Combined Prednisone and Mycophenolate Mofetil Treatment for Retroperitoneal Fibrosis

Successful therapy of retroperitoneal fibrosis due to IgG4-related disease with rituximab, cyclophosphamide and glucocorticoids followed by maintenance therapy wit ritutixmab

Idiopathic retroperitoneal fibrosis (IRF) is a rare condition characterized by the development of a peri-aortic and peri-iliac tissue showing chronic inflammatory infiltrates and pronounced fibrosis. Ureteral entrapment with consequent obstructive uropathy is one of the most common complications, which can lead to acute renal failure and, in the long term, to varying degrees of chronic kidney disease. Common symptoms at onset include lower back, abdominal or flank pain, and constitutional symptoms such as malaise, fever, and anorexia and weight loss. Pain is frequently referred to the hip, to the groin and to the lateral regions of the leg, with nocturnal exacerbations, and typically does not modify with position. We report a case of 56 year-old male with recurrent lower back pain and lower abdominal pain. Contrast-enhanced computed tomography and was suggestive of retroperitoneal fibrosis and unilateral ureteral occlusion. Histologic examination with immunohistochemical staining for IgG4 demonstrate IgG4-related retroperitoneal fibrosis. Therapy was started with prednison 1 mg/kg, but the tolerance of this dose was poor. Therefore the therapy was switched to combination of rituximab 375 mg/ m2 on day 1, cyclophosphamide 300 mg/m2 mg infusion and dexamethasone 20 mg total dose infusion on day 1 and 15 in 28 days cycle. FDG-PET/CT control in fourth month showed residual accumulation of FDG in retroperitoneal fibrotic mass, and therefore the therapy was prolonged to 8 month. The subjective symptoms of this diseases disappeared in the 8th month. Then the maintenance therapy, administration of rituximab in 6 month interval, was started. The activity of this disease be further evaluated by FDG-PET/CT imagination. Glucocorticoids are considered the cornerstone of therapy. The use of other immunosuppressive agents, including cyclophosphamide, azathioprine, methotrexate, mycophenolate mofetil and biological agents such as rituximab, tocilizumab and infliximab and sirolimus have been reported as a valuable option mostly in case reports, cases series and small studies. This agents allowed to reduce cumulative dose of glucocorticoids and its adverse effects. Therefore in our patients we preferred combination of rituximab cyclophosphamide s dexamethasone with lover dose of prednisonem. This combination is preferable for patients who cannot tolerate glucocorticoids or who are likely to suffer from significant glucocorticoids -related toxicity.

Management of retroperitoneal fibrosis with endovascular aneurysm repair in patients refractory to medical management

Background

Early diagnosis and treatment of under-recognized retroperitoneal fibrosis (RPF) are essential before reaching the poorly responsive fibrotic stage. Although most patients respond to medical therapy, relapses and unresponsiveness are common. However, open surgery in medically resistant patients is associated with major adverse clinical events.

Methods

This is a single-centre longitudinal study of optimal medical therapy (OMT) vs. endovascular aneurysm repair (EVAR) in patients presenting with RPF to our tertiary referral vascular centre. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst them, 1,006 were EVAR, TEVAR and BEVAR. Seventeen patients (1.09%) had documented peri-aortic RPF.

Results

Out of the 17 RPF patients, 11 received OMT only, while 6 underwent EVAR after the failure of OMT. 82% (n = 14) were male, and the median follow-up was 62.7 months (IQR: 28.2–106). Nine (52%) had immunoglobulin G4-related disease (4 OMT vs. 5 EVAR). EVAR patients had 100% technical success without perioperative mortality. Furthermore, all the EVAR patients were symptom-free following the intervention. Pre-operative aortic RPF index (maximum peri-aortic soft tissue diameter/maximum aortic diameter) was higher in the EVAR than in OMT. However, there was a significant decrement in the aortic RPF index following EVAR (P = 0.04).

Conclusion

We believe that when optimal medical therapy fails in RPF, EVAR provides a promising outcome. Further studies are recommended to establish the role of endovascular repair.

The contribution of the immune system to genitourinary fibrosis

Fibrotic diseases of the genitourinary tract are devastating and incompletely understood pathologies. These diseases include urethral and ureteral strictures, retroperitoneal fibrosis, and Peyronie's disease. They can contribute to obstructive uropathy and sexual dysfunction. Poor understanding of the pathophysiology of these diseases severely limits our ability to prevent and treat them. Genitourinary fibrotic diseases likely represent related pathologies that share common underlying mechanisms involving wound healing in response to injury. These diseases share the common feature of extracellular matrix abnormalities-such as collagen deposition, transforming growth factor-β accumulation, and dysregulation of collagen maturation-leading to abnormal tissue stiffness. Given the association of many of these diseases with autoimmunity, a systemic pro-inflammatory state likely contributes to their associated fibrogenesis. Herein, we explore the immunologic contribution to fibrogenesis in several fibrotic diseases of the genitourinary system. Better understanding how the immune system contributes to fibrosis in these diseases may improve prevention and therapeutic strategies and elucidate the functions of immunologic contributors to fibrosis in general.

