Intraoperative EBRT and resection for renal cell carcinoma : twenty-year outcomes.

PURPOSE: We report the outcomes of a multimodality treatment approach combining maximal surgical resection and intraoperative electron radiotherapy (IOERT) with or without external beam radiation therapy (EBRT) in patients with locoregionally (LR) recurrent renal cell carcinoma (RCC) after radical nephrectomy or LR advanced primary RCC. PATIENTS AND METHODS: From 1983 to 2008, 25 patients with LR recurrent (n = 10) or LR advanced primary (n = 15) RCC were treated with this approach. Median patient age was 60 years (range, 16-79 years). Fifteen patients (60%) received perioperative EBRT (median dose, 44 Gy). Surgical resection was R0 (negative margins) in 6 patients (24%) and R1 (residual microscopic disease) in 19 patients (76%). The median dose of IOERT was 14 Gy (range, 9-15). Overall survival (OS) and relapse patterns were calculated using the Kaplan-Meier method. RESULTS: Median follow-up for surviving patients was 22.2 years (range, 3.6-26 years). OS and DFS at 5 and 10 years were 38% and 18% and 19% and 14%, respectively. LR control (tumor bed or regional lymph nodes) and distant metastases-free survival rates at 5 years were 80% and 22%, respectively. The death rate within 30 days of surgery and IOERT was 4% (n = 1). Six patients (24%) experienced acute or late toxicities of grade 3 or higher according to the National Cancer Institute Common Toxicity Criteria (NCI-CTCAE) v4. CONCLUSION: In patients with LR recurrent or LR advanced primary RCC, a multimodality approach consisting of maximal surgical resection and IOERT with or without adjuvant EBRT yielded encouraging local control results, justifying further evaluation.

Prognostic factors and percutaneous nephrolithotomy morbidity: a multivariate analysis of a contemporary series using the Clavien classification.

PURPOSE: We stratified factors affecting treatment morbidity, compared the outcomes of percutaneous nephrolithotomy procedures from a single department and provided evidence of treatment benefits when percutaneous nephrolithotomy is performed in an expert setting. MATERIALS AND METHODS: Since the department became a dedicated endourological center in 2002 we grouped all percutaneous nephrolithotomy procedures into those performed before 2002 (group 1) and after 2002 (group 2). The modified Clavien classification was used to score morbidity. Independent variables with an influence on complications were studied including stone size, operating time, operative complications, dilation device, urine culture, group allocation and lithotripsy device. Contingency and logistic regression were used for univariate and multivariate analysis. RESULTS: Of the 244 percutaneous nephrolithotomy procedures 68 comprised group 1 and 176 formed group 2. Statistical preoperative differences were patient age, the use of anticoagulants and positive urinary cultures. Group 1 had a complication rate of 56.8% and group 2 had a complication rate of 37.2%. There were significant differences between the groups (p = 0.007). Almost all complications were grade 1 to 2. On univariate analysis the influence variables were urine culture (OR 1.69), group allocation (OR 2.20), stone size (OR 2.28), dilation device (OR 4.8), lithotripsy device (OR 1.22), perioperative complications (OR 2.83) and surgical time (OR 1.87). On multivariate analysis the independent factors in the complicated outcome were stone size (OR 1.25), type of lithotripsy device (OR 1.35) and incidence of perioperative complications (OR 3.71). CONCLUSIONS: The dedicated setting for percutaneous nephrolithotomy at our center resulted in decreased operative time, more uneventful procedures and decreased hospitalization time. The modified Clavien morbidity score is a reliable tool for more objective outcome comparisons after renal stone treatment.

Prognostic value of seminal vesicle involvement due to prostate cancer in radical prostatectomy specimens.

