P1478 Evaluation of reversibility of alcoholic cardiomyopathy using doubaimine stress echocardiography

Alcoholic cardiomyopathy (CM) is known as a reversible CM. Appropriate medications with cessation of alcohol may lead to full recovery of chamber size and contractility. But there is not much information about morphologic and hemodynamic changes over the course of treatment, and predictors of reversibility. We experienced the patient with alcoholic CM who was admitted with heart failure and recovered over 1 year and 5 months. He consumed daily 180g alcohol for 6 months before admission. On initial echocardiography, left atrial (LA) dimension, left ventricular (LV) systolic dimension (SD) and diastolic dimension (DD), inferior vena cava (IVC) size, and ejection fraction (EF) were 50 mm, 69 mm, 78 mm, 27 mm and 22%, respectively. Doppler examination revealed a restrictive pattern in tansmitral flow, and a systolic peak velocity/diastolic peak velocity (S/D) ratio of less than 1 in pulmonary vein flow (PVF). Pressure gradient through tricuspid regurgitation was 29 mmHg. Coronary angiogram confirmed no significant stenosis. Within 1 week after medications, LVEF increased mainly by decrease of enlarged LVSD which might be partly caused by volume overload, evidenced by respiratory variation of transmitral flow. On 8th day, we performed dobutamine stress echocardiography (DSE) to evaluate reversibility because LVEF slightly decreased despite decrease of LVDD. During dobutamine infusion, both LVDD and LVSD decreased along with increase of LVEF according to dose escalation. From 1 to 2 months, LVEF slightly increased with decrease of LVDD and LVSD. Afterwards, LVEF was normalized mainly with decrease of LVSD, and LVEF was completely normalized at 1 year and 5 month after initiation of treatment. Initial increase of LVEF might reflect decrease of LVSD by relief of volume overload rather than improving LV contractility. Based on this observation of serial change of chambers and LVEF, we speculate that increased LV wall tension, which is induced by increase of preload as a compensating mechanism for increasing stroke volume, might aggravate LVEF in later stage of heart failure with reduced EF. The sequence of normalization in chamber size was IVC, and then LA, and then LVDD. Transmitral flow as an indicator of diastolic dysfunction changed from restrictive (transiently existed only for 1 week) to abnormal relaxation pattern (no change since that time). PVF pattern showed S/D ratio < 1 until 1 week, and then triphasic pattern at 1 month, finally biphasic pattern at 8 month after initiation of medications. We observed a serial change of echocardiographic findings in patient with alcoholic CM, which might provide an insightful information to understand reverse of LV or LA remodeling associated with hemodynamic parameters, and DSE might be helpful to evaluate reversibility of LV systolic function and convince patients who are reluctant to medications.

Efficacy and safety of high concentration lidocaine for trigeminal nerve block in patients with trigeminal neuralgia

AIMS

Local anaesthetics, which act as neurolytics and Na(+) channel blockers, have been used for disrupting the neural firings in certain neuropathic pain conditions. This study was undertaken to investigate the clinical outcome of trigeminal nerve block with 10% lidocaine in the management of trigeminal neuralgia (TN).

METHODS

Thirty-five patients with primary TN received trigeminal nerve blocks with 10% lidocaine. Success was defined as complete pain relief or mild pain without medication 1 day after the treatment. We followed the patients up every 2 months assessing for pain recurrence, sensory changes and other complications for a total of 37-45 months (median 43 months).

RESULTS

Twelve of the 35 patients (34.3%) responded favourably to the treatment and were considered as success. Eleven patients experienced complete pain relief and one could tolerate pain without medication 1 day after the blocks, which lasted for 3-172 weeks. Four patients experienced mildly decreased sensation in the region of the face supplied by the nerve 1 day after the blocks; however, all recovered normal skin sensation in 6 months. There was neither allodynia nor other sensory discomfort. The pain intensity and current pain duration before treatment were significantly different between the two groups.

CONCLUSION

Trigeminal nerve block with high concentration lidocaine (10%) is capable of achieving an intermediate period of pain relief, particularly in patients with lower pain intensity and shorter pain duration prior to the procedure.

Metachronous colorectal cancer

OBJECTIVE

Although the diagnosis of metachronous colorectal cancer have increased, due primarily to improvements in diagnostic modalities, the potential risk factors for these tumours are not well known. We compared the characteristics of patients with metachronous and sporadic primary colorectal cancer to determine risk factors for its occurrence.

PATIENTS AND METHODS

We reviewed the records of 5447 patients with colorectal cancer, who had been treated at Asan Medical Centre between July 1989 and January 2004. A metachronous cancer was defined as a secondary colorectal cancer occurring more than 6 months after the index cancer.

RESULTS

Metachronous colorectal cancer occurred in 39 (0.7%) patients. Their average age was 53 years, somewhat younger than the average age of sporadic colorectal cancer patients (58 years). In patients with metachronous cancer, the cancer was more likely to be located in the right colon (P < 0.03), and the incidence of synchronous polyps or cancer was significantly higher (P < 0.001). The relative distributions of histological grades and clinicopathological characteristics were similar in index and metachronous cancers. Metachronous cancers were diagnosed more frequently at an early stage. The time interval between index and metachronous cancer ranged from 6 to 215 months (mean 39 months), with 13 (33.3%) patients diagnosed with metachronous cancer after 5 years.

