Prognostic variables to predict cancer-related death in incidental renal tumours.

OBJECTIVE: To identify, in a large multicentre series of incidental renal tumours, the key factors that could predict cancer-related deaths, as such tumours have a better outcome than symptomatic tumours and selected patients are increasingly being included in watchful-waiting protocols. PATIENTS AND METHODS: Data from 3912 patients were extracted from three international kidney-cancer databases. Age, gender, Eastern Cooperative Oncology Group (ECOG) performance status (PS), Tumour-Node-Metastasis (TNM) stage, tumour size, Fuhrman grade, and final pathology were recorded. Benign tumours and malignant lesions with incomplete information were excluded from final analysis. RESULTS: The mean (SD) age of the patients was 60.6 (12.2) years and the mean tumour size 5.5 (3.5) cm. Most tumours were malignant (90.2%) and of low stage (T1-T2, 71.7%) and low grade (G1-G2, 72.4%). There were nodal and distant metastases in 5.7% and 13% of the patients. In all, 525 (14.4%) patients died from cancer; in this group, tumours were >4 cm in 88.2% and had nodal or distant metastases in 20.2% and 49.3%, respectively. Multivariable analysis showed that tumour size >4 cm, ECOG PS >or=1, TNM stage and Fuhrman grade were independent predictors of cancer-related death. CONCLUSION: A significant proportion of incidental renal tumours can lead to the death of the patient. Standard prognostic variables for renal cell carcinoma appear to remain valid for this subset of patients. A watchful-waiting strategy should not be recommended if the tumour diameter is >4 cm, if biopsy confirms high-grade tumours, or if there is an impaired ECOG PS, or computed tomography findings suggest the presence of advanced T stage.

Does localized prostate cancer exist?

Does localized prostate cancer exist, and how do we diagnose it? Early diagnosis and screening programs for prostate cancer (PC) have led to a greater proportion of patients with a low-stage disease at diagnosis. More men are treated with curative intent by radical prostatectomy (RP), external beam radiotherapy, or brachytherapy. However, a substantial percentage of patients still experience a prostate-specific antigen (PSA) relapse within 5 years. Biochemical recurrence is observed in approximately 40% of patients who undergo RP, with 95% of those relapses in the first 5 years. To avoid the risk of recurrence, the recent tendency has been to detect PC at a lower PSA level than the level widely accepted (> or = 4.0 ng/ml). But the risk of overdiagnosis and overtreatment is a real problem in the PSA era. Discussion around the wide discrepancy between the high prevalence of histological changes recognizable as cancer and the much lower prevalence of clinical disease is prominent. The recent experience from studies on watchful waiting and the results of randomized trials between surgery and active surveillance have clearly demonstrated that many localized PC are overtreated. New screening and management strategies are required to target aggressive disease at an early stage while avoiding overdiagnosis and overtreatment.

[National prospective survey on the surgical quality of renal transplants in France. Study conducted by the Association Française d'Urologie Transplantation Committee]. / Enquête nationale prospective sur la qualité chirurgicale des greffons rénaux en France. Etude du Comité de Transplantation de l'Association française d'Urologie.

STUDY OBJECTIVE: The objective of this prospective study was to describe the nature of the lesions observed during brain-dead cadavre donor kidney harvesting in France and to identify the risk factors for these lesions. MATERIAL AND METHODS: A questionnaire elaborated by the AFU Transplantation Committee concerning the quality of kidneys harvested from cadavre donors was sent to all centres performing renal transplantation in France in 2000. This prospective study was conducted over a period of 1 year and concerned the overall multi-organ harvesting procedure based on all data concerning the renal parenchyma, arteriovenous and ureteric characteristics, and the outcome of the transplants. RESULTS: Twelve centres completed the survey, allowing analysis of the data of 201 donor kidneys. 91% of harvesting surgeons were urologists. Various incidents were reported during 11% of harvesting procedures, but 1/3 of the abnormalities were not recorded by the harvesting surgeon. Isolated kidney harvesting was found to be a risk factor (20% vs 8.6%). The rate of parenchymal abnormalities was 50%, 2/3 of which were related to inadequate removal of perirenal fat. Atheroma was a risk factor for arterial lesions during harvesting (21% vs 6.50). Venous abnormalities were detected in 9% of cases: 89% of them were due to the harvesting procedure and 59% of them were not identified by the harvesting surgeon. The fact of not being a transplant surgeon was a risk factor for venous lesions (21.9% vs 6.5%). 4% of ureteric lesions were observed with no consequence on graft outcome. CONCLUSION: Adequate removal of perirenal fat before conditioning is not acquired. Isolated kidney harvesting and atheroma were risk factors for parenchymal and arterial lesions, respectively. Venous harvesting anomalies were more frequent among non-transplant surgeons.

