The current role of radiotherapy in the treatment of invasive bladder cancer

Invasive bladder cancer remains a therapeutic challenge. Approximately 50% of patients treated with radical cystectomy die of metastatic disease. External beam radiation therapy when given alone has results inferior to that of surgery, and although it has shown some benefit when given in the preoperative setting, this was not verified by randomized trials. Altered fractionation radiation schemes and combined modality using a cisplatin-based combination chemotherapy with radiation have resulted in up to 60% bladder preservation.     

Selective bladder preservation by combination treatment of invasive bladder cancer

BACKGROUND: For patients with invasive bladder cancer the usual recommended treatment is radical cystectomy, although transurethral resection of the tumor, systemic chemotherapy, and radiotherapy are each effective in some patients. We sought to determine whether these treatments in combination might be as effective as radical cystectomy and thus might allow the bladder to be preserved and the cancer cured. METHODS: We enrolled 53 consecutive patients with muscle-invading bladder cancer (stages T2 through T4, NXM0) in a trial of transurethral surgery, combination chemotherapy, and irradiation (4000 cGy) with concurrent cisplatin administration. Urologic evaluation of the tumor response directed further therapy: radical cystectomy in the 8 patients who had incomplete responses, additional chemotherapy and radiotherapy (6480 cGy) in the 34 patients who had complete responses or who were unsuited for cystectomy, and alternative care in the 11 patients who could not tolerate either irradiation or chemotherapy. RESULTS: After a median follow-up of 48 months, 24 of the 53 patients (45 percent) were alive and free of detectable tumor. In 31 patients (58 percent) the bladder was free of invasive tumor and functioning well, even though in 9 (17 percent) a superficial tumor recurred and required further transurethral surgery and intravesical drug therapy. Of the 28 patients who had complete responses after initial treatment, 89 percent had functioning tumor-free bladders. CONCLUSIONS: Conservative combination treatment may be an acceptable alternative to immediate cystectomy in selected patients with bladder cancer, although a randomized clinical trial that included a group for simultaneous comparison would be required to produce definitive results.     

Eosinophilic cystitis masquerading as invasive bladder cancer

Bilateral torsion of testicular appendages is extremely uncommon. We present a rare clinical case of bilateral synchronous torsion of the hydatids of Morgagni. Clinical management was dictated by the clinical findings.     

Retroperitoneal endometriosis causing cyclical ureteral obstruction

Cooperativity between redox and protonation centres is known to be crucial for the function of complex proteins, but it is often difficult to describe in terms of thermodynamic parameters. Cytochrome c3 is a good model for these studies since, while retaining the overall complexity of larger systems, it is suitable for detailed crystallographic and spectroscopic studies. Assignment of the haem substituent NMR resonances, together with NMR redox titrations of cytochrome c3 from D. desulfuricans ATCC 27774, was used to correlate relative redox potentials to specific haems in the structure: haem II approximately equal to haem I < haem IV < haem III. This order is different from that determined for the homologous proteins studied and in disagreement with that previously reported for this cytochrome (Morais, J., Palma, N., Fraz?o, C., Caldeira, J., LeGall, J., Moura, I., Moura, J.J.G. and Carrondo, M.A. (1995) Biochemistry 34, 12830-12841).     

