To report on the outcome of patients with intermediate and high risk of recurrence who underwent ... more To report on the outcome of patients with intermediate and high risk of recurrence who underwent radical prostatectomy (RP). Eighty-five consecutive patients categorized as intermediate (17.5%) and high risk (82.5%) of failure after definitive therapy for carcinoma of prostate according to the National Comprehensive Cancer Network (NCCN) underwent RP between 1989 and 1997. Median preoperative PSA was 26 ng/ml (range 15 ng/ml-91 ng/ml). Fifty-nine patients (70%) received three months neoadjuvant hormone therapy. Thirty-six patients (42%) underwent early (three to four months after RP) adjuvant radiation for pT3 disease and/or positive surgical margins. The median follow-up was 58 months (range 12-104 months). There was no difference in the biochemical recurrence rate between the intermediate and high-risk group of patients. The overall relapse rate was 33%. Cancer-specific mortality was 3.5%. Patients with T1c tumors had a significantly lower biochemical recurrence rate (bRR) (7%) co...
From 1984 to 1987, 49 patients with transitional cell carcinoma of the bladder underwent radical ... more From 1984 to 1987, 49 patients with transitional cell carcinoma of the bladder underwent radical cystectomy during which intraoperative autotransfusion was used. Thirty-three patients were observed for a minimum of one year postoperatively; the mean and median follow-up periods in this group were 23.8 and 26.0 months. Twenty-nine of these 33 patients were alive at the time of reporting; 25 were alive with no evidence of disease, and seven had postoperative recurrence of disease, and seven had postoperative recurrence of tumor. Diffused metastatic disease compatible with intravascular dissemination of tumor during autotransfusion did not develop in any of the patients. Intraoperative loss of blood ranged from 400 to 4,000 milliliters; the mean was 1,497, and the median, 1,300 milliliters. The mean volume of autotransfused blood was 492 milliliters. Autotransfusion accounted for 40 per cent of the total transfusion requirements of the patients and proved to be cost effective for the e...
Radical cystectomy with pelvic lymph node dissection has been accepted as the standard treatment ... more Radical cystectomy with pelvic lymph node dissection has been accepted as the standard treatment for muscle-invasive bladder cancer. Radiation therapy and chemotherapy are increasingly being implemented in bladder-preservation protocols to provide an alternative treatment to cystectomy. We review experience with radiation and chemotherapy in treating bladder cancer and their use in bladder-preservation protocols. Multimodality organ-sparing treatment strategies offer overall survival rates comparable to radical cystectomy and pelvic lymph node dissection in selected cases. However, bladder-preservation techniques risk local recurrence of potentially aggressive tumors whose long-term effect on cancer-specific survival has not been fully characterized. No improvement in quality of life has clearly been demonstrated with bladder-preservation regimens. Bladder-preservation protocols are costly and require precise coordination of multiple specialists as well as strict, life-long patient ...
Advances in the treatment of invasive bladder cancer can allow many patients to receive curative ... more Advances in the treatment of invasive bladder cancer can allow many patients to receive curative treatment while preserving their bladder function. The hallmark of these contemporary treatment initiatives are multi-modality therapy combining conservative surgical excision with radiotherapy (external beam and/or interstitial implantation) and systemic chemotherapy. It is clear that bladder cancer can manifest itself in one of several forms, each with varying degrees of biological aggressiveness. The identification of the individual tumor characteristics will allow for the selection of the appropriate treatment alternatives. Patients with small volume disease and favorable prognostic factors are optimal candidates for treatment with external beam radiation and cisplatin. There is also evidence that a subset of these patients may be effectively managed with transurethral resection and intravesical therapy. Patients with greater tumor burden or less favorable prognostic indicators will benefit from systemic treatment with combination chemotherapeutic regimens. At the present time we have utilized systemic chemotherapy preceding treatment with radiation therapy and concomitant cisplatin. Using this approach, only 17% of patients have demonstrated persistent muscle-invasive disease at the completion of therapy. We are encouraged by this preliminary experience, but caution that follow-up is short and long-term survival data is unavailable.
