Estimates of prostate cancer burden in Italy

Age-standardized incidence rates of prostate cancer (PC) sharply increased during the period 1990-2005 in Italian areas covered by cancer registries, while corresponding mortality rates remained nearly constant. The latest observations have reported on a reversal of the incidence trend with decreasing values after 2005. We provided incidence, mortality, and prevalence estimates at national and geographical area levels, together with time projections up to the year 2020. We applied the MIAMOD method, using as input national mortality data for the years 1970-2010 and population-based survival data for the period of diagnosis (1985-2002). We assumed relative survival of prostate cancer remained constant after the year of diagnosis (2005). The age-standardized incidence rates of PC were estimated to increase during the period 1984-2005, from 31 per 100,000 in 1984 to 93 per 100,000 in 2005. From 2005 onwards, the estimated rates declined to 71 in 2015 and to 62 in 2020. Age-standardized mortality rates slightly increased from 1970 up to about 19 per 100,000 in 1999 and then started to decrease with an estimated reduction of about 2.3% per year. Mortality projections indicated a continuing reduction, with a predicted age-standardized rate of about 12 per 100,000 in 2020. Prevalence was estimated to continuously increase up to a crude prevalence value of 1.2% in the year 2020. The results indicate that the epidemic peak of PC was reached around the year 2005 followed by declining incidence rates, while a substantial decrease in mortality, starting during the early 2000s, is expected to continue during the 2010s.

The clinical use of statistical permutation test methodology: a tool for identifying predictive variables of outcome

OBJECTIVES

To identify the predictive variables affecting the outcome after radical surgery for bladder cancer by a newer statistical methodology, i.e. nonparametric combination (NPC).

METHODS

A multicenter study enrolled 1,312 patients who had undergone radical cystectomy for bladder cancer in 11 Italian oncological centers from January 1982 to December 2002. A statistical analysis of their medical history and diagnostic, pathological and postoperative variables was performed using a NPC test. The patients were included in a comprehensive database with medical history and clinical and pathological data. Five-year survival was used as the dependent variable, and p values were corrected for multiplicity using a closed testing procedure. The newer nonparametric approach was used to evaluate the prognostic importance of the variables. All of the analyses were performed using routines developed in MATLAB© and the significance level was set at α = 0.05.

RESULTS

A significant prognostic predictive value (p < 0.01) for tumor clinical staging, hydronephrosis, tumor pathological staging, grading, presence of concomitant carcinoma in situ, regional lymph node involvement, corpora cavernosa invasion, microvascular invasion, lymphatic invasion and prostatic stroma involvement was found.

CONCLUSIONS

The NPC test could handle any type of variable (categorical and quantitative) and take into account the multivariate relation among variables. This newer methodology offers a significant contribution in biomedical studies with several endpoints and is recommended in presence of non-normal data and missing values, as well as solving high-dimensional data and problems relating to small sample sizes.

PF-03446962, a fully-human monoclonal antibody against transforming growth-factor β (TGFβ) receptor ALK1, in pre-treated patients with urothelial cancer: an open label, single-group, phase 2 trial

Despite a compelling preclinical rationale for the use of anti-angiogenic drugs in urothelial cancer (UC), short-living responses have been observed in clinical trials. PF-03446962 is a novel monoclonal antibody against Activin Receptor-Like Kinase-1 (ALK1), a type I subclass of the TGFβ receptor, with dose-dependent anti-angiogenic activity. An open label, single-group, phase 2 trial of PF-03446962 was conducted in salvage setting. Patients failing at least one chemotherapy regimen were eligible. Design provided PF-03446962 10 mg/Kg intravenously fortnightly until disease progression (PD) or unacceptable toxicity. Two-month progression-free survival (PFS) was the primary endpoint. The trial was registered with ClinicalTrials.gov, number NCT01620970. Fourteen patients were enrolled from October 2012 to July 2013. Median age was 64 years (interquartile range [IQR]: 58.2-69.5), 9 patients had a Bellmunt score of 1-2, median number of prior drugs was 3. One stable disease and 13 PD were recorded and the study met the futility stopping rule of interim analysis. Median PFS was 1.8 months (95 %CI, 1.4-2.0). After a median follow up of 7.4 months (IQR 4.5-10.9), 8 patients are alive. Median overall survival (OS) was 8 months (95 %CI, 2.9-not estimable). Most common toxicities were thrombocytopenia (G1-2 in 5 cases, persistent G3 in one, with 3 dose delays and 1 dose interruption), fatigue and abdominal pain (G1-2 in 4 cases each). Impairment of quality of life (ESAS score) was observed as well as an increase from baseline to +2 month median levels of vascular endothelial growth factor (VEGF) and interleukin-8. PF-03446962 had no activity as single drug in refractory UC and we do not recommend further investigation outside of the combination with agents targeting the VEGF receptor axis.