Including Medical Management in the Urologic Approach to Idiopathic Retroperitoneal Fibrosis

OBJECTIVE

To characterize the timing and effectiveness of medical management in resolving stent-dependent ureteral compression secondary to idiopathic retroperitoneal fibrosis (RPF), the long-term relevant outcomes, and the side effects of treatment.

METHODS

A retrospective review of RPF patients diagnosed from 2002-2018 was performed. Patients with hydronephrosis due to ureteral involvement that were managed with medication and with temporary stenting as needed, but without initial ureterolysis, were included. Patient demographics and RPF management details were obtained, including the following subsequent events: ureterolysis, nephrectomy, recurrent upper tract obstruction, and medication side effects.

RESULTS

Fifty-two patients met inclusion criteria. Resolution of ureteral obstruction with medical management and temporary renal drainage as needed occurred in 36 (69%) patients with a median stent duration of 16 months, and median clinical and radiographic follow up of 4.2 and 3.3 years, respectively. Recurrent obstruction after a stent-free period occurred in 9 (18%) patients. Ureterolysis was performed in 8 (15%) patients at a median of 2.2 years for medication intolerance, lack of radiographic response to medication, or persisting pain. Potential medication side effects occurred in 6 (12%) patients.

CONCLUSIONS

Medical management supported successful resolution of ureteral obstruction in 69% of patients without the need for ureterolysis after temporary renal drainage using stents, with rare incidence of worsening renal dysfunction or medication side effect. To date, this is the largest reported series of systematically managed RPF patients with obstructive uropathy receiving initial medical therapy and serves to counsel patients and advise urologists and nephrologists of the expected course and advantages and disadvantages of medical versus surgical management.

Into Clinical Practice: Diagnosis and Therapy of Retroperitoneal Fibrosis

PURPOSE OF THE REVIEW

We aim to review the most relevant diagnostic features and treatment options of retroperitoneal fibrosis, in order to provide a useful guide for clinical practice.

RECENT FINDINGS

The recent literature highlights the role of imaging studies such as computed tomography, magnetic resonance imaging and positron emission tomography as useful tools for the diagnosis of retroperitoneal fibrosis, with retroperitoneal biopsy being reserved to atypical cases. The treatment approach is mainly conservative and is based on the use of medical therapies plus urological interventions. Medical therapies essentially comprise glucocorticoids and immunosuppressants-either traditional or biological agents such as rituximab. Surgical ureterolysis is only left for refractory cases. Recent findings in retroperitoneal fibrosis highlight the possibility of a non-invasive diagnostic approach and a conservative treatment strategy.

Current approach to diagnosis and management of retroperitoneal fibrosis

Retroperitoneal fibrosis is characterized by fibrotic lesions around the abdominal aorta and common ileac artery causing ureteral obstruction. Secondary retroperitoneal fibrosis is associated with malignant disease, drugs, exposure to radiation and surgery. In contrast, the majority of retroperitoneal fibrosis is classified into idiopathic retroperitoneal fibrosis, for which immunological etiology has been suggested. Recently, idiopathic retroperitoneal fibrosis has been considered to be a spectrum of immunoglobulin G4-related disease, a systemic inflammatory disease, the concept of which has been developed during the past decade. In the management of retroperitoneal fibrosis, assessment of systemic lesions associated with immunoglobulin G4-related disease and the exclusion of secondary retroperitoneal fibrosis is mandatory. Histological examination of retroperitoneal lesions is desired for accurate diagnosis and management. Laparoscopic or open biopsy is often beneficial, although it is more invasive than needle biopsy. Treatment for idiopathic retroperitoneal fibrosis consists of meticulous glucocorticoid therapy based on that for immunoglobulin G4-related disease, which is expected to be highly effective. Ureteral obstruction is usually managed with conservative procedures, such as ureteral stenting or percutaneous nephrostomy. The goal of treatment for retroperitoneal fibrosis should be freedom from the stent/nephrostomy with withdrawal of the glucocorticoid in addition to salvage of renal function; however, conservative management does not always provide favorable outcomes. In contrast, aggressive surgical treatment, such as ureterolysis, can achieve the goal; however, the procedure is associated with high morbidity. Establishment of a consensus about treatment for idiopathic retroperitoneal fibrosis, including the optimal indications for the invasive surgical procedure and conservative management, is desired.

Impact of CYP2D6 Polymorphisms on Tamoxifen Treatment in Patients With Retroperitoneal Fibrosis: A First Step Towards Tailored Therapy?