OBJECTIVE: To study the influence, in terms of prognosis, of the finding of seminal vesicle involvement in patients with prostate adenocarcinoma treated with radical prostatectomy. MATERIAL AND METHOD: We reviewed a series of patients with seminal vesicle involvement with clinically localized prostate adenocarcinoma who underwent radical prostatectomy between 1989 and 2009, focusing on their clinical-pathological characteristics, biochemical progression-free survival (BPFS) and specific survival (SS). We assessed the variables that influenced BPFS and designed a risk model. RESULTS: A total of 127 out of 1,132 patients who underwent surgery (11%) presented seminal vesicle invasion (i.e., pT3b). In the multivariate study of the entire series (Cox model), pT3b affects the BPFS (HR: 2; 95% CI: 1.4-3.3; P=.001). Other influential factors were the affected borders, initial prostate-specific antigen levels, pathological Gleason score and the presence of palpated tumor. The pT3b tumors have poorer clinical-pathological variables when compared with pT2 and pT3a tumors. Sixty-five percent of the patients evidenced biochemical progression. The BPFS was significantly poorer for pT3b (40 ± 4% and 28 ± 4% at 5 and 10 years, respectively) than for pT2 and pT3a (P<.0001). The SS was also poorer in patients with pT3b tumors (91 ± 2% and 76 ± 4% at 5 and 10 years, respectively) (P<.0001). The predictors within the pT3b patient group were: PSA levels >10 ng/mL (HR: 1.9; 95% CI: 1.04-3.6; P=.04) and pathological Gleason score 8-10 (HR: 2.1; 95% CI: 1.2-3.5; P=.03). We designed a risk model that accounts for the variables involved, which entails 2 groups with different BPFS (P=.004): Group 1 (0-1 variable), with a BPFS of 46 ± 7% and 27 ± 8% at 5 and 10 years, respectively; and Group 2 (2 variables), with a BPFS of 14 ± 7% and 5 ± 5% at 5 and 10 years, respectively. CONCLUSION: Seminal vesicle involvement severely and negatively affects the BPFS and SS. We designed a risk model with the independent influential variables in BPFS (pathological Gleason score 8-10 and PSA levels >10 ng/mL). This model confirms that pT3b tumors are a heterogeneous group, which includes an important group with better prognosis when surgical treatment is performed.

Intraoperative and external beam radiotherapy in invasive bladder cancer: pathological findings following cystectomy.

The pathological findings observed following intraoperative radiotherapy (IORT) boost (15Gy) to the whole bladder, external beam fractionated irradiation (46Gy in 5 weeks), and planned radical cystectomy in patients with deep invasive bladder carcinoma are analyzed. Clinical pretreatment stage of disease was T3 (16 cases) and T4 (two cases). No evidence of residual tumor (pT0) was demonstrated in 11 cystectomy specimens (61%) and residual tumor (pT+) was observed in seven (39%). Toxicity and complications related to the treatment approaches were minor and reversible. It is concluded that IORT is a feasible boosting modality in the management of invasive bladder cancer, able to induce high rates of pT0 cystectomy specimens, and might be considered as a valuable technique for organ preservation treatment programs.

Intraoperative and external preoperative radiotherapy in invasive bladder cancer: effect of neoadjuvant chemotherapy in tumor downstaging.

Absence of residual cancer (pT0) in the cystectomy specimen was evaluated in patients with invasive bladder cancer treated with intraoperative (IORT) (15 Gy) and preoperative external beam radiotherapy (EBR) (46 Gy/5 weeks) with or without neoadjuvant chemotherapy. The overall pT0 rate was 68% (67% and 70% in patients with or without neoadjuvant chemotherapy, respectively). The tolerance to the program was acceptable in both groups. It is concluded that intense, combined modality treatment is feasible in bladder cancer patients, and the addition of neoadjuvant chemotherapy does not increase the morbidity. Preliminary results on disease-free survival are encouraging.

Ureteral reflux of recipient's own kidneys. A potential source of error in renal transplant evaluation.

After transplantation, pre-existent vesicoureteral reflux caused a hot paravesical area mimicking urine extravasation.

[Intraoperative radiotherapy in locally advanced carcinoma of the kidney: initial experience]. / Radioterapia intraoperatoria en el carcinoma renal localmente avanzado: experiencia inicial.

