Surprisingly Late Metastasis of Renal Cell Carcinoma in the Thyroid Gland Detected by Routine Multiparametric Ultrasound

The differential diagnosis of thyroid nodules in patients treated for renal cell carcinoma in the past can be challenging unless they present sonographic features of malignancy. The possibility of metastases to the thyroid gland, even many years after the primary occurrence of the renal tumor, should always be considered. Here, we present the case of a patient diagnosed with metastases of a renal cell carcinoma to the thyroid 22 years after nephrectomy of the left kidney and uneventful follow-up.

Brain death activates donor organs and is associated with a worse I/R injury after liver transplantation

The majority of transplants are derived from donors who suffered from brain injury. There is evidence that brain death causes inflammatory changes in the donor. To define the impact of brain death, we evaluated the gene expression of cytokines in human brain dead and ideal living donors and compared these data to organ function following transplantation. Hepatic tissues from brain dead (n = 32) and living donors (n = 26) were collected at the time of donor laparotomy. Additional biopsies were performed before organ preservation, at the time of transplantation and one hour after reperfusion. Cytokines were assessed by real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and cytometric bead array. Additionally, immunohistological analysis of tissue specimens was performed. Inflammatory cytokines including IL-6, IL-10, TNF-alpha, TGF-beta and MIP-1alpha were significantly higher in brain dead donors immediately after laparotomy compared to living donors. Cellular infiltrates significantly increased in parallel to the soluble cytokines IL-6 and IL-10. Enhanced immune activation in brain dead donors was reflected by a deteriorated I/R injury proven by elevated alanin-amino-transferase (ALT), aspartat-amino-transferase (AST) and bilirubin levels, increased rates of acute rejection and primary nonfunction. Based on our clinical data, we demonstrate that brain death and the events that precede it are associated with a significant upregulation of inflammatory cytokines and lead to a worse ischemia/reperfusion injury after transplantation.

Survival benefit in patients after palliative resection vs non-resection colon cancer surgery

AIM: To evaluate survival in patients undergoing palliative resection versus non-resection surgery for primary colorectal cancer in a retrospective analysis.

METHODS: Demographics, TNM status, operating details and survival were reviewed for 67 patients undergoing surgery for incurable colorectal cancer. Palliative resection of the primary tumor was performed in 46 cases in contrast to 21 patients with non-resection of the primary tumor and bypass surgery. Risk factors for postoperative mortality and poor survival were analyzed with univariate and multivariate analyses.

RESULTS: The two groups were comparable in terms of age, gender, preoperative presence of ileus and tumor stage. Multivariate analysis showed that median survival was significantly higher in patients with palliative resection surgery (544 vs 233 d). Differentiation of the tumor and tumor size were additional independent factors that were associated with a significantly poorer survival rate.

CONCLUSION: Palliative resection surgery for primary colorectal cancer is associated with a higher median survival rate. Also, the presence of liver metastasis and tumor size are associated with poor survival. Therefore, resection of the primary tumor should be considered in patients with non-curable colon cancer.

Mini-incision for strictly retroperitoneal nephrectomy in living kidney donation vs flank incision

BACKGROUND

Mini-incision donor nephrectomies (MIDNs) were established during the last decade, as an alternative to traditional open donor nephrectomy (ODN) via flank incision. In this study, we investigated intra-operative and post-operative data on outcome following MIDN in comparison with ODN data.

METHODS

Data of 70 living kidney donations, performed at the University of Regensburg Medical Center since 1996, were evaluated. Donor operation was performed as either strictly retroperitoneal MIDN (n = 34) or as traditional ODN (n = 36) via flank incision. Total operation time, warm ischaemia time (WIT), perioperative pain-medication usage and creatinine levels as well as length of hospital stay, return to complete enteral nutrition and regular digestion were evaluated retrospectively.

RESULTS

Total operation times were similar in MIDN, n = 34 (132 +/- 26 min) and in ODN, n = 36 (140 +/- 37 min) (P = 0.424). WIT was also similar in both: MIDN (0.9 +/- 0.4 min) and ODN (0.9 +/- 0.4 min) (P = 0.568). The requirement for post-operative opioids in morphine equivalent doses was significantly lower in MIDN (8.4 +/- 16 mg) compared with ODN (44 +/- 57 mg) (P = 0.001). Additional application of non-opioids (metamizole) (MIDN: 4.8 +/- 6.3 g, ODN: 3.4 +/- 3.9 g) and non-steroidal antirheumatic (NSAR) (diclofenac) (MIDN: 322 +/- 361 mg, ODN: 247 +/- 474 mg) revealed no significant differences between the groups. The hospital stay was 4.9 +/- 1.4 days in MIDN which was significantly shorter than that in ODN (9.3 +/- 3.3 days) (P = 0.001). Patients achieved fully independent mobility earlier in MIDN than in ODN (P = 0.934). Start of enteral nutrition with fluids was significantly quicker in MIDN (1.9 +/- 7 h) compared with ODN (12 +/- 13 h) (P = 0.05). Full enteral nutrition was accomplished significantly earlier in MIDN (1.6 +/- 0.8 days) (P = 0.023). Return to normal digestion revealed no significant differences between groups. Serum creatinine levels of all kidney donors were in the normal range (66 +/- 18 micromol/l) one day before nephrectomy, increased on day 1 after surgery (119 micromol/l +/- 31 micromol/l) and were stable on day 3 (115 micromol/l +/- 30 micromol/l) without significant differences.

CONCLUSION

Strictly, retroperitoneal MIDN in living kidney donation is a fast and safe method for the procurement of a living donor graft, giving the patient a significantly shorter period of recovery, and thus is an attractive and recommendable alternative to traditional ODN procedures.

Significant reduction of proinflammatory cytokines by treatment of the brain-dead donor

INTRODUCTION

Experimental studies suggest that brain death in the donor has a significant impact on graft quality; however, there are no data correlating organ-specific cytokine expression and the corresponding serum protein levels in human organ donors. Furthermore, it is unknown whether donor treatment can reduce the up-regulation of proinflammatory cytokines and thereby optimize organ quality.

METHODS

We investigated the expression pattern of cytokines comparing serum (n = 53) and tissue expression (n = 25) in brain-dead human donors. The controls were living donors (n = 25). Additionally 41 deceased donors were treated with steroids before organ harvest (250 mg initial, afterward 100 mg/h until laparotomy). Hepatic tissue samples were obtained immediately after donor laparotomy to assess transcription rates of tissue cytokines (IL-6, IL-10, CD3, TGFb, TNFa, BAG, HO-1, Mipla) by RT-PCR. Serum samples were obtained after declaration of brain death and before laparotomy.

RESULTS

Transcription of proinflammatory cytokines was significantly increased in brain-dead compared to living donor grafts (P < .005). Donor treatment with steroids led to significantly decreased tissue and serum expression of proinflammatory cytokines (P < .01), which were comparable to living donors. Tissue levels of cytokines (IL-6, IL-10) correlated strongly with serum levels of the corresponding proteins.

CONCLUSIONS

Serum protein levels of proinflammatory cytokines proffer a valuable, easy accessible marker to define the immunological status of a graft. Our data suggest a beneficial effect of anti-inflammatory treatment of brain-dead organ donors.