Structural and ultrastructural changes in ileal neobladder mucosa: a 7-year follow-up

OBJECTIVE

To investigate the long-term morphological changes in the intestinal segment used to create an orthotopic ileal neobladder.

MATERIALS AND METHODS

Periodic endoscopy with biopsy of the ileal mucosa was performed in 90 patients 3-84 months after radical cystectomy and urinary diversion via an orthotopic neobladder. Three cold-cup biopsies were taken from each patient and mucosal specimens processed for light and electronic microscopy.

RESULTS

Early changes (up to 1 year after surgery) comprised a marked shortening of the villi with loss of microvilli. After 4 years, the prevalent finding was of flat, avillous epithelium that tended to stratify in some areas. The avillous areas were mixed with islets of villous mucosa. There was no dysplasia or malignancy in any of the 90 patients.

CONCLUSIONS

Prolonged contact with urine elicited a biphasic response in the ileal mucosa, i.e. an early inflammatory phase, ascribed to the noxious action of urine, followed by a regressive phase in which the epithelium tended to assume a morphology similar to the urothelium. The atrophic changes were almost totally completed after 4 years, although areas with marked modifications alternated with others where the morphology was normal, even many years after surgery. Late changes in the ileal neobladder mucosa appear to be an expression of a functional adaptation of the mucosa to the new environment.

[Vesica ileale Padovana (VIP): surgical technique, long-term functional evaluation, complications and management]

OBJECTIVE

An original technique for complete bladder replacement using an ileal segment--the VIP pouch--is described. The long-term functional results and early and late complications are presented.

METHODS

The records of 209 VIPs performed following radical cystectomy for invasive bladder cancer from 1987 through 1995 were reviewed. Follow-up ranged from 6 to 87 months (mean: 24 mo.); the age of the patients ranged from 35 to 76 years (mean: 59.6 yrs.).

RESULTS

188 patients with a follow-up of at least 6 months have been evaluated. There was 1 postoperative death from massive pulmonary embolism, 23 pts. died from tumor progression and 4 are still alive with metastases. Early complications were observed in 10.5% of the pts., comprising 9 cases of prolonged ileus (5 functional and 4 obstructive), 3 pelvic hematomas, 2 deep venous thrombosis and 2 fistulas between the enteric anastomosis and the VIP pouch. Late complications were observed in 39.5%, in particular, 28 uretero-ileal stenosis (15%), 21 urethro-ileal stenosis (11%) and 15 laparoceles (8%). Clinically relevant metabolic disturbance has not been observed. Complete daytime continence was achieved in more than 90% of the cases and night-time continence was observed in 75% of the patients. The mean VIP manometric capacity was around 400 ml with low pressure during reservoir emptying; 39 patients (20%), showed voiding problems with a mean postmicturition residual of 150 ml (3 pts. require clean intermittent self-catheterization).

CONCLUSIONS

VIP offers a simple and easy-to-perform surgical technique to provide a good capacity, low pressure, non refluxing reservoir employing only a 40 cm. ileal segment. The clinical and urodynamic results are good and offer high quality of life to patients undergoing cystectomy. The overall rate of late complications is fairly high, although conservative management is effective in most cases.

