Insertion of an SVA-E retrotransposon into the CASP8 gene is associated with protection against prostate cancer

Transcriptional and splicing anomalies have been observed in intron 8 of the CASP8 gene (encoding procaspase-8) in association with cutaneous basal-cell carcinoma (BCC) and linked to a germline SNP rs700635. Here, we show that the rs700635[C] allele, which is associated with increased risk of BCC and breast cancer, is protective against prostate cancer [odds ratio (OR) = 0.91, P = 1.0 × 10⁻⁶]. rs700635[C] is also associated with failures to correctly splice out CASP8 intron 8 in breast and prostate tumours and in corresponding normal tissues. Investigation of rs700635[C] carriers revealed that they have a human-specific short interspersed element-variable number of tandem repeat-Alu (SINE-VNTR-Alu), subfamily-E retrotransposon (SVA-E) inserted into CASP8 intron 8. The SVA-E shows evidence of prior activity, because it has transduced some CASP8 sequences during subsequent retrotransposition events. Whole-genome sequence (WGS) data were used to tag the SVA-E with a surrogate SNP rs1035142[T] (r² = 0.999), which showed associations with both the splicing anomalies (P = 6.5 × 10⁻³²) and with protection against prostate cancer (OR = 0.91, P = 3.8 × 10⁻⁷).

The impact of tumour size on the probability of synchronous metastasis and survival in renal cell carcinoma patients: a population-based study

BACKGROUND

The observed low metastatic potential and favorable survival of small incidentally detected renal cell carcinomas (RCCs) have been a part of the rationale for recommending partial nephrectomy as a first treatment option and active surveillance in selected patients. We examined the relationship between tumor size and the odds of synchronous metastases (SMs) (primary outcome) and disease specific survival (secondary outcome) in a nationwide RCC registry.

METHODS

Retrospective study of the 794 RCC patients diagnosed in Iceland between 1971 and 2005. Histological material and TNM staging were reviewed centrally. The presence of SM and survival were recorded. Cubic spline analysis was used to assess relationship between tumor size and probability of SM. Univariate and multivariate statistics were used to estimate prognostic factors for SM and survival.

RESULTS

The probability of SM increased in a non-linear fashion with increasing tumor size (11, 25, 35, and 50%) for patients with tumors of ≤4, 4.1-7.0, 7.1-10.0, and >10 cm, respectively. On multivariate analysis, tumor size was an independent prognostic factor for disease-specific survival (HR = 1.05, 95% CI 1.02-1.09, p < 0.001), but not for SM.

CONCLUSION

Tumor size affected the probability of disease-specific mortality but not SM, after correcting for TNM staging in multivariate analysis. This confirms the prognostic ability of the 2010 TNM staging system for renal cell cancer in the Icelandic population.

Chromophobe renal cell carcinoma in Iceland: an epidemiological and clinicopathological study

OBJECTIVE

Numerous studies have suggested that the rare chromophobe renal cell carcinoma (CRCC) has a more favourable prognosis than the other more common subtypes of RCC, clear cell RCC (CCRCC) and papillary RCC (PRCC). These studies have, however, usually involved selected patient cohorts and not whole populations. This study compared CRCC patients with patients with the other two major histological subtypes and established a population-based age-standardized incidence rate (ASR).

MATERIAL AND METHODS

Of 828 histopathologically confirmed RCCs diagnosed between 1971 and 2005 in Iceland, 15 CRCC cases were identified. Histological material was reviewed, the TNM system was used for staging and cancer-specific survival was estimated. Univariate and multivariate analysis was used to compare CRCC to both CCRCC (n = 740) and PRCC (n = 66). Mean follow-up was 6.7 years.

RESULTS

CRCC accounted for 1.8% of RCCs, the ASR being 0.17/100,000 per year. Compared to other subtypes, CRCC was detected incidentally less often (7% vs 29%, p = 0.02), but was more often diagnosed at lower stages (73% vs 45% at stage I + II, p < 0.001). One patient had synchronous metastasis and another developed recurrent CRCC; both died of CRCC. Five-year survival for CRCC, CCRCC and PRCC was 86%, 59% and 50%, respectively (p = 0.004). After correcting for TNM stage (odds ratio 1.98), multivariate analysis did not indicate that CRCC subtype was an independent predictive factor for survival.

