Iwao Fukui

Incidence of Benign Pathologic Lesions at Partial Nephrectomy for Presumed RCC Renal Masses: Japanese Dual-Center Experience with 176 Consecutive Patients

OBJECTIVESnTo determine the incidence of benign pathologic findings at elective partial nephrectomy for renal masses thought to be renal cell carcinoma (RCC) on preoperative imaging in Japanese patients.nnnMETHODSnFrom 1993 to 2007, 176 patients (46 women and 130 men) underwent elective partial nephrectomy for presumed RCC masses in 2 Japanese centers. The mean size of the resected lesions was 2.3 cm (range 0.3-5.8). Overall, 97 and 79 patients had a renal mass of < or = 2 cm and > 2 cm, respectively. Of the 176 patients, 100%, 89%, and 32% had preoperatively undergone computed tomography, ultrasonography, and magnetic resonance imaging, respectively.nnnRESULTSnOf the 176 masses resected, the pathologic examination revealed benign findings in 19 (11%), angiomyolipoma in 10 (5.7%), oncocytoma in 5 (2.8%), complicated cysts in 2 (1.1%), and a solitary fibrous tumor and scar of the kidney 1 each (0.6%). Of the 46 women, 12 (26.1%) had benign lesions compared with 7 of the 130 men (5.3%; P = .0003). Of the 10 angiomyolipomas diagnosed, 8 were diagnosed in women (P = .0004). Tumor size was not associated with benign histologic findings. The incidence of benign lesions was equivalent (10% and 12%) between the 2 centers.nnnCONCLUSIONSnThe present incidence (11%) of benign lesions in presumed RCC masses at surgery in Japanese patients was lower than the incidence of 20%-30% previously reported from Western countries, probably because of the low incidence of oncocytomas in Japanese patients. Women had almost 5 times the likelihood of having a benign lesion compared with men, because of the high incidence of angiomyolipomas in women.

In Vivo Staining Test with Methylene Blue for Bladder Cancer

An in vivo staining test with 0.2 per cent methylene blue was applied to 129 patients with bladder tumor and 16 patients with chronic cystitis within a 6-year interval. Although normal mucosa did not pick up the stain nonpapillary in situ and microinvasive carcinomas did so frequently. Moderate dysplasia was stained in about half of the patients. The intensity of the stain in papillary tumors was correlated with the histologic anaplasia (grade). Grade 1 tumors were stained poorly or unstained in 86 per cent of the tests, whereas grades 2 and 3 tumors picked up the stain in 74 and 96 per cent of the tests, respectively. Even a tiny tumor, if poorly differentiated, was identified easily by the blue stain. The histologic anaplasia of tumors could be assessed roughly according to the intensity of the stain. However, chronic cystitis occasionally took up the stain, especially in cases of marked inflammatory infiltrate a deep stain was recognized. To differentiate nonpapillary early cancer from chronic cystitis the addition of a cytologic examination may be necessary.

Clinical significance of cannibalism in urinary cytology of bladder cancer

OBJECTIVEnTo investigate the cytologic characteristics and clinical significance of cannibalism (cytophagocytosis), a characteristic histologic finding associated with malignancy, found in urinary cytology samples during the diagnosis of bladder cancer.nnnSTUDY DESIGNnThe subjects were 252 patients with bladder cancer initially treated from 1981 to 1991. For their pretreatment urine samples, membrane filtration was performed to determine the presence and amount of cannibalism, a tumor cell within a tumor cell. The urinary cytologic findings were then correlated with the histologic findings of primary bladder cancer.nnnRESULTSnOnly cells from urinary cytology-positive specimens demonstrated cannibalism. The positive rate of cannibalism was significantly higher in grade 3 (25%) than grade 1 (0%) or 2 (8%) superficial papillary cancer (P < .01) and also higher in muscle-invading bladder cancer (57%) than grade 3 superficial papillary cancer (P < .01). The rate did not differ significantly between muscle-invading cancer and superficial nonpapillary cancer (44%). In 198 patients with superficial bladder cancer, progression was observed in 19 (10%) during a mean follow-up of 72 months. All of them showed positive urinary cytology results in pretreatment samples, and among the patients with positive urinary cytology, the progression rate was significantly higher when cannibalism was present than when it was absent (38% vs. 17%, P < .05). Moreover, in high grade cases, cannibalism had significant predictive value for progression. By multivariate analysis, cannibalism was an independent factor for prediction of progression, as were tumor grade and stage.nnnCONCLUSIONnCannibalism in urinary cytology appears to be an indicator of both the anaplastic grade and invasiveness of transitional cell carcinoma of the bladder. Furthermore, cannibalism may provide a reliable predictor of progression of superficial bladder cancer.