To assess in a pilot study the safety, tolerability, and technical feasibility of administering i... more To assess in a pilot study the safety, tolerability, and technical feasibility of administering intravesical valrubicin immediately after transurethral resection of bladder tumors (TURBT) in patients with superficial bladder cancer and to evaluate the optimal dose of valrubicin and its systemic absorption. Twenty-two patients with recurrent or newly diagnosed Stage Ta or T1 transitional cell tumors received a single dose of 400 mg, 600 mg, or 800 mg of intravesical valrubicin immediately after TURBT. Four patients thought to be at high risk of recurrence were followed up with five additional doses of 800 mg valrubicin, given weekly. The use of valrubicin after TURBT was generally well tolerated. Little evidence was found to suggest a direct relationship among the dose of valrubicin, the time between the end of TURBT and drug instillation, and the occurrence of most bladder symptoms. The most commonly reported adverse events included dysuria (77%), hematuria (59%), and urgency/frequency (23%). Pharmacokinetic analyses revealed that the mean systemic exposure to valrubicin and its metabolites depended on the extent of the TURBT and the damage to the bladder wall. The results of this study indicated that administration of valrubicin immediately after TURBT is feasible.
A total of 20 patients underwent major urologic cancer surgery with the combined use of predeposi... more A total of 20 patients underwent major urologic cancer surgery with the combined use of predeposit autologous blood and intraoperative autotransfusion with the Haemonetics Cell Saver. The estimated blood loss ranged from 400 to 2,000 mL (mean 1,208 mL). Total transfusion requirements for the 20 patients were 85.5 units of which 82.5 (96%) were autologous. Predeposit autologous blood accounted for 53 percent, intraoperative autotransfusion blood 43 percent, and homologous blood 4 percent of the total transfusion requirements. Of the 20 patients in the study, only 1 received homologous blood. There were no complications related to either modality of autotransfusion. Our data suggest that using the combined modalities of predeposit autologous blood donation and intraoperative autotransfusion, major urologic cancer surgery can be performed without homologous blood in most cases.
The effect of papaverine on transplantable C1300 murine neuroblastoma model was evaluated. Subcut... more The effect of papaverine on transplantable C1300 murine neuroblastoma model was evaluated. Subcutaneous inoculation of A/J mice with 10(6) C1300 cells resulted in predictable tumor growth and animal death in 36 +/- 5 days. In 33% of control animals, lung and liver metastases were observed. Subcutaneous injections of papaverine prior to tumor inoculation and during the tumor growth failed to show any detectable effect on local growth of the tumor. Benign transformation of the primary tumor was not observed. However, papaverine injection 21 days after tumor inoculation was associated with only 9% incidence of metastatic development. Papaverine treatment, when started one day prior to tumor inoculation or 10 days after tumor implant, resulted in complete prevention of all detectable metastatic growth, while having no apparent effect on local tumor growth. Further study of papaverine effect in the neuroblastoma murine model is indicated.
The effect of Levamisole was studied in an animal model of Wilms’ tumor. No tumoridical effect of... more The effect of Levamisole was studied in an animal model of Wilms’ tumor. No tumoridical effect of Levamisole could be documented in this tumor model, and no effect was shown on prevention of tumor, when Levamisole was given before tumor implantation. In previous experience with Wilms’ tumor model, a good correlation between the human and animal tumor was found in
Purpose: Urinary diversion is an alternative treatment for conditions such as radiation and inter... more Purpose: Urinary diversion is an alternative treatment for conditions such as radiation and interstitial cystitis, neurogenic bladder and severe incontinence. The subsequent complication rate may reach 60% due to the retained nonfunctional bladder. The subsequent cystectomy rate may be as high as 20% because of pyocystis, hematuria, pelvic pain and rarely bladder cancer. We describe simple cystectomy involving bladder removal without the adjacent structures, avoiding deep pelvic dissection.
