Progressive asymmetrical peripheral neuropathy of both legs in a 64-year-old man

Between August 1983 and April 1996, 53 testicular germ cell tumors in 52 patients were treated at Toranomon Hospital. The average age of the patients was 36.1 years (range 21-89). The affected side was the right side in 24, left in 27 and bilateral in 1 case. Of the 53 tumors 34 (64.2%) were seminoma and 19 (35.8%) were non-seminomatous germ cell tumor (NSGCT). High ligation orchiectomy was performed in all cases. Of 29 stage I seminomas, post-operative adjuvant radiotherapy was performed in 6 cases prior to 1991. None of these tumors recurred. Two cases of relapses (8.7%) were found among the 23 stage I seminomas followed by surveillance. Of 8 stage I NSGCTs followed by surveillance, 4 (50.0%) tumors which contained embryonal carcinoma element and vascular invasion relapsed within 12 months after orchiectomy. A case of stage IIA seminoma was treated successfully by irradiation. Seven cases of stage II (3 seminomas and 4 NSGCTs) and 8 cases of stage III (1 seminoma and 7 NSGCTs) as well as cases of 6 stage I patients who developed relapse during surveillance were treated by VAB-6 chemotherapy. Of these 21 cases, 11 (52.4%) achieved complete response (CR) and 10 (47.6%) partial response (PR). Salvage surgery and/or additional chemotherapy was successful to bring the 10 PR cases into CR condition. One NSGCT patient, however, died of electrolyte imbalance during the maintenance chemotherapy for disease progression after achieving CR. All 34 patients with seminomas and 18 of the 19 with NSGCTs were alive without evidence of disease after a mean follow up period of 61.1 months (range 4-150 months).     

Primary chemotherapy for stage 2 testis cancer

To evaluate the efficacy and toxicity of primary chemotherapy in patients with stage 2 (retroperitoneal lymph node metastases) testis cancer, 20 consecutive patients referred to Groote Schuur Hospital between September 1992 and March 1994 were reviewed. There were 10 patients with non-bulky non-seminomatous germ cell tumour (NSGCT), 5 with bulky NSGCT and 5 with bulky seminoma. The treatment regimen consisted initially of 4 cycles of cisplatin, etoposide and bleomycin. Patients with NSGCT and a residual mass after chemotherapy subsequently underwent retroperitoneal lymph node dissection (RPLND) and those with seminoma underwent a low dose of irradiation to the mass. In 7 (70%) of the 10 patients with non-bulky NSGCT, there was a complete response to chemotherapy and 3 patients underwent limited RPLND. One patient relapsed at follow-up but remains clear of disease after salvage therapy. The survival rate is 100% at a median follow-up of 60 months (range 12-143 months). In 5 patients with bulky NSGCT there was no complete response to chemotherapy. Three have undergone limited RPLND. The survival rate is 52% at a median follow-up of 130 months (range 108-152 months). In 5 patients with bulky seminomas, the survival rate is 100% at a median follow-up of 55 months (range 29-92 months). Toxicity has been modest except for 1 patient who died postoperatively in the early part of the study. Four patients have fathered children after treatment. We conclude that primary chemotherapy is the treatment of choice for patients with stage 2 testis cancer.     

Lymph node metastasis in stage I ovarian carcinoma

One hundred and sixteen cases of stage I ovarian cancer from 6 hospitals in China were investigated for their lymph node metastasis from September, 1982 to April 1991. Of them, 70 had epithelial tumor, 36 malignant germ cell tumor, 8 gonadal stroma, and 2 undifferentiated tumor. Ovarian tumor confined to one ovary (stage Ia) in 89 patients, both ovaries involved (stage IIb) in 6, and documented stage Ic in 21. Systemic lymphadenectomy involving all pelvic groups of node together with aortic lymph node was accomplished in 82 patients. In the remaining 34 patients, pelvic lymph node dissection was performed. The incidence of lymphatic metastasis was 10.3% in this series. Serous cystadenocarcinoma was the most common lesion. All patients were followed up for at least half year. The mortality rate in patients with and without lymph node metastasis was 8.3% and 2.8% respectively. The clinical significance of retroperitoneal lymphadenectomy in early ovarian carcinoma was discussed.     

