Chronic hematuria and localized bladder damage following combined cyclophosphamide and local radiotherapy.

A 13-year-old white male had Ewing sarcoma of the right pubic and ischial bones. Initial therapy consisted of 5,400 rads in seven weeks to the right side of the pelvis and 14 intravenous injections of cyclophosphamide (Cytoxan, CTX) at 500 mg/m2; BCNU and Adriamycin maintenance therapy continued for a total of two years. He has now been disease-free for five years. Three months following the completion of the right pelvic radiotherapy (RT), while on intravenous CTX, severe hematuria appeared, which subsided, but at present he has continuous microscopic hematuria, as well as periodic episodes of gross hematuria. Serial cystocopies initially revealed thickening and hemorrhagic and edematous changes on the right (irradiated) side of the bladder, and recent multiple telangiectatic patches have been demonstrated as a late "healing" phase. This case demonstrates the additive toxicity to the bladder of CTX and RT, illustrating that the hemorrhagic cystitis can be extremely protracted lasting five years.     

Fine-needle aspiration of metastatic lesions and regional lymph nodes in genitourinary cancer

A percutaneous fine-needle aspiration biopsy of metastatic tumor and/or retroperitoneal, pelvic, or abdominal lymph nodes was accomplished in 101 patients. A diagnosis of metastatic disease was confirmed by this method in 49 patients. In 26 patients, surgical excisional biopsy or exploratory laparotomy was avoided. An unknown pelvic mass causation was diagnosed in 3 patients. In 15 of 57 patients with localized bladder, prostate, or testis cancer, involvement of regional lymph nodes was confirmed by transabdominal fine-needle aspiration. All 57 transabdominal aspirations were performed without complications. The method is inexpensive, safe, and can have a high accuracy in diagnosing a local tumor spread or distant metastases.     

Shigella sonnei bacteremia. Unusual antibody response from immunosuppressive therapy following renal transplantation

Shigella sonnei bacteremia developed in a patient who had undergone renal transplantation and immunosuppressive therapy; following treatment with chloramphenicol and lincomycin, the patient recovered from the infection. Possibly because of the concurrent immunosuppressive therapy, the patient had only a modest antibody response against the infecting microorganism but, unexpectedly, produced antibodies in high titer against a recently recognized antigen shared by enteric bacteria.     

Changing concepts in the treatment of advanced seminomatous tumors

The treatment of patients with advanced seminomatous tumors represents a challenge for the medical and urological oncologists. In contrast to the reported excellent results of radiotherapy in the treatment of patients with clinical stages I and II disease the survival rate for those with advanced seminomatous disease is only around 40 per cent. Six consecutive patients with metastatic seminomas were treated with systemic chemotherapy and all achieved a complete response. The combination of vincristine, cis-platinum, bleomycin and prednisone was used in 4 patients and an excellent tolerance was observed even in patients with previous radiation therapy. Two other patients who had had radiation therapy to the mediastinum were treated with VP-16 and cis-platinum and again a complete response was observed. However, a significant potentiation of myelosuppressive effect of VP-16 was observed in the previously radiated patients. In view of the observed sensitivity of seminomatous tumors it appears that all patients who present initially with metastatic or bulky retroperitoneal disease should be treated with multiple drug chemotherapy and cytoreductive surgery similar to the treatment modalities used for nonseminomatous germ cell tumors. Radiation therapy for patients with this stage of the disease seems to be not only ineffective but also may compromise the benefits of aggressive chemotherapy.     

RTOG 97-06: initial report of a phase I-II trial of selective bladder conservation using TURBT, twice-daily accelerated irradiation sensitized with cisplatin, and adjuvant MCV combination chemotherapy

To examine combination cisplatin and twice-daily accelerated irradiation (RT) after aggressive transurethral resection of bladder tumor (TURBT) in an attempt to preserve the bladder and to determine the likelihood that patients who complete this regimen could then complete three cycles of methotrexate, cisplatin, vinblastine (MCV) chemotherapy.Between 1998 and 2000, 52 patients with Stage T2-T4aN0M0 disease, from 17 institutions, were entered into the trial. Forty-seven patients were deemed eligible; the planned accrual was 40. Of the 46 patients, 68% were >60 years old, 70% were men, and 96% had a Karnofsky score >/=90. The clinical T stage was T2 in 66%, T3a in 25%, and T3b in 9%. The median follow-up at the time of analysis was 26 months. The protocol required TURBT within 6 weeks of the initiation of induction therapy. Induction treatment involved 13 days of concomitant boost RT, 1.8 Gy to the pelvis in the morning followed by 1.6 Gy to the tumor 4-6 h later. For sensitization, cisplatin (20 mg/m(2)) was given on the first 3 days of each treatment week. Three to four weeks after induction, patients were evaluated cystoscopically for residual disease. Patients whose biopsies and cytologic evaluations showed no disease completed consolidation chemoirradiation. Patients with residual tumor went on to cystectomy. After either consolidation or cystectomy, patients were to complete three cycles of MCV chemotherapy.Of the 47 patients, 45% completed all phases of the protocol treatment with minor, or no, deviations. Five patients refused either the postinduction evaluation or cystectomy and 6 refused adjuvant chemotherapy. The CR rate after induction therapy was 74%. For 2 patients, residual disease after induction was limited to positive cytologic findings, and for 8 patients, biopsy of the primary site revealed persistence. Of the 8 cystectomy patients, 2 had no evidence of disease in the bladder at pathologic review of the surgery specimen. Grade 3 toxicity related to chemotherapy was observed in 11% of patients during both induction and consolidation, and in 41% during adjuvant chemotherapy. A total of 8 patients (36% of those receiving adjuvant chemotherapy) went on to develop Grade 4 neutropenia or thrombocytopenia during additional adjuvant chemotherapy. Grade 3 toxicity due to RT was seen in 4% and 0% of patients during induction and consolidation, respectively. One patient developed Grade 4 hydronephrosis during consolidation. The projected 36-month value for locoregional failure, distant metastasis, overall survival, and bladder-intact survival was 27%, 29%, 61%, and 48%, respectively.After aggressive TURBT, twice-daily accelerated RT initiated in concomitant-boost format is well tolerated and results in a rate of complete response (74%) similar to that in previous bladder-sparing trials. The projected 2-year values for locoregional control, bladder-intact survival, and overall survival were also consistent with previously reported trials of bladder-sparing treatment. With only 45% of patients completing three cycles of MCV, this form of adjuvant chemotherapy appears to be poorly tolerated by most patients.     

