Salvatore Rovida

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.

Radical nephrectomy for renal cell carcinoma: long-term results and prognostic factors on a series of 328 cases.

Objectives: A series of 328 evaluable patients with renal cell carcinoma operated by radical transabdominal nephrectomy with regional lymphadenectomy was reviewed to assess the prognostic significance of various pathologic parameters (pT, N, M, G and venous involvement) and the value of lymphadenectomy and of surgery of venous tumor thrombus. Patients and Methods: The complete charts of 328 patients with renal cell carcinoma available to follow-up, who were operated between 1970 and 1993, were reviewed. All patients underwent transabdominal extrafascial nephrosurrenalectomy and in all but 14 metastatic ones a regional retroperitoneal lymphadenectomy was performed. Surgery of venous tumor thrombus was performed in 79 patients. Life expectancy according to pT stage, pN stage, M stage, nuclear grade and venous involvement was calculated by means of the life tables method and differences in survival were evaluated by means of the log rank test. Correlation analysis and multivariate data analysis according to the Cox model were also performed. Results: Overall survival of the 328 patients was 50.70% at 5 years, 35.10% at 10 years and 29% at 15 years. At multivariate data analysis the most important prognostic factors is the presence of metastases (8 % survival at 5 years and no patient surviving more than 7 years after surgery); tumor grade was the second prognostic factor and statistically significant differences were also found at life tables analysis among G1, G2 and G3 tumors. Local tumor stage was the third leading prognostic factor at multivariate data analysis and statistically significant differences were also found at life tables analysis. Nodal and venous involvement had only minor importance at multivariate data analysis although statistically significant differences were found at life tables analysis between the pN+ and the pN0 patients, also in the absence of venous involvement and distant metastases. Anyway survival of the pN+M0V0 patients was satisfactorily high (53,20% at 5 years, 39.10% at 10 years and 16% at 15 and 20 years). In patients with venous involvement no differences in survival were observed depending on the level reached by the tumor thrombus; differences in survival were observed between patients with venous involvement alone (38% surviving at 5 and 10 years) and patients who also had nodal or distant metastases (5.20% at 5 years and 0% at 10 years). Conclusions: From the review of our series it seems that the most important prognostic factors are synchronous metastases, tumor grading and the completeness of tumor exeresis. In fact, the low impact on survival of nodal involvement by itself is probably due to the completeness of lymphadenectomy. The value of regional lymphadenectomy is sustained by the high long term survival of N+M0V0 patients. Regarding venous involvement, it seems that V+ patients free from nodal and distant metastases may benefit from radical surgery, which on the contrary has only minimal impact on survival of V+M+/N+ patients.

Is intensive follow-up really able to improve prognosis of patients with local recurrence after curative surgery for rectal cancer?

Background: Because more than 90% of local recurrences after curative surgery for rectal cancer appear within the first 36 months after surgery, an intensive and strict follow-up program during this period could improve early diagnosis and, thus, prognosis of patients.Methods: Of the 216 patients who underwent surgery for rectal cancer, 127 entered an intensive follow-up program (median follow-up: 42 months); the clinical outcome of the remaining 89 patients was reconstructed with the help of their general practitioners.Results: Fifty eight (26.8%) of the 216 patients who were treated with curative surgery alone developed a local recurrence; pelvic recurrences were prevalent. Eleven (30.5%) of the 36 patients who had recurrence during follow-up, and 6 of the 22 who had not undergone follow-up, had a reoperation with curative intent; the median survival was 19 months vs. 8 months, respectively (P 5 ns). Four (44.4%) curative reoperations were performed on the 9 asymptomatic patients and in 13 (26.5%) of the 49 cases with symptomatic local recurrences. Median survival was 15 months vs. 14 months, respectively (P 5 n.s). All patients except one (living after 42 months from reoperation) died within 48 months.Conclusions: In our study, adherence to a strict follow-up program unfortunately proved to be ineffective for improving long-term survival for patients who underwent reoperation with curative intent.

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).