Immunohistochemical expression of Ki-67 to predict lymph node involvement in clinical stage I nonseminomatous germ cell tumors

PURPOSE: Primary archival tumor tissues of 89 patients with clinical stage I nonseminomatous germ cell tumors were analyzed for MIB-1 expression and histological parameters such as percentage embryonal carcinoma and presence of vascular invasion to determine the value of these parameters to predict absence or presence of occult lymph node disease. MATERIALS AND METHODS: A monoclonal antibody (MIB-1) developed for application in paraffin-embedded tissues was used to measure immunohistochemical expression of Ki-67 for the overall tumor (total MIB-1) and for each malignant cell type present. In addition, the primary tumors were examined for the presence of vascular invasion and determination of quantitative histology. Univariate and multivariate logistic regression models were used for statistical analysis. RESULTS: Univariate analysis neither revealed total MIB-1 score nor MIB-1 score in the highest area of staining of the different cell types to significantly predict pathological stage I or stage II disease. However, the presence of vascular invasion (p < 0.0001) and the percentage of embryonal carcinoma (p < 0.0001) were significant risk factors for occult nodal disease. Multivariate logistic regression analysis revealed the combination of vascular invasion and the percentage of embryonal carcinoma to be the best model to predict pathological stage II correctly (86.5%). DISCUSSION: The determination of immunohistochemical MIB-1 expression did not correlate with pathological stage in clinical stage I nonseminomatous germ cell tumors (NSGCT). We were not able to define high risk or low risk groups for occult nodal disease based on MIB-1 staining results. However, percentage of embryonal carcinoma and presence of vascular invasion accurately predicted absence or presence of lymph node metastasis in clinical stage I NSGCT. Our study underlines that a prospective multicenter trial is urgently needed to accurately assess the role of MIB-1 staining in management of clinical stage I NSGCT.     

Association of Down's syndrome and testicular cancer

PURPOSE: We present additional clinical evidence for the suspected association of Down's syndrome and testicular germ cell tumors. MATERIALS AND METHODS: Four cases of Down's syndrome and testicular cancer are reported. The literature was reviewed for previous cases and analysis regarding common features. RESULTS: The 4 patients were 29 to 35 years old and had clinical stage I seminoma of the testis. Two patients received prophylactic abdominal radiotherapy, 1 is being followed and 1 received adjuvant carboplatin treatment. There was no relapse at followup of 1 to 8 years. One patient also had contralateral cryptorchidism. A total of 16 cases with the association of Down's syndrome and testicular germ cell cancer was documented previously. CONCLUSIONS: Evidence for the suspected association of Down's syndrome and testicular cancer is now accumulating. Etiologically it is suspected that, along with genetically determined malformations in many other organs in trisomy 21, the gonads also undergo maldevelopment, thus creating the conditions for step 1 of germ cell tumor oncogenesis in utero. Physicians caring for patients with Down's syndrome should be aware of the possible association with testicular neoplasms.     

