Laparoscopic cryotherapy for small renal masses: Current State

OBJECTIVES

To provide an up-to-date review of the available literature on laparoscopic cryotherapy for small renal masses (SRMs) including technique description, indications and outcomes.

METHODS

A systematic literature search was conducted in March 2012, using MEDLINE and EMBASE via Ovid databases, to identify studies on laparoscopic cryotherapy for SRMs published during the last 10 years. Only English-language and human-based full manuscripts reporting case series studies with >20 participants, patient characteristics, efficacy and safety data were included.

RESULTS

No randomised controlled trials (RCTs)were identified. In total, 27 full reports addressing laparoscopic cryoablation (LCA) for SRMs were selected. The number of patients per study ranged from 20 to 144. Mean age of treated patients across the series ranged from 62 to 73 years. Mean size of renal tumors ranged from 2.7 to 4 cm, being in most cases <3 cm. The number of cryoprobes used for cryoablation ranged from 1 to 6, and only 10 series described the use of 17-gauge (1.47 mm) third-generation needles. Overall, more than 55% of all ablated lesions were pathologically confirmed RCC. Mean follow-up ranged from 9 to 93 months. Only 7 series presented a long-term follow-up of more than 36 months. Most studies were limited by a relatively short follow-up. At least four urologic groups reported intermediate- and long-term outcomes. Persistence rates ranged from 0% to 17% and recurrence rates ranged from 0% to 14%. Overall complication rates ranged from 0% to 40%.

CONCLUSIONS

Retrospective observational data and a few prospective series on LCA of SRMs show acceptable oncological 3- to 5-year outcomes with a low recurrence rate. It has proven to be a safe procedure with an overall low complication rate. It is mainly indicated for SRMs in elderly patients affected by co-morbidity and high surgical risk bearing tumours in the anterior valve of the kidney or in contact with the ureter or neighbouring organs.

Expression of E-cadherin in primary endometrial carcinomas: clinicopathological and immunohistochemical analysis of 30 cases

INTRODUCTION

Decreased expression of E-cadherin has been associated with poorly differentiated endometrial carcinomas and poorer outcomes.

AIM

The purpose of this study was to examine the distribution of E-cadherin immunohistochemical expression in specimens from primary endometrial carcinomas and its relation to classical clinicopathological prognostic factors.

MATERIALS AND METHODS

Surgically-resected tissues of 30 patients with primary endometrial carcinomas were studied. Histological type and grade, depth of myometrial invasion, lymph-vascular space invasion, fallopian tube or ovarian invasion, and the presence of tumoral necrosis were evaluated. Immunohistochemical examination was performed on deparaffinized four-microm-thick sections.

RESULTS

The mean age of patients was 65 years (+/- 11.41). The 63.54% of carcinomas were moderately/poorly differentiated. No statistical correlation was found between the score or intensity of E-cadherin immunohistochemical staining (strong or moderate positive expression) and the clinicopathological factors tested.

CONCLUSIONS

The association of E-cadherin immunoreactivity with the standard clinicopathological factors seemed to be contradictory. The classical clinicopathological factors remain the most important prognostic parameters.

Peritonitis due to iatrogenic colpotomy after large loop excision of the transformation zone (LLETZ) in a patient with cervical intraepithelial neoplasia III: our experience of a rare case with review of the literature

A case of peritonitis as an unusual complication of LLETZ (large loop excision of the transformation zone) for the treatment of CIN III associated with unrecognized iatrogenic posterior colpotomy is presented. After the procedure, the patient developed fever 38.3 degrees C and diffused severe pelvic pain. The contributing factors, prevention and management of this complication are discussed. Also, the complications of cold knife cervical conization and LLETZ procedure are reviewed.

