Unmanageable fever and granulomatous renal mass after intracavitary upper urinary tract bacillus Calmette-Guerin therapy.
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BCG Vaccine↗
Biomedical subjects
P Bassi
Publications and source records attributed to P Bassi.
The ablative effect of quarter dose bacillus Calmette-Guerin on a papillary marker lesion of the bladder.
PURPOSE: Low dose bacillus Calmette-Guerin (BCG) for stage TaT1 transitional cell carcinoma of the bladder has been given in various studies with the aim of decreasing side effects while maintaining the same efficacy as full dose bacillus Calmette-Guerin. However, its application in clinical practice remains controversial. We examined the ablative activity and incidence of side effects of intravesical quarter dose BCG given for a papillary marker lesion of the bladder. MATERIALS AND METHODS: Included in our study were 44 patients with primary or recurrent, multiple but no more than 10 lesions of stage pTaT1, grades 1 to 2 transitional cell carcinoma of the bladder. Intravesical treatment begun 14 days after the complete transurethral resection of all visible tumors except 1 marker lesion no larger than 1 cm. consisted of instillations of 30 mg. Connaught strain BCG diluted in 50 ml. saline once weekly for 6 consecutive weeks. Two weeks after the last instillation any residual tumor was completely resected. In cases of complete disappearance of the marker lesion deep biopsy of the tumor area was done. Urine cytology was also performed. RESULTS: There was a complete response in 27 of the 44 patients (61%), no response in 12 (27%) and progression to carcinoma in situ in 1 (2%), while the response was not evaluable in 4. Local side effects included dysuria in 54% of cases and macroscopic hematuria in 39%. Neither BCG induced infection nor BCG sepsis was observed. CONCLUSIONS: Quarter dose BCG has a clear ablative effect on superficial bladder cancer with a 61% response rate. Phase III trials are now required to compare its efficacy and toxicity to those of full dose BCG.
Adjuvants, Immunologic↗
Intracavitary therapy of noninvasive transitional cell carcinomas of the upper urinary tract. A review of the literature.
Noninvasive (stages Ta, T1, Tis) transitional cell carcinomas of the upper urinary tract are suitable for a conservative therapeutic approach. Intracavitary therapy (alone or as adjuvant treatment) has recently been proposed and successfully used by some authors. Even though bacillus Calmette-Guérin is the most frequent agent employed, chemotherapeutic drugs, such as mitomycin C and thiotepa, have also been successfully used. The current information available in the literature is therefore reviewed. According to the data available, intracavitary therapy is a worthwhile conservative therapeutic option for noninvasive upper urinary tract urotheliomas with acceptable side effects. For this reason it may be included in the routine urological armamentarium.
Adjuvants, Immunologic↗
[Superficial bladder neoplasia unresponsive to endocavitary treatment: when should the treatment approach be changed?].
PURPOSE: The appropriate treatment of superficial bladder neoplasm is still debated. The urologist must weigh the risk of tumor recurrence and progression against the possible side effects of conservative treatment (transurethral resection, intravesical therapy). Furthermore it is difficult to decide exactly when to abandon the conservative therapy and proceed with radical cystectomy and urinary diversion in order to prevent the potentially lethal sequelae of invasive bladder cancer. There are no certain scientific data on the appropriate therapeutic approach of recurrences of superficial bladder cancer after intravesical therapy and often the urologist takes a decision based on his personal experience ("art rather than science"). Based on these considerations, our aim was to evaluate applicable criteria to predict the risks of tumor recurrence and progression and so decide the best treatment for each patient. METHODS: 148 patients with multifocal, multirecurrent or persistent superficial bladder cancer (stage Ta-T1-Tis, G1-3) were treated with transurethral resection and/or two or more administration of intravesical chemo- (Mitomycin C, Doxorubicin, Epirubicin, Mitoxantron) or immuno-therapy (BCG) using common treatment schedule. Our first end point was the disease-free survival (DFS) evaluated by three different criteria: 1) "dynamic" stage (stage T1 diagnosed at the beginning, or during the follow-up or never); 2) "dynamic" grade (G3 tumor diagnosed at the beginning or during the follow-up or never); 3) "number of positive cystoscopies at the 3-year follow-up". Data were evaluated by a univariate statistical analysis (log-rank test) and a multivariate ones (MPLR stepwise procedure and L-ratio Cox's test). RESULTS: "Dynamic" stage: patients who never developed a T1 stage tumor have a better DFS than patients who developed a T1 stage tumor and even more than patients in which T1 was diagnosed from the beginning (p < 0.0001). "Dynamic" grade: patients who never developed a G3 tumor have a better DFS than patients who developed a G3 tumor and patients in which G3 tumor was diagnosed from the beginning (p < 0.0017). "Number of positive cystoscopies at the 3-year follow-up": patients with less than 3 positive cystoscopies have a better prognosis than patients with 3 or more positive cystoscopies at the three-year follow-up (p < 0.0380). DISCUSSION: We have found three independent predictive prognostic factors: "dynamic" stage, "dynamic" grade and number of positive cystoscopies at the 3-year follow-up. The statistical univariate and multivariate analyses allow us to define three risk categories for tumor progression (> or = T2): low, moderate, high.
