Hsiao-Jen Chung

Are There Useful CT Features to Differentiate Renal Cell Carcinoma From Lipid-Poor Renal Angiomyolipoma?

OBJECTIVE This study was an attempt to identify key CT features that can potentially be used to differentiate between lipid-poor renal angiomyolipoma and renal cell carcinoma (RCC). MATERIALS AND METHODS We conducted an analysis of patients who received nephrectomy or renal biopsy from 2002 to 2011 with suspected RCC. We included tumors smaller than 7 cm with a completed three-phase CT examination. A radiologist and a urology fellow, blinded to histopathologic diagnosis, recorded the imaging findings by consensus and compared the values for each parameter between lipid-poor angiomyolipoma, RCC subtypes, and RCC as a group. Multivariate logistic regression analysis was performed for each univariate significant feature. RESULTS The sample in our study consisted of 132 patients with 135 renal tumors, including 51 men (age range, 26-84 years; mean age, 57 years) and 81 women (age range, 29-91 years; mean age, 57 years). These tumors included 33 lipid-poor angiomyolipomas, 54 clear-cell RCC, 31 chromophobe RCC, and 17 papillary RCC. Multivariate analysis revealed four significant parameters for differentiating RCC as a group from lipid-poor angiomyolipoma (angular interface, p = 0.023; hypodense rim, p = 0.045; homogeneity, p = 0.005; unenhanced attenuation > 38.5 HU, p < 0.001), five for clear-cell RCC, two for chromophobe RCC, and one for papillary RCC. Lipid-poor angiomyolipoma and clear-cell RCC showed early strong enhancement and a washout pattern, whereas chromophobe RCC and papillary RCC showed gradual enhancement over time. CONCLUSION Specific CT features can potentially be used to differentiate lipid-poor renal angiomyolipoma from renal cell carcinoma.

Correlation between serum prostate specific antigen and prostate volume in Taiwanese men with biopsy proven benign prostatic hyperplasia.

PURPOSE We studied the correlation between serum prostate specific antigen and the volume of different zones of the prostate in Taiwanese men with biopsy proven benign prostatic hyperplasia. MATERIALS AND METHODS A total of 233 patients with a mean age of 71.4 years (range 42 to 89), serum prostate specific antigen less than 10 ng/ml and pathologically confirmed benign prostatic hyperplasia were enrolled in this study. Total prostate and transitional zone volumes were measured with transrectal ultrasonography. Peripheral zone volume was determined by subtracting transitional zone volume from total prostate volume. Correlations between patient age, total serum prostate specific antigen and the volume of each prostate zone were analyzed with the Pearson correlation coefficient. A linear regression model was used to determine the relationship between prostate specific antigen and prostate volume. The prostate specific antigen-prostate volume relationship in our patients was compared with published data on white and Japanese men. RESULTS Age did not significantly correlate with serum prostate specific antigen and prostate volume. Serum prostate specific antigen significantly correlated with the volume of each prostate zone. After log transformation the Pearson correlation coefficient between total prostate specific antigen and the volume of the whole prostate gland, the transitional zone and the peripheral zone were 0.369, 0.377 and 0.272, respectively (p <0.001). Taiwanese men had lower prostate volume per unit prostate specific antigen comparing with white men, while the prostate specific antigen-total prostate volume relationship between Taiwanese and Japanese men was similar. CONCLUSIONS In Taiwanese men with biopsy proven benign prostatic hyperplasia the volume of each prostate zone has significantly correlates with serum prostate specific antigen. The prostate specific antigen-total prostate volume relationship in Taiwanese men is different from that in white men. However, the prostate specific antigen-total prostate volume relationship between Taiwanese and Japanese men is similar.

