Liver pathology in COVID-19 related death and leading role of autopsy in the pandemic

BACKGROUND

Information on liver involvement in patients with coronavirus disease 2019 is currently fragmented.

AIM

To highlight the pathological changes found during the autopsy of severe acute respiratory syndrome coronavirus 2 positive patients.

METHODS

A systematic literature search on PubMed was carried out until June 21, 2022.

RESULTS

A literature review reveals that pre-existing liver disease and elevation of liver enzyme in these patients are not common; liver enzyme elevations tend to be seen in those in critical conditions. Despite the poor expression of viral receptors in the liver, it seems that the virus is able to infect this organ and therefore cause liver damage. Unfortunately, to date, the search for the virus inside the liver is not frequent (16% of the cases) and only a small number show the presence of the virus. In most of the autopsy cases, macroscopic assessment is lacking, while microscopic evaluation of livers has revealed the frequent presence of congestion (42.7%) and steatosis (41.6%). Less frequent is the finding of hepatic inflammation or necrosis (19%) and portal inflammation (18%). The presence of microthrombi, frequently found in the lungs, is infrequent in the liver, with only 12% of cases presenting thrombotic formations within the vascular tree.

CONCLUSION

To date, the greatest problem in interpreting these modifications remains the association of the damage with the direct action of the virus, rather than with the inflammation or alterations induced by hypoxia and hypovolemia in patients undergoing oxygen therapy and decompensated patients.

Isometric artifacts from polymerase chain reaction‐massively parallel sequencing analysis of short tandem repeat loci: An emerging issue from a new technology?

The recent introduction of polymerase chain reaction (PCR)‐massively parallel sequencing (MPS) technologies in forensics has changed the approach to allelic short tandem repeat (STR) typing because sequencing cloned PCR fragments enables alleles with identical molecular weights to be distinguished based on their nucleotide sequences. Therefore, because PCR fidelity mainly depends on template integrity, new technical issues could arise in the interpretation of the results obtained from the degraded samples. In this work, a set of DNA samples degraded in vitro was used to investigate whether PCR‐MPS could generate “isometric drop‐ins” (IDIs; i.e., molecular products having the same length as the original allele but with a different nucleotide sequence within the repeated units). The Precision ID GlobalFiler NGS STR panel kit was used to analyze 0.5 and 1 ng of mock samples in duplicate tests (for a total of 16 PCR‐MPS analyses). As expected, several well‐known PCR artifacts (such as allelic dropout, stutters above the threshold) were scored; 95 IDIs with an average occurrence of 5.9 IDIs per test (min: 1, max: 11) were scored as well. In total, IDIs represented one of the most frequent artifacts. The coverage of these IDIs reached up to 981 reads (median: 239 reads), and the ratios with the coverage of the original allele ranged from 0.069 to 7.285 (median: 0.221). In addition, approximately 5.2% of the IDIs showed coverage higher than that of the original allele. Molecular analysis of these artifacts showed that they were generated in 96.8% of cases through a single nucleotide change event, with the C > T transition being the most frequent (85.7%). Thus, in a forensic evaluation of evidence, IDIs may represent an actual issue, particularly when DNA mixtures need to be interpreted because they could mislead the operator regarding the number of contributors. Overall, the molecular features of the IDIs described in this work, as well as the performance of duplicate tests, may be useful tools for managing this new class of artifacts otherwise not detected by capillary electrophoresis technology.