Purpose: We assess the efficacy and safety of intravesical valrubicin for the treatment of carcin... more Purpose: We assess the efficacy and safety of intravesical valrubicin for the treatment of carcinoma in situ in patients with failure or recurrence after bacillus Calmette-Guerin (BCG) and who otherwise would have undergone cystectomy. Total anthracycline recovery in urine samples obtained within 24 hours of valrubicin administration was assessed in a subset of patients.
We discuss the subject of a second opinion for interpretations of anatomical pathology from the p... more We discuss the subject of a second opinion for interpretations of anatomical pathology from the perspective of patient care. We grouped 150 cases involving pathological review at our institution into 3 categories depending on the effect on patient care. Of 29 interpretive discrepancies 14 resulted in treatment changes but 7 of these 14 may have been interpreted differently by other practice groups. Whether the second opinion represents an interpretive error or a legitimate difference of opinion, the result may affect patient care. Patients referred for treatment among practice groups should have pathological findings reviewed as part of a complete assessment by the new physicians.
Radical cystectomy remains the gold standard in the treatment of patients with muscle invasive bl... more Radical cystectomy remains the gold standard in the treatment of patients with muscle invasive bladder cancer. However, the specter of high failure rates coupled with morbid treatment methods has caused urologists, oncologists, and radiotherapists to explore modifications in, and alternatives to, the traditional treatments for invasive bladder cancer. The identification of the active methotrexate-platinum-based combination chemotherapy regimens heralds a new era in our ability to treat advanced disease effectively. Patients with less extensive muscle invasive tumors may be efficiaciously treated using conservative surgical excision, either alone or in combination with adjunctive treatments. In addition, definitive radiation therapy, given via the interstitial route or in combination with radiosensitizers, may result in long-term survival and preservation of bladder function. Progress has been made on multiple fronts in our ability to improve overall survival rates while allowing for the preservation of bladder function. The ability of these new mixed multimodality treatment initiatives to produce viable statistics equal to that of radical exenteration is an important landmark on the route towards an ideal treatment for invasive bladder cancer.
To report on the outcome of patients with intermediate and high risk of recurrence who underwent ... more To report on the outcome of patients with intermediate and high risk of recurrence who underwent radical prostatectomy (RP). Eighty-five consecutive patients categorized as intermediate (17.5%) and high risk (82.5%) of failure after definitive therapy for carcinoma of prostate according to the National Comprehensive Cancer Network (NCCN) underwent RP between 1989 and 1997. Median preoperative PSA was 26 ng/ml (range 15 ng/ml-91 ng/ml). Fifty-nine patients (70%) received three months neoadjuvant hormone therapy. Thirty-six patients (42%) underwent early (three to four months after RP) adjuvant radiation for pT3 disease and/or positive surgical margins. The median follow-up was 58 months (range 12-104 months). There was no difference in the biochemical recurrence rate between the intermediate and high-risk group of patients. The overall relapse rate was 33%. Cancer-specific mortality was 3.5%. Patients with T1c tumors had a significantly lower biochemical recurrence rate (bRR) (7%) co...
From 1984 to 1987, 49 patients with transitional cell carcinoma of the bladder underwent radical ... more From 1984 to 1987, 49 patients with transitional cell carcinoma of the bladder underwent radical cystectomy during which intraoperative autotransfusion was used. Thirty-three patients were observed for a minimum of one year postoperatively; the mean and median follow-up periods in this group were 23.8 and 26.0 months. Twenty-nine of these 33 patients were alive at the time of reporting; 25 were alive with no evidence of disease, and seven had postoperative recurrence of disease, and seven had postoperative recurrence of tumor. Diffused metastatic disease compatible with intravascular dissemination of tumor during autotransfusion did not develop in any of the patients. Intraoperative loss of blood ranged from 400 to 4,000 milliliters; the mean was 1,497, and the median, 1,300 milliliters. The mean volume of autotransfused blood was 492 milliliters. Autotransfusion accounted for 40 per cent of the total transfusion requirements of the patients and proved to be cost effective for the e...
