Gender and cystectomy for bladder cancer: A high-volume tertiary urologic care center experience.

BACKGROUND: Differences have often been reported in the outcomes of bladder cancer (BC) patients according to gender. OBJECTIVE: This study aims to provide data on patients undergoing radical cystectomy (RC) in a high-volume tertiary urologic center and to assess whether gender discrepancies do exist in terms of surgical options and clinical outcomes. MATERIALS AND METHODS: Consecutive BC patients treated between 2016 and 2020 at a single center (Careggi University Hospital, Florence, Italy) were included in the study. The impact of gender on disease stage at diagnosis, overall survival (OS), and type of surgery was analyzed. RESULTS: The study series comprised 447 patients (85 females and 362 males). At a median follow-up of 28.3 months (IQR: 33.5), OS was 52.6% and cancer-specific survival was 67.6%. Significant differences in OS emerged for age, acute myocardial infarction (AMI), Charlson Comorbidity Index (CCI), pT, and pN. OS rates were higher in patients undergoing robot-assisted surgery and in those receiving open orthotopic neobladder (ONB) (p = 0.0001). No statistically significant differences were found between male and female patients regarding surgical offer in any age group, surgical time, early postoperative complications, pathologic stage, and OS. CONCLUSIONS: After adjustment for pathologic tumor stage and treatment modalities, female and male patients showed similar oncologic outcomes. Further studies should be undertaken to evaluate functional results in women subjected to RC.

Innovative in vivo and in vitro bioassays for the establishment of toxicity thresholds of pollutants in sediment quality assessment using polychaetes and their immune cells.

Sediment toxicity testing has become a crucial component for assessing the risks posed by contaminated sediments and for the development of sediment quality assessment strategies. Commonly used organisms for bioassays with estuarine sediments include amphipods, Arenicola marina polychaetes and echinoids. Among the latter, the Sea Urchin Embryo test (SET) is the most widely used. However, one relevant limitation of this bioassay is the unavailability of gametes all year-round, particularly outside the natural spawning seasons. Consequently, the establishment of an appropriate and complementary model organism for a continuous assessment of sediment quality is recommended. A reliable assessment of the hazards resulting from pollutants in sediments or pore water, can be achieved with ecologically relevant species of sediment such as the polychaete Hediste diversicolor, which is widespread in estuaries and has the capacity to accumulate pollutants. The aim of this work was to develop reliable in vivo and in vitro bioassays with H. diversicolor and its coelomocytes (immune cells) to determine the toxicity thresholds of different contaminants bounded to sediments or resuspended into water. Polychaetes were exposed to sublethal concentrations of CuCl2 (in vivo) and a non-invasive method for collection of polychaetes coelomocytes was applied for the in vitro bioassay, exposing cells to a series of CuCl2 and AgNPs concentrations. Same reference toxicants were used to expose Paracentrotus lividus following the SET (ICES Nº 51; Beiras et al., 2012) and obtained toxicity thresholds were compared between the two species. In vivo exposure of polychaetes to high concentrations of Cu produced weight loss and histopathological alterations. After in vitro approaches, a significant decrease in coelomocytes viability was recorded for both toxicants, in a monotonic dose-response curve, at very short-exposure times (2 h). The toxicity thresholds obtained with polychaetes were in line with the ones obtained with the SET, concluding that their sensitivity is similar. In conclusion, in vivo and in vitro bioassays developed with H. diversicolor are accurate toxicity screenings of pollutants that could be bounded to sediments or dissolved in the pore water, and may complement the SET outside the spawning period of the echinoderms. The bioassays herein developed could be applied not only to establish the toxicity thresholds of individual compounds or mixtures, but also to assess the toxicity of field collected sediments.

Trichilemmal cystis in metastatic melanoma: a case report.

The malignant melanoma is a neoplasm associated with a wide variety of cutaneous paraneoplastic syndromes, as dermatomyositis, systemic sclerosis, paraneoplastic pemphigus. We describe a case of four multiple trichilemmal cystis arising on frontal region in the same patient with brain metastasis and unknown primary melanoma and discuss their relationship.