CONCLUSION

We found that in patients aged < 50 years, existence of synchronous polyps or cancer influence on the development of metachronous colorectal cancer. Regular follow-up is necessary for early detection, even after 5 years, for these patients.

Feasibility of nerve-sparing prostate cryosurgery: applications and limitations in a canine model

BACKGROUND AND PURPOSE

In a canine model, we evaluated the feasibility of nerve-sparing cryosurgery by active warming of the neurovascular bundle (NVB). Furthermore, our aim was to determine if NVB warming increases the risk of acinar gland and stromal-tissue preservation in adjacent areas of the prostate. The effects of a single versus double freeze-thaw cycle on prostate tissue were also assessed.

MATERIALS AND METHODS

Ten prostate lobes from five dogs were evaluated. Nine lobes from five dogs were treated with cryoablation using 17-gauge gas-driven cryoneedles. Seven lobes wre treated with active warming of the NVB using helium gas, and two lobes were treated without active warming. A single or double freeze-thaw cycle was utilized. Prostate tissue ablation and NVB preservation were evaluated in histologic sections.

RESULTS

All seven prostate lobes treated with active warming demonstrated complete or partial NVB preservation. Four of these lobes had adjacent gland preservation. All lobes treated with a double freeze-thaw cycle showed complete and uniform ablation of prostate tissue. One of the three lobes treated with a single freeze-thaw cycle demonstrated incomplete ablation of the tissue.

CONCLUSIONS

This is the first study investigating the feasibility of NVB preservation under controlled experimental conditions. In our canine model, NVB preservation with active warming was possible but not consistently reproducible. In some cases, NVB preservation with active warming may result in incomplete peripheral tissue ablation. A double, but not a single, freeze-thaw cycle induces complete and effective necrosis of prostatic tissue. These results have significant clinical applications when attempting nerve-sparing cryosurgical ablation of the prostate.

Extrapedicular approach of percutaneous vertebroplasty in the treatment of upper and mid-thoracic vertebral compression fracture

PURPOSE

To evaluate the clinical outcome of the extrapedicular approach of percutaneous vertebroplasty (PVP) for upper and mid-thoracic vertebral compression fractures in patients.

MATERIAL AND METHODS

Extrapedicular vertebroplasty was performed in painful compression fractures at T4-T8 levels. The assessment criteria were changes over time in visual analog scale (VAS) and mobility score. We evaluated the volume of cement injected, the size of needle required, and complications.

RESULTS

Procedures were performed in 27 patients with a total of 34 affected vertebral bodies. Early (within a week) and one year later, clinical follow-ups showed that pain intensity had decreased by 50% one day after operation and later by 70-80%. Mobility scores of all patients were improved immediately after the procedure. Average volume of polymethylmethacrylate (PMMA) per vertebral body was 3.8 +/- 1.2 ml. Leakage of PMMA occurred in one vertebral level (intradiskal space), but did not cause clinical complications.

CONCLUSION

PVP of upper and mid-thoracic spine with an extrapedicular approach is an efficient and safe procedure for treating painful thoracic vertebral compression fracture under a cautious patient selection and meticulous technical procedure.

The effects of intentional cryoablation and radio frequency ablation of renal tissue involving the collecting system in a porcine model

PURPOSE

Ablative techniques for the treatment of urological malignancy are gaining acceptance and they are likely to become more widely used in clinical practice. Indications and limitations of the technologies are still evolving. In a porcine model we evaluated the safety and efficacy of cryotherapy and radio frequency ablation (RFA) of cortical and deep renal tissue.

MATERIALS AND METHODS

In 11 swine argon gas based cryoablation or RFA of renal tissue adjacent to the collecting system was performed using a laparoscopic or percutaneous approach. Lesions created in renal units 30 days or 2 hours prior to harvest were termed chronic or acute. Using single or multiple 17 gauge cryoneedles or 3.0 mm cryoprobes and 2 freeze-thaw cycles (10-minute freeze and 5-minute thaw) 13 acute and 10 chronic cryolesions were made. Using a single 16 gauge umbrella-shaped RFA probe and 2 heating cycles to maximum impedance 13 acute and 4 chronic RFA lesions were made. Gross and microscopic tissue analysis was performed to assess lesion size and renal parenchymal, collecting system and arterial effects. Acute cryolesion size estimation by laparoscopic or transcutaneous ultrasound (US) was compared with pathological lesion size.

RESULTS

Acute cryolesions on hematoxylin and eosin staining demonstrated uniform coagulative necrosis of renal parenchyma and chronic cryolesions demonstrated uniform necrosis with fibrous scar formation. Interlobar artery (adjacent to renal pyramid) preservation occurred in 7 of 13 acute and 5 of 9 chronic cryolesions. Urothelial architecture was preserved in 8 of 13 acute and 7 of 9 chronic cryolesions. Acute and chronic RFA lesions demonstrated indeterminate necrosis on hematoxylin and eosin staining, although triphenyl tetrazolium chloride staining of gross specimens confirmed necrosis most definitively in renal cortex. Interlobar artery preservation occurred in 6 of 13 acute and 3 of 4 chronic RFA lesions. Urothelial architecture was preserved in 1 of 13 acute and 2 of 4 chronic RFA lesions. Acute cryolesion dimensions measured by laparoscopic US equaled or underestimated lesion size measured grossly in all 6 cases. Lesion dimensions measured by transcutaneous US equaled or underestimated true lesion size in 3 of 6 cases. In 3 of 6 lesions transcutaneous US overestimated true lesion size by 20%, 76% and 260%, respectively.

