Caval tumor thrombus complicating renal cell carcinoma: a surgical challenge.

The surgical challenge of resection of renal cell carcinoma with vena caval invasion may require close cooperation between the urologist and cardiovascular surgeon. From 1977 to 1986, 13 patients with renal cell carcinoma and tumor thrombus invading the inferior vena cava (IVC) underwent radical surgical resection. In three of 13 patients the thrombus extended into the heart (right atrium two patients and right ventricle one patient). The tumor originated in the right kidney in 10 patients and in the left kidney in three patients. There were 10 men and three women with a mean age of 64 years (range, 46 to 75 years). Surgical management included midline incision, seven, with median sternotomy, four, and thoracoabdominal, two. After exposure of the renal vessels and IVC, all patients underwent radical nephrectomy. Two patients had caval sleeve resection, one had a partial caval resection, and seven had a 1 cm caval cuff. Planned cardiopulmonary bypass was used in three patients. The tumor thrombus was extracted by simultaneous atrial and caval approaches. One patient underwent unplanned emergency cardiopulmonary bypass after intraoperative cardiac arrest caused by a large tumor embolus of the pulmonary artery. No operative deaths occurred. Postoperative morbidity was significant in five of 13 patients, caval thrombosis in one, lower limb swelling in two, renal failure in one, and pulmonary edema in one patient. Two patients required long-term anticoagulation therapy for confirmed pulmonary emboli within 1 month of surgery. These complications resolved. The follow-up period ranged from 7 to 64 months with a mean of 36 months. Two patients died of metastatic disease at 24 and 48 months after surgery. Three patients are alive with metastatic disease at 6 to 64 months while one patient had a solitary metastatic lesion removed from the frontal lobe 4 years after nephrectomy and has been disease free a subsequent 18 months. Eight of 11 patients are disease free at 7 to 64 months (four patients greater than 52 months). Our 83% survival rate at a mean follow-up of 36 months suggests that this group of patients should not be denied aggressive resection. Documentation of tumor source and caval extension are essential to plan operative procedures, including use of cardiopulmonary bypass.

Prophylaxis against radiation injury. The use of elemental diet prior to and during radiotherapy for invasive bladder cancer and in early postoperative feeding following radical cystectomy and ileal conduit.

Previous studies done in animals have shown that significant prophylaxis against radiation injury could be afforded by feeding an elemental diet (ED) for three days before and during radiation. In the present study 20 patients were fed an ED for three days before and for the four days during radiotherapy (five fractions of 400 rad [4 Gy] each) prior to radical cystectomy and ileal conduit for invasive bladder cancer; ED feeding was recommenced 24 hours postoperatively via a feeding jejunostomy. The ED-fed patients exhibited positive nitrogen balance preoperatively and had an early return to positive nitrogen balance postoperatively (3.60 +/- 0.32 days). There was also prompt return of bowel sounds (3.00 +/- 0.32 days). Histologically and ultrastructurally, biopsy specimens of the ileal mucosa showed normal morphologic findings, with maintenance of normal levels of enzyme activity in the brush border. Severe or bloody diarrhea was absent in these patients. These data suggest that ED feeding provides prophylaxis against the acute phase of radiation injury in patients undergoing high-dose, short-course radiotherapy for invasive bladder cancer and that it is a safe and feasible means of postoperative nutritional support, even in the presence of a fresh bowel anastomosis.

Preoperative irradiation and cystectomy in 135 cases of bladder cancer.

The updated experience of the McGill Teaching Hospitals in treating cancer of the bladder with short course, high-dose radiation and immediate cystectomy is presented. Five-year life table survival for the 135 patients so managed was 43.9 per cent. Survivorship at five years was 34.5 per cent in high-stage disease and 64.1 per cent in low-stage disease. It was concluded that preoperative radiation and surgery as outlined in selected cases remains an effective method of management.

Microfilaria prevalence of diurnally subperiodic Wuchereria bancrofti among people having a medical checkup in American Samoa in the past 17 years.

The yearly change of microfilaria (mf) prevalence rates from 1974 to 1990 was studied in American Samoa with people who had medical checkups. The mf rates were found to have been kept at a low level (0.8-2.6%) in the past 17 years. The continued low prevalence reduced clinical filariasis significantly in the past 8 years. The low level of endemicity, despite very close communication with neighbouring Western Samoa where filariasis is much more prevalent, could be explained by the urbanized living conditions in American Samoa.

Leukocyte activation in advanced cancer as an explanation for absent leukocyte adherence inhibition to cancer extracts and chemoattractant.