Incidence and survival of rare urogenital cancers in Europe

BACKGROUND

The RARECARE project aims at increasing knowledge of rare cancers in Europe. This manuscript describes the epidemiology (incidence, prevalence, survival) of rare urogenital cancers, taking into account the morphological characterisation of these tumours.

METHODS

We used data gathered by RARECARE on cancer patients diagnosed from 1995 to 2002 and archived in 64 European population-based cancer registries, followed up to December 31st, 2003 or later.

RESULTS

The annual number of males that develop penile cancer in the EU is estimated at 3100, which is equivalent to an age standardised rate (ASR) of 12 per million males. The 5-year relative survival rate is 69%, while squamous cell carcinoma is the predominant morphological entity. Each year around 650 persons in the EU develop cancer of the urethra and 7200 develop cancer of the renal pelvis or ureter (RPU). The ASR for cancer of the urethra and RPU is 1.1 (males 1.6; females 0.6) and 12 (males 16; females 7) per million inhabitants, respectively. The 5-year relative survival rate for cancer of the urethra and RPU is 54% and 51%, respectively. Transitional cell carcinoma is the predominant morphological entity of cancer of the urethra and RPU.

CONCLUSIONS

In view of the low number of cases and the fact that one third to one half of the patients die of their disease, centralisation of treatment of these rare tumours to a select number of specialist centres should be promoted.

Sensitivity and specificity of osteopontin (OPN) versus prostate-specific antigen (PSA) in prostate carcinoma (PCa): A case- control study

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Background: OPN is a secreted adhesive glycoprotein overexpressed in human cancers. A stimulatory effect of OPN on human PCa cells in vitro has been demonstrated. This study intends to determine if measuring serum OPN and PSA levels can provide informative markers for the detection of PCa. Methods: Serum total PSA using a chemiluminescent immunoassay system (Hybritech PSA, DxI Beckman Coulter, Inc.) and plasma OPN using an ELISA technique (R&D Systems, Inc.) were measured in 263 male subjects referred for diagnostic prostate biopsy, including 167 control patients with benign prostate pathology (mean age: 65.30; median age: 66; SD: 6.80; range 46–83) and 96 PCa patients (mean age: 66.80; median age: 68; SD: 7.90; range 47–86). Sensitivity and specificity were determined for each marker. The relationship between sensitivity and specificity was profiled by receiver operating characteristic (ROC) curves of OPN and PSA. Results: Both markers levels were higher in PCa patients (OPN 51.98 ng/ml, SD 32.64, range 5.9–169.54; PSA 12.91 ng/ml, SD 14.73, range 1.69–90) than in controls (OPN 49.93 ng/m, SD 27.78, range 4.15–146.34; PSA 8.04 ng/ml, SD 5.94, range 0.46–45), although the elevation was significant (p<0.001) for PSA but not for OPN (p=0.59). The increase of serum OPN level paralleled the increase of the tumour size, defined by the T stage, and was more striking for T ≥2 PCa than for T1 PCa. The increase of PSA, related to the tumour size, was less evident and was observed only in high stage (T3) tumours. The ROC curve showed that OPN was not a marker that enabled the discrimination between PCa and non-cancer patients. For PSA, a cut-off value of 4 ng/ml had a sensitivity of 93% with a specificity of 13%. A cut-off value of 5 ng/ml resulted with a sensitivity of 85% and specificity of 26%. Conclusions: OPN and PSA are not correlated and therefore their combined evaluation in a larger study group could provide a novel insight into the natural history of PCa. A follow-up of the patients involved is ongoing in order to assess a possible prognostic role of the two markers. (The study was funded by the Alessandria branch of the Italian League against Cancer through a grant from the Cassa di Risparmio di Alessandria Foundation)

No significant financial relationships to disclose.

[Is prophyilaxis necessary after urodynamic tests? Our experience]

Urodynamic studies should be performed only on patients with sterile urine. The use of prophylaxis after urodynamic investigation is debated (positive urinoculture in 9 to 15% of cases). The Units of Urodynamics at the Urological Clinic of the University of Genoa and of the Galliera Hospital of Genoa assessed the prevalence of bacteriuria on a sample of 336 patients (314 females and 22 males), average age 62.3, between January and December 2006. All patients with sterile urine before examination underwent a complete urodynamic test. Concomitant diseases were: diabetes (7.7%), multiple sclerosis (3.5%), Parkinson's disease (1.2%), urinary retention treated by autocatheterism (1.2 %). Urinoculture was performed seven days after the urodynamic study. All patients were asymptomatic; 40/336 urinocultures were positive (E. coli 80%, Proteus M. 10%, other 10%). The prophylaxis does not eliminate but only reduces post-urodynamic infections; we believe that the cost-benefit ratio is unfavorable.