CONCLUSIONS

Renal cortical tissue can be effectively destroyed by cryoablation or RFA. However, treatment of deep parenchymal lesions with either modality may result in incomplete ablation. Cryosurgery but not RFA spares the collecting system in an acute setting. However, healing or regrowth of the urothelium may occur with time after RFA. Laparoscopic US is more accurate for cryolesion monitoring than transcutaneous US.

Cystic renal cell carcinoma: biology and clinical behavior

The purpose of the study was to evaluate unilocular and multilocular cystic renal cell carcinoma (cRCC). These tumors are a rare entity, comprising approximately 1 to 2% of all renal tumors, and their true biologic behavior is not well-known. Initial review of renal cell carcinoma (RCC) cases treated at our institution between 1989 and 2001 identified 39 cases of cRCC. However, histopathologic review of these cases by 2 pathologists revealed that only 18 cases met the criteria that all tumors have a cystic component that constitutes at least 75% of the total lesion without evidence of necrosis. These cases were compared to 614 conventional clear cell RCC cases with regards to clinical outcomes. All 18 patients presented with localized (N0M0) disease. Thirteen (72%) of the tumors were Fuhrman Grade 1, while the remaining 5 (28%) were Fuhrman Grade 2. By comparison, only 60% of the clear cell RCC tumors were Grade 1 or 2. Similarly, 83% of cRCC were pT1 tumors compared to only 35% of conventional clear cell tumors. Mean tumor size for the cRCC tumors was 4.9 cm compared to 7.4 cm for conventional clear cell tumors. Cystic RCC patients had an 82% four-year disease-specific survival (DSS). Unilocular and multilocular cRCC is a distinct subtype of clear cell RCC. Its biology appears to be more favorable with regards to important prognostic factors such as metastatic presentation, Fuhrman grade, 1997 T stage, and tumor size. These findings suggest that cRCC patients may benefit from nephron sparing surgery.

Use of the University of California Los Angeles integrated staging system to predict survival in renal cell carcinoma: an international multicenter study

PURPOSE

To evaluate ability of the University of California Los Angeles Integrated Staging System (UISS) to stratify patients with localized and metastatic renal cell carcinoma (RCC) into risk groups in an international multicenter study.

PATIENTS AND METHODS

4,202 patients from eight international academic centers were classified according to the UISS, which combines TNM stage, Fuhrman grade, and Eastern Cooperative Oncology Group performance status. Distribution of the UISS categories was assessed in the overall population and in each center.

RESULTS

The UISS stratified both localized and metastatic RCC into three different risk groups (P <.001). For localized RCC, the 5-year survival rates were 92%, 67%, and 44% for low-, intermediate-, and high-risk groups, respectively. A trend toward a higher risk of death was observed in all centers for increasing UISS risk category. For metastatic RCC, the 3-year survival rates were 37%, 23%, and 12% for low-, intermediate-, and high-risk groups, respectively; in 6 of 8 centers, a trend toward a higher risk of death was observed for increasing UISS risk category. A greater variability in survival rates among centers was observed for high-risk patients.

CONCLUSION

This study defines the general applicability of the UISS for predicting survival in patients with RCC. The UISS is an accurate predictor of survival for patients with localized RCC applicable to external databases. Although the UISS may be useful for patients with metastatic RCC, it may be less accurate in this subset of patients due to the heterogeneity of patients and treatments.

Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience

PURPOSE

We compared cancer specific survival of patients undergoing partial and radical nephrectomies for T1N0M0 renal tumors according to tumor size in a large multicenter series.

MATERIALS AND METHODS

A retrospective analysis of 1454 patients undergoing partial or radical nephrectomy for T1N0M0 renal tumors from 7 international academic centers was performed. Data were obtained for each patient including TNM stage (determined according to the 2002 TNM criteria), tumor size, type of surgery (partial versus radical nephrectomy) and cancer specific survival. Recurrence events were recorded when available.

RESULTS

Partial and radical nephrectomies were performed in 379 (26.1%) and 1075 (73.9%) cases, respectively. Mean followup +/- SD was 62.5 +/- 51.8 months. Recurrence data were available on 544 patients. There were no significant differences in local or distant recurrence rates between patients undergoing partial or radical nephrectomy for either T1a (p = 0.6) or T1b tumors (p = 0.5). For patients with T1a tumors, there was no significant difference in the rate of cancer specific deaths between the partial (314) and radical (499) nephrectomy groups (2.2% versus 2.6%, respectively, p = 0.8). For patients with T1b tumors there was also no significant difference in the rate of cancer specific deaths between patients undergoing partial (65) and patients undergoing radical (576) nephrectomy (6.2% versus 9%, respectively, p = 0.6).

CONCLUSIONS

Partial nephrectomy is becoming the gold standard for renal tumors less than 4 cm but this treatment is much more controversial for larger T1 tumors. This large multicenter study suggests that it is safe to expand the indications of partial nephrectomy to include patients with T1N0M0 tumors up to 7 cm. However, careful patient selection remains necessary.

Prognostic value of carbonic anhydrase IX and KI67 as predictors of survival for renal clear cell carcinoma

PURPOSE

The natural history of renal cell carcinoma (RCC) is complex and not entirely explained by conventional prognostic factors. In this study we evaluated the prognostic value of carbonic anhydrase IX (CAIX) and Ki67 to predict survival in RCC.