Administration, Intravesical↗
Early spontaneous regression of a hypothalamic/chiasmatic mass in neurofibromatosis type 1: MR findings.
A patient with neurofibromatosis type 1 was found to have an enhancing mass in the hypothalamus and in the anterior optic pathway. A 3-month MR study showed a reduction in the size and enhancement of the mass. At a 9-month MR follow-up the mass disappeared and ceased to enhance. This report shows the unusual behaviour of a hypothalamic/chiasmatic mass confirming that in such asymptomatic cases the conservative management can be considered the treatment of choice.
Child, Preschool↗
Loss of FHIT expression in transitional cell carcinoma of the urinary bladder.
Cytogenetic and loss of heterozygosity (LOH) studies demonstrated chromosome 3p deletions in transitional cell carcinoma (TCC). We recently cloned the tumor suppressor gene FHIT (fragile histidine triad) at 3p14.2, one of the most frequently deleted chromosomal regions in TCC of the bladder, and showed that it is the target of environmental carcinogens. Abnormalities at the FHIT locus have been found in tumors of the lung, breast, cervix, head and neck, stomach, pancreas, and clear cell carcinoma of the kidney. We examined six TCC derived cell lines (SW780, T24, Hs228T, CRL7930, CRL7833, and HTB9) and 30 primary TCC of the bladder for the integrity of the FHIT transcript, using reverse transcriptase-polymerase chain reaction (RT-PCR) to investigate a potential role of the FHIT gene in TCC of the bladder. In addition, we tested expression of the Fhit protein in the six TCC-derived cell lines by Western blot analysis and in 85 specimens of primary TCCs by immunohistochemistry. Three of the six cell lines (50%) did not show the wild-type FHIT transcript, and Fhit protein was not detected in four of the six cell lines (67%) tested. Fhit expression also was correlated with pathological and clinical status. A significant correlation was observed between reduced Fhit expression and advanced stage of the tumors. Overall, 26 of 30 (87%) primary TCCs showed abnormal transcripts. Fhit protein was absent or greatly reduced in 61% of the TCCs analyzed by immunohistochemistry. These results suggested that loss of Fhit expression may be as important in the development of bladder cancer as it is for other neoplasms caused by environmental carcinogens.
Acid Anhydride Hydrolases↗
Quality of life after radical cystectomy and orthotopic bladder substitution: a comparison between Italian and Swedish men.
OBJECTIVE: To investigate possible differences between Italian and Swedish men in health-related quality of life (HRQL) after cystectomy and orthotopic bladder substitution for bladder cancer. PATIENTS AND METHODS: Thirty-three men in Padua, Italy and 33 in Lund, Sweden were assessed after respective mean postoperative periods of 42 and 52 months. Three questionnaires were used: (i) dealing with view-of-life issues; (ii) the core questionnaire QLQ-C30(+3) from the European Organization for Research and Treatment of Cancer, with added questions on urinary symptoms and sexuality; and (iii) one focusing on postoperative psychosocial and sexual adjustment. RESULTS: While Italian and Swedish men did not differ in their central values, they differed significantly in belief-related values, such as religion. Urinary problems and erectile dysfunction were common in both groups, the former possibly commoner in the Swedish men and the latter in the Italians. Changes in mood and self-esteem were common in both groups. On a visual analogue scale, the Italian men reported a worse present mood than the Swedish men, but expressed a more favourable outlook on their future. CONCLUSION: Despite differences in philosophical attitudes between Italian and Swedish men, there were no major differences in HRQL. Caution is required in interpreting these findings because there were few participants and the possible inadequacy of the methods used to evaluate the complex concept of quality of life.
