Intratumor C-reactive protein as a biomarker of prognosis in localized renal cell carcinoma.

PURPOSE: Serum C-reactive protein has been shown to have prognostic value in localized and metastatic renal cell carcinoma. However, the prognostic value of intratumor C-reactive protein remains unknown. MATERIALS AND METHODS: A total of 95 patients with resected, clinically localized (T1-T4N0M0) clear cell renal cell carcinoma were followed postoperatively. Intratumor C-reactive protein expression was assessed in surgical specimens using immunohistochemical analysis. Patients were categorized by staining intensity into low risk (staining 0 to 1), intermediate risk (staining 2) and high risk (staining 3) groups. Kaplan-Meier and multivariate Cox regression analyses were used to examine overall survival across patient and disease characteristics. Variables examined in multivariate Cox regression analysis included T stage, Fuhrman nuclear grade, tumor size, preoperative serum C-reactive protein and intratumor C-reactive protein staining. RESULTS: Followup extended up to 46 months with a mean (SD) of 29.8 (11.0) months. Twelve patients (12.6%) died during followup. Of all tumors 49.5%, 25.3% and 25.3% were graded by intratumor C-reactive protein staining as low risk (0 to 1), intermediate risk (2) and high risk (3), respectively. After controlling for variables significant on univariate analysis, patients in the high risk (3) group experienced a 27-fold increased risk of overall mortality compared to those in the low risk (0-1) group (HR 27.767, 95% CI 1.488-518.182). After adjusting for tumor staining, preoperative serum C-reactive protein was not a significant predictor of overall survival (p = 0.741). CONCLUSIONS: Intratumor C-reactive protein may be a robust biomarker of prognosis in patients with localized renal cell carcinoma.

Absolute preoperative C-reactive protein predicts metastasis and mortality in the first year following potentially curative nephrectomy for clear cell renal cell carcinoma.

PURPOSE: C-reactive protein is an inflammatory biomarker associated with tumor burden and metastasis in renal cell carcinoma. Recent studies suggest that preoperative C-reactive protein predicts metastasis and mortality after nephrectomy for localized renal cell carcinoma. However, these studies dichotomized C-reactive protein (typically 10 mg/l or greater vs less than 10 mg/l). Considering the continuous range of C-reactive protein (less than 1 mg/l to greater than 100 mg/l) we assessed the ability of absolute preoperative C-reactive protein to predict metastases and mortality as a continuous variable. MATERIALS AND METHODS: Patients with clinically localized (T1-T3N0M0) clear cell renal cell carcinoma were followed for 1 year postoperatively. Metastases were identified radiologically and mortality was determined by death certificate. Univariate and multivariate binary logistic regression analyses examined 1-year relapse-free survival and overall relative survival across patient and disease characteristics. RESULTS: Of the 130 patients in this study metastases developed in 24.6% and 10.8% of the patients died. Mean (SD) preoperative C-reactive protein for patients in whom metastases did and did not develop was 89.17 (74.17) and 9.16 (30.62) mg/l, respectively. Mean preoperative C-reactive protein for patients who did and did not die was 102.61 (77.32) and 19.52 (46.10) mg/l, respectively. On multivariate analysis SSIGN score (p <0.001) and preoperative C-reactive protein (B 0.027, SE 0.003, p <0.001) were significant predictors of relapse-free survival, and preoperative platelets (p = 0.009) and preoperative C-reactive protein (B 0.011, SE 0.008, p <0.001) were significant predictors of overall relative survival. CONCLUSIONS: Absolute preoperative C-reactive protein is a robust predictor of metastasis and mortality after nephrectomy for localized renal cell carcinoma. Clinicians should consider absolute preoperative C-reactive protein to identify high risk patients for closer surveillance or additional therapy. In addition, predictive algorithms and models of metastasis should consider incorporating C-reactive protein as a continuous variable to maximize predictive ability.

Resection of atriocaval adrenal carcinoma using hypothermic circulatory arrest.

Carcinoma of the adrenal cortex may occasionally extend through the inferior vena cava to the right atrium without actually invading the vascular endothelium. Surgical resection may result in excellent palliation and the potential for prolonged survival when no other signs of advanced disease are present. Extrapolating from our experience with renal cell carcinoma extending to the right atrium, we resected a similar adrenocortical carcinoma using hypothermic circulatory arrest.

Further experience with staged ureterocolocolostomy urinary diversion.

