[Treatment of bladder cancer in the elderly]

BACKGROUND

In Germany, bladder cancer is the fourth most common malignancy in males, while it occupies the 14th place in females. About 75% of cases occur in patients aged 65 or more years.

OBJECTIVES

Elderly patients with nonmuscle-invasive bladder cancer appear to harbor a higher risk of disease recurrence and progression and should undergo the same treatment and careful surveillance as their younger counterparts. Elderly patients with muscle-invasive bladder cancer undergoing radical cystectomy are at an increased risk of perioperative morbidity and mortality and should be referred to experienced high-volume centers.

CONCLUSION

Beside radical cystectomy as standard treatment, several bladder-sparing approaches (transurethral resection, chemotherapy, radiotherapy, chemoradiotherapy) are available which may be treatment alternatives in carefully selected cases. Valid randomized comparisons between these approaches and radical cystectomy are, however, still lacking.

[Organ and function preservation in prostate cancer]

BACKGROUND

Curative treatment for prostate cancer is associated with risks which may adversely influence quality of life. Furthermore, there is a considerable rate of overdiagnosis of tumors which would be non-life-threatening if left untreated. Efforts have been made to reduce overtreatment.

DISCUSSION

Beside the traditional conservative symptomatic management especially in elderly patients with meaningful comorbidity, several prostate-sparing or deferred treatment options are currently discussed. For all of them, insufficient data on efficacy and safety are available.

RESULTS

Because of the required long-term follow-up of large sample sizes, conclusive data will not become available in the near future. Therefore, these treatment options have to be considered experimental to a large degree. This applies both to focally ablative techniques and to active surveillance of prostate cancer in patients with a long further life expectancy. Only in carefully selected patients with favorable tumor-associated risk profiles and high risk of medium-term competing mortality may active surveillance be considered a valid and relatively safe treatment option.

[Prostate-specific antigen for treatment monitoring]

Today, most incident prostate cancer cases are diagnosed in early and thus potentially curable stages because of the determination of prostate-specific antigen (PSA). Treatment monitoring is another important aspect of the tumor marker PSA. In this article, contemporary recommendations for the use of PSA in treatment monitoring are discussed in the settings of active surveillance, radical prostatectomy and radiotherapy.

[Acute abdominal pain due to a ventriculo-peritoneal shunt metastasis of an intracranial germ cell tumor]

INTRODUCTION

Extracranial metastases of pineal germinomas are rare.

CASE REPORT

The case of a metastasis of a primary intracranial germ cell tumor via a temporary-ventriculo-peritoneal shunt as a cause of acute abdominal pain is reported. The germ cell tumor markers were useful in establishing the diagnosis.

CONCLUSIONS

With an appropriate clinical history, intra-abdominal metastases via a temporary ventriculo-peritoneal shunt should be considered in the differential diagnosis of acute abdominal pain.

[Treatment of locally advanced prostate cancer]

The management of clinically locally advanced prostate carcinoma (cT3) remains a controversial issue. The clinical stage cT3 consists of a mixture of overstaged T2 carcinomas but also contains lymph node-positive cases. Treatment options consist of radical prostatectomy, external beam radiotherapy, hormonal deprivation (early or delayed) and the so-called watchful waiting. In many cases multimodal therapy is used. Radical prostatectomy in the clinical stage T3 can achieve acceptable tumour-specific survival rates if patients are well selected. In this way, tumour-specific survival rates can be reached for pT3 patients which closely approach those of pT2 cases. In lymph node-positive cases after radical prostatectomy adjuvant hormonal treatment can prolong survival, but not in lymph node-negative cases. A benefit of adjuvant radiotherapy after radical prostatectomy has not been proven. Although it can postpone or prevent biochemical recurrence, it does not prolong overall survival. Treatment of stage cT3 by external beam radiotherapy alone results in unfavourable tumour-specific survival rates. In these cases definite improvement can be achieved by adjuvant androgen deprivation with LHRH analogues. If in case of severe comorbidity or advanced age primary hormonal treatment is chosen, early vs deferred treatment seems to prolong survival marginally.

Bedeutung von Komorbidit�t und Alter bei der radikalen Prostatektomie

The coexistence of another diagnosis beside the index disease under study is defined as comorbidity. Comorbidity increases with advancing age. In candidates for radical prostatectomy, two aspects of comorbidity are of interest: its association with perioperative complications and long-term survival. The Charlson score is the most extensively studied comorbidity classification for the prediction of long-term outcome. Several studies have identified this score as an independent prognostic factor in the prostate cancer setting. In addition to the Charlson score, data collected during the preoperative cardiopulmonary risk assessment may deliver information identifying patients with an increased long-term mortality risk. The meaningfulness of comorbidity in predicting overall mortality seems to be comparable to that of the Gleason score, the most important tumor-related predictor of survival in prostate cancer. The identification of prognostically relevant single conditions and the development of a "radical prostatectomy-specific" comorbidity classification might improve the stratification of candidates for radical prostatectomy in the future.

[PSA rise after radical prostatectomy]

Approximately 18 % of patients will experience PSA failure only after radical prostatectomy. The rate of clinical (local or systemic) recurrence is in the same range. Clinical recurrence is accompanied by an increasing PSA in almost all cases. Altogether, the 10-year risk of PSA recurrence after radical prostatectomy for clinically localized prostate cancer is about 35 %. PSA relapse precedes the development of metastases by a median time of 8 years. The median survival after the manifestation of metastases is about 4-5 years. To differentiate the reasons of PSA failure, recurrence-free interval, Gleason score and PSA doubling time deliver important information. Patients with a high probability of isolated local failure (PSA relapse later than two years after radical prostatectomy) should undergo a biopsy, if a local radiotherapy is considered. The results of current clinical trials are eagerly awaited to answer the question weather immediate, delayed or intermittent hormonal therapy offer best results in individual cases.

pH-induced denaturation of spectrin changes the interaction of membrane proteins in erythrocyte ghosts. Biochemical and electron microscopic evidence

The influence of different buffer pH values on the properties of spectrin in erythrocyte ghosts and on isolated spectrin was investigated. Ultrastructural findings and the results of biochemical studies show that denaturation and aggregation of spectrin molecules rather than disulfide crosslinking are responsible for the precipitation of spectrin in acidic buffer. Since hemolysis in hypotonic buffer at pH 6.0 yields ghosts with spicules and microvesicles, the structure of spectrin in intact cells might also be changed and lead to the clustering of transmembrane proteins and the aggregation of components of the cytoplasmic network.