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We reviewed the sonographic, CT and angiographic findings in 19 patients with infiltrating transitional cell carcinoma of the kidney. Sonography revealed a defect of the central echo in 18 patients, and a low or slightly low echoic tumor in 15. Enhanced CT showed a poorly marginated tumor with lower attenuation than that of normal parenchyma in all 8 patients examined. Angiography showed narrowing and stretching of interlobar and arcuate arteries arranged radially from the renal hilus in all 11 patients examined and fine neovascularity in 10. These findings, especially the angiographic findings, were useful for distinguishing this disease from the common type renal cell carcinomas, and other infiltrating diseases of the kidney, such as lymphomas and sarcomas. Since the prognoses of these patients were poor with 1- and 2-year survival rates of 11.6 and 5.8%, respectively, careful examination of the above-mentioned findings was stressed to diagnose this disease.
To examine clinical features and the prognostic factors for renal function in patients with autosomal dominant polycystic kidney disease (ADPKD), a total of 118 patients (60 men and 58 women) were followed for 3 to 192 months (mean 77 months). The mean age of men at the diagnosis of ADPKD was younger than that of women. Main Symptoms were hematuria, hypertension and proteinuria. Forty-one % of the patients showed deterioration of renal function at the diagnosis. The rate of residual volume of renal parenchyma on CT findings was correlated well with renal function. Twenty-eight % of the patients preserved good and stable renal functions for over 5 years, while most of others had deterioration in their renal function. Thirty-four % of the patients started dialysis within 79 +/- 62 months from the diagnosis. The frequency of end stage renal failure was 7% at 40 years, 21% at 50 years, 36% at 60 years and 63% at 70 years old, respectively. Men needed hemodialysis at younger ages than women. Renal function of the patients with hypertension was worse than that of the patients without hypertension. The ratio of the value of P.S.P.120 to that of serum creatinine (PSP120/sCr), and the rate of residual volume of renal parenchyma revealed distinct prognostic factors for renal function.
The effects of chemotherapy on the metastasis of retroperitoneal lymph nodes from testicular cancer have been generally evaluated with bi-dimensional imaging methods. Since the structure of these lymph nodes seems to be complicated, it is expected that three dimensional imaging methods could achieve more correct evaluation of the disease extension and the treatment effects when compared with bi-dimensional ones. The present study was undertaken to reconstruct the three dimensional imaging from CT films using personal computer system. Twenty one patients with bulky retroperitoneal nodal metastases were examined before and after chemotherapy. The evaluation of treatment effects based on three dimensional imaging method reflected the clinical course more adequately than the bi-dimensional one. When shrinkage rate of the tumor volume was less than 65%, viable tumor cells remained in all cases. Only one of six cases with more than 90% shrinkage revealed viable tumor cells. All patients in whom the metastases were estimated to be more than 100 cm3 in volume before chemotherapy and less than 50 cm3 after chemotherapy were shown to have completely necrotic tissues. In conclusion, three dimensional imaging was useful to estimate the post-treatment volume and shrinkage rate which correlated to the effects of treatment and prognosis.
Forty patients who had transitional cell carcinoma of the bladder with positive pelvic lymph node metastasis, treated at Chiba University Hospital between April 1975 and March 1991 were investigated to evaluate the significance of pelvic lymph node dissection. The frequency of the patients with positive lymph node was 9.1% in all patients with transitional cell carcinoma of the urinary bladder, 4.0% in the clinical T1, 3.4% in T2, 35.7% in T3a, 32.1% in T3b, 46.2% in T4, and none in Tis and Ta. Of the 40 patients, 16 underwent cystectomy pelvic lymph node dissection, 19 had biopsy of suspicious lymph nodes which turned out to be positive for metastasis, and 5 were defined by computed tomography. Pelvic lymph node dissection was performed at the common iliac, presacral, external iliac, internal iliac, and obturator nodes. In the 16 patients who underwent cystectomy with pelvic lymph node dissection, the frequency of metastasis in each nodal group was 38% in common iliac, 31% in external iliac and obturator, and 25% in presacral and internal iliac. Out of the 16 patients, eight had regional lymphatic metastasis, three had only extra regional lymph node metastasis, and five had both regional and extra regional metastasis. Three of nine patients who had single positive node had common iliac or presacral positive node without regional lymph node metastasis.