Intraoperative radiotherapy (IORT) is a rather interesting therapeutic modality in multidisciplinary oncology. Its greatest advantages reside in the approach of deeply seeded abdomino-pelvic tumors. Its inclusion in the therapeutic approach of renal carcinoma with a high local relapse rate has been analyzed in this study in relation to its technical aspects and preliminary clinical results. 11 stage III or IV patients or with local relapse in lumbar fossa were treated with nephrectomy or exeresis surgery and OIRT (10-20 Gy). Surgical exposure of the lumbar fossa and nodal drainage areas was appropriate in dal cases. No toxic signs or sequellae relating to OIRT were observed. Local tumor controls at 8 months of follow-up on the average (range from 2 to 33 months), was 82%. The data obtained in this series suggest the viability of the combined approach nephrectomy or rescue surgery and IORT. The initial clinical results suggest HIGH local tumor control without an increase in the toxicity rate or complications.

[Monotherapy of ureteral calculi with extracorporeal shockwave lithotripsy]. / Monoterapia de los cálculos ureterales con litotricia extracorpórea por ondas de choque.

We reviewed our experience with ESWL in the treatment of 401 patients with ureteral stones in order to evaluate if a higher disintegration and clearance rates could be achieved without prior manipulation of ureteral calculi, i.e., ESWL used as "in situ" monotherapy. The global stone free rate were 83%, 85% and 91% at 15 days, 1 month and 3 months after ESWL. We also analyzed the results according to the efficiency quotient (EQ).

[Potentiation of cytotoxicity of electromagnetic shock waves by suramin, "in vitro" study]. / Potenciación de la citotoxicidad de las ondas de choque electromagnéticas por la Suramina, estudio "in vitro".

The objective of this experimental study is to assess the inhibition of tumoral cells growth induced by electromagnetic shockwaves at different energy levels in PC-3, the human prostate adenocarcinoma cell line. Also, an assessment is made of the inhibition of cell growth caused by adding Suramin to the growth medium and the enhancement of cytotoxicity when associated to that produced by electromagnetic shockwaves. Cells viability is determined by life staining exclusion methods and nucleoside incorporation. Cytotoxic action of electromagnetical shockwaves in the PC-3 cell line is dose dependent (p < 0001). Suramin significantly inhibits cell viability (p < 0001). The association of both therapeutical approaches enhances significantly their individual cytotoxicities (p < 0001).

[Diagnosis of cancer of the prostate by determining the blood levels of specific prostatic antigen, rectal examination, and transrectal echography]. / Diagnóstico del cáncer de próstata mediante la determinación sérica de antígeno prostático específico, tacto rectal y ecografía transrectal.

The usefulness of Prostate Specific Antigen (PSA), tactile rectal examination (TRE) and transrectal ultrasound (TRU) for the diagnosis of prostate cancer (PCa) was studied in 114 patients who came in for an evaluation of their mictional symptoms. Patients underwent random ultrasound-guided transrectal biopsies following findings of abnormal TRE and/or serum PSA concentrations > 5 ng/ml. Of the total series, 71% presented TRE abnormalities and 52% presented hypoechoic areas in the TRU (only ones to be considered suspicious). Also, 26%, 23% and 51% of patients presented normal (0-5 ng/ml), intermediate (5-10 ng/ml), and high (> 10 ng/ml) concentrations of serum PSA. Incidence of PCa was 31%. Based on the individual tests, both positive and negative predictive values were higher for serum PSA concentrations > 10 ng/ml. By combining the tests results, the diagnosis percentage was also higher with PSA levels > 10 ng/ml. Positive predictive value was 81% in patients with all three tests positive, 73% with suspicious TRE and high PSA and 70% with suspicious TRU and high PSA. Our results corroborate the superiority and efficacy of random biopsies over selective biopsies of hyperechoic areas. Nevertheless, of 21 patients with negative prostate biopsies who underwent TUR or retropubical adenomectomy, 28% had PCa. These findings indicate that random biopsies are associated with a percentage of false negatives which varies depending on the features of the sample being studied. In conclusion, PSA is the ideal complement to TRE, and the association of these two tests constitutes the best indication for an ultrasound-guided random prostate biopsy, with independence of any TRU findings.

[Prognostic value of local vascular infiltration in infiltrating transitional carcinoma of the bladder]. / Valor pronóstico de la infiltración vascular local en el carcinoma transicional infiltrante de vejiga.

