Gaetano Mobilio

Dichloromethylene-Diphosphonate in Patients with Prostatic Carcinoma Metastatic to the Skeleton

A total of 17 patients with multiple osteoblastic bone metastases owing to prostatic carcinoma was treated with 2-dichloromethylene-diphosphonate, a powerful inhibitor of bone resorption. The drug was given intravenously (300 mg.) for 2 weeks and then orally (3,200 mg.) or intramuscularly (100 mg.) for 4 to 11 weeks. A definite improvement in pain, assessed by daily consumption of analgesic drugs and by an analogic scale, was observed within 10 days in 16 of the 17 patients. Four patients confined to bed rest for pain were able to walk after 2 weeks and reversal of paralysis also was noted in 1 patient. Transient changes in serum calcium (decreasing) and alkaline phosphatase (increasing) were observed in most patients. In the 3 patients in whom it was performed, repeated bone scanning showed a partial regression of pathological areas in 2 and the complete disappearance of most pathological areas in 1. Our results suggest that 2-dichloromethylene-diphosphonate may represent an important supportive treatment in patients with bone metastases owing to prostatic carcinoma, providing sustained relief of pain and regression of bone destruction without undesirable side effects.

Prognostic Factors in Patients with Renal Cell Carcinoma: Retrospective Analysis of 675 Cases

OBJECTIVES To identify independent predictors of cause-specific survival in patients affected by renal cell carcinoma (RCC). MATERIAL AND METHODS We evaluated retrospectively 675 patients who underwent in our department from 1976 to 1999 radical nephrectomy for RCC. Pathological stage of the primary tumor (TNM, 1997) was pT1 in 326 cases (48%), pT2 in 133 (20%), pT3a in 66 (10%), pT3b in 138 (20%) and pT4 in 12 (2%). According to TNM classification (Union International Contre le Cancer (UICC), 1997) the pathological stage was I in 303 cases (45%), II in 119 (18%), III in 150 (22%) and IV in 103 (15%). Histological grading was assigned according to Fuhrmans classification in only 333 cases: G1 in 25%, G2 in 35%, G3 in 33% and G4 in 7%. RESULTS Cause-specific survival was 77% at 5 years, 69% at 10 years, 64% at 15 years and 57% at 20 years. Five and 10 year cause-specific survival was, respectively 91.4 and 88.5% in pT1 tumors, 84.8 and 72.7% in pT2, 57.4 and 35.6% in pT3a, 47.2 and 33.6% in pT3b-c, and 29.6% in pT4 (P < 0.0001). In relation to the pathological stage according to TNM classification, 5 and 10 year cause-specific survival was, respectively 94 and 91.6% in stage I tumors, 89.7 and 78% in stage II, 63.4 and 46.4% in stage III and 28 and 16.3% in stage IV (P < 0.0001). In relation to the nuclear grade of the primary tumor 5 and 10 year cause-specific survival was, respectively 94 and 88% in G1 tumors, 86 and 75% in G2, 59 and 40% in G3 and 31% in G4 (P < 0.0001). At multivariate analysis pathological stage of the primary tumor, lymph nodes involvement, presence of distant metastases at diagnosis and nuclear grading resulted all independent predictors of cause-specific survival in patients with RCC. CONCLUSION Pathological stage of primary tumors, lymph nodes involvement, presence of distant metastases at diagnosis and nuclear grading according to Fuhrman resulted all independent predictors of cause-specific mortality in patients with RCC.

Prognostic Value of Renal Cell Carcinoma Nuclear Grading: Multivariate Analysis of 333 Cases

Objective: To evaluate the independent predictive value of the nuclear grading system according to Fuhrman in relation to the disease-specific survival of patients with renal clear cell carcinoma. Material and Methods: 333 patients who underwent radical nephrectomy for renal clear cell carcinoma between 1983 and 1999 were evaluated. In all patients we retrospectively studied nuclear grading, average tumor size, multifocality, pathologic stage of primary tumor, vein invasion, lymph node involvement and distant metastases. The Kaplan-Meier method was applied to evaluate disease-specific survival rates. The log rank test was used to compare survival curves and for univariate analysis. The Cox proportional hazards model was used for the multivariate analysis. Results: Histologic grade was G1 in 83 cases (25%), G2 in 117 cases (35%), G3 in 110 cases (33%) and G4 in 23 cases (7%). Our data showed that nuclear grading according to Fuhrman is related to medium tumor size (p < 0.0001), pathologic stage of cancer (p < 0.001), venous system invasion (p < 0.001), lymph node involvement (p < 0.001) and distant metastases (p < 0.001). The disease-specific survival after 5 and 10 years was 94 and 88%, respectively, in patients with G1, 86 and 75% in patients with G2, 59 and 40% in patients with G3 and 31% in patients with G4 (log rank p value < 0.0001). Multivariate analysis showed that nuclear grading by Fuhrman has a prognostic independent predictive value (hazard ratio = 1.8461, p = 0.002). Conclusions: Nuclear grading is an important independent predictive factor of disease-specific survival in patients with renal cell carcinoma.