Medication Errors in Pediatrics: Proposals to Improve the Quality and Safety of Care Through Clinical Risk Management

Medication errors represent one of the most common causes of adverse events in pediatrics and are widely reported in the literature. Despite the awareness that children are at increased risk for medication errors, little is known about the real incidence of the phenomenon. Most studies have focused on prescription, although medication errors also include transcription, dispensing, dosage, administration, and certification errors. Known risk factors for therapeutic errors include parenteral infusions, oral fluid administration, and tablet splitting, as well as the off-label use of drugs with dosages taken from adult literature. Emergency Departments and Intensive Care Units constitute the care areas mainly affected by the phenomenon in the hospital setting. The present paper aims to identify the risk profiles in pediatric therapy to outline adequate preventive strategies. Precisely, through the analysis of the available evidence, solutions such as standardization of recommended doses for children, electronic prescribing, targeted training of healthcare professionals, and implementation of reporting systems will be indicated for the prevention of medication errors.

Spine surgery and fat embolism syndrome. Defining the boundaries of medical accountability by hospital autopsy

BACKGROUND

Fat Embolism Syndrome (FES) is a clinical condition characterized by neurological, respiratory, hematological and cutaneous manifestations. Fatal FES has been described as a rare complication during or after spinal elective surgery. The investigation of the cause of death in fatalities related with spine surgery should be mandatory to exclude or confirm fat embolism; a detailed methodological approach to the body in these cases suggests to provide a cautious dissection of surgical site and collection of samples to detect embolized fat globules in vessels.

METHODS

Two fatal cases of fat embolism syndrome after posterior spinal fusion are presented.

CONCLUSIONS

A complete post mortem examination by means of histochemical and immunohistochemical analysis explained the cause of death and prevented medical malpractice litigation.

Supporting Decision Making in Intensive Care: Ethical Principles for Managing Access to Care During the COVID-19 Pandemic

The pandemic from COVID-19 causes a health threat for many countries and requires an internationally coordinated response due to the high spread of the infection. The current local and international situation gives rise to logistical and ethical considerations regarding the imbalance between needs for assistance and availability of health resources in the continuation of the emergency. A shortage condition will require healthcare professionals to choose between patients who will have access to respiratory support and those who will have to continue without. The sharing of criteria for the introduction of patients to the different therapeutic paths is fundamental to prevent the onset of ethical issues. The present paper analyzes the critical issues related to the scarcity of healthcare resources and the limitation of access to intensive care with the aim of proposing ethically sustainable principles for the management of the current pandemic situation.

Cytokine storm and histopathological findings in 60 cases of COVID-19-related death: from viral load research to immunohistochemical quantification of major players IL-1β, IL-6, IL-15 and TNF-α

This study involves the histological analysis of samples taken during autopsies in cases of COVID-19 related death to evaluate the inflammatory cytokine response and the tissue localization of the virus in various organs. In all the selected cases, SARS-CoV-2 RT-PCR on swabs collected from the upper (nasopharynx and oropharynx) and/or the lower respiratory (trachea and primary bronchi) tracts were positive. Tissue localization of SARS-CoV-2 was detected using antibodies against the nucleoprotein and the spike protein. Overall, we tested the hypothesis that the overexpression of proinflammatory cytokines plays an important role in the development of COVID-19-associated pneumonia by estimating the expression of multiple cytokines (IL-1β, IL-6, IL-10, IL-15, TNF-α, and MCP-1), inflammatory cells (CD4, CD8, CD20, and CD45), and fibrinogen. Immunohistochemical staining showed that endothelial cells expressed IL-1β in lung samples obtained from the COVID-19 group (p < 0.001). Similarly, alveolar capillary endothelial cells showed strong and diffuse immunoreactivity for IL-6 and IL-15 in the COVID-19 group (p < 0.001). TNF-α showed a higher immunoreactivity in the COVID-19 group than in the control group (p < 0.001). CD8 + T cells where more numerous in the lung samples obtained from the COVID-19 group (p < 0.001). Current evidence suggests that a cytokine storm is the major cause of acute respiratory distress syndrome (ARDS) and multiple organ failure and is consistently linked with fatal outcomes.