Adult↗
Outcome of radical cystectomy for invasive bladder cancer.
Even though radical cystectomy still remains the 'gold standard' for the treatment of invasive bladder cancer, newer insights and developments are entering the urological arena: a 'tailored' surgical approach combining a less extensive procedure and a better quality of life seems feasible for selected patients without compromising the outcome; the type of urinary diversion has no impact on the risk of complications, the ability to receive postoperative salvage treatments and the natural history of the disease; the depth of extension of the tumour and the nodal involvement are the only independent 'classical' predictors of survival after radical cystectomy; pelvic node dissection is curative in patients with limited nodal involvement; the clinical application of newer molecular prognostic factors still remains controversial.
Cystectomy↗
Modified induction course: a solution to side-effects?
Side-effects are commonly manifested during intravesical Bacillus Calmette-Guérin (BCG) immunotherapy of superficial bladder cancer. This often causes delays or interruptions of the instillations and consequently reduces the efficacy of treatment. Treatment strategies aimed at reducing the side-effects of BCG immunotherapy while maintaining efficacy are currently being considered in the search for an optimal treatment regimen. The following two approaches to BCG immunotherapy were investigated at the Department of Urology of Padova University by specific Phase II and III trials designed to evaluate the possibility of reducing BCG-related side-effects without compromising therapeutic efficacy: (1) by reducing the dose of BCG per instillation 'low-dose' regimen, (2) by delaying the interval of the instillations 'slow-rate' regimen.
Administration, Intravesical↗
[Radiologic diagnosis of spondylodiscitis: role of magnetic resonance].
PURPOSE: To report the Magnetic Resonance Imaging (MRI) features of acute and chronic spontaneous spondylodiscitis as well as any typical patterns which can be useful for the differential diagnosis between pyogenic and tuberculous forms. MATERIAL AND METHODS: Eleven patients affected with spontaneous spondylodiscitis were selected for the study; they were 7 men and 4 women ranging in age 33-87 years (mean: 64). We excluded the patients with iatrogenic spondylodiscitis. MR images were acquired with a superconductive magnet at 1.5, with the following sequences: sagittal PD and T2-weighted TSE, sagittal T1-weighted SE, axial PD and T2-weighted TSE for the lumbar spine, axial T2-weighted GRE for the cervical and dorsal spine and axial and sagittal T1-weighted SE after contrast agent (gadolinium DTPA) injection. MR images were reviewed by three experienced radiologists and morphological and signal intensity changes of vertebral body and disk were recorded on a standard form. In 9 patients it was possible to compare MR to CT findings. RESULTS: At the time of our observation all patients reported pain at the spine level, associated with fever and weight loss in 50% of cases and with increased values of the inflammatory markers. Three patients had infectious diseases in other organs and 2 were diabetics. Biopsy was performed in two cases only and demonstrated Staphylococcus aureus in one and Mycobacterium tuberculosis in the other patient. MRI allowed the correct diagnosis to be made in all cases, demonstrating the pathological involvement of the paravertebral structures and into the spinal canal earlier and more accurately than CT. A common finding in pyogenic and tuberculous spondylodiscitis was the low signal of the subcortical bone marrow on T1-weighted sagittal images, which enhanced after Gd-DTPA administration and became intermediate or high on T2-weighted images. Moreover, the steady high signal intensity of the disk on T2-weighted images and its contrast enhancement on T1-weighted images is typical for an acute inflammatory process. CONCLUSIONS: Based on our personal experience and literature data, we believe MRI to be the most sensitive technique for the diagnosis of spondylodiscitis in the acute phase, whereas it is comparable to CT in the chronic stage of the disease. At present MRI does not allow to differentiate pyogenic from tuberculous forms.
