Preliminary results in invasive bladder cancer with transurethral resection, neoadjuvant chemotherapy and combined pelvic irradiation plus cisplatin chemotherapy.

Preliminary data are presented of a clinically feasible pilot study to select a significant subgroup of patients among those with muscle-invading bladder tumors for local cure and bladder preservation, while also to offer all patients the possibility of preventing the development of distant metastases. Transurethral debulking surgical resection was combined with neoadjuvant methotrexate, cisplatin and vinblastine chemotherapy plus 2 additional courses of cisplatin and 4,000 cGy. If tumor was found on cystoscopic re-evaluation by biopsy and for cytology after cisplatin and partial irradiation (4,000 cGy.) immediate cystectomy was advised. If tumor was not found consolidation by a radiotherapy boost to a total of 6,480 cGy. plus 1 additional course of cisplatin was given. Of 53 consecutive patients the planned treatment was completed in 42 (79%). With a median followup of 26 months (range 15 to 42 months), 72% of all entered patients were alive, 70% have not required cystectomy and 74% have not had distant metastases. Among the 42 patients who completed the planned protocol chemotherapy dose reductions were required in 39% for stomatitis, bone marrow depression and/or renal dysfunction. There were 2 serious complications but no treatment-related sepsis, deaths or significant renal dysfunction. Eight patients underwent immediate radical cystectomy because of positive biopsy and/or cytology results after 4,000 cGy., while 34 completed full chemotherapy and radiotherapy without any significant bladder or bowel injury. Of 42 patients 22 (52%) have maintained the bladder without any recurrence, and of those selected for full chemotherapy and radiotherapy this number increased to 65%. To date 12 patients have persistent or recurrent bladder tumors: 5 (15%) had invasive tumors treated by cystectomy and 7 (21%) had carcinoma in situ treated by intravesical therapy. The true success of this or other selective bladder-preserving treatments will require 3 to 5 years of followup to be confident that such treatment has sterilized the bladder of cancer. This feasibility study has been clinically practical, modestly well tolerated and encouraging for the significant proportion of patients with a sustained complete response and for the 70% over-all survival rate at 2 years. To evaluate critically the efficacy of methotrexate, cisplatin and vinblastine chemotherapy in the prevention of occult distant micrometastases and in increasing the rate of successful bladder preservation, in May 1988 we began a randomized phase 3 trial with and without neoadjuvant methotrexate, cisplatin and vinblastine chemotherapy.

Radiation therapy for localized prostate carcinoma: experience at the Massachusetts General Hospital (1973-1981).

The success following irradiation in 370 patients with clinically localized prostate carcinoma was measured by overall patient survival as well as the cumulative incidence with time of treated patients who developed either local tumor regrowth or progression with distant metastases. With a minimum follow-up of 5 years in living patients, we evaluated the cumulative frequency curves using both univariate and multivariate (Cox) analyses. Overall patient survival and probability of progression with distant metastases were significantly influenced by initial tumor stage and the degree of histologic differentiation. The results at 8 years are significantly better for patients with T2 (B) tumors (local regrowth in 8%, distant metastases in 18%) than for patients with T3-T4 (C) tumors (local regrowth in 28%, distant metastases in 60%). Patient tolerance of external-beam radiation therapy was carefully analyzed in 121 consecutively treated patients in 1980 and 1981 for subsequent radiation-related sequelae. Minor transient intestinal and urologic sequelae were observed in 21% and 23% of the patients, respectively. These mild to moderate symptoms resolved in all but 7% of the patients who are continuing with mild symptoms. One patient had a major complication, i.e., a cystectomy required for persistent bleeding. Erectile potency has been maintained in 63% of potent patients. No specific benefit or detriment in outcome was seen in the minority of 51 patients who were irradiated by iodine-125 implantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Mucinous adenocarcinoma of bladder. Case associated with extensive intestinal metaplasia of urothelium in patient with nonfunctioning bladder for twelve years.

A mucin-secreting adenocarcinoma of the bladder arose in a fifty-one-year-old man twelve years after he had an ileal conduit and urinary diversion for a neurogenic bladder which was due to a myelomeningocele. The patient presented with a mucinous penile discharge, and cystoscopy showed several papillary tumors with mucoid material coating the intervening mucosa. Examination of the resected bladder showed almost total intestinal metaplasia of the urothelium with numerous foci of dysplasia, adenocarcinoma in situ, papillary and invasive adenocarcinoma. The clinical and pathologic features of this case and the risk of carcinoma developing in a nonfunctioning bladder are discussed.

