Normal regional anatomy of the shoulder

Transitional cell carcinoma of the bladder is associated with a high relapse rate, locally and systemically, particularly in patients with nodal or soft-tissue involvement, despite radical cystectomy. The responsiveness of the disease to chemotherapy in the metastatic setting has stimulated the use of systemic therapy in earlier stage disease, either before (neoadjuvant) or after (adjuvant) definitive local therapy. Interpretation of the data is hampered by low patient accrual to randomized trials, lack of standardization of local treatment modalities, and the use of a variety of chemotherapy agents and regimens pointing to the difficulty in reaching a consensus as to what constitutes standard therapy. In this article, we review the use of adjuvant and neoadjuvant chemotherapy, the advantages and disadvantages of both approaches, and the recommendations that can be made based on available data. New approaches to improving survival, potentially with organ preservation, include the development of more effective chemotherapy, and the identification of prognostic features-clinical or biologic-that might be a better guide to patient selection.     

Fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a more common a condition than previously estimated. The most recent estimates are that 3 to 6 million patients have been diagnosed with FMS. The ACR criteria, established in 1990, provide the primary care provider with definitive subjective and objective findings that have shown to be 88% accurate in their ability to diagnose patients with the syndrome. There is no cure for FMS. It is a chronic condition, but patients quality of life can be improved when fatigue and pain are reduced. The institution of a plan that is developed collaboratively by the patient and the provider is the essence of successful symptom management. The hallmarks of the management plan include: improving the quality of sleep through the judicious use of medications that boost the body's level of serotonin (therefore reducing fatigue), and reducing pain through complimentary modalities such as exercise, physical therapy, relaxation techniques, massage, and biofeedback.     

Association analysis in an evolutionary context: cladistic analysis of the DRD2 locus to test for association with alcoholism

Recent clinical trials of adjuvant therapy for early stage breast cancer support two general observations. First, overall survival is not impacted by the extent of surgery. Low rates of axillary relapse in patients treated with total mastectomy alone combined with the availability of systemic therapy as a substitute for surgical control of the axilla mean that patients can often be spared the morbidity of axillary node dissection. In problematic cases, newer diagnostic approaches, such as sentinel node biopsy, can help in making appropriate treatment decisions. Second, systemic therapy can reduce the clinical manifestations of disease. The incorporation of more sophisticated approaches to predicting outcomes, to varying timing and dose of treatment, and to developing new modalities of treatment, including immunotherapy, will contribute to a general strategy aimed at reducing the tumor to a harmless parasite. These observations support a paradigm shift in our definition of 'adjuvant'. Rather than referring to the use of systemic therapy after the patient's known disease has been surgically removed, adjuvant therapy would be re-defined to refer to local therapy used to eradicate any residual tumor remaining after systemic therapy has been completed.     

Does pelvic irradiation play a role in the management of prostate cancer?

The optimal management of patients with lymph node-positive prostate cancer remains controversial. The role of pelvic irradiation in patients at high risk for nodal involvement continues to be debated. Studies of prostate irradiation with and without inclusion of the pelvic lymph nodes show poor outcomes for node-positive patients, supporting the concept that many of these patients have systemic disease at presentation. Although no randomized trial has examined the role of pelvic irradiation in pathologically node-positive patients, available data fail to reveal any significant benefit of this approach over prostate-alone irradiation. More promising therapeutic approaches involve the combination of local therapy and sustained hormonal therapy. Series comparing prophylactic irradiation of the pelvis and prostate to irradiation of the prostate alone have shown no clear benefit of pelvic irradiation. Pelvic irradiation may play a role in the treatment of early-stage or occult nodal disease, although this has yet to be examined. Until prospective, randomized trials demonstrate the efficacy of pelvic irradiation in the management of prostate cancer, its use cannot be routinely recommended. Data support the use of lymphadenectomy in high-risk patients to identify those with positive nodes, since these patients require androgen withdrawal therapy.     