A randomized clinical trial of neoadjuvant endocrine therapy followed by either surgery or irradiation and a resumption of endocrine therapy for stages B2 and C prostate cancer has been in progress since 1989. A hundred patients entered the trial between 1989 and 1993, and 95 cases were evaluated. Forty-six patients received surgery and 49 were treated with irradiation. Neoadjuvant endocrine therapy for two months resulted in prostate shrinkage and prostate specific antigen lowering. Except for two patients, one dying of a progression of disease and the other of another concurrent cancer, all are alive with an average follow-up term of 25 (range 3-53) months. The good prognostic results obtained from both treatment groups at present seem to be due in part to the neoadjuvant endocrine therapy; but in order to reach a final conclusion further comparisons need to be made.
The frequency of integration with human papillomavirus (HPV) and its genotypes in Japanese penile cancer was examined with relation to p53 gene mutations using polymerase chain reaction amplification. Tissues were obtained from 13 patients (eight from freshly frozen and five from paraffin-embedded samples). HPV DNA was detected in seven out of the 13 (54%), and their genotypes were type 16 in four, type 31 in one and type 33 in two cases. Neither HPV-detected nor -undetected tissues showed mutated alterations in exons 4-9 of p53 genes. The results suggest HPV to be, at least to some extent, involved in the oncogenesis of penile cancer, and that p53 gene mutations may not correlate with the development of penile cancer.
A huge rectosigmoidal cancer which extended into the urinary bladder in a 64-year-old man is herein described. The tumor occupied the pelvic and lower abdominal cavities, while the rectosigmoid was totally obstructed. No hepatic or pulmonary metastasis was evident. The ventral and flank sides of the peritoneum in the right lower abdomen, right common iliac vessels, bilateral ureters, terminal ileum, cecum, ascending colon, and urinary bladder were all directly invaded by the tumor, but the aorta, sacrum, and lower rectum were free of cancer. Consequently, an anterior pelvic exenteration was carried out along with an ileal conduit and a right hemicolectomy. Immediately after the exenteration, intra-pelvic hyperthermochemotherapy was performed using a 46-47 degrees C perfusate containing 40 micrograms/ml of mitomycin C (MMC) and 200 micrograms/ml of cisplatin (CDDP), for 90 min, in an attempt to prevent any further local recurrence. A right hemicolectomy and a permanent colostomy were done simultaneously with the hyperthermia treatment. After an uneventful postoperative course, the patient was prescribed adjuvant chemotherapy, i.e., two administrations of 17 mg/m2 and 21 mg/m2 of MMC, and ten doses of 710 mg/m2 of 5-fluorouracil (5-FU) followed by five doses of 535 mg/m2 of 5-FU. At the time of this writing, the patient is still alive without recurrence at 21 months after surgery.
This paper reviews the theoretical development of automatic control strategies for arterial blood pressure regulation. The literature is classified by control strategy. Proportional-integral-derivative controllers, optimal controllers, adaptive controllers, and rule-based controllers are the most commonly encountered strategies in the literature. A brief description of each control scheme is given, followed by examples of each from the literature. Validation methods for the control performance vary from computer simulations to clinical tests on human patients. A number of reports of clinical success support the feasibility of advanced control systems in this problem. Issues on control systems in the clinical environment are also discussed.
Assessing the QOL in cancer clinical trials is becoming increasingly important. However, a suitable device of assessment of QOL has not been developed yet for prostate cancer patients in Japan. We tried to assess the QOL of prostate cancer patients using the EORTC questionnaire translated in Japanese, and examined its validity and reliability. Thirty-six patients filled in a questionnaire. The reliability of this device was confirmed by the results of test-retest reproducibility. Good correlation was shown between the results and patients performance status, and between the results and clinical stages, which support the validity of the device. As for the results of assessment of QOL, these patients were severely damaged in sexuality. Those factors of functional status, physical symptoms and fatigue/malaise were closely related to disease activity and clinical stage.