MATERIALS AND METHODS

Immunohistochemical analysis using a CAIX and a Ki67 monoclonal antibody was performed on tissue microarrays constructed from paraffin embedded specimens from 224 patients treated with nephrectomy for clear cell renal carcinoma. CAIX and Ki67 staining were correlated with clinical factors, pathological features and survival. Median followup was 34 months (range 0.3 to 117) and disease specific survival was the primary end point assessed.

RESULTS

Univariate statistical analysis showed that high Ki67 staining and low CAIX staining correlated significantly with poor median survival (21 months, p < 0.001 and 22 months, p = 0.011, respectively). Each marker was highly significant for stratifying patient groups defined by T stage, Fuhrman grade, nodal status, metastatic status and performance status. On multivariate analysis CAIX and Ki67 were significant predictors of survival with an HR of 1.78 (p = 0.014) and 1.75 (p = 0.009), respectively. Although CAIX and Ki67 staining were inversely correlated (p = 0.009), Ki67 significantly substratified patient subgroups defined by high or low CAIX staining (p = 0.001 and 0.003, respectively). When Ki67 and CAIX were combined into a single parameter, RCC tumors could be stratified into low, intermediate and high risk groups with a median survival of greater than 101, 31 and 9 months, respectively (p <0.001). On multivariate analysis the combined parameter consisting of Ki67 and CAIX was a significant predictor of survival (p <0.001) and it was able to displace histological grade.

CONCLUSIONS

Ki67and CAIX are useful prognostic biomarkers for RCC that improve the survival prediction and classification of kidney cancer.

Cachexia-like symptoms predict a worse prognosis in localized t1 renal cell carcinoma

PURPOSE

Although cachexia is a common sequela of advanced and metastatic renal cell carcinoma (RCC), cachexia-like symptoms may also represent a paraneoplastic finding. We assessed the prognostic significance of these symptoms in patients with stage T1 RCC.

MATERIALS AND METHODS

Using the kidney cancer database at our institution 250 patients were identified who underwent partial or radical nephrectomy for T1N0M0 RCC between 1989 and 2001. The prognostic significance of the symptoms present at diagnosis and findings on preoperative laboratory evaluation were examined.

RESULTS

Mean and median followup was 33 and 43 months, respectively. Malaise, weight loss, anorexia and hypoalbuminemia were cachexia related findings that were significant predictors of worse disease specific survival (DSS). DSS in patients with 1 vs greater than 1 cachexia related symptoms was not significantly different (p = 0.077). Therefore, any patient with at least 1 cachexia related finding was considered to be positive for cachexia and cachexia occurred in 37 (14.8%). Cachexia was associated with significantly worse recurrence-free survival (HR 3.03, p = 0.032) and DSS (HR 4.39, p = 0.011) even after controlling for tumor size, grade and performance status. The 5-year survival rate in patients with low grade (1 or 2) tumors with and without cachexia was 91% and 81%, respectively. The 5-year survival rate in patients with high grade (3 or 4) tumors with and without cachexia was 75% and 55%, respectively.

CONCLUSIONS

Cachexia-like symptoms independently predict a worse prognosis in patients with T1 RCC. Patients with cachexia (malaise, weight loss, anorexia and hypoalbuminemia), especially when associated with high grade tumors, should be considered for clinical trials of adjuvant therapies.

Prostate Stem Cell Antigen Expression is Associated With Gleason Score, Seminal Vesicle Invasion and Capsular Invasion in Prostate Cancer

PURPOSE

Few successful therapeutic options exist for men who present with metastatic prostate cancer (CaP) or for the 30% with recurrence. The development and characterization of molecular markers are vital to the development of prognostic and therapeutic modalities in CaP. We investigated the expression and potential clinical usefulness of prostate stem cell antigen (PSCA) in CaP using tissue microarrays.

MATERIALS AND METHODS

Immunohistochemical analysis using a PSCA monoclonal antibody was performed on tissue microarrays constructed from paraffin embedded specimens from 246 patients who underwent radical retropubic prostatectomy. PSCA staining was correlated with established prognostic factors, such as Gleason score, prostate specific antigen (PSA), and seminal vesicle invasion. In addition, recurrence-free survival was analyzed.

RESULTS

A high PSCA intensity of 3 was associated with adverse prognostic features, such as Gleason score 7 and above (p = 0.001), seminal vesicle invasion (p = 0.005) and capsular involvement (p = 0.033). On univariate analysis tumors with a PSCA intensity of 3 carried an increased risk of PSA recurrence (p = 0.031, HR 1.77, 95% CI 1.05 to 2.96). However, after adjusting for these variables a PSCA intensity of 3 was no longer an independent predictor of PSA recurrence.

CONCLUSIONS

We found that high PSCA intensity is significantly associated with adverse prognostic features such as high Gleason score and extra-organ disease. The results of this study suggest that PSCA is a promising tumor marker for the selection of patients at high risk but additional studies are necessary to assess the usefulness of PSCA in patient biopsies.

Routine pouchograms are not necessary after continent urinary diversion

OBJECTIVES

Pouchograms are routinely performed before catheter removal after continent urinary diversion at our institution. Our aim was to determine the necessity of pouchograms based on a review of our experience.

METHODS

A retrospective review of patient records and radiographic studies was done for patients undergoing radical cystectomy and continent urinary diversions between 1991 and 2001.