The present retrospective study analyzes the evolution and survival of 79 patients with bladder infiltrant transitional carcinoma (T2-T3), which were treated with radical cystectomy and bilateral ilio-obturating lymphadenectomy. Pre-operative radiotherapy (57/79) and neo-adjuvant chemotherapy (24/79) was used as supplementary therapy. The univariate analysis showed the relationship between tumour vascular infiltration (TVI) and presence of nodes micrometastasis (p = 0.002). The variables with greater forecast power in the multivariate analysis for survival were a decline in the post-radio and/or neo-adjuvant chemotherapy tumoral stage (p = 0.000) and TVI (p = 0.001). Survival decreased significantly in patients with TVI (p = 0.008), this finding denoting a worse prognosis than the presence of nodular micrometastasis (p = 0.01).

[Inhibition of tumor cell growth by the action of high-energy sources]. / Inhibición del crecimento celular tumoral por acción de las fuentes de alta energía.

In vitro comparison of the cytotoxic action of high-energy shockwave and megavoltage radiotherapy on tumoral cells. The inhibitory action these two therapeutic approaches have on cell viability is determined both singly and jointly, through life staining exclusion and nucleoside uptake tests. High energy shockwaves have a cytotoxic action significantly greater than low- and medium-energy levels of megavoltage radiation. The cytotoxic effect from megavoltage radiation is significantly greater than that resulting from high levels of high-energy shockwave as shown by the life staining exclusion tests. However, the nucleoside uptake test shows that cytotoxicity from either type of energy is no significantly different. When measuring the cumulative cytotoxic action of high energy shockwaves plus megavoltage radiation, the level of cytotoxicity is greater than the individual inhibitory actions on cell viability, but the degree of cytotoxicity induced cannot be comparable to that produced by higher energy levels from both sources separately.

[Leiomyosarcoma of the vena cava: presentation of 2 clinical cases]. / Leiomiosarcoma de cava: presentación de dos casos clínicos.

Presentation of two cases of leiomyosarcoma of a cava vein, an infrequent retroperitoneal tumour. Both cases were treated by means of anatomical reconstruction by a PTFE prosthesis. Brief review of diagnostic and therapeutical choices.

[Survival analysis in renal cell carcinoma with invasion of the vena cava]. / Análisis de la supervivencia en el carcioma de células renales con invasión de la vena cava.

Ninety-nine consecutive patients with renal cell carcinoma in stages pT1-4/N0-3/V0-2/M0 were analyzed. Overall 5 year survival was 61%. Factors with greater impact on survival were: 1) degree of anaplasia (DI 73%, DII 47%, DIII 27%; p = 0.0005), 2) pathological stage (pT1-2 87%, pT3 39%; p = 0.0000), 3) perirenal fat invasion (pT1-2 87%, pT3a 60%; p = 0.007), 4) node status (N0 72%, N1-3 17%; p = 0.0000) and 5) veins invasion (V0 74%, V1-2 35%; p = 0.005). No difference in survival between V1 and V2 (40% vs 33%; p0.05) tumours was found. A multivariable study showed that the degree of anaplasia and veins invasion have a significant and separate influence on survival (p = 0.0000). Among patients with vascular invasion, those with no perirenal fat invasion or node damage show better survival rates than patients with capsular infiltration (62% vs 40%; p) and perform significantly better than patients with capsular invasion and nodal implication (62% vs 30%; p). No survival differences were observed between pT3b stages with venous invasion only and pT1-2 stages (p0.05). Venous invasion is not in itself of prognostic relevance; the prognostic significance of vascular invasion is directly related to the presence of perirenal fat invasion and/or nodal implication.

[Urologic complications in 237 recipients of cadaveric kidney transplantation]. / Complicaciones urológicas en 237 receptores de trasplante renal cadavérico.

We describe the urological complications occurred in 237 patients undergoing cadaveric renal transplant in 13 years. Two techniques of extravesical ureterocystoneostomy were used. Thirty patients (13%) presented 35 (15%) urological complications: 23 (9.7%) urinary fistula and 12 (5.1%) ureteral stenosis. The vast majority (80%) were early complications (before 90 days): 82% fistulas and 18% stenosis. All early complications were identified as technical deficiencies; all late complications were obstructive in nature. A new ureteral reimplant was performed in 15 patients, with successful results in 14. Six patients underwent nephrectomy and pyelostomy, 2 of these required a second operation. Seven patients underwent endo-urological procedures with good results. Three patients undergoing conservative treatment for urinary fistula required surgical drainage of an infected urinoma. No statistical difference was observed in the survival rates of both the grafts and the patients presenting or not urinary complications.