Prognostic value of histologic subtypes in renal cell carcinoma: a multicenter experience.

PURPOSE: To analyze to what extent histologic subtype is of prognostic importance in renal cell carcinoma based on a large, international, multicenter experience. PATIENTS AND METHODS: Four thousand sixty-three patients from eight international centers were included in this retrospective study. Histologic subtype (1997 International Union Against Cancer [UICC] criteria of tumor response), age, sex, TNM stage, Fuhrman grade, tumor size, Eastern Cooperative Oncology Goup performance status (ECOG PS), and overall survival were determined in all cases. The prognostic values of clear cell, papillary, and chromophobe histologic features were assessed by uni- and multivariate analysis using the Kaplan-Meier method and Cox model, respectively. RESULTS: Clear cell, papillary, and chromophobe carcinomas accounted for 3,564 (87.7%), 396 (9.7%) and 103 (2.5%) cases, respectively. In univariate analysis, a trend toward a better survival was observed when clear cell, papillary, and chromophobe histologies were considered prognostic categories (log-rank P = .0007). However, in multivariate analysis, TNM stage, Fuhrman grade and ECOG PS, but not histology, were retained as independent prognostic variables (P < .001). CONCLUSION: The stratification in three main renal cell carcinoma histologic subtypes as defined by the 1997 UICC-American Joint Committee on Cancer consensus should not be considered a major prognostic variable comparable to TNM stage, Fuhrman grade and ECOG PS.

[Management of urinary tract infections in women. Epidemiologic survey of 7916 women in general practice]. / Les infections urinaires de la femme en médecine générale. Résultats d'un observatoire réalisé auprès de 7916 patientes.

OBJECTIVE: To evaluate the management of urinary tract infections in women by general practitioners and compare it with official French guidelines. METHODS: This survey enrolled 1587 general practitioners in France and 7916 adult women. Exclusion criteria for patients included: pregnancy, diabetes, neurogenic bladder, or urinary catheters. During the visit at which the diagnosis was made, physicians completed a questionnaire that included diagnostic and management details, in particular, prescription of further examinations. RESULTS: According to the French guidelines, 37% of women had an upper or complicated urinary tract infection, although one third of the complicated infections were so defined only by the patient's age (>65 years). Additional testing was prescribed for 36% of the women with acute uncomplicated cystitis. CONCLUSION: This study shows that the management of urinary tract infections in women does not comply with current guidelines, especially in cases of acute uncomplicated cystitis. The use of age alone as a complicating factor should be reconsidered.

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.

The utility of Ki-67 expression in the differential diagnosis of prostatic intraepithelial neoplasia and ductal adenocarcinoma.

