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Prostatic intraepithelial neoplasia (PIN) is a putative premalignant change in the human prostate. Previously, the spatial association of PIN with invasive carcinoma has been described in the study of total prostatectomies. PIN is frequently recognized in prostate needle biopsy specimens in which no carcinoma is apparent. To further define the potential significance of PIN, we performed repeat ultrasound-guided prostate needle biopsy in 21 men who had PIN identified on prostate biopsy performed because of an abnormal finding on digital rectal examination. Twelve patients (57%) had carcinoma identified on their second procedure including all who had intermediate- and high-grade PIN on the initial procedure. Prostate-specific antigen correlated with PIN grade and carcinoma on the secondary procedure, although this did not achieve statistical significance. Men with PIN on prostate needle biopsy should undergo repeat sampling to exclude missed carcinoma.

We performed total bladder replacement with a detubularized segment of sigmoid colon in patients after cystoprostatectomy. The surgical technique and long-term results in 27 patients are reported. This neobladder configuration compared favorably with other neobladder types regarding ease of construction. The surgical complications were acceptable. Initial reservoir function was good but improved further with time. After 1 year the capacity averaged 600 cc, pressures during filling and at capacity were low (average 12 and 16cm. water) and emptying was satisfactory (residual urine 4 to 80 cc). All patients were continent during the day and 67% were continent at night without excessive voiding habits. Nighttime incontinence was further resolved in 2 patients by using the AMS 800 artificial sphincter around the bulbous urethra. The detubularized sigmoid is an excellent neobladder configuration after cystoprostatectomy.

We evaluated the location of recurrent disease in 63 patients with carcinoma of the prostate who had abnormal levels of prostate specific antigen (greater than 0.4 ng./ml., Tandem-R assay) 6 to 240 months after radical prostatectomy but who were otherwise considered to be without evidence of disease. The evaluation involved physical examination including digital rectal examinations by 3 urologists, isotopic bone scans, computerized tomography scans of the abdomen and pelvis, cystoscopy, and random needle biopsies of the urethrovesical anastomotic area. In 6 patients metastatic disease to the bone and/or lymph nodes was found and local prostate cancer was discovered in 5. Among 57 patients without evidence of disease by the usual methods of evaluation needle biopsies of the anastomosis revealed local disease in 42%. No local disease was discovered in 30 post-radical prostatectomy patients with normal prostate specific antigen levels. There was a wide range of transrectally palpable contours after radical prostatectomy in patients with and without elevated prostate specific antigen levels. We conclude that prostate specific antigen but not digital rectal examination is an excellent early indicator of possible local recurrence after radical prostatectomy. Whether the prevalence of local disease after radical prostatectomy using prostate specific antigen levels and needle biopsies of the anastomosis is greater than heretofore has been appreciated will require further study.

Context.—The percentage of free prostate-specific antigen (PSA) in serum has been shown to enhance the specificity of PSA testing for prostate cancer detection, but earlier studies provided only preliminary cutoffs for clinical use.Objective.—To develop risk assessment guidelines and a cutoff value for defining abnormal percentage of free PSA in a population of men to whom the test would be applied.Design.—Prospective blinded study using the Tandem PSA and free PSA assays (Hybritech Inc, San Diego, Calif).Setting.—Seven nationwide university medical centers.Participants.—A total of 773 men (379 with prostate cancer, 394 with benign prostatic disease) 50 to 75 years of age with a palpably benign prostate gland, PSA level of 4.0 to 10.0 ng/mL, and histologically confirmed diagnosis.Main Outcome Measures.—A percentage of free PSA cutoff that maintained 95% sensitivity for prostate cancer detection, and probability of cancer for individual patients.Results.—The percentage of free PSA may be used in 2 ways: as a single cutoff (ie, perform a biopsy for all patients at or below a cutoff of 25% free PSA) or as an individual patient risk assessment (ie, base biopsy decisions on each patient's risk of cancer). The 25% free PSA cutoff detected 95% of cancers while avoiding 20% of unnecessary biopsies. The cancers associated with greater than 25% free PSA were more prevalent in older patients, and generally were less threatening in terms of tumor grade and volume. For individual patients, a lower percentage of free PSA was associated with a higher risk of cancer (range, 8%-56%). In the multivariate model used, the percentage of free PSA was an independent predictor of prostate cancer (odds ratio [OR], 3.2; 95% confidence interval [CI], 2.5-4.1; P