Non-surgical management of urinary stress incontinence

This article reviews the non-surgical approach to urinary stress incontinence. As the cost of medical care increases and the waiting lists for surgical operations grow bigger, non-surgical management of incontinence takes on importance. The cure rates or improvement of quality of life with conservative management of urinary stress incontinence are not as good as with the surgical approach but it is an option which may be used in selected patients. Whenever a patient or the health care provider embarks upon the non-surgical options, consideration should be given to the success rates of the modality, either used alone or in combination. The motivation and compliance of patient is important, individuals who have realistic expectations from non-surgical management of urinary stress incontinence usually have the best result.Recent literature was reviewed and an attempt has been made to present an objective assessment for all the modalities currently available for the incontinent woman. It is necessary to stress the need for the use of a combination of modalities for better results when non-surgical approach is used as the first line option. It is also important to be empathetic and supportive of such women as they usually have an extremely poor self esteem, are depressed and reclusive.     

Glutamate release in the nucleus tractus solitarius induced by peripheral lipopolysaccharide and interleukin-1 beta

PURPOSE: The selection of therapy for stage T1 bladder cancer is controversial, and reliable biomarkers that identify patients likely to require cystectomy for local disease control have not been established. We evaluated our experience with T1 bladder cancer to determine whether early cystectomy improves prognosis, and whether microvessel density has prognostic value for T1 lesions and could be used for patient selection. MATERIALS AND METHODS: We retrospectively reviewed the records of 88 patients with T1 transitional cell carcinoma of the bladder. Patient outcome was correlated with therapeutic intervention. Paraffin embedded tissue from 54 patients was available for factor VIII immunohistochemical staining for microvessel density quantification. RESULTS: Median followup was 48 months (range 12 to 239). Of the patients 34% had no tumor recurrence. The rates of recurrence only and progression to higher stage disease were 41 and 25%, respectively. The survival of patients in whom disease progressed was diminished (p = 0.0002). Grade did not predict recurrence or progression nor did cystectomy provide a survival advantage. Microvessel density did not correlate with recurrence or progression. CONCLUSIONS: Patients with T1 bladder cancer have a high risk of recurrence and progression. Tumor progression has a significant negative impact on survival. Neither grade nor early tumor recurrence predicted disease progression. Because early cystectomy did not improve patient outcome, we suggest reserving cystectomy for patients with progression or disease refractory to local therapy. Microvessel density is not a prognostic marker for T1 bladder cancer and has no value in selecting patients with T1 disease for cystectomy.     

Bladder cancer in Sweden

The survival of patients with bladder cancer has not improved significantly during the past decades in spite of new diagnostic methods and treatment modalities. This observation underlines the need for improved routines to ensure earlier detection of the disease by patients and doctors and thereby start the treatment sooner. The common finding of treatment failures in patients who have shown no sign of local recurrence but have undergone radical cystectomy indicates that subclinical metastases are primarily responsible for the poor outcome in most cases. This indicates that, in addition to radical surgery, effective chemotherapy is needed to counteract the systemic spread of the disease.     

The surgical management of breast cancer, especially breast conserving treatment

The management of breast cancer is highly controversial. Various operations have been performed at different hospitals. Herein, we reviewed the results of randomized clinical trials regarding breast conserving treatment, and axillary and internal mammary lymph node dissections. Variations in local-regional therapy may not substantially affect survival, but the incidence of local-regional failure is inversely related to the extent of operation and/or radiotherapy. At present, surgeons are highly recommended to perform adequate surgery which provides the ultimate local control, does not compromise the chance for cure and gives the best cosmetic and aesthetic results. Therefore, quadrantectomy with or without immediate reconstruction, axillary dissection and internal mammary biopsy and breast irradiation are more preferably recommended for ensuring local control and for providing a better cosmetic and psychological impact.     

