Estimated glomerular filtration rate is unreliable in detecting renal function loss during follow-up after cystectomy and urinary diversion.

PURPOSE: To evaluate the accuracy of estimated glomerular filtration rate (eGFR) against the reference standard of isotopic GFR (iGFR) in monitoring renal function during follow-up after cystectomy and urinary diversion. METHODS: Patients who had undergone cystectomy and ileal conduit urinary diversion at two centres between August 2001 and August 2006 were identified. eGFR calculated using the MDRD formula was compared to (51)Cr EDTA measured iGFR values measured at similar time-points during follow-up. RESULTS: Six hundred and fourteen paired iGFR and eGFR results were analysed from 166 patients (18% female, median age 70 years). There was a significant difference between paired iGFR and eGFR measurements (p < 0.0001) with a mean bias of +1.8 mls/min/1.73 m(2) (SD 18.0) and a 95% limit of agreement of -33.5 to 37.2 mls/min/1.73 m(2). iGFR and eGFR values converged at a GFR of approximately 45 mls/min/1.73 m(2). 70.6% of patients experienced a loss of renal function greater than expected (>0.58 mls/min/1.73 m(2)/year). In 22.4% of these patients, a decline of greater than 10% in iGFR occurred that was undetected by eGFR measurements, which overestimated GFR. There was no significant relationship between patient height, weight or body mass index and the accuracy of eGFR measurements. CONCLUSIONS: iGFR measurement is recommended following ileal conduit urinary diversion if early signs of renal function loss are to be detected. eGFR overestimates GFR in critically relevant ranges and fails to detect loss in a clinically significant proportion of patients.

Accuracy of preoperative CT T staging of renal cell carcinoma: which features predict advanced stage?

AIMS: To characterise CT findings in renal cell carcinoma (RCC), and establish which features are associated with higher clinical T stage disease, and to evaluate patterns of discrepancy between radiological and pathological staging of RCC. MATERIALS AND METHODS: Preoperative CT studies of 92 patients with 94 pathologically proven RCCs were retrospectively reviewed. CT stage was compared with pathological stage using the American Joint Committee on Cancer (AJCC), 7(th) edition (2010). The presence or absence of tumour necrosis, perinephric fat standing, thickening of Gerota's fascia, collateral vessels were noted, and correlated with pT stage. The sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) for predicting pT stage ≥pT3a were derived separately for different predictors using cross-tabulations. RESULTS: Twenty-four lesions were pathological stage T1a, 21 were T1b, seven were T2a, 25 were T3a, 11 were T3b, four were T3c, and two were T4. There were no stage T2b. Sixty-three (67%) patients had necrosis, 27 (29%) thickening of Gerota's fascia (1 T1a), 25 had collateral vessels (0 T1a), 28 (30%) had fat stranding of <2 mm, 20 (21%) of 2-5mm and one (1%) of >5 mm. For pT stage ≥pT3a, the presence of perinephric fat stranding had a sensitivity, specificity, PPV and NPV of 74%, 65%, 63%, and 76%, respectively. Presence of tumour necrosis had a sensitivity, specificity, PPV, and NPV of 81%, 44%, 54%, and 72%, respectively. Thickening of Gerota's fascia had a sensitivity, specificity, PPV, and NPV of 52%, 90%, 81% and 70%, respectively; and enlarged collateral vessels had a sensitivity, specificity, PPV, and NPV value of 52%, 94%, 88%, and 71% respectively. CONCLUSION: The presence of perinephric stranding and tumour necrosis were not reliable signs for pT stage >T3a. Thickening of Gerota's fascia and the presence of collateral vessels in the peri- or paranephric fat had 90% and 94% specificity, with 82% and 88% PPV, respectively, for the presence of tumour stage for pT stage >T3a. These are considered reliable signs of locally advanced renal cancer.

Histological outcome of delayed orchidectomy after primary chemotherapy for metastatic germ cell tumour of the testis.

AIMS: To identify the incidence of viable local tumour in the testis of patients undergoing delayed orchidectomy after initial presentation with advanced germ cell tumour (GCT) treated by primary chemotherapy. PATIENTS AND METHODS: Thirty-three patients presenting with advanced metastatic GCT were reviewed. The median age at presentation was 34 years. All received chemotherapy without previous orchidectomy. The decision to initiate chemotherapy without orchidectomy was based on a heavy tumour load and the patient's condition at initial presentation. A histological diagnosis was available from a biopsy of metastases in 23 patients; treatment in the remaining 10 patients was initiated after diagnosis based on a combination of elevated serum tumour markers, testicular findings and the presence of a retroperitoneal mass. RESULTS: Seminomatous GCT (SGCT) was diagnosed in 13 patients, non-seminomatous GCT (NSGCT) in 17 patients and mixed GCT (MGCT) in the remaining three patients. Bleomycin/etoposide/cisplatin-based chemotherapy was the principle regimen. After initial chemotherapy, all patients with pure SGCT had only scar tissue in the orchidectomy specimen, with no residual tumour. Nine of 17 patients (52.9%) with NSGCT had viable tumour remaining in the orchidectomy specimen. All three cases of MGCT had persistent viable invasive seminoma. Twenty-seven patients (81.8%) were recurrence free and alive after a median of 49 months of follow-up. CONCLUSIONS: Thirty-six per cent of patients had residual tumour locally in the testis after primary chemotherapy for metastatic GCT of the testis. However, in the cases with pure seminomatous disease, there was no residual tumour present. It may not be necessary to undertake delayed orchidectomy in these patients.

Adjuvant and salvage treatment after radical prostatectomy: current practice in the UK.

OBJECTIVE: To survey UK urologists and radiation oncologists in the evaluation and treatment of localised prostate cancer in the adjuvant and salvage setting. METHODS: Postal questionnaires were mailed to 292 urologists and 98 radiation oncologists in the UK. RESULTS: In all, 188 (48%) questionnaires were returned. In total, 72/128 (56%) of the urologist respondents and 58/60 (97%) of the oncologist respondents perform routine radical prostate treatment. Among 43 (60%) of the urologist, 40 (69%) recommended adjuvant treatment, which could be radiotherapy, hormonal treatment or combined hormonal and radiation treatment. There is no significant difference between the modality of treatment recommended. The poor prognostic factors that would influence the decision to offer adjuvant treatment include a detectable postoperative PSA, seminal vesicle involvement, positive margins, Gleason score>8 and pathological T3. With regard to the choice of hormonal treatment, most urologists preferred antiandrogens, whereas most oncologists prefer lutienising hormone releasing hormone (LHRH) analogue (P=0.03). Regarding salvage treatment, there is a wide variation in the PSA threshold and number of PSA rises before initiation of investigations and treatment. Significantly more urologists recommended salvage radiotherapy (P=0.02), whereas oncologists recommended combined hormonal radiation therapy (P=0.03). There is a wide variation of practice regarding the duration of hormonal treatment, the type of investigations initiated, range of radiotherapy doses and treatment volumes. CONCLUSION: There is a wide variation in practice among UK clinicians.