Comparison of anti-fracture effectiveness of zoledronate, ibandronate and alendronate versus denosumab in a registry-based cohort study

This registry-based study of 3068 patients with osteoporosis compared the anti-fracture effectiveness of denosumab versus bisphosphonates. Denosumab was associated with significantly greater risk reduction than alendronate or ibandronate for vertebral and any fractures. No difference in fracture risk reduction was found between zoledronate and denosumab.

PURPOSE

To analyse the fracture risk of patients with osteoporosis receiving bisphosphonates or denosumab in a real-world setting.

METHODS

This registry-based cohort study evaluated patients taking denosumab, bisphosphonates or both sequentially. Fractures were analysed using rates, rate ratios and hazard ratios (HR), including both therapies as time-varying co-variates. Fracture risk hazards were adjusted (aHR) for baseline T-Scores and trabecular bone score (TBS) and were additionally analysed with inverse probability treatment weighting.

RESULTS

A total of 3068 patients (89% female; median age at treatment onset, 69 years [63 to 76]) received denosumab (median duration 2.8 years, [2.2 to 4.7]), bisphosphonates (3.4 years, [2.1 to 5.7]) or both sequentially. Thus, 11,078 subject-years were assessed for bisphosphonates (41% alendronate, 36% ibandronate, 23% zoledronate) and 4216 for denosumab. Moreover, 48,375 subject-years were observed before treatment onset, in addition to 2593 years of drug holidays. A total of 1481 vertebral fractures (435 under therapy), 1508 non-vertebral fractures (499 under therapy) and 202 hip fractures (67 under therapy) occurred after age 50. The risks of vertebral, non-vertebral and hip fractures were significantly lower under all bisphosphonates, denosumab and drug holidays than before treatment onset (all p < 0.001). After adjusting for age, baseline T-scores and TBS, denosumab was associated with lower risk than alendronate or ibandronate for vertebral fractures (aHR 0.47 (0.35 to 0.64) and 0.70 [0.53 to 0.91], p < 0.001 and p = 0.009, respectively) and any fractures (aHR 0.62 [0.51 to 0.76] and 0.77 [0.64 to 0.92], p < 0.001 and p = 0.004). With propensity weighting, denosumab was associated with a lower hip fracture risk compared to alendronate (HR 0.54 [0.29 to 0.98], p = 0.044). No difference in fracture risk reduction (vertebral, non-vertebral or hip) was found between zoledronate and denosumab.

CONCLUSIONS

When adjusting for disease severity, denosumab was associated with significantly greater risk reduction than alendronate and ibandronate for vertebral fractures. No difference in fracture risk reduction was found between zoledronate and denosumab.

Effects of zoledronate on bone mineral density and bone turnover after long-term denosumab therapy: Observations in a real-world setting

BACKGROUND

The rebound effect after denosumab discontinuation is lessened with subsequent zoledronate therapy. However, it is unclear whether this mitigation is sufficient after long-term denosumab treatment.

OBJECTIVE

This retrospective observational study analysed bone mineral density (BMD) and bone turnover marker (BTM) changes after denosumab therapy according to treatment duration and subsequent zoledronate regimen.

METHODS

We measured the outcomes of 282 women with postmenopausal osteoporosis who discontinued denosumab and received zoledronate 6 months later. In patients with longer denosumab therapy (≥5 years), BTMs were measured every 3 months and a second zoledronate infusion was administered if BTM levels increased by ≥2-fold. The BMD of all women was measured before denosumab therapy, at the last injection and 1 to 2 years after the first zoledronate.

RESULTS

Bone loss after switching from denosumab to zoledronate was higher in patients with 10 ± 2 denosumab injections (n = 84) compared to 5 ± 2 injections (n = 144, p < 0.001 for lumbar spine and femoral neck), but there was no further increase with treatment durations of ≥15 ± 2 injections (n = 54, p = 0.35 and p = 0.20, respectively). BTMs in patients with ≥10 denosumab injections were elevated 6 months after zoledronate in some patients, but not all. Twenty-four women received a second zoledronate dose 6 months after the first one. BTMs in these patients were subsequently lower, but bone loss at both the lumbar spine and hip was comparable to that in patients with only one zoledronate dose (p = 0.37 for lumbar spine and p = 0.97 for femoral neck).

