Extrarenal renal cell carcinoma arising in the kidney proximity but without an identifiable renal primary - an intriguing dilemma: report of three cases and review of the literature.

AIM: To raise awareness of the existence of extrarenal renal cell carcinoma (RCC). METHODS AND RESULTS: We report three patients with extrarenal RCC found in the renal proximity, but unattached to the kidney. None had a history of RCC or an identifiable primary renal neoplasm at the time of the diagnosis and on follow-up. The patients included two males and one female aged 57, 77, and 63 years, respectively. One carcinoma was found in the perirenal tissue adjacent to the adrenal, one involved the adrenal gland, and one was a retroperitoneal mass found within the lymph nodes. Two extrarenal RCCs represented clear-cell RCCs and one was an unclassifiable RCC. No patient had evidence of metastases at presentation and disease progression during the follow-up. This report adds to the literature on this unusual clinical scenario and further supports the concept of extrarenal RCC, which is not a well-recognized clinical phenomenon. We also reviewed other similar reports documenting the absence of identifiable renal primaries in the setting of either disseminated metastatic disease or isolated distant metastases of presumed renal origin. Similarly, some carcinomas of apparent renal derivation have been also identified during a work-up of metastatic carcinomas of unknown primary. CONCLUSIONS: There should be an awareness of this unusual and intriguing clinical scenario that currently lacks a definitive explanation and standardized therapy strategies. Establishing a correct diagnosis may allow treatment with specific targeted therapies in selected clinical cases.

MRI-TRUS registration methodology for TRUS-guided HDR prostate brachytherapy.

PURPOSE: High-dose-rate (HDR) prostate brachytherapy is an established technique for whole-gland treatment. For transrectal ultrasound (TRUS)-guided HDR prostate brachytherapy, image fusion with a magnetic resonance image (MRI) can be performed to make use of its soft-tissue contrast. The MIM treatment planning system has recently introduced image registration specifically for HDR prostate brachytherapy and has incorporated a Predictive Fusion workflow, which allows clinicians to attempt to compensate for differences in patient positioning between imaging modalities. In this study, we investigate the accuracy of the MIM algorithms for MRI-TRUS fusion, including the Predictive Fusion workflow. MATERIALS AND METHODS: A radiation oncologist contoured the prostate gland on both TRUS and MRI. Four registration methodologies to fuse the MRI and the TRUS images were considered: rigid registration (RR), contour-based (CB) deformable registration, Predictive Fusion followed by RR (pfRR), and Predictive Fusion followed by CB deformable registration (pfCB). Registrations were compared using the mean distance to agreement and the Dice similarity coefficient for the prostate as contoured on TRUS and the registered MRI prostate contour. RESULTS: Twenty patients treated with HDR prostate brachytherapy at our center were included in this retrospective evaluation. For the cohort, mean distance to agreement was 2.1 ± 0.8 mm, 0.60 ± 0.08 mm, 2.0 ± 0.5 mm, and 0.59 ± 0.06 mm for RR, CB, pfRR, and pfCB, respectively. Dice similarity coefficients were 0.80 ± 0.05, 0.93 ± 0.02, 0.81 ± 0.03, and 0.93 ± 0.01 for RR, CB, pfRR, and pfCB, respectively. The inclusion of the Predictive Fusion workflow did not significantly improve the quality of the registration. CONCLUSIONS: The CB deformable registration algorithm in the MIM treatment planning system yielded the best geometric registration indices. MIM offers a commercial platform allowing for easier access and integration into clinical departments with the potential to play an integral role in future focal therapy applications for prostate cancer.

Manometric parameters, when measured with the 3-dimensional high-definition anorectal manometry probe, poorly predict prolonged balloon expulsion time.