Argyrophilic Nucleolar Organizer Regions (AgNORs) were examined in 96 patients with renal cell carcinoma undergoing nephrectomy at Department of Urology, Chiba University Hospital during 1985-1990. Silver staining was performed with one-step method described by Ploton5), and average numbers of grains in a cell were obtained by counting 100 cells. Numbers of AgNORs were increased along with up grading. When AgNORs were compared in various cell types, the number in pleomorphic and spindle types and that in Bellini duct carcinomas were more than that in common types. The number of AgNORs correlated with pT and pV factors, but no relationship was shown between the number and these factors when compared in the same grade. The tumor size correlated with the number of AgNORs. The number of AgNORs in the primary legion showed a reversed correlation with doubling times calculated from either primary, recurrent or metastatic legions examined in 22 cases. In all cases it tended that the number of AgNORs correlated with survival, however survival in G3 cases was not influenced due to worse prognosis. It was concluded that the number of AgNORs in renal cell carcinoma was an additional factor for estimating the properties of tumor cells.
To predict histological grade of renal cell carcinoma preoperatively, an equation using plasma immunosuppressive acidic protein (IAP) level and tumor diameter was proposed. Between April 1977 and December 1991, 281 patients, 195 males and 86 females, aged between 20 and 84-year-old, were operated at our institutions. Multivariate analysis was performed to detect relationship between tumor grade and various factors that have continuous quantity. Among plasma components tested, plasma IAP levels showed the best correlation with grade (r value = 0.526, n = 157). Tumor diameter also showed correlation with grade (r value = 0.476, n = 273). Therefore, these two factors were used as variates. Discriminant analysis was applied to differentiate the patients with grade 1 or grade 2 tumor from those with grade 3 ones. From this analysis the linear function was obtained; z = 6.9429 - 0.0048x1 - 0.4118x2 (x1: IAP (micrograms/ml), x2: diameter (cm)). Tumor was assumed to be grade 1 or grade 2 when z value was positive, and it was assumed to be grade 3 when z value was negative. Overall accuracy was 87.7%. Positive predictive value of grade 1 or grade 2 tumor, and grade 3 tumor was 91.7% and 77.8%, respectively. Sensitivity was 90.9% for grade 1 or grade 2 tumor, and 79.5% for grade 3 tumor. As a result, it's possible to estimate tumor grade before operation using discriminant analysis in patients with renal cell carcinoma.
We report a patient who developed a fistula between the right ureter and the right common iliac artery aneurysm. He had had replacement of a synthetic graft for abdominal aortic aneurysm sixteen years previously. The diagnosis was confirmed by angiography, retrograde pyelography and computed tomography. The fistula was treated by right nephroureterectomy and resection of right common iliac artery aneurysm. A brief description of the case is provided and the review of the literature is described.
X-ray findings of bone metastatic lesions from 81 cases of stage D2 prostatic cancer were examined before and following endocrine therapy. Untreated lesions were classified into five types; osteoblastic (15%), mixed, but mainly osteoblastic (31%), mixed, but mainly osteolytic (17%), osteolytic (10%), and undetermined with a positive bone scan (27%). Patients with two mixed types had a tendency of widely speeded areas of metastasis and elevated serum prostatic acid phosphatase. Temporal enlargement of sclerotic lesion immediately after the start of therapy did not indicate disease progression. In many cases, changes from osteolytic to osteoblastic patterns were noticed in the same lesion regardless of the effects of endocrine therapy. Remodeling to the sclerotic pattern appeared as curative changes. From these findings, it was concluded that the natural course of bone lesions showed a tendency to change from the osteolytic to osteoblastic type and relapse was often accompanied by an increase of the osteolytic type lesion. Evaluation of therapeutic effects based on remodeling, changes in number and areas of lesions, and the appearance of new lesion correlated well with prognosis.
A multicentric randomised trial was conducted for the purpose of investigating the efficacy of intravesical chemoprophylaxis of superficial bladder cancers. A total of 443 patients (number of evaluable patients, 284) were registered from July 1987 to December 1989 and randomised into 3 groups. Group A received 21 intravesical instillations of Adriamycin (ADM) at 20 mg/40 ml physiological saline for 2 years after undergoing transurethral resection (TUR); group B was given the same dose as group A but received 6 intravesical instillations for 2 weeks before undergoing TUR; and group C served as a control and underwent TUR only. Better prophylactic effects were obtained in group A. The overall non-recurrence rates calculated for groups A and B differed significantly (P less than 0.05) on day 240, and those determined for groups A and C were also significantly different (P less than 0.01) on day 480. No benefit was obtained using intravesical instillation prior to TUR (group B). The major side effects encountered were pollakisuria and miction pain, which occurred in 32% of the patients in group A and in 52% of those in group B.