Treatment of invasive bladder cancer by cisplatin and radiation in patients unsuited for surgery

Seventy patients with muscle-invading bladder carcinoma (clinical stages T2 to T4) who were not candidates for cystectomy were treated with combined cisplatin and full-dose external-beam radiation on a multi-institutional prospective protocol from 1980 through 1985. Thirty-six patients are alive, all but three without evidence of cancer. The complete response rate is 77% in the 62 patients completing planned irradiation and 70% for all patients. Among the complete responders, 73% are currently maintained, and this group has a significantly higher four-year survival than those not having a complete response and those with recurrence of disease--57% vs 11%. The observed high complete response rates in patients in all stages and the high survival rates suggest irradiation plus cisplatin therapy offers an important therapeutic gain over radiation therapy alone for invasive cancer of the bladder. These results encourage further evaluation of combining cisplatin-based, multidrug chemotherapy with irradiation in patients with locally very-advanced bladder tumors who are not suited for surgery.     

The impact of dyadic social support on self-efficacy and depression after radical prostatectomy

OBJECTIVE: To assess the effect of one-on-one peer support at enhancing self-efficacy and decreasing depression in older men treated by radical prostatectomy for prostate cancer. METHODS: Six weeks after surgery, 72 men (M(age) = 60) were randomly assigned to a treatment (n = 37) or control group ( n = 35). Treatment group participants were paired to form dyads with a trained support partner who had similar treatment and related side effects; control group participants received usual health care. Dyads met 8 times over 8 weeks to discuss concerns and coping strategies. RESULTS: At posttest, the treatment group had significantly higher self-efficacy than the controls (M = 328.89 and M = 304.54, respectively) and significantly less depression (M = 0.92 and M = 2.49, respectively). Depression outcomes remained significant when controlling baseline self-efficacy and social support (F = 4.845, p = .032). DISCUSSION: Findings confirm pilot study results and are theoretically consistent with the self-efficacy enhancing nature of vicarious experience described by Bandura in self-efficacy theory.     

Filling of the obturator nodes in pedal lymphangiography: fact or fiction

The value of pedal lymphangiography as a staging procedure for carcinoma of the prostate and the bladder continues to be debated because of the fact that the obturator lymph nodes apparently are not visualized during this diagnostic technique. This study involves 25 patients who have undergone pedal lymphangiography followed by fine needle aspiration. Pelvic lymph node dissection was performed and pelvic x-rays were taken once the external iliac nodes had been excised, leaving the obturator nodes behind. The next step was the removal of the remaining nodes in the obturator fossa, after which another x-ray was obtained. With this technique we could prove whether these obturator lymph nodes opacified on routine pelvic x-ray. In a review of the radiography consistent filling of the obturator nodal chain was noted in all of the cases, as well as the consistent prediction of the location of these lymph nodes before fine needle aspiration.     

Severely contracted bladder following intravesical mitomycin C therapy

Most superficial bladder tumors are best treated by transurethral resection. However, because of their multifocal origin and high rate of recurrence they often present challenging therapeutic problems. Intravesical chemotherapy often is used in such cases in the treatment and prevention of recurrent transitional cell carcinoma of the bladder. Recently, mitomycin C intravesical chemotherapy was shown to be effective in the treatment of superficial bladder tumors. No systemic toxicities were described but bladder irritation and drug-related palmar desquamation were noted. We report a case of a severely contracted bladder requiring urinary diversion following intravesical chemotherapy with mitomycin C. A possible relationship of this complication to the mitomycin C treatment is suggested.     

Primary malignant melanoma of the male urethra

Primary malignant melanoma of the male urethra is a rare disease, with only 24 cases previously reported in the literature, including 1 black patient. We describe 2 additional patients with primary malignant melanoma of the urethra, one of whom was a black man. The literature is reviewed briefly and treatment recommendations are discussed.