CONCLUSIONS

Rebound-associated bone loss reached a plateau after denosumab treatment durations of 4-6 years, irrespective of the frequency of subsequent zoledronate therapy.

Incidence of Atypical Femoral Fractures in Patients on Osteoporosis Therapy – a Registry‐based Cohort Study

Atypical femoral fractures (AFFs) have been reported in patients taking bisphosphonates (BPs) for osteoporosis therapy but also in patients with no exposure to these drugs. In contrast, less is known about the incidence of AFFs in patients taking denosumab. This registry‐based cohort study analyzed the incidence of AFFs in patients with suspected or confirmed osteoporosis who were included in the osteoporosis register of the Swiss Society of Rheumatology between January 2015 and September 2019. Statistical analyses included incidence rates, rate ratios, and hazard ratios for AFFs, and considered sequential therapies and drug holidays as time‐dependent covariates. Among the 9956 subjects in the cohort, 53 had subtrochanteric or femoral shaft fractures. Ten fractures occurred under BP or denosumab treatment and two under teriparatide therapy. Five fractures were classified as AFFs based on the revised American Society of Bone and Mineral Research case definition of AFFs from 2014. Three AFFs occurred in women being treated with denosumab at the time of diagnosis, all with prior BP use (10, 7, and 1 years, respectively). One AFF developed in a woman receiving ibandronate and one arose in a woman receiving glucocorticoids rather than antiresorptive therapy. The incidence of AFFs per 10,000 observed patient‐years was 7.1 in patients receiving denosumab and 0.9 in patients with BP‐associated AFFs, yielding a rate ratio of 7.9 (95% confidence interval [CI] 0.63–413), p = 0.073. The risk of AFFs was not significantly higher in patients receiving denosumab therapy compared with BP therapy (hazard ratio = 7.07, 95% CI 0.74–68.01, p = 0.090). We conclude that the risk of AFFs is low in patients taking BPs, denosumab, or both sequentially. All three patients with AFFs under denosumab therapy had undergone prior BP therapy. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Risk of Osteonecrosis of the Jaw Under Denosumab Compared to Bisphosphonates in Patients With Osteoporosis

Osteonecrosis of the jaw (ONJ) is a rare but serious adverse event associated with antiresorptive treatment. There is little evidence regarding the incidence of ONJ among patients with osteoporosis who are treated with denosumab versus bisphosphonates (BPs). The aim of this study was to determine the risk of ONJ in a real-world population. Subjects who underwent at least one dual-energy X-ray absorptiometry (DXA) examination were included in the osteoporosis register of the Swiss Society of Rheumatology between January 1, 2015, and September 30, 2019. Statistical analyses included incidence rates, rate ratios, and hazard ratios for ONJ, considering sequential therapies and drug holidays as covariates. Among 9956 registered patients, 3068 (89% female, median age 69 years [63 to 76]) were treated with BPs or denosumab for a cumulative duration of 11,101 and 4236 patient-years, respectively. Seventeen cases of ONJ were identified: 12 in patients receiving denosumab at the time of ONJ diagnosis and 5 in patients receiving oral or intravenous BP therapy. The diagnosis of ONJ was confirmed by independent and blinded maxillofacial surgeons, using the American Association of Oral and Maxillofacial Surgeons case definition of ONJ. The incidence of ONJ per 10,000 observed patient-years was 28.3 in patients receiving denosumab and 4.5 in patients with BP-associated ONJ, yielding a rate ratio of 6.3 (95% confidence interval [CI] 2.1 to 22.8), p < 0.001. Nine of 12 patients who developed ONJ during denosumab treatment had been pretreated with BPs, but none of the 5 patients with BP-related ONJ had previously received denosumab. The risk of ONJ was higher in patients receiving denosumab therapy compared with BPs (hazard ratio 3.49, 95% CI 1.16 to 10.47, p = 0.026). Previous BP therapy before switching to denosumab may be an additional risk factor for ONJ development. © 2021 American Society for Bone and Mineral Research (ASBMR).