Is Prophyilaxis Necessary after Urodynamic Tests? Our Experience

Urodynamic studies should be performed only on patients with sterile urine. The use of prophylaxis after urodynamic investigation is debated (positive urinoculture in 9 to 15% of cases). The Units of Urodynamics at the Urological Clinic of the University of Genoa and of the Galliera Hospital of Genoa assessed the prevalence of bacteriuria on a sample of 336 patients (314 females and 22 males), average age 62.3, between January and December 2006.

All patients with sterile urine before examination underwent a complete urodynamic test. Concomitant diseases were: diabetes (7.7%), multiple sclerosis (3.5%), Parkinson's disease (1.2%), urinary retention treated by autocatheterism (1.2 %). Urinoculture was performed seven days after the urodynamic study. All patients were asymptomatic; 40/336 urinocultures were positive (E. coli 80%, Proteus M. 10%, other 10%). The prophylaxis does not eliminate but only reduces post-urodynamic infections; we believe that the cost-benefit ratio is unfavorable.

Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study

BACKGROUND

A number of elderly cancer patients do not receive standard surgery for solid tumors because they are considered unfit for treatment as a consequence of inaccurate estimation of the operative risk. To tailor treatment to onco-geriatric series, oncologists are now beginning to use a comprehensive geriatric assessment (CGA). This study investigates the value of an extended CGA in assessing the suitability of elderly patients for surgical intervention.

PATIENTS AND METHODS

Preoperative assessment of cancer in the elderly (PACE) incorporates validated instruments including the CGA, an assessment of fatigue and performance status and an anaesthesiologist's evaluation of operative risk. An international prospective study was conducted using 460 consecutively recruited elderly cancer patients who received PACE prior to elective surgery. Mortality, post-operative complications (morbidity) and length of hospital stay were recorded up to 30 days after surgery.

RESULTS

Poor health in relation to disability (assessed using the instrumental activities of daily living (IADL)), fatigue and performance status (PS) were associated with a 50% increase in the relative risk of post-operative complications. Multivariate analysis identified moderate/severe fatigue, a dependent IADL and an abnormal PS as the most important independent predictors of post-surgical complications. Disability assessed by activities of daily living (ADL), IADL and PS were associated with an extended hospital stay.

CONCLUSION

PACE represents a valuable tool in enhancing the decision process concerning the candidacy of elderly cancer patients for surgical intervention and can reduce inappropriate age-related inequity in access to surgical intervention. It is recommended that PACE be used routinely in surgical practice.

Phase I-II trial of weekly bicalutamide in men with high PSA and negative biopsy

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Background: Men with persistent PSA elevation after non-cancer findings are at high risk of prostate cancer (PC). Bicalutamide (Bic) is an androgen receptor antagonist, which, unlike finasteride, is not associated with testosterone (T) escape. Given its long half-life (6–8 days), allowing for a weekly administration with potentially reduced side effects, Bic may be a suitable chemopreventive agent. We assessed the activity and safety of a weekly low-dose Bic in a phase I-II study in subjects with PSA >4 ng/ml and no PC at initial biopsies (10- 12 cores). Methods: Eligible subjects were sequentially assigned to either Bic 50 mg/week (group A), or 100 mg/week (group B), or no treatment (group C) for 6 mos. The outcome measures were the 6 mos changes in tissue Ki67 (primary endpoint), topoisomerase-IIa, Bcl- 2, and COX-2 by IHC, morphology and circulating PSA, prostatic acid phosphatase (PAP) and hormones. Results: From May, 2004 to June, 2006, 107 subjects were screened and 80 were enrolled: 26 in group A, 28 in group B, and 26 in group C. High-grade (HG) PIN decreased from 32% to 23% in the treated group and increased from 24% to 34% in controls; proliferative inflammatory atrophia (PIA) decreased from 41% to 32% in the treated group and increased from 14% to 19% in the controls. Complete remission of HG-PIN was found in 10/14 treated subjects versus 1/5 controls. Cancer or HG-PIN were found in 11 control subjects (52%) versus 16 subjects (36%) in the treated arms at 6 mos. Ki67 expression was significantly higher in HG-PIN lesions than in normal tissue (12% vs. 3%, p<0.01), but it was not modulated by Bic. Bcl-2 expression in normal tissue was 0/1+ in most subjects, and increased in 36% of treated subjects versus 20% of controls. Total and free PSA, as well as PAP, decreased by >30% on Bic. T, LH, estradiol and SHBG increased on Bic by 50–60%. There was no dose-related modulation in any biomarker. Treatment was well tolerated, mild (G1) breast pain and gynecomastia being recorded in 40% of treated subjects. Conclusions: Weekly Bic is active and safe in subjects with high PSA and negative biopsy. It seems to be associated with HG- PIN remission, Bcl-2 overexpression and a favorable modulation of PSA. The dose of 50 mg/week should be selected for future chemoprevention trials.

