Durable and complete remission of a metastatic bladder sarcomatoid carcinoma with chemotherapic and surgical treatments.

The sarcomatoid carcinoma of the urinary bladder is a rare variant of transitional carcinomas with an extremely aggressive clinical course and dismal prognosis regardless therapies. The diagnosis of a bladder sarcomatoid carcinoma involving perivesical tissues with limphnodal, hepatic and lung metastasis was done in a 34-years old male. The disease underwent complete remission after neoadjuvant chemotherapy with adriblastine and ifosfamide, radical surgery and adjuvant chemotherapy with the same drugs, as confirmed by CT, vesical biopsies during chemotherapy and by the findings detected on the surgical specimen. Follow-up is negative for relapses at 72 months. The sarcomatoid bladder carcinoma is a rare variant of transitional carcinoma (0.31%), usually diagnosed in the late decades of life, with a survival time of a few months for metastatic patients regardless of any adopted therapies. The case presented is remarkable due to the young age of the patient but, overall, for the complete and durable regression of the disease achieved applying a chemotherapic scheme commonly adopted to treat pure sarcomatous mesenchimal neoplasms. Due to the rarity of the disease and the consequent unfeasibility of randomized studies, in our opinion these results, even if obtained in a single case, suggest a viable therapeutic option

Use of the appendix as ureteral substitute in a patient with a single kidney affected by relapsing upper urinary tract carcinoma

The treatment of upper urinary tract transitional cell carcinoma (UT-TCC) in single-kidney patients requires the radical removal of cancer, but also, when feasible, the preservation of the continuity of the urinary tract by various surgical techniques. In case of wide resections during ureteral surgery, a ureteral replacement could be advocated. In the literature, the cecal appendix has rarely been used as a ureteral substitute, moreover in benign pathological conditions, showing encouraging early results. The positive functional and oncological outcomes obtained after a lengthy follow-up in a single-kidney patient with UT-TCC treated by ureteral resection and appendix interposition confirm the viability of this surgical option

The follow-up management of non-metastatic renal cell carcinoma: definition of a surveillance protocol.

OBJECTIVE: To define a follow-up protocol based on the University of California Los Angeles Integrated Staging System (UISS) for patients undergoing surgery for N0M0 renal cell carcinoma (RCC). PATIENTS AND METHODS: The clinical records of patients treated with radical surgery for N0/NXM0 RCC and monitored through periodic follow-up studies (> or =24 months in disease-free patients) were reviewed retrospectively from 1399 patients surgically treated for renal neoplasms between 1983 and 2005. Each case was assigned a UISS risk category; recurrence features, time and site were recorded. In particular, recurrence sites were categorized into local, renal (ipsilateral or contralateral) and distant (single-site or disseminated). RESULTS: The records were reviewed of 814 patients with a mean follow-up of 75.6 months. UISS risk categories were distributed as follows: high-risk (HR) 17.2%, intermediate-risk (IR) 51.6% and low-risk (LR) 31.2%. Disease-free survival rates at 5 years were 63.9%, 88.3% and 96.5% (log-rank test P < 0.001), respectively. The disease recurred in 193 patients (23.7%), at distant sites (73.0% of recurrences), locally (11.9%), in the contralateral kidney (10.9%) and in the ipsilateral kidney (4.1%). There was a significant correlation between UISS category and risk of distant or local (both P < 0.001) recurrences, whereas there was no correlation of recurrences in the operated kidney (P = 0.372) or contralateral kidney (P = 0.898). CONCLUSIONS: The prognostic accuracy and applicability of the UISS for distant and local recurrences is confirmed, whereas renal relapses have an independent course. A follow-up scheme tailored to the recurrence patterns observed in each UISS risk group is recommended

Surgical treatment of adrenal metastasis from renal cell carcinoma: a single-centre experience of 45 patients