Novel bifunctional anthracycline and nitrosourea chemotherapy for human bladder cancer: analysis in a preclinical survival model

A hybrid drug [N-2-chloroethylnitrosoureidodaunorubicin (AD312)] that combines structural and functional features of both anthracyclines and nitrosoureas was evaluated in a preclinical survival model of human bladder cancer. To measure the therapeutic activity of AD312, UCRU-BL13 transitional cell carcinoma cells were grown as xenografts in nude mice, and tumor growth rates were compared after i.v. administration of the drug at three dose levels. AD312 treatment at 45 and 60 mg/kg achieved 7-10-fold inhibition of tumor growth and increased host survival by 156 and 249%, respectively. Doses of 60 mg/kg showed optimal therapeutic efficacy, with sustained tumor growth inhibition, an over 2-fold increase in life span, and 40% of mice tumor free ("cured") at 120 days. Tumors were unresponsive to maximum tolerated doses of doxorubicin, a standard anthracycline used as a single agent and in combination therapies for bladder cancer. 1,3-Bis-[2-chloroethyl]-1-nitrosourea was used as a control for the apparently enhanced response of human tumors in murine hosts to nitrosoureas. 1, 3-Bis-[2-chloroethyl]-1-nitrosourea administered in three injections of 20 mg/kg did not cure mice but temporarily inhibited tumor growth by 70% and prolonged survival by 55%; its activity in this model suggests that it may be included in the repertoire of alkylating agents currently used for treatment of bladder cancers. AD312 showed increased antitumor activity with less toxicity than doxorubicin, and its bifunctional properties provide the opportunity for simultaneous treatment of individual cancer cells with two cytotoxic modalities as well as treatment of heterogeneous populations typical of bladder cancers. This novel cytotoxic drug cured doxorubicin-refractory disease and should be investigated for the clinical management of bladder cancer.     

Current questions and controversies on the treatment of prostate cancer

The treatment of prostatic adenocarcinoma is the subject of debate and controversy at all stages of the disease. At the initial "subclinical" stage, discovered in transurethral resection or prostatectomy specimens, the conservative approach generally adopted should sometimes be replaced by curative treatment in young patients or in the case of high grade cancers. The localised, intraprostatic stage is amenable to curative treatment. However, radical prostatectomy may not be indicated in the presence of lymph node metastases and the discovery of positive margins on histological examination of the resection specimen raises the question of the necessity and the chronology of complementary treatments. At the stage of locally advanced cancer, all therapeutic modalities have been proposed in various combinations. The most controversial question concerns neoadjuvant endocrine therapy prior to radical prostatectomy. Metastatic disease is treated by endocrine therapy. However, the necessity of complete androgen blockade chemotherapy has still not been demonstrated. No effective therapeutic solution has yet been found for "endocrine escape", but a number of palliative measures should improve the quality of the patient's limited survival.     

Trace analysis of benzalkonium chloride on skin by flow injection ionspray mass spectrometry-mass spectrometry

We report a case of symptomatic hypercalcemia in a patient with muscle-invasive, resectable squamous cell carcinoma of the bladder. Serum parathyroid hormone was consistent with secretion of parathyroid hormone-related protein. After radical cystoprostatectomy, calcium levels returned to normal. Patients with squamous cell carcinoma and an abnormal serum calcium level may have localized disease and should not be denied definitive local therapy.     

Vesicorectostomy revisited

Between 1948 and 1959 vesicorectostomy, a permanent anastomosis between the bladder and rectum, was constructed in 7 male patients. Scattered reports of this procedure exist but none since 1959 and long-term followup has never been reported. we present long-term followup, including renal function, excretory urography and voiding cystorectography, and review the quality of life in the 7 patients. The most frequent complication was stenosis of the anastomosis. None of the patients in this series with normal preoperative upper tracts showed radiographic or chemical deterioration postoperatively. Since this procedure maintains urinary continence, does not disturb the normal physiology of the ureterovesical junction and minimizes urinary reabsorption its use should be considered in certain patients as an alternative method of urinary diversion.     

Do medical conditions affect cognition in older adults?