Successful treatment of metastatic adenocarcinoma of the urachus: report of 2 cases with more than 10-year survival.

Metastatic urachal cancer is often considered lethal. We report 2 cases of metastatic urachal carcinoma successfully treated with surgical excision followed by combinations of surgery, radiation, and chemotherapy against local recurrence and/or distant metastases, with a recurrence-free survival period of more than 10 years. These cases provide support for multimodal treatments of metastatic urachal cancer.

Intravesical Mitomycin C and Doxorubicin Sequential Therapy for Carcinoma in Situ of the Bladder: A Longer Followup Result

A total of 43 patients with carcinoma in situ of the bladder (primary in 26 and secondary in 17) who underwent intravesical mitomycin C and doxorubicin sequential therapy for 2 multicenter studies were followed for a median period of 45 months (range 10 to 84). Of the patients 32 (74%) achieved complete response after induction therapy and underwent maintenance therapy with either mitomycin C plus doxorubicin, mitomycin C alone or observation only. Of the complete responders 13 (41%) had a local recurrence, and subsequent repeat intravesical mitomycin C and doxorubicin sequential therapy as well as bacillus Calmette-Guerin was effective in a significant proportion (75% or greater). The maintenance therapy did not have a favorable effect on the recurrence rate. In 8 patients (19%) (3 of 32 complete responders and 5 of 11 nonresponders) progression developed, including invasive cancers in 4, metastatic disease in 2 and both conditions in 2. Initial complete responders had a significantly higher progression-free rate than initial nonresponders, although there was no difference in the sites of progression between them. At the last followup 35 patients (81%) remained free of disease with 31 (72%) having a normally functioning bladder. According to these results, intravesical mitomycin C and doxorubicin sequential therapy appears to be applicable as initial treatment for carcinoma in situ of the bladder.

Intravesical combination chemotherapy with mitomycin C and doxorubicin for superficial bladder cancer: a randomized trial of maintenance versus no maintenance following a complete response.

SummaryBetween November 1986 and April 1989, 101 patients with superficial bladder cancer were treated with intravesical instillations of mitomycin C on day 1 and doxorubicin on day 2 of each week for 5 consecutive weeks. Of 61 complete responders, 23 patients with carcinoma in situ and 28 with papillary cancer were randomly assigned to a non-maintenance group or to a group receiving maintenance therapy consisting of monthly instillations of the same drugs for 12 months. The 2-year non-recurrence rate calculated for patients with carcinoma in situ was significantly better in the maintenance group than in the non-maintenance group. A similar tendency was observed for patients with papillary cancer, although the difference was not significant. Side effects were considerable, with moderate to severe bladder irritation occurring in approximately half of the patients. In addition to our previous findings, the present results indicate that this intravesical combination chemotherapy is effective in eliminating superficial bladder cancers and that since the effect is not durable, even in complete responders, maintenance therapy is necessary to reduce subsequent tumor recurrence.

Late recurrence and progression after a long tumor-free period in primary Ta and T1 bladder cancer.

Objective: To determine the probability and risk factors of recurrence and progression (to T2 or worse) after a long tumor-free period in patients with superficial (stage Ta and T1) bladder cancer. Patients and Methods: A consecutive series of 100 patients with superficial bladder cancer who remained tumor-free for longer than 4 years after initial treatment were reviewed. The rates of recurrence and progression were statistically assessed and the significance of risk factors was determined. Results: Of the 100 patients, 24 (24.0%) recurred within 15 years after the initial treatment. The 10- and 15-year recurrence-free rates were 76.0 and 59.6%, respectively. Among the clinicopathological variables examined, intravesical chemotherapy was determined by a log-rank test to be a significant unfavorable risk factor for late recurrence (p < 0.001). Progression of the tumor occurred in 5 patients. Four variables including presence of multiple tumors, involvement of the bladder neck, positive urine cytology, and intravesical chemotherapy were found by a univariate analysis to be significant risk factors for late progression (p < 0.05). Among these factors, initial presence of multiple tumors (3 or more) was determined by a multivariate analysis to be an independent risk factor for late progression. Conclusion: Recurrence and progression continue to occur in patients with superficial bladder cancer even after long periods of dormancy. Regular follow-up urological assessments should be continued until at least 15 years of tumor-free existence, especially in patients treated by intravesical chemotherapy or those initially having multiple tumors.