OBJECTIVE

To investigate the influence of CYP2D6 polymorphisms on outcomes and health-related quality of life of patients with retroperitoneal fibrosis (RPF) receiving tamoxifen (TMX). TMX is an effective alternative to corticosteroids for patients with RPF. Conversion of TMX to more potent endoxifen is dependent on enzyme activity of CYP2D6.

MATERIALS AND METHODS

CYP2D6 genotyping and phenotype prediction of all patients treated with TMX between 02/2007 and 01/2018 was assessed using multiplex polymerase chain reaction (PCR). Groups were classified by phenotype: extensive (EM) vs poor and intermediate (PM + IM) vs ultrarapid metabolizer (UM). Retrospective evaluation of outcome (including magnetic resonance imaging and positron emission tomography-computed tomography) and health-related quality of life using the SF-36 was performed.

RESULTS

A total of 63/194 patients received TMX, 40/63 with complete follow-up were sequenced: Twenty-nine patients with EM phenotype, 8 PM + IM and 3 UM. The median therapy duration was 364.5 days with a mean follow-up of 62.9 months. Seven therapy terminations occurred due to lack of response (17.5%), including all UM patients (P <.001). Magnetic resonance imagings showed a regression of fibrosis for EM and PM + IM in 69% and 62.5% of cases and a progression for UM in 100% (P = .004). In positron emission tomography-computed tomography, glucose utilization of RPF decreased significantly for EM and PM + IM. The physical sum-score of SF-36 improved for EM and PM + IM and decreased for UM (P <.05). The removal of DJ-stents was successful for EM, PM + IM, and UM in 48.3%, 75%, and 0% of cases (P = .0581).

CONCLUSION

Contrary to expectations, UM showed the lowest success rate, which concludes that genotyping of RPF-patients may be useful in the sense of a tailored-therapy.

Anti-fibrotic effect of mycophenolate mofetil on Peyronie's disease experimentally induced with TGF-β

The aim of the present study was to evaluate the histological, histochemical, and stereological changes caused by mycophenolate mofetil (MMF) on the tunica albuginea of rat penises submitted to an injection of transforming growth factor beta (TGF-β) for the induction of Peyronie's disease (PD). Twenty adult male Wistar rats were divided into four groups: Control group; TGF-β group (TGF-β injection); MMF-7d group (treated with MMF 7 days after induction with TGF-β); and MMF-30d group (treated with MMF 30 days after induction with TGF-β). The steorological evaluation included the relative volume of different types of connective fibres of the tunica albuginea. The histochemical analysis revealed the fragmentation and degradation of elastin in the tunica albuginea. This process was partially reversed in the MMF-7d group and a situation very close to normality was observed in the MMF-30d group. In the collagen III/collagen I ratio it was observed increase in this ratio in the TGF-β (59.4 ± 5.53) and MMF-7d (49 ± 18.2) groups and a decrease in the MMF-30d group (28.7 ± 4), approaching normality. The injection of TGF-β promoted fibrotic alterations in the penile tunica albuginea in Wistar rats corresponding to PD. In this model, MMF acts as a regenerating anti-fibrotic agent.

Bladder and Ureteral Dysfunction Leading to Hydronephrosis and Hydroureteronephrosis in Adults

Chronic non-stone-related hydronephrosis from supravesical or bladder dysfunction in adults is often detected incidentally. This study aims to review the literature regarding supravesical obstruction or bladder dysfunction leading to bilateral hydronephrosis in adults and to develop an algorithm to identify patients at risk of renal failure. Cross-sectional studies, retrospective and prospective cohorts, clinical trials, and systematic reviews from 1980 to 2017 were included. From 8115 articles screened, 39 met the inclusion criteria. Despite the lack of studies addressing this issue, this review brings up a rational evidence-based algorithm to diagnose and manage adults with bilateral hydronephrosis due to supravesical or bladder disease or dysfunction.

Idiopathic retroperitoneal fibrosis and its overlap with IgG4-related disease

Retroperitoneal fibrosis (RPF) is a rare disease characterised by fibrous tissue proliferation in the retroperitoneum, with encasement of the ureters and large vessels of the abdomen as the most destructive of potentially severe complications. It can either be idiopathic, or secondary to infections, malignancies, or the use of certain drugs. The idiopathic form accounts for approximately 75% of the cases, and is usually responsive to immunosuppressive therapy. In recent years, the emergence of a new clinical entity, IgG4-related disease (IgG4-RD), shed light on many fibro-inflammatory disorders once thought to be separate clinical entities, although frequently associated in the so-called multifocal fibrosclerosis. Among these, together with sclerosing pancreatitis and cholangitis, pseudotumour of the orbit, idiopathic mediastinal fibrosis and other conditions, is idiopathic retroperitoneal fibrosis (IRF). Both IRF and IgG4-RD can be associated with a wide variety of disorders, usually governed by immune-mediated (and particularly auto-immune) mechanisms. In our review, we discuss the clinical and therapeutic challenges IRF presents to the internist, as well as the meaning of its recent inclusion in the IgG4-RD spectrum from a clinical practice standpoint.