Primary cardiac angiosarcoma: a fatal disease.

A 42-year-old man with a cardiac tamponade underwent an urgent pericardiotomy that showed tumoral tissue, covering the surface of the right atrium. The tumor was then partially excised, and the histological examination revealed the presence of a moderately-differentiated angiosarcoma. The patient was then referred to the oncology unit and scheduled for a chemotherapy schedule including Epirubicin (60 mg/m(2), on days 1 and 2) plus Ifosfamide (2000 mg/m(2), on days 1 to 3) and Uromitexan (2000 mg/m(2) at hours 0, 4, 8 after IFO). All drugs were administered every three weeks. After two cycles, a restaging work-up revealed a partial remission. The treatment was continued for another two cycles. A new evaluation by cardiac MRI evidenced a local and distant (lung) progression of disease. The patient died after three months. This paper confirms that cardiac angiosarcoma is a fatal disease, and the prognosis is usually 6-11 months from time of diagnosis.

Gemcitabine with or without continuous infusion 5-FU in advanced pancreatic cancer: a randomised phase II trial of the Italian oncology group for clinical research (GOIRC).

This study was performed to determine the activity of adding continuous infusion (CI) of 5-fluorouracil (5-FU) to gemcitabine (GEM) vs GEM alone in advanced pancreatic cancer (APC). In all, 94 chemo-naïve patients with APC were randomised to receive GEM alone (arm A: 1000 mg m(-2) per week for 7 weeks followed by a 2 week rest period, then weekly for 3 consecutive weeks out of every 4 weeks) or in combination with CI 5-FU (arm B: CI 5-FU 200 mg m(-2) day(-1) for 6 weeks followed by a 2 week rest period, then for 3 weeks every 4 weeks). Overall response rate (RR) was the primary end point and criteria for decision were planned according to the Simon's optimal two-stage design. The overall RR was 8% (arm A) and 11% (arm B) (95% confidence interval: 0.5-16% and 2-22%), respectively, and stable disease was 29 and 28%. The median duration of RR was 34 weeks (range 25-101 weeks) for GEM and 26 weeks (range 16-46 weeks) for the combination. The median progression-free survival (PFS) was 14 weeks (range 2-65 weeks) and 18 weeks (range 4-51 weeks), respectively. The median overall survival (OS) was 31 weeks (range 1-101 weeks) and 30 weeks (1-101 weeks). Toxicity was mild in both arms. This study does not show promising activity in terms of RR, PFS and OS for the double combination arm in APC.

Weekly gemcitabine plus Epirubicin as effective chemotherapy for advanced pancreatic cancer: a multicenter phase II study.

The current role of chemotherapy in pancreatic carcinoma is limited, and progress in the treatment of this disease represents a significant challenge to medical oncology. The most promising drug under study is gemcitabine, a relatively new antimetabolite that represents an attractive candidate for combination chemotherapy because of its excellent side-effect profile and the absence of overlapping toxicities with other chemotherapeutic agents. Combined administration of gemcitabine and anthracyclines could result in the induction of DNA breaks that are not easily repaired by the cell's machinery, thus enhancing the apoptotic signals triggered by these lesions. Forty-four patients with locally advanced and/or metastatic pancreatic adenocarcinoma were enrolled in this multicenter study. Patients received Epirubicin 20 mg m(-2) for 3 weeks followed by 1 week of rest (1 cycle) and gemcitabine 1000 mg m(-2) after Epirubicin on the same day. All were assessable for toxicity and response, 11 patients responded to treatment with one complete response and 10 partial responses, for an overall response rate of 25%. Median survival was 10.9 months (range, 2-26 months). Therapy was well tolerated, with a low incidence of haematologic grade >2 toxicity. A total of 12 of 27 (44.4%) eligible patients attained a clinical benefit response. Our findings suggest that the gemcitabine-epirubicin schedule is active and well tolerated in patients with advanced pancreatic cancer.

Phase II trial of weekly intravenous gemcitabine administration with interferon and interleukin-2 immunotherapy for metastatic renal cell cancer.