CONCLUSION

CRCC is a rare neoplasm with an ASR of 0.17/100,000 per year. These tumours often present with symptoms despite being at lower stages than the other RCC subtypes. The more favourable survival of the CRCC subtype appears to be explained by these tumours being diagnosed at low stages. These findings may suggest that CRCC has a different biological behaviour.

Genetic correction of PSA values using sequence variants associated with PSA levels

Measuring serum levels of the prostate-specific antigen (PSA) is the most common screening method for prostate cancer. However, PSA levels are affected by a number of factors apart from neoplasia. Notably, around 40% of the variability of PSA levels in the general population is accounted for by inherited factors, suggesting that it may be possible to improve both sensitivity and specificity by adjusting test results for genetic effects. To search for sequence variants that associate with PSA levels, we performed a genome-wide association study and follow-up analysis using PSA information from 15,757 Icelandic and 454 British men not diagnosed with prostate cancer. Overall, we detected a genome-wide significant association between PSA levels and single-nucleotide polymorphisms (SNPs) at six loci: 5p15.33 (rs2736098), 10q11 (rs10993994), 10q26 (rs10788160), 12q24 (rs11067228), 17q12 (rs4430796), and 19q13.33 [rs17632542 (KLK3: I179T)], each with P(combined) <3 × 10(-10). Among 3834 men who underwent a biopsy of the prostate, the 10q26, 12q24, and 19q13.33 alleles that associate with high PSA levels are associated with higher probability of a negative biopsy (odds ratio between 1.15 and 1.27). Assessment of association between the six loci and prostate cancer risk in 5325 cases and 41,417 controls from Iceland, the Netherlands, Spain, Romania, and the United States showed that the SNPs at 10q26 and 12q24 were exclusively associated with PSA levels, whereas the other four loci also were associated with prostate cancer risk. We propose that a personalized PSA cutoff value, based on genotype, should be used when deciding to perform a prostate biopsy.

Sequence variants at the TERT-CLPTM1L locus associate with many cancer types

The common sequence variants that have recently been associated with cancer risk are particular to a single cancer type or at most two. Following up on our genome-wide scan of basal cell carcinoma, we found that rs401681[C] on chromosome 5p15.33 satisfied our threshold for genome-wide significance (OR = 1.25, P = 3.7 x 10(-12)). We tested rs401681 for association with 16 additional cancer types in over 30,000 cancer cases and 45,000 controls and found association with lung cancer (OR = 1.15, P = 7.2 x 10(-8)) and urinary bladder, prostate and cervix cancer (ORs = 1.07-1.31, all P < 4 x 10(-4)). However, rs401681[C] seems to confer protection against cutaneous melanoma (OR = 0.88, P = 8.0 x 10(-4)). Notably, most of these cancer types have a strong environmental component to their risk. Investigation of the region led us to rs2736098[A], which showed stronger association with some cancer types. However, neither variant could fully account for the association of the other. rs2736098 corresponds to A305A in the telomerase reverse transcriptase (TERT) protein and rs401681 is in an intron of the CLPTM1L gene.

[Renal cell carcinoma diagnosed at autopsy in Iceland 1971-2005]

INTRODUCTION

The incidence of renal cell carcinoma (RCC) is rising in Iceland. This has been attributed to increased diagnostic activity, such as abdominal imaging of unrelated diseases, rather than changes in the behavior of the disease. The aim of this study was to compare RCCs diagnosed in living patients and at autopsy, but also to investigate the relationship between the incidence of RCC and autopsy findings.

MATERIAL AND METHODS

RCC found incidentally in individuals at autopsy was compared to patients diagnosed alive over three decades in Iceland (1971-2005). Stage at diagnosis and tumor histology was reviewed.

RESULTS

110 tumors were diagnosed at autopsy with a rate of 7.1/1000 autopsies. When compared to patients diagnosed alive (n = 913) the mean age at diagnosis was higher in the autopsy group (74.4 vs. 65 yrs.) while male to female ratio and laterality was similar. Tumors found at autopsy were smaller (3.7 vs. 7.3 cm), at lower stage (88% at stage I+II vs. 42%) and at lower tumor grade (85% at grade I+II vs. 56%). A difference, although smaller, is present when the autopsy detected cases are compared to only incidentally detected RCCs in living patients. Furthermore the autopsy detected tumors were more frequently of papillary cell type (21% vs. 8%). After correcting for declining autospy rate (>50%), a slight trend for a reduced rate of autopsy dectected RCC cases was seen during the last 10 years of the period but the difference was not significant.

