[Clinical evaluation of intra-operative radiotherapy combined with subtotal cystectomy for invasive bladder carcinoma].

From 1981 to 1994, intra-operative radiotherapy after subtotal cystectomy was performed on 22 patients with invasive bladder carcinoma on whom radical cystectomy could not be recommended because of old age or condition. All the patients received 25 to 30 Gy of radiotherapy focused on trigonum and internal urethral orifice after subtotal cystectomy with uretero-cutaneostomy. Of 22 patients, 15 patients died. Five patients died of bladder cancer, one died of gastric cancer, one died of rectal cancer and the others died of pneumonia, heart failure, sepsis and senility. The five-year survival rate was 41% and the cause-specific five-year survival rate was 75%. Local recurrence was seen only in one patients, who received second intra-operative radiotherapy and recovered well in complete remission. We believe that intra-operative radiotherapy after subtotal cystectomy is useful for patients with invasive bladder carcinoma on whom radical cystectomy could not be recommended because of old age or condition.

[The clinical usefulness of urinary determinations of cytokeratin 19 fragment (CYFRA 21-1) in urothelial tumor].

The urinary CYFRA 21-1 value corrected for urinary creatinine (ng/ml/creatinine), was studied in the urine of patients with urothelial tumors. To examine its clinical significance we studied urinary CYFRA 21-1 excretion (ng/ml/creatinine), in a total of 22 urine samples from patients with bladder cancer, 7 from patients with renal pelvic and ureteral tumor, 6 from patients with urinary infection 6 from patients with urinary diversion called ileal conduit, and 8 from healthy adult men. The excretion of CYFRA 21-1 in urine was determined by two specific monoclonal antibodies (Ks 19.1 and BW 19.21). The mean value of urinary CYFRA 21-1 in healthy adult men was 1.96 +/- 1.33 (mean +/- SD) ng/ml/creatinine. Urinary CYFRA 21-1 showed a higher value in the urine of urinary infection and urinary diversion. As to bladder cancer, urinary CYFRA 21-1 showed a higher value in a larger volume of tumor than in a smaller volume of tumor in transitional cell carcinoma regardless of the grade and stage. These findings suggest that urinary CYFRA 21-1 may be a non-specific marker in urothelial tumors.

[Single-stomal ureterostomy by extraperitoneal approach].

Single-stomal ureterostomy such as double barreled ureterocutaneostomy and cutaneous transureteroureterostomy have usually been performed by transperitoneal approach. However, extraperitoneal method is preferable since the patients for whom ureterocutaneostomy is indicated usually have a deteriorating general condition. We have reported single-stomal ureterocutaneostomy which can be done extraperitoneally. A total of thirteen patients, one man and twelve women, for whom permanent urinary diversion was indicated, have undergone this extraperitoneal ureterocutaneostomy for February 1988 to June 1994. Those with retroperitoneal lesions or with a history of paraaortic radiotherapy were excluded. The mean age was 61.7 (range: 42-76). The reasons for urinary diversion were vesicovaginal fistula in seven, obstructive nephropathy in four, rectovesical fistula in one and postoperative urine leak from the bladder in one. All patients had been treated for malignant diseases and had undergone transperitoneal surgery. Six patients had colostomy and ten had clinically evident recurrent diseases. In the operation, left ureter was dissected and severed extraperitoneally through left paramedian incision or left lumbotomy. The ureteral end was pushed to the right in a retroperitoneal tunnel created by blunt dissection. Then the ureter was picked up through the contralateral retroperitoneal approach. After both ureters were exposed, ureterocutaneostomy was made in right hypogastrium. Transureteroureterstomy with end-cutaneous ureterostomy, double barreled ureterocutaneostomy and ureteroureterostomy with loop ureterostomy were done in six, four and three patients, respectively. The mean operative time was 119 (range: 75-175) minutes and the mean intraoperative blood loss was 210 (range: 48-682) grams. Arrhythmia developed during retroperitoneal manipulation in one patient for whom the operation was done under spinal anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

Retroperitoneal malignant mesenchymoma: a case report.