Synthetic cannabinoids and cathinones cardiotoxicity: evidences actualities and perspectives

New psychoactive substances (NPS) constitute a group of psychotropic substances, designed to mimic the effects of traditional substances like cannabis, cocaine, MDMA, khat, which was not regulated by the 1961 United Nations Convention on Narcotics or the 1971 United Nations Convention on Psychotropic Substances. Illegal laboratories responsible for their production regularly developed new substances and placed them on the market to replace the ones that have been banned; for this reason, during the last decade this class of substances has represented a great challenge for the public health and forensic toxicologists. The spectrum of side effects caused by the intake of these drugs of abuse is very wide since they act on different systems with various mechanisms of action. To date most studies have focused on the neurotoxic effects, very few works focus on cardiotoxicity. Specifically, both synthetic cannabinoids and synthetic cathinones appear to be involved in different cardiac events, including myocardial infarction and sudden cardiac death due to fatal arrhythmias. Synthetic cannabinoids and cathinones cardiotoxicity are mainly mediated through activation of the CB1 receptor present on cardiomyocyte and involved with reactive oxygen species production, ATP depletion and cell death. Concerns with the adrenergic over-stimulation induced by this class of substances and increasing oxidative stress are mainly reported. In this systematic review we aim to summarize the data from all the works analyzing the possible mechanisms through which synthetic cannabinoids and synthetic cathinones damage the myocardial tissue.

The Model of "Informed Refusal" for Vaccination: How to Fight against Anti-Vaccinationist Misinformation without Disregarding the Principle of Self-Determination

Vaccines are arguably a public health success story as well as an incredibly cost-effective medical resource. Despite this, worldwide concerns about their safety are growing, with the risk of increased morbidity and mortality in vaccine-preventable diseases because of vaccine refusal. The global political trend in developed countries is to increasingly reduce mandates and the compulsory nature of vaccination programs. This is due to strong opposition from anti-vaccination movements and groups. While these have existed since the beginnings of vaccinology, they have recently gained a strong foothold through massive exploitation of the media and especially the internet. This has led to widespread misinformation and greater difficulty for governments and health institutions in dealing with parents’ concerns and misconceptions. Common strategies in order to maintain a high degree of public acceptance of vaccines include the enhancement of adverse effect reporting systems, the enrichment of scientific literature, and the dissemination of targeted information to parents and health care providers. Vaccine risk perception, in fact, largely exceeds the evidence and is linked to well-known general population cognitive bias, which must be recognized and corrected. Although there is no doubt about the convenience of universal vaccination, a lively international debate is underway with regard to the legitimacy of mandatory vaccination programs. Most scientists agree that the individual’s right to self-determination should be preserved. The only way to simultaneously protect the right to health is to introduce an informed refusal model, which aims to guarantee the highest coverage rates for vaccination.

Multi-organ complement deposition in COVID-19 patients

BACKGROUND

Increased levels of circulating complement activation products have been reported in COVID-19 patients, but only limited information is available on complement involvement at tissue level. The mechanisms and pathways of local complement activation remain unclear.

METHODS

We performed immunofluorescence analyses of autopsy specimens of lungs, kidney and liver from nine COVID-19 patients who died of acute respiratory failure. Snap-frozen samples embedded in OCT were stained with antibodies against complement components and activation products, IgG and spike protein of SARS-CoV-2.

FINDINGS

Lung deposits of C1q, C4, C3 and C5b-9 were localized in the capillaries of the interalveolar septa and on alveolar cells. IgG displayed a similar even distribution, suggesting classical pathway activation. The spike protein is a potential target of IgG, but its uneven distribution suggests that other viral and tissue molecules may be targeted by IgG. Factor B deposits were also seen in COVID-19 lungs and are consistent with activation of the alternative pathway, whereas MBL and MASP-2 were hardly detectable. Analysis of kidney and liver specimens mirrored findings observed in the lung. Complement deposits were seen on tubules and vessels of the kidney with only mild C5b-9 staining in glomeruli, and on hepatic artery and portal vein of the liver.