CONCLUSION

RCCs diagnosed at autopsy are at a lower stage and tumor grade than in patients diagnosed alive. The autopsy-rate is declining in Iceland with fewer RCCs found per autopsy. After correcting for the decline in autopsy rate, the rate of RCC detected at autopsy is relatively unchanged. The increase in incidence of RCC is therefore not explained by findings at autopsy.

[Pulmonary resections for metastatic renal cell carcinoma in Iceland]

OBJECTIVE

At the time of diagnosis, approximately 20% of renal cell carcinoma (RCC) patients have pulmonary metastasis. These patients have poor survival with less than 10% of the patients being alive 5 years after diagnosis. However, recent studies have reported 30-49% 5-year survival in selected patients that underwent pulmonary resection for RCC metastases. The aim of this study was to analyse the outcome of this patient group in Iceland over a 23 year period.

MATERIALS AND METHODS

This is a retrospective population-based study including all patients in Iceland that underwent pulmonary resection for RCC metastasis between 1984 and 2006. Complications were tabulated and the histology of all tumors reviewed by a pathologist. The renal tumors were classified and staged according to the TNM staging system (WHO). Crude survival was calculated using 1st of March 2007 as an endpoint, with mean follow up of 82 months.

RESULTS

A total of 14 patients were identified, 10 males and 4 females with an average age of 59 years (range 45-78). One patient had pulmonary metastases at the diagnosis of RCC. In the other patients, metastasectomy was performed on average 39 months after the nephrectomy (range 1-132 months). Most of these patients (n=11) had a single metastasis, with an average size of 27 mm (range 8-50). Lobectomy was the most common procedure (n=7), wedge resection and pulmectomy were performed in three cases each, and one patient underwent both lobectomy and wedge resection. There were no major surgical complications. and all patients survived surgery. Today, four of the 14 patients (29%) are alive with 2- and 5-year survival of 64% and 29%, respectively.

CONCLUSION

In this retrospective study, every third patient survived five years after pulmonary resection of RCC metastases. This is a favorable survival-rate when compared to patients with metastases not operated on (9.8% survival). These operations seem to be safe and complications are most often minor. It should be kept in mind, however, that a selected cohort was studied and a well defined control group was absent.

Common sequence variants on 2p15 and Xp11.22 confer susceptibility to prostate cancer

We conducted a genome-wide SNP association study on prostate cancer on over 23,000 Icelanders, followed by a replication study including over 15,500 individuals from Europe and the United States. Two newly identified variants were shown to be associated with prostate cancer: rs5945572 on Xp11.22 and rs721048 on 2p15 (odds ratios (OR) = 1.23 and 1.15; P = 3.9 x 10(-13) and 7.7 x 10(-9), respectively). The 2p15 variant shows a significantly stronger association with more aggressive, rather than less aggressive, forms of the disease.

Two variants on chromosome 17 confer prostate cancer risk, and the one in TCF2 protects against type 2 diabetes

We performed a genome-wide association scan to search for sequence variants conferring risk of prostate cancer using 1,501 Icelandic men with prostate cancer and 11,290 controls. Follow-up studies involving three additional case-control groups replicated an association of two variants on chromosome 17 with the disease. These two variants, 33 Mb apart, fall within a region previously implicated by family-based linkage studies on prostate cancer. The risks conferred by these variants are moderate individually (allele odds ratio of about 1.20), but because they are common, their joint population attributable risk is substantial. One of the variants is in TCF2 (HNF1beta), a gene known to be mutated in individuals with maturity-onset diabetes of the young type 5. Results from eight case-control groups, including one West African and one Chinese, demonstrate that this variant confers protection against type 2 diabetes.

Genome-wide association study identifies a second prostate cancer susceptibility variant at 8q24

Prostate cancer is the most prevalent noncutaneous cancer in males in developed regions, with African American men having among the highest worldwide incidence and mortality rates. Here we report a second genetic variant in the 8q24 region that, in conjunction with another variant we recently discovered, accounts for about 11%-13% of prostate cancer cases in individuals of European descent and 31% of cases in African Americans. We made the current discovery through a genome-wide association scan of 1,453 affected Icelandic individuals and 3,064 controls using the Illumina HumanHap300 BeadChip followed by four replication studies. A key step in the discovery was the construction of a 14-SNP haplotype that efficiently tags a relatively uncommon (2%-4%) susceptibility variant in individuals of European descent that happens to be very common (approximately 42%) in African Americans. The newly identified variant shows a stronger association with affected individuals who have an earlier age at diagnosis.