Tumor angiogenesis and metastasis: correlation in invasive renal cell carcinoma

BACKGROUND: Experience suggests that tumor growth is dependent on angiogenesis. The intensity of angiogenesis in human cancer is reported to be predictive of the probability of metastasis in many types of cancer. The aims of this study were 1) to determine the relationship of microvessel density (MVD) in renal cell carcinoma to pathologic stage, and 2) to evaluate the role of MVD in metastasis. METHODS: Paraffin-embedded tumor specimens were reviewed from 34 unselected patients with RCC who had undergone surgery from 1986 to 1990 at Taichung Veterans General Hospital. The pathology findings and clinical records were reviewed to note relationships between pathologic stage and whether or not metastasis had occurred. Specimens were studied from 16 cases (eight Stage I cancers, five Stage II and three Stage III) without metastasis and from 18 cases (two Stage I, six Stage II, six Stage III and four Stage IV) in which metastasis later developed. Microvessels were highlighted by immunostaining endothelial cells for factor VIII-related antigen. Microvessels were counted in a x-400 field (0.1885 mm2/field) in the most active areas of neovascularization. RESULTS: The 16 patients without metastasis have survived for between 65 and 136 months (mean, 94.5 months), up to the present time. Of the 18 patients with metastasis, 15 died and three survived, with mean survivals of 42.8 months (range, 12-99 months). Mean overall MVD was 99.6 vessels; mean MVD was 98.5, 96.2, 109.3 and 90.0 in Stages I, II, III and IV tumors, respectively. Mean MVD was 99.3 in patients without metastasis and 99.9 in patients with metastasis. CONCLUSIONS: MVD does not correlate with pathologic stage and is of no prognostic significance in renal cell carcinoma.     

Risk-adapted treatment of clinical stage 1 non-seminoma testis cancer

250 patients with clinical stage 1 non-seminomatous germ cell tumours of the testis (NSGCT 1) were included into a prospective multicentre protocol during 1990-1994 and treated according to three risk strata: patients without tumour cell invasion of vascular structures in the testis (VASC-) and elevated serum AFP levels (AFP+) at orchiectomy were considered low risk (LR) and only observed closely. VASC- and AFP- or VASC+ and AFP+ patients were presumed intermediate risk (IR) and pathologically staged (PS) by retroperitoneal lymph node dissection (RPLND). VASC+ and AFP-patients were regarded as high risk (HR) and received adjuvant chemotherapy (PEB x 3). At a median observation time of 40 (7-68) months, all patients were alive and without evidence of active germ cell cancer. The actuarial relapse rate in the 106 LR patients was 22%, and 70% (14/20) had elevated serum tumour markers at relapse. One of 32 (3%) HR patients relapsed with a resectable retroperitoneal mature teratoma despite adjuvant chemotherapy. Only 14% of the 99 IR patients who underwent RPLND had PS2 disease, and the actuarial relapse rate in 85 PS1 patients was 18%. This multicentre study demonstrated that excellent therapeutic outcome is possible when 18 comparatively small urological and oncological centres follow a strict and formal cancer care programme. The useful prognostic effect of VASC was once again verified. Pathological staging by RPLND in NSGCT1 is, in our opinion, not necessary, with presumed low-risk patients offered surveillance and high-risk patients offered adjuvant chemotherapy.     

Application of the new classification for cancer of the cardia

BACKGROUND: Cancer of the cardia is now topographically classified into three types: type I, with the tumor center in the distal esophagus treated with subtotal esophagectomy; type II, arising at the gastroesophageal junction and treated with distal esophagectomy and either proximal or total gastrectomy; and type III, subcardial cancer treated with extended total gastrectomy. Our objective was to review the new classifications and compare the outcomes in patients grouped and treated according to these classifications. METHODS: Seventy-four patients with cancer of the cardia--15 with type I, 30 with type II, and 29 with type III cancer--underwent surgical resection at our institution between 1992 and 1997. Postoperative complications, UICC stages, and survival (Kaplan-Meier) were compared. RESULTS: The majority of patients with type I (73%) or type II (53%) cancer had stage I or II tumors, but only 27% of patients with type III cancer had this tumor stage (P < .05). Overall 30-day mortality was 4% and morbidity was 31%. Curative resections were performed in 73% (54 of 74) of the patients with 3-year survival rates of 72% (type I), 68% (type II), and 61% (type III). CONCLUSION: The recommended therapy for the different types of cancer of the cardia results in acceptable morbidity, mortality, and survival rates.     