Women with breast cancer today have many more therapeutic options available to them for their surgical therapy. Almost all patients with breast cancer have some options for breast conservation. Active patient involvement in analyzing and understanding the pros and cons of each of these options seems extremely important to the long-term emotional and psychological outcome of their breast cancer therapy. Several reports this year have reintroduced the issue of adequate local control. The common philosophy a decade ago was that because systematic therapy (adjuvant chemotherapy) was improving, local therapy would become of lesser importance. Several studies this year have indicated the extreme importance of local control in maximizing survival advantage because of the relationship of increasing local failure and deteriorating survival from systemic disease. Despite significant improvements in treatment, our screening and diagnostic approaches have still failed to identify the majority of lesions prior to the patient's own palpation of the tumor. Using new diagnostic modalities that do not involve surgery, the biopsy of lower probability lesions with great accuracy is expected to improve the efficacy of the current screening measures. Despite all the improvements, the most important therapeutic step in the management of breast cancer remains earlier diagnosis and earlier extirpation of the initial invasive focus of malignancy.     

Small cell carcinoma of the bladder. Report of a new case

Contribution of a case report of vesical small cell carcinoma (SCC) seen at our Centre and managed with partial cystectomy and systemic chemotherapy (CMT) with M-VAC. SCC is an uncommon neoplasia of the bladder usually associated with an aggressive behaviour. The effectiveness of radical surgery has not been demonstrated, so a conservative treatment was chosen which has allowed to preserve a high quality of life until now, 36 months after diagnosis. The studies of local and distant relapses show no signs of residual disease.     

Circulating kallikreins during sodium chloride infusion in normal and hypertensive humans

Early radical cystectomy for a high-grade tumor invading the lamina propria (T1) remains controversial. In 1997, we cannot identify accurately which of these high-risk tumors will progress to muscle-invasive disease and metastases. In the near future, urologists may be able to use the presence of genetic alterations, such as p53 mutations, to help make therapeutic decisions. Previous reports on superficial bladder cancer treated with intravesical bacillus Calmette-Guérin immunotherapy have demonstrated a decrease in recurrence and progression. Unfortunately, there is no reliable method to predict which patients with a high-grade T1 tumor will fail to respond to intravesical therapy. Failure of intravesical therapy to control these aggressive tumors is associated with a significant rate of pathological upstaging and metastases. Radical cystectomy will cure a high percentage of these T1 tumors with acceptable morbidity and low mortality. In an era of nerve-sparing cystectomy and orthotopic neobladder reconstruction, early radical cystectomy is an alternative that should be discussed with the patient before instituting intravesical therapy.     

Trends in the use of radiation and chemotherapy in the initial management of patients with carcinoma of the uterine cervix

PURPOSE: The Commission on Cancer of the American College of Surgeons conducts Patient Care Evaluation studies to describe practice patterns and trends in disease management. This report surveys changing strategies in the initial treatment of patients with invasive cancer of the uterine cervix. METHODS AND MATERIALS: Using a standard data collection form designed by a multidisciplinary committee of specialists, cancer registrars at 703 hospitals submitted anonymous data on 11,721 total cervical cancer patients diagnosed in 1984 and 1990. RESULTS: Between the two study years, the use of radiation as all, or a component, of the initial course of therapy declined from 70 to 60.3%, coincident with a 32.3% increase in the use of hysterectomy alone and a 33.7% reduction in the use of radiation alone. The percentage of all patients receiving combined hysterectomy and radiation (preoperative or postoperative) remained virtually unchanged--10.2% in 1984, and 9.3% in 1990. However, women who were treated by hysterectomy in 1990 were less likely to receive radiation as part of their treatment than patients treated by hysterectomy in 1984. Among patients treated by radiation without hysterectomy, the use of intracavitary brachytherapy techniques substantially exceeded interstitial brachytherapy techniques in both study years. Among patients treated by local radiation without hysterectomy, the frequency of adjunctive chemotherapy use increased from 6.9% in 1984 to 24.8% in 1990, with chemotherapy and radiation increasingly administered concurrently rather than sequentially. Although differences based on age, histology, race/ethnicity, and insurance status were observed, these general management trends were seen in all groups. CONCLUSIONS: Changes in the utilization of radiation and surgery may reflect the increasing surgical involvement of gynecologic oncologists in the management of early stage cervical cancer, rather than significant alterations in the demographics of the disease. Although brachytherapy is recognized as an important component of radiation treatment, some patients may not receive the potential benefit of this modality. Despite controversy concerning its efficacy, the use of adjuvant systemic chemotherapy to supplement local treatment modalities appears to be increasing rapidly.     