General State of Health and Psychological Well-Being in Patients after Surgery for Urological Malignant Neoplasms

Objective: To evaluate the general state of health and the psychological well-being in a group of 155 patients after surgery for urological malignant neoplasms. Materials and Methods: Surgery was performed in 55 patients for renal cell carcinoma, in 54 for invasive bladder carcinoma, in 30 for adenocarcinoma of the prostate, and in 16 for squamous penile carcinoma. All patients were invited to self-compile the General Health Questionnaire (GHQ) – 12 items according to Goldberg and the Hospital Anxiety and Depression Scale. Results were compared with those in a group of patients who underwent retropubic prostatectomy for benign prostatic hyperplasia. Results and Conclusion: The general state of health was significantly more impaired in neoplastic patients than in the control group. Levels of anxiety were significantly higher but depression levels were similar in both groups. As far as the type of tumor is concerned, patients who underwent radical cystectomy for bladder carcinoma and those treated with partial penectomy for squamous penile carcinoma showed a significant impairment of the general state of health compared with controls. Higher levels of anxiety were observed in patients who underwent ileal conduit after radical cystectomy, in those treated with radical prostatectomy for prostate cancer and in those who underwent partial penectomy. Significantly higher levels of depression than in the control group were observed only in patients with ileal conduit.

Genital treatment of penile carcinoma.

Squamous penile carcinoma is an uncommon neoplastic disease with an incidence of one in 100 000 men per year in Western countries. The role of penile-sparing treatment represents one of the three main issues in management of squamous carcinoma of the penis. Most authors consider conservative therapy as an indicated alternative treatment to partial or total penectomy in small size, low stage and grade tumours. At present, external or interstitial beam radiotherapy and lasertherapy represent the best available conservative therapeutic approaches. Another issue is the role of prophylactic inguinal lymphadenectomy in patients with negative palpable nodes. An early inguinal lymphadenectomy is indicated especially in patients with a high occult nodal micrometastases risk (G3 and pT2-4). The third point of discussion is represented by the use of chemotherapy in patients with metastatic disease. In this stage of disease, polychemotherapy with cisplatin, methotrexate and bleomycin seems to be more effective. The small number of patients investigated and the rapid evolution of the disease make it extremely difficult to carry out suitable perspective studies.

Renal Vein and Vena cava Involvement Does Not Affect Prognosis in Patients with Renal Cell Carcinoma

Objectives: The prognostic value of tumor extension into the renal vein or vena cava is still a controversial issue. The aim of this study is to report our experience with radical surgery in patients with renal cell carcinoma (RCC) extending into the renal vein or subdiaphragmatic vena cava. Methods: We evaluated 142 patients with RCC involving the renal vein or inferior subdiaphragmatic vena cava. RCC had extended into the renal vein in 118 patients and into the inferior vena cava in the remaining 24. Radical nephrectomy was performed in all cases with renal vein invasion. Radical nephrectomy with cavotomy and tumor thrombus removal was carried out in all cases with inferior subdiaphragmatic vena caval invasion. Cause-specific survival was calculated by means of the Kaplan-Meier method. The log rank test was used for survival comparisons and univariate analysis. Results: The 5- and 10-year cause-specific survival rates were 51.5 and 39%, respectively, in the group of patients with tumor extension into the renal vein and 33.4% in those with inferior vena caval involvement. In 52 patients (44%), RCC extended only into the renal vein. In the remaining 66 patients, renal vein invasion was associated with other adverse prognostic factors. Life expectancy was lower for patients with other concurrent adverse prognostic factors than for those affected by renal vein involvement alone (p < 0.0001). In the latter group, survival expectancy was similar to those with stage T2N0M0 tumor. In 7 cases (29%), inferior vena caval invasion was not associated with other adverse prognostic factors. In the remaining 15 patients (71%), vena caval involvement was associated with other adverse prognostic factors. Concurrence of other adverse prognostic factors with vena caval invasion significantly decreased the disease-specific survival expectancy in comparison with the patients in whom vena caval involvement was the main prognostic factor (p = 0.008). In these patients, disease-specific survival was similar to those with stage T2N0M0 tumor. Conclusion: Renal vein or inferior subdiaphragmatic vena caval involvement does not significantly affect prognosis in patients with RCC.

Diagnostic and therapeutic problems in multicentric renal angiomyolipoma.

Multicentric renal angiomyolipoma is a rare form of benign tumor. However, its effective incidence as evaluated in autopsy studies may be as high as 8%. There are 2 main types of renal angiomyolipoma, that is isolated forms and those associated with other diseases, such as phakomatosis, polycystic kidneys and fibromuscular dysplasia. The tumor may also display malignant behavior with local invasiveness and regional lymph node involvement. However, the clinical course is benign and multicentricity is important for prognosis. Histopathological diagnosis often is difficult. Immunohistochemical analysis of surgical specimens using a panel of monoclonal antibodies, including HMB-45 and actin, enabled us to make a definitive diagnosis in 3 cases of multicentric renal angiomyolipoma.