Transvaginal bone-anchored synthetic sling for the treatment of stress urinary incontinence : An outcomes analysis

OBJECTIVES To evaluate the results and complications of a new transvaginal minimally invasive procedure for the treatment of stress urinary incontinence. METHODS Sixty-seven women aged 37 to 77 years underwent a pervaginal bone-anchoring synthetic sling procedure between April 1997 and February 1999. Sixty-three patients had a defect of the anatomic support, and 4 had iatrogenic intrinsic sphincteric deficiency (ISD). Patients were assessed at least 1 year postoperatively, underwent physical examination, and filled in the self-assessment questionnaire with the help of a nonpartisan health care provider. The questionnaire inquired about urine leakage, obstructive and irritative symptoms, quality of life, and satisfaction with the treatment received. The physician and questioner had no knowledge of each other. RESULTS Mean follow-up was 17 months. Perfect dryness was seen in 82% of patients with improvement in 9% and failure in 9%. Patients reporting a failed outcome were significantly older than those reporting improvement or cure (P = 0.01). All patients with ISD failed. Moderate obstructive symptom scores have been noticed in 31% of patients. Irritative voiding symptoms have been recorded in 22% of cured patients and 83% and 80% of improved and failed patients, respectively (P <0.001). Three percent of patients experienced pain during intercourse. Mild pelvic pain was found in 8% of patients. The only main complication of the operation was the vaginal erosion and sling removal in 16% of patients. Seventy-two percent of patients were completely satisfied with the treatment received. CONCLUSIONS This procedure allows a high cure rate in patients with urinary incontinence due to a defect of anatomic support, and it is unsuitable when incontinence is due to ISD. The only main complication came from the use of the gelatin-coated Dacron sling that resulted in vaginal erosion, often necessitating the sling removal. The use of different synthetic or nonsynthetic materials may be advisable.

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.

Plasma fibronectin in psoriatic arthritis subgroups

SummaryPlasma from 38 patients suffering from one of the five broad clinical subgroups of Psoriatic Arthritis (PA) were studied for soluble plasma Fibronectin (pFn). The mean total concentration of pFn was 453.03μg/ml ± 142.83 SD, with a significant statistical difference (p<0.01) versus a healthy control group matched with respect to sex and age. In order to evaluate the biological role that pFn might play in this pathological condition, observed concentrations were correlated with the degree and duration of the psoriasis and arthritis. In addition, pFn was correlated to some biohumoral parameters that are modified during inflammatory processes (ESR, CRP, sCu, sFe, Hb) and to uric acid levels. Tissue typing (HLA) was done where possible. From our observations, we suggest that pFn most likely is not an acute phase protein and rather than having specificity for a particular disease, might, in widespread and severe cases be,a general and useful marker of the connective-tissue organizing and repairing response, following its injury.

Variables Influencing the Choice and Outcome of Noncurative Surgery for Advanced Gastric Cancer

Of 550 patients with gastric cancer presenting in an 18-year period, 274 (49.8 %) underwent noncurative surgery. Surgery was noncurative due to invasion of adjacent organs (T4) in 19.7% of patients, extensive lymph node involvement (N3) in 4%, unresectable distant metastases in 27.7% or a combination of all three conditions in 48.5% of cases. Resection was carried out in 41.4% of patients with primary situated in the antrum and in only 12.2.% with multicentric primary ( p 70 years old) and tumor stage. Six of the total 274 patients were alive 5 years from noncurative surgery. Subtotal gastric resection is the surgical procedure to be preferred. In the absence of distant metastases, resection should be considered in patients with primary situated in the body or antrum, with T4N0–2 or T3N3 lesions. Resection is also warranted when distant metastases can be excised.

Grading as a prognostic factor: review of 209 primary gastric cancer patients.

Two hundred and nine cases of primary gastric cancer were treated surgically from January 1968 to December 1983 and analyzed retrospectively. All patients were followed up for a minimum of 5 years. There were 25 SI cases (12 %), 22 SII (10.5%), 55 SIII (26.3%) and 107 SIV (51.2%). Tumor grade according to Broders classification showed 50 cases of G1 lesions (23.9%), 44 G2 (21.1 %) and 115 G3 (55%). Patients with well differentiated G1 lesion, compared to G2-G3 patients, presented a greater incidence of T1-T2 tumors and decreased incidence of T4 tumors (p < 0.05). The lymph node involvement rate significantly increased with variation of T (p < 0.001) but not with tumor grade. Survival results correlated with tumor stage (p < 0.01) but not with tumor grade or histological type.

Optimized macular recovery test for the early diagnosis and risk prediction of retinopathy in diabetics

SummaryThe authors present a clinical study on the macular recovery test, in a new optimized version, in normal subjects and in diabetic patients. The discriminating thresholds between normals and retinopathic diabetics and between non-retinopathic and retinopathic diabetics were statistically analyzed.