Proteolytic matrix metallopeptidases and inhibitors in BCR-ABL1-negative myeloproliferative neoplasms: correlation with JAK2 mutation status

BACKGROUND/AIMS

Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs) share the same acquired lesion JAK2(V617F) and may exhibit substantial overlap. Variability in JAK activation and allele burden, complemented by host, genetic and non-genetic modifiers, determine the phenotype. The aim of this study was to investigate the presence of the JAK2 mutation in association with the ratio of metallopeptidases inhibitors (TIMPs) to tissue metallopeptidases (MMPs) in MPNs, where inhibitory rather than proteolytic activity in marrow microenvironment appears to predominate.

METHODS

94 patients with polycythemia vera, essential thrombocythemia and primary myelofibrosis, and 102 healthy individuals were evaluated. Allele-specific PCR and RFLP were used to detect JAK2 and genomic status. Serum concentrations of MMP and TIMP were measured by ELISA. The parameters were assessed with covariance analysis, and adjusted for gender, age and co-morbidity.

RESULTS

Mutation frequency was 81.91%. Abnormal TIMP/MMP ratios were identified in all three diseases. JAK2 mutation was correlated with significant changes in TIMP concentrations.

CONCLUSIONS

Identification of an abnormal TIMP/MMP ratio in all three diseases, regardless of the JAK2 status, indicates invariable marrow remodeling. In this particular group of patients, presence of a JAK2(V617F) mutation, being associated with even higher ratios, appears to be a concurring participant in bone marrow-reforming processes. Additional research may delineate correlates with the JAK2 allelic burden.

A novel intraoperative sensor for soft tissue balancing in total knee arthroplasty

Ligament balancing during total knee arthroplasty (TKA) is a controllable and critical procedure necessary for the longevity of the prosthesis. Intraoperative knowledge of the magnitude and location of tibiofemoral forces, can guide the surgeon to an accurate balancing throughout the operation. We developed a novel sensor device in order to monitor tibiofemoral forces during TKA ligament balancing procedure. The device predicts loads with an error of ± 1.5%, following a linear trend of slope = 0.9933 and R(2) = 0.9987; while the location of load is predicted with a practically acceptable error of ± 0.5 mm. The device was subjected to a surgical validation with in situ application during simulated TKAs on composite and cadaveric knees, with a very satisfactory outcome and no operative time elongation. The device can be a useful intraoperative instrument for accurate TKA ligament balancing procedures based on objective and graphically demonstrated and recorded evidence.

[MR aspect of the prostate in CPPS patients (chronic pelvic pain syndrome)]

PURPOSE

To describe typical morphological patterns of abacterial prostatitis using magnetic resonance imagine (MRI) in chronic pelvic pain syndrome patients including spectroscopy.

MATERIALS AND METHODS

18 patients (age range between 25 and 67 years, average 46.2 years) with recurrent chronic pelvic pain syndrome for at least 3 months were evaluated clinically in the urological department and included if there were no suspicious findings from endorectal digital palpation and if their PSA values were < 5 ng/ml. A retrospective analysis of these 18 patients with 30 contrast-enhanced MRI investigations with endorectal coils in 28 of 30 cases was performed with a 1.5T MRI. T 2w signal intensity (SI) and spectroscopy data (9 / 18 patients) were acquired for the normal peripheral zone, the central zone, for the peripheral zone suspected of inflammation and for the muscle including SI ratios for the unaltered and the suspicious inflammatory peripheral zone.

RESULTS

Typical MR patterns of signal alterations suspected of inflammation of CPPS patients were able to be detected as T 2w hypointense triangular, stringy (n = 12, 66.6 %) contrast-enhancing signal alterations without a nodular shape with well circumscribed margins of the capsula and without pericapsular signal alterations. In 6 patients changes also had a triangular but more homogeneous aspect (33.3 %). Three patients had an additional periurethral uptake (16.6 %). T 2w SI measurements and T 2w SI ratios showed much lower values for the peripheral zone suspected of inflammation as compared to the normal peripheral zone of the prostate (277.29 STD 77.5 to 432.9 STD 112.02 and 4.94 STD 1.47 to 7.58 STD 2.01 respectively). The spectroscopic analysis of the signal alterations suspected of inflammation showed normal Cholin+Creatin/Citrate SI ratio values in 3 patients (SI < 0.5), ratios suspected of low grade cancer in 3 patients (SI 0.5 and < 0.7) and ratios suspected of intermediate grade prostate cancer in 3 patients (SI > 0.7 and < 3.0).