Bone matrix proteins

Seminomas account for 50% of testicular germ-cell tumors, and more than 90% of these are classic seminomas. When patients with a histologically pure testicular seminoma show an elevated level of serum á-fetoprotein (AFP), it is generally assumed that an undetected focus of yolk sac tumor (YST) is present and the patient is managed with a treatment regimen for non-seminomatous tumor. We studied 10 cases of histologically pure seminoma with elevated levels of serum AFP in an attempt to identify any distinctive clinical, histopathologic, or immunohistochemical features. The patients ranged in age from 27 to 48 years (mean, 31 years). Eight patients had primary tumors of the testis, and two presented with supraclavicular and ileal tumors. The clinical stage at presentation varied: four tumors were stage I, four were stage II, and two were stage III. Serum levels of AFP were elevated in all patients at ranges of 10.4 to 16 ng/ml (mean, 12.0 ng/ml). In all patients, the primary tumors and metastases when present exhibited classic seminoma histology without other germ-cell components. The tumor cells expressed keratin in seven cases. The pattern of keratin immunoreactivity ranged from focal staining in five cases to moderate staining in two cases. All cases were negative for AFP, and the nine cases in which staining for CD30 (Ki-1) was performed were also negative. All four patients with stage I tumors underwent the conventional therapy for pure seminoma, i.e., orchiectomy and subsequent radiation therapy. Five patients received treatment for non-seminomatous tumors, i.e., chemotherapy after orchiectomy. Extensive work-up failed to detect the primary tumor in one patient, and he was treated for a non-seminomatous tumor, undergoing chemotherapy and irradiation. All patients are alive and well, and none has developed evidence of YST at a mean follow-up of 6 years (range, 6 months to 10 years). However, one patient who presented with an ileal metastasis recently developed a second primary extragonadal mediastinal mixed germ-cell tumor with YST and embryonal carcinoma components and an elevated serum level of AFP (27,000 ng/ml) after a 10-year disease-free follow-up. This study strongly suggests that minor elevations (相似文献   

The role of cell communication in the pathogenesis of breast cancer]

OBJECTIVE: The aim of the study is to analyse long-term results of patients with small cell lung cancer (SCLC) treated at the same institution according to a prospective study including surgery, chemotherapy, and radiotherapy. METHODS: From 1981 to 1995, 104 patients with a proven histology of SCLC underwent surgery, chemotherapy, and radiotherapy. Fifty-one patients with operable stage I or II lesion received surgical resection followed by adjuvant chemotherapy and radiotherapy. Fifty-three patients with proved SCLC and clinical stage III received induction chemotherapy followed by surgery and radiotherapy. All patients received from four to six courses of chemotherapy and 36 had prophylactic cranial irradiation (PCI). All patients had follow-up for at least 1 year, and survival time was calculated from the date of the diagnosis until death or most recent follow-up. RESULTS: Ninety-six patients were male and eight female. We performed 29 pneumonectomies, eight bilobectomies, 66 lobectomies and one no resection. Regarding the clinical stage, 35 patients (33.6%) had stage I, 16 patients (15.4%) had stage II and 53 (51%) had stage III. Post-operative pathologic staging revealed stage I in 37 patients (35.6%), stage II in nine patients (8.6%), stage III in 45 patients (43.3%), and in 13 patients (12.5%) there was no more tumor. The 30-day mortality was 2% (two patients). Fourteen patients (13.4%) had post-operative complications. Fifty-one patients (49%) had a relapse. The median follow-up was 55 months. Twenty-six patients remain alive and 78 patients have died. The overall 5-year survival rate was 32%, with an estimate median survival time of 28 months; according to the pathologic stage, the survival data were 52.2%, 30% and 15.3% for stage I, II and III, respectively (P < 0.001). The 5-year survival was 41% in patients without SCLC after chemotherapy. CONCLUSION: As with non-small cell lung cancer, survival following surgery and chemotherapy clearly correlates with the stage. At present, it is not clear whether surgery is truly effective for patients with SCLC. In our experience, the complete elimination of small cell lung cancer is associated with an improvement in survival (41% at 5 years).     

