Metastatic renal cell cancer: interleukin-2 toxicity induced by contrast agent injection.

We describe a clinical syndrome occurring after contrast medium injection in patients who previously received recombinant interleukin-2 (rIL-2) and recombinant interferon-alpha 2A treatment for metastatic renal cancer. The clinical picture mimics many aspects of rIL-2-related systemic side effects. The patients were managed conservatively but the potential for severe manifestations can occur, requiring more intensive treatment.

Renal cell carcinoma: basic biology and current approaches to therapy.

Renal cell carcinoma (RCC) represents an unusual solid tumor for which no treatment other than surgical therapy has been effective. The remarkable heterogenous behavior of this tumor and the documented rare spontaneous regressions suggest an unusual sensitivity to host immunologic control. In recent years, exciting developments in molecular genetics, growth factors, modulators of invasion of metastases, and cytokine-lymphocyte interactions have produced new hypotheses and a wealth of information regarding the origin, behavior, and control of RCC. Interest in the immunotherapy of metastatic RCC has recently increased with the demonstrated reproducible tumor responses obtained with recombinant human interferon-alpha or interleukin-2. Durable clinical remissions in some patients with advanced RCC can now be achieved by using cytokine therapy alone or in combination with activated killer cells. This article reviews the current understanding of the basic biology of RCC, surgical approaches to localized RCC, and biologic therapy for advanced disease.

The role of interferon and interleukin-2 in the immunotherapeutic approach to renal cell carcinoma.

Approximately 24,000 cases of renal cell carcinoma are expected in the United States in 1990. Although approximately 50% of patients with local disease are cured by surgery, in patients with metastatic disease the median survival is only approximately 10 months. Neither chemotherapy nor radiation therapy has been shown to be effective against metastatic renal cell carcinoma. Immunotherapy has come to the forefront of clinical research for the treatment of metastatic renal cell carcinoma. In the past decade, the development of recombinant DNA techniques has enabled the production of large quantities of biologic response modifiers such as the interferons and interleukins. Following initial reports in 1983 by the University of California-Los Angeles (UCLA) group and the investigators at M. D. Anderson Hospital, in Houston, TX, numerous trials have demonstrated a reproducible objective response rate to interferon of 15% to 20%. These responses are independent of the interferon preparation used, and optimal dosage/schedule has not been determined. In general, responses have been correlated with the following patient factors: previous nephrectomy, good performance status, a long disease-free interval, and lung-predominant disease. Median response durations of from 8 to 10 months can be expected. The addition of vinblastine, gamma-interferon, or aspirin has not improved the therapeutic index. Interleukin-2 therapy has produced encouraging results in 10% to 15% of patients. Although high-dose therapy is associated with substantive side effects, a small cohort of patients have been in continuous remission for extended periods of time, raising the possibility of "true" complete remissions of clinical significance. Recent trials, including our trials at UCLA, have combined the interleukins and interferons in this patient population. This combination has a sound scientific basis and the results are encouraging, especially when the toxicity profile is considered. Most patients receive these combinations as outpatients and have not required hospitalization nor suffered the toxicities of the high-dosage regimens. Complete pathologic remissions have been observed using this lower dosage, outpatient schedule. Clinical trials suggest that interferon and interleukin-2 may have an expanding role in metastatic kidney cancer both as single agents and in combination outpatient biologic therapy. The future clinical trials of kidney cancer will continue to incorporate these biologic response modifiers into the therapeutic strategies of the 1990s.

Ischemia of neobladder. Clinical manifestations and management.

Substitution enterocystoplasty is becoming more common in a selected group of patients. Acute or chronic ischemia is an exceptional event. We describe the clinical manifestations and management of chronic ischemia of a neobladder that occurred weeks after a successful initial operation. The possible mechanisms responsible for this complication are reviewed.

Laparoscopic nephrolithotomy: the value of intracorporeal sonography and color Doppler.