A common variant associated with prostate cancer in European and African populations

With the increasing incidence of prostate cancer, identifying common genetic variants that confer risk of the disease is important. Here we report such a variant on chromosome 8q24, a region initially identified through a study of Icelandic families. Allele -8 of the microsatellite DG8S737 was associated with prostate cancer in three case-control series of European ancestry from Iceland, Sweden and the US. The estimated odds ratio (OR) of the allele is 1.62 (P = 2.7 x 10(-11)). About 19% of affected men and 13% of the general population carry at least one copy, yielding a population attributable risk (PAR) of approximately 8%. The association was also replicated in an African American case-control group with a similar OR, in which 41% of affected individuals and 30% of the population are carriers. This leads to a greater estimated PAR (16%) that may contribute to higher incidence of prostate cancer in African American men than in men of European ancestry.

Effect of incidental detection for survival of patients with renal cell carcinoma: results of population-based study of 701 patients

OBJECTIVES

To conduct a population-based study to evaluate the effect of incidental detection of renal cell carcinoma (RCC) on survival. Incidental detection of RCC has increased significantly in recent years because of widespread use of abdominal imaging. The patients with incidentally diagnosed RCC have better survival; however, because of possible "lead time" bias and stage migration, the real implications of incidental detection on survival have been a matter of debate.

METHODS

All living patients diagnosed with RCC in Iceland between 1971 and 2000 were included (n = 701). The histologic findings were verified, the stage (extent) of the disease was determined, and the incidence, mortality, and survival were evaluated.

RESULTS

The strongest predictors of mortality were stage and nuclear grade. After correcting for these factors in the multivariate analysis, incidental diagnosis, histologic subtype, and gender lost their significance as independent prognostic factors of death. However, the incidentally diagnosed tumors were 2.3 cm smaller on average and at a lower stage and grade than symptomatic tumors, with significantly better patient survival than those with symptomatic tumors on univariate analysis (76% versus 44% 5-year disease-specific survival). An increased incidence of RCC was only seen in men, but incidental detection increased threefold during the study period in both sexes, with significant improvement in survival for the whole group as a result.

CONCLUSIONS

The increased frequency of incidental detection has improved the survival of patients with RCC in Iceland. Incidental detection was not an independent prognostic factor of death, indicating that these tumors are of a similar biologic nature as symptomatic RCCs, only diagnosed earlier.

Renal oncocytoma: a clinicopathological analysis of 45 consecutive cases

OBJECTIVE

To evaluate the clinical behaviour and pathology of renal oncocytoma in a well-defined population over a 30-year period.

PATIENTS AND METHODS

In a retrospective population-based study we assessed relevant clinical and pathological factors in 45 patients (31 men and 14 women) diagnosed with renal oncocytoma in Iceland between 1971 and 2000. Clinical presentation, pathology, survival and causes of death were evaluated.

RESULTS

The age-standardized incidence was 0.3 per 100,000 per year for both men and women, the incidence of oncocytomas being 5.5% of renal cell carcinomas (RCCs) diagnosed during the same period in Iceland. Fourteen patients were diagnosed at autopsy for an unrelated disease. Of 31 living patients (mean age 70.5 years), seven were diagnosed incidentally (23%), and the others had presented with haematuria (32%), abdominal pain (29%), and weight loss (10%). All the patients had a radical nephrectomy, except for one with bilateral oncocytoma who had a partial nephrectomy. The mean (range) tumour size was 5.7 (0.9-12) cm. Eighteen patients (58%) were diagnosed at Tumour-Node-Metastasis stage I, 10 at stage II (32%) and three at stage III (10%), all of those at stage III having renal capsular penetration or tumour invasion into perirenal fat tissue (T3aN0M0). No patients were diagnosed with lymph node or distant metastasis. Two cases of coexisting RCC were detected. After a median follow-up of 8.3 years there were no recurrences or deaths from oncocytoma (100% disease-specific survival). The overall 5-year survival was 63%, with most patients dying from cardiovascular diseases or nonrenal cancers.