A case of a 37-year-old woman with a retroperitoneal tumor is reported. Angiography revealed that the tumor was partially supplied via an intercostal artery, suggesting that the cause of the tumor might be located in the rib. Histologically the tumor was diagnosed as a malignant mesenchymoma composed of chondrosarcoma and myxoid liposarcoma in addition to fibrosarcoma. The chondrosarcomatous element was predominant, a phenomenon which is extremely rare. Pulmonary metastases developed 8 mo after surgical removal of the tumor and the patient died of the disease 2 yr postoperatively.

Acute pulmonary embolism after conservative surgery for renal cyst: a case report.

A case of acute pulmonary embolism which developed one week after conservative surgery of the renal cyst is reported. He was 41 years old and had a long habit of cigarette smoking. He underwent wedge resection of the renal mass which was proved to be a multilocular renal cyst pathologically. The acute pulmonary embolism which developed on the seventh postoperative day was confirmed by lung scintigraphy. The patient recovered from the disease by thrombolytic therapy. Postoperative bed rest seemed to be closely associated with the incidence in this case. Early ambulation is recommended. In addition, the thromboprophylactic therapy may be justified in patients undergoing kidney-sparing surgery which requires postoperative bed rest.

The aggressive treatment of choriocarcinoma of the testis associated with lung bone, and brain metastases.

A case of metastatic choriocarcinoma of the testis involving the retroperitoneum, lung, bone, and brain was successfully treated by surgery, chemotherapy and radiotherapy.

[Effect of lentinan for advanced prostate carcinoma].

A prospective, randomized multi-center study was conducted to assess the clinical effectiveness of Lentinan, an immunomodulatory agent, in the metastatic prostate cancer. Of seventy-five patients enrolled from July 1987 to June 1992, 69 were eligible. All patients received hormonal therapy and chemotherapy using Tegafur p.o. at a dose of 400-800 mg/day. While 33 patients received Lentinan i.m. for at least three months, the other 36 did not. The dose of Lentinan was 2 mg weekly for inpatients and 4 mg every other week for outpatients. The mean age of treated and control patients was 70 (range; 53-83) and 71 (range; 50-86), respectively. The 50% survival length of treated and control patients was 48 and 35 months, respectively. The five-year survival rate of treated patients was 43% according to the Kaplan-Meier method, while that of control patients was 29% (p < 0.05). We conclude that Lentinan is effective in metastatic prostate cancer when incorporated into hormonochemotherapy.

Extragonadal germ cell tumor of retroperitoneal origin: report of two cases.

Two cases of primary extragonadal germ cell tumor of retroperitoneal origin are reported. One was a 26-year-old man complaining of back pain. He had a large retroperitoneal tumor with lung, liver and supraclavicular lymph node metastases. He was referred to us after being treated for malignant lymphoma. The serum AFP, beta-subunit of human chorionic gonadotropin (hCG-beta), CEA and CA-19-9 were elevated. The retroperitoneal disease was treated surgically and with radiotherapy. The pathological diagnosis was that of embryonal carcinoma and teratoma. The lung, liver and supraclavicular lymph node metastases disappeared completely after two courses of cisplatin-based chemotherapy. While further chemotherapy was postponed due to myelosuppression, the disease relapsed and was resistant to subsequent therapy. The patient died twelve months after he first saw us. The second case was that of a 36-year-old man complaining of edematous legs and external genitalia. He had an extensive retroperitoneal tumor with multiple pulmonary metastases. The serum AFP level was high. Suspected of having an extragonadal germ cell tumor, he was referred to us promptly. Cisplatin-based chemotherapy coupled with resection of residual retroperitoneal and pulmonary disease resulted in complete remission. The pathological diagnosis was that of possible embryonal carcinoma. Further chemotherapy was given as scheduled, using granulocyte colony-stimulating factor. The patient has been in complete remission for two years. The chemotherapeutic regimen and surgical policy in the treatment of the two patients were essentially same. Early diagnosis, adequate initial therapy and the use of granulocyte colony-stimulating factor may be relevant to the favorable prognosis in the latter case.