Cribriform and/or papillary prostatic lesions observed on limited tissue, such as needle biopsy, can pose diagnostic dilemmas. One such area of difficulty is the distinction between papillary and/or cribriform prostatic high-grade prostatic intraepithelial neoplasia (HG-PIN) and ductal adenocarcinoma. Over 48 months, we identified 17 cases of ductal adenocarcinoma and 17 cases of HG-PIN from radical retropubic prostatectomy specimens. The HG-PIN lesions were in all cases associated with an acinar prostatic adenocarcinoma component. For each case, we evaluated the proliferative activity, assessed by Ki-67 immunohistochemistry. The majority (82%) of ductal adenocarcinomas were composed of mixed papillary and cribriform patterns, with the remaining demonstrating pure papillary or cribriform patterns. The HG-PIN lesions showed a papillary, cribriform, or mixed papillary/cribriform architecture. The proliferative activity, defined as Ki-67 labeling index, was statistically higher in ductal adenocarcinoma (mean 33%, range 21%-66%) as compared with HG-PIN (mean 6%, range 2%-15%), with no overlap in the Ki-67 indices (P = 0001). A combination of histological features and measurements of cellular proliferation may be helpful to distinguish HG-PIN from ductal adenocarcinoma in limited prostatic tissue samples.

[Risks and benefits of total nephrectomy in elderly patients over the age of 80]. / Risques et bénéfices de la néphrectomie totale chez le sujet agé de plus de 80 ans.

OBJECTIVE: There is currently no consensus concerning the age limit for the surgical management of kidney tumours and very limited data are available in the literature. The objective of this study was to evaluate the morbidity of renal cancer surgery in elderly patients in order to determine the benefit/risk balance. MATERIAL AND METHODS: A retrospective study was conducted in 157 patients operated for kidney tumour in our department. Two groups were defined: one group of 40 patients over the age of 80 years and another group of 117 patients under the age of 80 years at the time of surgery. The following elements were compared in the 2 groups: presence or absence of symptoms, general state (evaluated by the Eastern Cooperative Oncology Group score), associated comorbidities (evaluated by the American Society of Anesthesiologists score), preoperative haemoglobin and serum creatinine, histological examination of the tumour, medical and surgical complication rate, postoperative mortality, length of hospital stay and specific survival. RESULTS: Tumour characteristics were identical in each group except for the presence of distant metastases which were more frequent in the group of patients young than 80. Older patients had a significantly higher preoperative serum creatinine (p = 0.01), a higher ASA score (p = 0.001), a higher medical complication rate (p < 0.00001) and a higher mortality (p = 0.04). At the end of follow-up, the specific survival was comparable in the two groups (32.5% versus 40%). CONCLUSION: Tumour characteristics and specific survival after surgical management of kidney tumours are comparable in elderly patients and younger patients. The risks of complications and impaired renal function were higher in elderly patients undergoing total nephrectomy. Close surveillance as well as minimally invasive alternatives will probably have an increasingly important place in the future, especially in patients presenting a major surgical risk.

[Management of acute prostatitis, based on a series of 100 cases]. / Prise en charge d'une prostatite aiguë: à propos de 100 cas.

OBJECTIVES: To evaluate the current diagnostic and therapeutic management of acute prostatitis. MATERIAL AND METHODS: The authors report a series of 100 consecutive patients with a diagnosis of acute prostatitis managed between January 1999 and December 2003. They analysed the clinical and laboratory data and imaging findings leading to the diagnosis of acute prostatitis and then the modalities of treatment and follow-up of these patients. RESULTS: The median age was 56.5 years (range: 19-86 years). In 77% of cases, the initial septic syndrome was considered to be severe. Prostatic tenderness was detected on digital rectal examination in 68% of cases. In 76% of cases, the micro-organism responsible was Escherichia coli. 8% of patients had positive blood cultures. All patients presented laboratory signs of inflammatory syndrome, with elevated C Reactive Protein (CRP) in most cases. Renal and bladder ultrasound was performed in 49% of cases and CT was performed in 16% of cases. 92% of patients were treated with fluoroquinolones, as monotherapy in 34% of cases. The duration of prescription ranged from 2 weeks to 6 weeks. No aetiology was detected in 48% of cases, 8% were considered to be iatrogenic and 44% were associated with incomplete bladder emptying. CONCLUSION: Acute prostatitis, rapidly treated by aggressive and adapted antibiotics has a rapidly favourable outcome. Elevation of CRP and the presence of leukocyturia on urine dipsticks are almost constant and, when they are normal, the diagnosis of acute prostatitis should be questioned. Imaging is not required in the absence of diagnostic doubt and any suspicion of progression to abscess. The duration of antibiotic therapy varies from prescriber to prescriber reflecting the various guidelines. Guidelines on this subject are contradictory and further effort is required to achieve homogenization and application of these guidelines.

