RESUMEN
BACKGROUND: The value of lymph node dissection (LND) in the treatment of bladder urothelial carcinoma is well established. However, standards for the quality of LND remain controversial. OBJECTIVE: We compared the distribution of lymph node (LN) metastases in a two-institution cohort of patients undergoing radical cystectomy (RC) using a uniformly applied extended LND template. DESIGN, SETTING, AND PARTICIPANTS: Patients undergoing RC at the University of Southern California (USC) Institute of Urology and at Oregon Health Sciences University (OHSU) were included if they met the following criteria: (1) no prior pelvic radiotherapy or LND; (2) lymphatic tissue submitted from all nine predesignated regions, including the paracaval and para-aortic LNs; (3) bladder primary; and (4) category M0 disease. The number and location of LN metastases were prospectively entered into corresponding databases. MEASUREMENTS: LN maps were constructed and correlated with preoperative and pathologic characteristics. Kaplan-Meier curves were constructed to estimate overall survival (OS) and recurrence free survival (RFS) among LN-positive (LN+) patients. RESULTS AND LIMITATIONS: Inclusion criteria were met by 646 patients (439 USC, 207 OHSU), and 23% had LN metastases at time of cystectomy. Although there was a difference in the median per-patient LN count between institutions, there were no significant interinstitutional differences in the incidence or distribution of positive LNs, which were found in 11% of patients with ≤pT2b and in 44% of patients with ≥pT3a tumors. Among LN+ patients, 41% had positive LNs above the common iliac bifurcation. Estimated 5-yr RFS and OS rates for LN+ patients were 45% and 33%, respectively, and did not differ significantly between institutions. CONCLUSIONS: LN metastases in regions outside the boundaries of standard LND are common. Adherence to meticulous dissection technique within an extended template is likely more important than total LN count for achieving optimal oncologic outcomes.
Asunto(s)
Carcinoma/cirugía , Cistectomía , Escisión del Ganglio Linfático/métodos , Ganglios Linfáticos/cirugía , Neoplasias de la Vejiga Urinaria/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma/secundario , Cistectomía/efectos adversos , Cistectomía/mortalidad , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Los Angeles , Escisión del Ganglio Linfático/efectos adversos , Escisión del Ganglio Linfático/mortalidad , Ganglios Linfáticos/patología , Metástasis Linfática , Masculino , Persona de Mediana Edad , Oregon , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Neoplasias de la Vejiga Urinaria/mortalidad , Neoplasias de la Vejiga Urinaria/patología , Urotelio/patología , Urotelio/cirugíaRESUMEN
Minimally invasive procedures are gaining in popularity for application in reconstructive surgeries of the kidney in children. The use of robotic assistance for these laparoscopic procedures is an emerging option. Here, we describe our straight-arm positioning technique, which serves as a simple and effective alternative to classic flank positioning in pediatric renal cases, and the associated port placement strategies for these robotic-assisted laparoscopic reconstructive renal procedures.
Asunto(s)
Aneurisma Falso/etiología , Hemostáticos/efectos adversos , Arteria Ilíaca , Pelvis/lesiones , Choque Hemorrágico/cirugía , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/terapia , Angiografía , Vendajes , Servicio de Urgencia en Hospital , Estudios de Seguimiento , Hemostasis Endoscópica/métodos , Hemostáticos/uso terapéutico , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Reoperación , Medición de Riesgo , Choque Hemorrágico/etiología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Heridas por Arma de Fuego/complicaciones , Adulto JovenRESUMEN
There is increasing evidence for the role of epigenetic gene silencing in superficial bladder cancer. The aim of the current study was to investigate the prognostic value of epigenetic alterations in patients with non-muscle invasive bladder carcinoma. We checked the methylation status of 20 cancer associated genes (p14ARF, p16 CDKN2A, STAT-1, SOCS-1, DR-3, DR-6, PIG-7, BCL-2, H-TERT, BAX, EDNRB, DAPK, RASSF-1A, FADD, TMS-1, E-Cadherin, ICAM-1, TIMP-3, MLH-1, COX-2) for DNA methylation. We analysed microdissected tumour samples from 105 consecutive patients with primary non-muscle invasive bladder carcinoma. Quantitative methylation analysis of CpG sites in the promoter region of the genes was performed with methylation sensitive quantitative real time PCR ('Methylight'). Univariate analysis for association with tumour recurrence was carried out with the Kaplan-Meier analysis and the log-rank test. Follow-up data were available in 95/105 patients (91.4%). A tumour recurrence was observed in 26 patients (27.3%). We could identify six genes (SOCS-1, STAT-1, BCL-2, DAPK, TIMP-3, E-Cadherin), where methylation was associated with tumour recurrence. In Kaplan-Meier analysis, TIMP-3 showed a significant association with recurrence free survival. Methylation of TIMP-3 predicted prolonged disease free interval. In this study, we report a comprehensive analysis on prognostic relevance of gene methylation in non-muscle invasive bladder cancer. We identified one gene (TIMP-3) where methylation was associated with a more favourable outcome. Our data strongly support the usefulness of gene methylation as a prognostic marker in patients with non-muscle invasive bladder cancer.