Risk factors for vertebral fractures and bone loss after denosumab discontinuation: A real-world observational study

BACKGROUND

Denosumab discontinuation without subsequent bisphosphonates (BPs) is associated with bone loss and multiple vertebral fractures.

OBJECTIVE

Identifying risk factors for bone loss and vertebral fractures after denosumab discontinuation.

METHODS

This retrospective study measured the outcome of 219 women with osteoporosis who discontinued denosumab treatment and received subsequent treatment with zoledronate, other BPs or a selective estrogen receptor modulator (SERM), or no therapy. Fracture rate, longitudinal bone mineral density (BMD) changes and bone turnover markers (BTMs) within 2 years after denosumab discontinuation were analysed. Linear regression analysis evaluated loss of BMD and age, BMI (kg/m²), denosumab treatment duration, pre-treatment, prior fracture state, baseline T-scores, use of glucocorticoids or aromatase inhibitors and BMD gains under denosumab therapy.

RESULTS

171 women received zoledronate after denosumab discontinuation, 26 had no subsequent treatment and 22 received other therapies (other BPs or a SERM). Zoledronate was associated with the fewest vertebral fractures (hazard ratio 0.16, p = 0.02) and all subsequent therapies retained BMD at all sites to some extent. Higher BMD loss was associated with younger age, lower BMI, longer denosumab treatment, lack of prior antiresorptive treatment and BMD gain under denosumab treatment. BTM levels correlated with denosumab treatment duration and bone loss at the total hip, but not the lumbar spine.

CONCLUSIONS

Compared to no subsequent therapy, zoledronate was associated with fewer vertebral fractures after denosumab. Further, BMD loss depended on denosumab treatment duration, age, prior BP therapy and BMD gain under denosumab therapy, whereas BTM levels were associated with bone loss at the total hip and denosumab treatment duration.

A Single Infusion of Zoledronate in Postmenopausal Women Following Denosumab Discontinuation Results in Partial Conservation of Bone Mass Gains

Discontinuation of denosumab is associated with a rapid return of bone mineral density (BMD) to baseline and an increased risk of multiple vertebral fractures. No subsequent treatment regimen has yet been established for preventing either loss of BMD or multiple vertebral fractures after denosumab discontinuation. The aim of this 8-year observational study was to investigate the effect of a single zoledronate infusion, administered 6 months after the last denosumab injection, on fracture occurrence and loss of BMD. We report on 120 women with postmenopausal osteoporosis who were treated with 60 mg denosumab every 6 months for 2 to 5 years (mean duration 3 years) and then 5 mg zoledronate 6 months after the last denosumab injection. All patients were evaluated clinically, by dual-energy X-ray absorptiometry (DXA) and vertebral fracture assessment (VFA), before the first and after the last denosumab injection and at 2.5 years (median) after denosumab discontinuation. During this off-treatment period, 3 vertebral fractures (1.1 per 100 patient-years) and 4 nonvertebral fractures (1.5 per 100 patient-years) occurred. No patients developed multiple vertebral fractures. Sixty-six percent (confidence interval [CI] 57% to 75%) of BMD gained with denosumab was retained at the lumbar spine and 49% (CI 31% to 67%) at the total hip. There was no significant difference in the decrease of BMD between patients with BMD gains of >9% versus <9% while treated with denosumab. Previous antiresorptive treatment or prevalent fractures had no impact on the decrease of BMD, and all bone loss occurred within the first 18 months after zoledronate infusion. In conclusion, a single infusion of 5 mg zoledronate after a 2- to 5-year denosumab treatment cycle retained more than half of the gained BMD and was not associated with multiple vertebral fractures, as reported in patients who discontinued denosumab without subsequent bisphosphonate treatment. © 2020 American Society for Bone and Mineral Research.