Disenchantment with the long-term results with ureterosigmoidostomy and ileal loop urinary diversion led to increased use of the nonrefluxing colon conduit. In 1978, we reported our initial experience with 3 adult patients in whom such a diversion was initially performed followed by conversion with an end-to-side colocolostomy achieving a staged nonrefluxing ureterocolocolostomy. We believed that a staged procedure would allow decompression of the upper urinary tract away from the fecal stream, that one could confirm the adequacy of the nonrefluxing tunnels prior to exposure to the fecal stream, and that this might have a lower instance of electrolyte problems and pyelonephritis. Further follow-up on these original 3 patients as well as our experiences with two others, as reported here has somewhat tempered our initial enthusiasm.

Obstructing posterior urethral valves in octogenarian.

A unique case of bladder outlet obstruction secondary to posterior urethral valves in an octogenarian is presented.

Dissolution of uric acid calculi with intravenous 1/6 molar lactate.

The use of intravenous 1/6 molar sodium lactate for dissolution of uric acid calculi is reported in 4 patients. All presented with a urine pH of 5. The calculi were located in the proximal ureter in 2 patients and in the renal pelvis in the other 2 patients. After infusion of 1/6 molar lactate, rapid alkalinization of the urine to pH 8 was achieved and maintained. The mean time required for dissolution of the calculi was 6.2 days precluding the need for surgical intervention. The mechanism of action of lactate is oxidative conversion to bicarbonate, providing a sustained alkaline urine. While our patients experienced no metabolic complications, one should monitor serum electrolytes, blood pressure, and fluid balance, particularly in cardiac-compromised patients.

Endoscopic vesicourethropexy. Experience and complications.

Thirty-one patients with stress urinary incontinence were treated with the optical vesicourethropexy. Of these patients, 70.9 per cent had previous pelvic or vaginal operations, of which 59 per cent also had failed stress incontinence procedures. In 90 per cent of the cases, cure or improvement was obtained. However, the procedure is not free of complications (38%). Aside from the problems reported by others, vaginal bleeding or discomfort due to erosion of the mucosa by the Dacron pledget was observed. We also had a case complicated by an obstruction of the small bowel secondary to fixation of a jejunal loop to the retropubic area. We believe that excellent results may be obtained with this technique in patients with previous pelvic surgery or concomitant medical problems. Remarks in the evaluation of these patients and technical aspects of the procedure are presented.

Radiolabeled monoclonal antibody indium 111-labeled CYT-356 localizes extraprostatic recurrent carcinoma after prostatectomy.

OBJECTIVES: The sites of recurrent carcinoma of the prostate were localized with radiolabeled monoclonal antibody, and these sites were correlated with the response of patients treated with pelvic radiation after prostatectomy. METHODS: Radionuclide scans were performed with indium 111-labeled CYT-356, a monoclonal antibody that binds to prostate epithelial cells, in 48 men diagnosed with recurrent carcinoma detected by prostate-specific antigen (PSA) screening after radical retropubic prostatectomy. RESULTS: In 48 patients with recurrent carcinoma detected by PSA screening following radical retropubic prostatectomy, 73% had monoclonal antibody activity beyond the prostatic fossa, and only 3 patients (6%) had activity in the prostatic fossa alone; 65% had monoclonal antibody activity in pelvic lymph nodes despite the fact that lymph node dissections were pathologically negative at the time of prostatectomy in 90% of the patients; and 23% of patients had monoclonal antibody activity in abdominal and extrapelvic retroperitoneal nodes. Of 48 patients, 13 underwent external beam radiation therapy after monoclonal antibody scans. Six patients had scans showing activity beyond the field of radiation, and radiation therapy failed in 4 of these patients. Seven patients had scans with no activity beyond the field of radiation therapy, and radiation therapy failed in only 2 of these patients. CONCLUSIONS: The scans frequently show monoclonal antibody uptake in pelvic, abdominal, and extrapelvic retroperitoneal sites beyond the region of limited obturator node dissections and may account for the understaging and subsequent failure of radical prostatectomy in some patients. The monoclonal antibody scan seems to be a good predictor of which patients will respond to radiation therapy after radical prostatectomy, but because these patients often have nodal activity beyond the radiated field, this initial response may not be curative.

The Kock pouch urinary reservoir.

