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C Zippe

Publications and source records attributed to C Zippe.

12 recordsLinked to original sources
PubMed2001

Locally advanced prostate cancer.

Standard therapy for clinically localized prostate cancer includes radical prostatectomy, external beam radiotherapy, or transperineal interstitial brachytherapy. Patients eligible for standard therapy are those with low risk features as defined by various risk group classifications, which generally include clinical stage T1 or T2a, serum prostate-specific antigen (PSA) less than 10 ng/mL, and biopsy Gleason sum of 6 or less. Although there has been important evolution in the performance of these techniques, particularly with respect to functional outcomes, these approaches for low-risk disease are relatively mature, and the cure rates with each of these therapies are similar in this patient population; locally advanced disease is more difficult to cure, however. Biochemical disease-free survival rates in men undergoing radical prostatectomy are clearly related to the pathologic stage. Prognostic groups can be defined based on pathologic stage with increasingly worse outcomes based on extracapsular extension (ECE), margin status, and the status of the lymph nodes and seminal vesicles. In patients with low risk features, the positive margin rate is generally low, making the presence or absence of ECE the dominant variable in predicting the likelihood of treatment failure. These observations suggest that more aggressive therapy is needed to cure those who are likely to have ECE or other adverse histologic features. Several nomograms predicting the likelihood of ECE or 5-year biochemical failure rates are now in routine clinical use, and can be used to select men at high risk of failure with single modality therapy for more aggressive treatment strategies. However, the optimal form of aggressive therapy for these patients is unknown.

Adenocarcinoma↗
PubMed2000

Dosimetric comparison of pre-planned and or-planned prostate seed brachytherapy.

PURPOSE: To compare the dosimetry of the traditional two step procedure (volume study + treatment planning several weeks later) with that of an OR-based single procedure in which these two steps follow one another immediately. Computer generated treatment plans were used in both procedures. METHODS AND MATERIALS: Several dosimetric parameters relating to target coverage were obtained from dose volume histograms of CT-based evaluation plans developed either 1 or 3 days following seed implantation. A total of 113 patients with early stage (T1C, T2A) prostate cancer were used for this retrospective study. RESULTS: The fraction of target (prostate) covered by the prescription dose (144 Gy), 90% of the prescription dose (115 Gy), and the dose encompassing 90% of the target in the evaluation plan were all statistically significantly improved for OR-based plans compared to pre-planned cases. CONCLUSION: In our hands, there is a small but significant improvement in dose coverage of the prostate when the ultrasound volume study and treatment planning are combined into a single procedure.

Brachytherapy↗
PubMed1999

Declining rates of extracapsular extension after radical prostatectomy: evidence for continued stage migration.

PURPOSE: Prostate-specific antigen (PSA)-based screening is responsible for a profound clinical stage migration in newly detected prostate cancers. Extracapsular extension (ECE) is an important predictor of outcome after radical prostatectomy (RP). We examined trends in the rate of ECE for cancers detected by PSA screening in 731 RP specimens between 1987 and 1997, when screening became routine urologic practice in the United States. METHODS: The rates of ECE were examined in 311 prostates with nonpalpable (stage T1c) disease and 420 with palpable but clinically localized (stage T2) disease. Specimens were step-sectioned and examined by a senior pathologist. Rates of ECE were compared with respect to time, and logistic regression was used to identify predictors of ECE. RESULTS: The rate of ECE decreased from 81% to 36% during the 10-year observation period. Multivariateanalysis involving clinical tumor stage, preoperative serum PSA level, and Gleason score demonstrated that year of treatment was an independent predictor of ECE, with a two-fold reduction of risk occurring during the study period (P <. 001; odds ratio, 1.96; 95% confidence interval, 1.37 to 2.78). CONCLUSION: PSA screening has resulted in a downward trend in pathologic stage in clinically localized prostate cancer, independent of preoperative PSA level, tumor stage, and Gleason score. This time-dependent downward stage migration suggests the need for continuous updating of predictive nomograms and caution in interpreting differences in contemporarily treated patients compared with historical controls. Further study is needed to determine whether this trend will translate into improved disease-free survival.

Aged↗
PubMed1999

NMP22 is a sensitive, cost-effective test in patients at risk for bladder cancer.