Pancreatic metastases: CT assessment

We report the CT appearance of pancreatic metastases and describe their features in relation to the originating primary tumor. We also discuss some limitations in their differential diagnosis and report some theories explaining the pathogenesis of their occurrence. A total of 20 cases (9 males and 11 females) of pancreatic metastases were diagnosed at staging or follow-up of oncologic patients. All patients were evaluated with CT before and after contrast medium administration and had subsequent pathologic confirmation. In 1 case metastases were located solely in the pancreas; in 6 there was only another metastatic location, and in the remaining 13 there was diffuse spread throughout the body. Two of our patients exhibited a multinodular metastatic involvement of the pancreas, 11 had a solitary nodule or mass, and the remaining 7 had a diffusely enlarged pancreas, without any signs of focal disease. All but one of the solitary lesions measured more than 4 cm. In 2 cases a metachronous malignancy was detected at follow-up. Primary malignancies were located: 6 in the lungs, 2 on the skin (melanomas), 3 in breasts, 2 in the ovaries, 3 in the colon, 1 in the stomach, 2 in the kidney, and 1 the thyroid. Our findings confirm the existence of three patterns of metastatization to the pancreas: large solitary masses, multinodular lesions, and diffuse enlargement of the pancreas without focal signs at CT. In contrast to other studies, the large solitary lesion was our most frequent encounter, therefore making differential diagnosis vs primary cancer difficult. Metastases tended to repeat the imaging pattern of the primary. Nevertheless, we wrongly diagnosed pancreatitis due to a small nondetected metastasis, pseudo-cystic mass as a mucinous cystadenocarcinoma, conglomerate of peripancreatic lymph nodes, and a solitary pancreatic mass diagnosed as primary pancreatic cancer. Thus, when faced with a solitary pancreatic lesion at follow-up, histologic diagnosis is strongly recommended. In 2 cases changes in aspect and size were related to therapy.

Laparoscopy in the diagnosis and treatment of cryptorchidism

Laparoscopy plays an outstanding role in the diagnosis of non palpable testis. Laparoscopy is as accurate as surgical exploration but, compared with the latter, is less invasive and faster; moreover in cases of testicular absence it makes surgery unnecessary. Concerning laparoscopic surgery in the case of abdominal testis, orchiectomy is an easy procedure which prolongs diagnostic laparoscopy for only a short time. It is indicated in pediatric patients with hypoplasic testis. In adult patients, except for cases of monorchidism and bilateral abdominal testis, orchiectomy is always recommended. At present laparoscopic orchiopexy does not seem to offer sure advantages compared to traditional surgery.

[AIDS-related neoplasms: a clinico-radiological study]

Although high-grade non-Hodgkin's lymphoma (NHL) and an unusually aggressive form of Kaposi's sarcoma (KS) remain the most common malignancies seen in AIDS patients, other tumors such as cervical cancer, Hodgkin's disease and others, have been increasingly observed, probably because these patients now live longer. We report the imaging findings of 80 AIDS patients with pathologically confirmed neoplasms from a series of 340 AIDS patients examined 1986-1994. Twenty-four of 80 patients had NHL, 4 Hodgkin's disease, 31 KS, 4 cervical cancer, 2 leukemia, 2 testicular, 1 larynx, 2 lung, 2 breast, 1 esophagus, 1 stomach, 1 liver, 2 kidney and 3 adrenal carcinomas. Twenty of 24 NHLs exhibited extranodal involvement--to the liver (13/24), brain (9/24), lung (7/24) and gastrointestinal tract (6/24). Visceral KS involved the gastrointestinal tract (6/32), lung (4/32) and liver (2/32). The most accredited pathogenetic theories concerning the role of HIV infection in oncogenesis advocate the effect of multiple growth factors produced by HIV-infected lymphocytes (KS) or the disregulation of B-cells caused by T-cell destruction (NHL). The atypical morphostructural features of AIDS-related tumors are discussed--e.g., atypical presentation, occurrence in younger individuals, aggressive clinical course and poor response to conventional therapy--together with the differential diagnostic problems, especially vs. opportunistic infections.

Topical chemo-immunotherapy in upper urinary tract transitional cell carcinomas

— Intracavitary chemo or immunotherapy for upper urinary tract transitional cell carcinomas has been recently introduced. From published data, Bacillus Calmette-Guerin appears to give significant and durable response rates (70% as prophylaxis, 81% as therapy) with acceptable side effects. The anecdotal use of chemotherapeutical agents prevents any conclusion being made about the therapeutical impact. To date, intracavitary percutaneous Bacillus Calmette-Guerin treatment is suggested for patients with “in situ” or occult carcinoma of the upper urinary tract, bilateral and synchronous tumors and/or with severe renal failure or not suitable for radical surgery.