Impact of viral E2-gene status on outcome after radiotherapy for patients with human papillomavirus 16-positive cancer of the uterine cervix

PURPOSE

Integration of high-risk papillomavirus DNA has been considered an important step in oncogenic progression to cervical carcinoma. Disruption of the human papillomavirus (HPV) genome within the E2 gene is frequently a consequence. This study investigated the influence of episomal viral DNA on outcome in patients with advanced cervical cancer treated with primary radiotherapy.

METHODS AND MATERIALS

Paraffin-embedded biopsies of 82 women with locally advanced cervical cancer could be analyzed for HPV infection by multiplex polymerase chain reaction (PCR) by use of SPF1/2 primers. E2-gene intactness of HPV-16-positive samples was analyzed in 3 separate amplification reactions by use of the E2A, E2B, E2C primers. Statistical analyses (Kaplan-Meier method; log-rank test) were performed for overall survival (OS), disease-free survival (DFS), local progression-free survival (LPFS), and distant metastases-free survival (DMFS).

RESULTS

Sixty-one (75%) of 82 carcinomas were HPV positive, 44 of them for HPV-16 (72%). Seventeen of the 44 HPV-16-positive tumors (39%) had an intact E2 gene. Patients with a HPV-16-positive tumor and an intact E2 gene showed a trend for a better DFS (58% vs. 38%, p = 0.06) compared with those with a disrupted E2 gene. A nonsignificant difference occurred regarding OS (87% vs. 66%, p = 0.16) and DMFS (57% vs. 48%, p = 0.15).

CONCLUSION

E2-gene status may be a promising new target, but more studies are required to elucidate the effect of the viral E2 gene on outcome after radiotherapy in HPV-positive tumors.

Correlation between the tumoral expression of beta3-integrin and outcome in cervical cancer patients who had undergone radiotherapy

Integrins are cell-surface receptors, which mediate cell-to-cell and cell-to-extracellular matrix adhesion. Besides playing an important role in tumour angiogenesis, β3-integrin is also expressed in several types of epithelial cancer cells. It was the purpose of the present study to evaluate the prognostic value of β3-integrin expression in patients with cervical cancer. Biopsies were taken from 82 patients with squamous cell or adenocarcinomas of the uterine cervix who had undergone external-beam radiotherapy with or without brachytherapy. These tissue samples were analysed immunohistochemically for the expression of β3-integrin. The impact of immunoreactivity for β3-integrin on survival end points was assessed by univariate and multivariate analyses, and its correlation with clinicopathological characteristics evaluated by crosstabulations. β3-integrin was expressed in 61% (50 of 82) of the patients. Kaplan–Meier curves revealed local progression-free survival, distant metastasis-free survival and cause-specific survival to be significantly shorter (P-values according to the log-rank test: 0.002, 0.04 and 0.01, respectively) in patients with β3-integrin expression. The prognostic impact of this parameter was even higher than for other well-known prognostic parameters and remained statistically significant in the multivariate analyses. β3-integrin, which is expressed in the majority of patients with advanced cervical cancer, has a significant prognostic impact on outcome according to univariate and multivariate analyses.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG)

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Significant correlation of hypoxia-inducible factor-1alpha with treatment outcome in cervical cancer treated with radical radiotherapy

PURPOSE

In the early stages of cervical cancer treated with surgery alone, hypoxia-inducible factor-1alpha (hif-1alpha) expression is prognostic for overall survival. Because hypoxia plays an important role in radiation resistance, we investigated hif-1alpha expression in cervical cancer treated with local radical radiotherapy (RT).