Feasibility and pharmacokinetics of continuous subcutaneous infusion of low-dose interferon-gamma: a pilot study.

Continuous subcutaneous infusion of interferon-gamma was carried out in an attempt to improve the therapeutic efficacy of the agent, one of the most potent immunomodulatory cytokines. Seven patients with renal cell carcinoma underwent the therapy using battery-powered micro-infusion pumps. In four patients, recombinant human interferon-gamma, 15 x 10(6) JRU (Japan Reference Unit)/body, was administered subcutaneously and continuously for five days. The therapy was repeated without interruption up to three times in four patients, including one for whom a single course of five-day therapy had been given three months previously. The major side effects were fever, anorexia, general malaise and local skin reaction. Discontinuation of the therapy was necessary in two patients, one in single five-day therapy and the other in repeated therapy, due to generalized skin eruption and general malaise, respectively. Serum interferon-gamma levels, as determined by radioimmunoassay, increased gradually and reached 20-30 IU/ml on day 4 or 5. Among patients who received two or three courses of therapy, the interferon-gamma levels showed high inter-individual differences after day 6. The levels gradually fell after the therapy terminated with a half-life of about 2 days. No clinical response was observed. Our data suggest that interferon-gamma can be administered by continuous subcutaneous infusion, and warrants further study.

[Intraoperative radiotherapy for local recurrence of intrapelvic malignancies].

From 1986 to 1992, seventeen patients with recurrent intrapelvic malignancies have been treated with intraoperative radiotherapy (IOR) in Saitama Cancer Center. They were 8 males and 9 females. The age ranged 44 to 83 (mean:61.6). The primary organs involved were rectum in 7, urinary bladder in 5, uterine cervix in 3 and ovary in 2. Invasion of recurrent disease into bony pelvis was noted in all but one patient. A total of 27 IORs were done on 18 occasions for 17 patients. The mean radiation dose was 25.6 Gy (range: 12-30). The cones used were 4 to 7 (mean: 5.4) cm in diameter. Debulking surgery was performed in 13 patients just before IOR. Chemotherapy and/or external radiotherapy were done in addition to IOR in most of the cases. As of May 1992, 14 patients had died with a mean survival time of 10 months (range:0.5-29.8). IOR seems to be useful in controlling the intrapelvic recurrent disease and may warrant further investigation.

[Clinical efficacy of tosufloxacin on the patients with urinary tract infections].

We evaluated a newly developed quinolone agent, tosurofloxacin (TFLX), for its safety and clinical efficacy on patients with urinary tract infections (UTI). Among 138 cases satisfying the UTI criteria, 75 cases were acute simple UTI and 63 cases were chronic complicated UTI. In principle, a daily dose of 450 mg of TFLX was administered for 3 days and for 5 days for acute simple UTI and for chronic complicated UTI, respectively. Clinical efficacy of TFLX in these cases was evaluated according to the criteria of Japanese UTI committee. Bacteriologically, all 80 strains isolated from acute simple UTI were eradicated following TFLX administration. However, 2 gram positive strains and 1 gram negative strain, appeared following the treatment. In cases of chronic complicated UTI, 29 out of 32 gram positive strains and 29 out of 44 gram negative strains were eradicated. Among the isolated strains, P. aeruginosa and S. marcescens persisted, which suggests that they were less sensitive to TFLX. Overall clinical effectiveness rate of TFLX on acute simple UTI was 100%, while that on chronic complicated UTI was 73%. Adverse drug side effects were minimum, stomach discomfort and constipation was observed in one case each. These findings indicate that TFLX is a useful agent for the treatment of both simple and complicated UTI.

[Effect of tegafur administration combined with hormonal therapy in patients with newly diagnosed stage D prostatic cancer].