Results of salvage abdominoperineal resection for anal cancer after radiotherapy

PURPOSE: Nonsurgical treatment of anal cancer by radiotherapy alone or combined with chemotherapy is the standard therapy for epidermoid carcinoma of the anal canal. Surgery is only recommended for treatment failures. Very few studies have been devoted to the outcome of this salvage surgery. The aim of this study is to evaluate these results. METHODS: A retrospective review from 1986 to 1995 revealed 21 patients with residual or recurrent anal canal carcinoma after initial radiotherapy, operated on by abdominoperineal resection. Patients were reviewed as to age, gender, initial treatment, any symptoms of recurrence, duration until recurrence, any diagnosis imaging, treatment, and outcome. RESULTS: None of these 21 patients had known lymph node involvement or metastases at radiotherapy or at salvage abdominoperineal resection. Eleven patients had residual disease (positive biopsy less than 6 months after the end of radiotherapy) and 10 had tumor recurrence (more than 6 months after cessation of treatment). Recurrence occurred at a mean of 15 (range, 9-41) months after radiotherapy. All 21 patients underwent an abdominoperineal resection. Pathologic examination of the 21 specimens showed complete excision in all cases except one and lymph node metastases in two cases. There was no perioperative mortality. The mean follow-up after surgery was 40 months; no patients were lost to follow-up. Of the 21 patients, 10 died and 11 lived, of whom 9 are disease free. The overall survival rate at three years after salvage abdominoperineal resection was 58 percent. The overall survival rate for patients with residual disease (vs. recurrence) at three years was 72 percent (vs. 29 percent) and at five years was 60 percent (vs. 0 percent; P = 0.06). CONCLUSIONS: Salvage abdominoperineal resection for anal cancer can be expected to yield a number of survivors from residual disease, but the low rate of survival after abdominoperineal resection for recurrent disease suggests the need for additional postoperative treatment if salvage abdominoperineal resection is performed.     

Late invasive recurrence despite long-term surveillance for superficial bladder cancer

Superficial transitional cell carcinoma of the bladder is associated with a 15 to 70% recurrence rate within 2 years. Most recurrences are superficial. A recurrence after 2 disease-free years is unusual. A review of the tumor registry revealed 124 patients followed for superficial disease at the Veterans Administration Center in Baltimore. Of the patients 20 were identified with either stage Ta (7) or stage T1 (13) papillary transitional cell carcinoma who had completed at least 5 years of surveillance without tumor recurrence. Invasive transitional cell carcinoma of the bladder requiring cystectomy developed in 7 of these 20 patients after remaining tumor-free for 5 years (stage Ta in 4 and stage T1 in 3). All 7 patients had organ-confined disease and were alive with no evidence of disease at 18 months to 5 years after cystectomy. These results demonstrate that superficial, low grade transitional cell carcinoma of the bladder can become muscle invasive despite careful surveillance and a long dormant period. In our series yearly cystoscopy and urine cytology identified tumor recurrence before metastases developed, suggesting that long-term surveillance is required in patients with superficial bladder cancer.     

Internal iliac arterial infusion chemotherapy for rabbit invasive bladder cancer

Eleven patients with T4 breast cancer received induction intraarterial chemotherapy (IACT) as the first step in multidisciplinary therapy. The IACT agents (epirubicin and mitomycin C), were delivered weekly in the outpatient department by bolus injection through an implantable port-catheter system. A modified technique of port-catheter system implantation was used. The precise localization of the catheter was dually confirmed by angiography and dye test. The effectiveness of the treatment was evaluated by clinical appearance, image study, and microscopic examination. A 91% response rate was obtained, and the lesions were resectable in < or = 8 weeks. No obvious systemic toxicity resulted from the IACT. Our results show that weekly IACT by bolus injection through a port-catheter system for treating locally advanced T4 breast cancer is feasible and efficacious.     

The ureteral "J" sign: radiographic demonstration of iatrogenic distal ureteral obstruction after ureteral reimplantation

Progressive caliceal and ureteral dilatation in postoperative patients is assumed to be secondary to either postoperative distal ureteral stricture or ureteral atony. Any study used to differentiate obstruction from atony must be done with an awareness of the effect of a full bladder on the upper tracts, since it can by itself produce varying degrees of ureteral dilatation. We describe 2 patients who had virtually complete distal ureteral obstruction on anterograde pyelography with a "J" shaped distal ureteral segment. The striking observation was that the deformity and associated distal ureteral obstruction could be made to appear and disappear at will, merely by distending or emptying the bladder. We believe that this is an important factor in the progressive dilatation, as well as in the observed deterioration of renal function, and it is properly regarded as an iatrogenic complication.     