RESULTS

Seventy-two patients underwent continent urinary diversion (orthotopic, n = 59; cutaneous, n = 13) during the study period. All underwent pouchogram postoperatively (median 22 days; range 20 to 27). Six patients (8.3%) had a demonstrable radiographic leak; in 5 of the 6 patients, the urine leak was suspected on clinical grounds. Three patients (4.7%) developed urosepsis after pouchogram.

CONCLUSIONS

Our findings indicate that routine pouchograms before pouch activation after continent urinary diversion may not be necessary.

Prognostic Significance of Venous Thrombus in Renal Cell Carcinoma. Are Renal Vein and Inferior Vena Cava Involvement Different?

PURPOSE

The prognostic significance of the level of venous involvement in renal cell carcinoma (RCC) is controversial. It has been suggested that the 1997 TNM classification of venous involvement system should be revised.

MATERIALS AND METHODS

The records of 226 patients who underwent a nephrectomy and tumor thrombectomy, 117 for renal vein (RV) and 109 for inferior vena cava (IVC) involvement, between 1989 and 2001 were reviewed and compared to those of 654 patients undergoing nephrectomy without venous involvement.

RESULTS

In patients with localized RCC (N0M0), the risk of recurrence after nephrectomy was significantly increased in patients with venous thrombus compared to patients without venous thrombus (p = 0.005). However, the difference was not significant in a multivariate analysis including T stage (1, 2, 3 or 4), Fuhrman grade and Eastern Cooperative Oncology Group performance status. In patients with localized RCC disease specific survival was similar (p = 0.536) in patients with RV (T3b) and IVC involvement below the diaphragm (T3b). However, patients with IVC involvement above the diaphragm (T3c) had a significantly worse survival rate even after controlling for Fuhrman grade and Eastern Cooperative Oncology Group performance status in a multivariate analysis (p = 0.020). All patients treated for metastatic RCC had a similar prognosis regardless of the level of venous involvement.

CONCLUSIONS

For patients with pT3b disease, local tumor stage and grade are better predictors of prognosis than extent of venous involvement. Based on our data we support the current TNM classification of venous involvement with RV and IVC invasion categorized as T3b and IVC involvement above the diaphragm categorized as T3c.

Primary leiomyosarcoma of the inferior vena cava presenting as a renal mass

Leiomyosarcoma of the inferior vena cava (IVC) is an extremely rare entity. We present the case of a 62-year-old woman who was found to have a large right upper quadrant mass upon examination by her primary care physician in evaluation for diffuse abdominal pain accompanied by anorexia and weight loss. A computed tomographic scan and magnetic resonance imaging demonstrated a 13-cm retroperitoneal lesion that appeared to stem from the right kidney and yielded a tumor thrombus up to the level of the hepatic venous confluence. The patient underwent a right radical nephrectomy and IVC thrombectomy for treatment of a presumed renal cell carcinoma. Instead, pathology revealed the tumor to be a leiomyosarcoma of the IVC. We document this unusual presentation of an extremely rare tumor entity.

Validation of an Integrated Staging System Toward Improved Prognostication of Patients With Localized Renal Cell Carcinoma in an International Population

PURPOSE

Outcome prediction for patients with renal cell carcinoma is based on a combination of factors. In this study a previously published clinical outcome algorithm based on 1997 T stage, Fuhrman grade and performance score is validated using an international database.

MATERIALS AND METHODS

A total of 1,060 patients from Nijmegen, the Netherlands (NN), MD Anderson (MDA) and University of California, Los Angeles (UCLA) who had localized renal cell carcinoma were evaluated for outcome prediction using a clinical outcome algorithm previously shown to stratify patients into low, intermediate and high risk groups. Validation was performed by comparing the 3 risk groups separately within the 3 centers as well as by comparing hazard ratios and concordance indices among the 3 centers.

RESULTS

Estimated disease specific survival rates at 5 years for the low risk groups were 94% (NN), 92% (MDA) and 93% (UCLA). The 5-year disease specific survival rates for the intermediate risk groups were 65% (NN), 73% (MDA) and 78% (UCLA), while the rates for the high risk groups were 40% (NN), 30% (MDA) and 48% (UCLA). The concordance indices for each of the databases were 79% (NN), 86% (MDA) and 84% (UCLA).

CONCLUSIONS

A clinical algorithm that uses only 3 prognostic variables (1997 T stage, Fuhrman grade and performance status) to stratify patients with localized renal cell carcinoma into 3 risk groups has been shown to be applicable to external databases. This algorithm may be useful for patient counseling, surveillance and identification of high risk patients for enrollment in clinical trials.

Treatment of Organ Confined Prostate Cancer with Third Generation Cryosurgery: Preliminary Multicenter Experience

PURPOSE

Cryosurgical ablation of the prostate is 1 approach to the treatment of localized prostate cancer. Third generation cryosurgery uses gas driven probes that allow for a decrease in probe diameter to 17 gauge (1.5 mm). The safety, morbidity and preliminary prostate specific antigen (PSA) results of 122 cases are reported.

MATERIALS AND METHODS

A total of 106 patients have undergone percutaneous cryosurgery using a brachytherapy template with at least 12 months of PSA followup. Immediate and delayed morbidities were evaluated. PSA results at 3 and 12 months were recorded, and failure was defined as the inability to reach a nadir of 0.4 ng/ml or less.