Fibrose rétropéritonéale: revue de littérature

La fibrose rétropéritonéale (FRP) est une maladie rare, caractérisée par la présence d’un tissu fibro-inflammatoire aberrant qui se forme souvent autour de la portion sous-rénale de l’aorte abdominale et des artères iliaques. Une obstruction urétérale est souvent observée. Récemment, la FPR idiopathique est rapportée parmi les manifestations de la maladie à IgG4. L’imagerie joue un rôle important dans le diagnostic de la FRP. Les glucocorticoïdes sont le traitement de référence, utilisés en monothérapie ou en association avec d’autres agents médicamenteux. En cas d’échec des mesures conservatrices, la chirurgie peut être proposée. Récemment, des techniques minimalement invasives ont été utilisées.

Retroperitoneal fibrosis

Retroperitoneal fibrosis (RPF) is a rare disease that is marked by systemic inflammation and the development of a periaortic fibroinflammatory mass. The fibroinflammatory infiltration can encase the abdominal aorta, ureters, and other abdominal organs. The clinical presentation often includes constitutional symptoms, abdominal pain, and signs of renal insufficiency or renal failure related to ureteral obstruction. Less frequently, RPF may present with vascular complications, such as venous thrombosis or claudication. The idiopathic form of RPF is most common but secondary forms have been described and are associated with malignancy and a variety of different medications. The pathophysiology is uncertain, but RPF has been linked with periaortitis and IgG4-related disease. Treatment centers on the relief of symptoms and complications associated with mass effects. Corticosteroids and other immunosuppressant therapies can improve constitutional symptoms, reduce infiltrate mass, and achieve disease remission, but a chronic relapsing course is not uncommon.

Tamoxifen monotherapy in the treatment of retroperitoneal fibrosis

OBJECTIVE

To evaluate the therapeutic effect of tamoxifen monotherapy in patients with retroperitoneal fibrosis (RPF).

PATIENTS AND METHODS

From 2007 on, 31 patients with idiopathic RPF were treated with tamoxifen monotherapy. Follow-up investigations included magnetic resonance imaging, laboratory measurements, registration of side effects and changes or removal of ureteral stents. Data were stored in the Else Kröner-Fresenius Registry of Retroperitoneal Fibrosis.

RESULTS

25 men and 6 women with a mean age of 56.6 years were treated with tamoxifen monotherapy. Mean duration of treatment was 13.3 months, mean follow-up 26.8 months. A total of 44 renal units were affected by hydronephrosis and covered by DJ stents. Radiological regression of fibrosis was detected in 22 cases (71.0%); removal of ureteral stents was possible in 27/44 renal units (61.4%) and 17/29 patients (58.6%), respectively. Most patients showed only mild or no side effects of therapy. In 7 cases (22.3%) tamoxifen therapy had to be abandoned because of severe side effects, progression of fibrosis or persistent intolerance.

CONCLUSIONS

Tamoxifen is an alternative in the medical treatment of RPF, especially if patients want to avoid glucocorticoids. The potential of regression of fibrosis seems to be slightly inferior and the relapse rate is higher compared to steroids, but the rate of successful DJ removals is comparable.

Retroperitoneal fibrosis

Retroperitoneal fibrosis is a rare syndrome hallmarked by a fibrosclerotic tissue in the retroperitoneum, often leading to encasement of the ureters. About two-thirds of cases of retroperitoneal fibrosis are idiopathic, while the remaining cases are secondary to a variety of different causes, including drugs, tumors and infections. Idiopathic retroperitoneal fibrosis may be associated with abdominal aorta aneurysms, with vasculitis of the thoracic aorta and of epi-aortic vessels, or both. Most patients present with abdominal and/or low back pain. Serum markers of inflammation are usually, but not invariably, elevated. The diagnosis is secured by computed tomography or magnetic resonance imaging, which typically show an enhancing retroperitoneal mass medially dislodging the ureters. Positron emission tomography can be useful to document the extent and metabolic activity of the inflammatory process. Treatment rests on glucocorticoids with a tapering scheme variably combined with immunosuppressive agents. In cases of ureter obstruction, relief of obstruction by stenting or ureterolysis is required.

An aid to decision-making in therapy of retroperitoneal fibrosis: dynamic enhancement analysis of gadolinium MRI

Background

Idiopathic retroperitoneal fibrosis (IRF) as an uncommon cause of obstructive uropathy is often primarily treated medically by the attending urologist. We evaluated dynamic enhancement analysis (DEA) as a possible predictor of response to medical treatment and for treatment monitoring.

