Luc Baert - Böcker

In the United States in 1997, 28800 new cases of malignant tumors of the kidney and renal pelvis were diagnosed along with 2100 new cases of malignant tumors of the ureter and other urinary organs, 7200 primary malignant tumors of the testis, and 1300 primary malignant tumors of the penis and other genital organs. In large measure, surgery is the treatment of choice for these tumors, but radiation therapy is in­ creasingly recognized as having significant and important curative and palliative bene­ fits in each of these tumor sites. Surgery is the standard form of treatment for non­ metastatic renal cell carcinomas as well as for malignancies of the renal pelvis and ureter, with radical nephrectomy and radical uretectomy being employed. However, postoperative radiation therapy is of value for those patients who demonstrate evi­ dence of residual tumor following surgery, transection of tumor during surgery, or positive regional lymph node drainage. As regards the rare tumors that involve the female urethra, surgical resection is appropriate for those that are limited and local in character and amenable to partial ureterectomy. With tumors that are more advanced in character, however, local recurrence and lymphatic dissemination are significant problems, and treatmentby radiation therapy programs alone yield satisfactory control rates as well as limited recurrences and long-term survivors. For primary tumors involving the testis, the major approach to nonseminomatous tumors is surgical resection with postsurgical systemic chemotherapy.

Bladder cancer represents a major challenge to the oncologist. In spite of new tech­ niques for early diagnosis and innovative imaging procedures for staging, the outcome in terms of cure has not improved during the past ten years. Fortunately, about 74% of the patients present with localized disease, with 18% presenting with localized and regional disease, and 3% with distant metastases at diagnosis. In accordance with the stage at presentation, 94% of patients with localized disease are controlled at 5 years, as are 50% of patients with local and regional disease but un­ fortunately only 7% of those with distant disease. The survival data for Afro-Americans are more grave, with only 79% of patients with localized disease surviving at 5 years, 38% with local and regional disease, and 4% with disseminated disease. Even after 5 years, however, patients continue to fail not only locally and regionally but also with disseminated disease, thereby creating enigmas as to the continued influence of basic molecular changes, basic etiologic agents, and unsuspected more advanced disease, as well as demonstrating the inadequacies of local surgical treatment programs. These factors have led to braoder programs of combined integrated multimodal treatment earlier in the course of the disease process. Clearly, these newer innovative programs have placed increasing emphasis on the combination of surgery with radiation therapy and chemotherapy.

The American Cancer Society anticipates that during 1995, 244000 new cases of cancer of the prostate will have been diagnosed in the United States, with 40400 deaths from the disease process. The rapid increase in the actual number of new cases in the United States is directly related to more regularized digital rectal examinations and the more frequent and widespread use of prostate-specific antigen (PSA) screening programs. As a conse­ quence, major controversies have emerged in how best to manage the patient with cancer of the prostate. These include the necessity of PSA screening programs, how to interpret PSA values, what imaging studies are most appropriate for definition of the true extent of the disease process, the value of pretreatment surgical staging of the disease process, and the value of different treatments. The latter encompass a wide range of options: observa­ tion, radical prostatectomy, the Walsh-type prostatectomy procedure, definitive external beam radiation therapy, local interstitial implantation using iodine-125, iridium-l92, or palladium-103, orchiectomy, cryosurgery, hyperthermia, and various antitestosterone agents such as estrogens or LH,RH agonists. The present volume deals with the major parameters of controversy with regard to cancer of the prostate and will enable the reader to acquire a better understanding of the disease and how best it might be managed to achieve an optimal outcome with a minimum of complications.