CONCLUSIONS

In most cases renal oncocytoma behaves like a benign tumour; the long-term prognosis is excellent. Thus, in the present patients, radical nephrectomy could be regarded as an over-treatment and nephron-sparing surgery as more appropriate, especially in patients with small tumours. However, both coexisting RCC and perirenal fat invasion, a hallmark of malignant behaviour, might indicate that more radical surgery is warranted in some of these patients.

Histological Subtyping and Nuclear Grading of Renal Cell Carcinoma and Their Implications for Survival: A Retrospective Nation-Wide Study of 629 Patients

OBJECTS

The aim of this study was to evaluate the prognostic significance of the current WHO histological subtyping and Fuhrman nuclear grading on the survival of patients with renal cell carcinoma (RCC).

MATERIALS AND METHODS

A retrospective population-based study was carried out on all patients with a histopathologically confirmed diagnosis of RCC in Iceland between 1971 and 2000. Fuhrman grade, TNM stage, and survival were evaluated and multivariate analysis applied in order to determine prognostic factors.

RESULTS

Out of 629 patients (387 males, 242 females, mean age 64 years), 558 (88.7%) had clear cell, 53 (8.4%) papillary, and 13 (2.1%) chromophobe RCC. Patient demographics were comparable for the two major subtypes, but chromophobe RCCs were larger in size and were diagnosed at a younger age. Clear cell RCCs were more often of higher grades (G3+G4, 48.4%) and at advanced TNM stages (III+IV, 59.3%) than papillary RCCs (22.6% and 34% respectively, p<0.001). Linear regression analysis showed a strong correlation between grade, tumor size, and stage (p<0.001). Chromophobe RCCs had a better survival in univariate analysis than both papillary and clear cell RCCs (84.6% vs. 66.5% and 54.9% 5-year disease specific survival, p<0.001). However, in the multivariate analysis, only the patient's age, calendar year of diagnosis, TNM stage, and nuclear grade were independent prognostic factors of survival.

CONCLUSION

In this complete nation-wide series nuclear grading is important in predicting survival of patients with RCC. It is strongly related to both tumor size and stage, with stage being by far the strongest prognostic factor. Different histological subtypes confer different survival. However, in spite of the distinctive cytogenetic and molecular characteristics of the subtypes, the survival difference is to a large extent due to differences in grade and particularly stage.

A population-based familial aggregation analysis indicates genetic contribution in a majority of renal cell carcinomas

The etiology of RCC is incompletely understood and the inherited genetic contribution uncertain. Although there are rare mendelian forms of RCC stemming from inherited mutations, most cases are thought to be sporadic. We sought to determine the extent of familial aggregation among Icelandic RCC patients in general. Medical and pathologic records for all patients diagnosed with RCC in Iceland between 1955 and 1999 were reviewed. This included a total of 1,078 RCC cases, 660 males and 418 females. With the use of an extensive computerized database containing genealogic information on 630,000 people in Iceland during the past 11 centuries, several analyses were conducted to determine whether the patients were more related to each other than members drawn at random from the population. Patients with RCC were significantly more related to each other than were subjects in matched groups of controls. This relatedness extended beyond the nuclear family. RRs were significantly greater than 1.0 for siblings, parents and cousins of probands. RRs were 2-3 for first-degree relatives and 1.6 for third-degree relatives. The risk of RCC is significantly higher for members of the extended family of an affected individual, as well as the nuclear family. Our results indicate that germline mutations are significantly involved in what has been defined as sporadic RCC.

[Validation of an Icelandic version of the Geriatric Depression Scale (GDS).]

OBJECTIVE

Health-related quality of life (HRQL) is increasingly used to estimate needs for medical treatment, to evaluate its outcome and quality of care. The aim of this study was to compare the HRQL of several diagnostic groups before and after treatment with the HL-test (HL = IQL, Icelandic Quality of Life test) and to study its validity for measuring changes in quality of life.

MATERIAL AND METHODS

Patients on waiting lists for coronary catheterization, orthopedic or urologic operations, patients in psychiatric out-patient treatment and patients entering treatment for alcohol dependence were asked to fill in the HL-test, a total of 1195 patients. Three months after treatment they were retested. The results of tests were standarized with population norms available to make them directly comparable with those of the general population.

RESULTS

The response rate was 75% in each round. The HRQL of all patients was reduced in all aspects compared to that of the general population, that of the heart and urology patients less so than that of the orthopedic and psychiatric patients. Each group had a specific profile, especially marked for the orthopedic and psychiatric patients. Following treatment the HRQL or some aspects of it improved in all groups, especially for those which it had been most impaired.