INTERPRETATION

Complement deposits in different organs of deceased COVID-19 patients caused by activation of the classical and alternative pathways support the multi-organ nature of the disease.

FUNDING

Grants from the Italian Ministry of Health (COVID-2020-12371808) to PLM and National Institutes of Health HL150146 to NP are gratefully acknowledged.

Is hospital autopsy auditing suitable for clinical risk management? Actualities and perspectives of auditing in the autopsy room following Italian Law 24/2017 on patient safety

BACKGROUND

autopsies are a valuable tool for understanding the physiopathology of a disease and it is the gold standard to assess the cause of death. The clinical autopsy is the ultimate medical service for a patient and plays a crucial role in the context of quality control, education of physicians and other medical personnel, as well as mitigation of risk of malpractice claims.

OBJECTIVE

This study aims to demonstrate the importance of improving an autopsy service and the relevance of this investigation procedure in daily clinical practice by evaluating the rate of major discrepancies between the assumed cause of death and the ascertained cause of death after a complete post mortem investigation. A further aim is to classify these discrepancies as class I or class II discrepancies according to Goldman's criteria in order to asses performance quality.

METHODS

a retrospective study of the hospital autopsies performed from June 2018 to March 2020 was conducted by considering a diversified dataset, including age and sex of the deceased as well as the clinical and pathological causes of death.

RESULTS

362 cases were taken into consideration. Major discrepancies were found in 71.3% of cases, with a class I error of 22.7% and a class II error of 48.6%. The most frequent misdiagnoses were cardiovascular disorder, embolism and aneurism rupture.

DISCUSSION

The rate of major discrepancies and the rate of class I and class II errors are way above the rate found in literature. Despite the high rate of major discrepancy evidences collected from hospital autopsies (i.e. certainty of the cause of death, unknown comorbidities) strengthened the legal defense in cases of medical malpractice litigation. In our experience, by accurately determining the cause of death, revealing new or unexpected findings and possible diagnostic or technical errors, postmortem examinations can significantly contribute to the improvement of team performance and quality of care.

CONCLUSION

The presence of clinicians during autopsy and the early sharing of results can be considered a new auditing strategy for hard clinical cases. Finally, by providing a clearer understanding of the nature and cause of the illness, the autopsy results assisted in the grieving process by reassuring family members that action or inaction on their part had not contributed to the death.

More than Pneumonia: Distinctive Features of SARS-Cov-2 Infection. From Autopsy Findings to Clinical Implications: A Systematic Review

Despite safety recommendations for the management of corpses with COVID-19 infection and the high number of deaths worldwide, the post-mortem investigation rate is extremely low as well as the scientific contributions describing the pathological features. The first results of post-mortem investigations provided interesting findings and contributed to promoting unexplored therapeutic approaches and new frontiers of research. A systematic review is provided with the aim of summarizing all autopsy studies up to February 2020 in which a complete post-mortem investigation in patients with COVID-19 disease was performed, focusing on histopathological features. We included case reports, case series, retrospective and prospective studies, letters to the editor, and reviews. A total of 28 studies fulfilled the inclusion criteria, producing a pooled dataset of 407 full autopsies. Analyzing the medical history data, only 12 subjects had died without any comorbidities (for 15 cases the data were not available). The post-mortem investigation highlighted that acute respiratory distress syndrome (ARDS) and multiple organ failure represent the main clinical features of COVID-19 disease, often leading to pulmonary thromboembolism and superimposed bronchopneumonia. The discussed data showed a strict relationship among the inflammatory processes, diffuse alveolar, and endothelial damage. In light of these results, the full autopsy can be considered as the gold standard to investigate unknown infections or pathogens resulting in death.

The Prevalence of patients with panic attacks (PAs) and panic disorder (PD) visiting Emergency Departments of the Verona Hospital

BACKGROUND

Panic Attacks (PAs) and Panic Disorder (PD) represent a heavy burden not only because of the difficulty in distinguishing them from other pathologies and in treating them appropriately but also because of their impact on public health worldwide. In Europe, PD constitutes one of the five most common mental disorders adversely affecting quality of life.