CONCLUSIONS

We saw typical MR patterns in CPPS patients. However, spectroscopy can mimic findings of cancer so that the knowledge of typical morphological patterns and a solid clinical evaluation play a major role in the diagnosis of CPPS.

Comparison of 11C-choline-PET/CT and whole body-MRI for staging of prostate cancer

Aim of this study was to compare the diagnostic accuracy of positron emission tomography and computed tomography with (11)C-Choline (Cho-PET/CT) and whole body magnetic resonance imaging (WB-MRI) for diagnostic work-up of prostate cancer.

PATIENTS, METHODS

We evaluated retrospectively 42 patients with untreated prostate cancer (n = 17), or increasing levels of prostate-specific antigen (PSA) after curative therapy (n = 25) who had been investigated by both Cho-PET/CT and WB-MRI. MRI, CT, and PET images were separately analyzed by experienced radiologists or nuclear medicine experts, followed by consensus reading. Validation was established by histology, follow-up, or consensus reading.

RESULTS

88/103 detected lesions were considered as malignant: 44 bone metastases, 22 local tumor, 15 lymph node metastases, 3 lung, and 3 brain metastases. One further lesion was located in the adrenal gland, which was a second tumor. Overall sensitivity, specificity and accuracy for Cho-PET/CT were 96.6%, 76.5%, and 93.3%, resp., and for WB-MRI 78.4%, 94.1%, and 81.0%, resp. 3 vertebral metastases had initially been missed by Cho-PET/CT and were found retrospectively. MRI identified 2 bone metastases and 1 lymph node metastasis after being informed about the results of Cho-PET/CT.

CONCLUSIONS

Cho-PET/CT and WB-MRI both presented high accuracy in the detection of bone and lymph node metastases. The strength of MRI is excellent image quality providing detailed anatomical information whereas the advantage of Cho-PET/CT is high image contrast of pathological foci.

[Radiofrequency ablation of renal cell carcinomas using MR imaging: initial results]

PURPOSE

First results of a study about the efficacy of magnetic resonance-(MR-)guided radiofrequency ablation of renal cell carcinomas (RCC) are presented.

MATERIAL AND METHODS

Eight patients (63 to 82 years old) with RCC up to 3.9 cm in diameter were treated by percutaneous RF ablation under MR-guidance in an open MR scanner at 0.2T field strength. For positioning of the RF-electrode, fluoroscopic rapid gradient echo sequences (acquisition time about 2 sec) were used. The ablation was monitored by intermittent imaging with T1- and T2-weighted spin echo sequences.

RESULTS

In each patient, the applicator was successfully positioned within the tumor using MR-guidance. Seven of eight patients were completely treated within one single session; one patient had to be retreated for tumor relapse at 13 months. The mean number of electrode repositionings under MR guidance for complete ablation was 2.0; ablation time ranged between 12 and 28 minutes. Maximum diameter (volume) of induced coagulation necrosis within one session was 3.9 cm (30.2 cm (3)) by using cluster electrodes. With single electrodes, maximum short axis diameter of coagulation without repositioning was 2.4 cm (11.6 cm (3)). All patients are now disease-free after a mean follow up of 13 months (5 to 21 months). No major complications occurred during or after the ablation procedure.

CONCLUSION

MR-guided RF ablation in an open interventional 0.2T MR-unit is a safe and effective modality for the treatment of RCC. Fast MR-imaging is a convenient method for exact positioning of MR-compatible RF-electrodes. Near on-line MR-monitoring of ablation procedure with T2-weighted imaging allows for immediate assessment of the coagulation extent.