Relationship of tumor angiogenesis and nuclear p53 accumulation in invasive bladder cancer

The purpose of this investigation was to evaluate the relationship between tumor angiogenesis and nuclear p53 accumulation in invasive bladder cancer. We studied 161 patients with invasive transitional cell carcinoma of the bladder who had previously undergone radical cystectomy. Analysis was performed to determine the presence of p53 nuclear accumulation and extent of tumor-associated angiogenesis. p53 status identified a group of patients at high risk for tumor progression (p53-altered tumors), and microvessel density determinations added additional prognostic information by identifying a subset of aggressive tumors within the wild-type p53 subgroup. At 5 years, patients with tumors exhibiting no evidence of p53 alterations and low microvessel counts demonstrated 3% recurrence and 88% survival, compared to 43% recurrence and 59% overall survival for patients with intermediate vessel counts and 61% recurrence and 43% overall survival for patients with the highest vessel counts (P < 0.001 and P = 0.003, respectively). Angiogenesis also provides additional prognostic information to patients with tumors that demonstrate p53 alterations. An association between angiogenesis and p53 status did exist (P = 0. 05); however, 27% of the tumors that showed no evidence of p53 alterations exhibited high microvessel counts, and 26% of tumors with evidence of p53 alterations had low microvessel counts. Tumor-associated angiogenesis adds additional useful prognostic information to that which is obtained from p53 status in patients with invasive transitional cell carcinoma of the bladder. Although an association between p53 status and the degree of angiogenesis was identified, other factors appear to play a role in the regulation of tumor-induced neovasularization.     

Neoadjuvant treatment for invasive bladder cancer: is it worthwhile?

The clinical relevance of laparoscopy (LS) and laparoscopic echography (LSEG) in diagnosing and staging gastrointestinal carcinomas is assayed in the light of diagnostic methods in current use. The study covers 257 patients undergoing LS, and 23-LSEG. For the purpose a rigid 7.5 MHz echolaparoscopic probe is used. In 16 per cent of the cases LS fails to resolve the basic diagnostic problems faced, whereas in 35 per cent it alters completely the preliminary clinical diagnosis. In over 90 per cent of cases LSEG supplements or modifies the laparoscopic diagnosis. Emphasis is laid on the role played by LSEG in defining the loco-regional stage of gastric and colorectal carcinomas, as well as on the contribution of the method to establish pancreatic carcinomas not lending themselves to resection. What is more, LSEG demonstrates inoperable cases by detecting small, unsuspected metastases, not prominating above the hepatic surface.     

Neuroanatomical changes in the rat bladder after bladder outlet obstruction

OBJECTIVE: To evaluate the perinatal and 2-year outcomes in pregnancies complicated by preterm premature rupture of membranes (PROM) during the second trimester. METHODS: Fifty-three consecutive singleton pregnancies with PROM at 14 to 28 weeks of gestation were studied retrospectively. Management goals were to prolong the pregnancies to 32 weeks through expectant management and to avoid fetal compromise through closer monitoring and active intervention, when necessary, after 23 weeks. Outcome of the surviving infants was based on neurologic, audiometric, and ophthalmologic examinations at 2 years of corrected age. RESULTS: Rupture of membranes occurred at 14-19 weeks (mean 17.4 weeks) in 10 women, at 20-25 weeks (mean 24.0 weeks) in 24, and at 26-28 weeks (mean 27.6 weeks) in 19. The median latency periods to delivery were 72 days, 12 days, and 10 days when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively. The overall incidence of chorioamnionitis was 28%. There were no fetal deaths and nine neonatal deaths. When rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, the perinatal survival rates were 40%, 92%, and, 100%, respectively. Pulmonary hypoplasia accounted for seven deaths. Of the live-born infants, 81% were alive at 2 years of corrected age. Survival without major impairment was observed in 75%, 80%, and 100% of the survivors when rupture of membranes occurred at 14-19 weeks, 20-25 weeks, and 26-28 weeks, respectively. CONCLUSION: Expectant management of second-trimester PROM offers better perinatal and long-term survival than previously thought.     