Laparoscopic nephrolithotomy was used as an alternative to open surgery in a patient who had failed extracorporeal shock-wave lithotripsy and whose anteriorly located stone-bearing calix precluded percutaneous extraction. Endocavitary ultrasonography and color Doppler render the procedure safe and effective; localization of the stone, selection of an optimal nephrotomy site away from large vessels and where cortical thickness is minimal, and control of fragment clearance are greatly facilitated.

Undetectable prostate-specific antigen in aging men.

Undetectable prostate-specific antigen was found in three aging men despite the absence of any prostatic surgery or exogenous hormonal deprivation. Clinical and elementary hormonal workup revealed the presence of secondary hypogonadism. This finding confirms the hormonal dependency of this prostatic marker and may, in some cases, explain the discrepancy between prostatic volume and the value of serum prostate-specific antigen.

Controversies in ilioinguinal lymphadenectomy for cancer of the penis.

One of the most important aspects in oncology is the definition of clinically relevant subgroups of patients whose disease wil have different behavior to enable decision making about therapeutic methods. The appropriate management of regional adenopathy in patients with penile cancer has generated a number of controversies. Generally, clinical determination of the extent of local disease is difficult. About 50% of patients with node enlargement have no tumor on histologic examination, and 20% of patients with clinically negative nodes have micrometastases. Lymph node biopsies, including sentinel node biopsy, are of limited staging value. Patients with lesions that do not invade the corpora and who have no palpable nodes should be followed carefully at 2- to 3-month intervals after excision of the primary tumor. Those with persistent adenopathy should undergo superficial lymph node dissection first, and if positive nodes are found, bilateral deep node dissection should be performed. Bilateral inguinal and pelvic lymphadenectomy is recommended for patients with lesions invading the corpora with clinically negative or positive nodes because of the high incidence of lymph node metastases in such cases (Table 1). When adenopathy persists after excision of the primary tumor, we advocate first a limited pelvic dissection. If the pelvic nodes are negative or not extensively involved, bilateral groin dissection should be performed, preferably in two stages. Percutaneous fine-needle aspiration of palpable or nonpalpable nodes can be helpful in preoperative staging in patients with penile cancer. Potential areas of study include identification of better risk factors and improvement of preoperative staging methods. This goal is hampered by the fact that penile cancer is a rare finding.(ABSTRACT TRUNCATED AT 250 WORDS)

[Motor evoked potentials of the perineal floor. Preliminary results]. / Les potentiels évoqués moteurs du plancher périnéal. Résultats préliminaires.

Neuromotor pathways from the brain to the pelvic floor have been poorly documented. The recent development of Motor Evoked Potentials may well fill this gap in our basic knowledge. Our technique consists of transcutaneous stimulation of the motor cortex and sacral roots with a magnetic device while recording the evoked response from the bulbocavernosus muscle and anal sphincter. Cortical stimulation is performed first at rest and then during voluntary contraction of the examined muscles ("facilitation" procedure). Sacral root stimulation is performed at rest. Stimulation at 2 different levels allows measurement of the total transit time (brain to muscle transit time) and the peripheral transit time (sacral roots to muscle). By subtracting the latter from the former, the central transit time (brain to sacral roots) is obtained. The technique is painless, and to our knowledge no side effects have been reported. The authors present the preliminary results of this new technique.

[Reversal of urinary diversion after radical surgery for rhabdomyosarcoma of the bladder]. / Dé-dérivation urinaire après chirurgie radicale pour rhabdomyosarcome de la vessie.

The authors report a case of reversal of urinary diversion in a 14 year old boy who had presented, three years previously with an embryonal rhabdomyosarcoma of the base of the bladder. The initial treatment had consisted of preoperative and postoperative chemotherapy combined with radical cystoprostatectomy with urinary diversion via a colonic conduit. The principle of the technique of reversal of urinary diversion are discussed in the light of this unusual case.