[Treatment of benign prostatic hyperplasia (BPH) by transurethral needle ablation (TUNA) and 36-month follow-up of the retreatment rate]. / Traitement de l'hyperplasie bénigne de prostate (HBP) par thermocoagulation au moyen d'aiguilles par voie trans-urétrale (TUNA) et suivi a 36 mois du taux de retraitement.

OBJECTIVE: Benign prostatic hyperplasia (BPH) is a disease affecting about 25% of men over the age of 40. One half of these men report symptoms that interfere with their daily activities. MATERIAL AND METHODS: In this multicentre study, 102 patients with BPH were treated by transurethral needle ablation (TUNA). The efficacy of treatment was evaluated for 12 months after the operation by means of Madsen and IPSS (International Prostate Symptom Score) scores. The course of uroflowmetry and quality of life (International Score) and sexual function were also assessed for one year. The safety of treatment was evaluated according to the type and frequency of complications. The results show an immediate and significant improvement of symptoms (p < 0.0001 for Madsen and IPSS scores and maximum flow rate between M0 and M12) demonstrating the efficacy of the TUNA system. A very positive impact of TUNA was demonstrated on quality of life. No negative impact was reported on sexual function and the operation had very few repercussions with a low adverse event rate. The retreatment rate (surgical and/or drug) was evaluated 36 months after the operation by means of an optional follow-up questionnaire subsequently completed by the investigators. RESULTS: After 3 years, based on the 80 questionnaires returned, 43 patients (53.8%) were stable and did not need any other medical or surgical treatment for BPH. Thirty-seven (37) patients (46.3%) required retreatment: 21 were treated with drugs (26%), 17 were treated surgically (21.25%) including 1 patient who was also retreated with drugs. This study demonstrates the significant and lasting improvement of BPH symptoms by TUNA, which constitutes an alternative attractive to surgery in young patients and/or patients worried about their sexuality.

Immunohistochemical analysis of tumor polyamines discriminates high-risk patients undergoing nephrectomy for renal cell carcinoma.

Renal cell carcinoma (RCC) is known to display a wide variation in biological behavior and clinical outcome. Although usual bioclinical prognostic parameters (eg, nuclear grade, tumor stage) are to a certain extent useful in predicting the outcome of RCC after radical nephrectomy, they now appear to be insufficient. The polyamines (spermidine, spermine, and putrescine) are ubiquitous polycations that are essential for cell proliferation. To support their excessive proliferation, cancer cells have high rates of polyamine metabolism. Indeed, malignant cells typically have higher polyamine levels than their normal counterparts. Before this report, antipolyamine antibodies that are potentially valuable tools for the in situ observation of polyamines had not been exploited in clinical conditions. In the present study, tumor tissues obtained from radical nephrectomy performed for RCC (n = 73) were immunostained with the anti-spermine monoclonal antibody Spm8-2, and the immunoreactivity was evaluated as a prognostic tool. RCC cells displayed various reactivity to the antibody Spm8-2 that translated into a heterogeneous cytoplasmic staining. The prognostic value of the labeling index (LI) on clinical outcome was correlated with the usual clinicopathologic parameters, and the cell proliferation rate was evaluated using Ki-67 labeling. Multiple correspondence analysis and ascending hierarchical classification were performed to determine significant prognostic factors. Univariate statistical survival analysis demonstrated that tumor size (P < .001), nuclear grade (P < .01), necrosis (P < .007), tumor stage (P < .004), metastasis (P < .001), Ki-67 LI (P < .0003), and Spm8-2 immunoreactivity (P < .0001) were predictors of tumor-related death. A positive correlation was found between Ki-67 LI and Spm8-2 immunoreactivity (r' = .53). Multivariate analysis revealed that only Ki-67 LI and Spm8-2 immunoreactivity were significant independent factors in patients with metastases (P < .04 and <.001, respectively) and in patients without metastases (P < .006 and <.001, respectively). Moreover, 100% of the patients with Spm8-2 immunoreactivity <10% were alive at the end of the follow-up. In terms of predictive values, Spm8-2 immunoreactivity had the highest predictive values (sensitivity, 89; specificity, 75; risk ratio, 11) of all clinicopathologic parameters. This study demonstrates that the anti-spermine monoclonal antibody Spm8-2 may be used at the time of radical nephrectomy as a reliable prognostic marker for defining RCC patients at high risk for progression.