To study the effect of tegafur administration combined with hormonal therapy on the survival rate of newly diagnosed patients with stage D prostatic cancer, 66 patients, 70.9 years old in mean age, were treated from 1979 to 1986. The cancer was proven by the histological or cytological examination of the specimen which was obtained by the needle biopsy and/or aspiration biopsy of the prostate. The histopathological diagnosis of 59 patients was as follows: well differentiated type of adenocarcinoma was observed in 13 patients, moderately differentiated type in 19 cases, poorly differentiated type in 24 cases and mixed type in 3 cases. Daily 600 mg tegafur was administered orally as long as possible from the beginning of the treatment combined with hormonal therapy. Actual and relative 5 year survival rates calculated with Kaplan-Meier's method were 31.2% and 39.2%, respectively. When deaths other than prostatic cancer death were counted as lost cases, the actual survival rate was 47.5%. The present study also demonstrated that there were some factors affecting the patients' prognosis. They were the age of onset of the disease (patients under 64 years old were worse than those over 65 years old; p less than 0.05), performance status (patients with PS from 0 to 2 at the first admission were better than those with PS 3 to 4; p less than 0.025), differentiation of the tumor (well differentiated type was better than moderately; p less than 0.025 or poorly differentiated type; p less than 0.005).

[Multiple malignant schwannoma treated with a multidisciplinary therapy--a case report].

A 32-year-old man, complaining of an abdominal mass, was admitted to hospital where, on undergoing examination, the mass, which had spread widely through the abdominal cavity and the retroperitoneal space, was diagnosed as a malignant schwannoma with a liver metastasis. Thus, a multidisciplinary treatment was initiated and a remission was achieved. Later, however, he developed a multiple, local recurrence and died forty months after onset of his clinical symptoms. Since the prognosis of patients with a malignant schwannoma that do not undergo radical surgery is extremely poor, the authors emphasize the necessity of research for an effective adjuvant therapy.

[70% glucose solution: clinical usefulness for postoperative management of anuric patients].

Hemodialysis is necessary for postoperative management of the patients with bilateral renal tumor or chronic renal failure, but taking into account the heavy burden imposed upon the patients, use of postoperative hemodialysis should be kept to the minimum. As one bottle (300 ml) of 70% glucose solution contains 840 cal, two bottles per day (its volume is nearly equal to intensive perspiration) is enough in calorific value. This 70% glucose solution was found useful for the management of patients with acute renal failure. Because the postoperative state of anuric patients is similar to the state of acute renal failure, this time we studied the clinical usefulness of a 70% glucose solution for the postoperative management of these patients. We administered 600 ml of a 70% glucose solution to three postoperative patients, who were operated on for bilateral renal tumor, bilateral renal pelvic tumor, and renal tumor with lung metastasis and who had been on chronic hemodialysis. The rate of blood urea nitrogen increase was very low, and hyperkalemia was not seen. We concluded that a 70% glucose solution was useful to delay the start of hemodialysis and to lessen its frequency, which suggests that it is useful to improve the postoperative course of anuric patients.

[Translumbar radical nephrectomy of renal cell carcinoma].

We invented a new surgical approach to the kidney through the flank to perform a radical nephrectomy for renal cell carcinoma. With the patient in usual lateral decubitus position keeping the dorsum vertical to the operating table, a skin incision is made over the XII rib from the posterior axillary line to the lateral edge of the rectus muscle. After the tip of XII rib is resected by about 5 cm, the retroperitoneal space is entered. Blunt dissection of the posterior aspect of Gerota's fascia from fasciae of the quadratus lumborum and psoas muscle is easily carried out with a liver retractor or intestinal spatula. The pulsating renal artery can be identified through Gerota's fascia when the renal hilus is exposed. Following ligation and division of the artery, renal vein is exposed. On the left side, adrenal, gonadal and occasionally lumbar veins are also ligated and severed in addition to the renal vein. Then, the kidney in Gerota's fascia is removed en bloc with perinephric adipose tissue and adrenal gland. Of 21 patients with renal cell carcinoma seen during 1 year and 3 months from June 1987, 11 underwent this operation, and other 10 patients transperitoneal radical nephrectomy because of the possible tumor extension into the renal vein, inferior vena cava or adjacent organ, the severe spinal deformity or metastases and the necessity of additional surgical procedures for concomitant benign intraperitoneal diseases. The blood loss was smaller and operating time was shorter significantly in the translumbar group than the evaluable transperitoneal group. None of those in the translumbar group received blood transfusion. As complications, pneumothorax due to pleural injury during operation and postoperative incisional hernia occurred each in one patient, but no other serious one was found. From the above results, this approach seems to be one of choices for the surgical treatment of renal cell carcinoma, as long as the tumor is not likely to extend to adjacent organs, ipsilateral nodes or the inferior vena cava.

