower than the 2% value reported in surveillance series. Although not statistically significant, these consistent results reported for two eras (pre- and postplatinum) spanning a period of 25 years suggest a sound basis for the surgical approach. The anatomic and medical principles in oncology, which have supported this approach, remain cogent today. They are discussed herein. Now that nerve-sparing techniques have been developed, the one long-term morbidity of RPLND (i.e., anejaculation) can be avoided.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part I--Vena cava.

A total of 42 patients underwent inferior vena cava resection (n = 40) or intraluminal tumor thrombectomy (n = 2) during retroperitoneal lymph-node dissection (RPLND) for bulky abdominal metastatic nonseminomatous germ-cell cancer (7% of all postchemotherapy RPLND cases). The three indications for caval resection included tumor clearance (38%), caval scar occlusion (14%), and caval tumor thrombus (48%). En bloc caval resection to achieve tumor clearance was justified by subsequent nodal pathology (cancer in 63% of specimens, teratoma in 31% specimens). Caval resection in the presence of scar occlusion was required de facto by virtue of its incorporation in the specimen. Caval resection or thrombectomy is indicated for intraluminal tumor thrombus because thrombus pathology (cancer, 35%; teratoma, 45%; fibrosis, 20%) reflected nodal pathology in 71% of cancer cases, 78% of teratoma cases, and 100% of fibrosis cases. The complications of caval resection were generally transitory. The 71% survival rate justifies this intensive surgical approach because these patients had exhausted all chemotherapeutic options.

Adolescent↗
PubMed1994

Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: Part II.

A total of 710 patients underwent postchemotherapy retroperitoneal lymph-node dissection (RPLND) from 1965 to 1992. Ten patients, all with bulky disease, required aortic replacement either postoperatively (n = 3) or during RPLND (n = 7). The principal risk factor for aortic rupture after RPLND was an extended subadventitial aortic dissection made necessary by tumor fixation. Also, duodenal enterotomy or extensive violation of the bowel serosa was a further risk for aortoenteric fistula. Prospective aortic grafting may be indicated in the presence of these risk factors. In our four elective cases, there was no further vascular or bowel complication. Omental interposition further protects against fistula formation. Although rarely indicated except under the most extenuating circumstances, the exposure requirements of RPLND permit aortic grafting as a relatively straightforward procedure that is feasible and well tolerated in this small subset of patients.

Aorta↗
PubMed1994

Unusual neoplasms detected in testicular cancer patients undergoing postchemotherapy retroperitoneal lymphadenectomy.

Approximately 30% of patients with disseminated testicular cancer who receive platinum-based chemotherapy will experience normalization of tumor markers but have persistent, radiographically evident disease in the retroperitoneum. These patients are usually subjected to retroperitoneal lymph-node dissection (RPLND). In all, 45 of 557 patients (8.1%) undergoing postchemotherapy RPLND at Indiana University Medical Center (IUMC) were found to have neoplastic elements distinct from the classic germ-cell tumor types within their resected specimens. Examples included various sarcomas in 14 patients (3.7%), other nonsarcomatous non-germ-cell cancers in 18 patients (3.2%), and cystic atypical choriocarcinoma in 8 patients (1.4%). No distinct patient characteristic or histologic pattern in the primary tumor was predictive of these unusual findings in the RPLND specimen, although sampling error in the orchiectomy specimen could be the reason for this lack of correlation. Surgical resection of these chemoresistant tumors is potentially curative, with disease-free survival being obtained in 13 of 19 patients (68.4%) with sarcoma, 10 of 18 patients (55.6%) with nonsarcomatous cancers, and 7 of 8 patients (87.5%) with cystic atypical choriocarcinoma at mean follow-up intervals of 30.6, 42.5, and 24.7 months, respectively.

Adult↗
PubMed1994

Predictive parameters in biologic assessment of low-stage retroperitoneal lymph-node dissection.

In all, 30% of patients felt to have clinical stage A nonseminomatous testis cancer in fact have pathologic stage B disease. Although patients with clinical stage A nonseminoma currently enjoy a very high change for cure, a better assignment of therapy at diagnosis could lead to an overall decrease in the morbidity of treatment. This study analyzed orchiectomy specimens from 102 patients with clinical stage A nonseminomatous testis cancer, all of whom underwent pathologic staging via retroperitoneal lymph-node dissection (RPLND). Various parameters of the orchiectomy specimen were analyzed to determine whether or not clinical staging could be improved on the basis of these factors. Statistical analysis resulted in the following model. If the orchiectomy specimen consisted of 100% embryonal carcinoma the patient was classified as being at high risk for retroperitoneal metastasis. In the absence of this finding the aneuploid cell line as determined by flow cytometry was considered. If the percentage of aneuploid cells in the S phase was less than 29% the patient was felt to be at low risk for retroperitoneal metastasis. If this percentage was greater than 29% the patient was classified as being at high risk. Using this paradigm, 77% of pathologic stage A patients and 91% of pathologic stage B patients were correctly classified. The test efficiency was 82%. This pilot study resulted in an interesting model that should be tested prospectively in consecutive patients to determine whether it is clinically useful.