Prognostic factors in muscle-invasive bladder cancer treated with radiotherapy: an immunohistochemical study

OBJECTIVE: To determine the prognostic role of p53, Ki-67 and p21 for patients with muscle-invasive bladder cancer treated with curative intent by radiotherapy. PATIENTS AND METHODS: The study included 131 patients (24 women and 107 men, median age 72 years, range 40-86) with transitional cell carcinoma (T2-T4) treated with external definitive pelvic radiotherapy between 1985 and 1994. Paraffin-embedded pretreatment biopsies from the patients were examined for the presence of p53, p21 and Ki-67, detected by immunohistochemistry, and related to tumour stage, grade and patient survival. RESULTS: The expression of p53 protein correlated positively with the detection of Ki-67 (P < 0.05) but did not correlate with p21. None of the immunohistochemical variables (p53, p21 or Ki-67) correlated with T category and only Ki-67 correlated with histological grade. Patients with > 5% p21 expression tended to live longer than those with < 5% (P = 0.09). In a multivariate analysis, the T category (T2/T3 vs. T4), histological grade (2 vs. 3) and p21 expression (< or = 5% vs. > 5%) were independent prognostic factors for overall survival. CONCLUSION: Further investigation is warranted in patients with muscle-invasive bladder cancer undergoing different types of treatment p21 seems to play an independent prognostic role in these patients, in addition to T category and grade.     

Pediatric ureteral ureteral outlet obstruction and obstructive megaureter: observation or operation?

Thirty-nine extracts of 13 plants used traditionally as medicinal by the Ese'ejas were studied in order to determine their cytotoxic effect in the brine shrimp. Infusions showed no toxicity. Those plants that tested positive for methanolic and dichloromethane extracts were assayed for DNA-binding activity. Cytotoxicity was not due to the presence of compounds that interact with DNA. Antimicrobial activity of plants used to treat infectious diseases was also performed for the decoctions. These proved to be active against some of the test microrganisms used in the assay.     

Prostatitis and bladder neck obstruction

BACKGROUND AND OBJECTIVES: Development in surgical technology must demand not only improved efficacy and risk reduction but also a reduction in costs and efficient use of human resources. For 25 years we have discussed the development of optical access trocars and their probable benefits. They are now available in the form of the OPTIVIEW by Ethicon and the SURGIVIEW by US Surgical. METHODS: Between December 1996 and March 1997, we utilized the optic obturator trocar, OPTIVIEW, in 104 cases of gynecological operative laparoscopy. The instrument was equipped with an axial grip to facilitate ergonomic handling. RESULTS: The optical trocar was used with a Z-incision techniques in 16 cases; a vertical incision was used in 58 cases. In all of the gynecological procedures, the optical trocar was more advantageous than classic trocars placed without direct vision. Our estimation was that separation of tissue layers was very good in 71 cases, good in 26 cases and problematic in 5 cases. No complications occurred with the use of this trocar. The Z-incision was preferable to the vertical incision although it required a longer time of insertion of up to 5 seconds. Altogether, the OPTIVIEW presented an easy way of avoiding intestinal and vascular injury during initial trocar entry. CONCLUSIONS: The application of this new tool is practical, safe and handy. However, it requires training in its appropriate use. Vertical incisions should be sutured after removal of the instrument. Additional trocars need not be optical trocars as they can be placed under direct vision and laparoscopic control. It is our opinion that a combination of sophisticated new technologies such as the OPTIVIEW trocar, robotic arm, harmonic scalpel and 3-D vision would provide safe and efficient means to accomplish gynecologic laparoscopic surgical procedures.     

Transurethral incision in primary bladder neck obstruction

Sixty-one patients presenting primary obstruction of the neck of the urinary bladder are subjected to transurethral operative intervention and postoperative follow-up study in the period 1986 through 1990. The indications for performing transurethral incision of the bladder neck are established on the basis of subjective complaints against the background of data from uroflowmetry, miction cystourethrography and endoscopic study of the lower urinary ways. The obtained results point to an improvement of the subjective complaints in 74 per cent of the cases. In 78 per cent of the patients peak urinary flow exceeds 15 ml/sec. Repeated transurethral incision is necessitated in 8.1 per cent, and transurethral resection in the postoperative period is done in twelve patients (19.6 per cent). Postoperative strictures of the urethra are discovered in 8 patients (13.1 per cent), and retrograde ejaculation is documented in three patients (8.5 per cent) over the maximum observation term of 64 months. Postoperative hospitalization is average 3.2 days (range 2.7 to 5.9 days).