Acute Disease↗
Comparison of the BTA stat test with voided urine cytology and bladder wash cytology in the diagnosis and monitoring of bladder cancer.
OBJECTIVE: To compare the BTA stat test (BTA stat), a new one-step immunochromatographic assay that can be performed in the urologist's office or in the laboratory, to voided urine cytology and bladder wash cytology (cytology) in the diagnosis and monitoring of cancer of the bladder (BC). METHODS: BTA stat and cytology were performed in a double-blinded, prospective, clinical study on specimens from 240 subjects (68 females; mean age of subjects: 64 years) suspected of having BC. RESULTS: In 107 subjects with final diagnoses of BC confirmed by cystoscopy or cystoscopy and biopsy, the overall sensitivities of BTA stat and cytology were 65 and 33%, respectively. For tumor grades I, II, and III, the sensitivities of BTA stat were 39, 67 and 83%, respectively. Those of cytology were 4, 20 and 69%. Nine subjects had a diagnosis of 'suspicious for bladder cancer'. The specificities of BTA stat and cytology in the 124 subjects without BC were 64 and 99%, respectively. In the subjects with a history of BC (n = 74), the specificities of BTA stat and cytology were 72 and 99%, respectively. The specificity of BTA stat was lower in subjects with benign or malignant genitourinary disease other than BC (46%) than in subjects without genitourinary disease (71%). CONCLUSIONS: The BTA stat test is considerably more sensitive than cytology in the detection of BC and can replace cytology as an adjunct to cystoscopy in the diagnosis and follow-up of patients with BC. However, due to low specificity, BTA stat should not be used without first ruling out potential interferences such as infections, renal disease and cancer, or genitourinary trauma.
Adult↗
Multicenter trial of the quantitative BTA TRAK assay in the detection of bladder cancer.
BACKGROUND: Human complement factor H-related protein (hCFHrp) is produced by several bladder cancer cell lines and may be useful as a cancer marker. The aim of this study was to compare urinary hCFHrp and cytology for the detection of bladder cancer found by cystoscopy in patients with suggestive signs, symptoms, or preliminary test results. METHODS: The BTA TRAK assay, a quantitative enzyme immunoassay for the bladder tumor-associated antigen in urine, was compared with exfoliative cytology in 220 patients (155 men, 65 women; mean age, 64.2 years) presenting with signs, symptoms, or preliminary diagnostic results suggestive of this disease. Cystoscopy was the standard of detection. RESULTS: In the 100 patients found to have bladder cancer, the overall sensitivities of the BTA TRAK assay (at a previously determined decision threshold of 14 kilounits/L) and cytology were 66% (66 of 100) and 33% (33 of 100), respectively (P <0.001). The BTA TRAK assay proved to be statistically more sensitive than cytology for tumor grades I and II and for stage Ta and T1 tumors. In contrast, the overall specificity of the BTA TRAK assay in the 120 patients without cystoscopically confirmed bladder cancer was 69% (83 of 120) and that of cytology was 99% (119 of 120; P <0.001). The specificity of the BTA TRAK assay was higher in patients without benign or malignant genitourinary disease other than bladder cancer (76%; n = 89) than in patients with these conditions. When the BTA TRAK assay and cytology were used together such that a positive result in either test was scored as positive and the results compared with those of the BTA TRAK assay alone, increases in overall sensitivity and equivalent specificity were observed. CONCLUSION: Because of its relatively high sensitivity, the BTA TRAK assay could complement cytology as an adjunct to cystoscopy in the diagnosis and follow-up of most patients with bladder cancer.
Adult↗
Prognostic factors of outcome after radical cystectomy for bladder cancer: a retrospective study of a homogeneous patient cohort.
