Immune checkpoint inhibitor refractory colitis leading to total colectomy in a melanoma patient.

Immunotherapy is becoming more and more relevant in the treatment of advanced melanoma. Proper management of its side effects can prevent severe complications. We describe the case of a 73-year-old patient with severe refractory colitis secondary to immunotherapy. The patient has been treated for 6 months with Nivolumab, an anti-PD-1, as adjuvant therapy for locally advanced melanoma. He was admitted to the hospital with a deteriorating general condition associated with severe diarrhea and rectal bleeding for 3 weeks. Despite three lines of treatment (high dose corticosteroids, infliximab, mycophenolate mofetil), the patient still presented clinical and endoscopic colitis, with additional infectious complications. The patient required surgical management for total colectomy. In this article we present one of the rare cases of autoimmune colitis that did not respond to various immunosuppressive treatments and required surgery.

[Complete radical prostatectomy and positive lymph nodes (stages pT1 to 4, N1 to 3, M0, D1)]. / Prostatectomie radicale totale et ganglions positifs (stades pT1 à 4, N1 à 3, M0, D1).

Lymph node metastases are rarely detected during radical prostatectomy (55/647 patients in our series or 8.5%) and several authors consider that lymphadenectomy is unnecessary in most cases. Criteria based on clinical stage, PSA and tumor grade have been elaborated in order to avoid pelvic lymph node dissection in a low risk population. It is commonly admitted that patients with clinically localized prostate cancer, a PSA level < 10 ng/ml, and a Gleason score < 7 could be spared a pelvic lymphadenectomy. In our series, these patients account for 12% of positive nodes. The best treatment for prostate cancer patients with a nodal disease is controversial. We compare the evolution of two groups of patients: radical prostatectomy alone or combined with an immediate adjuvant hormonal treatment. We observe a difference between the two groups for biological progression (PSA failure) but not yet for clinical progression nor for survival as our mean follow-up in only 6 years.

Is adrenalectomy part of radical nephrectomy?

Standard radical nephrectomy entails en bloc removal of the kidney together with Gerota's fascia and the ipsilateral adrenal. Thanks to the refinement of imaging techniques (ultrasound, CT and MRI), smaller tumors are being diagnosed. In addition, direct extension to the adrenal gland or adrenal metastasis can be detected in most cases. This is why several authors reserve adrenalectomy for large and/or upper pole tumors or abnormal appearing glands on preoperative CT-scan. However, preoperative diagnosis is not always accurate. Furthermore, micrometastatic adrenal invasion at the time of nephrectomy and late recurrences in the persistent adrenal have been documented, so that partisans of adrenalectomy only spare the adrenal in exceptional cases. The authors have reviewed several series in the litterature as well as there own, and conclude that ipsilateral adrenalectomy can be omitted for small middle- or lower pole tumors when the adrenal appears normal on CT and during the surgical intervention.