[Urinary continence after radical prostatectomy: importance of the vesico-urethral anastomosis. Objective evaluation]. / Continence urinaire après prostatectomie radicale: importance de l'anastomose vésico-urétrale. Evaluation objective.

Urinary continence after radical prostatectomy is frequently evaluated subjectively. The authors describe their technique of vesicourethral anastomosis and report their method of objective evaluation of postoperative urinary continence. At the 6th postoperative week, 15% of patients presented with severe incontinence. This percentage fell to 3.3% by the 16th postoperative week.

Obstructive urinary retention in a young female: case report.

The authors report a case of acute urinary retention in a young female patient with a large uterine leiomyoma. Urinary symptoms resolved completely after surgery.

[The effects of mepartricin on the symptomatology of prostatic hypertrophy--double-blind controlled trial]. / Etude de l'effect de la mépartricine sur la symptomatologie de l'hypertrophie prostatique--expérimentation contrôlée en double aveugle.

Seventy one patients were treated with mepartricin or placebo in three urological centres for a mean duration of 102 days (extremes: 60 and 142 days). An analysis of the results was carried out for 34 patients in the placebo group and 36 patients in the mepartricin group. The results indicate a significant improvement in both the placebo group and the mepartricin group. The irritative and obstructive symptoms are improved in the active treatment group with a response rate of the order of 70%, compared to approx. 45% in the placebo group. An improvement of the values on the flow meter, though not statistically significant, is observed following treatment with mepartricin, compared to the placebo group. There were no significant differences in the evolution of the prostate gland volume, determined by ultrasound in the placebo group and the active treatment group. Side-effects were minor and only one patient reported epigastric pain.

Leydig cell tumor: estradiol level at different locations.

The authors report on estradiol levels at different locations in a patient with a Leydig cell tumor. The highest value was found in the testicular vein. The estradiol level was, however, ten times higher in the peritesticular vaginal fluid than in the peripheral veins.

[Local recurrence following radical nephrectomy for renal adenocarcinoma]. / Récidive locale après néphrectomie radicale pour adénocarcinome rénal.

PRESENTATION: If the rate of tumoral relapse after partial nephrectomy for hypernephroma is 8-10%, this element is rarely reported in the literature after radical nephrectomy. PATIENTS AND METHODS: 159 patients (pts) have undergone radical nephrectomy for kidney adenocarcinoma. Mean age is 61.3 years (26-85 years). The mean duration of follow-up is 50.8 months (12-183 months). The patients were regularly followed by abdominal CT scan at 6 months and than yearly by CT scan and chest X-ray. CONCLUSION: Considering the poor incidence of local relapse (1.3%) after nephrectomy and in a period where economical aspect weigh on our practice, a new policy of post-operative follow-up should be carried.

Pathologic response and long term results of preoperative M-VAC regimen in regionally advanced transitional cell carcinoma of the bladder.

Patients with tumor extending through the bladder wall with invasion of adjacent structures or lymph node metastases are seldom cured by radical surgery. Preoperative chemotherapy was given to 17 patients with T3-T4, N0, N+ tumor to assess operability and long-term survival. Tumor downstaging (T0, Ta, T1, CIS, N0) occurred in 4 (80%) of the 5 T3 patients, and in 3 (25%) of the 12 patients with T4 tumors. All patients have been followed until death or for a minimum of 42 months (mean: 56 months, range 42 to 78 months). Surgery was possible in all patients. Long-term survival is realized in only 30%, suggesting that this approach did not alter the ultimate course of the natural history of the disease. Although local recurrence did not occur, 70% of the patients with downstaged cancers developed distant metastases.

Detection of local recurrence after radical prostatectomy by prostate specific antigen and transrectal ultrasound.