Radical cystectomy with pelvic lymph node dissection has been accepted as the standard treatment ... more Radical cystectomy with pelvic lymph node dissection has been accepted as the standard treatment for muscle-invasive bladder cancer. Radiation therapy and chemotherapy are increasingly being implemented in bladder-preservation protocols to provide an alternative treatment to cystectomy. We review experience with radiation and chemotherapy in treating bladder cancer and their use in bladder-preservation protocols. Multimodality organ-sparing treatment strategies offer overall survival rates comparable to radical cystectomy and pelvic lymph node dissection in selected cases. However, bladder-preservation techniques risk local recurrence of potentially aggressive tumors whose long-term effect on cancer-specific survival has not been fully characterized. No improvement in quality of life has clearly been demonstrated with bladder-preservation regimens. Bladder-preservation protocols are costly and require precise coordination of multiple specialists as well as strict, life-long patient ...
Advances in the treatment of invasive bladder cancer can allow many patients to receive curative ... more Advances in the treatment of invasive bladder cancer can allow many patients to receive curative treatment while preserving their bladder function. The hallmark of these contemporary treatment initiatives are multi-modality therapy combining conservative surgical excision with radiotherapy (external beam and/or interstitial implantation) and systemic chemotherapy. It is clear that bladder cancer can manifest itself in one of several forms, each with varying degrees of biological aggressiveness. The identification of the individual tumor characteristics will allow for the selection of the appropriate treatment alternatives. Patients with small volume disease and favorable prognostic factors are optimal candidates for treatment with external beam radiation and cisplatin. There is also evidence that a subset of these patients may be effectively managed with transurethral resection and intravesical therapy. Patients with greater tumor burden or less favorable prognostic indicators will benefit from systemic treatment with combination chemotherapeutic regimens. At the present time we have utilized systemic chemotherapy preceding treatment with radiation therapy and concomitant cisplatin. Using this approach, only 17% of patients have demonstrated persistent muscle-invasive disease at the completion of therapy. We are encouraged by this preliminary experience, but caution that follow-up is short and long-term survival data is unavailable.
To assess in a pilot study the safety, tolerability, and technical feasibility of administering i... more To assess in a pilot study the safety, tolerability, and technical feasibility of administering intravesical valrubicin immediately after transurethral resection of bladder tumors (TURBT) in patients with superficial bladder cancer and to evaluate the optimal dose of valrubicin and its systemic absorption. Twenty-two patients with recurrent or newly diagnosed Stage Ta or T1 transitional cell tumors received a single dose of 400 mg, 600 mg, or 800 mg of intravesical valrubicin immediately after TURBT. Four patients thought to be at high risk of recurrence were followed up with five additional doses of 800 mg valrubicin, given weekly. The use of valrubicin after TURBT was generally well tolerated. Little evidence was found to suggest a direct relationship among the dose of valrubicin, the time between the end of TURBT and drug instillation, and the occurrence of most bladder symptoms. The most commonly reported adverse events included dysuria (77%), hematuria (59%), and urgency/frequency (23%). Pharmacokinetic analyses revealed that the mean systemic exposure to valrubicin and its metabolites depended on the extent of the TURBT and the damage to the bladder wall. The results of this study indicated that administration of valrubicin immediately after TURBT is feasible.
A total of 20 patients underwent major urologic cancer surgery with the combined use of predeposi... more A total of 20 patients underwent major urologic cancer surgery with the combined use of predeposit autologous blood and intraoperative autotransfusion with the Haemonetics Cell Saver. The estimated blood loss ranged from 400 to 2,000 mL (mean 1,208 mL). Total transfusion requirements for the 20 patients were 85.5 units of which 82.5 (96%) were autologous. Predeposit autologous blood accounted for 53 percent, intraoperative autotransfusion blood 43 percent, and homologous blood 4 percent of the total transfusion requirements. Of the 20 patients in the study, only 1 received homologous blood. There were no complications related to either modality of autotransfusion. Our data suggest that using the combined modalities of predeposit autologous blood donation and intraoperative autotransfusion, major urologic cancer surgery can be performed without homologous blood in most cases.