[Complications of TVT]. / Les complications du TVT.

Surgical repair of stress urinary incontinence by TVT was first performed in France in 1998, without any real evaluation of the morbidity related to this product before its release onto the market. In the context of the Necker 2002 report, a review of the literature and a multicentre study were performed to clarify this point. Bladder perforation, frequent during the early part of the learning curve, requires repositioning of the TVT and bladder catheterization for 48 hours, but does not cause any increase in postoperative morbidity. Urethral perforation, much less common, is a contraindication to maintenance of the TVT. Postoperative obstruction occurs in 5% to 12% of cases, and initially requires self-catheterization, as early section of TVT must be avoided. De novo instability is observed in 6% to 12% of cases, especially in the case of incomplete obstruction or a gaping bladder neck. Erosions due to TVT appear to be uncommon and are essentially vaginal.

[PSA: the difficult position of general practitioners between patients and urologists]. / PSA: le difficile positionnement du médecin généraliste entre patients et urologues.

OBJECTIVE: To determine the reasons for ordering PSA assay and delayed referral to an urologist following detection of elevated PSA in general practice. MATERIAL AND METHOD: Retrospective study of 200 patients referred to the department by general practitioners for elevated PSA from September 2000 to April 2001. RESULTS: The median age was 67 years (range: 52 to 87). The median PSA was 7.9 ng/ml (range: 4.1 to 897). Patients were referred after 1 to 5 PSA assays (mean: 1.6) with a median interval after discovery of elevated PSA of 1.7 months. The referral time was greater than 6 months for 52 patients (26%) and 31 patients (15.6%) were referred after more than two PSA assays were found to be elevated. PSA assay was ordered in the absence of symptoms or abnormal digital rectal examination in 43% of patients over the age of 70 years. CONCLUSION: Prostate cancer screening is regularly performed in general practice. The information given to general practitioners, faced with a well informed population, appears to be insufficiently clear, as PSA assay is sometimes incorrectly ordered or interpreted.

[Intraperitoneal bladder rupture during transurethral resection of the prostate]. / Rupture intra-péritonéale de vessie au cours d'une résection trans-urétrale de prostate.

Bladder explosions are a rare complication of endoscopic surgery caused by massive cellular hydrolysis during electrocoagulation, releasing a mixture of gases that becomes explosive in contact with oxygen. Oxygen may enter the bladder as a result of manipulation of the resector, incorrect use of the Ellick evacuator bulb or introduction of air bubbles via the irrigation tubing. This risk can therefore be limited by taking certain precautions. The authors report a new case of intraperitoneal bladder rupture during transurethral resection of the prostate.

[Correlation between the mode of presentation of renal tumors and patient survival]. / Corrélation entre le mode de présentation des tumeurs du rein et la survie des patients.