Twenty patients with detectable levels of prostate specific antigen (PSA) after radical prostatectomy with no identifiable distant metastases were evaluated for local recurrence by digital rectal examination and transrectal ultrasound combined with biopsies. Of the patients 9 (45%) were found to have histological evidence of local recurrence at the initial assessment. All 4 patients with an abnormal digital rectal examination had recurrent disease. Transrectal ultrasound displayed abnormalities in 12 of the 20 patients, 7 of whom had positive biopsies. Random biopsies of the vesicourethral junction were performed in 8 patients who had negative ultrasound findings and an unremarkable digital rectal examination, of whom 2 had histological documentation of local recurrence. Complications occurred in 1 patient (5%) who presented with clot retention. We conclude that PSA is an excellent tool for identification of recurrent disease after radical prostatectomy, and transrectal ultrasound guided biopsy is a useful diagnostic approach in patients suspected of local failure, especially when the digital rectal examination is unremarkable.

[The value of laparoscopy in the diagnostic evaluation of cryptorchism with non-palpable testicles]. / Intérêt de la laparoscopie dans le bilan diagnostic des cryptorchidies avec testicules non palpables.

From 1986 to 1989, diagnostic laparoscopy was performed in 12 boys, before operation of non-palpable testes. Cryptorchidism was unilateral in all but one case. Preoperative physical examination and ultrasonographic studies of the inguinal region had been performed in all of them and failed to localize the testis. Laparoscopy demonstrated six intra-abdominal testes in five children: five testes were brought down into the scrotum and one was removed because endoscopic diagnosis of complete epididymo-testicular dissociation. Four of the seven other boys were not operated on because of laparoscopic findings. In the last three cases, systematic surgical exploration of the inguinal region was performed and demonstrated total atrophy of the testis. Performed in good condition the procedure is very safe and simple to achieve. It does not increase significantly the duration of the operation and gives objective elements for the operative procedure.

Neoadjuvant hormonal deprivation in patients with locally advanced prostate cancer.

A total of 22 patients with locally advanced prostate cancer (stage B2 to C) was entered into a protocol for 3 months of preoperative hormonal deprivation. Of the patients 8 were judged to have clinical stage B2 and 14 to have stage C disease. The protocol regimen consisted of daily administration of flutamide (250 mg. orally 3 times per day) and leuprolide injection (7.5 mg. intramuscularly) every month. Patients with objective evidence of downstaging by prostate specific antigen (PSA) levels and transrectal ultrasound were offered surgical therapy. Of the 22 patients 20 have completed the protocol and are evaluable, and 2 of them did not show significant downstaging and elected radiotherapy. Preoperative hormonal therapy produced an average 33% downsizing of the prostate gland as determined by transrectal ultrasound volumetrics. Decreases in serum PSA values were demonstrated from a pre-hormonal average of 30 micrograms./l. (range 0.7 to 97.7) to an average of 0.53 micrograms./l. (range 0.2 to 5.7) after hormonal therapy. Of the 18 patients who underwent an operation after demonstrating significant downsizing 7 had pathologically confirmed stage B disease, 7 had stage C cancer and 4 had positive pelvic lymph nodes. Of the 8 clinical stage B2 cancer patients 3 had pathological stage B2 disease following the protocol. Of the 12 clinical stage C cancer patients 3 had pathological stage B disease, 4 had positive pelvic lymph nodes and the remainder had pathological stage C cancer. Thus, only 3 of 20 patients (15%) demonstrated pathological downstaging from the clinical stage. Downsizing the prostate volume and PSA changes with hormonal therapy were not predictive of patient outcome either alone or in combination. Preoperative hormonal therapy did not appear to facilitate the surgical procedure. Patients completing neoadjuvant hormonal therapy had an average estimated blood loss of 1,238 ml. and an average operating time of 183 minutes. A group of 20 consecutive patients with stage B2 prostate cancer who underwent radical prostatectomy without preoperative hormone therapy had an average estimated blood loss of 1,296 ml. and an average operating time of 171 minutes.