METHODS AND MATERIALS

Between 1990 and 1998, 91 patients with squamous cell or adenocarcinoma of the uterine cervix were treated with external beam RT with and without brachytherapy. Biopsies from 78 patients were available for immunohistochemistry. The impact of the immunoreactivity of hif-1alpha in regard to survival end points was determined by univariate and multivariate analyses. Correlations with clinicopathologic characteristics were determined by cross-tabulations.

RESULTS

Hif-1alpha was expressed in 73 (94%) of 78 patients. It was closely linked to the pretreatment hemoglobin level (p = 0.04, r = -0.22, Spearman correlation test). The Kaplan-Meier curves showed a significantly shorter local progression-free survival (p = 0.04, log-rank) and overall survival (p = 0.01, log-rank) and a trend for shorter disease-free survival (p = 0.15) for patients with increased hif-1alpha expression. The multivariate analyses revealed hif-1alpha expression to be an independent factor for overall survival (p = 0.02).

CONCLUSION

Hif-1alpha is expressed in the vast majority of patients with advanced cervical cancer and had a prognostic significance. A weak but significant correlation was noted with pretreatment hemoglobin level.

Bladder substitution in women

Bladder substitution in women with transitional cell carcinoma (TCC) is not a universally accepted procedure. There are many concerns, one of which is the potential risk of metachronous and synchronous urethral transitional cell carcinoma involvement. Another concern is that voiding dysfunction may be more frequent than in male patients. The numbers of female patients who have had this procedure are still small, and follow-up data are relatively brief. Thus, the true role for orthotopic bladder substitution in the female is still being evaluated. This paper reviews the data on this type of surgery in women, with emphasis on urethral TCC risk and on voiding dysfunction. Early results from a number of institutions are encouraging, particularly in correctly selected patients. Based on more than 15 years experience in an albeit small number of patients, we believe that if there is a functional external sphincter and tumor margins can be safely cleared, this form of surgery offers patients the best opportunity to preserve quality of life following cystectomy.

How to treat blunt kidney ruptures: primary open surgery or conservative treatment with deferred surgery when necessary?

OBJECTIVE

We analyzed two consecutive series of 69 and 34 patients, respectively, with kidney ruptures covering two time periods with different treatment strategies to assess whether outcome is better after initial surgical or initial conservative treatment.

METHODS

One hundred and three patients with blunt kidney ruptures grade 2-4 (American Association for the Surgery of Trauma) excluding patients with pedicle injuries of the main renal vessels were evaluated. In the first time period, 1973-1988 (group A) the primary routine treatment of blunt kidney rupture at our institution was surgical. In the second time period 1989- 1995 (group B) the treatment was primarily conservative. Surgery was deferred and performed only if necessary. Rates of surgery, time of surgery, surgical procedures (open or minimal invasive) and loss of renal parenchyma by surgery or trauma were analyzed for the two time periods. Blood loss was estimated for all patients. Postoperative hypertension was evaluated for all patients excluding those who were treated by nephrectomy.

RESULTS

In group A 42 of the 69 patients had 42 surgical interventions (61%) and in group B 11 of the 34 patients had 12 interventions (35%). Thirty-nine of the 69 group A patients (57%) had immediate surgery and 3 (4%) had deferred surgery. In group B 1 of the 34 patients (3%) had immediate surgery and 11 (32%) had deferred surgery. All interventions in group A were open. In group B 5 of the 12 interventions were minimally invasive (percutaneous or internal drainage with a JJ-stent). Partial or total nephrectomies were performed in 33 of the 42 surgically treated group A patients (79%) and in 5 of the 12 group B patients (42%). Blood loss in patients with isolated grade 4 kidney rupture seems to be less when treated conservatively or with deferred surgery than with immediate open surgery. The hypertension rate in patients after blunt kidney rupture is 10%; in a similar control population without renal trauma it is 12%.

CONCLUSION

Patients with primary conservative treatment of blunt kidney rupture seem to need less surgery, especially less open surgery and loose less blood and renal parenchyma than patients treated by initial surgery. Posttraumatic hypertension is not higher than in a similar control population, independent of the treatment.