RESULTS

Complications in patients undergoing primary cryosurgery included tissue sloughing (5%), incontinence (pads, 3%), urge incontinence/no pads (5%), transient urinary retention (3.3%) and rectal discomfort (2.6%). There were no cases of fistulas or infections. Postoperative impotence was 87% in previously potent patients. For patients who underwent salvage cryosurgery there were no fistulas reported and 2 (11%) patients required pads after salvage cryosurgery. A total of 96 (81%) patients achieved a PSA nadir of 0.4 ng/ml or less at 3 months of followup, while 79 of 106 (75%) remained free from biochemical recurrence at 12 months. A total of 42 (78%) low risk patients (Gleason score 7 or less and PSA 10 or less) remained with a PSA of 0.4 ng/ml or less at 12 months of followup, compared to 37 (71%) high risk patients. All patients were discharged within 24 hours.

CONCLUSIONS

After a followup of 1 year 3rd generation cryosurgery appears to be well tolerated and minimally invasive. The use of ultrathin needles through a brachytherapy template allows for a simple percutaneous procedure and a relatively short learning curve. A prospective multicenter trial is ongoing to determine the long-term efficacy of this technique.

Renal cell carcinoma with retroperitoneal lymph nodes. Impact on survival and benefits of immunotherapy

BACKGROUND

The current study was performed to determine the impact of the presence of retroperitoneal lymphadenopathy on the survival and response to immunotherapy of patients with metastatic renal cell carcinoma (RCC).

METHODS

A retrospective cohort study was performed with outcome assessment based on the chart review of demographic, clinical, and pathologic data from 1087 patients. Patients with RCC who did not present with metastatic disease, who did not undergo nephrectomy as part of their cancer treatment, and those in whom either the lymph node (N) or metastatic (M) status was unknown, were excluded. A total of 322 M1 patients who met these criteria and who underwent nephrectomy for unilateral RCC formed the principal study population.

RESULTS

Two hundred thirty-six patients presented with N0M1 disease and 86 patients presented with N+M1 disease. In M1 patients, the presence of positive regional lymph nodes was associated with larger sized, higher grade, locally advanced primary tumors that were more commonly associated with sarcomatoid features. N0M1 patients were more likely to achieve an objective response to systemic immunotherapy compared with N+M1 patients (P = 0.01). N+M1 patients overall had worse short-term and long-term survival compared with N0M1 patients, with a median survival of 10.5 months compared with 20.4 months, respectively. The median survival of N0M1 patients was improved to 28 months in those who received adjunctive immunotherapy (P = 0.0008), whereas the median survival of patients with N+M1 disease was the same in those treated with and those treated without adjunctive immunotherapy (P = 0.18).

CONCLUSIONS

Even in the modern era of systemic immunotherapy, the presence of regional lymphadenopathy exerts a detrimental effect on the survival of patients with metastatic RCC. Lymph node status is a strong predictor of the failure to achieve either an objective immunotherapy response or an improvement in survival when immunotherapy is given as an adjunctive treatment after cytoreductive nephrectomy. However, in multivariate analysis, including both clinical and pathologic variables, lymph node status was found to have less of an impact on survival than primary tumor stage and grade and patient performance status.

Renal cell carcinoma with retroperitoneal lymph nodes: role of lymph node dissection

PURPOSE

We better defined the benefits and morbidity of lymph node dissection in patients with localized renal cell carcinoma using the experience of patients treated at our institution.

MATERIALS AND METHODS

A retrospective cohort study was performed with outcome assessment based on the chart review of demographic, clinical and pathological data in 1,087 patients with renal cell carcinoma treated at our institution. Patients with renal cell carcinoma who did not undergo nephrectomy as part of cancer treatment, those with bilateral disease and those for whom nodal status was unknown were not included in this study. A total of 900 patients meeting these criteria who underwent nephrectomy for unilateral renal cell carcinoma at our medical center form the principal study population.

RESULTS

Positive lymph nodes were associated with larger, higher grade, locally advanced primary tumors that were more commonly associated with sarcomatoid features. Positive nodes were 3 to 4 times more common in patients with metastatic disease and the majority of these patients could be identified preoperatively. The survival of patients with regional lymph node involvement only was identical to that of patients with distant metastatic disease only. Patients with regional nodes and distant metastases had significantly inferior survival to those with either condition alone. In node negative cases lymph node dissection can be performed with no additional morbidity but it confers no survival advantage. In node positive cases lymph node dissection can also be performed safely but it is associated with improved survival and a trend toward an improved response to immunotherapy.

CONCLUSIONS

Regional lymph node dissection is unnecessary in patients with clinically negative lymph nodes since it offers extremely limited staging information and no benefit in terms of decreasing disease recurrence or improving survival. In patients with positive lymph nodes lymph node dissection is associated with improved survival when it is performed in carefully selected patients undergoing cytoreductive nephrectomy and postoperative immunotherapy. When lymph nodes are present, they should be resected when technically feasible.

Novel kidney cancer immunotherapy based on the granulocyte-macrophage colony-stimulating factor and carbonic anhydrase IX fusion gene

PURPOSE

We investigated the ability of the fusion protein granulocyte-macrophage colony-stimulating factor and carbonic anhydrase IX (GMCA-9)(1) to induce an immune response in vitro and in vivo for the development of a GMCA-9-based kidney cancer vaccine.