Tube leukocyte adherence inhibition (LAI) measures human immunity by antigen-binding leukocytes releasing chemoattractant-like mediators that are the ultimate inhibitors of adherence by bystander leukocytes. We determined whether the absent LAI responses to cancer extracts for patients with large body burdens of bladder cancer was related to a defect in antigen binding or chemoattractant responsiveness. Leukocytes from patients with small body burdens of bladder cancer gave positive LAI responses of a similar extent to either bladder cancer extracts or chemoattractant [n-formyl-L-methionylleucylphenylalanine (FMLP)]. Of the adherent leukocytes, about 20-30% became non-adherent with a positive LAI response: monocytes, neutrophils and lymphocytes responded. In the control tubes, leukocytes from patients with large body burdens of bladder cancer were more non-adherent and about 15% less adherent than leukocytes from controls or patients with early cancer. They showed no further decrease in adherence, or conversely increase in non-adherence, with either extracts of bladder cancer or FMLP. The leukocytes also failed to transduce transmembrane signals to the same stimuli. The defect was reversible since PGE2 restored the adherence of leukocytes to normal, and subsequently they exhibited membrane potential changes and about 34% non-adherence to either bladder cancer extracts or FMLP. From these results we conclude that chemoattractant LAI-responsive leukocytes from patients with large body burdens of bladder tumor are activated in vivo, probably by mediators from inflammatory cells.

A study of the immune response to the organ-specific neoantigen of human bladder cancer.

The antitumor immune response of monocytes armed with cytophilic antitumor antibody to an organ-specific neoantigen of human bladder cancer was measured by the tube leukocyte adherence inhibition assay. Of 29 patients with Stage A bladder cancer, 27 had positive tests, whereas of 11 patients with Stage B, C and D bladder cancer, 2 had positive tests. If the leukocytes from advanced bladder cancer patients were preincubated briefly with prostaglandin E2, the negative response was converted to positive. Of 189 patients with diseases of other organs, 2 had positive tests. Patients with acute or chronic cystitis had negative tests. The sensitivity of the assay was 88 per cent; specificity was 95 per cent. The bladder cancer extracts prepared from metastatic tissue or the tissue-cultured cell line, T24, had similar activity in the assay. Normal bladder tissue did not share the bladder cancer organ-specific neoantigen nor did cancers of other organs. Bladder epithelial cells expressed the OSN before they acquired invasive properties since patients with dysplastic bladder epithelium or in-situ cancer had positive tests. Antitumor immunity was often detectable before a recurrence became obvious by cystoscopy or cytology of urine and became undetectable quickly after removal of the bladder cancer. Of 100 patients with prior bladder cancer without evidence of exophytic tumor, 18 had positive tests; the possibility must be considered seriously that some had precancerous changes which formed no visible gross abnormalities. The results suggested that antitumor immunity to bladder cancer was a sensitive indicator of precancerous or cancerous changes existing in epithelial cells.

Results of radical nephrectomy in 178 cases of renal cell adenocarcinoma.

One hundred and seventy-eight patients with renal cell adenocarcinoma were classified by stage and treated by radical nephrectomy. A transabdominal approach was used in 92% of cases and lymphadenectomy was not performed unless ipsilateral hilar nodes were involved. Survival rates are presented in the form of life-table curves. These curves indicate that survival depends on the stage of the disease at the time of initial treatment; about 80% of patients with stage 1 lesions (tumour confined to the kidney) survived for 10 years compared with only 30% to 35% of stage 2 (involvement of perinephric fat) and stage 3 (involvement of renal vein or regional lymph nodes) patients and less than 10% of stage 4 (metastatic spread) patients. Radical nephrectomy appears to be the best method of treatment for patients with stage 1, 2 or 3 lesions. Simple palliative nephrectomy may be indicated in selected patients with stage 4 lesions.

Effect of a hepatitis B vaccination program on the prevalence of hepatitis B virus infection.

In April 1991, surveys for serologic evidence of hepatitis B virus (HBV) infection were conducted among 3- to 4-year-old children born after a hepatitis B immunization program of newborns began and among 6- to 11-year-old children targeted for early childhood vaccination in American Samoa. Compared with 3- to 4-year-olds tested in 1991, children tested at baseline in 1985 were more likely to have been infected with HBV (5/40 vs. 2/93; prevalence ratio [PR] = 5.8, 95% confidence limits [CL] = 1.2, 28.7) and to have chronic infection with HBV (3/40 vs. 0/95; PR = undefined, lower CL = 1.2). Compared with 6- to 11-year-olds tested in 1991, children in 1985 were more likely to have been infected with HBV (32/121 vs. 53/386; PR = 1.9, CL = 1.3, 2.8) and to have chronic infection with HBV (8/121 vs. 7/386; PR = 3.6, CL = 1.3, 9.8). The incorporation of hepatitis B vaccine into routine childhood vaccination schedules can prevent acute and chronic HBV infection in areas of high endemicity.