OBJECTIVES: To establish a symptom score and to test its prognostic value in comparison with the usual histological prognostic criteria. MATERIAL AND METHODS: 388 renal tumours were classified into three symptomatic grades according to the circumstances of discovery: S1: incidental discovery, S2; patient presenting with haematuria or low back pain, S3: patient presenting with alteration of general state or symptomatic metastasis. The following prognostic criteria were studied: age, gender, tumour volume, symptom score, ECOG (0 vs 1 or more), stage (TNM 1997), Fuhrman grade, venous and adrenal invasion. Survival rates were compared by the Kaplan-Meier method (Log rank test). Multivariate analysis was performed according to the Cox model. RESULTS: Tumours were classified as T1, T2, T3, T4 in 140 (36.1%), 73 (18.80%), 162 (41.8%) and 13 (3.4%) cases, respectively. 31 tumours were graded as G1 (8%), 167 as G2 (43%), 152 as G3 (39.2%) and 38 as G4 (9.8%), 143 tumours were classified as S1 (36.9%), 159 as S2 (41%) and 86 as S3 (22.10%). 45 patients were N+ (11.6%) and 54 were M+ (13.9%), The mean follow-up was 73 months. The significant parameters on univariate analysis were: ECOG, symptom score, TNM stage, grade, venous and adrenal invasion and tumour volume (p < 0.001), while symptom score, TNM stage and Fuhrman grade were significant on multivariate analysis (p < 0.001). CONCLUSION: The symptom score is an independent prognostic factor in the same way as tumour stage and grade. This score could be used in a mathematical algorithm predictive of survival of patients with renal cancer.

[Clinical and histological prognostic factors of renal cancer with caval thrombus]. / Facteurs pronostiques cliniques et anatomo-pathologiques des cancers du rein avec thrombus cave.

OBJECTIVES: The objective of this study was to determine the clinical and histological factors influencing survival of patients with renal cancer and caval thrombus. MATERIAL AND METHODS: The clinical and pathological data of 46 patients operated for renal cancer with caval thrombus were reviewed. The following prognostic factors were studied: tumour stage and grade, tumour diameter, invasion of the perirenal fat or adrenal gland, presence of lymph node involvement or distant metastases, level of the thrombus, invasion of the wall of the vena cava, partial or complete nature of the resection. Survival was determined by the Kaplan-Meier method and multivariate analysis was performed with the Cox test. RESULTS: The study population comprised 30 males and 16 females with a mean age of 64.4 years. The mean tumour diameter was 10.6 cm. Twelve thrombi were perirenal (26.1%), 15 were infrahepatic (32.6%), 12 were retrohepatic (26.1%), and 7 were supradiaphragmatic (15.2%). Forty four tumours were stage T3 and 2 were stage T4. Fifteen tumours were N1-2 or M1 (32.6%). The median disease-specific survival was 22 months and the 5-year survival rate was 25%. On univariate analysis, complete resection, lymph node invasion and metastases and adrenal gland invasion had an impact on survival. On multivariate analysis, only the presence of metastases had an independent prognostic value. CONCLUSION: This study confirms the prognostic value of certain factors (lymph node invasion and metastases, complete tumour resection) and raises the question of the prognostic significance of adrenal gland invasion. On the basis of these data, the authors recommend that surgery should only be performed in patients with a good general status, without metastases and in whom complete resection of the tumour mass appears to be possible.

[Neuroendocrine differentiation of bladder tumors]. / Différenciation neuro-endocrine des tumeurs de vessie.

Neuroendocrine bladder tumours (NET) constitute a group of various tumours with a common neuroendocrine phenotype. This is a very well defined entity (morphological, immunohistochemical, and ultrastructural). The great majority of bladder NETs reported in the literature are high-grade small cell carcinomas, but large cell carcinoma are probably underestimated due to the lack of systematic investigation. This paper reviews these rare, poorly known tumours, which require specific management. All bladder NETs are described. The frequency and diagnostic and therapeutic strategy of neuroendocrine bladder tumours are described.

[Local immune tolerance mechanisms in kidney cancer]. / Mécanismes de tolérance immunitaire locale dans les cancers du rein.