The use of detubularized ileum for the Kock pouch produced a low pressure, high capacity system superior to large bowel segments that provided excellent continence and protection of the upper urinary tracts. The early enthusiasm was tempered, however, by the technically demanding aspects of the construction of the nipple valves, the early and late complications, and occasional catheterization problems. With simple modifications in the fixation of the intussuscepted nipples, limiting use of staples and mesh collars, and tapering of the stoma, much of those problems have been resolved. The nipple valve is reliable and superior to the tunneled implant for the dilated ureter. With more widespread indications for continent neobladders, the hemi-Kock reservoir remains one of the most dependable and stable neobladders.

Retroperitoneoscopic technique for treating symptomatic caliceal diverticula.

Calculous disease in a caliceal diverticulum is a rare entity. The standard treatment currently is endoscopic surgery with marsupialization or fulguration or both with dilatation of the neck of the diverticulum. We present the fifth reported case of retroperitoneoscopic management of a caliceal diverticulum in a patient with a long history of flank pain and suggest that this treatment offers a stone-free rate comparable to that of open surgery with less morbidity than is associated with endoscopic treatments.

Immunohistochemical demonstration of human chorionic gonadotropin in tumors of the urinary bladder.

All transitional cell carcinomas of the bladder diagnosed in male patients within a five year period were studied for human chorionic gonadotropin (hCG) production. Biotin-avidin immunoperoxidase analysis for hCG was performed on all paraffin blocks containing carcinoma-in-situ, grade I, grade II, and grade III transitional cell carcinoma. Of a total of 29 patients, one case of carcinoma-in-situ (1/5), and five cases of grade III transitional cell carcinoma (5/15) were found to have hCG-positive tumor cells. The findings indicate that transitional cell carcinoma should be added to the list of malignant tumors capable of producing hCG.

Postoperative better than preoperative C-reactive protein at predicting outcome after potentially curative nephrectomy for renal cell carcinoma.

OBJECTIVES: Preoperative C-reactive protein (CRP) predicts metastasis and mortality in localized renal cell carcinoma (RCC). However, the predictive potential of after resection of localized RCC remains unclear. Therefore, we assessed the absolute ability of postoperative CRP to predict metastases and mortality as a continuous variable. METHODS: Patients with clinically localized (T1-T3N0M0) clear-cell RCC were followed for 1 year postoperatively. Metastases were identified radiologically and mortality by death certificate. Univariate and multivariate binary logistic regression analyses examined 1 year relapse-free survival (RFS) and overall survival (OS) across patient and disease characteristics. RESULTS: Of the 110 patients in this study, 16.4% developed metastases and 6.4% died. Mean (SD) postoperative CRP for patients who did and did not develop metastases were 69.06 (73.55) mg/L and 5.27 (7.80), respectively. Mean (SD) postoperative CRP for patients who did and did not die were 89.31 (69.51) mg/L and 10.88 (30.32), respectively. In multivariate analysis, T-stage (OR: 12.452, 95% CI: 2.889-53.660) and postoperative CRP ((B: .080, SE: .025; P < .001) were significant predictors of RFS. T-Stage (OR: 11.715; 95% CI: 1.102-124.519) and postoperative CRP (B: .017; SE: .007; P < .001) were also significant predictors of OS. After adjusting for postoperative CRP, preoperative CRP was not predictive of these outcomes. CONCLUSIONS: Postoperative, not preoperative, CRP is the better predictor of metastasis and mortality following nephrectomy for localized RCC. Clinicians should consider absolute postoperative CRP to identify high-risk patients for closer surveillance or additional therapy. Predictive algorithms should consider incorporating postoperative CRP as a continuous variable to maximize predictive ability.

Expression of fascin in oral and oropharyngeal squamous cell carcinomas has prognostic significance - a tissue microarray study of 129 cases.

AIMS: To elucidate the role of fascin in oral and oropharyngeal squamous cell carcinoma (OSCC) by correlation with clinical parameters. METHODS AND RESULTS: Paraffin sections using tissue microarrays of 129 patients with OSCC were investigated immunohistochemically. Fascin protein was overexpressed in OSCC cells compared with their non-neoplastic epithelial counterparts. For evaluating the intensity of fascin, 39 (30.2%) were classified as weakly immunoreactive, 76 (58.9%) as moderate reactive and 14 (10.9%) as intensely reactive. For evaluating the distribution of fascin, 64 (49.6%) were classified as < 55% and 65 (50.4%) were classified as >/= 55%. Fascin protein expression was correlated with size or extent of the tumour (P < 0.001), positive lymph node metastasis (P < 0.001), distant metastasis (P = 0.014) and clinical staging (P < 0.001). The immunoreactivity scores of fascin in OSCC were variable but showed significant correlation with histological grade, clinical TNM system and stage. CONCLUSION: Expression of fascin protein may play an important role in progression of OSCC. Overexpression of fascin contributes to a more aggressive clinical course and suggests the potential of fascin as a new molecular target for therapeutic intervention.