PURPOSE: Since metastatic renal cell carcinoma has a poor prognosis and treatment strategies, including hormone therapy, chemotherapy and immunotherapy, have little impact on the quality of life and global survival statistics, new interest has recently focused on the combination of immuno-chemotherapy using pyrimidine analogues, such as gemcitabine. MATERIALS AND METHODS: In a phase II study 16 patients with metastatic renal cell carcinoma were treated with 1,000 mg./m. gemcitabine intravenously on days 1, 8, 15 and 28 for 6 months, 3 MU (1 MU = 1 x 10(6) IU) interferon (IFN)-alpha intramuscularly 3 times a week and 4.5 million IU interleukin (IL)-2 subcutaneously daily for 5 days a week for 2 consecutive weeks every month for 6 months. Responding and nonprogressing cases were maintained on immunotherapy consisting of IFN-alpha and IL-2 for further 6 months. RESULTS: In 15 evaluable patients overall response rate (1 complete response plus 3 partial response) was 28% while stable disease was achieved in 7 (47%). Median survival duration was 20 months (range, 9 to 26+) and median time to tumor progression was 14 months (6 to 26+). The complete response lasted 24+ months and partial response lasted 16 months. The regimen was well tolerated with only 1 case of neutropenia (WHO grade 3), while anorexia, fatigue and flu-like symptoms were the most common toxicity problems but were never greater than grade 2. CONCLUSIONS: Despite the small sample size, this study demonstrates that gemcitabine combined with standard doses of IFN-alpha and low doses of IL-2 is effective treatment for metastatic renal cell carcinoma. This biotherapy was well tolerated and resulted in an optimum objective response and relatively long-term survival.

Raltitrexed plus oxaliplatin as first-line chemotherapy in metastatic colorectal carcinoma: a multicentric phase II trial.

For advanced colorectal carcinoma, two new drugs, raltitrexed (TOM) and oxaliplatin (L-OHP), have recently shown interesting results. Preclinical and clinical studies suggest that this combination, because of its favorable toxicity profile, high response rate and convenient schedule of administration, can be administered successfully in this disease. In our phase II study, 37 non pre-treated patients with metastatic colorectal carcinoma were treated with TOM (3 mg/m(2)) and L-OHP (130 mg/m(2)) every 3 weeks. In total, 222 cycles were administered; all patients received at least 2 cycles (median 6, range 2-8). There were two complete and 14 partial responses for an overall response rate of 43% (95% CI 27-69%). The median time to response was 2.5 months (range 2-4) and the median duration was 10.3 months (range 5-18). Twelve of the 23 (52%) patients with symptomatic colorectal cancer were classified as clinical benefit responders for at least 4 weeks during the study period. Treatment was well tolerated, and both acute, essentially hematologic, and cumulative hepatic and neurologic toxicities were manageable and reversible. Response rate and toxic effects observed during this study warrant additional studies comparing this TOM-L-OHP regimen with CPT-11 and/or capacitebine-containing regimens in metastatic colorectal carcinoma.

Gemcitabine plus Epi-doxorubicin as first-line chemotherapy for bladder cancer in advanced or metastatic stage: a phase II.