Significance of bladder neck involvement on progression in superficial bladder cancer.

Objectives: To determine the significance of bladder neck involvement in predicting disease progression in superficial (stage Ta and T1) transitional cell carcinoma (TCC) of the urinary bladder. Patients and Methods: A series of 277 patients with newly diagnosed superficial TCCs of the bladder was reviewed, and disease progression (to T2 or worse) was considered. The significance of several risk factors including bladder neck involvement was assessed in univariate and multivariate analysis. Results: Progression occurred in 28 (10.1%) of 277 patients during a median follow-up period of 7.7 years. Nineteen died of bladder cancer. The following variables were found to be statistically significant at the univariate analysis (p < 0.05): irritative symptoms, urine cytology, tumor stage, involvement of the bladder neck, and tumor grade. Indeed, only involvement of the bladder neck, tumor stage, and grade retained their value as independent factors for progression at multivariate analysis. Patients were divided into three groups according to the number of independent risk factors they had. Groups having none, one, and two or three risk factors included 129, 99, and 49 patients with 5-year progression rates of 0.8, 4.6 and 27.5%, and 15-year rates of 4.0, 20.1 and 42.7%, respectively. Conclusion: Involvement of the bladder neck is a significant and independent risk factor for progression of superficial TCCs in addition to the histologic grade and stage. The combination of these three risk factors offers better prediction of progression in an individual patient.

Carcinoma in situ of the urinary bladder. Effect of associated neoplastic lesions on clinical course and treatment

Clinical courses of 67 patients with carcinoma in situ (CIS) of the urinary bladder bladder during 14 years from 1971 to 1984 were investigated according to the clinical type of CIS and treatment methods. CIS was classified into four types: (1) the primary group included 18 patients who had neither prior nor simultaneous tumors of the urinary tract; (2) the secondary group included 10 patients who had CIS diagnosed subsequent to the treatment of superficial papillary bladder tumor; (3) the concurrent group included 14 patients who had CIS concomitantly with superficial papillary bladder tumor; and (4) the nonpapillary T1 group included 25 patients who presented with CIS with concomitant nonpapillary T1 tumor. As a rule, the initial treatment was conservative (transurethral resection [TUR] or intravesical chemotherapy) for the primary, secondary, and concurrent CIS groups, whereas treatment was radical (total cystectomy or irradiation) for the nonpapillary T1 group. Five‐year survival rates of the primary, secondary, concurrent, and nonpapillary T1 groups were 41%, 100%, 49%, and 68%, respectively. Secondary CIS revealed a rather good prognosis, probably due to the early detection of CIS and early application of intravesical chemotherapy when compared to other groups. Except for patients with nonpapillary T1 tumors, the 5‐year rate of malignant progression (invasion or metastasis) and multiple recurrences leading to delayed cystectomy was 81% in 16 patients treated by TUR, whereas it was 39% in 21 patients treated by instillation therapy. It appears likely that intravesical chemotherapy was preferrable to other conservative therapies as an initial treatment of CIS. Radical therapy, however, may be the choice for CIS with nonpapillary T1 tumors, ab initio. Cancer 59:164–173, 1987.

Changing expression of ABH blood group and cryptic T‐antigens of noninvasive and superficially invasive papillary transitional cell carcinoma of the bladder from initial occurrence to malignant progression

Thirteen patients who developed malignant progression after frequent recurrence of noninvasive or superficially invasive (Ta or T1) papillary transitional cell carcinoma of the bladder were studied for expression of ABH‐antigens in tumor tissues throughout their clinical courses and cryptic Thomsen‐Friedenreich antigen (T‐Ag) expression in the tumor tissues was examined simultaneously in nine of them. Five patients who experienced recurrent bladder tumors for more than 5 years without any malignant progression were served as control. ABH‐antigens in initial tumors were negative in only two of 13 patients developing malignant progression and in two of five controls. Cryptic T‐Ag was positive in all patients examined. Recurrent tumors revealed eliminated or decreased expression of ABH‐antigens and cryptic T‐Ag before malignant progression in, respectively, ten of 11 and six of nine patients with antigen‐positive initial tumors. In contrast, recurrent tumor of controls with antigen‐positive initial tumors showed neither elimination nor decrease in expression of antigens throughout their clinical courses.