PURPOSE: The early diagnosis of bladder cancer is central to its effective treatment. This study was designed to determine the clinical use of NMP22 as a urinary marker for the early detection of transitional cell carcinoma of the bladder in patients with hematuria or other indications at risk for malignancy. The sensitivity and specificity of the NMP22 test were compared with urinary cytology, and the results of both tests were then compared to cystoscopic findings. We also determined if NMP22 provided a cost advantage over our current modalities in our patient population. MATERIALS AND METHODS: Each patient submitted a single voided urine which was divided in 2 parts, of which 1 was stabilized with the NMP22 urine collection kit and 1 was preserved in the appropriate cytology medium for cytopathological testing. All patients provided the urine samples before cystoscopic examination. Of the 330 patients 114 (34.5%) presented with microscopic hematuria and 66 (20.4%) with gross hematuria. Other indications for cystoscopy included atypical cytology or unexplained voiding symptoms refractory to medical therapy. RESULTS: There were 18 patients with biopsy confirmed bladder cancer and 312 with benign conditions of the bladder. Median NMP22 value for the malignant bladder tumors was 31.6 units per ml. (95% confidence interval 13.4 to 90.9) and 4.3 units per ml. (3.8 to 4.8) for benign conditions of the bladder. The urinary NMP22 values in the bladder cancer group were significantly higher than those in the benign condition group (p <0.001). The sensitivity of NMP22 was 100% with a specificity of 85% at a reference value of 10.0 units per ml., while cytology had a sensitivity of only 33% and specificity of 100%. Given a negative predictive value of 100% for NMP22, a cost savings of $28,302 to $111,072 (depending on the type of insurance carrier) would have been achieved if it was used alone as the indication for cystoscopy. CONCLUSIONS: This study indicates that urinary NMP22 is a simple, noninvasive, cost-effective marker for the detection of bladder cancer.

Aged↗
PubMed1997

Indications for excluding the seminal vesicles when treating clinically localized prostatic adenocarcinoma with radiotherapy alone.

PURPOSE: The indications for treating the seminal vesicles (SV) in patients with clinically localized carcinoma of the prostate are controversial. We sought to define subgroups of patients in whom coverage could be avoided, using pretreatment prostate specific antigen (PSA) values and the Gleason score. Because the rectum is the major dose-limiting structure, we also measured the extent of rectal sparing achieved by excluding the SV from external beam treatment fields. METHODS AND MATERIALS: We retrospectively studied lateral x-ray simulation films of 43 patients treated with standard four-field radiotherapy and dose-volume histograms of eight patients treated with conformal radiotherapy. The rectal surface areas were measured and the volumes were calculated including and excluding the SV. The pathology reports of patients treated with radical prostatectomy alone between 1987 and 1993 were reviewed. Patients without preoperative PSA levels or biopsy Gleason scores, or who received neoadjuvant hormonal therapy were excluded. Of the 368 remaining patients, 66 (18%) had preoperative PSA levels < or = 4, 172 (47%) had PSA levels 4-10, and 130 (35%) had PSA levels > 10. The Gleason score was < or = 6 in 269 (73%), and 99 (27%) had a score > or = 7. RESULTS: The reduction in the total irradiated rectal areas to full doses when the SV were excluded ranged from 5 to 67% in individual patients (median, 44%). The median reduction in the irradiated rectal volumes to 50% of the prescribed dose, as determined by dose-volume histograms, was 51% (range: 37-76%). The median reduction in bladder volumes was 9% (range: 6%-15%). The incidence of SV involvement was 19% (70 out of 368). Patients with normal PSA levels (< or = 4 ng/mL) had a 3% (2 out of 66) rate of SV involvement. Patients with PSA levels between 4-10 ng/mL had a 8% (10 out of 126) rate of SV involvement. All other cases had at least 20% rate of SV involvement, with a combined rate of 33%. Using a cutoff of 15%, two low risk groups were identified: all patients with PSA levels < or = 4, and patients with PSA 4-10 and Gleason score < or = 6. These constituted 52% (192 out of 368) of all patients. Overall, the low-risk patients had a 6% (12 out of 192) incidence of SV involvement vs. 33% (58 out of 176) for the high risk patients (p < or = .001). CONCLUSIONS: Excluding the SV from the treatment field can significantly reduce (40%-50%) the volume of irradiated rectum. Our data confirm that pretreatment PSA levels and Gleason scores can be effectively used to define subgroups of patients in whom SV irradiation can be avoided. We propose excluding the SV in all patients with PSA levels < or = 4, and patients with PSA levels 4-10 and a Gleason score < or = 6.