BACKGROUND: There are little data evaluating the performance of the 3-dimensional high-definition anorectal manometry (3D-HDAM) system in the diagnosis of dyssynergic defecation. Physical properties of the thicker, rigid, 3D-HDAM probe may have implications on the measurements of anorectal pressures. AIM: Our aim was to compare 3D-HDAM to balloon expulsion test and magnetic resonance (MR) defecography. METHODS: Consecutive constipated patients referred for anorectal function testing at the Calgary Gut Motility Centre (Calgary, Canada) between 2014 and 2019 were assessed. All patients underwent anorectal manometry with the 3D-HDAM probe, and a subset underwent BET or MR defecography. Anorectal manometric variables were compared between patients who had normal and abnormal BET. RESULTS: Over the study period, 81 patients underwent both 3D-HDAM and BET for symptoms of constipation. 52 patients expelled the balloon within 3 minutes. Patients with abnormal BET had significantly lower rectoanal pressure differential (RAPD) (-61 vs. -31 mmHg for normal BET, p = 0.03) and defecation index (0.29 vs. 0.56, p = 0.03). On logistic regression analysis, RAPD (OR: 0.99, 95% CI: 0.97-0.99, p = 0.03) remained a negative predictor of abnormal BET. On ROC analysis, RAPD had an AUC of 0.65. There was good agreement between dyssynergic patterns on 3D-HDAM and defecographic evidence of dyssynergia (sensitivity 80%, specificity 90%, PLR 9, NLR 0.22, accuracy 85%). CONCLUSIONS: Manometric parameters, when measured with the 3D-HDAM probe, poorly predict prolonged balloon expulsion time. RAPD remains the best predictor of prolonged balloon expulsion time. The 3D-HDAM probe may not be the ideal tool to diagnose functional defecatory disorders.

Transarterial chemoembolization in patients with hepatocellular carcinoma: predictors of survival.

BACKGROUND: Transarterial chemoembolization (TACE) is the mainstay of management for patients with hepatocellular carcinoma who are not suitable for curative treatments. OBJECTIVE: To determine factors associated with mortality after the first TACE procedure. METHODS: From January 2004 to May 2008, 60 patients underwent TACE as treatment for hepatocellular carcinoma. Clinical and biochemical parameters before TACE, and response after TACE, were evaluated with conventional classifications (WHO, Response Evaluation Criteria in Solid Tumors [RECIST], and European Association for the Study of the Liver [EASL] criteria) and with one-, two- and three-dimensional assessment. RESULTS: Overall median survival after the first TACE procedure was 17.1±3.4 months. According to Cox regression analysis, having an alpha-fetoprotein level of greater than 200 ng/mL (HR 2.35 [P=0.02]) and a Model for End-stage Liver Disease (MELD) score of greater than 10 (HR 4.19 [P=0.001]) were associated with higher risk of mortality; whereas reduction in tumour size measured in one dimension (HR 0.96 [P=0.005]), two dimensions (HR 0.98 [P=0.004]) and three dimensions (HR 0.98 [P=0.001]) was associated with lower risk of mortality. Moreover, reduction in tumour size by 3% or more assessed in one, two or three dimensions was associated with lower risk of mortality (HR 0.48 [P=0.04]; HR 0.36 [P=0.01]; HR 0.31 [P=0.003], respectively). The three conventional classifications were not useful for predicting mortality (WHO: HR 1.07 [P=0.9]; RECIST: HR 0.94 [P=0.9]; EASL: HR 0.94 [P=0.9]). CONCLUSIONS: Having an alpha-fetoprotein level of greater than 200 ng/mL and a MELD score of greater than 10 before undergoing TACE was associated with a greater risk of mortality. Conventional classifications of response were not useful for predicting mortality. Reduction in tumour size after the first TACE procedure was associated with better survival, primarily if patients had more than a 3% reduction in tumour size assessed by three-dimensional measurement.

A case series of aggressive angiomyxoma: Using morphologic type and hormonal modification to tailor treatment.

Aggressive angiomyxoma is a rare tumour type with a predilection for the female pelvis, high rates of estrogen and progesterone receptor positivity and local recurrence. A retrospective chart review of patients with aggressive angiomyxoma treated at 2 cancer centres is presented. Nine patients were identified with a mean age of 41. Five patients had deeply invasive tumours that were difficult to surgically resect. Four patients had pedunculated tumours with less complex resections. In only two cases was aggressive angiomyxoma considered before resection: one due to classic magnetic resonance imaging findings and one with a preoperative biopsy. Four patients had positive margins after resection, with only one having persistent disease. Two patients were treated with gonadotropin-releasing hormone (GnRH) agonists resulting in tumour regression in one and no recurrence in the other. In this case series, aggressive angiomyxoma presented in deeply invasive and pedunculated forms. Previously reported high rates of recurrence were not observed in this group, perhaps secondary to easier resection in the pedunculated forms. GnRH agonists were successfully used as adjuncts to surgery. Evidence in this case series could be used to provide tailored treatment to patients with aggressive angiomyxoma.