Intraarterial chemotherapy via reservoir system for far-advanced bladder and prostate cancer

A clinical study was performed on the efficacy of intraarterial chemotherapy using reservoir system for far-advanced urological malignancy. The reservoir system was indwelled in the femoral subcutaneous layer using Seldinger's method. Fifteen cases with inoperable complicated advanced bladder cancer and ten cases with postoperative local recurrent bladder cancer received intraarterial chemotherapy using the reservoir system. Then, 23 cases with local relapsed prostate cancer and two cases with endocrine-resistant prostate cancer received chemotherapy. The administered anti-cancerous agents were methotrexate, cis-platinum and adriamycin, and 5-FU or carboplatin were administered as maintenance therapy. The mean courses of chemotherapy were six for bladder cancer and four for prostate cancer. During stabilization of the local lesion, no distant deterioration was recognized. Overall clinical efficacy was as follows: PR:18 cases and NC:7 cases for bladder cancer; then, PR:11 cases and 14 cases for prostate cancer. The median duration of stabilization was as follows: 23 months for bladder cancer and 12 months for prostate cancer. Complications were fewer than with systemic chemotherapy.     

Development of oriented ocular dominance bands as a consequence of areal geometry

BACKGROUND: Breast cancer has become a national health problem, affecting more than 180,000 women each year. Although advances in early detection and treatment have been made, it remains the second leading cause of cancer-related death in women. KEY POINTS: The treatment of breast cancer requires the careful integration of systemic and local methods. Although the application of hormonal therapy or chemotherapy is becoming less distinct, this discussion will review the important clinical trials and future directions of chemotherapy in the management of breast cancer. Data support the use of chemotherapy in the adjuvant setting, for preoperative tumor reduction of locally advanced disease, and as palliation in metastatic disease. The optimal chemotherapeutic regimen is not known; however, data support a role for adjuvant doxorubicin in node-positive disease, neoadjuvant therapy for high-risk disease, and high-dose chemotherapy to consolidate responding metastatic disease. CONCLUSIONS: The clinician must determine the risks and potential benefits of systemic chemotherapy before recommending treatment strategies. Although progress has been made, future advances can only occur through active participation in clinical trials.     

Local excision of rectal cancer

The prospect of treating a rectal cancer often leads to significant fear among patients because of the possibility of a permanent colostomy. Although radical resection, in particular abdominoperineal resection, has been used effectively for rectal cancer treatment, other techniques such as local excision with or without adjuvant therapy have been used with significantly less morbidity than that of the abdominoperineal resection, with excellent cure rates. There are essentially three local excision techniques that can be used to remove a small rectal cancer completely. Selection criteria are critical for choosing the appropriate patient for these techniques. Tumors must be less than 4 cm in diameter and take up less than 40% of the rectal wall circumference. They also need to be relatively close to the dentate line and have no evidence of any invasion into the mesorectum or perirectal nodes. Preoperative staging with endorectal ultrasonography, computed tomography, and digital examination helps select appropriate patients. Retrospective series have shown significant success using local excision techniques, with local recurrence rates ranging from 0% to 11% for early-stage lesions. Prospective series have shown similar recurrence rates. Postoperative function with or without adjuvant therapy has not been adequately documented along with quality of life and must be part of any future reports on local excision techniques as well as all rectal cancer treatment studies. Local excision does, however, seem to provide adequate treatment in well selected patients and provides a less morbid alternative to the treatment of rectal cancer than radical resection, particularly abdominoperineal resection, which obligates the patient to a permanent colostomy.     

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.