Use of reversed nephroureteral stent as suprapubic cystoureteral catheter.

By the reversal of the existing nephroureteral stent system a vesicoureteral stent exiting through the suprapubic site is created. The major advantages of this system include avoidance of side holes along the stent, avoidance of a urethral catheter, ease of access for contrast medium studies to monitor healing, comfort and ease of removal. The major application of the system would be for lower ureteral surgery. Development of a 5F catheter with a shorter kidney-to-bladder length would permit use of this system in children.

Withdrawal phenomenon with the antiandrogen casodex.

Total androgen blockade with castration and antiandrogens has become the primary therapy in metastatic prostate carcinoma. Several reports have been published on the flutamide withdrawal syndrome with a favorable response in patients with progression of disease after lengthy remission while taking combined hormone therapy. The experience with withdrawal of the experimental nonsteroidal antiandrogen casodex in 3 patients is reported. All patients received casodex monotherapy initially, then luteinizing hormone-releasing hormone analogues were added on progression of disease (bone scan and prostate specific antigen [PSA]) and eventually casodex was withdrawn on further progression of disease (PSA and bone scan). Two patients had declines in PSA levels of 42% and 75% sustained for 3 to 6 months, and 1 patient had a stable condition for 2 months. These responses were similar to those of withdrawal of flutamide, which were limited to patients who had received combination therapy at the onset of treatment. Thus, the observations in this report would suggest that the initial and sustained exposure to an antiandrogen is the more important factor in the withdrawal phenomenon rather than the low androgen environment alone that occurs with initial luteinizing hormone-releasing hormone analogue monotherapy, orchiectomy or combination luteinizing hormone-releasing hormone analogue and antiandrogen.

Ureteroileal fistulas.

Of the fistulas that involve the urinary and intestinal tracts vesicointestinal fistulas are the most common and nephrointestinal fistulas are infrequent. Ureteroileal fistulas are extremely rare, with only 6 previously reported cases. Three recent cases are presented to highlight current management. In all 3 patients the ureteroileal fistula developed postoperatively, including 1 after radical pelvic surgery for advanced ovarian carcinoma, 1 following failed transureteroureterostomy and 1 after a repeat left ureteral reimplant with a pelvic abscess. Infection and/or urinary leakage had a major role in these cases, similar to the previously reported fistulas. In contrast to the previously reported patients, all of whom underwent surgical excision or revision, the 3 patients described herein were managed successfully with percutaneous nephrostomy or indwelling ureteral stents. Although successful management today may bypass operative intervention in these rare fistulas most are preventable operative complications.

Retrograde nephrostolithotomy in management of complex renal calculi.

From October 1986 to July 1990 we evaluated 22 patients with complex renal calculi in 25 kidneys for initial therapy using retrograde percutaneous nephrostolithotomy. In 3 patients we could not attain renal access in a retrograde fashion. In the remaining patients residual fragments after percutaneous nephrostolithotomy were treated with a combination of extracorporeal shock wave lithotripsy (ESWL), chemolysis and retrieval of small calculi with a flexible nephroscope. Successful treatments were achieved in 6 of the 22 kidneys (27%) using percutaneous nephrostolithotomy alone and in 17 (77%) using all modalities. Retrograde and antegrade percutaneous nephrostolithotomy in conjunction with ESWL, chemolysis and flexible nephroscopy in the treatment of patients with complex calculi yield comparable success rates. However, retrograde percutaneous nephrostolithotomy can be performed without the aid of an interventional radiologist and it provides easy access to the nondilated collecting system.

Laparoscopic marsupialization of massive renal cyst.

Laparoscopic approaches to urological problems continue to increase. We describe laparoscopic marsupialization and fulguration of a symptomatic giant renal cyst. Transient obstruction at the marsupialized window illustrated the importance of using omental or epiploic fat to maintain patency. Complete resolution of the cyst and hydronephrosis ensued.