Objective To report, in a retrospective study, the diagnostic problems and oncological results of surgery in patients with either synchronous or metachronous adrenal metastasis, which are uncommon in renal cancer, at 2-10% of patients. Patients and Methods Of 1179 patients treated for renal cancer between 1987 and 2003, 914 had renal surgery with concomitant ipsilateral adrenalectomy (routinely in 875 and for abnormal findings on computed tomography, CT, in 39) and 15 contralateral adrenalectomy (all after suspicious findings on CT). During the follow-up after renal surgery, another 14 patients had adrenalectomy for CT evidence of an abnormal adrenal gland, contralateral to the previous renal tumour in 12 and bilaterally in two. Results Of 914 ipsilateral adrenal glands removed during renal surgery, 854 (93.5%) were normal on pathological examination, 28 (3%) had a benign pathology, six (0.8%) were directly infiltrated by the tumour and 26 (2.7%) were metastatic. For both benign and metastatic ipsilateral adrenal pathology, CT had sensitivity, specificity and positive/negative predictive values of 47%, 99%, 73% and 96%, respectively. Of 29 contralateral glands removed because of suspicious CT findings (15 at diagnosis of renal cancer, 14 during the follow-up) there was no abnormality in one (3.4%), a benign pathology in seven (24%) and a metastasis in 21 (72%). Thus there were 32 synchronous (incidence 2.7%; ipsilateral to the renal tumour in 24, contralateral in six and bilateral in two), and 13 metachronous adrenal metastases (incidence 1.0%; contralateral in 11 and bilateral in two). The metachronous metastases were diagnosed at a mean (range) interval of 30.6 (8-73) months after renal surgery. No ipsilateral adrenal metastases were discovered at diagnosis or during the follow-up in the 382 patients with an organ-confined renal tumour of < 4 cm in diameter. Twenty-seven patients with an isolated adrenal metastasis (synchronous in 14, metachronous in 13) had statistically significantly (P < 0.001) better survival than the 18 (all synchronous) with multiple sites of metastatic disease. In particular, there was long-term survival (mean 83 months) in 10 patients with an isolated adrenal metastasis. Conclusions Sparing the ipsilateral adrenal is advisable only for organ-confined renal tumours of < 4 cm in diameter; clinical local staging of renal cancer is the best predictor of the risk of adrenal metastasis. Conversely, CT had good diagnostic ability for the contralateral adrenal gland, especially during the follow-up. Some patients with isolated adrenal metastasis could be treated by metastasectomy, with long-term survival free of disease and confirming that, even if in a few and unselectable patients, removing all the neoplastic bulk can be curative. Nevertheless, the high rate of relapse underlines the need for an effective systemic therapy, and more so for widespread metastatic disease that currently cannot be cured

Detection of muscarinic receptor subtypes in human urinary bladder mucosa: Age and gender-dependent modifications

Aims: Muscarinic receptor subtypes expressed in the human urinary bladder mucosa were characterized, investigating whether there were gender-dependent differences and if aging could induce changes in their expression. Methods: The study was carried out on 34 subjects, 22 men and 12 women, divided in four groups, based on gender and age. Gene expression was evaluated by quantitative RT-PCR. The Western blot was performed using the 4–12% NuPAGE Bis–Tris Gel System. Results: The molecular expression of each subtype of the M1 receptor family was observed and it was not influenced either by gender or age. M2 receptor family transcripts revealed that both M2 and M4 were detected and that the M2 transcripts were modified by both gender and age. Indeed, M2 mRNA was lower in old rather than adult men (P < 0.05), but higher in rather old than adult women (P < 0.05). Further, adult men expressed more M2 mRNA than adult women (P < 0.05), while the opposite was detected in old age (P < 0.05). The Western blot followed by quantification confirmed that the mRNAs were translated into proteins, and that the M2 subtype showed similar modifications found at molecular level. Discussion: The selective modification of M2 receptors observed at the urinary bladder mucosa levels indicates that this anatomical structure could play an active role in the pathophysiology of micturition and supports evidence suggesting an effect of antimuscarinic drugs at this level. Whether these results may influence the age-dependent development of micturition disorders remains to be determined