Experience and results of application of remote afterloading system (RALS) optimization program for intracavitary treatment of squamous cell carcinoma of the uterine cervix

An optimization program for a remote after-loading system (RALS) for intracavitary treatment of cancer of the uterine cervix was established in 1982 by Tabushi and his co-workers. This system has been used in our hospital since 1986, using MODULEX. Seventy-three cases of untreated squamous cell carcinoma of the uterine cervix have been treated under RALS, 29 under conventional RALS and 44 under the RALS optimization program. The cumulative 5-year survival rates were obtained for the groups treated under each system by the Kaplan-Meier method. The 5-year survival rate of stage II cases treated under the RALS optimization program was 68.2%, and that of stage III cases 58.5%. On the other hand, that of stage II cases treated under conventional RALS was 56.3%, and that of stage III cases 44.9%. There was no significant difference between these two groups. Local control rates for stage II and III cases were higher than 5 year-survival rates. Among complications, the frequency of grade 2 radiation colitis was 15.9% with the RALS optimization program cases, and that of grade 2 radiation cystitis was 4.5%. We consider the RALS optimization program to be a clinically useful method for the intracavitary treatment of squamous cell carcinoma of the uterine cervix.     

Characteristics of rare ovarian tumors--possibilities of organ preservation

Whereas 65-70% of ovarian malignancies are of the epithelial type, the occurrence rate of stromal tumors is of approx. 7% and that of germ cell tumors of approx. 15%. Stromal tumors are mostly of the granulosa cell type, whereas germ cell tumors occur mainly as dysgerminoma (occurrence 0.9-2%), endodermal sinus tumors, or teratoma. Organ preservation is discussed in relation to the characteristics of these special tumor types. Granulosa cell tumors, representing 70% of the tumors of the gonadal stroma, occur unilaterally in approx. 97% of cases. 10-year-survival in stage I is over 90%. In stages II and III a complete remission after chemotherapy (acc. to the PVB, VAC, or BEP protocol) may be achieved in approx. 60% of cases. Due to these characteristics organ preservation seems feasible. Since dysgerminoma represent the most common malignant germ cell tumor in children, adolescents and pregnant women (up to 17% of all dysgerminoma are diagnosed during pregnancy), the wish for organ preservation is the more understandable. However, bilaterality, occurring in 20% of cases, has to be considered. Especially in large tumors lymphatic metastases also have to be taken into account. In cases of endodermal sinus tumors and teratoma, overall survival, mainly in patients with advanced disease, depends on the response to an aggressive chemotherapy. Preconditions for organ preservation are the patients' urgent childbearing desire, their information concerning the 5-7% risk of recurrence, an adequate oncologic postoperative care and optimally, after delivery, removal of the contralateral ovary and re-staging. The operative procedure requires removal of the corresponding adnexa, wedge dissection of the contralateral ovary, omentectomy, and depending on the histological tumor type a pelvic, possibly paraaortal lymph node dissection. No generally accepted standards are available for organ preserving surgery of stromal tumors, especially of the granulosa cell type. Prognosis is essentially influenced by a possible rupture being present, tumor size, cellular atypia, and the mitotic index. If one takes into consideration the possibility of lymph node metastases, at least a pelvic lymph node dissection should be recommended. In cases of metastases additionally a chemotherapy (VAC protocol) is indicated. Among germ cell tumors, dysgerminoma and non-dysgerminoma are treated differently. Non-dysgerminoma are endodermal sinus tumors, teratoma, embryonal carcinoma and mixed forms. For both groups operative management may aim at tumor reduction and in principle organ preservation. Whereas for dysgerminoma an adjuvant radiation therapy is feasible, in cases of non-dysgerminoma the response to a chemotherapy is the only factor influencing prognosis. Chemotherapy as adjuvant treatment is not indicated for pure dysgerminoma stage Ia, and pure solid teratoma stage Ia Gl. For all other dysgerminoma adjuvant chemotherapy, VAC protocol, and chemotherapy according the the BEP protocol for non-dysgerminoma is recommended. In cases of metastatic spread, in both groups an aggressive chemotherapy (BEP protocol) is most commonly performed.     