Is stage pT4a (D1) reliable in assessing transitional cell carcinoma involvement of the prostate in patients with a concurrent bladder cancer? A necessary distinction for contiguous or noncontiguous involvement

PURPOSE

A series of patients with concurrent transitional cell carcinoma involvement of the prostate and bladder is reviewed to define the impact of prostate involvement pathways and the degree of prostate invasion on survival rate.

MATERIALS AND METHODS

A total of 72 patients who underwent radical cystectomy for pathological stage pT4a (D1) cancer was divided into contiguous--stage pT4a, transitional cell carcinoma of the bladder extended into the prostate through the bladder wall and noncontiguous--stage pT4a simultaneous transitional cell carcinoma of the prostate and bladder carcinoma that did not directly infiltrate into the prostate through the bladder wall. In the latter group the degree of prostate invasion was classified as urethral mucosal involvement, ductal/acinar involvement, stromal invasion and extracapsular extension. The survival rate was estimated by the Kaplan-Meier and Cox proportional hazards methods. Comparisons between curves were performed by univariate log rank and multivariate L-ratio tests.

RESULTS

The overall 5-year survival rate for stage pT4a was 21.5% (median followup 64 months). Furthermore, 46% and 7% of patients in noncontiguous and contiguous pT4a groups, respectively, were estimated to be alive (p < 0.000). Those with positive nodes experienced a poor outcome in both groups. Of patients with noncontiguous pT4a stage 100% with urethral mucosal involvement, 50% with ductal/acinar involvement and 40% with stromal invasion were estimated to be alive. The major prognostic factors were bladder tumor stage, nodal involvement and degree of prostate invasion.

CONCLUSIONS

The invasion pathways of the prostate in patients with transitional cell bladder carcinoma have a statistically significant prognostic role. Contiguous and noncontiguous involvements are 2 distinct clinicopathological features and they should not be included in the same stage. In the noncontiguous stage pT4a group bladder and prostate transitional cell carcinoma should be separately staged, and prostate involvement also should be staged according to invasion degree.

Characteristics of hybrid modes in proton-exchanged lithium niobate waveguides

A rigorous numerical model, verified by experimental results, gives an explanation of the particular electromagnetic behaviors observed in x-cut proton-exchanged lithium niobate waveguides. This approach, which allows an exact calculation of the weights of the coupled ordinary and extraordinarywaves that make up the hybrid modes, provides deeper insight into the study of the strains induced by the proton-exchange process in the waveguide itself, showing that the optical axis of the exchanged layer is not parallel to the waveguide plane.

AIDS-related Burkitt's lymphoma. Morphologic and immunophenotypic study of biopsy specimens

In patients infected with HIV, high-grade B-cell non-Hodgkin's lymphomas (NHL), including the small noncleaved cell (SNCC) category, exhibit pleomorphic features, which makes precise definition difficult. Sixty-nine pathologic specimens with HIV-related systemic lymphomas, including 42 SNCC, 20 immunoblastic lymphomas (IBL), and 7 cases with features "intermediate" between SNCC and IBL were morphologically and immunophenotypically investigated. The host immune status was also analyzed in 57 of 69 patients. In 29 representative SNCC lymphomas, in 9 IBL cases, and an additional 3 intermediate lymphomas, both p53 protein overexpression and the association of Epstein-Barr virus (EBV) genetic information were assessed. Small noncleaved cell lymphomas included tumors exhibiting features of the 2 established subtypes (27 Burkitt's and 15 non-Burkitt's). In the seven intermediate cases, cells showed features intermediate between SNCC with plasmablastic differentiation and immunoblasts plasmacytoid. Immunoblast-like cells were also present. p53 protein overexpression and EBV association were found in a proportion of SNCC (14 of 29; 7 of 29) and intermediate (3 of 3; 2 of 3) lymphomas. Conversely, IBL cases were consistently p53 negative, but showed a high EBV association (7 of 9). All the evaluated patients with intermediate lymphomas had a considerably lower mean (76.6 per mm3 +/- 77.4 SD) and median (54 per mm3) number of CD4+ lymphocyte count than SNCC patients (mean 227.9 per mm3 +/- 186.9 SD, median 193 per mm3), thus mirroring IBL patients (mean 95.3 per mm3 +/- 82.8 SD, median 81 per mm3). All data provide evidence that lymphomas showing intermediate features constitute a distinct subgroup from either SNCC or IBL.