Maximum androgen blockade using LHRH agonist buserelin in combination with short-term (two weeks) or long-term (continuous) cyproterone acetate is not superior to standard androgen deprivation in the treatment of advanced prostate cancer. Final analysis of EORTC GU Group Trial 30843. European Organization for Research and Treatment of Cancer (EROTC) Genito-Urinary Tract Cancer Cooperative Group

This is the final analysis of EORTC GU Group Trial 30843 in which the treatment of advanced, metastatic prostate cancer with a combination of the LHRH agonist buserelin (nasal spray) and cyproterone acetate (Androcur), either continuously of only during the first 2 weeks, was compared with orchidectomy. There was no significant difference between the three arms as far as response rate, time to progression (subjective and objective) and duration of survival are concerned. Retrospective stratification according to the most important prognostic factors did not change the conclusions. Possible reasons for the difference with trial 30853, which used the same entry criteria but compared goserelin and flutamide with orchidectomy, are discussed. Reasons for using cyproterone acetate in combination treatment are the prevention of flare of the disease after LHRH agonists only and the prevention/reduction of toxicity in the form of hot flushes.

[The therapy of equine sarcoid with a non-specific immunostimulator--the epidemiology and spontaneous regression of sarcoids]

20 sarcoid-affected horses from a practice in the northern Jura were used in this experiment. The mean age of the 20 horses was 3.9 years at the time of the first observation of sarcoid tumors. On the average, 4.4 tumours were noted per horse. 10 of the horses were treated in a double-blind study with an unspecific immunostimulant (Baypamun P), 10 others received a placebo. One single tumour only was treated per horse. The injections were given under and around the sarcoid. In eight out of the 20 horses all tumours regressed totally or for more than 50% of their initial size. Five of these had received placebo, three the immunostimulant. Four animals showed a modest, but measurable reduction in tumour size (3 immuno-stimulant, 1 placebo) and in the remaining eight horses (4:4) no reduction or even an increase in tumour size was observed. The phenomenon of tumour regression was very probably due to spontaneous regression and horses which had been observed to develop sarcoid within the last three months had significantly more regressions than animals with older tumours (p < 0.05). The haplotype of the equine leucocyte antigens was thought to predispose 12 of the 20 horses for the sarcoid. However, the ELA-type did not measurably influence the phenomenon of tumour regression.

Orchidectomy versus Buserelin in combination with cyproterone acetate, for 2 weeks or continuously, in the treatment of metastatic prostatic cancer. Preliminary results of EORTC-trial 30843

This prospective randomized phase III trial compares orchidectomy as standard androgen-deprivative therapy of advanced (metastatic) prostatic cancer with treatment using the LHRH agonist Buserelin administered as nasal spray 3 daily doses of 400 micrograms, and combined with cyproterone acetate (CPA) 3 daily doses of 50 mg orally for 2 weeks initially to prevent flare-up of the disease, or continuously as complete androgen blockade. The trial was closed to entry in September 1989 when 367 patients were recruited. Patients were stratified for performance status (WHO) and metastatic status prior to randomization. According to patient and disease characteristics spreading of patients over the 3 arms was without statistical significant differences. Ineligibility was 5 and 4% of the patients were only partly evaluable. In March 1990 a first, preliminary analysis was performed. At that time 207 patients were off-study for progression or death and median follow-up was 1 yr. As to time-to-progression and survival there were no significant differences between the 3 arms. The meaning of this in regard to results of other trials with complete androgen blockade is discussed.

[Diagnostic and therapeutic problems in angiomyolipoma of the kidney]

The diagnostic problems are being discussed specifically in 9 patients with angiomyolipoma. Ultrasound and computerised tomography show clear results in tumours with a fatty structure, where angiography is a better method to show vascular elements. Where an inhomogeneous tissue structure is given, an exact diagnosis is only possible by using a combination of different examination methods. It is important to define a renal cell carcinoma preoperatively, as during the operation a differentiation from an angiomyolipoma is in most cases not possible. With a correct diagnosis an organ saving operation can be performed on symptomatic patients, respectively a conventional management can be discussed for the treatment of asymptomatic patients.