Since the early 1990s when the ACS developed guidelines for the early detection of prostate cancer, many variants of the tPSA assay have been introduced to increase the sensitivity of screening programs (cancer detection) while maintaining specificity (elimination of unnecessary biopsies). Again, the NCCN guidelines recommend how individuals and their physicians can use these new methods rationally for the early detection of prostate cancer. These guidelines are not designed to provide an argument for using early detection programs for prostate cancer, but are meant to provide a vehicle with which early detection efforts can be practiced in an evidence-based, systematic fashion in patients who choose to participate in these programs.56 These NCCN guidelines incorporate many new validated findings in addition to the DRE and tPSA test. These new factors include percent fPSA, PSAV, cPSA, biopsy pathology, and TRUS-guided biopsy techniques. The panel will re-examine the clinical usefulness of these new modalities annually, and the guidelines will be modified accordingly. In addition, future iterations of these guidelines may incorporate new serum markers currently undergoing clinical investigation. The goal of the NCCN and this guideline panel in updating these algorithms is to help men and clinicians choose a program of early detection of prostate cancer and make decisions about the need for prostate biopsy. Any clinician who uses these guidelines is expected to exercise independent medical judgment in the context of the individual clinical circumstances to determine each patient's need for prostate biopsy. These guidelines will continue to evolve as the field of prostate cancer advances. © Journal of the National Comprehensive Cancer Network.

An estimated 8250 new cases of testicular cancer will be diagnosed in the United States in 2006, with germ cell tumors (GCTs) constituting 95% of the malignant tumors arising in the testes. Although GCTs are relatively uncommon tumors, they are the most common solid tumor in men between the ages of 15 and 34 years. The worldwide incidence of these tumors has more than doubled in the past 40 years. More than 90% of all patients diagnosed with GCTs are cured, including 70% to 80% of patients with advanced tumors who are treated with chemotherapy. Standard therapy has been established at essentially all stages of management and must be closely followed to ensure the potential for cure. For the most recent version of the guidelines, please visit NCCN.org

An estimated 61,420 new cases of urinary bladder cancer will be diagnosed in the United States in 2006, making it the fourth most common cancer in men and the ninth most common neoplasm in women. Because the median age of diagnosis is 65 years, medical comorbidities are a frequent consideration. The clinical spectrum of bladder cancer can be divided into 3 categories: noninvasive tumors, invasive lesions, and metastatic lesions. These categories differ in prognosis, management, and therapeutic goals, and these guidelines discuss management strategies to achieve the best possible outcomes. For the most recent version of the guidelines, please visit NCCN.org

An estimated 38,890 Americans will be diagnosed with kidney cancer and 12,840 will die of this disease in the United States in 2006. Renal cell carcinoma (RCC) constitutes approximately 2% of all malignancies, with a median age at diagnosis of 65 years. Smoking and obesity are among the risk factors for RCC development, and tumor grade, local extent of the tumor, presence of regional nodal metastases, and evidence of metastatic disease at presentation are the most important prognostic determinants of 5-year survival. These guidelines discuss evaluation, staging, treatment, and management after treatment. For the most recent version of the guidelines, please visit NCCN.org

The treatment of localized prostate cancer is a matter of considerable controversy. For decades experts vigorously debated the relative merits of radical prostatectomy and external-beam radiotherapy. During those years the proportion of patients who received radiotherapy remained high, because of the complications of surgery and the older age of the patients, and because most physicians believed that external-beam radiotherapy was the only cure for disease that had spread outside the prostate (i.e., stage T3 or T4). In the past decade, however, the proportion of patients treated with radiation changed dramatically. Because of the widespread use of prostate-specific-antigen (PSA) testing for . . .

