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.

Collagen graft interposition in vesicovaginal fistula treatment.

Vesicovaginal fistula (VVF) is a quite rare complication of gynecological surgery. The first attempt to repair the fistulous tract offers the best opportunity for cure. We report the successful repair of VVF in 2 patients using a combined anterior vaginal approach and porcine dermal collagen grafting as interposition tissue. Favorable results confirm technical simplicity, safety and efficacy of this procedure.

Intraoperative radiotherapy in recurrent gynecological cancer.

A retrospective analysis to assess the feasibility and clinical tolerance of intraoperative radiotherapy (IORT) in the treatment of recurrent gynecologic cancer is reported. From February 1985 to September 1992, 26 patients with recurrent gynecologic tumors entered this trial. The clinical experience comprises two different categories of disease situations: tumors relapsing after full dose radiation therapy (group I) and recurrent disease to previous surgery (group II). Cervical carcinoma was the initial tumor site of involvement in 18 patients (69%). Treatment consisted in maximal surgical resection + IORT boost (10-25 Gy) to the high-risk areas for recurrence. Non previously irradiated patients also received external beam irradiation (EBRT) (+/- chemotherapy) pre- or postoperatively. IORT-related toxicity was one episode of motor neuropathy. Local control rates have been 33% and 77%, respectively in groups I and II. The 4-year actuarial overall survival in Group I is 7% and 6-year actuarial overall survival in Group II is 33%. The addition of IORT to surgical debulking achieves modest local control and long-term survival rates if tumor-free margins cannot be obtained in previously irradiated patients. Combined EBRT (+/- chemotherapy) maximal surgical resection plus IORT could render some long-term survivors among those surgical recurrent patients not candidates for radical surgery with curative intent.

Long survival of a patient with paratesticular rhabdomyosarcoma with inferior vena cava involvement.

A 13-year-old boy with a paratesticular embryonal rhabdomyosarcoma and a large thrombus into the inferior vena cava reaching the suprahepatic vein is presented. We used cardiopulmonary bypass with deep hypothermic circulatory arrest to realize a complete exeresis of the tumor and thrombus, followed by systemic chemotherapy and radiotherapy. Ten years later the patient is alive and doing well without any sequelae.

Use of biventricular circulatory support as bridge to simultaneous heart and kidney transplantation.

A 64-year-old man with dilated cardiomyopathy and chronic renal insufficiency (without dialysis) was admitted in cardiogenic shock urgently requiring a circulatory biventricular assist device (Thoratec). Twenty-nine days later we performed orthotopic cardiac and heterotopic renal transplantations with organs from the same donor. Postoperatively secondary renal insufficiency occurred due to rejection of the graft, bleeding ulcer with hypovolemic shock, and peritonitis due to Streptococcus faecalis and Candida. In the postoperative course only one rejection of the cardiac graft was detected. The patient was discharged after 4 months, resuming a normal life.

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.

[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.

[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.

[Prognostic value of the tissue expression of human chorionic gonadotropin (beta-HCG) in infiltrating transitional carcinoma of the bladder]. / Valor pronóstico de la expresión tisular de gonadotrofina coriónica humana (beta-HCG) en el carcinoma transicional infiltrante de vejiga.

Study of the ectopic secretion of Human Chorionic Gonadotrophin (beta-HCG) in the tumoral tissue of 62 patients diagnosed with infiltrant transitional carcinoma of the bladder. The inmunohistochemical tests showed specific stains in 15/62 patients. Bi-varied analysis showed that vesical tumours with beta-HCG ectopic expression present associated nodular disease with a significantly higher prevalence (p = 0.02). Survival of patients with beta-HCG+ tumours was overall lower that of patients with beta-HCG-tumours, but this difference did not reach statistical significance. Multivariate analysis of survival showed no prognostic value for the tissue expression of beta-HCG, when it is considered as an isolated variable. Complete local response was seen in 5/6 beta-HCG+ patients treated with pre-operative chemo and radiotherapy and in 1/4 patients treated with pre-operative radiotherapy. Tissular expression of beta-HCG is a poor prognostic factor due to its relationship with another 2 variables of larger predictive capability: the presence of metastatic nodular disease and the infiltration of venous and/or lymphatic structures of the vesical wall.

[Multivariate analysis of local response to preoperative treatment in patients with infiltrating carcinoma of the bladder]. / Análisis multivariado de la respuesta local al tratamiento preoperatorio en pacientes con carcinoma infiltrante de vejiga.

The article presents a multivariate study carried out by means of a logistic regression of local responses (reduction to stage p0, p1 or p 'in situ') in 82 patients with transitional infiltrant carcinoma of the bladder, undergoing 3 different types of radical therapy: 25 patients treated with TUR and radical cystectomy; 33 patients treated with TUR, pre-operative radiotherapy (45-60 Gy) and radical cystectomy; and 24 patients treated with TUR, intra-operative radiotherapy (15 Gy), external radiotherapy (46 Gy), neo-adjuvant chemotherapy and radical cystectomy. Local response increased with the intensity of pre-operative therapy, there being a better relationship with this approach than with the initial clinical stage of the tumour. The factors which better explain the prospect of an objective local response are the use of radiotherapy associated to chemotherapy and the absence of metastatic lymphatic nodes. These 2 variables can adequately predict the local response in 87% of patients.

[Shockwave cytotoxicity on neoplastic and non-neoplastic cells]. / Evaluación de la citotoxicidad de las ondas de choque sobre células tumorales y no tumorales.

Since initial application of high-energy shockwaves to treat renal lithiasis, their usefulness has been extended within both the clinical and experimental fields. Shockwaves cytotoxic action is determined by means of cell viability methods of vital staining exclusion and nucleoside uptake. Application of shockwaves on cell cultures is carried out by means of an electromagnetic lithotripter. High-energy shockwaves have had cytotoxic action both on non-tumoral and tumoral cells, during "in vitro" experiments. The cytotoxicity produced by the shockwaves, however, is different in tumoral and non-tumoral cells, the viability inhibition being higher in tumoral cells.

[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.

[Urachal cyst: an unusual cause of intestinal obstruction]. / Quiste de uraco: causa inusual de obstrucción intestinal.

Contribution of one case of urachal cyst in a patient initially diagnosed with intestinal obstruction due to a probable colon-sigma neoplasia. The patient underwent discharge colostomy after finding an extension of the likely tumour to abdominal wall, bladder and right ureter. Later, the patient was reassessed and the CT showed a mass in the bladder's anterior edge with disclosure of purulent material and inflammatory cytology through the PAAF. The treatment performed was partial cystectomy, closure of colostomy and rectum-sigma re-anastomosis. Histological diagnosis was urachal cyst, abscess and pyogenic membranes, with no evidence of tumoral tissue. The idiosyncrasy of this urachal cyst is the simulation of an intestinal obstructive process of tumoral origin. Differential diagnosis in these intestinal processes rarely includes urachal cyst.

[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.

[Errors in the clinical staging of prostatic cancer]. / Errores en el estadiaje clínico del cáncer de próstata.

The relationship between the clinical and pathological stages of clinically localized prostate cancer (PCa) was analyzed in 68 patients. All of then underwent ilio-obstructive lymphadenectomy and node affectation was found in 16 patients (23%). Out of 64 patients undergoing radical prostatectomy, 23 (36%) presented invasion of prostate capsule and/or seminal vesicle infiltration. Of the total 68 patients, 28 (41%) showed local dissemination and/or nodular affectation. A direct correlation was seen between clinical stage and both incidence of local dissemination and nodular affectation. Pre-operative PSA and tumoral grade were correlated to the pathological stage.

["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.