Correlation of bFGF expression in renal cell cancer with clinical and histopathological features by tissue microarray analysis and measurement of serum levels

The prognostic value of bFGF for surgically treated renal cell cancer (RCC) patients was evaluated by immunohistochemistry (IHC) and the tissue microarray technique (TMA). Additionally, preoperative serum bFGF levels were correlated to tumour stage and the presence of metastases at initial diagnosis. Serum levels of bFGF were measured by ELISA in 39 healthy volunteers, in 37 patients with benign urologic diseases and in 74 RCC patients, 26 of whom revealed lymph node or distant metastases. bFGF expression as detected by IHC was investigated in 777 tissue cores from 259 different RCC patients [median follow-up: 138 (36-240) months]. Eighty eight patients died from tumour progression. For each patient, the TMA slides contained a tissue core from the primary tumour, its invasion front and the normal renal parenchyma. bFGF serum levels were higher in RCC patients vs healthy volunteers (P<0.01) and vs patients with benign urologic diseases (P<0.01). Metastasized patients revealed higher bFGF serum levels than organ-confined specimens (P<0.01). As detected by IHC only increased bFGF expression in the invasion front tissue correlated with the patients' long-term survival (log rank test) (P=0.03). In multivariate analysis regional LN metastases (P<0.01), the histological grading (P<0.01), and an increased bFGF expression in the invasion front (P=0.04) independently predicted the patients' clinical prognosis. Not the expression of bFGF in the primary tumour but in its invasion front reflects the aggressiveness of RCC, hereby indicating a different biological potential within both areas. The value of bFGF serum levels as indicators of systemic tumour dissemination remains to be determined.

Impact of tumor size on the long-term survival of patients with early stage renal cell cancer

As the biological behaviour of even early stage renal cell cancer (RCC) strongly correlates with tumor size, it has been argued that the inclusion of RCC up to a maximum diameter of 7 cm into a common subgroup classified as T1 according to the 5th edition of the TNM system would not adequately represent the different biological aggressiveness of these malignancies. Taking this into account, the TNM classification, which now categorizes T1 RCC as T1a and T1b according to a cutoff size of 4 cm, was recently modified. However, only a few larger investigations, mainly based on univariate statistical analyses, that support the suitability of this cutoff are at present available from the literature. Therefore, it was the aim of the present investigation to determine the tumor size that best separates patients with low responses from those with high risk for tumor progression by univariate (log rank test) and multivariate (Cox regression model) statistical analyses. Between 1981 and 2000, 652 patients (443 males and 209 females) underwent tumor nephrectomy in our clinic for the diagnosis of RCC. Of these, 243 patients revealed primary tumors with a local growth not extending beyond the renal capsula at the time of surgery. For the different cutoff levels (starting from 2 cm in increments of 1 cm up to 8 cm) that were selected to subdivide the patients into groups according to the maximum tumor diameter, the correlation between tumor size and overall survival was determined by univariate and multivariate statistical analyses. It became evident that although during univariate analysis the prognostic value of a cutoff size of 4 cm was confirmed, multivariate analysis identified the highest relative risk for cause-specific death (2.93) for patients having tumors larger than 5 cm in maximum diameter. Therefore, the 5 cm cutoff seems to best determine the clinical prognosis of patients undergoing tumor nephrectomy for early stage RCC. The present study demonstrates the need for multivariate statistical approaches when the latest modification of the TNM classification system is critically evaluated.