The effect of papaverine on transplantable C1300 murine neuroblastoma model was evaluated. Subcut... more The effect of papaverine on transplantable C1300 murine neuroblastoma model was evaluated. Subcutaneous inoculation of A/J mice with 10(6) C1300 cells resulted in predictable tumor growth and animal death in 36 +/- 5 days. In 33% of control animals, lung and liver metastases were observed. Subcutaneous injections of papaverine prior to tumor inoculation and during the tumor growth failed to show any detectable effect on local growth of the tumor. Benign transformation of the primary tumor was not observed. However, papaverine injection 21 days after tumor inoculation was associated with only 9% incidence of metastatic development. Papaverine treatment, when started one day prior to tumor inoculation or 10 days after tumor implant, resulted in complete prevention of all detectable metastatic growth, while having no apparent effect on local tumor growth. Further study of papaverine effect in the neuroblastoma murine model is indicated.
The effect of Levamisole was studied in an animal model of Wilms’ tumor. No tumoridical effect of... more The effect of Levamisole was studied in an animal model of Wilms’ tumor. No tumoridical effect of Levamisole could be documented in this tumor model, and no effect was shown on prevention of tumor, when Levamisole was given before tumor implantation. In previous experience with Wilms’ tumor model, a good correlation between the human and animal tumor was found in
Purpose: Urinary diversion is an alternative treatment for conditions such as radiation and inter... more Purpose: Urinary diversion is an alternative treatment for conditions such as radiation and interstitial cystitis, neurogenic bladder and severe incontinence. The subsequent complication rate may reach 60% due to the retained nonfunctional bladder. The subsequent cystectomy rate may be as high as 20% because of pyocystis, hematuria, pelvic pain and rarely bladder cancer. We describe simple cystectomy involving bladder removal without the adjacent structures, avoiding deep pelvic dissection.
Purpose: We assess the efficacy and safety of intravesical valrubicin for the treatment of carcin... more Purpose: We assess the efficacy and safety of intravesical valrubicin for the treatment of carcinoma in situ in patients with failure or recurrence after bacillus Calmette-Guerin (BCG) and who otherwise would have undergone cystectomy. Total anthracycline recovery in urine samples obtained within 24 hours of valrubicin administration was assessed in a subset of patients.
We discuss the subject of a second opinion for interpretations of anatomical pathology from the p... more We discuss the subject of a second opinion for interpretations of anatomical pathology from the perspective of patient care. We grouped 150 cases involving pathological review at our institution into 3 categories depending on the effect on patient care. Of 29 interpretive discrepancies 14 resulted in treatment changes but 7 of these 14 may have been interpreted differently by other practice groups. Whether the second opinion represents an interpretive error or a legitimate difference of opinion, the result may affect patient care. Patients referred for treatment among practice groups should have pathological findings reviewed as part of a complete assessment by the new physicians.
Radical cystectomy remains the gold standard in the treatment of patients with muscle invasive bl... more Radical cystectomy remains the gold standard in the treatment of patients with muscle invasive bladder cancer. However, the specter of high failure rates coupled with morbid treatment methods has caused urologists, oncologists, and radiotherapists to explore modifications in, and alternatives to, the traditional treatments for invasive bladder cancer. The identification of the active methotrexate-platinum-based combination chemotherapy regimens heralds a new era in our ability to treat advanced disease effectively. Patients with less extensive muscle invasive tumors may be efficiaciously treated using conservative surgical excision, either alone or in combination with adjunctive treatments. In addition, definitive radiation therapy, given via the interstitial route or in combination with radiosensitizers, may result in long-term survival and preservation of bladder function. Progress has been made on multiple fronts in our ability to improve overall survival rates while allowing for the preservation of bladder function. The ability of these new mixed multimodality treatment initiatives to produce viable statistics equal to that of radical exenteration is an important landmark on the route towards an ideal treatment for invasive bladder cancer.
Uploads
Papers by Zev Wajsman