HMDB: the Human Metabolome Database.

The Human Metabolome Database (HMDB) is currently the most complete and comprehensive curated collection of human metabolite and human metabolism data in the world. It contains records for more than 2180 endogenous metabolites with information gathered from thousands of books, journal articles and electronic databases. In addition to its comprehensive literature-derived data, the HMDB also contains an extensive collection of experimental metabolite concentration data compiled from hundreds of mass spectra (MS) and Nuclear Magnetic resonance (NMR) metabolomic analyses performed on urine, blood and cerebrospinal fluid samples. This is further supplemented with thousands of NMR and MS spectra collected on purified, reference metabolites. Each metabolite entry in the HMDB contains an average of 90 separate data fields including a comprehensive compound description, names and synonyms, structural information, physico-chemical data, reference NMR and MS spectra, biofluid concentrations, disease associations, pathway information, enzyme data, gene sequence data, SNP and mutation data as well as extensive links to images, references and other public databases. Extensive searching, relational querying and data browsing tools are also provided. The HMDB is designed to address the broad needs of biochemists, clinical chemists, physicians, medical geneticists, nutritionists and members of the metabolomics community. The HMDB is available at: www.hmdb.ca.

The human cerebrospinal fluid metabolome.

With continuing improvements in analytical technology and an increased interest in comprehensive metabolic profiling of biofluids and tissues, there is a growing need to develop comprehensive reference resources for certain clinically important biofluids, such as blood, urine and cerebrospinal fluid (CSF). As part of our effort to systematically characterize the human metabolome we have chosen to characterize CSF as the first biofluid to be intensively scrutinized. In doing so, we combined comprehensive NMR, gas chromatography-mass spectrometry (GC-MS) and liquid chromatography (LC) Fourier transform-mass spectrometry (FTMS) methods with computer-aided literature mining to identify and quantify essentially all of the metabolites that can be commonly detected (with today's technology) in the human CSF metabolome. Tables containing the compounds, concentrations, spectra, protocols and links to disease associations that we have found for the human CSF metabolome are freely available at http://www.csfmetabolome.ca.

Can Ultrasound With Contrast Enhancement Replace Nonenhanced Computed Tomography Scans in Patients With Contraindication to Computed Tomography Contrast Agents?

PURPOSE: Our purpose is to determine the efficacy of ultrasound (US), with the addition of contrast enhancement (CEUS), in the identification and characterization of abdominal pathology compared with nonenhanced computed tomography (CT) scan (NECT). METHODS: This prospective cohort study recruited 197 patients with NECT, the majority with renal failure, to have US, with addition of CEUS, if focal pathology was detected, occurring in 145 patients. Nonenhanced CT scan, US, and CEUS images/video files were presented to 2 blinded readers, in anonymous order. Examination quality and positive observations were recorded. True diagnosis was determined with pathology, follow-up imaging, and clinical notes. Data analysis showed sensitivity of NECT and US in the identification and characterization of pathology and sensitivity of CEUS to characterize abnormalities. RESULTS: Most pathology involved liver (n = 87), kidney (n = 35), and peritoneum (n = 13). Ultrasound alone was superior to NECT in the identification of hepatic and renal pathology, with both performing poorly at characterization. With addition of CEUS, characterization of hepatic and renal pathology reached 100%. Nonenhanced CT is superior to US in identification of peritoneal pathology, especially in large patients. Further solid and hollow organ pathology identified and characterized was of insufficient size to draw conclusions. CONCLUSIONS: Nonenhanced CT has limited ability to identify and characterize solid and hollow organ pathology. Ultrasound with the benefit of CEUS is superior to NECT in the characterization of focal liver, kidney, and peritoneal pathology. Contrast-enhanced ultrasound outperforms NECT in evaluation of suspect abdominal pathology in those with renal failure.