L. Giuliani

Radical Extensive Surgery for Renal Cell Carcinoma: Long-Term Results and Prognostic Factors

We studied 200 consecutive patients with renal cell carcinoma who underwent radical nephrectomy and extensive lymphadenectomy. Of the patients 25% already had distant metastasis at operation. Higher T stages tended to be associated with positive nodes (p less than 0.01) and distant metastasis (p less than 0.001). However, in patients with stage N0M0V0 tumors we found no statistically significant difference in survival in relationship to the T stage of the disease (5-year survival: stage T1 80%, stage T2 68% and stage T3 70%). Of all patients 10% had positive nodes without distant metastases and no venous spread of the tumor, and the 5-year survival rate was 52%. The 5-year survival rate of patients with distant metastases was 7%. Patient survival in the presence of a vena caval tumor thrombus is similar to that of patients with distant metastases. Based on our results the different stages in disease progression may be classified as having a good prognosis--intracapsular tumors (stages T1 to T2, N0M0V0) and tumors with involvement of perirenal fat (stage T3N0M0V0), an intermediate prognosis--tumors with nodal metastases alone (stages T1 to T3, N1 to 2, M0V0) and a poor prognosis--tumors with venous invasion and/or distant metastases. Histological grading and size of tumor can be used to assess prognosis but are not more accurate than pathological staging.

Monotherapy with Nilutamide, A Pure Nonsteroidal Antiandrogen, in Untreated Patients with Metastatic Carcinoma of the Prostate

A total of 26 previously untreated patients with metastatic carcinoma of the prostate received the pure nonsteroidal antiandrogen nilutamide as a single agent. Objective response rate was 38.5 +/- 18.7% (95% confidence interval). Median progression-free survival and median survival were 9 and 23 months, respectively. Of 13 patients with progression on antiandrogen 5 showed an additional objective response to a second-line endocrine treatment. The drug was generally well tolerated, except for 2 patients who discontinued treatment because of moderate gastrointestinal symptoms. Approximately a third of the patients complained of decreased adaptation to darkness. An electroretinogram and dark adaptation test revealed the presence of functional damage and visual complaints reversed in all patients on cessation of therapy. The other most frequent side effects were slight nausea (26.9% of the patients) and alcohol intolerance (19.2%). A nonsignificant increase in testosterone levels was shown within 1 month of treatment, after which the levels remained stable. Approximately half of the sexually active men claimed maintenance of libido and sexual potency during treatment. A slightly significant increase in hemoglobin was observed during the long term, suggesting the occurrence of a trophic effect by androgens on erythropoiesis. The results indicate that nilutamide as a single agent has an acceptable toxicity and a moderate activity, and may maintain sexual interest in a discrete number of cases. Whether monotherapy with nonsteroidal antiandrogens offers a valid option in the palliation of advanced disease remains to be seen in comparative prospective trials.

Alternating chemo-radiotherapy in bladder cancer: A conservative approach

PURPOSE The aim of this Phase II study was to determine a bladder-sparing treatment in patients with invasive bladder cancer, allowing a better quality of life. Objectives were to test toxicity and disease-free and overall survival of patients given an alternated chemo-radiotherapy definitive treatment. METHODS AND MATERIALS Seventy-six patients with bladder cancer Stage T1G3 through T4 N0 M0 were entered in the same chemotherapy regimen (Cisplatin 20 mg/mq and 5-Fluorouracil 200 mg/mq daily for 5 days) alternated with different radiotherapy scheduling, the first 18 patients received two cycles of 20 Gy/10 fractions/12 days each; the second group of 58 patients received two cycles of 25 Gy/10 fractions/12 days each (the last 21 patients received Methotrexate 40 mg/mq instead of 5-Fluorouracil). RESULTS A clinical complete response was observed in 57 patients (81%), partial response in 7 patients (10%), and a nonresponse in 6 patients (9%). At a median follow-up of 45 months, 33 patients (47%) were alive and free of tumor. The 6-year overall survival and progression-free survival was 42% and 40%, respectively. Systemic side effects were mild, while a moderate or severe local toxicity was observed in 14 patients and 13 patients (about 20%), respectively. CONCLUSION Our conservative combination treatment allowed bladder-sparing in a high rate of patients and resulted in a survival comparable to that reported after radical cystectomy.

Results of Radical Nephrectomy with Extensive Lymphadenectomy for Renal Cell Carcinoma

Radical nephrectomy with extensive lymphadenectomy was performed by the same surgeon on 104 consecutive patients with renal cell carcinoma. No significant differences in over-all survival owing to age, sex and preoperative embolization were noted. Only extension of the disease proved to be important as a prognostic factor. In the light of the statistical analysis of this variable the prognosis for patients with renal cell carcinoma has been classified as 1) good--patients with tumors confined to the kidney, 2) intermediate--patients with perirenal fat involvement, lymph node metastases and venous extension, and 3) poor--patients with distant metastases.