[Bladder leiomyoma: report of a new case]. / Leiomioma vesical: aportación de un nuevo caso.

We present one case of vesical intramural leiomyoma in one adult woman in which an echographic fortuitous diagnostic was made. We have reviewed the bibliography and the diagnostic and therapy considerations.

[Multivariate analysis of the factors influencing the occurrence of surgical complications in renal transplantation]. / Análisis multivariado de los factores influyentes en la aparición de las complicaciones quirúrgicas en el trasplante renal.

Study of 307 renal corpse transplants performed in our centre, gathered in two series according to the immunosuppressive approach used, with and without cyclosporin A (Current and Historic Series, respectively). The surgical complications encountered are assessed and divided into urinary, vascular and other. Using a multivariate analysis, the factors influencing the occurrence of each of them are examined. In the Historic Series, the prognostic factors for the occurrence of urinary complications are the type of extraction and the duration of cold ischaemia. Regarding vascular complications, these factors are the type of anastomosis and the receptor's age. With respect to all other complications, the single influential factor is the initial delayed function. In the Current Series, the prognostic factors relative to urinary complications are the receptor's age, the duration of cold ischaemia, and the donor's age. No multivariate analysis is made of vascular complications due to their small number. The remaining complications are related, as in the other series, to the initial delayed function.

["De novo" malignant tumors in kidney transplant receptors]. / Tumores malignos "de novo" en receptores de trasplante renal.

Presentation of the "de novo" tumours developed in two series of renal transplant receptors over the last 16 years. The first series, Historic, comprises the group of 178 patients who were given Azathioprin or Cyclophosphamide plus Prednisone for immunosuppression. The second series, Current, includes 129 patients who received immunosuppressive therapy with Cyclosporin A. Overall incidence of these "de novo" malignant tumours was 4% (13/307), 9 of which corresponded to the Historic Series (incidence, 5%) and 4 to the Current Series (incidence, 3%). Mean time interval from transplantation to diagnosis was 87.3 months (range, 9-177) in the Historic Series and 34.5 (range, 8-67) in the Current Series, the difference being statistically significant (p = 0.02). By locations, skin and lip tumours represent 38.5%, followed in frequency by lymphoma (23%) and lung carcinoma (15%). No urological tumours were recorded.

[Adjusted survival of the graft in renal transplantation. Multivariate analysis of prognostic factors]. / Supervivencia ajustada del injerto en el trasplante renal. Analisis multivariado de los factores pronóstico.

Three hundred and seven first corpse transplantations performed in the Clínica Universitaria of Navarra since 1976 are analyzed. The cases are divided in two series, Current and Historic, depending on whether the immunosuppressive protocol included cyclosporin A. First, actual survival curves from both series were compared, obtaining a significantly improved survival in the cyclosporin A series (p). Then, the most influential prognostic features in each series are analyzed for the various post-transplantation periods. With regard to adjusted graft survival in the Historic Series, both initial function and the number of rejections have influence during the first post-transplantation year. HLA A + B identities and the donor's age influence during the immediate one-to-three months period. In the Current Series, time of cold ischaemia and number of rejections act during the earliest (first month) and the latest (between one to three years) periods. The donor's cause of death and the recipient's age influence during the first month of evolution. The initial function and the presence of surgical complications influence between the first month and the first year.

[TPS in prostate cancer]. / TPS en cáncer de próstata.

A study of the tumour proliferation marker TPS in prostate cancer has been carried out. The levels of this marker were determined in the following groups: controls (n = 51), prostate hyperplasia (n = 17), prostate cancer in clinical remission (n = 15), and progressive prostate cancer (n = 13). An upper normal limit of 129 U/l (percentile 95) was established. When the progressive disease group was compared with the other groups, a significant difference (p < 0.001) was found. Sensitivity, specificity and positive predictive value obtained in order to dismiss progression were 71%, 94% and 62% respectively.