Aneuploidy↗
PubMed1994

Fertility considerations in nerve-sparing retroperitoneal lymph-node dissection.

Nerve-sparing retroperitoneal lymph-node dissection (RPLND) maintains the patient's ability to ejaculate postoperatively. However, since testicular cancer patients sometimes have diminished spermatogenesis, questions have been raised as to the advisability of nerve preservation relative to ultimate fertility. Fertility status was assessed in clinical stage A patients by two methods. These included standard semen analysis and a post-RPLND survey. The results show that approximately 75% of non-seminomatous testicular cancer patients who present in clinical stage A have fertility potential as based on semen analysis. Additionally, of those patients responding to the post-RPLND survey who had attempted pregnancy following RPLND, 76% reported attainment of pregnancy. Nerve-sparing RPLND maintains fertility potential in clinical stage I patients; furthermore, this fertility potential appears to be worth preserving as many patients will be capable of impregnating their partners.

Ejaculation↗
PubMed1994

Complications of primary retroperitoneal lymph-node dissection for low-stage testicular cancer.

The surgical complications encountered in 478 patients who underwent primary retroperitoneal lymph-node dissection for clinical stage A and B nonseminomatous testicular cancer during the period ranging from 1982 to 1992 were reviewed. There were 54 complications in 51 patients (10.6%), and there was no surgery-related mortality. There were 16 minor complications and 38 major complications. The most frequent complication encountered was superficial wound infection, and many of the major complications were related to small-bowel obstruction and atelectasis. The incidence of complications was significantly lower in patients operated on during the last 6 years of the study (1987-1992). The complication rate was lower in patients who underwent modified unilateral procedures than in those who had bilateral dissections. The ejaculation rate of patients undergoing nerve-sparing procedures was 98%. This study reinforces the conclusion that primary retroperitoneal lymph-node dissection is an operation yielding minimal morbidity and no long-standing effect.

Ejaculation↗
PubMed1994

Stage II nonseminomatous germ-cell testicular tumors--the Indiana experience and risk-benefit analysis.

Controversy exists in the appropriate management of patients with nonseminomatous testicular cancer presenting as clinical stage B disease. Traditional treatment in the United States has included retroperitoneal lymph-node dissection (RPLND). Conversely, in Europe and other places some of these patients have been managed with primary chemotherapy. The experience with RPLND in clinical stage B disease at Indiana University from 1965 to 1989 was reviewed. A total of 174 patients were considered to be in clinical stage B prior to RPLND. After RPLND, 23% of these patients (n = 41) were found to have pathological stage A disease. In all, 77% (n = 133) were determined to be in pathological stage B. Of those pathological stage B patients who did not receive adjuvant chemotherapy, 65% were cured by RPLND alone. The pathological stage B patients who went on the receive postoperative adjuvant chemotherapy displayed an overall 14% chance of relapse. (Patients treated early in the series did not receive cisplatin-based chemotherapy.) The overall survival over the entire period was 96%. In the more modern era, during which cisplatin-based chemotherapy was available, the overall survival was 98%. RPLND is an effective procedure for the management of clinical stage B nonseminomatous testicular cancer. It provides excellent survival in patients found to have pathological stage B disease; additionally, it avoids the unnecessary toxicity of chemotherapy in the 23% of patients who in fact are in pathological stage A.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1994

Quantitative DNA measurement by flow cytometry and image analysis of human nonseminomatous germ cell testicular tumors.

Current clinical staging, which includes the use of serum tumor markers and imaging techniques, fails to identify the 30-40% of clinical stage I (CS I) nonseminomatous germ cell testicular tumor (NSGCT) patients who have occult metastatic disease. Therefore, there is a real clinical need to evaluate new biological parameters of the primary tumor that might be useful as predictors of occult metastatic disease. This study was undertaken to compare quantitative DNA measurements by flow cytometry and image analysis in CS I NSGCT, and to analyze the relevance of these parameters for predicting occult lymph node involvement. Different blocks of formalin-fixed, paraffin-embedded NSGCTs of 62 CS I patients who underwent retroperitoneal lymph node dissection between 1985 and 1989 were prepared according to the Hedley technique, and analyzed by quantitative cytometry. Thirty-six (58.1%) patients had histologically proven lymph node involvement (pathological stage II), whereas 26 (41.9%) patients (pathological stage I) had neither lymph node metastases according to retroperitoneal lymph node dissection (RPLND) specimens nor tumor recurrence during follow-up. Concordant results were found in 76.5% of the samples by both cytometric techniques. For flow cytometry, the percentages of aneuploid cells in the S- and the G2M + S-phase were the most robust predictive parameters for lymph node involvement, whereas for image analysis the 5c exceeding rate (5cER) had the most predictive significance. Based on the experience obtained in this study, both cytometric techniques provide additional information on tumor aggressiveness that might be useful in therapeutic selection of early stage NSGCT patients for either RPLND or surveillance only.