No significant financial relationships to disclose.

Pre-operative assessment of cancer in the elderly (PACE): A comprehensive assessment of underlying characteristics of elderly cancer patients prior to elective surgery

BACKGROUND

Cancer is a disease that particularly affects the elderly and, although surgery is the first treatment choice, many elderly cancer patients do not receive standard surgery because they are considered unfit for treatment due to an inaccurate estimation of operative risk. Pre-operative Assessment of Cancer in the Elderly (PACE) was developed in order to address the need to provide detailed information about the functional reserve of the elderly cancer patient to aid individualised management.

METHODS

PACE incorporates a battery of validated instruments including the Comprehensive Geriatric Assessment (CGA), Brief Fatigue Inventory (BFI), Eastern Cooperative Oncology Group Performance Status (ECOG-PS), and American Society Anesthesiologists (ASA) grade. An international prospective study was conducted with 460 consecutive elderly cancer patients (216 breast, 146 GIT, 71 GUT, 27 other) receiving PACE prior to receiving elective surgery.

RESULTS

Three hundred and eighty four patients (83.4%) were observed to have at least one co-morbidity; the most common being hypertension (n=246, 53.5%). More than two thirds of the patients had good functional and mental status according to PACE. After adjusting for age, sex and type of cancer, six of the seven items of PACE were found to be significantly associated with co-morbidities (according to the Satariano's Index of Co-morbidities (SIC)). A multivariate analysis identified IADL, BFI and ASA to be the most important instruments in explaining SIC.

DISCUSSION

PACE has been effectively used to describe the functional capacity and health status in an international cohort of elderly cancer patients. The majority of PACE instruments have been found to be significantly associated with co-morbidities (SIC) and can distinguish between type and severity of cancer. PACE represents a useful tool in evaluating onco-geriatric fitness for surgery.

Can preoperative assessment of cancer in the elderly (PACE) predict 30-days postoperative outcomes?

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Background: Surgery is the treatment of choice for solid cancers. Frequent functional impairment/comorbidities in the elderly enhances the risk of treatment related complications. Inability to forecast short term outcomes after cancer surgery in elderly affects clinical practice, denying optimal treatment. No validated instrument is available to help make informed decision; a compilation of validated questionnaires (PACE) is established to preoperatively inform on the health condition of elderly cancer pts. This international multicentre study investigates how components of PACE preoperatively assessed are associated with postoperative outcomes. Methods: A prospective series of consenting elderly cancer pts (≥70 yrs) receiving elective surgery (moderate-major+) were recruited from 8 hospitals (UK, Netherlands, Italy, Japan, Belgium) (07/2003–12/2005) and assessed using PACE (Comorbidities, IADL, ADL, GDS, BFI, PS, MMS, ASA). 30day morbidity, hospital stay and mortality were recorded. Results: 448 pts [breast (48%), GI (30%), GU (16%), miscellaneous (6%)] were recruited and followed postoperatively. Observed morbidity was 36% (161 pts), mortality 4% (16 pts) and median hospital stay was 5 days (range 2 -10). All components of PACE but ASA were associated with morbidity (p<0.05) and hospital stay (p<0.05) on univariate analysis. Operative deaths were too few to look for associations. Forward stepwise logistic regression models (multivariate analysis) identified 3 components of PACE as best describing the occurrence of post-surgical morbidity: BFI (OR (upper quartile)= 2.4; 95% CI=1.2–4.9); PS (OR=1.9; 95% CI=1.1–3.4); IADL (OR=1.7; 95% CI=1.0–3.0). The same components were also selected into the model as best describing hospital stay beyond average: BFI (OR (upper quartile)=18.1; 95% CI=7.2–45.3), PS (OR=2.2; 95%=1.2–4.4) and IADL (OR=2.7; 95% CI=1.4–5.1). Of those pts exposed to all 3 factors entered into the regression models 61% experienced complications and >80% had a longer hospital stay. Conclusions: BFI, PS and IADL appear to be the most relevant prognosticators of short term surgical outcomes. A holistic appraisal of elderly pts undergoing surgery is warmly recommended when consenting the patient and during the decision making process.