Transcatheter Embolization of the Hypogastric Arteries in Cases of Bladder Hemorrhage from Advanced Pelvic Cancers: Followup in 9 Cases

Bilateral transcatheter embolization of the hypogastric arteries is effective hemostatic treatment for patients with chronic life-threatening bladder hemorrhage from advanced pelvic cancers. We reviewed 9 cases in which this procedure had been done to investigate the immediate results, clinical effects, complications and late results. The minimum followup is 1 year except for 4 patients who were followed until death, which occurred in less than 1 year. Bleeding relapse occurred in only 2 cases and another embolization procedure was done in 1 case without major complications. A considerable decrease in the size of the tumor was noted in 1 patient after the bilateral hypogastric arterial embolization procedure. A rare complication, the Brown-Séquards-like syndrome, is discussed.

Results of radical cystectomy for primary bladder cancer: Retrospective Study of More than 200 Cases

During a seven-year period 202 patients with primary bladder cancer had radical cystectomy with bilateral pelvic lymphadenectomy and urinary diversion. Lymph node metastases were found in 28.7 per cent. No significant differences in overall survival owing to age were apparent. Only extension and grade of histopathologic differentiation of the tumor proved to be an important prognostic factor. The five-year survival rates for pT1, pT2, pT3, and pT4 tumors were 76, 56, 19, and 0 per cent, respectively. In patients with deep invasive (T3 and T4) tumors no significant differences of survival rate depending on N and M categories were found. Nevertheless in pT3 tumors the probability of remaining alive was significantly decreased in those patients with histologic grade 3 compared with grade 2 tumors (P less than 0.01). The prognosis for patients submitted to radical cystectomy for bladder cancer has been classified as good: tumors confined to superficial muscle (pT1 and pT2); intermediate: tumors mildly differentiated infiltrating the deep muscle (pT3/G2); fairly poor: tumors undifferentiated infiltrating deep muscle (pT3/G3); and poor: adjacent invasive bladder tumors (pT4).

Treatment of advanced prostatic carcinoma with cyproterone acetate and orchiectomy--5-year follow-up.

We report the results from 106 patients with extracapsular (stage C) or widespread (stage D) prostatic cancer, who were treated with cyproterone acetate and orchiectomy and followed for 5 years. As controls we used 40 patients, chosen at random, with stage C and stage D cancer of the prostate gland who were treated with stilbestrol and orchiectomy. The survival rate is improved in patients treated with cyproterone acetate and orchiectomy compared to the patients treated with stilbestrol and orchiectomy. Treatment with cyproterone seems more effective in those patients with low-stage and low-grade prostatic cancer. The side effects of this therapy are less and milder than those described in estrogenic treatment alone or with orchiectomy.

Embolization of renal cell carcinomas with isobutyl-2-cyanoacrylate: Experimental study and first clinical application

Abstract Isobutyl-2-cyanoacrylate (IBC) is an acrylic monomer which polymerizes quickly in contact with blood. It has rarely been used as an embolic material and never in embolization of renal cell carcinoma. IBC was used in experimental transcatheter embolization of rat kidneys and in 2 clinical cases of preoperative embolization of renal cell carcinoma. IBC is a substance which can produce a very efficient and lasting embolization; no significant complication was observed.

Percutaneous Temporary Embolization of the Internal Pudendal Arteries in Idiopathic Priapism: 2 Additional Cases

We report 2 cases of successful treatment of priapism by transcatheter embolization of the internal pudendal arteries. Recovery of penile blood flow was confirmed by Doppler flowmetry and potency was preserved. Embolization with autologous clot is at least partially reversible and interventional angiography warrants consideration in the treatment of priapism.

Surgical management of renal cell carcinoma with vena cava tumor thrombus

The results of the surgical management of 28 patients with renal cell carcinoma extending into the inferior vena cava have been analyzed. 8 patients had caval tumor thrombus extension at the level of the renal veins, 14 had infrahepatic, 5 retrohepatic and 1 atrial tumor thrombus extension. The caval wall was infiltrated by tumor in 7 cases. 9 patients had metastases. Lymph node involvement was seen in 9 patients. Life-table analysis of all 28 patients revealed on overall probability of survival of 32 and 9% at 2 and 5 years, respectively. The patients with caval involvement alone (N0M0) had a 2-year survival rate of 69%. Those with distant metastases or caval infiltration had a 2-year survival of 27 and 0% (p = NS). The level of caval tumor thrombus extension had a statistically insignificant influence on the survival of patients. In fact the 2-year survival rates of patients with caval thrombus at the level of the renal veins, below the large hepatic veins and above the large hepatic veins were 30, 36 and 32%, respectively. Our statistical data demonstrate that caval involvement has a very negative impact on the prognosis of patients with renal cancer.