Methods

From 2007, 24 patients with fibrosis were assessed by magnetic resonance imaging (MRI) with DEA. The dynamic enhancement quotient (DEQ) was measured before therapy with prednisone (n = 12) or tamoxifen (n = 12) and in follow-up investigations after 3 and 6 months. Response to medical treatment was recorded by changes in the retroperitoneal mass on MRI and possible relief of ureteral obstruction, which was monitored by intravenous pyelogram and/or MAG3 scan after removal of DJ stents.

Results

Treatment groups did not differ significantly as to age, gender, or laboratory values, and response to medical treatment showed no significant difference between agents. Overall there were no cases of progression, 2 cases of stable disease, 11 cases of mild fibrotic regression, and 11 of significant or complete regression. DJ stents could successfully be removed in 21 of 35 renal units (60.0%). In a total of 61 DEAs the DEQ was significantly higher (P < 0.001) in patients with a good response (DEQ = 4.02) than in those with an average response (3.11) or none (2.14).

Conclusions

DEA was able to distinguish between patients with different response rates to medical treatment of IRF and may be useful to individualize therapeutic decision-making.

CCL18 -- potential biomarker of fibroinflammatory activity in chronic periaortitis

OBJECTIVE

Promising therapeutic approaches have emerged in chronic periaortitis, whereas peripheral blood biomarkers are lacking. CC-chemokine ligand 18 (CCL18) is known as a marker of fibrotic activity and prognosis in pulmonary fibrosis. We investigated whether CCL18 levels are increased in patients with chronic periaortitis and are associated with clinical, laboratory, and imaging findings.

METHODS

In this retrospective study, serum concentrations of CCL18 were assessed in 30 patients with chronic periaortitis and related to clinical data, laboratory variables, and imaging studies. Serum levels were compared to 15 apparently healthy volunteers and 15 controls with aortic sclerosis.

RESULTS

Serum concentrations of CCL18 were increased in patients with chronic periaortitis (median 197.6 ng/ml, range 73.7-301.0) compared to healthy volunteers (median 34.6 ng/ml, range 22.6-70.4; p < 0.0001) and controls with aortic sclerosis (median 50.4 ng/ml, range 24.5-141.2; p < 0.0001). CCL18 levels correlated with (n = 30; r = 0.461, p = 0.01) and increased with the transversal diameter of the periaortic mantle < 5, 5-10, and ≥ 10 mm (p = 0.008). Contrast enhancement (p = 0.044), treatment naivety (p = 0.042), and the occurrence of systemic symptoms (p = 0.007) were associated with higher CCL18 levels. During followup, changes of CCL18 correlated with changes of the transverse diameter of the periaortic mantle (n = 17; r = 0.512, p = 0.033).

CONCLUSION

Serum concentration of CCL18 reflects fibroinflammatory activity and extent of disease in patients with chronic periaortitis.

[¹⁸F]FDG-PET/CT in patients affected by retroperitoneal fibrosis: a bicentric experience

PURPOSE

The aim of our study was to assess the feasibility and usefulness of 2-[(18)F]-fluoro-2-deoxy-D: -glucose positron emission tomography computed tomography ([(18)F]FDG-PET/CT) in patients affected by retroperitoneal fibrosis.

MATERIALS AND METHODS

We retrospectively evaluated 25 patients studied in two centers: 18 underwent [(18)F]FDG-PET/CT as initial evaluation, three during follow-up, three during steroid therapy, and one to re-evaluate the disease. Among the group who underwent initial evaluation, ten underwent a second [(18)F]FDG-PET/CT after steroid therapy.

RESULTS

[(18)F]FDG-PET/CT was positive in 18 patients and negative in seven. Among the ten patients who underwent a second study after steroid therapy, six showed complete metabolic response, three partial response, and one no significant maximum standardized uptake value (SUV(max)) reduction.

CONCLUSION

Our preliminary results show that [(18)F]FDG-PET/CT is feasible and suitable for evaluating retroperitoneal fibrosis and is useful in assessing therapy response. Larger studies are desirable to confirm these findings and to determine the appropriate position of [(18)F]FDG-PET/CT in the diagnostic flow chart for this disease.

Prednisone versus tamoxifen in patients with idiopathic retroperitoneal fibrosis: an open-label randomised controlled trial

BACKGROUND

Glucocorticoids are the mainstay of treatment of idiopathic retroperitoneal fibrosis, but they often have substantial toxic effects. Several reports have suggested tamoxifen as an alternative to glucocorticoids. We compared the efficacy of prednisone with that of tamoxifen in maintainance of remission in patients with idiopathic retroperitoneal fibrosis.