STUDY DESIGN

The aim of this study is to evaluate the period prevalence of visits to the Emergency Departments of the University Hospital of Verona (North East of Italy) over the period between 2012-2016 because of symptoms of PAs or PD in order to quantify the burden of the disorder.

METHODS

This study was carried out by retrospectively collecting data from the medical records of all the patients assessed at the Emergency Departments (EDs) of the Verona Hospital because of symptoms of PAs or PD over a 5-year period (1 January 2012 - 31 December 2016). The search words used in reviewing the medical records registered in the hospital discharge reports from the Gynecological, Pediatric and General Medicine Emergency Departments were: "Anxiety" and/or "Panic". A multiple logistic regression model was also created to evaluate the predictors of ED visits for PAs or PD over the period that was investigated.

RESULTS

The study identified 3,771 cases of PAs or PD; 62.3% were females and 37.7% were males. The female-to-male ratio was 1.7:1. The mean age was 44 years (46 for the females and 41 for the males). The majority of the patients fell into two age categories: 30 to 39 (20.6%) and 40 to 49 (23.8%). The proportion of visits to the EDs for PAs or PD was approximately 20% per year, with an average of approximately 754 patients visiting the EDs every year. The period prevalence of accesses for PAs or PD over the five year period studied in the mean resident population (1.4%) and the mean visits to the EDs (2.5%) were calculated. Study results showed that the majority of the patients (80.9%) were referred to their general practitioner (GP) at the end of the assessment protocol at the EDs. According to the regression logistic model, the following variables were significant (p<0.05) risk factors for PAs or PD: being female vs. male (OR 1.899; 95% CI 1.785-2.020), being Italian vs. Foreigner (OR 1.292; 95% CI 1.174-1.421), having a white or green priority code at arrival (low urgency) vs. the other ones (OR 1.195; 95% CI 1.100-1.297), and being aged ≤42 years old (OR 1.091; 95% CI 1.024-1.161).

CONCLUSION

The role of the GP is crucial in the management of PD and PAs. Given the difficulty of implementing primary and secondary prevention programs for these conditions, public health officials should make every effort to promote tertiary prevention in order to reduce the burden of the ailment and societal cost.

Small low-risk pulmonary nodules on chest digital radiography: can we predict whether the nodule is benign?

AIM

To evaluate digital chest radiography (CR) performance compared to computed tomography (CT) for characterising small low-risk pulmonary nodules detected incidentally in non-oncological patients. A second aim was to assess the prevalence of calcification and possible false-positive findings mimicking nodules.

MATERIALS AND METHODS

Two hundred and seven patients who presented with a pulmonary nodule on CR and underwent CT were included prospectively. Nine radiologists blinded to the CT images reviewed the CRs assessing for the presence of nodules. Afterwards, the same radiologists evaluated the corresponding CT for the presence of nodules, dimensions, and calcification. If the nodule was not present on CT, it was considered a false-positive finding, and possible confounding factors on CR were investigated.

RESULTS

Among all 213 nodules seen on CR, 32.4% were revealed to be false-positive findings on CT, mostly due to images formed by vessels (53.6%), osseous aetiologies (30.4%), and skin lesions (13%). Most nodules <6 mm detected on radiographies had benign calcification on CT (n=90; 67.7%). Comparatively, only 41.2% of nodules ≥6 mm on the CR had benign calcification. Among all nodules <6 mm detected on CR, 95.5% were calcified or not present at CT against 81.2% for those ≥6 mm (p<0.001).

CONCLUSION

The present study demonstrated that 95.5% of pulmonary nodules smaller than 6 mm on CRs are either calcified (benign) or represent a false-positive finding on CT. These results suggest that nodule measures on CR smaller than 6 mm most likely represent a benign finding.