Clinical presentation and prognostic factors in sodium monofluoroacetate intoxication

From 1970 to 1992 a total of 63 patients underwent operation for ampullary tumor: 40 pancreatoduodenectomies (PDs), 3 total PDs, 8 ampullectomies, and 12 bypass or exploratory laparotomies. The resectability rate was 68%. There were 9 benign tumors, 1 anaplastic tumor, and 53 adenocarcinomas. According to Martin's classification, there were 7 stage I, 11 stage II, 14 stage III, and 21 stage IV tumors. All patients with stage I, II, and III tumors underwent resection. Patients with stage IV tumors had either resection (n = 11) or bypass (n = 10). The mean duration of hospital stay was 20.6 days. Operative mortality was 12.7% for the whole series and 7.5% after PD (2.5% for the last 10 years). Overall survival was 40% at 5 years (85% for stage I, 65% for stage II, 44% for stage III, and 8% for stage IV). Survival was better for stages I, II, and III after PD than after ampullectomy. For stage IV patients survival was 70% after PD versus 20% after bypass at 1 year and 25% versus 0% after 2 years. In our opinion, PD should be proposed even for benign lesions because two of our patients had to undergo repeat operation (PD) 4 and 22 years later, respectively, for stage IV disease. PD is our choice for all tumors of the ampulla.     

Pathologic staging of papillary carcinoma of the thyroid with airway invasion based on the anatomic manner of extension to the trachea: a clinicopathologic study based on 22 patients who underwent thyroidectomy and airway resection

We received the clinical and pathologic features of 22 cases of papillary carcinoma of the thyroid that invaded the trachea and were treated by thyroidectomy and airway resection with or without reconstructive surgery over an interval of 16 years. We studied the fine relationships between lamina propria and lymphatics in the region between the isthmus of the thyroid and the trachea. The manner of invasion of papillary carcinoma of the thyroid was by blunt dissection along blood vessels and collagen fibers oriented perpendicularly to the tracheal lumen between cartilaginous rings. Although lymph node metastases were found in 14 patients (64%), we observed lymphangitic tumor in the tracheal mucosa in only three patients (14%). We devised a staging system for papillary carcinoma of the thyroid based on the extent of invasion of the trachea. Of the 11 patients with stage I, II, or III disease, none of six (0%) followed for 5 years died of thyroid cancer in the 5-year observation period; one patient in this group died later of thyroid cancer. Of the 11 patients with stage IV disease, five of seven (71%) followed for 5 years died of thyroid cancer in the 5-year observation period; one additional patient in this group died later of thyroid cancer.     

Breast cancer in women who undergo screening mammography: relationship of hormone replacement therapy to stage and detection method

PURPOSE: To compare the breast cancer stages and detection methods in screened women who receive hormone replacement therapy (HRT) with those in screened women who do not receive HRT to determine whether HRT affects the stage or mammographic detection of malignancy. MATERIALS AND METHODS: One hundred fifteen cases of breast cancer in women (age range, 55-65 years) in whom at least one screening mammogram had been obtained at least 24 months before diagnosis and in whom the history regarding HRT could be determined were reviewed retrospectively. Statistical analysis was performed with CHI-2 analysis and the Fischer exact test. RESULTS: The cancer stages in the 58 women who received HRT were stage 0 in 15 (26%), stage I in 28 (48%), stage II in 13 (22%), and stage III in two (3%) women. The stages in the 57 women who did not receive HRT were stage 0 in 19 (33%), stage I in 24 (42%), stage II in 11 (19%), stage III in two (4%), and stage IV in one (2%) woman. Cancers in 38 (67%) of the women who did not receive HRT and in 38 (66%) of those who did receive HRT were detected with mammography alone; false-negative mammograms were obtained in five (9%) women in the non-HRT group and in four (7%) women in the HRT group (P = .89). CONCLUSION: Among screened women who developed breast cancer, there were no significant differences in cancer stages or in the number of mammographically detected cancers or false-negative mammograms between the HRT group and the non-HRT group.     