KP1/CD68 expression in malignant neoplasms including lymphomas, sarcomas, and carcinomas

Expression of KP1/CD68 macrophage-associated antigen in a series of 840 selected malignant neoplasms, including immunomorphologically characterized cases of non-Hodgkin's lymphoma (NHL) (434), Hodgkin's disease (HD) (115), soft tissue sarcoma (147), carcinoma (49), and other tumors (95), was examined. KP1 expression was detected in a significant number of NHLs (107 of 434; 24.7%), most of them (65 of 107; 60.7%) of the diffuse small cell subtype. Only 14 of the 155 large cell lymphomas, compared to 10 of the 51 Ki-1/CD30+ anaplastic large cell (ALC) lymphomas examined, were KP1 positive. Conversely, none of the T-lineage NHL--other than Ki-1/CD30+ ALC lymphomas--or the HD cases tested was labeled by KP1 antibody. Among the other neoplasms tested, KP1 was reactive with a variable proportion of cases of malignant fibrous histiocytoma (19 of 24; 79.2%), malignant schwannoma (8 of 22; 36.4%), liposarcoma (3 of 9; 33.3%), leiomyosarcoma (8 of 37; 21.6%), cutaneous or metastatic melanoma (51 of 73; 69.9%), and renal cell carcinoma (3 of 5; 60%). These results indicate that KP1 shows a relatively wide spectrum of immunoreactivity with malignant neoplasms of presumed non-histiocyte origin, thus arguing against its expected specificity and high value in diagnostic pathology. Although the significance of KP1 expression by some subsets of NHLs remains to be elucidated, its close association with B-cell NHLs, mostly of the diffuse small cell type, should stimulate further pathologic and clinical investigations.

CT of secondary neoplasms. Unusual structural features--a pictorial essay

The newer anticancer therapies, the routine employment of cross-sectional imaging modalities for staging and follow-up, and the increased survival rate of patients with neoplastic lesions have markedly widened the range of pathological and imaging features of secondary neoplasms. Moreover, the changes occurring in morphological and structural aspects of metastases may be the direct effect of the improved therapeutic tools, and in turn may offer revealing clues to the clinician regarding the outcome of therapy itself. The scope of this essay is to show the atypical computed tomographic (CT) aspects of a series of metastatic lesions. We selected the lesions on the basis of their unusual structural features, such as calcification; hemorrhage; superinfection; pseudocystic, cystic, and lipoid appearance; and hypervascularity. A highly detailed assessment of such changes is nowadays possible and appears mandatory.

CT of renal metastatic disease. A pictorial essay

The routine use of computed tomography (CT) for the staging and follow-up of malignant neoplasm has improved the detection of secondary spread to the kidneys. This essay illustrates the gamut of the CT aspects of such secondary lesions. Seven main patterns of metastatic features are identified. Some of these patterns appear to reproduce the same radiological features seen in the corresponding primary lesions. Where feasible, differential diagnostic criteria are offered.

Improving the efficacy of BCG immunotherapy by dose reduction

Several clinical trials have shown intravesical bacillus Calmette-Guérin (BCG) to be effective in the prophylaxis of papillary tumour recurrences and in the therapy of bladder carcinoma in situ (CIS), as well as in delaying progression to muscle invasion. Nevertheless, the optimal regimen of BCG therapy for superficial bladder cancer has still to be defined. In a previous phase II trial, a low-dose regimen (BCG Pasteur strain, 75 mg) was able to achieve clinically significant response rates with a decrease in side-effects compared with other reported studies using standard-dose BCG. However, a phase III randomized trial--low dose versus standard dose (BCG Pasteur strain, 75 vs. 150 mg)--was considered necessary to clarify definitively the relationships between dose, efficacy and toxicity. The results of the interim analysis of 183 patients (performed in 1993) have shown response rates to be better in patients submitted to a low-dose BCG regimen (p = 0.0009) and a significant decrease in most of the common side-effects (cystitis, fever, haematuria; p < 0.05). Breaking down the results by stage, no differences in response rates were found in patients with stage TaM (70 vs. 62% in low-dose and standard-dose regimens, respectively, p = 0.5). In T1M and CIS stages, 82 and 0 (p = 0.07), and 64 and 0% (p = 0.0003) of patients were free of tumour following low-dose and standard-dose therapy, respectively. An additional 6-week course in patients who failed the induction course retrieved additional responses in both groups. No differences in progression rates were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Intestinal co-infection by Cyclospora sp. and Cryptosporidium parvum: first report in an AIDS patient