PURPOSE: Pathological predictors of outcome for patients undergoing radical cystectomy for bladder cancer are needed as few data are available in the literature. We retrospectively analyzed a homogeneous and contemporary series of patients treated with radical surgery as monotherapy for bladder cancer to identify the independent predictors of survival. MATERIALS AND METHODS: We evaluated 369 of 535 patients with bladder cancer treated with radical cystectomy, pelvic node dissection and urinary diversion by the same staff at a single institution between February 1982 and February 1994. Patients treated with radiation therapy and/or chemotherapy, and those who did not undergo formal pelvic node dissection were excluded from study. The end point of univariate and multivariate analyses was the overall 5-year survival. RESULTS: Univariate analysis revealed that tumor stage, nodal involvement, ureteral obstruction, and vascular, lymphatic and perineural invasion were prognostic predictors of survival (p <0.05). However, only tumor stage (p <0.0000) and nodal involvement (p <0.0000) were independent prognostic variables of survival on multivariate analysis. CONCLUSIONS: Tumor stage and nodal involvement are the only independent predictors of survival to be used to select the optimal therapy after radical cystectomy, stratify patients in controlled trials and evaluate new prognostic factors.
Adult↗
Structural and ultrastructural changes in ileal neobladder mucosa: a 7-year follow-up.
OBJECTIVE: To investigate the long-term morphological changes in the intestinal segment used to create an orthotopic ileal neobladder. MATERIALS AND METHODS: Periodic endoscopy with biopsy of the ileal mucosa was performed in 90 patients 3-84 months after radical cystectomy and urinary diversion via an orthotopic neobladder. Three cold-cup biopsies were taken from each patient and mucosal specimens processed for light and electronic microscopy. RESULTS: Early changes (up to 1 year after surgery) comprised a marked shortening of the villi with loss of microvilli. After 4 years, the prevalent finding was of flat, avillous epithelium that tended to stratify in some areas. The avillous areas were mixed with islets of villous mucosa. There was no dysplasia or malignancy in any of the 90 patients. CONCLUSIONS: Prolonged contact with urine elicited a biphasic response in the ileal mucosa, i.e. an early inflammatory phase, ascribed to the noxious action of urine, followed by a regressive phase in which the epithelium tended to assume a morphology similar to the urothelium. The atrophic changes were almost totally completed after 4 years, although areas with marked modifications alternated with others where the morphology was normal, even many years after surgery. Late changes in the ileal neobladder mucosa appear to be an expression of a functional adaptation of the mucosa to the new environment.
Follow-Up Studies↗
[Ovarian lymphoma. Findings with ultrasonography, computerized tomography and magnetic resonance].
PURPOSE: Lymphomatous ovarian involvement is an uncommon event, both for primary and systemic lymphoma. It presents different diagnostic and therapeutic implications from the more common ovarian epithelial cancer. We investigated the role of imaging techniques in the diagnosis of these lesions. MATERIAL AND METHODS: Eight patients, aged 13 to 70 years (mean: 47) were selected from all the CT examinations performed from 1986 to 1996 to assess the most typical imaging patterns. All the patients underwent a CT examination, with contiguous 8 or 10 mm thick slices and thin (4-5 mm) detailing slices; iodinated contrast agents were administered in 6 cases. Six patients were also examined with sonography (US). Lastly, 3 patients underwent a MR examination, 2 of them with paramagnetic contrast agent. RESULTS: All the patients were affected with non-Hodgkin lymphoma (6 diffuse lymphomas--1 lymphoplasmocytoid, 2 Burkitt, 1 large cells, 1 large and oat cells, 1 immunoblastic large cells, 2 follicular large cells lymphomas). Two patients had primary lesions and the other 6 had a systemic lymphoma; ovarian involvement was bilateral in 6 cases. The lesion size always exceeded 5 cm. Ascitis was present in only one case. The US patterns of the lesions were aspecific, homogeneous and hypoechoic; color Doppler US showed mild vascularization. CT showed clear-cut lesions, hypodense and with mild contrast enhancement in all cases. Spin-echo MRI showed homogeneous masses which were moderately hypointense on T1-weighted images and slightly hyperintense on T2-weighted images. Gd-T1-weighted images showed mild enhancement. DISCUSSION: The differential diagnosis of ovarian primary lymphoma is usually made with ovarian epithelial neoplasms, which normally have a complex structure with cystic or necrotic areas and solid components usually enhancing after contrast agent administration. Also sarcomas and, in children, neuroblastomas usually have an inhomogeneous structure. In ovarian involvement with systemic lymphoma the concrurrent finding of adenopathy can help the diagnosis. CONCLUSIONS: Despite the absence of typical imaging patterns, we emphasize the importance of considering ovarian lymphoma in the differential diagnosis of ovarian cancers, especially if bilateral and homogeneous, without ascitis. These findings, uncommon in ovarian epithelial tumors, can help to make the correct diagnosis.