Long-term results after inferior vena caval resection during retroperitoneal lymphadenectomy for metastatic germ cell cancer

PURPOSE: The long-term sequelae of inferior vena caval (IVC) resection during retroperitoneal lymph node dissection for metastatic nonseminomatous germ cell testis tumor (NSGCT) were assessed. METHODS: Between December 1973 and September 1996, 2126 of our patients underwent RPLND for retroperitoneal nodal metastases from NSGCT; 955 had bulky disease (stages B2, B3, or C) after cytoreduction chemotherapy. Of this latter group, 65 patients (6.8%) required infrarenal IVC resection during tumor excision for cure. Our protocol does not include IVC reconstruction in such cases. Indications for IVC resection included tumor encasement or encroachment, postchemotherapy desmoplastic compression, or thrombus with tumor or clot in which cavotomy and thrombectomy cannot be performed. RESULTS: Twenty-four of the 65 patients (postoperative follow-up period range, 11 months to 16 years; median, 89 months) were alive and able to be examined or interviewed by written and/or phone survey to assess the long-term morbidity of their IVC resection. Based on the 1994 American Venous Forum International Consensus Committee reporting standards, the clinical classifications of these 24 patients were C0A (4), C3S (4), C4A (2), C4S (13), and C6A (1). Long-term disability was mild or absent in 75% of these patients. CONCLUSION: Only 1 (4.2%) of the patients surveyed had chronic venous sequelae that would fulfill the accepted criteria for subsequent elective IVC reconstruction. Despite recent reports of IVC reconstruction demonstrating relatively good patency rates and low morbidity, the addition of such a complex, time-consuming procedure to extensive retroperitoneal lymph node dissection for metastatic NSGCT involving IVC resection is generally not necessary.     

Sarcomatoid renal carcinoma

OBJECTIVE: Sarcomatoid carcinoma of the kidney is a unique, uncommon variety of parenchymatous tumors and is considered to have a worse prognosis by stage than the other histological types. Our experience is reviewed and compared with the larger series reported in the literature. METHODS: Of 101 cases of renal carcinoma submitted to surgery at our department from January, 1990 to December, 1996, there were 4 cases of sarcomatoid carcinoma of the kidney. We compared our cases with the larger series (91 cases in total) reported in the literature for incidence, age, distribution according to sex, tumor size, location, form of presentation, stage and survival. RESULTS: Sarcomatoid renal carcinoma accounts for 1% to 6% of parenchymatous tumors of the kidney according to the different series. The mean age at presentation was 48 years (range 27-61) in our series; there was no prevalence according to sex or location; the renal capsule was not compromised in 3 out of the 4 cases; only one case showed regional lymph node involvement and no case showed distant metastasis at the time of diagnosis. Although these tumors are diagnosed in the advanced stages, two of our cases were incidentally discovered in the early stages (one died 13 months thereafter and the other is alive at 42 months). Patients that are alive and disease-free can only be found in the patient group with stage I or II tumor. All patients with tumor stage III and IV have died. This histological type has a worse prognosis. Most of the series report a mean survival of 5 months. CONCLUSIONS: Sarcomatoid renal carcinoma accounts for 1%-6% of all renal carcinomas. It can present at any age and has a very poor prognosis, with a mean survival of 6 months.     