Asunto(s)
Genes Relacionados con las Neoplasias , Neoplasias de la Vejiga Urinaria/genética , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores de Tumor , Estudios de Cohortes , Metilación de ADN , Supervivencia sin Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/genética , Reacción en Cadena de la Polimerasa/métodos , PronósticoRESUMEN
PURPOSE: There is increasing evidence for a fundamental role for epigenetic silencing of apoptotic pathways in cancer. Changes in DNA methylation can be detected with a high degree of sensitivity, so we used the MethyLight assay to determine how methylation patterns of apoptosis-associated genes change during bladder carcinogenesis and whether DNA methylation could be detected in urine sediments. EXPERIMENTAL DESIGN: We analyzed the methylation status of the 5' regions of 12 apoptosis-associated genes (ARF, FADD, TNFRSF21, BAX, LITAF, DAPK, TMS-1, BCL2, RASSF1A, TERT, TNFRSF25, and EDNRB) in 18 bladder cancer cell lines, 127 bladder cancer samples, and 37 samples of adjacent normal bladder mucosa using the quantitative MethyLight assay. We also analyzed the methylation status in urine sediments of 20 cancer-free volunteers and 37 bladder cancer patients. RESULTS: The 5' regions of DAPK, BCL2, TERT, RASSFIA, and TNFRSF25 showed significant increases in methylation levels when compared with nonmalignant adjacent tissue (P < or = 0.01). Methylation levels of BCL2 were significantly associated with tumor staging and grading (P < or = 0.01), whereas methylation levels of RASSF1A and ARF were only associated with tumor stage (P < or = 0.04), and TERT methylation and EDNRB methylation were predictors of tumor grade (P < or = 0.02). To investigate clinical usefulness for noninvasive bladder cancer detection, we further analyzed the methylation status of the markers in urine samples of patients with bladder cancer. Methylation of DAPK, BCL2, and TERT in urine sediment DNA from bladder cancer patients was detected in the majority of samples (78%), whereas they were unmethylated in the urine sediment DNA from age-matched cancer-free individuals. CONCLUSIONS: Our results indicate that methylation of the 5' region of apoptosis-associated genes is a common finding in patients with bladder carcinoma. The ability to detect methylation not only in bladder tissue, but also in urine sediments, suggests that methylation markers are promising tools for noninvasive detection of bladder cancers. Our results also indicate that some methylation markers, such as those in regions of RASSF1A and TNFRSF25, might be of limited use for detection because they are also methylated in normal bladder tissues.
Asunto(s)
Apoptosis , Metilación de ADN , Neoplasias de la Vejiga Urinaria/genética , Neoplasias de la Vejiga Urinaria/orina , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Línea Celular Tumoral , Islas de CpG , Cartilla de ADN/química , Humanos , Lipopolisacáridos/química , Persona de Mediana Edad , Membrana Mucosa/metabolismo , Proteínas Proto-Oncogénicas c-bcl-2/biosíntesis , Receptores del Factor de Necrosis Tumoral/biosíntesis , Miembro 25 de Receptores de Factores de Necrosis Tumoral , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Factores de Tiempo , Proteínas Supresoras de Tumor/genética , Vejiga Urinaria/metabolismoRESUMEN
We report 3 recent cases of angiomyolipoma of the kidney. Although generally regarded as a benign neoplasm, angiomyolipoma rarely behaves in an aggressive manner, producing complicated clinical courses leading to metastasis and death. The presence of epithelioid elements within the tumor can result in difficulty differentiating benign from malignant angiomyolipoma and differentiating this tumor from renal adenocarcinoma. The presence of lymph node involvement can cause difficulty in differentiating multicentric disease in lymph nodes from metastasis to lymph nodes. The presence of cytologic abnormalities in the primary tumor can result in difficulty in differentiating atypia in benign angiomyolipoma from malignant sarcomatous transformation of a benign lesion. The 3 cases reported show many of these problems. Criteria for predicting malignancy in epithelioid tumors and sarcomatous transformation are not well recognized because of the rarity of this entity. The typical immunophenotype of all types of angiomyolipoma (cytokeratin-negative and melanomarkers-positive) is very useful in diagnosis but does not help in the differentiation from renal adenocarcinoma at frozen section. We report the empiric use of Ki67 and p53 in these cases as adjuncts to clinical and histologic assessment in predicting behavior. High Ki67 expression was a feature of malignant epithelioid angiomyolipoma. Low levels of p53 expression were seen in the angiomyolipoma with sarcomatous transformation. Benign angiomyolipomas were consistently negative for both Ki67 and p53.
Asunto(s)
Angiomiolipoma/metabolismo , Angiomiolipoma/patología , Neoplasias Renales/metabolismo , Neoplasias Renales/patología , Adulto , Antígenos de Neoplasias , Humanos , Inmunohistoquímica , Queratinas/metabolismo , Antígeno Ki-67/metabolismo , Antígeno MART-1 , Antígenos Específicos del Melanoma , Persona de Mediana Edad , Proteínas de Neoplasias/metabolismo , Proteína p53 Supresora de Tumor/metabolismo , Vimentina/metabolismoRESUMEN
Renal angiomyolipoma is generally benign, although an uncommon subtype (epithelioid angiomyolipoma) may behave more aggressively. Sarcomatous transformation of the disease is exceedingly rare. We report the first case of a high grade round cell liposarcoma arising in a renal angiomyolipoma.
Asunto(s)
Angiomiolipoma/patología , Neoplasias Renales/patología , Liposarcoma/patología , Adulto , Transformación Celular Neoplásica , Humanos , Masculino , PronósticoRESUMEN
Primary carcinoid tumors originating in a normal kidney are exceptionally rare. We describe a case of a 52-year-old woman who presented with vague back pain and was found to have a 4-cm mass in the medial aspect of the left kidney. Radical nephrectomy and retroperitoneal lymphadenectomy were performed. Histopathology revealed a typical carcinoid tumor with 1 out of 17 lymph nodes involved. She has no evidence of recurrence or metastasis on 7-month follow-up.