Toshio Shimoji

Surgical treatment of renal cell carcinoma metastases: prognostic significance.

Between January 1980 and March 1993, 166 patients with renal cell carcinoma were treated at Nagoya University Hospital. Among them 16 (9.6%) underwent surgical removal of 21 metastatic lesions: 12 patients had distant metastases at diagnosis and the other 4 demonstrated new distant metastases during their clinical course after nephrectomy. The metastatic lesions involved the brain in 6 patients, bone in 4, lung in 2, contralateral adrenal glands in 2, soft tissues in 2, lymph nodes in 2, pleura in 1, pancreas in 1, and contralateral renal pelvis in 1. All of the 16 patients underwent nephrectomy and 15 of them (93%) received interferon-α therapy. Patients with lesions which were completely resected had significantly longer survival than those with lesions which were palliatively treated and those with metastatic lesions at other sites (p=0.02). Improvement of performance status was observed in 5 of 6 (83%) patients undergoing palliative surgical treatment. The present study suggests that surgical removal of metastatic lesions prolongs survival in a limited number of renal cell carcinoma patients and that it improves performance status in those symptoms related to metastasis.

Clinicopathological characteristics of small renal cell carcinomas.

To clarify the clinicopathological characteristics of small renal cell carcinomas (RCCs) the authors reviewed data for 154 RCC patients treated between January 1980 and September 1992. Of 20 patients with tumours of 3 cm or less in diameter, 12 (60%) had no related symptoms: 6 (30%) were found during routine physical check-ups and 6 (30%) were incidentally detected during examinations for diseases other than RCC. The remaining 8 (40%) patients demonstrated indicative symptoms. Most small tumours showed expansive growth and nuclear atypia was minimal or moderate. In all 20 cases, the lesions of 3 cm or less were confined to the kidney (pT1 to pT2b) and no lymph node metastasis was found. Only one (5%) had a distant metastasis, and venous involvement was also microscopically observed in only one patient (5%). The 5-year survival rates were 95% for patients with tumours of 3 cm or smaller, 74% for those of 3.1 to 5 cm, and 68% for those of greater than 5 cm. These findings revealed small RCC to demonstrate biologically less malignant behaviour. Early detection of such small lesions by ultrasonography should therefore improve the overall survival of patients with RCC.

Intravesical bacillus Calmette-Guérin (Tokyo 172 strain) therapy for carcinoma in situ of the bladder

To evaluate the clinical response to intravesical instillation therapy with bacillus Calmette-Guérin (BCG) Tokyo 172 strain for carcinoma in situ (CIS) of the bladder and subsequent patient prognosis, we reviewed data for 30 patients treated between 1985 and 1994. Median follow-up was 56 months. The CIS cases comprised two groups: primary (19 patients) and subsequent to development of a gross neoplasm (11 patients). Either 40 mg (n=20) or 80 mg (n=10) doses of BCG were instilled weekly for 8 weeks. This intravesical therapy resulted in apparent eradication of tumour cells in 25 of the 30 patients for a complete response (CR) rate of 83%, with no difference found between primary and secondary groups. Tumours later recurred in 6 of the 25 patients (24%) and disease progression was found in only 3 (12%). In contrast, progression occurred in 3 of 5 patients (60%) for which a complete response was not achieved with intravesical BCG therapy. The difference between these two groups was significant (p=0.04). Total cystectomy was performed in 2 of 25 CR patients (8%) first and in 4 of the 5 unresponsive (80%), the statistical difference being highly significant (p=0.003). The 5-year survival rate was 96% for the study subjects as a whole. In conclusion, CIS unresponsive to BCG therapy should be treated with immediate total cystectomy while cases demonstrating a complete response should be followed up for a long period.

A randomized trial of early intravesical instillation of epirubicin in superficial bladder cancer

A total of 135 patients with superficial bladder cancer diagnosed as totally resectable were entered into a randomized multicenter trial to investigate the efficacy of early intravesical epirubicin instillation after resection in comparison with transurethral resection (TUR) alone. Epirubicin (40 mg/40 ml saline) was given within 24 h of TUR and once during the 1st week, weekly for 4 weeks, and then monthly for 11 months. In all, 122 patients (90.4%) were eligible and 119 (88.1%) were evaluable. The interval to initial recurrence was significantly longer (P=0.02) in the epirubicin group (36 months; 95% confidence interval, 32–40 months) than in the group receiving TUR alone (28 months; 95% confidence interval, 24–32 months). The recurrence rate per year in the epirubicin group was less than that in the TUR-alone group (0.13 versus 0.29 annual recurrences). Disease progression was observed in only one patient in the epirubicin-instillation group. The main toxicity encountered was bladder irratation (13.8%). These results demonstrate that early intravesical epirubicin instillation is efficacious in preventing local recurrence.

Metastasis of Renal Cell Carcinoma to the Contralateral Renal Pelvis

Extremely rarely renal cell carcinoma metastasizes to the contralateral renal pelvis or ureter. The present report concerns a case where a metastatic tumor could be successfully removed from the left renal pelvis 3 years after right nephrectomy for the primary tumor. A review of the literature revealed this to be only the fourth such case documented.

Remarkable Responses of Metastatic Renal Cell Cancer in Multiple Organs Treated with Alpha-Interferon

We report a case of renal cell carcinoma with metastases in the lungs, humerus and brain, which we treated with alpha-interferon. After a transperitoneal nephrectomy the patient received a series of intramuscular injections of alpha-interferon every 2 days. Two months after the initial therapy complaints of pain in the humeral bone gradually decreased and the palpable mass in the right brachial region disappeared completely. A computerized tomography scan revealed only the scar of the intracranial metastasis. Most of the pulmonary lesions disappeared 4 months later except for the metastasis at the apex of the left lung.

A case of intraperitoneal testicular cancer with ascites.

We report an initial case of intraperitoneal testicular cancer with ascites. Although the cytology of aspirated ascites revealed no tumor cells, the beta-HCG and AFP values were high. Preoperative cisplatin-based combination chemotherapy was used without any pathological diagnosis. Following 2 cycles of chemotherapy, the beta-HCG and AFP values normalized. Furthermore, no ascites was observed on CT scan. Although an accurate histological diagnosis was not established before treatment, it was thought that the ascites originated from the disseminated testicular cancer cells in the peritoneum.