4640 Background: The addition of chemotherapy (CTX) to primary treatment is being evaluated in clinical trials to improve outcomes in high-risk prostate cancer. Factors that predict relapse after combined treatment with CTX and radical prostatectomy (RP) are not known. Understanding which clinical and pathologic factors affect outcome can facilitate the design of studies of combined modality treatment of high-risk prostate cancer. Methods: Using the Kaplan-Meier method and log-rank test for univariate analyses and Cox’s proportional hazards regression for the multivariate analysis, we examined the relationship between progression-free survival (PFS, defined as time to serum PSA ≥ 0.4 ng/mL) and a series of variables in men with high risk prostate cancer (cT2b or T3a or PSA ≥ 15 ng/mL or Gleason score (GS) ≥ 4+3) who received 4 cycles of docetaxel (35 mg/m2) and mitoxantrone (2–5 mg/m2) weekly for 3 of every 4 weeks prior to RP. Pre-CTX variables were PSA, PSA density (PSAD), age, biopsy GS, and cT stage. ...

We analyzed the effects of pelvic radiation therapy given to patients who had an elevated prostate specific antigen level after radical prostatectomy. Among men who previously received adjuvant radiation therapy and had appropriately stored serum 15 had elevated prostate specific antigen levels after radical prostatectomy but before radiation therapy

The tumor marker prostate-specific antigen (PSA) has changed the way we think about and manage carcinoma of the prostate to a degree unprecedented in human oncology. Elevated serum concentrations can occur in men with benign prostatic hyperplasia but are more frequent and higher in those with cancer. Serum PSA measurements have become indispensable for monitoring disease, but their use for screening is controversial and highlights the paradoxes of this neoplasm. See also p 289. What confuses us about prostate cancer is that it usually grows slowly and is predominately a malady of aging. Among men older than 70 years who die of something else, 30% also have "autopsy" cancer of the prostate, usually with cancer volumes less than 0.2 cm3and low-grade cell types.1Yet prostate cancer is the second leading cause of male cancer death. Clinical cancer of the prostate can only be cured if localized, and

The field of prostate cancer is important, changing, and confusing. Prostate cancer is the most frequent cancer and the second most common cause of cancer death among US men. Yet autopsy studies show that many men without clinical prostate cancer have some cancer in their prostates, albeit in small volumes. This, plus the fact that prostate cancer occurs in aging men and often grows slowly, means that many more men die with prostate cancer than of it. In the past, early diagnosis was advocated by periodic digital rectal examinations (DREs), treatments for curative intent consisted of radical prostatectomy and/or radiation therapy, and significant palliation as afforded by androgen ablation therapies. Yet the mortality from prostate cancer has not altered in decades. 1 Today, concepts about prostatic cancer treatment are changing rapidly, principally because of the availability of spring-loaded biopsy guns and transrectal ultrasonography (which make prostate biopsies safer, easier, and

Thirty-five patients who had received a penile implant were interviewed to assess their pre- and postsurgical ejaculatory and orgasmic experience. Prior to surgery, most men were able to experience ejaculation (71%) and orgasm (80%) even though erectile capability was impaired or lost completely. The implantation of a prosthetic device did not interfere with ejaculation or orgasmic functioning. Two patients who lost their ejaculatory functioning following surgery did so because of advances in their illnesses. Five men who had been non-orgasmic earlier reported having orgasm after surgery. In these cases of psychogenic orgasmic dysfunction, the penile prosthesis helped overcome the psychological barriers to this function.

Between 1970 and 1980, 82 patients with pathologic stage II nonseminomatous germ cell testicular carcinoma were treated at the University of Minnesota. Of the 30 patients treated with a retroperitoneal lymph node dissection, 22 (77%) relapsed. Of the 18 patients treated with retroperitoneal lymph node dissection and adjuvant radiotherapy, 12 (63%) relapsed. Sixteen patients received adjuvant chemotherapy before 1976, and 14 (87.5%) relapsed. After 1976, 18 patients received adjuvant chemotherapy (11 with cisplatin) and 2 (11%) have relapsed. No patient treated with cisplatin-based adjuvant chemotherapy has relapsed. The toxicity has been modest. Cisplatin-based chemotherapy is an effective and a safe adjuvant therapy for stage II nonseminomatous germ cell testicular carcinoma.