The use of cytological examination of vaginal smears (CEVS) in the selection of rabbits for superovulation

In the present study, we examined two factors associated with the reproduction of rabbit does, cytology of vaginal smears and color of vulva, as potential predictors of the success of superovulation treatment. Vulval color and vaginal smear cytology were assessed in 55 young New Zealand does. Superovulation was then induced by a single administration of eCG (20 IU/kg BW i.m.). Does were artificially inseminated 3 days later, followed by intravenous administration of hCG (120 IU per animal). Does were classified with regard to vulval color (white, rose, red, purple), and the predominant cell type in the vaginal smear (i.e. parabasal, intermediate, superficial, or anuclear). Furthermore, we categorized cells into two groups because we usually observed parabasal and intermediate cells (Group A), and superficial and anuclear cell (Group B) in the same smear. Does were humanely killed 19 h after administration of hCG and the total numbers of corpora lutea (CLs), oocytes, and zygotes (i.e. 1-cell embryos) were determined. The zygotes were assessed by morphological appearance and classified as normal or abnormal. The color of the vulva at the time of eCG treatment did not predict the success of superovulation in terms of the number of CLs, oocytes or zygotes. Does with predominantly superficial cells in vaginal smears yielded significantly fewer CLs and oocytes-zygotes (OZ) compared to does with predominantly parabasal, intermediate, or anuclear cells (P<0.05). Does with predominantly superficial cells in vaginal smears tended to yield fewer normal zygotes (nZ), but this reached significance only when compared to does with predominantly parabasal cells (P<0.05). Does in Group A yielded significantly more (P<0.05) CLs, OZ and nZ compared to does in Group B. Does with predominantly parabasal and intermediate cells in vaginal smears and rose color vulva tended to yield more OZ and nZ (P<0.05). These results suggest that the cytology of vaginal smears may help identify does with a significantly higher likelihood of yielding low numbers of CLs, oocytes, or nZ.

Late relapse after treatment for nonseminomatous testicular germ cell tumors according to a single center-based experience

The introduction of cisplatin-based systemic chemotherapy into the clinical routine has resulted in a substantial improvement of the recurrence-free and long-term survival of patients with metastatic testicular germ cell tumors. Late relapses after the completion of first-line therapy, comprising systemic chemotherapeutic treatment in combination with a complete resection of residual tumor masses visible in about 25-50% of patients, have been reported to occur in 1-5% of patients later than 2 years following the initial treatment. It has been reported that the risk for the development of late recurrence is correlated to the tumor burden at first diagnosis and/or the presence of teratomatous components within the primary testicular cancer. Second-line chemotherapy in combination with surgery, although not very well standardized, has been recommended as the most effective therapeutic regimen during the treatment of patients suffering from late recurrent germ cell tumors. Herein, we report our single-center experience with 14 patients in different clinical stages who developed late relapse after successful first-line therapy. In the present series, the risk for late relapse was not correlated to the clinical stage at first diagnosis or the presence of teratomatous elements within the primary tumor. It became evident that in selected cases chemotherapy alone can be considered a curative treatment option.

Reduction of wild type p53 function confers a hormone resistant phenotype on LNCaP prostate cancer cells

BACKGROUND

The protein encoded by the p53 gene is required for some forms of apoptosis and loss or mutations in this gene are found with increased frequency in advanced and hormone resistant human prostate cancers. In order to better appreciate whether reduction of wildtype p53 function in prostate cancer cells might contribute to the development of therapeutic-resistance by these cells, we created stable variants of the androgen-responsive, wild type p53-expressing human prostate cancer cell line, LNCaP, by transfection with expression vectors designed to reduce expression or function of wildtype p53 in them. These cells were then tested for their ability to form tumors in castrated male nude mice.

METHODS

A conditional eukaryotic expression vector (under tetracycline regulation) expressing antisense p53 cDNA was constructed and either directly transfected into LNCaP cells or tranduced into these cells using recombinant retroviruses containing the vector. Stably transfected/transduced cells (LNCaP/Asp53) were evaluated by Western blot analysis for the ability of doxycycline to reduce p53 protein expression and for their ability to form tumors in castrated male nude mice treated or untreated with doxycycline. Additionally, we derived an LNCaP subline (LNCaP/DD) stably expressing a dominant-negative form of p53 and tested these cells for their ability to form tumors in castrated male nude mice.