EXPERIMENTAL DESIGN

Human dendritic cells (DCs) were transduced with a recombinant adenovirus containing the GMCA-9 gene and tested for their capacity to induce CA9-specific cytotoxic T lymphocytes in vitro. Tumor growth was studied in severe compromised immunodeficiency disease (SCID) mice s.c. injected with R11-GMCA-9, a human renal cell carcinoma cell line stably transfected with the GMCA-9 gene. Involvement of natural killer (NK) cells in the antitumor activity of GMCA-9 was determined in SCID mice treated with the NK-blocking agent anti-asialoGM-1.

RESULTS

DC and R11 cells transduced with GMCA-9 produced a GMCA-9 protein that is targeted to the cell membrane and partially processed to granulocyte macrophage colony-stimulating factor- and CA9-like products. Furthermore, GMCA-9 was capable of inducing DC maturation, as well as CA9-specific cytotoxic lymphocytes in vitro. Tumor growth of R11 cells in SCID mice was significantly inhibited after transfection with the GMCA-9 fusion gene (P < 0.01). In mice treated with anti-asialoGM-1, R11-GMCA-9 tumors grew significantly faster than those of control mice (P < 0.05), suggesting an involvement of NK cells.

CONCLUSIONS

Our results suggest that the fusion protein GMCA-9 is capable of generating an immune response both in vitro and in vivo. Additional studies will confirm the utility of ex vivo GMCA-9-transduced DCs as a kidney cancer vaccine.

TNM T3a renal cell carcinoma: adrenal gland involvement is not the same as renal fat invasion

PURPOSE

Upper pole tumors with direct extension into the adrenal gland are currently staged as pT3a tumors in the 1997 TNM staging system. To determine whether the clinical behavior of pT3a adrenal tumors differs from that of tumors with perinephric fat invasion (also stage pT3a) a retrospective analysis was performed.

MATERIALS AND METHODS

Of 1,087 patients who underwent nephrectomy 27 were identified with direct adrenal involvement and 187 were identified with perinephric fat or renal sinus involvement. Variables and outcomes analyzed in each group included the percent of patients with metastatic disease at presentation, lymph node involvement, Eastern Cooperative Oncology Group score, response to immunotherapy, and median and overall survival using Kaplan-Meier curves.

RESULTS

Median survival for patients with pT3a disease and perinephric or renal sinus fat involvement was 36 months with a 36% 5-year cancer specific survival rate. In contrast, patients with adrenal gland invasion had significantly worse survival at a median of 12.5 months and a 0% 5-year cancer specific survival rate (p <0.001), which was similar to median survival of those with stage pT4 disease (11 months).

CONCLUSIONS

Upper pole tumors with direct extension into the adrenal gland predict significantly worse survival than similarly staged tumors with fat invasion and they have a prognosis similar to that of stage pT4 disease. While these data await external validation, consideration should be given to re-categorizing tumors with direct adrenal gland involvement as stage pT4 or in a subcategory such as pT4a.

Number of metastatic sites rather than location dictates overall survival of patients with node-negative metastatic renal cell carcinoma

OBJECTIVES

To perform a retrospective study to determine whether survival and immunotherapy response are related to the site of metastases (lung versus bone) and to the number of organ sites involved (one versus multiple). The most common sites of metastatic renal cell carcinoma (mRCC) are the lung and bone.

METHODS

The records of 434 patients with mRCC were reviewed. Patients with pathologic evidence of nodal involvement were excluded, leaving 120 patients with mRCC to lung only, 33 patients to bone only, and 144 patients with multiple organ involvement. The response rates to immunotherapy and overall survival were compared. The variables evaluated in statistical analyses included Eastern Cooperative Oncology Group score, grade, 1997 tumor stage, and multiple organ involvement.

RESULTS

The median survival for patients with lung only and bone only mRCC was 27 months; patients with multiple organ involvement had a median survival of 11 months. In patients who underwent nephrectomy followed by immunotherapy, the median survival time was 31, 31, and 13 months in the lung, bone, and multiple sites groups, respectively. The response rate to immunotherapy after nephrectomy was 44%, 20%, and 14% in the lung, bone, and multiple organ groups, respectively. Multivariate analysis confirmed that metastatic disease to more than one organ site was associated with poor prognosis (2.05 risk ratio, P <0.001).

CONCLUSIONS

Patients with mRCC to only one organ site fared significantly better than patients who had evidence of disease in multiple organs. Survival in patients with disease limited to the lung was similar to that of patients whose disease was limited to bone.

Risperidone-induced priapism

Priapism is well documented as a potential side effect of psychotropic medications. To date, there have been no reports of risperidone-induced priapism in the urologic literature. We report a case of risperidone-induced priapism requiring surgical treatment.

Prognostic factors and molecular markers for renal cell carcinoma

Renal cell carcinoma is the most common cancer in the kidney, affecting nearly 30,000 Americans every year and is associated with over 12,000 deaths annually. If detected early, renal cell carcinomas can be cured surgically. However, once metastatic disease develops the prognosis for long-term survival is poor. Unfortunately, one-third of patients have metastatic disease at the time of diagnosis and approximately 50% of the patients undergoing surgical resection for less advanced disease eventually relapse. This review examines the clinical and molecular prognostic tools currently available or under investigation for kidney cancer.

Management of penile toilet seat injury--report of two cases

Blunt trauma to the penis is an uncommon injury in young children. We present two cases of blunt penile trauma secondary to mechanical compression from a toilet seat.