METHODS

In this open-label, randomised controlled trial, we enrolled patients aged 18-85 years with newly diagnosed idiopathic retroperitoneal fibrosis at the Parma Hospital, Parma, Italy, between Oct 1, 2000, and June 30, 2006. After induction therapy with 1 mg/kg daily of prednisone for 1 month, the patients who achieved remission were randomly assigned to receive tapering prednisone (initial dose 0·5 mg/kg daily) for 8 months or tamoxifen (fixed dose 0·5 mg/kg daily) for 8 months. The sequence of randomisation (1:1), blocked in groups of two and four (with block size randomly selected), was generated by the trial statistician with a computer programme. After the end of treatment, the patients were followed up for an additional 18 months. Neither patients nor those giving interventions or analysing the data were masked to group assignment. The two radiologists who assessed CT and MRI scans were masked. The primary endpoint was the relapse rate by the end of treatment (month 8), which was analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00440349.

FINDINGS

After induction therapy, 36 of the 40 enrolled patients achieved remission and were randomly assigned to treatment (18 per group). One patient (6%) in the prednisone group and seven patients (39%) in the tamoxifen group relapsed by the end of treatment (difference -33% [95% CI -58 to -8, p=0·0408]. The difference in relapse rate between the groups was sustained after the additional 18-month follow-up: the 26-month estimated cumulative relapse probability was 17% with prednisone and 50% with tamoxifen (difference -33% [-62 to -3, p=0·0372]). Cushingoid changes and grade 2 hypercholesterolaemia were more common in the prednisone group than in the tamoxifen group (p=0·0116 and p=0·0408, respectively).

INTERPRETATION

Prednisone is more effective in prevention of relapses than is tamoxifen in patients with idiopathic retroperitoneal fibrosis. Therefore, prednisone should be considered as first-line treatment for patients with newly diagnosed idiopathic retroperitoneal fibrosis.

FUNDING

Parma University Hospital.

Aortitis and periaortitis in ankylosing spondylitis

Aortic involvement is a potential life-threatening complication of ankylosing spondylitis, usually occurring late in the course of this frequent disease. Inflammatory lesions evolving to fibrosis are primarily localized in the aortic root causing regurgitation, but this process can extend into the left atrium (subaortic bump) involving the mitral valve and the heart conduction system. First, second and third degree atrioventricular blocks are the most common conduction alterations described and they can be temporary. Chronic periaortitis has been described in ankylosing spondylitis patients. This disease is characterized by inflammation evolving to fibrosis and it is localized in the periaortic and peri-iliac retroperitoneum. It causes compressive effects on ureters and venous, arterial and lymphatic vessels. Its treatment employs endoscopic and/or surgical procedures and administration of corticosteroids, even in association with immunosuppressive agents. Both aortitis (with conduction system alterations) and periaortitis should be kept in mind by the physicians because they can significantly influence the prognosis of ankylosing spondylitis patients and they can need a rapid treatment.

Antifibrosis: to reverse the irreversible

Fibrosis is a pathological process that includes scar formation and overproduction of extracellular matrix by the connective tissue as a response to tissue damage. The fibrotic process involves multiple organs and results in progressive life-threatening diseases. Today, we know more about the molecular mechanism that leads to fibrosis involving different type of cells, cytokines, chemokines, and tissue enzymes. Fibrosis was considered an irreversible process, at least clinically, and is still usually treated by anti-inflammatory and immunosuppressive agents. No proven antifibrotic therapy has shown efficacy in ameliorating the clinical course of fibrotic diseases, but our current understanding led to the development of different drugs with promising results, like: mycophenolate mofetil, interferon, relaxin, and intravenous immunoglobulin. This review will provide a glance to this heavily investigated subject.

University of Michigan surgical experience with ureterolysis for retroperitoneal fibrosis: a comparison of laparoscopic and open surgical approaches

OBJECTIVES

To compare our experience with open surgical ureterolysis (OU) and laparoscopic ureterolysis (LU) to determine any differences in success and convalescence. OU for extrinsic compression of the ureters secondary to retroperitoneal fibrosis effectively releases the ureters from the fibrotic environment in most cases. Reports have suggested that LU provides similar benefits, with a decreased intensity and duration of convalescence.

METHODS

We retrospectively reviewed the data from 22 patients who had undergone 25 ureterolysis procedures for retroperitoneal fibrosis from 1997 to 2006 at our institution.

RESULTS

LU was performed in 13 cases (10 patients) and a total of 16 ureters. No conversion to open surgery was required. OU was performed in 12 cases (12 patients) and a total of 16 ureters. LU was associated with a significantly shorter hospital stay than OU (mean 2.1 versus 5.9 days, P = .004). Laparoscopic intraperitonealization of the ureters was performed in 97.5% of all affected ureters compared with 50% with OU (P = .02). No difference was seen between the 2 groups in the performance of an omental wrap, postoperative creatinine level, complication rate, operating time, or transfusion requirement. With a mean follow-up of 30 months for the OU group and 24 months for the LU group, the success rate was 87.5% after OU and 93.8% after LU (P = 1.0).