RESULTS

LNCaP/Asp53 cells showed reduced expression of p53 protein when cultured in a medium containing doxycycline and tested sublines were able to efficiently form tumors in castrated male nude mice only when the mice were treated with doxycycline. LNCaP/DD cells were readily able to form tumors in castrated male nude mice whereas parental LNCaP cells or control-transfected LNCaP cells were not.

CONCLUSION

Loss of wildtype p53 function can contribute to the phenotype of hormone resistance of prostate cancer cells.

Effect of avidin on channel kinetics of biotinylated gramicidin

Membrane protein functioning basically depends on the supramolecular structure of the proteins which can be modulated by specific interactions with external ligands. The effect of a water-soluble protein bearing specific binding sites on the kinetics of ionic channels formed by gramicidin A (gA) in planar bilayer lipid membranes (BLM) has been studied using three independent approaches: (1) sensitized photoinactivation, (2) single-channel, and (3) autocorrelation measurements of current fluctuations. As shown previously [Rokitskaya, T. I., et al. (1996) Biochim. Biophys. Acta 1275, 221], the time course of the flash-induced current decrease in most cases follows a single-exponential decay with an exponential factor (tau) that corresponds to the gA single-channel lifetime. Addition of avidin does not affect tau for gA channels, but causes a dramatic increase in tau for channels formed by gA5XB, a biotinylated analogue of gA. This effect is reversed by addition of an excess of biotin to the bathing solution. The average single-channel duration of gA5XB was about 3.6 s as revealed by single-channel recording of the BLM current. After prolonged incubation with avidin, a long-lasting open state of the gA5XB channel appeared which did not close for more than 10 min. The data on gA5XB photoinactivation kinetics and single-channel measurements were confirmed by analysis of the corresponding power spectra of the current fluctuations obtained in the control, in the presence of avidin, and after the addition of biotin. We infer that avidin produces a deceleration of gA5XB channel kinetics by motional restriction of gA5XB monomers and dimers upon the formation of avidin and gA5XB complexes, which would stabilize the channel state and thus increase the single-channel lifetime.

In vitro release of new quinolones from biodegradable systems: a comparative study

A new biodegradable delivery system based on low molecular weight poly(lactic acid) has been formulated, with potential application in the sustained antibiotic release against bone infection. The in vitro release of two new quinolones (ofloxacin and ciprofloxacin) from the biodegradable matrix showed that the delivery of ofloxacin from the matrix lasted fifty-six days, whereas that of ciprofloxacin lasted fifty-one days. In both cases, release is controlled by the drug diffusion and the matrix degradation, the latter being the most critical factor. The obtained concentration levels are well above the Minimum Inhibitory Concentration (MIC) against the major causative bacteria of osteomyelitis. This fact in combination with the good reproducibility of measurements indicated that the system studied could be of value for the preparation of implantable controlled release systems for treatment of diseases in the bone system.

Sustained release of fleroxacin in vitro from lactic acid polymer

The time-delayed release of fleroxacin, a newer fluoroquinolone, from a mixture of racemic D-L-Lactic acid is reviewed. Ten in vitro experiments for each fleroxacin concentration of 1% and 10%, were performed. Pre-formed D-L-Lactic acid, plus fleroxacin clots were preserved in sterile 1 cm diameter tubes with one ml of nutrient broth at 37 degrees C until they were fully disintegrated. Every 24 hours the tubes were sampled and replaced by standard broth volumes. Fleroxacin levels were measured by a microbiological method. The release of fleroxacin impregnated in D-L-Lactic acid clots in these two concentrations (1% and 10%) is very promising; the levels obtained over a two month period were much higher than the minimum bacterial concentration of the expected pathogens implicated in bone infections.