Cyclospora is recently described new human pathogenic coccidian causing intermittent diarrhoeal enteritis which may persist for weeks or months in immunocompetent subjects, particularly travellers visiting some tropical areas and countries, such as Nepal, the Caribbean, Peru and Mexico. More rarely this enteric pathogen affects immunocompromised humans, namely HIV-infected people or AIDS patients, with some clinical pictures recognized in normal hosts. We describe the first case of Cyclospora sp. and Cryptosporidium parvum associated diarrhoeal enteritis in an adult AIDS patient.

Antibodies producing complement-mediated thyroid cytotoxicity in patients with atrophic or goitrous autoimmune thyroiditis

Thyroid-cytotoxic antibodies (thyroid-cytotoxic Abs) have been described in patients with autoimmune thyroiditis, but their role in the development of hypothyroidism remains to be clarified. In this study, we evaluated the pathogenetic role of thyroid-cytotoxic Abs in 20 patients with atrophic thyroiditis (idiopathic myxedema; AT) and 94 patients with goitrous Hashimoto's thyroiditis (HT). Among patients with HT, 27 were euthyroid (HT-E), 27 had subclinical hypothyroidism (HT-SH), and 40 had overt hypothyroidism (HT-H). Seventeen normal subjects and 8 patients with nonthyroidal illnesses were used as controls (C). To detect thyroid-cytotoxic Abs, human thyroid cells expressing thyroid peroxidase (TPO) were labeled with 51Cr and challenged with the immunoglobulin G (IgG) fraction of serum plus rabbit complement. The cytotoxic effect of IgGs was calculated as the percent specific lysis (% SL), taking into account the lytic effect of complement alone and the maximal lysis produced by a detergent. Most C-IgGs decreased the cytotoxic effect of complement (median % SL, -3.3). IgGs from hypothyroid patients with thyroiditis had a greater cytotoxic effect than C-IgGs, either as a whole group (P < 0.001), or when subdivided according to clinical diagnosis: HT-SH (median % SL, 4.8; P < 0.005), HT-H (%SL, 2.2; P < 0.0001), or AT (%SL, 0.9; P < 0.01). Among patients with HT, the lytic activity of IgGs from patients with subclinical and overt hypothyroidism was higher than that of IgGs from euthyroid patients (P < 0.05). The results of IgGs from euthyroid patients with HT (median % SL, -0.9) did not significantly differ from those of C-IgGs. By taking a cut-off over the upper range of % SL produced by C-IgGs (> 2), the prevalence of thyroid-cytotoxic Abs was 30% in AT, 59% in HT-SH, and 55% in HT-H. However, 37% of euthyroid patients with HT also had thyroid-cytotoxic Abs. No IgG containing TPO antibodies (TPOAb) at low titer (< 40(2)) was cytotoxic. However, the levels of thyroid-cytotoxic Abs did not correlate with TPOAb titers, and preabsorption with TPO only partially abolished the lytic effect of some HT-IgG. These findings suggest that TPO is a target of thyroid-cytotoxic Abs, but other thyroid antigens are also involved in the cytotoxic reaction.(ABSTRACT TRUNCATED AT 400 WORDS)

Influence of oral contraceptives on fasting gallbladder volume

A total of 615 healthy fertile women (518 pill users and 97 non-users) were examined by real-time ultrasonography for fasting gallbladder volume, gallstones and biliary dysmorphism. None of the six examined combinations of oral contraceptives appeared to influence fasting gallbladder volume significantly. When fasting gallbladder volumes were reanalyzed according to the presence or absence of recognized biliary risk factors, significant modifications were detected, in both pill users and non-users. These changes related only to age and parity. Relative risks of cholelithiasis and biliary dysmorphism were not affected by contraceptive treatment.