Long-term results were analyzed in terms of tumor progression and survival in patients with superficial bladder cancer who were enrolled in the second intravesical chemoprophylactic study of the Japanese Urological Cancer Research Group for Adriamycin, which was started in July 1982. This study was a prospective, randomized, controlled trial conducted on primary tumors treated with a long-term instillation regimen that involved control versus intravesical instillations of Adriamycin or mitomycin C given once a week for the first 2 weeks, once every other week for 14 weeks, once a month for 8 months, and once every 3 months for 1 year, for a total of 21 instillations in 2 years. An analysis of the prophylactic effects of such treatment on bladder tumors after TUR has previously been performed, and the results have been published elsewhere. The present study represents a follow-up of the above trial. Of the 671 cases previously analyzed with regard to tumor prophylaxis, 158 cases (23.5%) were eligible to be followed for tumor progression and survival. A detailed comparison of the background factors between these 158 patients and the other 513 cases revealed no statistically significant difference. Thus, the 158 evaluable cases might reasonably be considered to represent all patients enrolled in the second study, and the results were thought to be reasonable enough to reflect the long-term efficacy of the long-term instillation regimen adopted in this study. The median follow-up for these 158 cases was 6.6 years. Tumor progression in terms of the disease stage and/or grade occurred in 43 of 127 patients who received prophylactic instillations and in 12 of 31 control cases. No significant difference in the incidence of tumor progression was found between the treatment and the control groups. In addition, no difference in survival was observed between the treatment group and the control group. Survival was also compared between patients who showed tumor progression and those who did not. All patients whose tumors did not progress survived, whereas the 7-year survival of those exhibiting tumor progression was less than 90%.
Intravesical chemotherapy involving the sequential instillation of mitomycin C (MMC) and Adriamycin (ADM) was performed in 40 patients with superficial bladder cancer (pathological stages Ta and T1). In all, 20 mg MMC on day 1 and 30 mg ADM on day 2 were instilled into the bladder. This treatment was repeated weekly for 6 consecutive weeks and then monthly for 22 months in cases patients who did not experience serious side effects. A total of 20 patients were treated for multiple recurrences, and the efficacy was evaluated. In all, 9 subjects (45%) achieved a complete response and 6 (30%) showed a partial response, for an overall response rate of 75%. The other 20 patients, including 9 with primary multiple or high-grade tumors and 11 with recurrent tumors, received prophylactic instillation therapy after undergoing transurethral resection (TUR) of their lesions. Of the 9 primary cases, 3 recurred at 19, 8, and 3 months after TUR, respectively, whereas 6 showed no recurrence over a mean follow-up period of 14 months. Of the 11 recurrent cases, the 100-patient-month recurrence rate of 11.9 obtained prior to this treatment fell to 1.4 after the start of therapy. Chemical cystitis was observed in 20 of the 40 patients treated, but the symptoms were transient and tolerable.
In a cooperative study of the Japanese Urological Cancer Research Group for Adriamycin, the usefulness of chemotherapy with methotrexate, vinblastine, Adriamycin, and cisplatin (M-VAC therapy) in treating advanced or recurrent bladder cancer was examined. Evaluation of the clinical responses obtained in 86 evaluable patients revealed 13 complete responses, 29 partial responses, 4 minor responses, 19 cases of no change, and 21 cases of progressive disease. The overall response rate was 48.8% (42/86). The rate of response to M-VAC therapy at each disease site was as low as 21.4% (3/14) in bone lesions but exceeded 40% in the primary lesion, the lymph nodes, the lung, the liver, and other lesions. The clinical response to M-VAC therapy was not significantly influenced by the performance status of the patients, the dose intensity, or previous therapy. The median duration of response for the 42 responders was 22.7 weeks (range, 8.1-134.1 weeks), and the median duration of survival for the 86 evaluable patients was 9.8 months. Side effects were frequently encountered; the patients experienced anorexia, nausea, vomiting, malaise, alopecia, and leukopenia, but all of these symptoms were tolerable.