No significant financial relationships to disclose.

[Recovery of urinary incontinence after retropubic radical prostatectomy. Results in 100 patients]

AIM OF THE STUDY

To shorten the time to recovery of full urinary continence after radical retropubic prostatectomy and to increase the postoperative continence rate.

MATERIALS AND METHODS

One hundred and five consecutive patients were submitted to radical retropubic prostatectomy for prostate cancer, with curative intent, focusing our attention on three steps of the operation. First, to achieve a complete control of bleeding from the dorsal vein complex and to perform a minimal touch dissection of the urethral stump; second, to perform a conservative dissection of the bladder neck, and, third, to implement a vascular type, watertight, vesico urethral anastomosis. Continence was assessed 24 hours after catheter removal and at monthly follow up visits until full recovery and graded as dry if no dropping was visible and the patient was able to interrupt the urinary stream during micturition; stress incontinence, if any dropping was observed during abdominal strain between micturitions; and wet, if uncontrollable dropping occurred, and the number of pads needed per day recorded.

RESULTS

At a median follow-up time of 18 months, range 6 to 30, a total of 87 of 100 evaluable patients (87%) resulted as dry; 10 patients (10%) resulted as having a variable degree of stress incontinence needing one to three pads per day, and 3 patients (3%) resulted as wet. In 41 of the 87 dry patients (47.1%) continence was achieved within the first day from catheter removal, and in a median time of 4 weeks, range 2 to 16 in the remaining 46 patients (52.9%).

CONCLUSIONS

The results of total continence rate of the present study seem to compare to the recent literature except for the time to full recovery which is shorter; it is difficult to identify the contribution of each single surgical step.

Reversal of clinical resistance to LHRH analogue in metastatic prostate cancer by the pineal hormone melatonin: efficacy of LHRH analogue plus melatonin in patients progressing on LHRH analogue alone

OBJECTIVE

Experimental and preliminary clinical studies have suggested that the pineal hormone melatonin (MLT) may stimulate hormone receptor expression on both normal and cancer cells. Moreover, MLT has appeared to inhibit the growth of some cancer cell lines, including prostate cancer, either by exerting a direct cytostatic action, or by decreasing the endogenous production of some tumor growth factors, such as prolactin (PRL) and insulin-like growth factor-1 (IGF-1). On this basis, a study was carried out to evaluate the clinical efficacy of a neuroendocrine combination consisting of the LHRH analogue triptorelin plus MLT in metastatic prostate cancer progressing on triptorelin alone.

MATERIAL AND METHODS

The study including 14 consecutive metastatic prostate cancer patients with poor clinical conditions (median age: 70.5 years; median PS: 50%), refractory or resistant to a previous therapy with the LHRH analogue triptorelin alone. Triptorelin was injected i.m. at 3.75 mg every 28 days, and MLT was given orally at 20 mg/day in the evening every day until progression, starting 7 days prior to triptorelin.

RESULTS AND CONCLUSIONS

A decrease in PSA serum levels greater than 50% was obtained in 8/14 (57%) patients. Moreover, PSA mean concentrations significantly decreased on therapy of triptorelin plus MLT. In addition, a normalization of platelet number was obtained in 3/5 patients with persistent thrombocytopenia prior to study. Mean serum levels of both PRL and IGF-1 significantly decreased on therapy. Finally, a survival longer than 1 year was achieved in 9/14 (64%) patients. This preliminary study would suggest that the concomitant administration of the pineal hormone MLT may overcome the clinical resistance to LHRH analogues and improve the clinical conditions in metastatic prostatic cancer patients.

Effects of cis-platinum and luteinizing hormone releasing hormone analogues on rat spermatogenesis. A morphologic and flow cytometric study

OBJECTIVE

To evaluate morphologically and flow cytometrically the effects of cis-platinum (cis-diaminedichloroplatinum [CDDP]) administered acutely and chronically with and without gonadotropin releasing hormone analogue (LRA) pretreatment on adult rats to verify the feasibility of protecting the spermatic epithelium before chemotherapy.

STUDY DESIGN

Six groups of adult Wistar rats were studied: 2 were treated with an LD50 dose of CDDP in single and 2 in multiple administrations, 1 of each was pretreated with LRA and 1 LRA control and one untreated group were also evaluated. Relative frequency of spermatogenic phases, qualitative alterations, Johnsen's score and percentage of cells in each DNA region were determined.