3D modeling of phased array generated ultrasounds in lossy media

A general algorithm for three-dimensional (3D) modeling of acoustic fields generated by phased array transducers and propagating in uniformly lossy media is introduced and illustrated also with the help of specific examples. Applications of the method are foreseen in the analysis and the design of transducers for echographic applications in order to evaluate and/or optimize their performances.

Effects of bacillus of Calmette-Guerin, Candida albicans and human recombinant interferon-gamma on RNA metabolism and on in vitro release of tumor necrosis factor-alpha by human monocytes/macrophages

Bacillus of Calmette-Guerin (BCG) was found to be effective in the therapy of superficial bladder cancer, although the mechanisms by which this occurs have not yet been clarified. One hypothesis is related to the ability of monocytes/macrophages (MN/M phi) to release tumor necrosis factor-alpha (TNF-alpha), a monokine with cytotoxic and cytostatic effects against certain tumor cell lines. The present study demonstrates that BCG and C. albicans are both very efficient inducers of TNF-alpha, while they inhibit uridine uptake and incorporation into human MN/M phi RNA. However, unlike C. albicans, BCG is cytotoxic for MN/M phi, as determined by release of labelled leucine from target cells.

Percutaneous Bcg Treatment in Superficial Transitional Cell Cancer of the Upper Urinary Tract

From January 1989 to September 1992, 5 patients (age 58–68 years) were treated with percutaneous Pasteur BCG for superficial transitional cell carcinoma of the upper urinary tract. In 4 cases BCG was prophylactic after endourological resection of the tumors. In one case of bilateral Tis of the upper urinary tract, BCG was administered for therapeutical purposes. Every patient received 375 mg Pasteur BCG in 250 ml saline, every 2 weeks for 6 consecutive weeks in 2 patients, 5 weeks in 1, and 4 in 2. No major complications were observed. After a median follow-up of 10.2 months, 4 patients are disease free, 1 patient underwent nephroureterectomy. Percutaneous BCG in upper tract superficial transitional cell cancer seems a feasible option in selected cases.

Low dose flunarizine in the prophylaxis of migraine

In a period of one year (1990) we selected 40 patients suffering from migraine. For an open randomized study there were 2 groups of patients: the first were treated with 10mg of flunarizine per day and the second with 3 mg per day. The patients were treated for 4 months consecutively. There were 11 drop outs (27.5%): nine for poor compliance and 2 due to side effects. The efficacy of flunarizine in the prophylaxis of migraine was essentially identical in the two dosage groups while the incidence of side effects was considerably reduced in the patients treated with the lower dose.

Clinical value of pathologic changes after intravesical BCG therapy of superficial bladder cancer

Bladder pathologic features related to intravesical bacillus Calmette-Guerin (BCG) therapy in superficial bladder cancer (Ta, T1, Tis) were evaluated and related to clinical outcome. A total of 105 patients were treated with 75 mg Pasteur BCG weekly for six consecutive weeks. When tumor was not demonstrated a maintenance course was given. An additional six-week course was given when tumor recurrence or persistence, without progression, was observed after the induction course. An inflammatory change in the bladder was the most common pathologic finding. Granuloma was the only specific BCG-related feature and did not appear to be a prognostic factor because of low incidence (24%) and lack of correlation with clinical course. Dysplasia occurred more frequently (57%) in nonresponder patients and (26%) in responder patients, often heralding recurrence of tumor. All patients showing concurrent squamous and/or glandular metaplasia were unresponsive to BCG therapy. Histology and cytology did not correlate perfectly: cytology was ineffective in low-grade tumors and improved diagnostic accuracy, particularly when dysplasia was histologically evident.