CONCLUSIONS

Studies of HRQL provide information useful for planning and delivery of health services. The HL-test is an instrument with good validity and reliability which is easy to use for such studies.

Metanephric adenoma

A 59-year old woman was diagnosed with a tumour in her right kidney. A nephrectomy was performed, and a 45 mm diameter tan-pink coloured tumour was found. Microscopy revealed small, dark cells in organized arrays of small round acini and tubules with glomeruloid infoldings. A diagnosis of metanephric adenoma was made. The tumour cells proved diploid on flow cytometry and immunohistochemical staining was positive for CAM 5.2 and AE-3. FISH analysis of three chromosomes did not reveal any abnormal karyotype. It is important to differentiate metanephric adenoma from renal cell carcinoma and adult Wilm's tumour, since it has a benign course.

[Wilms' tumor in Iceland 1961-1995. A retrospective study.]

OBJECTIVE

Wilms' tumor is a malignant disease in the kidneys that usually affects young children. Information about the clinical behaviour of this tumor in Iceland has been scarce. The aim of this study was to find the incidence, clinical presentation, treatment and survival of patients with Wilms' tumor.

MATERIAL AND METHODS

Included in the study were all patients diagnosed with Wilms' tumor in Iceland from 1st of January 1961 to 31st of December 1995. Altogether, there were 17 patients, 15 children, mean age 33 months (standard deviation 19, range 5-77 months) and two adults (age 25 and 29), with M/F ratio 0.7. Information was gained from each patient's record and the cancer registry of the Icelandic Cancer Society. All the tumors were re-evaluated by a pathologist and staged according to the NWTS staging system.

RESULTS

Age adjusted incidence during the study period was 0.2/100,000 per year (1.0 for children under 15 years). Abdominal mass (65%) and abdominal pain (53%) were the most common symptoms. Histology was typical in all cases except one with anaplasia and another with sarcomatous growth. One patient was diagnosed in stage I (6%), six in stage II (35%) and seven in stage III (41 %). Two patients had pulmonary metastases (stage IV) and one had bilateral tumor (stage V). Nephrectomy was performed in all cases. The operative mortality was 12%. Of the 15 patients surviving surgery, 12 received radiotherapy, 12 chemotherapy and nine both treatments. Crude five-year-survival for the whole group was 42%, 25% for the patients diagnosed 1961-1976 and 61% for those diagnosed 1977-1995 (p=0.13). The patient with bilateral tumor was still alive 13 years after diagnosis.

CONCLUSION

As in other Western countries, Wilms' tumor is rare in Iceland and has similar incidence and clinical presentation. Two thirds of the patients were diagnosed in stage II or III. Even patients with distant metastases can be cured with multimodal treatment: surgery, chemotherapy and radiotherapy. There was a trend toward better survival during the study period.

[A retrospective study on Icelandic men diagnosed with non-seminomatous testicular cancer 1971-1995.]

INTRODUCTION

Survival of patients with testicular cancer has changed dramatically over the last two decades. This is mainly related to more successful chemotherapy, using combinations of drugs including cisplatinum. Therapy with cisplatinum was started in 1978 in Iceland. The survival of Icelandic men with non-seminoma testicular cancer, before and after this change in therapy, is not known.

OBJECTIVE

Therefore a retrospective population-based study was carried out on all Icelandic males diagnosed with non-seminoma testicular cancer between 1971 and 1995.

MATERIAL AND METHODS

Fifty-seven males with an average age of 29.1 years (range 17-52) were included in the study. Clinical information was obtained from the Icelandic Cancer Registry and hospital records. All specimens were reexamined by a pathologist and the modified staging system of Boden and Gibb was used for staging the disease. Crude survival was evaluated with the Kaplan-Meier method.