RESULTS

Acute CDDP treatment reduced spermatids, spermatozoa and haploid cells. Chronic CDDP treatment induced in some rats a reduction in tetraploid cells and in others an increase associated with morphologically abnormal spermatids and cells showing aberrant hypodiploid content in analogy to all chronic CDDP LRA-pretreated animals.

CONCLUSION

Single-dose CDDP reduces spermatids by killing rapidly cycling spermatogonia and inducing alterations in maturation; in repeated doses, more marked reductions in spermatogonia are seen, followed by a compensatory proliferation of residual stem cells with generation of cells with an aberrant DNA content. These alterations are not prevented by LRA treatment sufficient to determine inhibition of serum testosterone levels.

Immunotherapy of advanced renal cell carcinoma

Although many different treatments have been evaluated in the last thirty years, advanced renal cell carcinoma still has a poor prognosis, characterised by a survival rate which is less than 5% at 3 years from diagnosis. Many different therapeutic approaches have been carried out in addition to cytotoxic chemotherapy, which shows obvious limits such as an overall response rate that does not go above 10-15%. One of the more promising treatments that has been studied the most is undoubtedly immunotherapy. We present a literature review aimed at summing up all the results obtained until now with immunotherapy of renal cell carcinoma, whether alone or in combination with cytotoxic chemotherapy. Unanswered questions of major concern are stressed, such as treatment choice, dosage, the most convenient schedules with particular regard to the cost-benefit issue.

Antibiotic prophylaxis in prosthetic penile surgery: critical assessment of results in 75 consecutive patients

OBJECTIVE

Antibiotic prophylaxis in prosthetic surgery was administered prospectively according an original protocol. Routine pre-operative preparation included also scrupulous, repeated disinfection of the skin of the genital and perineal region.

METHODS

Vancomycin 500 mg i.v. every 6 h on the day of surgery and gentamicin 1 mg/kg i.v. every 8 h on the day of surgery and for the following 48 h were administered to 75 consecutive patients. Overall 87 prosthetic devices were implanted. The patients were evaluated at 6 weeks and at 6 months after surgery.

RESULTS

No infection was observed.

CONCLUSION

Support from this study to antibiotic prophylaxis in penile prosthetic surgery is uncertain. The importance of scrupulous routine pre-operative preparation is probably underestimated.

Salvage immunotherapy with subcutaneous recombinant interleukin 2 (rIL-2) and alpha-interferon (A-IFN) for stage D3 prostate carcinoma failing second-line hormonal treatment

Immunotherapy with subcutaneous rIL-2 and alpha IFN was administered to stage D3 prostate cancer patients after failure of secondary treatment with oral estramustine phosphate. Of a total of 15 patients, 2 are in partial response, with estramustine maintained after 44+ and 36+ weeks, respectively. Response to estramustine was observed initially in 7 of 13 patients, with a median duration of 12 weeks (range 8-20). No response to estramustine was observed in the remaining 6 patients. After the failure of estramustine, 13 patients were treated with immunotherapy. After the first cycle, progression of disease no therapy was given to those patients. A reduction of PSA levels was observed during the first cycle in 2 patients (15.3%); levels subsequently increased during the second cycle of treatment. A partial response was observed in 4 patients (30.7%), with a reduction of PSA levels in 3. The duration of response was 28 and 32 weeks in 2 patients who survived after failure for 18 and 21 weeks, respectively. Two patients are still alive, with continued partial response at 62+ and 42+ weeks. Side effects were represented mainly by a flu-like syndrome, associated with fever and nausea in all patients. The serum concentration of IL-10 was measured in 8 patients under study and in 11 matched controls. Levels higher than mean + 2D of controls before, during, or after immunotherapy were correlated with treatment failure, whereas levels below 6 ng/ml were encountered among the patients who showed a clinical response and a reduction of PSA during treatment. Within the limitations of this pilot study, it appears difficult to distinguish between a spontaneously slowly progressing disease and a true response to therapy.

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.

Renal angiomyolipoma with extrarenal involvement--in vascular, lymph-node and perirenal tissue. Reports of four cases

Extrarenal involvement was found in four cases of renal angiomyolipoma. In one case the wall of the inferior right bronchial artery was infiltrated, lymph nodes were involved in two cases and the perirenal fat in one case. Extrarenal extension does not seem to alter the prognosis of renal angiomyolipoma. Expectant treatment of this rare condition therefore appears to be warranted.