Adenocarcinoma↗
PubMed1996

Correlation of clinical and pathologic factors with rising prostate-specific antigen profiles after radical prostatectomy alone for clinically localized prostate cancer.

OBJECTIVES: To better identify factors affecting prostate-specific antigen (PSA) level elevation after radical prostatectomy alone in men with clinical Stage T1-2 prostate cancer, we have reviewed our experience in the PSA era with 337 cases. The identification of these factors permits better understanding of the impact of case selection on treatment outcome in prostate cancer. METHODS: The charts of all patients treated with radical prostatectomy alone between 1987 and 1993 were reviewed. Patients with clinical Stage T3 disease, without preoperative Gleason scores or PSA levels, with synchronous bladder cancer, and who received adjuvant or neoadjuvant therapy were excluded. The distribution of cases by pretreatment PSA levels was as follows: 4 ng/mL or less (16%); greater than 4 to 10 ng/mL (48%); greater than 10 to 20 ng/mL (22%); and greater than 20 ng/mL (14%). The median pretreatment PSA level for the entire group was 8 ng/mL. Only 26 patients (8%) had pathologically positive pelvic lymph nodes. The overall margin involvement rate was 43%. Margin involvement rates increased with increasing preoperative PSA levels. One hundred eighty-two patients (54%) had surgical Gleason scores of 7 or higher and 208 (62%) had extracapsular extension. The median follow-up time was 36 months. RESULTS: The 3- and 5-year relapse-free survival (RFS) rates were 74% and 61%, respectively, with relapse being defined as either a clinically detectable recurrence or detectable/rising PSA levels. Among preoperative factors, PSA level was the only independent factor predicting relapse (P = 0.006); the 5-year RFS was 89% in patients with preoperative PSA levels of 4 ng/mL or less; 62% for PSA level of 4 to 10 ng/mL; 56% for PSA level to 10 to 20 ng/mL; and 26% for a PSA level greater than 20 ng/mL. Among pathologic parameters, margin involvement was the most potent independent factor predicting relapse (P < 0.001), followed by Gleason score (P = 0.002) and capsular penetration (P = 0.006). The 5-year RFS rates for margin-positive versus margin-negative patients were 37% versus 80%, respectively (P < 0.001). With pretreatment PSA levels of 10 ng/mL or less, lymph node involvement was seen in 3%, and margin involvement in 36%; the 5-year RFS rate was 71%. With pretreatment PSA levels of greater than 10 ng/mL, lymph node involvement was seen in 16%, and margin involvement in 57%; the 5-year RFS rate was 42%. However, patients with an initial PSA level greater than 10 ng/mL and positive margins had a 5-year RFS rate of 22% versus 73% in patients with a PSA level of 10 ng/mL or less or negative margins (P < 0.001). All clinical relapses were accompanied by a rise in PSA. In patients manifesting a clinical recurrence, PSA elevations preceded clinical recurrences by an average of 15 months (range 0 to 71). Only 34 cases (10%) had clinical failures within 5 years. CONCLUSIONS: Pretreatment PSA is the most potent clinical factor independently predicting biochemical relapse. The great range in the relapse-free survival rates predicted by preoperative PSA levels demonstrates the importance of pretreatment PSA levels in case selection. Gleason score, extracapsular extension, and surgical margin involvement are also independent predictors of biochemical relapse. Achieving negative margins, even in relatively advanced disease, provides excellent long-term local control.

Adult↗
PubMed1985

Trendelenburg versus PASG application in moderate hemorrhagic hypoperfusion.

In hemorrhagic hypoperfusion one of the therapeutic goals of pneumatic antishock garment (PASG) application is to increase cardiac output, presumably by augmenting venous return from below the diaphragm, an effect expected to be similar to Trendelenburg positioning. The purpose of this study was to compare the hemodynamic response of these two common therapeutic interventions in hemorrhagic hypoperfusion. Five anesthetized dogs were bled over 10 minutes 24% of measured blood volume on two separate days. At the beginning of hemorrhage, they randomly received either PASG application or Trendelenburg positioning. PASG pressures of 30 +/- 5 mm Hg were applied to produce an inferior vena cava pressure of 10-15 mm Hg. Such PASG pressure had been shown previously to not diminish cardiac output from PASG application. Mean arterial pressure was maintained throughout the experiment with both therapies. With PASG application, cardiac index was depressed and systemic vascular resistance was elevated at 10, 20, and 30 minutes following hemorrhage. In contrast, Trendelenburg therapy maintained cardiac index and produced no significant increase in systemic vascular resistance index. Thus Trendelenburg therapy preserved mean arterial pressure primarily by maintaining cardiac output, probably by increasing venous return, whereas PASG application preserved mean arterial pressure primarily by increasing systemic vascular resistance. For treatment of moderate hemorrhagic hypoperfusion, Trendelenburg positioning may be superior therapy to PASG application.