Villous adenoma of the urinary bladder: a morphologic or biologic entity?

Villous adenomas in the urinary bladder are rare neoplasms whose malignant potential is unclear. A case of a morphologically benign non-invasive mucin producing papillary neoplasm of the urinary bladder associated with cystitis glandularis is presented. Absence of A tissue isoantigen from the neoplastic and metaplastic cells and the presence of H tissue isoantigen in both neoplastic and metaplastic cells is observed in a patient whose blood type is A, indicating incomplete maturation of surface coat constituents. The histologically benign appearance of this lesion may belie a malignant potential.

Protons or megavoltage X-rays as boost therapy for patients irradiated for localized prostatic carcinoma. An early phase I/II comparison.

A total of 180 patients with carcinoma of the prostate limited to the pelvis were treated with one of two external beam irradiation techniques between 1972 and 1979. One hundred and sixteen patients were treated with conventional pelvic megavoltage x-ray therapy. Sixty-four patients were treated with combined pelvic x-ray therapy plus a perineal proton beam boost to a carefully defined prostatic tumor volume. A 160 MeV proton beam has been modified to irradiate patients with localized tumors by using conventional treatment schedules. This proton beam has the physical advantage over megavoltage x-rays of reducing the dose to normal tissues adjacent to the tumor volume. By using the proton beam boost we have delivered an increased prostatic tumor dose of 500 to 700 cGy without increasing treatment morbidity at all. The two groups are actuarially analyzed for patient survival, disease-free survival and local recurrence-free survival, and thus far, no significant differences have been noted. Because of the minimal complications observed in the proton group despite a 10% increase in dose, a randomized clinical trial comparing these two treatment techniques is studied.

Obstructive uropathy--a potentially serious complication of reconstructive vascular surgery.

We treated successfully 3 patients with upper urinary tract obstruction after an aortoiliac reconstructive vascular operation: 2 with ureterolysis and 1 with transureteroureterostomy. A review of the literature reveals that the incidence of this complication of reconstructive vascular surgery is unknown. Obstruction occurred whether the ureter was anterior or posterior to the graft, and usually presented within 1 year postoperatively in 62 per cent of the patients and was silent in 13 per cent. The obstruction was caused by retroperitoneal fibrosis in 90 per cent of the patients, direct surgical injury in 5 per cent and pseudoaneurysm formation in 5 per cent. Prior pelvic irradiation, and extensive and/or repeat vascular surgical procedures may have been contributory. Ureterolysis, the most common form of treatment, resulted in improvement in 85 per cent of the upper tracts, while renal loss occurred in 10 per cent. The ureter should be placed anterior to the graft during aortoiliac graft procedures. A prospective study is needed to ascertain the true incidence of this complication after reconstructive vascular surgery.

Prognostic factors in carcinoma of the ureter.

The records and pathological slides of 60 patients with ureteral cancer were reviewed with particular attention being paid to the tumor-adjacent mucosa. Mucosal abnormalities increased as grade and stage increased but their presence did not correlate with survival nor with the presence of urothelial tumors elsewhere, that is previous, concomitant and subsequent tumors. Patients with papillary and solid tumors survived equally well. Survival among patients with stage B tumors was better than that reported previously (82 per cent survived 5 years).

Ileal conduit undiversion: experience with tunneled vesical implantation of tapered conduit.

Reconstruction of the urinary tract after ileal conduit diversion was done in 9 patients by antirefluxing vesical implantation of the tapered conduit. Of the patients 5 required prior operative rehabilitation of the lower tracts, while 4 had urodynamically normal lower tracts. Reoperation for post-undiversion reflux was necessary in 2 patients; reimplantation was satisfactory in 1 but ileocecocystoplasty was required in the other. Followup showed a stable or improved upper tracts and renal function in the remaining patients.

Successful management of ileal conduit-enteric fistula: the case against loopograms.

The second reported case of ileal conduit-enteric fistula successfully managed with long-tube decompression and intravenous hyperalimentation is presented. Loopograms are not indicated unless excretory urography is contraindicated or intraperitoneal leakage is suspected.

Sipple's syndrome. A urologist's viewpoint.

A case of Sipple's syndrome, a triad of medullary carcinoma of the thyroid, pheochromocytoma, and parathyroid hyperplasia is presented. The cause, laboratory diagnosis, and operative management of the syndrome are discussed. The need for thorough endocrine screening of patients with pheochromocytoma and family screening of patients with the full syndrome is stressed.