CONCLUSIONS

The results of our study have shown that LU is a safe and effective surgical procedure for retroperitoneal fibrosis. LU offers similar results and a shorter hospital stay compared with OU and should be considered the technique of choice, when available.

Positron emission tomography as a tool for the 'tailored' management of retroperitoneal fibrosis: a nephro-urological experience

BACKGROUND

Retroperitoneal fibrosis (RF) is a complex clinical entity characterized by a fibro-inflammatory reaction around the abdominal aorta and iliac arteries extended into the retroperitoneum. No biochemical marker correlates with the disease severity and progression, and imaging data fail to discriminate between fibrotic and florid lesions. Positron emission tomography (PET) was recently suggested as a promising tool to detect the disease.

METHODS

We report on seven consecutive cases of RF managed by tailoring therapeutic interventions to the metabolic activity detected by PET. In 2006-09, seven patients with RF (five new diagnoses) were referred to the same nephro-urological facility. There were six males and one female aged 41-79. RF was associated with autoimmune diseases in three patients, with an aortic aneurysm in another three, and was 'idiopathic' in one. The diagnoses were made by imaging techniques [computed tomography (CT) or nuclear magnetic resonance (NMR)]; PET scan was performed in all patients in the same setting at referral and during follow-up.

RESULTS

Patients were followed up with tailored interventions (medical therapy: tamoxifen, steroids, and immunosuppressors according to disease activity, side effects and tolerance). Six patients needed ureteral stenting for obstruction. PET imaging was used as a guide for the tapering of immunosuppressors and for stent removal. In this way, stents were safely removed when a negativization of disease activity was revealed by PET. Only one relapse was recorded over 163 months of follow-up (median 24 months) detected in time by PET.

CONCLUSION

PET is a promising tool for surveillance of disease activity and for planning the removal of ureteral stents in RF.

Percutaneous transvenous stent implantation to external iliac vein stenosis in a patient with retroperitoneal fibrosis

A 59-year-old man visited our hospital due to right leg edema and right leg pain. Computed tomography revealed that the circumferential enhancement of bilateral external iliac arteries by soft tissue that had similar density as the adjacent psoas muscle and that the right external iliac vein that was constricted by those tissues. The patient was diagnosed as retroperitoneal fibrosis. He underwent stent implantation to the right external iliac vein stenosis and steroid therapy. His right leg edema and pain was immediately improved after the stent implantation and he achieved remission.

Combined mycophenolate mofetil and prednisone therapy in tamoxifen- and prednisone-resistant Reidel's thyroiditis

BACKGROUND

Mycophenolate mofetil is a recently identified therapy for disorders associated with systemic fibrosis, but has never been reported in the treatment of Reidel's thyroiditis. We report the first case of Reidel's thyroiditis that became resectable after treatment with mycophenolate and prednisone.

SUMMARY

A 27-year-old woman presented to an outside hospital with thyromegaly associated with compressive symptoms. The patient underwent a neck exploration with thyroid biopsy that revealed evidence of fibrosing variant Hashimoto's thyroiditis. The patient was then treated with tamoxifen and prednisone at an outside hospital without resolution. After initial evaluation she underwent an open thyroid wedge biopsy that revealed Reidel's thyroiditis. She was subsequently treated with both 1 g mycophenolate twice daily and 100 mg prednisone daily. The patient experienced immediate subjective improvement of compressive symptoms and objective decrease in mass size at 30 days, as seen by serial computed tomography examination. By 90 days of therapy the mass had decreased to a size small enough to allow subtotal thyroidectomy, which was completed over two staged procedures.

CONCLUSIONS

Reidel's thyroiditis remains a primarily surgical disease. Patients who are not surgical candidates have been treated with tamoxifen and prednisone with equivocal results. Our report is the first to suggest the combination of mycophenolate and prednisone as a viable treatment option for patients with Reidel's thyroiditis.

Retroperitoneal fibrosis: the clinical, laboratory, and radiographic presentation

