Masamichi Hagiwara

Multimodal treatment of advanced adult Wilms tumor.

We report 2 cases of advanced adult Wilms tumor that were treated with surgery, radiation and chemotherapy. The first patient had relapse of a Wilms tumor in the liver 2 years after nephrectomy. Combination chemotherapy, consisting of actinomycin D and vincristine, radiation therapy and final resection of the liver metastasis were successful and the patient has been free of disease for 4 years. The second patient had undergone transcatheter embolization of the renal artery elsewhere with the tentative diagnosis of an inoperable renal cell carcinoma metastatic to both lungs. A left renal tumor, weighing 4,500 gm., and a tumor thrombus in the vena cava extending to the right atrium were removed, and histologically diagnosed as a Wilms tumor. Subsequent chemotherapy and radiotherapy resulted in complete disappearance of the lung metastases. We conclude that multimodal treatment, namely a well timed combination of surgery, chemotherapy and radiotherapy, could potentially eradicate the disease even at an advanced stage.

Phase II trial of carboplatin in patients with advanced germ-cell testicular tumors and transitional cell carcinomas of the urinary tract

SummaryCarboplatin, an analog of cisplatin, was evaluated in a phase II study involving 25 patients with advanced testicular tumor and 45 with transitional cell carcinoma (TCC) of the urinary tract; 21 and 38 cases, respectively, were evaluable for response. Prior treatment with cisplatin-based chemotherapy had occurred in 7 of the testicular cancer patients and in 11 with TCC. The response rate (complete + partial response) in testicular tumors was 47.6%. The best response rate was observed in seminomas (70.0%), whereas the response rate in nonseminomas was 27.3%. The seminoma patients had mainly stage IIIA or less than IIA disease, with metastatic lesions restricted to the lymph nodes. Three responses were seen in patients previously treated with cisplatin. In TCC, the response rate was 18.4%. Good-risk patients were treated with a dose of 400 mg/m2 every 4 weeks, whereas poor-risk patients received a lower dose of 300 mg/m2. The response rates for good-risk patients were 50.0% in testicular lesions and 26.1% in TCC. For poor-risk patients, the response rates were 40.0% and 6.7%, respectively. Carboplatin was well tolerated, with no significant renal impairment or ototoxicity detected. Nausea and vomiting were experienced by 51.7% of patients, but the severity was low; half of these patients demonstrated WHO grade I toxicity. However, myelosuppression was severe. In conclusion, carboplatin demonstrated activity in both testicular tumors and TCC and is worthy of further study, especially in combination with other active drugs.

A modified procedure for construction of a Kock continent ileal urinary reservoir: Nonafferent limb procedure

SummaryA modified technique for the construction of a Kock continent ileal urinary reservoir (Koch pouch) is reported. Our procedure avoids the afferent limb mechanism by direct uretero-pouch anastomosis using the Le Duc-Camey procedure; the nipple valve of the efferent limb is fixed directly to the pouch wall by the King procedure. This modified procedure was used in five patients with invasive bladder cancer, and the postoperative condition of the urinary tracts were periodically evaluated by image diagnostic techniques. Neither hydronephrosis nor hydroureter was observed during the study period. Pouchography and pouchometry were done in all cases studied; no pouch-ureteral reflux was observed, and both day-and night-time continence were maintained in all cases. No patient has thus far had problems with selfcatheterization. This modified technique could be a promising operative approach for the construction of a continent ileal urinary reservoir.

Continent urinary reservoir (CUR) for supravesical diversion. Pouchmetric properties of the colonic CUR and role of detubularization

Eight patients underwent pouchmetry at 12 months after creation of the colonic continent urinary reservoir (CUR) for supravesical diversion. Pouchmetry revealed a volume-dependent tonic and phasic increase in pouch pressure in 3 patients who had undergone pouch construction using the partially detubularized right colon (Heineke-Mikulicz type closure after splitting the transverse and ascending colon at the antimesenteric border), whereas the volume-dependent phasic increase in pouch pressure was much less remarkable in 5 patients whose pouch was constructed using the totally detubularized right colon (Heineke-Mikulicz type closure after splitting the whole colonic segment including the cecum). The maximum pouch pressure at the pouch volume of 400 to 500 ml was significantly higher (p less than 0.05) in the partial detubularization group (46 +/- 6.0 cmH2O, mean +/- S.D.) than in the total detubularization group (12 +/- 1.6 cmH2O). In creation of the low-pressure pouch using the right colon, detubularization should extend to the whole portion of the isolated colonic segment.