Combination chemotherapy with newer, more active drugs in patients with advanced and/or metastatic bladder cancer might show improved response rate and survival. Gemcitabine (GEM) and Epidoxorubicin (EPI) have demonstrated activity in this disease. In addition, experimental studies in vitro have shown that the two agents have additive-synergistic effects when used in combination. Our prior phase I dose-finding study in previously untreated patients with advanced or metastatic bladder cancer defined recommended doses for further trials of GEM 1000 mg/m2 and EPI 25 mg/m2 on days 1, 8 and 15 every 28 days. A phase II trial at this dose level was initiated in previously untreated patients to assess efficacy and toxicity. Eligible patients had measurable disease; Karnofsky performance status (PS) of > 40; no prior chemotherapy; and adequate bone marrow reserve, cardiac, hepatic and renal function. Thirty- one patients (22 males, 9 females) with median age of 64 (range 44-75) and median PS of 80 were accrued, and all were eligible. Twelve patients had T4N1-2 M0, 8 had lymph node only metastases, while 11 had visceral metastases (liver, bone, lung). A total of 181 cycles was administered (range 3-7 per patient). Major toxicities (WHO grade > or = 3) were: neutropenia in 5 patients, thrombocytopenia in 2 patients, and anemia in 2 patients. Three patients had febrile neutropenic episodes and only 3 patients required dose reduction. Grade 1-2 non-hematological toxicities included nausea/vomiting, stomatitis and alopecia. No cardiac toxicity was observed. Of the 30 response evaluable patients, 17 (57%) demonstrated a major response (3 complete and 14 partial) (95% CI: 39%-75%), 7 had stable disease (23%) and 6 progressed (20%). These preliminary results confirm the phase I observation that the combination of GEM--EPI is highly active in the treatment of advanced and metastatic bladder cancer with a favourable toxicity profile.

[Treatment of intracranial aneurysm in interventional neuroradiology. What problems for the anesthetist?]. / Il trattamento degli aneurismi intracranici in neuroradiologia interventistica. Quali i problemi per l'anestesista?

AIM: To outline the most occurring complications during endovascular treatment of intracranial aneurysms. DESIGN: Retrospective review of thirty-four patients treated from October 1994 to February 1996 with the placement of mechanically detachable microcoils inside the aneurysmal sac. SETTING: Interventional neuroradiology suite equipped for anesthetic care. PATIENTS: Thirty-four patients with ruptured (88%) or unruptured (12%) intracranial aneurysm submitted to elective (38%) or emergency (62%) endovascular treatment. Aneurysms were located in the anterior circulation in twenty-six patients (76%) and in the posterior circulation in eight patients (24%). INTERVENTIONS: A microcatheter was introduced into the arterial cerebral circulation to deliver tungsten microcoils to aneurysmal sac. The transfemoral approach was used in most cases. All patients were treated under general anesthesia with tracheal intubation, conventional mechanical ventilation and neuromuscular blockade. The procedure was performed under anticoagulation with heparin and intravenous nimodipine administration. MEASUREMENTS: Neurological assessment was performed at the time of treatment (H&H 1) and six hours after the end of intervention (H&H 2) using Hunt and Hess classification system. The outcome was scored at four weeks following treatment using Glasgow Outcome Scale (GOS). RESULTS: Twenty-two (65%) interventions were successful. Attempted embolization failed in twelve (35%) patients due to intraoperative complications (17.6%) or technical difficulties (17.6%). Failures were more frequently determinated by vasospasm and haemorrhage. CONCLUSIONS: The time of intervention, the use of heparin and the patient medical conditions need to be considered in preventing the complications of endovascular treatment.

Postspinal headache in Taylor's approach: a comparison between 21- and 25-gauge needles in orthopaedic patients.

A randomized study was carried out on 160 patients aged 30-60 years with the aim of finding a method of preventing postdural puncture headache (PDPH). In Taylor's lumbosacral approach to the subarachnoid space, two different needle sizes were used (21-gauge versus 25-gauge) for injecting the anaesthetic solution. Our results show an overall incidence of PDPH in nearly 8% of patients, with no significant difference related to the size of the needle employed. Patients with PDPH showed mild symptoms which disappeared in a short time and none needed epidural blood patching. The possibility of using larger needles, facilitating the execution of the block without increasing PDPH incidence, renders this technique particularly attractive in patients where the midline approach is not feasible, or when pencil-point needles are not available.

The orthogonal two-needle technique: a new axillary approach to the brachial plexus.