Many arguments suggest that renal tumours are immunogenic. However, the immune cells present around or within the tumour are unable to induce tumour rejection and the results of immunotherapy in metastatic renal cancer remain disappointing regardless of the protocols used. The objective of this study was to review the main mechanisms by which a renal tumour can escape immune destruction. These mechanisms can concern: tumour antigens, antigen-presenting molecules on the cell surface or defects of the cell machinery leading to the preparation of these molecules. Defects may also concern intercellular communications, especially adhesion and co-stimulation molecules. The immune cells present may also be defective, presenting qualitative or quantitative deficits, abnormalities of the T receptor, defect of cytokine production and these defects may concern both effector cells and antigen-presenting cells. The capacity of tumour cells to release anergic substances, i.e. substances which paralyze the immune system, also constitutes another very powerful immunosuppressive mechanism. These substances are cytokines, especially TGF-b. This anergy can also be mediated by intercellular contacts between tumour cells and lymphocytes, especially via the Fas system. It is important to study these mechanisms for several reasons: 1/Understanding of anergy mechanisms in order to discover new therapeutic targets or to short-circuit these mechanisms in vitro; 2/Definition of an "immune phenotype" of the tumour which should be evaluated as a prognostic marker both for survival after radical surgery of localized tumours as a prognostic factor for response to immunotherapy in metastatic forms.

[Peri-prostatic nerve block at the level of the apex versus intrarectal lidocaine gel]. / Blocage nerveux périprostatique au niveau de l'apex contre gel de lidocaïne intrarectal.

INTRODUCTION: After a review of the contradictory results of studies concerning periprostatic nerve block, the authors decided to prospectively evaluate the efficacy of periprostatic nerve block in the apex compared to the use of endorectal lidocaine gel. METHODS: From January 2001 to January 2002, 110 patients underwent prostatic biopsies. Patients were randomized to receive 10 cc of 2% lidocaine gel in the endorectal (group 1), or 10 cc of 1% lidocaine solution injected into the apex to induce bilateral periprostatic nerve block (group 2). Pain was evaluated by a 10-point linear visual analogue pain scale (VAS), and a 5-point digital visual scale (DVS). RESULTS: 96 patients were included in the study: 43 in group 1 and 53 in group 2. The mean pain score on the VAS was 2.76 +/- 1.69 and 1.73 +/- 1.26 for groups 1 and 2, respectively (p = 0.001). The DVS score was 2.26 +/- 0.82 and 1.62 +/- 0.56 for groups 1 and 2, respectively (p < 0.001). No significant difference was observed for mean age (p = 0.348), prostatic volume (p = 0.899), PSA level (p = 0.932) and complications between the two groups. The number of biopsies per patient was significantly higher in group 2 (p = 0.006), with significantly lower pain scores on each of the 2 scales. CONCLUSIONS: Apical periprostatic nerve block ensured better pain control during transrectal prostate biopsy, compared to the use of endorectal lidocaine gel, with no increase in the complication rate.

[Renal cell carcinoma before the age of 40: prognostic factors]. / Le carcinome à cellules claires du rein avant 40 ans: facteurs pronostiques.

OBJECTIVE: To study the prognostic value of tumour diameter, TNM stage, Führman's nuclear grade and CD44 adhesion molecule expression in renal cell carcinoma (RCC) before the age of 40 years. MATERIAL AND METHODS: Nineteen patients under the age of 40 (12 males and 7 females; mean age 30.8 years), undergoing total nephrectomy for RCC were included in this study. Tumour diameter, TNM 1997 stage, and Führman's nuclear grade were defined for each tumour. Standard CD44 adhesion molecule (CD44H) expression was evaluated semiquantitatively by immunohistochemistry on each tumour. The prognostic value of the various variables was determined by Mann-Whitney and Chi-square tests and survival analysis was performed by the Kaplan-Meier method. RESULTS: Six patients (31.5%) died from their cancer with a mean follow-up of 81.4 months. Mean tumour diameter was 9 +/- 4.5 cm. Tumours were Führman I/II in 4 cases, Führman III/IV in 15 cases, T1/T2 in 14 cases and T3/T4 in 5 cases. CD44H expression was high (> or = 20%) in 9 cases (47.3%). The prognostic factors identified in this study were: tumour stage (p = 0.01), grade (p = 0.04), venous extension (p = 0.001) and CD44H overexpression (p = 0.003). CONCLUSION: Prognostic factors of renal cancer in patients under the age of 40 years do not appear to be different from those of older patients. The prognostic factors identified in this study must be validated by multicentre studies based on larger populations.