Short Schedule Intravesical Mitomycin Preceding Transurethral Resection for Recurrent Ta-T1, G1-G2 Bladder Cancer

Aims and Background

Intravesical instillations commonly follow resection, when all visible lesions have been removed, making impossible any direct assessment of efficacy. The study was conceived to evaluate the ablative effect on the tumor and the efficacy in reducing the risk of recurrence of short schedule intravesical chemotherapy administered before endoscopic resection.

Study design

Four weekly intravesical instillations of mitomycin C followed by transurethral resection (TUR) were administered to 31 patients with recurrent small volume superficial bladder cancer.

Results

At TUR no evidence of disease was found in 22 patients (70.9%) and residual disease in the remaining 9 (29.1%). At a median follow-up of 15 months (range, 3-33) 16 of 31 patients (51.6%) had recurrence of disease. The treatment was well tolerated.

Conclusions

Short-schedule intravesical chemotherapy can completely ablate small volume recurrent superficial bladder cancer in a relevant number of patients but is probably not sufficient to obtain long-term prophylaxis.

Video laparoscopic excision of a seminal vesicle cyst associated with ipsilateral renal agenesis

A 6 cm. cystic right seminal vesicle was successfully removed using operative laparoscopy. Advantages of the laparoscopic approach over open surgery include excellent exposure of the deep pelvic structures and rapid convalescence. Among the disadvantages are the potential complications associated with laparoscopic transperitoneal access.

Five-year results of neoadjuvant cisplatin, methotrexate and vinblastine chemotherapy plus radical cystectomy in locally advanced bladder cancer

Neoadjuvant systemic cisplatin, methotrexate and vinblastine chemotherapy has been used in the treatment of 69 patients with advanced bladder cancer (stages T2-T4 N+/N0 M0). Sixty patients were evaluable for response at a median follow-up of 48 months. Preoperative resection of the tumor was purposely avoided in order to keep a marker lesion. After planned radical cystectomy, pathological complete responses (pCRs) and partial responses (pPRs) were documented in 5 (8.3%) and 29 cases (43.4%), respectively. These patients had a 5-year disease-free survival rate of 80%, which was statistically superior (p = 0.0013) to 35% for the remaining nonresponding patients. One patient (20%) with a pCR died of systemic disease after 14 months, while the remaining 4 patients (80%) are alive and free of disease after a median follow-up of 57 months. A higher percentage of pCRs and pPRs was observed in the group of patients with stage T3b-T4 tumor (pCR 11%, pPR 63%) in contrast to the patients with stage T2-T3a disease (pCR 4.5%, pPR 45.5%), even if no significant difference in the 5-year survival rate was observed between the 2 groups. Patients with a G2 tumor before chemotherapy survived longer (5-year survival rate of 78%) than those with G3 disease (5-year survival rate of 61%), but no significant difference was achieved.

Benefits and complications of laparoscopic pelvic lymphadenectomy for detection of stage D1 prostate cancer: a multicenter experience

One hundred fifty-eight consecutive patients with clinically localized prostate cancer were submitted to staging laparoscopic pelvic lymphadenectomy (LPL) at 5 cooperative centers with one or more of the following conditions which were considered as risk factors for nodal disease: clinical stage C (or T3) disease, serum prostate-specific antigen > 20 ng/ml, Gleason sum > 6. The mean number of lymph nodes removed was 11 (range 2-29). Metastases from prostate cancer were found in 41 patients (25.9%). The proportion of lymph node-positive patients increases significantly with the presence of one, two or three of the conditions considered as risk factors (p < 0.00005). The benefit of LPL is limited to the lymph node-positive patients who can be spared a second operation.

[Extrarenal angiomyolipoma: vascular, lymphonodal, and perirenal localization. Report of 4 cases]

Angiomyolipomas are rare renal tumors considered benign even though evidences of occurrence of the disease in lymphnodes and vascular structures as well as in a variety of distant sites, such as the liver, the uterus, the nasal cavity and others, have occasionally been reported. We describe one case of late lesion of angiomyolipoma within the wall of the inferior bronchial artery, two cases of lymphnodes involvement and one case of angiomyolipoma extending into the perirenal fat.

[Immunotherapy with subcutaneous recombinant IL-2 and interferon combined with surgery in advanced stage carcinoma of the kidney]

Twelve consecutive patients with metastatic renal cell carcinoma were submitted to an integrate treatment plan of immunotherapy with subcutaneous IL-2 and IFN and radical surgery in a pilot study. Partial response were observed in 2 patients, stable disease in 5 patients and progression of disease under treatment were observed in 5. Two RP were maintained for 12 and 18+ months and 1 SD is maintained at 12+ months. Treatment was well tolerated without significant toxicity. Integrated radical surgery and immunotherapy with s.c. IL-2 and IFN can produce occasionally protracted clinical responses.