Implementing Activities Developed by the Organ Transplantation Academic Society of the Hospital Dom Vicente Scherer: A Pilot Study

BACKGROUND

The number of academic societies has been growing significantly in Brazilian universities, offering an extra opportunity for the development of educational activities and research. Because organ donation and transplantation is an area still insufficiently approached during the graduation of health professionals, we evaluated how academic societies might be a valuable tool.

METHODS

Participants of the course promoted by the Organ Transplantation Academic Society of the Hospital Dom Vicente Scherer were evaluated through the use of a questionnaire and cognitive tests with 16 multiple-choice questions about topics approached during the course, before and after the lectures. Topics approached consisted of a general introduction about transplantation in Brazil, brain death, organ allocation and removal, post-transplant follow-up, and clinical cases.

RESULTS

Of the 45 participants, 30 answered the tests at both times. The subjects were students of medicine, nursing, and phonoaudiology; 93.3% were organ donors, 84.6% said their families knew about this decision, and 65% had relatives who were organ donors. The mean score of correct answers was 7.63 of 16 before the activities and 12.54 after activities, demonstrating a 64.4% improvement.

CONCLUSIONS

The improvement in performance suggests that academic societies are a useful resource for educational purposes and for students to get a deeper insight about organ donation and transplantation.

Two-year Experience of the "Organ Donation Week" of the Federal University of Health Sciences of Porto Alegre, Brazil

BACKGROUND

Today, Brazil is the second country of the world in number of transplants. Nonetheless, waiting lists are getting longer. This lack of organs occurs mostly because of people's reduced knowledge about the donation process. With the aim of changing this scenario, in 2013 and 2014, "Organ Donation Week" events were held at the Federal University of Health Sciences of Porto Alegre.

METHODS

During the 2 years, documentaries followed by a cycle of debates with experts in this area were exhibited. In 2013, a "flash-mob" took place, with the purpose of performing a "transplant waiting list" around the perimeter of Santa Casa's Hospital Complex. In 2014, a morning full of educational activities was planned for the pediatric patients from the Santo Antônio Children's Hospital and their relatives.

RESULTS

It is estimated that approximately 1774 people were directly reached by the projects. Among these people, we can include medical students, healthcare professionals, university staff, transplanted patients, and their families. We believe that education and consciousness are central points in the donation and transplant process. Through this project, we could inform people about it, solving their doubts and myths and stimulating this kind of conversation among the family circle, making the moment when the family must make the decision much easier.

CONCLUSIONS

Education and public awareness are essential for enhancing the number of organ donations. Therefore, events such as "Organ Donation Week" should be encouraged among medical schools.

[Subclinical atherosclerosis in patients with psoriatic arthritis: a case-control study. Preliminary data]

OBJECTIVE

The aim of this study was to evaluate the prevalence of subclinical atherosclerosis in patients with psoriatic arthritis (PsA), correlated with some traditional risk factors of atherosclerosis and with PsA-related disease factors.

METHODS

Forty-one patients and 41 healthy subjects were evaluated for intima-media thickness (IMT) and flow-mediated dilation (FMD), using carotid duplex scanning. IMT values were expressed like IMT mean (cumulative mean of all the IMT mean) and M-MAX (cumulative mean of all the higher IMT). Subclinical atherosclerosis markers were correlated with age, body mass index (BMI) and blood pressure in both groups, with duration of arthritis, duration of psoriasis, tender and swollen joints, BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), BASFI (Bath Ankylosing Spondylitis Functional Index), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in patients.

