Bertrand Dufour

Combined radiation and chemotherapy for invasive transitional-cell carcinoma of the bladder: a prospective study

PURPOSE To improve the results obtained by cystectomy alone and to determine the possibilities of conservative treatment in invasive bladder cancer, we designed a prospective study using a combination of fluorouracil (5-FU) plus cisplatin and concomitant radiation therapy, followed by either cystectomy or additional chemoradiotherapy. PATIENTS AND METHODS Fifty-four patients with stage T2 to T4 operable untreated invasive bladder cancer were entered onto the study. Treatment was begun in all patients by transurethral resection (TUR) and followed by the 5-FU-cisplatin combination with concomitant bifractionated split-course radiation therapy. A control cystoscopy was performed 6 weeks after completion of the neoadjuvant program. Patients with persistent tumor underwent cystectomy. Complete responders were treated by either additional chemoradiotherapy (group A) or cystectomy (group B). RESULTS At control cystoscopy, 40 of 54 patients (74%) had a histologically documented complete response. Four responders developed recurrent pelvic disease after a mean follow-up time of 27 +/- 12 months (three in group A and one in group B). Metastatic disease, which developed in 16 patients, occurred more frequently in the nonresponders (71%) than in responders (15%). The disease-free survival rate at 3 years was 62%; it was significantly better in responders (77%) than in nonresponders (23%). There was no difference in survival between groups A and B. CONCLUSION This neoadjuvant chemoradiotherapy combination, easy to implement and well tolerated even in elderly patients, provides a high complete response rate. It may prove to be effective in inoperable patients and may be proposed as conservative treatment in patients with a complete response to the initial course of chemoradiation.

Postoperative radiation therapy in 26 patients with invasive transitional cell carcinoma of the upper urinary tract : no impact on survival ?

PURPOSE To evaluate the role of adjuvant radiation therapy in invasive transitional cell carcinoma of the upper urinary tract, we retrospectively reviewed a series of 26 patients who underwent radical surgery plus postoperative prophylactic irradiation for such a tumor. MATERIALS AND METHODS Between February 1980 and October 1993, 18 men and 8 women (mean age 65 +/- 9 years, standard deviation) were treated for an invasive transitional cell carcinoma of the upper urinary tract. Tumor location was the renal pelvis in 15 patients (58%). The tumor was pathological stage B in 11 patients (42%) and stage C in 15 (58%). Tumor grade was 2 in 10 patients, 3 in 15 and unknown in 1. One patient had epidermoid metaplasia of urothelial cancer and 9 had node involvement. All patients underwent surgery followed by radiation therapy to a total dose of 45 Gy. to the tumor bed (23) and/or regional nodes (18). RESULTS After a mean followup of 45 months 13 patients (50%) were alive and 11 were disease-free at analysis. Local tumor relapse, nodal recurrence and metastasis were noted in 1, 4 (15%) and 14 (54%) patients, respectively. All patients with nodal recurrence had metastasis. A secondary location was noted frequently (6 bladder, 1 contralateral renal pelvis and 1 urethral tumors). Overall 5-year survival rate and 5-year survival rate with no evidence of disease were 49% and 30%, respectively. Overall 5-year survival rates were 60% for stage B and 19% for stage C disease (p = 0.07), 49% for node-negative versus 15% for node-positive cancer (p = 0.04), and 90% for grade 2 and 0% for grade 3 tumors (p < 0.01). CONCLUSIONS In our trial using a radio-surgical approach, local control of disease and survival rates were similar to those reported previously in surgical series. Prophylactic postoperative radiation therapy is not recommended except in prospective randomized studies.

Renal cell carcinoma of the grafted kidney: how to improve screening and graft tracking.

Renal cell carcinoma of transplanted kidneys is rare. We report three such cases among 1,250 kidney grafts that were performed or followed from 1968 to 2002. A strategy to diagnose these lesions is needed because of their rarity, late detection, and therapeutic repercussions. At the least, the strategy should include annual ultrasonography of the graft throughout its lifespan. Because the risk of tumor development in another organ from the same donor is not negligible, a national registry should be established to rapidly alert graft recipients with the same donor and other transplantation centers about the risk of graft tumors.

Mortality and Morbidity after Nephrectomy for Renal Cell Carcinoma Using a Transperitoneal Anterior Subcostal Incision

Objectives: We have reviewed our surgical experience to document intra- and postoperative mortality and morbidity in 656 patients with renal cell carcinoma who underwent nephrectomy through a transperitoneal anterior subcostal incision (TASI). Materials and Methods: From 1986 to 1997 we performed 656 nephrectomies for renal cell carcinoma using a TASI. Details of the surgical procedure are presented together with a retrospective analysis of the postoperative data concerning both the patient and the complications related to this approach. Results: The mean time of operation was 130 min and the mean discharge from hospital 11 days. An additional surgical procedure in relation with the cancer facilitated by this approach was necessary in 2.1% of cases. The rates of intra- and postoperative complications were respectively 6.4 and 29.7%. The rate of intestinal complications was 1.8% and a splenic injury occurred in 8% of left nephrectomy. The mortality rate was 0.6%. Conclusions: The TASI is a large convenient incision which allows safe control of the renal pedicle in a very large number of renal tumors, even those located in the upper pole of the kidney. The rate of gut complications is very acceptable. Splenic injury is the major problem during left nephrectomy but careful dissection and surgical experience could decrease this complication, especially in case of upper pole renal tumor. We consider the TASI to be the main radical nephrectomy incision for renal cell carcinoma.