Intensive short course chemotherapy in the management of tuberculous meningitis

SETTING: Short course chemotherapy for tuberculous meningitis (TBM) is advocated by several groups, but relatively few children have been so treated and followed up. METHODS: A prospective, observational study of isoniazid (INH), rifampicin (RMP) and ethionamide (ETH) in a dosage of 20 mg/kg, and pyrazinamide (PZA) 40 mg/kg, all given once daily in hospital for 6 months. Surviving children were followed up for a year after discharge. RESULTS: Ninety five children, 39 (41%) at stage III, 52 (55%) at stage II and 4 (4%) at stage I TBM were studied. Ten (26%) at stage III and 3 (6%) at stage II died before completion of therapy. Five surviving children (6%) moved on discharge and were untraceable; seven children (9%) were lost during follow up and three were inadvertently restarted on antituberculosis therapy. Two children with severe stage III disease died after discharge. One child experienced a probable disease recrudescence 1 month after discharge. Eighteen children (20%) developed a mildly elevated serum bilirubin concentration during the first month of treatment. In five of these children INH, RMP, ETH and PZA were stopped and streptomycin (SM) and ethambutol substituted. In all cases the original treatment was restarted without incident. One child developed overt jaundice after 5 months of treatment due to hepatitis A infection. CONCLUSIONS: Our experience suggests that young children with TBM can be safely treated for 6 months with high doses of antituberculosis agents without overt hepatotoxicity and with a low risk of relapse.     

The prognostic significance of tumor cell detection in intraoperative pleural lavage and lung tissue cultures for patients with lung cancer

METHODS: Three hundred forty-two patients with lung cancer and 99 patients with nonneoplastic lung diseases (control group) underwent intraoperative pleural lavage with 300 ml physiologic saline solution before (lavage I) and after resection (lavage II). RESULTS: Studies of the lavage fluid in all control patients were negative, that is, there were no false positive findings. Tumor cells were found in lavage I in 132 patients (38.6%) and also in lavage II in 99 of them. In stage I (pT1 N0, pT2 N0) lung cancer, tumor cell detection was possible in 47 patients (28.6%). The 4-year survival of patients with resected non-small-cell lung cancer was 24% (95% confidence interval, 16% to 32%) if lavage I results were positive and 52% (95% confidence interval, 45% to 59%) if lavage I results were negative (all stages, p = 0.007). For patients with stage I disease (n = 164) the 4-year survival was 35% (95% confidence interval, 18% to 52%) if lavage I results were positive (n = 47), and 69% (95% confidence interval, 60% to 78%) if lavage I results were negative (n = 117) (p = 0.037). On multivariate analysis the positive cytologic result in intraoperative pleural lavage was an additional prognostic factor for our patients. To prove how the tumor cells enter the pleural cavity, we performed tissue cultures of tumor-free parenchyma in 23 cases of lung cancer. Tumor cell detection by histology and immunohistology was possible in 16 cases (69.6%). Detection of tumor cells in pleural lavage fluid before resection proves that tumor cells have spread into the pleural cavity. CONCLUSION: The positive result in pleural lavage seems to be a prognostic predictor for patients with lung cancer.     

Stage I seminoma of the testis: long term results and toxicity with adjuvant radiotherapy

AIMS AND BACKGROUND: Pure testicular seminoma has historically been treated with post-orchidectomy radiation therapy with excellent results. Recently, several aspects of the treatment of stage I seminoma have been questioned. We assessed long-term results and toxicity of patients with pure testicular seminoma treated at the Department of Radiation Oncology of S. Chiara Hospital, Trento, METHODS: From 1953 to 1987, 102 patients with stage I pure testicular seminoma were given megavoltage irradiation with curative intent. All patients had a minimum follow-up of 3 years (maximum 37 years, median 13 years). They received a mean para-aortic/pelvic dose of 33.07 Gy (range 23.70-45.20 Gy) with different doses and fields reflecting the change in techniques over a long period of time. RESULTS: The cause-specific actuarial survival at 30 years was 99% and crude survival 67%. One patient had an out-field relapse (inguinal) after a few months and was cured with radiotherapy and chemotherapy. Another patient relapsed with widespread metastases and died after 1 year of progressive disease. Early toxycity was mild and the treatment was well tolerated. Late side effects were reported in 8/102 patients. CONCLUSIONS: In our series adjuvant radiation therapy resulted in cure rates corresponding to those reported in the literature. The 30-year actuarial survival of 99% was extremely good and the toxicity of the treatment was mild. Post-orchidectomy radiation to the para-aortic and ipsilateral pelvic nodes is a safe and effective method of preventing recurrences and is currently to be considered the treatment of choice in stage I testicular seminoma.