RESULTS

Age standardized incidence for non-seminoma testicular cancer was 1.8 / 100,000 males per year for the whole period. Among the 57 patients, testicular swelling (93%) and pain (56%) were the most common symptoms at diagnosis. All 57 patients underwent orchiectomy, and 37 received chemotherapy as well. The most common histological type was embryonal carcinoma (44%) and average tumor diameter was 4.3 cm with a range of 1-12 cm. Tventy-six (51%) patients had stage I disease at diagnosis but 10 (17%) had stage IV. Crude five and 10 year survival for the whole group was 85% and 83%. From 1971 to 1977 the crude five year survival was 36% but 98% for the period 1978-1995. In December 1995 seven (64%) of 11 patients diagnosed between 1971-1977 have died of the disease. On the other hand only two patients (4%) diagnosed after 1977 have died as of december 1995. One because of acute myelogenic leukemia, nearly seven years after diagnosis of testis cancer. The other died of teratocarcinoma 12 months after diagnosis despite intensive chemotherapy including cisplatinum.

CONCLUSION

Survival of patients with non-seminoma testicular cancer in Iceland has improved dramatically after the introduction of cisplatinum based chemotherapy in 1978. Of 46 patients diagnosed after 1977 only one (2%) has died because of the disease and median follow up was eight years. The incidence is low compared to other Western countries if Norway and Danmark are not included, were the incidence is much higher. Clinical presentation of the disease is similar between these countries.

A population-based analysis of survival and incidental diagnosing of renal cell carcinoma patients in Iceland, 1971-1990

The significance of incidental diagnosing in relation to survival of renal cell carcinoma (RCC) patients is not known. A retrospective, population-based study was carried out in order to evaluate the survival of RCC patients, with emphasis on incidental diagnosing. Included in the study were all patients diagnosed with RCC in Iceland between 1971 and 1990. The tumours were classified and the extent of the disease staged by Robson's method. Crude probability of survival was evaluated for every stage, and multivariate analysis applied in order to determine prognostic factors. Out of 408 patients, 15% were diagnosed incidentally between 1971 and 1980 and 20% between 1981 and 1990 (p > 0.1), most often by intravenous urography. Only 5 tumours were detected incidentally by ultrasound techniques and 4 by CT scans. Crude five-year survival was 76% for stage I disease and 11% for stage IV disease. After correction for staging by multivariate analysis, incidental diagnosis and the year of diagnosis were not independent significant prognostic factors for mortality. As in many other studies, our data indicate that incidentally diagnosed RCCs are at a lower stage at the time of diagnosis. On the other hand, the results of our population-based study show that ultrasound and CT scanning have not significantly increased the number of incidentally diagnosed tumours. It is therefore not very surprising that surviving of RCC patients in Iceland has remained the same for the last two decades.

[Can finasteride reverse the progress of benign prostatic hyperplasia? A two-year placebo-controlled study.]

OBJECTIVE

To study if placebo-induced improvement in men with symptomatic benign prostatic hyperplasia (BPH) is maintained over two years, and to study the efficacy and safety from intervention with finasteride 5 mg for 24 months.

METHODS

This was a multicenter, double-blind, placeba-controlled study involving 707 patients with moderate symptoms of BPH enrolled at 59 centers in five Scandinavian countries. Following enrollment and a four-week single-blind placebo run-in period, patients were randomized to receive finasteride 5 mg once daily or placebo for 24 months. Urinary symptoms, urinary flow rate, prostate volume, postvoiding residual urinary volume, and serum concentrations of prostate-specific antigen together with laboratory safety parameters were measured at entry and at months 12 and 24. Interim physical and laboratory examinations were performed when indicated clinically.

RESULTS

In finasteride-treated patients the total symptom score improved throughout the study, with a significant difference between the two groups at 24 months (p<0.01) whereas in placebo-treated patients, there was an initial improvement in the symptom score but no change from baseline at 24 months. The maximum urinary flow rate decreased in the placebo group, but improved in the finasteride group, resulting in a between-group difference of 1.8 mL/s at 24 months (p<0.01). The mean change in prostate volume was +12% in the placebo group versus -19% in the finasteride-treated group (p%lt;0.01). Finasteride was generally well tolerated throughout the two-year study period.

CONCLUSIONS

The efficacy of therapy with finasteride 5 mg in improving both symptoms and maximum urinary flow rate and reducing prostate volume has been shown to be maintained during 24 months while patients receiving placebo experienced a return to baseline or deterioration of these parameters during the study. These results demonstrate that finasteride can reverse the natural progression of BPH.

[Good survival of Icelandic men diagnosed with testicular seminoma between 1971 and 1990 - A retrospective study.]