DNA, Neoplasm↗
PubMed1994

High-intensity focused ultrasound in the treatment of prostatic tissue.

OBJECTIVE: Beginning in 1987, high-intensity focused ultrasound was investigated in the canine model to determine the feasibility of destroying prostate tissue. After demonstrating the ability to ablate prostate tissue reliably in a canine model, a 15-patient pilot clinical study was undertaken at Indiana University in the fall of 1992. This pilot study was undertaken to assess the safety in the human clinical situation, as well as to give some early efficacy results. METHODS: The early canine feasibility studies were conducted via a suprapubic extracorporeal approach using two separate transducers, one for imaging and the other for therapy. Subsequent to this, a transrectal probe, which had the dual capability of both imaging and therapy, was developed and used to treat canine prostates in a formal, "good laboratory practice" study to determine the safety of this technology prior to beginning treatment of human benign prostatic hypertrophy. RESULTS: The formal canine studies demonstrated that prostatic tissue could be reliably ablated in the therapy zone. The dosimetry and duty cycle required to ablate canine prostatic tissue effectively was also determined in this study. The study also demonstrated that the prostatic tissue could be ablated without injury to the intervening rectal tissue or periprostatic tissue. The human pilot study has also demonstrated safety of high-intensity focused ultrasound, as well as early efficacy. CONCLUSIONS: These early clinical results are encouraging, but assessment of efficacy will require a randomized study comparing high-intensity focused ultrasound to sham and to transurethral prostatectomy. This multicenter trial is currently planned.

Animals↗
PubMed1994

The fertility of patients with clinical stage I testis cancer managed by nerve sparing retroperitoneal lymph node dissection.

Nerve sparing retroperitoneal lymph node dissection reliably preserves emission and ejaculation in patients with clinical stage I nonseminoma. The fertility of 51 patients who underwent nerve sparing retroperitoneal lymph node dissection was assessed by 3 different methods: standard semen analysis, analysis of chromatin content by deoxyribonucleic acid histogram and assessment of ultimate fertility status by a questionnaire. Approximately 75% of these patients have semen analyses generally considered to be in the normal range. Virtually all patients who underwent deoxyribonucleic acid histogram analysis had histograms similar to controls. A retrospective analysis of fertility was performed in 201 patients who had previously undergone nerve sparing retroperitoneal lymph node dissection. Of these patients who attempted pregnancy after nerve sparing retroperitoneal lymph node dissection 76% have been successful. Approximately 75% of patients who present with clinical stage I nonseminoma are potentially fertile. Nerve sparing retroperitoneal lymph node dissection is capable of preserving this potential in allowing these patients to father children.

Female↗
PubMed1994

Unusual neoplasms detected in testis cancer patients undergoing post-chemotherapy retroperitoneal lymphadenectomy.

Approximately 30% of patients with disseminated testis cancer who receive platinum-based chemotherapy will experience normalization of tumor markers but have persistent, radiographically evident disease in the retroperitoneum. These patients usually undergo retroperitoneal lymph node dissection. Of 557 patients undergoing post-chemotherapy retroperitoneal lymph node dissection at our university medical center 45 (8.1%) had neoplastic elements distinct from the classical germ cell tumor types within the resected specimens. Examples include various sarcomas in 19 patients (3.7%), other nonsarcomatous nongerm cell cancers in 18 (3.2%) and cystic atypical choriocarcinoma in 8 (1.4%). No distinct patient characteristics or histological patterns in the primary tumor are predictive of these unusual findings in the retroperitoneal lymph node dissection specimen, although sampling error in the orchiectomy specimen could be the reason for this lack of correlation. Surgical resection of these chemoresistant tumors is potentially curative, with disease-free survival in 13 of 19 patients (68.4%) with sarcoma, 10 of 18 (55.6%) with nonsarcomatous cancer and 7 of 8 (87.5%) with cystic atypical choriocarcinoma at a mean followup of 30.6, 42.5 and 24.7 months, respectively.

Combined Modality Therapy↗
PubMed1994

Nerve sparing retroperitoneal lymphadenectomy after primary chemotherapy for metastatic testicular carcinoma.

Initial success with nerve sparing retroperitoneal lymph node dissections in patients with low stage nonseminomatous germ cell tumors of the testis has led to the application of these techniques to a select group of 40 patients treated after chemotherapy at our institution between March 1988 and November 1991. A minimum 1-year followup was available for 38 patients. There have been no abdominal relapses, and 34 of the 38 patients report normal ejaculation postoperatively. Nerve sparing techniques are applicable to select patients undergoing retroperitoneal lymph node dissection after primary chemotherapy for metastatic disease without increasing the chance of local recurrence. Emission and ejaculation are preserved in the majority of patients.

Adult↗
PubMed1994

Benign testicular tumor associated with Klinefelter's syndrome.

Testicular tumors associated with Klinefelter's syndrome are rare. We report a benign testicular epidermal cyst that was diagnosed in a patient with Klinefelter's syndrome. The association between testicular tumors and Klinefelter's syndrome, and management of a testicular epidermal cyst are discussed.

Adolescent↗