Laparoscopic pelvic lymphnodes dissection for prostate and bladder cancer: indication, techniques and results

Laparoscopic pelvic lymphadenectomy has been proposed for staging of prostate cancer and it might be used, in selected cases, also in bladder cancer. On a total of 31 laparoscopic lymphadenectomies (LPND), 18 for prostate cancer and 13 for bladder cancer, we found positive nodes in 8 cases (26.1%), 4 in prostate and 4 in bladder cancer group. We had no intraoperative complications and negligible postoperative complications (in 10% of cases shoulder-tip pain and in 24% subcutaneous emphysema); all these spontaneously disappeared after 24-36 hours. Patients with negative nodes underwent radical surgery except two prostate cancer patients who underwent radiotherapy, and patients with positive nodes underwent hormonal therapy (for prostate cancer) or chemoradiotherapy protocol (for bladder cancer). In conclusion, laparoscopic lymphadenectomy proved to be a feasible and safe method for staging urological malignancies, being less invasive, with shorter hospitalization and postoperative convalescence than open lymphadenectomy. It should be mainly indicated in high risk prostate cancer patients (elevated PSA and/or Gleason score). In bladder cancer patients, it could be proposed in bladder sparing investigational protocols, as the percentage of pelvic nodes metastases in T2/T3 bladder cancer is sufficiently high to justify an additional staging procedure.

[Treatment with rufloxacin of complicated urinary tract infections]

Eighteen patients of either sex (14 M; 4 F), ranging in age from 23 to 79 years, with clinical diagnosis of complicated cystitis due to Rufloxacin sensitive pathogens, were enrolled. Rufloxacin was administered orally at the dosage of 400 mg/die the first day; 200 mg/die the following 6 days or more. The mean duration of treatment was 7.25 +/- 0.78 days. No concomitant antimicrobial therapy was administered during the study. At the end of therapy 5/14 evaluable patients recovered, 9/14 evaluable patients improve; 4 patients were considered by Investigator as "not evaluable". Causative pathogens were isolated in all patients and eradicated in 18 out of 18 bacteriologically evaluable patients (eradication rate = 100%). Neither reinfections nor superinfections occurred. No clinical adverse event related to study medication was reported. The results indicate that Rufloxacin at the oral dose of 200 mg/die is well tolerated and effective in the treatment of complicated cystitis.

Systemic preoperative chemotherapy with cisplatin, methotrexate and vinblastine for locally advanced bladder cancer: local tumor response and early followup results

A total of 44 patients with infiltrating, locally advanced bladder cancer (stages T 3a-b, T 4a-b and N+/N0) were treated with the systemic chemotherapy regimen of cisplatin, methotrexate and vinblastine (CMV) in the neoadjuvant setting, of whom 39 were evaluable for response. After planned radical cystectomy and 2 to 3 cycles of chemotherapy no tumor was found on the pathological specimen of 4 patients (10%), the tumor was downstaged in 19 (49%) and no change was observed in 16 (41%). Toxicity included leukopenia in 29 patients (66%), 1 of whom died of granulocytopenic sepsis, nausea and vomiting in 39 (89%) and mild to moderate mucositis in 18 (41%). Median followup is 12 months with a range of 6 to 39 months. Of 32 patients followed for longer than 6 months 6 (19%) experienced progression or recurrence of disease. We conclude that preoperative CMV chemotherapy is effective in inducing downstaging of the tumor, although systemic toxicity limits its use to cautiously selected patients.

Long-Term Results with the Gn-Rh Analogue, Buserelin, in Metastatic Prostate Cancer

LH-RH analogues have come into use to suppress the synthesis of testosterone by the testes and to induce palliation in advanced prostate cancer. Twenty-one patients were treated with buserelin (Hoe 766), and 19 were evaluable. Stages of disease were D1-D2. Seventeen patients responded to treatment, 3 patients are still in partial response, and 16 underwent progression. The median time to progression was 12 months (range, 3–36), and the median follow-up time was 10 months (mean, 25.4; range, 5–48).

[Extracorporeal shockwave lithotripsy: treatment of choice in ureteral calculi]

Extracorporeal shock wave lithotripsy represents the therapy of choice for reno-ureteral stone disease being resolutive in more than 85% of cases. This procedure can be successfully applied to ureteral stones providing appropriate preoperative cystoscopic manipulations and a correct positioning of the patient on the stretcher of the lithotripter. We hereby report our experience in 119 patients with ureteral lithiasis submitted to extracorporeal shock wave lithotripsy with a 98% success rate.