Retroperitoneal fibrosis (RPF) is an inflammatory disorder that affects the infrarenal great vessels and surrounding structures. Although first described in 1948 by Ormond, much of the information currently available on this disease is conflicting and results from multiple definitions used by different investigators. We conducted the current study to describe the clinical, laboratory, and radiographic presentation of RPF from a single center using data collected in a prospective fashion.Data on all patients who were referred to our RPF clinic were prospectively collected. We obtained information on presenting signs and symptoms, and on the presence or absence of "traditional risk factors," comorbidities, and family histories. All patients underwent the same battery of laboratory testing, including complete blood count, renal function profile, erythrocyte sedimentation rate (ESR), thyroid-stimulating hormone, and antinuclear antibodies (ANA). All patients had contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen and pelvis. The extent of disease was classified based on the anatomic location of the soft-tissue density.Forty-eight patients (26 male and 22 female) met the criteria for RPF and were included in the study. The mean age was 54.25 years. Few patients had traditional risk factors for RPF. Pain and weight loss were the most common presenting symptoms. The mean hemoglobin was 11.6 g/dL. The mean ESR was 40.5 mm/h. Nine patients had positive ANA, all with negative antibodies to dsDNA. CT or MRI revealed the presence of a periaortic soft-tissue density in all (100%) patients; 69% had pericaval involvement, 62% had obstruction of 1 or both ureters, and 35% of patients had involvement of the renal artery or renal vein.In the current report we present the demographics and laboratory and radiographic presentation of a homogenous group of patients with RPF. We attempt to solidify a proper scheme of classification for the disease, and suggest an anatomic classification system that may be used for future studies.

Association between Familial Mediterranean Fever and Retroperitoneal Fibrosis: Retroperitoneal Fibrosis Regression after Colchicine Therapy

Retroperitoneal fibrosis (RPF) is a disease characterized by inflammatory fibrotic processes affecting the retroperitoneal structures. Familial Mediterranean Fever (FMF) is an autosomal recessive disorder, characterized by fever and attacks of sterile serositis. Colchicine is the only suitable drug for prevention of acute episodes. We describe a case of association between RPF and FMF in a 48-year-old male, in whom therapy with colchicine, besides preventing acute episodes, allowed RPF regression. To date the association between FMF and RPF and the use of colchicine therapy alone for RPF has not been described.

Successful mycophenolate mofetil therapy in nine patients with idiopathic retroperitoneal fibrosis

OBJECTIVE

To assess the therapeutic benefit of mycophenolate mofetil (MMF) in retroperitoneal fibrosis (RF).

METHODS

MMF 2 g/day and prednisone 1 mg/kg were initiated in nine patients with radiological (9/9) and histological verification (2/9) of idiopathic RF. Out of nine patients, seven needed bilateral ureteral stenting due to extensive hydronephrosis.

RESULTS

All patients experienced regression of radiological extension. Out of seven patients, five were free of ureteral catheters after a mean of 5.6 months and two remained on stenting due to secondary stenosis. Within 6 months mean creatinine and CRP fell from 2.5 to 1.2 mg/dl and from 4.0 to 1.4 mg/dl, respectively. MMF was discontinued after a mean of 27 months. Prednisone was tapered to zero after a mean of 7 months. Side-effects were urinary tract infections in 7/9 patients and impaired glucose tolerance in 3/9. No recurrence occurred after withdrawal of glucocorticoids and MMF in 7/9 patients after a mean overall follow-up of 55 months (range 12-120).

CONCLUSIONS

Treatment with MMF and glucocorticoids was successful in inducing partial or complete and lasting remission in RF. The results suggest the use of MMF as additional immunosuppressive option.

Management of ureteral obstruction due to advanced malignancy: optimizing therapeutic and palliative outcomes

PURPOSE

Treatment of ureteral obstruction due to advanced abdominal or pelvic malignancy is a clinical challenge. We discuss improvements and modern day outcomes in the palliative treatment of patients with ureteral obstruction by antegrade or retrograde ureteral decompression. Also, potential areas of clinical investigation involving ureteral stent improvement and pharmacological management of relief of symptoms resulting from ureteral obstruction are discussed.

MATERIALS AND METHODS

A literature search was performed using the Entrez-PubMed(R) database. All relevant literature on ureteral obstruction, advanced malignancy and nephrostomy, ureteral stent and associated topics concerning palliative care and quality of life were reviewed and analyzed.

RESULTS

Presenting symptoms are varied and depend on the acuity of the underlying problem. Mechanisms underlying the pain and symptoms of extrinsic ureteral compression have not fully been explored but they may include prostaglandin and renin-angiotensin pathways with medical interventions potentially directed at such therapeutic targets. Progressive obstructive uropathy may likely lead to clinical manifestations, such as uremia, electrolyte imbalances and persistent urinary tract infections, if obstruction is not bypassed. New approaches to antegrade and retrograde stenting, and the evaluation of new stent materials may help minimize the complications and side effects of such procedures. Unfortunately the finding of ureteral obstruction due to malignancy carries a poor prognosis with a resulting median survival of 3 to 7 months. This prognosis highlights the importance of maintaining quality of life in these patients.

CONCLUSIONS

Patients presenting with symptoms of ureteral obstruction due to advanced malignancy should be informed of the therapeutic options in the context of the poor prognosis. In the meantime research is needed to find methods of urinary diversion and pharmacological intervention for symptomatic relief without compromising quality of life in patients at the end of life.