Surgical treatment of penile carcinoma : Our experience from 1976 to 1997

Objective: The purpose of this work is to evaluate our experience with the surgical treatment of penile squamous carcinoma, analyzing the therapeutic results in terms of local recurrence rates, survival and mortality rates. Material and Methods: From 1976 to 1997, 47 patients were treated at our institution for carcinoma of penis. Treatment of primary tumor was conservative in 8 patients (17%). Partial penectomy was performed in 30 patients (63.8%); total penectomy in 5 (10.7%) and emasculation in 4 (8.5%). Pathological stage was pTis in 2 cases (4.2%), pT1 in 20 (42.6%), pT2 in 21 (44.7%) and pT3 in 4 (8.5%). The tumor was clinically overstaged in 13 patients (27.7%) and understaged in 4 (8.5%). Bilateral inguinal lymphadenectomy was performed only in 4 patients clinically N+ (pN2) and in 3 clinically N0 (pN0). Results: Local recurrence rate was 43% in the patients with pT1 stage tumor treated conservatively. No local recurrence was observed after penectomy. 19 patients (40.4%) are alive and disease-free; 17 patients (36.2%) died of the tumor and 11 patients (23.4%) died of other causes but disease-free. Mean follow-up is 69.43 months. The overall 5-year survival rate was 34%. Conclusion: Partial penectomy gives better results than conservative treatment in the local management of the T1 stage tumor. Survival and mortality rates are related to both pathological and histological stages. The high mortality rate observed in the pT2 stage tumors in our experience might be related to the fact that in this stage an inguinal lymphadenectomy was not performed as a rule.

Unilateral Laparoscopic Retroperitoneal Lymph Node Dissection for Clinical Stage I Nonseminomatous Germ Cell Testicular Neoplasm

Objective: The aim of this study is to evaluate the reliability of laparoscopic retroperitoneal lymph node dissection (LRPLND) in the management of clinical stage I nonseminomatous germ cell tumors (NSGCT). Methods: Since June 1993, unilateral LRPLND was performed in 6 patients diagnosed with clinical stage I NSGCT. All patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in 3 cases and right-sided in the other 3 cases. Preoperative staging by means of tumor marker assessment, computerized tomography scan of the chest and abdomen and chest X-ray was unremarkable for metastatic disease. Results: All procedures were accomplished without any complications in a mean time of 325 min (275–420 min). The estimated perioperative blood loss was minimal (<50 ml), and none of the patients required blood transfusion. In the case of the first patient, the hospital stay was 18 days due to a widespread subcutaneous emphysema. In the remaining 5 cases, the average hospitalization was 4.8 days, ranging from 4 to 6 days. The patients resumed normal activities within 12–27 days (mean 16.16 days) postoperatively. The mean number of lymph nodes removed was 6.8, ranging from 5 to 9. Histologic examination of the dissected lymph nodes revealed microscopic metastases from embryonal carcinoma in 2 patients. Both of these patients received adjuvant chemotherapy. The mean follow-up period is 21.3 months, ranging from 6 to 36 months. To date, no relapses have been observed. Conclusion: In accordance with other reports, we believe that LRPLND is both feasible and effective. However, the definitive assessment of the efficacy and morbidity of this diagnostic procedure requires a larger and more comprehensive series as well as longer follow-up.

Experience in the Surgical Treatment of Fraley’s Syndrome

Objective: To report our 20–year experience with nephron–sparing surgery in the treatment of Fraley’s syndrome.Materials and Methods: From September 1976 to July 1996, 6 women, 18–43 years old, underwent surgical treatment. All patients had been suffering debilitating right flank pain for at least 6 months before the operation. Diagnosis was in call cases made with the use of intravenous pyelography and renal arteriography, which showed a vascular impression on the superior infundibulum with secondary dilatation of the upper pole calyx. This was localized only on the right side in 5 cases, while in 1 it was bilateral though more severe on the right. Ipsilateral nephroptosis was observed in 2 of the patients. In 2 cases in whom the superior infundibulum was sufficiently long, an infundibulo–infundibulostomy with everted flaps was performed. In a case in whom a short infundibulum was compressed between a venous and an arterial branch, Fraley’s infundibulopyelostomy was carried out. In 1 patient in whom the infundibulum was compressed by the anterior–superior segmental artery, a Heineke–Mikulicz–type infundibulorrhaphy was combined to vasopexy. In the remaining 2 cases, the infundibulum was not cut: in one case, a simple vasopexy of two vascular branches was carried out, while in the other, a minor arterial branch was ligated and divided. In 4 patients, nephropexy was also performed.Results: No significant intra– or postoperative complications were observed. Follow–up averaged 102.5 months. Pain relief was complete in 5 cases, in whom disappearance of the vascular impression was also radiologically demonstrated. Only 1 patient, who underwent infundibulorrhaphy and vasopexy, experienced occasional flank pain and urinary infection after the operation, with just a slight improvement in the excretory urogram.Conclusions: Surgical treatment of Fraley’s syndrome is indicated only in symptomatic and/or complicated cases; in relation to the type of obstruction and the anatomy of the intrarenal structures, whether excretory or vascular, several effective nephron–sparing techniques can be selected.