Results of curative pion therapy at SIN

The experiences of the treatment of bladder carcinoma indicated the direction in which the dose optimization program of intraabdominal tumours can be carried out. Small intraabdominal target volumes seem to tolerate doses from 31 to 33 Gy applied in 20 fractions. The best results with local tumour control and low complication rates have so far been reached in carcinoma of the cervix. It has not so far been organizationally possible at SIN to treat with pions on more than four days per week. This restricts changes to the fractionation scheme in the treatment of highly malignant gliomas. An improvement of results could be possible on the basis of experience to date. The significance of a postbiopsy preoperative radiotherapy, of the increase of target volume and the increase of the total dose will be tested in a study by the SAKK (Swiss Group for Clinical Cancer Research).

[Fine needle puncture of prostatic cancer]

Before commencing treatment for prostatic cancer the diagnosis must be confirmed by microscopic examination of prostatic tissue. Fine-needle aspiration biopsy by an experienced clinician is as accurate as the more invasive Tru-cut or Vim-Silverman needle biopsies. It involves fewer complications such as hemorrhage or infection, and does not require anesthesia. From 1971 to 1981 we performed more than 2300 fine needle biopsies including 2209 in outpatients. Only 4 patients (0.18%) needed hospitalizing for severe complications. Where the clinical examination prompts suspicion of prostatic cancer and the first fine needle biopsy is negative, the procedure should be repeated. When repeated aspirations were performed only 4 (2%) false negative cytologies were found out of 195 patients in whom prostatic cancer was clinically evident and confirmed by either cytology or histology. False negative cytological results are usually due to sampling errors by the physician rather than interpretation by the cytologist. The histology was false negative in 11.5% of 200 cases and this was due to failure of transurethral resection to reach a focal carcinoma situated in the capsule or sphincter region. Identical histological and cytological grading was found in 66% of the 168 cases where both investigations were positive. If a difference of one grade was accepted, the concurrence is 99%. The results of fine needle biopsy depend on the skill of the clinician in obtaining the right sample, and especially on the experience of the cytologist in its interpretation.

[Psycho-social reintegration of the urostoma patient]

In certain functional disorders of the urinary bladder or invasive carcinoma, cystectomy with urinary diversion to the abdominal wall (urostomy) is indicated and life-prolonging. In order to know what the consequences were for these patients, and if their life with a urostomy is still outwardly worth living, 66 of our urostomy patients have been surveyed. Only one patient is on a disablement pension because of the urostomy. The limitations on leisure are mostly the realms of sport and travel; married life, despite sexual problems, is comparatively little affected. The causes for the limitations are discussed. For most patients the urinary diversion brought an improvement in "life comfort", and, generally, it can be said that urostomy is not an disabling operation and psychosocial reintegration is possible.

[Cause and therapeutic consequence of arterial hypertension and kidney tuberculosis]

In 36 patients who underwent partial or total nephrectomy for tuberculous lesions, all 6 with preoperatively severe hypertension were cured postoperatively without any further antihypertensive treatment. The predictive values of renal vein renin determinations and the importance of renal surgery in this kind of hypertension are emphasized.

[Hemolytic-uremic syndrome in a young woman following the use of ovulation inhibitors]

After prolonged intake of oral contraceptives a 28-year-old woman developed a hemolytic uremic syndrome with microangiopathic hemolytic anemia, renal failure, malignant hypertension and blindness due to papillary congestion. Renal biopsy revealed widespread arteriolar alterations with massive intimal thickening, narrowing of the lumina and fibrinoid necrosis. During treatment with anticoagulation, antihypertensives and hemodialysis the hemolysis disappeared and vision improved, but the renal failure persisted. The possible relation between oral contraceptives and hemolytic uremic syndrome is mentioned and the literature is reviewed.