Testicular cancer is the most common cancer diagnosed in males aged 20 to 34 in Iceland. A retrospective population-based study was carried out on all Icelandic males diagnosed between 1971 and 1990 to evaluate presentation and survival of seminoma in Iceland. Fortyseven males with average age of 36 years (range 21-71) were included. Clinical informations were gained from the Icelandic Cancer Registry and hospital records. The staging system used was a modification of the system orginally proposed by Boden and Gibb and crude probability of survival was evaluated with the Kaplan-Meier method. Age standardized incidence for seminoma was 2.0/ 100,000 males per year for the whole period. Forty-five patients were diagnosed with symptoms where testicular swelling (98%) and pain (42%) were the most common symptoms. Two patients were diagnosed incidentally. All the patients except one underwent orchiectomy, 66% also received radiotherapy and 9% chemotherapy. Average tumor diameter was 8 cm before 1981 but 5.2 cm after 1981 (p=0.02). Most patients were diagnosed in stage I (73%), but 27% had disseminated disease at diagnosis (stage II-IV), most commonly retroperitoneal lymphnode metastases (85%). Crude five and 10 year survival was 89% and 84% respectively. Nine patients have died (August 1994) but none of seminoma. The incidence of seminoma is moderate in Iceland compared to the Nordic countries. Clinical symptoms and stage at diagnosis are similar. Survival is excellent for the group as a whole. For small localized tumors orchiectomy and surveillance seem to be an appropriate approach.

[Impotence among Icelandic males 1986-1991]

The estimated prevalence of impotence in western societies approximates 7%. A retrospective descriptive study was performed on 282 Icelandic males (mean age 53.5 years, range 19-79) referred for evaluation of impotence during the period 1986-1991. Diagnostic modalities included measurements of nocturnal penile tumescence (NPT) and penilebrachial index (PBI), hormonal profile and cavernosography. In 55% the NPT was abnormal. In contrast, only 8.2% of PBI was abnormally low. By logistic regression abnormal NPT results correlated with increasing age. Measurements of hormonal profile was performed in 73.4% of the patients. Testosterone was found to be below normal in 12.1%. However, primary or secondary hypogonadism was only found in 3.9% and elevated prolactin in 2.8%. By cavernosography, venous leakage was demonstrated in 3.2% of the men and subsequently ligation of the dorsal penile vein was performed. A trial of testosterone treatment was given in 39.4% of the patients. Impotence is a common complaint among men. Psychological factors predominate in young men and the contribution of somatic etiologic factors increases with age. In the majority of patients relatively simple studies can give useful information on the etiology of impotence.

[Renal cell carcinoma in Iceland: 1971-1990. Survival and incidental diagnosis]

Incidence and mortality of renal cell carcinoma (RCC) is very high in Iceland. Studies have shown increased incidence of incidentally diagnosed RCCs. The significans of incidental diagnosis relating to survival of RCC patients is not known. A retrospective population-based study was carried out on all patients diagnosed with RCC between 1971 and 1990 in Iceland. The aim of the study was to evaluate survival of RCC patients in Iceland with emphasis on incidental diagnosis. By incidental diagnosis we mean tumours that were detected due to imaging techniques or an operation for other than RCC symptoms or signs. Of 236 males and 172 females diagnosed, 308 patients underwent radical nephrectomy with operative mortality of 2.6%. The tumours were classified and staged by Robson's method. Crude probability of survival was evaluated for every stage and multivariate analysis used to find prognostic factors. 224 patients presented with symptoms, the most common of which were abdominal pain, hematuria and weight loss. Between 1971 and 1980 15% of the patients were diagnosed incidentally and 20% between 1981 and 1990 (p>0.1), most often because of intravenous urography. Only 5 tumours were detected by ultrasound and 4 by CT-scans. Five year survival was 76% for stage I and 11% for stage IV. Advanced age, low haemoglobin and high ESR at diagnosis are significant independent risk factors of mortality in multivariate analysis. The year of diagnosis is not a significant prognostic factor after correction for stage. Survival of RCC patients in Iceland is comparable to that in neighbouring countries. Patients diagnosed incidentally have better survival because of a lower stage. The use of ultrasound and CT-scans has not significantly increased incidentally diagnosed tumours. Survival has remained the same for the last two decades.

Spontaneous retroperitoneal hemorrhage as first presentation of carcinoma of the kidney. A case report

In a case of renal adenocarcinoma the presenting features were sudden appearance of an abdominal mass and hypovolemia due to spontaneous retroperitoneal hemorrhage. The diagnosis was established following emergency nephrectomy.