Ninety-eight patients scheduled for elbow, forearm, wrist or hand surgery were allocated randomly to one of two different techniques of brachial plexus block, both using the axillary approach. The blocks were all performed at the level of the insertion of the lateral margin of the pectoralis major muscle on the humerus. The same mixture and volume of anaesthetic solution (30 mL of a mixture of equal parts of 0.5% bupivacaine with adrenaline 1:200 000 and 2% lignocaine) was injected through two needles positioned above and below the axillary artery, in the fascial compartments containing the median and ulnar nerves, respectively. Confirmation of correct needle placement was obtained by elicitation of paraesthesias. In one group of patients (n = 40) the needles were inserted parallel to the axillary artery pathway and the anaesthetic solution was injected toward the apex of the axilla. In a second group (n = 58) the needles were inserted orthogonally with respect to the neurovascular bundle pathway, aimed towards the posterior fascial compartment containing the radial nerve. Using the second technique, all the terminal branches of the brachial plexus were more frequently involved in the block, including the distribution of the musculocutaneous nerve. It seems likely that the inclination of the needles causes a preferential spread of the anaesthetic solution which follows the direction of the needle shaft.

[Fibromyalgia and trigger points]. / Fibromialgia e trigger points.

Trigger points in chronic pain and myofascial syndromes are often localized at a distance from the painful area. Infiltration of trigger points with Bupivacaine 0.5% greatly reduces pain and can eliminate it with no need of any other analgesic therapy.

How many interscalenic blocks are there? A comparison between the lateral and posterior approach.

This study compares the areas of analgesia obtained with the lateral and posterior approaches to the interscalene space after injection of equal volumes of anaesthetic solution (40 ml of a mixture of 0.5% bupivacaine with adrenaline 1:200,000 and 2% lignocaine in equal parts). There was a significant difference in the distribution of the areas of analgesia between the two approaches. With the posterior approach, the region supplied by the radial, medial and ulnar nerves and the post-axial border of the upper limb were more frequently involved, whilst with the lateral approach the area of analgesia was usually confined to the regions supplied by the most caudal roots of the cervical plexus and the upper trunk of the brachial plexus (pre-axial border of the upper limb). On these grounds it appears that two different types of interscalene block are possible.

[The external jugular vein course as surface landmark in subclavian perivascular block]. / Il decorso della vena giugulare esterna quale punto di repere di superficie nel blocco perivascolare succlavio.

A study of 88 orthopaedic patients undergoing upper limb surgery, was carried out using the external jugular vein as surface landmark of the brachial plexus in subclavian perivascular technique. A significant statistical relationship was found between the insertion point of the needle, relatively to the external jugular vein course, and the block outcome. The best results were observed when the needle was inserted on the postero-lateral side of the vein or when the insertion point coincided with the vein course. Worse results were obtained by foreward insertion. So the external jugular vein could be used as surface landmark to improve the plexus localization in the subclavian perivascular technique of brachial plexus anaesthesia.

[How many interscalene blocks are there? Reflections on 109 cases studied with various techniques]. / Quanti sono i blocchi interscalenici? Riflessioni su 109 casi eseguiti con tecniche diverse.

The effects of interscalene block were studied on 109 patients undergoing upper extremity elective orthopaedic surgery. Blocks were performed in a non-randomized manner with three different techniques, the site where anaesthetic solution was injected being the main distinguishing mark. The anaesthetic solution was injected into the interscalenic compartment both in the case of patients where classic technique had been carried out and in the group where the nerve stimulator had been used. In the "double needle" technique group, on the contrary, the anaesthetic solution was injected close to the vertebral column. The spread of analgesia involves the caudal portion of the cervical plexus and the cranial portion of the brachial plexus, but with the cervical plexus is almost certain to be involved, the brachial is not. Block outcome was related to the surgical procedure (surgery or orthopaedic manipulation), the site of surgery, paraesthesia elicitation, prolonged surgery and height, weight, age and sex of patients. Results also different according to the technique used. When the anaesthetic solution was injected close to the vertebral column analgesic cover was more widespread and lesser amounts of anaesthetic needed. When the block was performed within the interscalenic compartment, the analgesic cover was usually restricted to the area supplied by the primary superior trunk of the brachial plexus. The different results were explained by the presence of fibrous sheaths within the interscalenic compartment limiting spread of the anaesthetic, which are absent close to the vertebral column. Therefore two types of interscalene block were postulated: an intrascalene or troncular block within the interscalenic compartment and a radicular or paravertebral block close the vertebral column.