Prophylactic effects of perioperatively administered neocarzinostatin in renal cell carcinoma.

Eighteen patients with stages I to III renal cell carcinoma were treated with Neocarzinostatin before, during and after nephrectomy. The mean cumulative dose of Neocarzinostatin was 18.0 mg. With a minimum follow-up period of 57 months (4.8 years), two of 18 patients developed metastasis and both were dead. Of 17 control patients who were observed for 72 months (6.0 years) or more, ten had recurrent disease and eight of them were dead. The 5-year survival rates were 94% for patients who received Neocarzinostatin and 62% for control patients. There was a statistical difference in survival between these two groups. Neocarzinostatin seems to be effective in the prevention of postoperative recurrence of renal cell carcinoma.

[Neocarzinostatin therapy of advanced renal cell carcinoma].

Fifteen patients with advanced renal cell carcinoma underwent chemotherapy of neocarzinostatin (NCS). First, 6-8 mg of NCS was infused into renal artery at angiography; second, 6-8 mg was infused by the same route just before ligation of renal artery at nephrectomy, if possible; and third, 2 mg was given intravenously at 2-week intervals, about 10 times. One patient who suffered from metastatic renal cancer on rs. tibia was treated by femoral arterial injection of 2 mg NCS 5 times. By treatment of NCS for advanced renal cell carcinoma 2 out of fifteen patients achieved complete regression, one patient showed partial regression and four a minor response. Effective rate (CR + PR) of NCS for metastatic renal cancer was 20%, and the response rate (CR + PR + MR) was 47%. We consider that NCS is presently the most effective drug for renal cell carcinoma.

[Intraoperative radiotherapy (IORT) in prostatic cancer].

Between February 1982 and February 1986, 30 patients with prostatic cancer received intraoperative radiotherapy (IORT). First 10 cases were treated by the transperineal approach, and after April 1983, 20 cases were done by the retropubic approach. We chose the retropubic approach, because it has advantages over the transperineal approach, which has a risk of rectal damage, lymph-adenectomy can not be performed and the patient can not sit down for a long time after the operation. In the IORT procedure for prostatic cancer by the retropubic approach, a longitudinal lower abdominal incision is made, and pushing down the bladder, the treatment cone is inserted to the prostate. We performed lymph-adenectomy at the same operation, if hard and large lymph-nodes were touched. Of 30 patients, 2 had stage B disease, 10 had stage C and 18 had stage D disease. The overall 5-year survival rate (Kaplan-Meier method) after IORT was 42.6% where as that the 31 cases seen (stage C: 6 cases, stage D: 25 cases) since the Center was founded (October 1975) until the introduction of IORT was 3.2%. Although no definite conclusion can be drawn because all cases received multidisciplinary therapy, IORT appears useful for the treatment of carcinoma of the prostate.

[Treatment of complicated urinary tract infections by ofloxacin].

To study the treatment effects of ofloxacin (OFLX) on the patients with complicated urinary tract infections (UTI), OFLX at a daily dose of 600 mg divided into either two or three doses per day, was administered for 14 days to 114 patients with complicated UTI. Among the 114 patients, 67 patients satisfied the criteria for clinical evaluation of complicated UTI. One hundred and one organisms were isolated from these patients' urine. Among them, 82 organisms were eliminated following OFLX administration. Twenty organisms appeared newly by the replacement of organisms. Among them, 6 organisms belonged to Candida sp. As to the overall efficacy of OFLX, an excellent response was seen in 37.3% and sum of efficacy rate was 65.7%. Side effects were observed in 3 of the 114 patients. These results indicate that OFLX is both safe and effective enough to be used for the treatment of the patients associated with complicated UTI.