Low predictive accuracy of the Kattan postoperative nomogram for renal cell carcinoma recurrence in a population of French patients

The aim of the current study was to establish the predictive accuracy of the Kattan postoperative nomogram for nonmetastatic renal cell carcinoma (RCC) by comparing predictions with actual disease recurrence in patients who underwent surgery in a single center in France.

NEPHRON SPARING SURGERY FOR RENAL CELL CARCINOMA USING SELECTIVE RENAL PARENCHYMAL CLAMPING

PURPOSE We describe a technical artifice facilitating nephron sparing surgery for renal cell carcinoma without clamping the renal pedicle. MATERIALS AND METHODS Selective renal parenchymal clamping was performed using a large curved DeBakey aortic clamp placed around and sufficiently far from the tumor. The lesion was resected with a surrounding margin of normal renal parenchyma. The intrarenal vessels were suture ligated and the collecting system was closed as necessary. Time was not limited since the artery was not clamped. RESULTS Ten patients with renal cell carcinoma in whom nephron sparing surgery was indicated underwent selective renal parenchymal clamping. The indication was elective in 8 patients and urgent in 2. The tumor was at the renal pole in 3 cases and peripheral in 7. Mean tumor size was 32 mm. (range 19 to 52). Blood loss was insignificant. Operative time was 81 minutes (range 61 to 125) and there were no perioperative or postoperative complications. CONCLUSIONS Selective renal parenchymal clamping is a simple and efficient technical maneuver for facilitating nephron sparing surgery without pedicle dissection and clamping for renal peripheral or pole tumors. Neoplasm location and size are the limiting factors of this technique.

Serum tissue polypeptide antigen (S‐TPA) in bladder cancer as a tumor marker. A prospective study

Background. Tissue polypeptide antigen (TPA) is a differentiation and a proliferation tissue marker of non‐squamous epithelia. Increased urinary and serum TPA (S‐TPA) levels were found in some patients with invasive bladder cancer. The authors report the results of a prospective study evaluating the role of serum TPA (S‐TPA) in bladder carcinoma.

Coloepiploic mobilization during left radical nephrectomy for renal cell carcinoma is indicated to reduce the risk of iatrogenic splenectomy

OBJECTIVES To determine whether coloepiploic mobilization (CEM) is indicated to reduce the incidence of iatrogenic splenectomy during left radical nephrectomy for renal cell carcinoma. The incidence of iatrogenic splenectomy during a left nephrectomy is estimated to be between 1.4% and 24%. In a recent study, we reported that the incidence of iatrogenic splenectomy was 8% during a left nephrectomy performed for renal cell carcinoma through a transperitoneal anterior subcostal incision. METHODS A left radical nephrectomy was performed in 233 consecutive patients for renal cell carcinoma through a transperitoneal anterior subcostal incision with a CEM procedure in which the left colonic flexure was completely detached from the epiploa. Perioperative and postoperative complications, including splenic injury, were noted in a database. The mean patient age was 51.3 years (range 21.3 to 90.2). The mean tumor size was 58 mm (range 15 to 230). RESULTS An iatrogenic splenectomy was required in 3 patients, and in 1 patient, a splenic injury was treated conservatively. The incidence of iatrogenic splenectomy accompanying left radical nephrectomy was 1.3%. The mean operative time was 120 minutes (range 80 to 240). The mean time to normal gut motility was 3.4 days (range 2 to 11) and to discharge from the hospital it was 9.3 days (range 6 to 19). Regarding CEM, we did not observe any significant abdominal complications. CONCLUSIONS The incidence of iatrogenic splenectomy during a left radical nephrectomy through a transperitoneal anterior subcostal incision may be reduced by performing the technique of CEM.

Concomitant 5-FU-CDDP and bifractionated split course radiation therapy for invasive bladder cancer

Till now, radical cystectomy is considered the most effective treatment for local control of invasive bladder cancer but failed to cure more than 50 % of patients because the subsequent frequency of metastatic disease. Recent encouraging results, using exclusive chemo-radiotherapy without surgery, have been reported and such a conservative treatment could appear as a tangible reality for selected patients [1–3].

Preliminary results of a protocol of pre-operative radiation therapy with concomitant chemotherapy for invasive bladder cancer

The classical treatment of T3 Bladder Cancer is surgery. The place of irradiation remains limited, for example in the frame of associated radio-surgery protocol. The incidence of pathological down-staging following 40–50 Gy preoperative irradiation has been noted in more than 60 % of patients, and the incidence of histologically positive lymph nodes is half of the expected incidence (20 %). But only 30 to 40 % of the patients, with clinical T3 bladder cancer have no tumor in cystectomy specimen after pre-operative irradiation. Furthermore, in the NSABP trial, the survival of patients who were down-staged to pT0 enjoyed a significant survival advantage over patients whose tumors were not down-staged [1].