Adolescent↗
Pancreatic metastases: CT assessment.
We report the CT appearance of pancreatic metastases and describe their features in relation to the originating primary tumor. We also discuss some limitations in their differential diagnosis and report some theories explaining the pathogenesis of their occurrence. A total of 20 cases (9 males and 11 females) of pancreatic metastases were diagnosed at staging or follow-up of oncologic patients. All patients were evaluated with CT before and after contrast medium administration and had subsequent pathologic confirmation. In 1 case metastases were located solely in the pancreas; in 6 there was only another metastatic location, and in the remaining 13 there was diffuse spread throughout the body. Two of our patients exhibited a multinodular metastatic involvement of the pancreas, 11 had a solitary nodule or mass, and the remaining 7 had a diffusely enlarged pancreas, without any signs of focal disease. All but one of the solitary lesions measured more than 4 cm. In 2 cases a metachronous malignancy was detected at follow-up. Primary malignancies were located: 6 in the lungs, 2 on the skin (melanomas), 3 in breasts, 2 in the ovaries, 3 in the colon, 1 in the stomach, 2 in the kidney, and 1 the thyroid. Our findings confirm the existence of three patterns of metastatization to the pancreas: large solitary masses, multinodular lesions, and diffuse enlargement of the pancreas without focal signs at CT. In contrast to other studies, the large solitary lesion was our most frequent encounter, therefore making differential diagnosis vs primary cancer difficult. Metastases tended to repeat the imaging pattern of the primary. Nevertheless, we wrongly diagnosed pancreatitis due to a small nondetected metastasis, pseudo-cystic mass as a mucinous cystadenocarcinoma, conglomerate of peripancreatic lymph nodes, and a solitary pancreatic mass diagnosed as primary pancreatic cancer. Thus, when faced with a solitary pancreatic lesion at follow-up, histologic diagnosis is strongly recommended. In 2 cases changes in aspect and size were related to therapy.
Adult↗
["Snow storm" ultrasonography pattern in multiple organs in a patient with AIDS and disseminated Mycobacterium avium intracellulare infection].
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Acquired Immunodeficiency Syndrome↗
[Vesica ileale Padovana (VIP): surgical technique, long-term functional evaluation, complications and management].
OBJECTIVE: An original technique for complete bladder replacement using an ileal segment--the VIP pouch--is described. The long-term functional results and early and late complications are presented. METHODS: The records of 209 VIPs performed following radical cystectomy for invasive bladder cancer from 1987 through 1995 were reviewed. Follow-up ranged from 6 to 87 months (mean: 24 mo.); the age of the patients ranged from 35 to 76 years (mean: 59.6 yrs.). RESULTS: 188 patients with a follow-up of at least 6 months have been evaluated. There was 1 postoperative death from massive pulmonary embolism, 23 pts. died from tumor progression and 4 are still alive with metastases. Early complications were observed in 10.5% of the pts., comprising 9 cases of prolonged ileus (5 functional and 4 obstructive), 3 pelvic hematomas, 2 deep venous thrombosis and 2 fistulas between the enteric anastomosis and the VIP pouch. Late complications were observed in 39.5%, in particular, 28 uretero-ileal stenosis (15%), 21 urethro-ileal stenosis (11%) and 15 laparoceles (8%). Clinically relevant metabolic disturbance has not been observed. Complete daytime continence was achieved in more than 90% of the cases and night-time continence was observed in 75% of the patients. The mean VIP manometric capacity was around 400 ml with low pressure during reservoir emptying; 39 patients (20%), showed voiding problems with a mean postmicturition residual of 150 ml (3 pts. require clean intermittent self-catheterization). CONCLUSIONS: VIP offers a simple and easy-to-perform surgical technique to provide a good capacity, low pressure, non refluxing reservoir employing only a 40 cm. ileal segment. The clinical and urodynamic results are good and offer high quality of life to patients undergoing cystectomy. The overall rate of late complications is fairly high, although conservative management is effective in most cases.
Adult↗