Animals↗
PubMed1981

Thoracotomy in patients over age seventy years: ten-year experience.

Recent reports have demonstrated satisfactory long-term survival following pulmonary resection in the elderly. However, the high operative risk commonly cited in patients over 70 years of age has led some authors to conclude that advanced age is a contraindication to pulmonary resection. During 1969 to 1978, 218 thoracotomies were performed in patients over the age of 70 years. Operations performed include 175 pulmonary resections and 43 miscellaneous thoracic surgical procedures. Primary or metastatic cancer was the indication for 174 operations (pulmonary resection, 150 cases; exploration and biopsy, 16 cases; pleurectomy, eight cases). One hundred thirty-seven patients (63%) had a benign course, whereas 74 patients experienced a total of 83 complications. Minor complications of atrial fibrillation, air leaks persisting for 7 to 14 days, and successfully managed retention of secretions were seen in 34 patients (16%). Nonfatal major complications were predominantly cardiac and respiratory in nature and occurred in 40 patients (18%). The overall hospital mortality was 3% (seven patients). Lung-sparing procedures were utilized whenever possible among the 150 patients undergoing pulmonary resection for carcinoma (sleeve lobectomy, 13 cases; segmental resection, 52 cases; wedge resection, 12 cases). The hospital mortality of 4% among these 150 patients was significantly lower (p < 0.001) than the 17% mortality among 308 elderly patients compiled from five series reported by other centers between 1973 and 1978. Long-term follow-up was obtained in 129 of the 139 (93%) available patients surviving pulmonary resection for cancer. The overall 5 year survival rate is 27%, ranging from 13% for patients having pneumonectomy to 42% for those having segmental resection.

Age Factors↗
PubMedDate not supplied

Sexual dysfunction after pelvic surgery.

Pelvic surgeries are among the most common causes of organic sexual dysfunction in men and women. The impact of nerve-sparing surgery on potency has been well documented in radical prostatectomy. However, its impact on potency needs to be evaluated in other pelvic surgeries. Sexual dysfunction is highly prevalent even after multiple technical advances in the field of oncological surgeries. The prevalence varies from 8 to 82%, depending on the type of pelvic surgery. In females, sexual dysfunction has not been evaluated adequately using validated questionnaires. However, in subspecialized circles, treatment for female sexual dysfunction is becoming routine. Currently, physicians have several options for the treatment of erectile dysfunction (ED) in men. Since the introduction of oral PDE-5 inhibitors, oral therapy has become the first-line treatment option for ED, irrespective of etiology. Currently available treatment options for the female sexual dysfunction include estrogens, androgens, phosphodiesterase inhibitors, and dopamine receptor antagonists. Initial reports regarding the role of early rehabilitation are encouraging and may become the part of routine practice in the management of ED after pelvic surgery. In this article, we summarize the sexual dysfunction following pelvic surgeries and their management.

Animals↗
PubMedDate not supplied

NMP22: a sensitive, cost-effective test in patients at risk for bladder cancer.

BACKGROUND: This study was designed to determine the clinical utility of NMP22 as a urinary marker for the early detection of transitional cell carcinoma (TCC) of the bladder in patients with hematuria or other indications for risk of malignancy. Its utility will be measured by sensitivity and specificity estimates as compared to cystoscopy. Since urine cytology is normally collected in this population of patients, it will also be analyzed and compared to cystoscopy. MATERIALS AND METHODS: Each patient submitted a single voided urine which was stabilized with the NMP22 urine collection kit or preserved in the appropriate cytology medium for cytopathologic testing. All patients provided the urine samples before cystoscopic exam. Of the 146 patients, there were 43 patients with microscopic hematuria and 13 with gross hematuria. Other indications for cystoscopy included unexplained or medically refractory voiding. There were 8 patients with biopsy confirmed bladder cancer and 138 patients with benign conditions of the bladder. RESULTS: The median NMP22 value for the bladder cancer malignancies was 27.8 U/mL (95% Confidence interval: 10.5-32.1 U/mL). The median NMP22 value for the benign conditions of the bladder was 3.25 U/mL (95% Confidence interval: 2.5-3.8 U/mL). The urinary NMP22 values from the bladder cancer group was statistically different (p < .000001 Mann-Whitney U test) than the NMP22 values in the benign conditions group. Using a reference value of 10.0 U/mL, the sensitivity of NMP22 was 100% with a specificity of 90%, while cytology had a sensitivity of 25% and a specificity of 100%. Due to its high negative predictive value, using NMP22 alone could have eliminated 124 cystoscopies with total savings ranging from $24,824 to $63,264 depending on the type of insurance carrier. CONCLUSIONS: This study indicates that urinary NMP22 is a useful, cost-effective marker for the early detection of bladder cancer.