RESULTS

IMT mean and M-MAX were both higher in PsA patients compared with controls (0.7+/-0.15 vs 0.62+/-0.09 mm; p<0.01 and 0.86+/-0.21 vs. 0.74+/-0.13 mm; p<0.01 respectively). FMD was smaller in patients than in controls (5.9+/-2 vs 7.5+/-2.8%; p<0.01). Univariate analysis showed a correlation between IMT mean and SBP (r=0.217; p=0.05) and a correlation between M-MAX and age (r=0.392; p<0.001), BMI (r=0.252; p<0.05), SBP (r=0.446; p<0.001) in both groups. In PsA patients M-MAX resulted correlated with ESR (r=0.338; p<0.05) and BASDAI (r=0.322; p<0.05).

CONCLUSIONS

PsA patients exhibited endothelial dysfunctions which is an early marker of subclinical atherosclerosis, as well as an higher IMT. An interesting correlation between M-MAX and PsA activity index (ESR and BASDAI) was found.

Rare association of renal angiomyolipoma and oncocytoma

The association of renal angiomyolipoma and renal oncocytoma in the same kidney is rare, only 7 cases having been previously reported. We report a 69-year-old woman affected by the simultaneous presence of renal angiomyolipoma and oncocytoma in the right side with a decrease of renal function on the left side due to a stenosis of the superior polar branch that was successfully treated preoperatively by angioplasty. An enucleation of renal masses on the right side was performed with renal function preservation after 2 years.

Embryonal adenoma of the kidney. A rare embryonal adenoma of the kidney

We report the case of a 47-year-old man who underwent partial nephrectomy for an embryonal adenoma which was characterized by a monomorphous appearance. No adjuvant therapy was given and at the 5-year follow-up the patient is in perfect health and no relapse has been observed.

Study on the Influence of the “Learning Curve” in Percutaneous Surgery Complications

In order to check how the learning curve of the method influenced complications in percutaneous surgery, we analysed two distinct periods of time during which the same operator accomplished 166 and 61 percutaneous procedures. We evaluated the results, stressing minor and major complications as well as final outcomes. Improvements in surgical technique were proved by a reduction in both operating time and hospital charge, and by better endopyelotomy results. Failure to improve PCNL results is due to the increased presence of staghom calculi in the second period (43.3% vs 32.7%).

Laparoscopic lymphadenectomy for clinical stage I nonseminomatous testicular tumour

We report our experience in laparoscopic lymphadenectomy in non-seminomatous stage I testicular neoplasia. This technique is an alternative to the formal retroperitoneal lymphadenectomy. Between 1993 and 1996 we carried out 8 retroperitoneal laparoscopic lymphadenectomies in patients, aged 19–40 years, affected by non-seminomatous testicular neoplasia. We removed from 13 to 24 lymph nodes. Operating time ranged between 200 and 300 minutes. The mean stay in hospital was 5 days. Histological findings revealed micrometastatic lymph nodes in half the patients. No complications were reported except in one patient, who underwent TC-guided drain owing to voluminous lymphocele one week after the laparoscopic operation. Normal antegrade ejaculation was preserved in all cases and no retroperitoneal recurrence was noted at a mean 18 months follow-up.

Up-front intravesical chemotherapy for low stage, low grade recurrent bladder cancer

PURPOSE

We evaluated the ablative and prophylactic potential of short schedule, up-front topical chemotherapy on low stage and grade recurrent bladder tumors.

MATERIALS AND METHODS

The study design consisted of 4 weekly instillations followed by transurethral resection during week 5. Mitomycin C was administered initially and mitoxantrone was administered following the same schedule if disease recurred during followup.

RESULTS

After up-front mitomycin C, 29 of 42 patients (69%) had a complete response with no need for transurethral resection, whereas residual disease was resected in the remaining 13 (31%). Disease recurred during followup in 22 of the 42 patients (52.4%), who were then treated with up-front mitoxantrone with a complete response in 14 (63.7%). Residual disease was resected in 8 patients (36.3%) with progression to grade 3 in 2.

CONCLUSIONS

Short schedule intravesical chemotherapy can completely ablate small volume recurrent superficial bladder cancer in a relevant number of patients but it is not adequate prophylaxis.