Metastatic renal cell carcinoma presenting as an oral tumor

Metastatic cancer presenting as an oral lesion is exceedingly uncommon. To the best of our knowledge this is the first reported instance of renal cell carcinoma presenting initially as an oral lesion.

Lymphatic mapping and intraoperative lymphoscintigraphy for identifying the sentinel node in penile tumors

Lymph node mapping has become an integral part of the management of melanoma and breast cancer with regard to both staging and treatment. We report our technique for lymphatic mapping and intraoperative lymphoscintigraphy applied to a patient with penile melanoma. This technique may improve the sensitivity of identifying the sentinel lymph node in patients with malignant penile lesions.

Ureteroenteric anastomosis in continent urinary diversion: long-term results and complications of direct versus nonrefluxing techniques

PURPOSE

Controversy exists over the importance of antireflux mechanisms in large volume, low pressure intestinal bladder substitutions. Despite the theoretical benefits of reflux prevention, antirefluxing ureteral reimplantations may have a greater risk of anastomotic stricture. We hypothesize that this inherent stricture rate may outweigh the potential benefits associated with reflux prevention. To assess this question critically we compare our results to those of direct and nonrefluxing techniques of ureterointestinal anastomosis during continent diversion.

MATERIALS AND METHODS

Between 1990 and 1998, 58 patients underwent continent urinary diversion using an Indiana pouch or ileal orthotopic neobladder following cystectomy for muscle invasive bladder cancer. A total of 56 renal units were implanted using an end-to-side Nesbit direct anastomosis and 60 were implanted in a nonrefluxing manner. Clinical end points included anastomotic stricture formation, hydronephrosis, pyelonephritis, upper tract stone formation and renal deterioration, and were assessed with a mean followup of 41 months.

RESULTS

Of 60 nonrefluxing ureteroenteric anastomoses 8 (13%) resulted in nonneoplastic stricture formation compared to 1 of 56 (1.7%) direct anastomoses, which was statistically significant (Fisher's exact test p <0.05). Strictures occurred up to 6 years following the original surgery. There was no significant difference between the 2 groups in regard to hydronephrosis, pyelonephritis, upper tract stone formation or azotemia.

CONCLUSIONS

Nonrefluxing methods of ureterointestinal reimplantation resulted in a statistically significant higher rate of anastomotic stricture than the end-to-side direct anastomosis. This finding appears to outweigh any theoretical benefits of preventing pyelonephritis, stones or azotemia. For patients undergoing large volume, low pressure continent diversion the refluxing ureterointestinal anastomosis may be the technique of choice since it preserves renal function as well as the nonrefluxing method, is technically easier to perform and poses less risk of stricture. Delayed stricture formation years after surgery underscores the necessity for long-term radiological followup in patients following continent diversion.

Prospective evaluation of endorectal magnetic resonance imaging to detect tumor foci in men with prior negative prostastic biopsy: a pilot study

PURPOSE

Prostate cancer foci have a characteristic appearance on endorectal magnetic resonance imaging (MRI) which might be useful for prostate cancer detection. In this pilot study the ability of endorectal MRI to detect prostate cancer foci prospectively in men at risk for a malignant prostatic neoplasm is assessed.

MATERIALS AND METHODS

Endorectal MRI was performed in 33 consecutive men with 1 or more prior negative prostatic biopsies. All studies were read by 2 MRI dedicated study radiologists in consensus before and after receiving patient clinical data. Areas of interest on endorectal MRI were mapped as low, moderate or high suspicion for carcinoma on a prostate model. Directed needle biopsy cores of the prostate were obtained based on this model, and the histopathological findings were compared with MRI results.

RESULTS

Carcinoma was detected in 7 of 33 men (21.2%) on post-MRI biopsy, including 1 of 18 (5.6%) with low, 1 of 8 (12.5%) with moderate and 5 of 7 (71.4%) with high suspicion MRI. The site of positive biopsy correlated correctly with the area of suspicion on MRI in 85.7% of cases. Overall, endorectal MRI had 40% positive predictive value (moderate or high suspicion), 94.4% negative predictive value (low suspicion) and 69.7% accuracy. On multivariate analysis positive endorectal MRI was associated with an 11.3-fold risk of positive biopsy.

CONCLUSIONS

Endorectal MRI may effectively stratify patients with prior negative prostatic biopsy into low, moderate and high risk groups for a malignant prostatic neoplasm, and may improve our ability to identify prostatic tumor foci prospectively.

Endovascular stent graft for management of ureteroarterial fistula after orthotopic bladder substitution

We describe the first case of an ureteroarterial fistula developing after orthotopic neobladder substitution and its minimally invasive management using endovascular stent grafting. We outline the risk factors for the development of ureteroarterial fistulae and trace the evolution of diagnostic and therapeutic modalities used in the management of these life-threatening complications. Minimally invasive management with endovascular stent grafting and exclusion of two pseudoaneurysms in the iliac artery system was performed successfully. After successful endovascular exclusion of two pseudoaneurysms, the patient's hematuria resolved and he recovered fully. Three-dimensional computed tomography performed 3 months later documented a patent aortoiliac arterial system without evidence of pseudoaneurysm or endovascular leak. Ureteroarterial fistula after orthotopic bladder substitution was managed with an endovascular stent graft without the need for extra-anatomical vascular bypass. Early recognition, stabilization, and angiographic evaluation followed by this minimally invasive technique may avoid open operative repair and attendant morbidity.