Biomarkers, Tumor↗
PubMedDate not supplied

External beam radiotherapy versus radical prostatectomy for clinical stage T1-2 prostate cancer: therapeutic implications of stratification by pretreatment PSA levels and biopsy Gleason scores.

PURPOSE: Prostate-specific antigen (PSA) has affected the management of prostate cancer by allowing better case selection. The comparison between the two definitive treatment modalities, radiotherapy (RT) and radical prostatectomy (RP), can now be made accurately with respect to case selection and treatment outcome. PATIENTS AND METHODS: The charts of 787 patients with prostate carcinoma who were treated with either RP alone or RT alone between 1987 and 1993 were reviewed. Patients with stage T3 disease, without pretreatment PSA levels or biopsy Gleason scores (GS), with synchronous bladder cancers or receiving adjuvant therapy, were excluded. Patients with less than 2 years' follow-up were also excluded. Of the remaining 551 patients, 253 were treated with RT and 298 with RP. The median pretreatment PSA level for RP patients was 8.1 versus 12.1 for the RT patients. The median radiation dose was 68.4 Gy. Positive margins were reported in 49% after RP. The median follow-up time was 42 months (range: 24 to 108). RESULTS: For the 551 patients, the 5-year biochemical relapse-free survival (bRFS) rate was 53%, with biochemical relapse being defined as either a detectable PSA level after RP, or two consecutive rising PSA levels after RT. All clinical relapses were associated with rising PSA levels. The 5-year bRFS rates for RT versus RP were 43% versus 57%, respectively. Multivariate time-to-failure analysis using the proportional hazards model for clinical parameters showed pretreatment PSA level and biopsy Gleason scores to be the only independent predictors of relapse. Clinical stage and treatment modality were not independent predictors of failure. Using PSA and GS, two risk groups were defined: low risk (PSA < or = 10.0 and GS < or = 6) and high risk (PSA > 10.0 or GS > or = 7). The 5-year RFS rates for the low-versus high-risk groups were 81% versus 34%, respectively. Forty-eight percent of RP patients were low-risk cases versus 33% of RT patients. The rate of surgical margin involvement in RP patients was 39% in the low-risk group versus 59% in the high-risk group. For low-risk patients, the 5-year RFS rates for patients treated with RT versus RP were 81% versus 80%, respectively. In this subgroup, the bRFS rates for patients with negative margins were identical to the bRFS rates of patients treated with radiotherapy. However, patients with positive surgical margins fared significantly worse. For high-risk patients, the 5-year RFS rates for patients treated with RT versus RP were 26% versus 37%, respectively. In this subgroup, there was a definite advantage to surgery if negative margins were achieved: 5-year bRFS 62%, compared to 26% for RT and 21% for surgery with positive margins. CONCLUSIONS: By using biochemical failure as an endpoint, more failures are documented after RP or RT than previously suspected. However, case selection using pretreatment PSA levels and biopsy GS can result in large differences in control rates. Significantly more high-risk patients are treated with RT. By stratifying cases using PSA and biopsy GS, treatment outcome is equivalent after either radiotherapy or surgery. Further follow-up is needed to confirm these findings after 5 years. For low-risk cases, there is no difference between radiotherapy and surgery, even when negative margins are achieved. Positive surgical margins predict for poor outcome even in low-risk cases. Standard radiotherapy alone should not be used for lesions with aggressive features. The outcome in high-risk cases is better with surgery if negative margins are achieved. For such high-risk patients, several new treatment approaches are currently being investigated with either high-dose conformal radiotherapy with or without androgen blockade, or neoadjuvant androgen blockade or radical prostatectomy.

Adult↗