Renal Oncocytoma: Clinical Experience of Taipei Veterans General Hospital

Background: Renal oncocytoma has been reported mostly in the Western literature, and only a few cases have been reported in Eastern populations. In the present study, we review the clinical course of renal oncocytoma in our institution. Methods: We obtained the files of 13 cases of renal oncocytoma between 1988 and 2006 from the pathological archives of Taipei Veterans General Hospital. We retrospectively analyzed the patients’ characteristics, clinical manifestations, surgical technique and clinical outcome. Results: The study population comprised 10 men and 3 women, and the mean age at diagnosis was 59.6 years (range, 37–75 years). Twelve patients (92%) were asymptomatic at presentation and were incidentally diagnosed to have renal tumor by sonography (9 patients), computed tomography (1 patient) or magnetic resonance imaging (2 patients), and 1 presented with hematuria. The clinical impression of oncocytoma was made preoperatively in only 3 patients by imaging studies, and most of the patients (76.9%) were diagnosed with renal cell carcinoma before surgery. Ten were treated with radical nephrectomy, 2 with partial nephrectomy, and 1 received excisional biopsy. All patients had unilateral solitary renal tumor; the right kidney was involved in 7 cases (54%) and the left in 6 (46%). Mean tumor size was 5.3 cm (range, 2.7–8.5 cm). Three patients were lost to follow‐up in our series, and there was no recurrence or death (100% disease‐specific survival) in the remaining 10 patients (77%) who were followed‐up for a mean duration of 53.2 months (range, 10–117 months). Conclusion: Renal oncocytoma has a benign clinical course with excellent long‐term outcomes. Currently, nephron‐sparing surgery is the mainstay of treatment, especially in patients with small tumors. However, accurate preoperative diagnosis based only on imaging studies is difficult, and radical nephrectomy was performed for most of the patients in our series. [J Chin Med Assoc 2008;71(5):254–258]

Bilateral renal cell carcinoma in a patient with autosomal dominant polycystic kidney Disease

Renal cell carcinoma (RCC) in autosomal dominant polycystic kidney disease (ADPKD) is very rare. Only 11 cases of bilateral RCC in ADPKD have been reported since 1954. Herein, we present a 58-year-old male who received laparoscopic bilateral radical nephrectomy for bilateral RCC with different cell variants in ADPKD and end-stage renal disease under regular hemodialysis.

Laparoscopic Radical Cystectomy Combined with Bilateral Nephroureterectomy and Specimen Extraction Through the Vagina

Radical cystectomy is the gold standard for muscle-invasive urothelial carcinoma of the bladder because this operation provides excellent local cancer control. Laparoscopic radical cystectomy with different urinary diversions has been reported since 1992 and proposed as an alternative to open radical cystectomy. However, the reconstruction part of the operation is time-consuming and challenging. For a patient already under dialysis, concomitant radical cystectomy with bilateral nephroureterectomy could obviate the need to create urinary diversion and treat upper urinary tract tumors at the same time. Generally the specimen has to be removed through a mini-laparotomy. But for female patients, specimen extraction through the vagina has been reported to be safe and efficient. Thus, patients with multiple comorbidities can benefit from the avoidance of mini-laparotomy. Herein, we present a 65-year-old female with invasive urothelial carcinoma of the urinary bladder and end-stage renal disease who underwent laparoscopic radical cystectomy combined with bilateral nephroureterectomy, where the specimen was extracted transvaginally.

The Significance of Plasma C-reactive Protein in Patients With Elevated Serum Prostate-specific Antigen Levels

Objective Prostatic infection/inflammation may increase serum prostate-specific antigen (PSA) levels. We hypothesized that prostatic infection/inflammation can be identified by elevated plasma C-reactive protein (CRP) levels. Measuring plasma CRP levels may help to differentiate benign conditions from prostate cancer in patients with elevated serum PSA levels. Materials and Methods A total of 139 patients with serum PSA levels greater than 4.0 ng/mL received transrectal ultrasound guided biopsy. All of the patients had plasma high-sensitivity CRP levels measured. CRP levels higher than 0.5 mg/dL were considered abnormal. CRP and PSA levels, and prostate size were compared between benign and malignant groups. The association of CRP levels with cancer stages was also analyzed. Results Thirty-four out of 139 (24.5%) patients were found to have prostate cancer. There was no significant difference in CRP levels between the malignant and benign groups. Five out of 34 (14.7%) patients with prostate cancer and 13 of 105 (12.4%) patients with benign lesions had elevated CRP levels. The incidence of abnormal CRP levels was not significantly different between the groups ( p = 0.77). Patients with high PSA and CRP levels did not have a higher probability of a benign condition. It is interesting to note that in the malignant group, there was a significant positive correlation between CRP and PSA levels ( r = 0.44, p = 0.01). No significant correlation between CRP levels and cancer stages was noted. Conclusion Measuring plasma CRP levels does not assist in the identification of benign conditions in patients with elevated PSA levels. However, plasma CRP levels are well-correlated with serum PSA levels in prostate cancer patients, suggesting a potential correlation between prostate inflammation and prostate cancer.

Complications of pure transperitoneal laparoscopic surgery in urology: the Taipei Veterans General Hospital experience.

Background: We present our experience of complications of pure transperitoneal laparoscopic surgery in urology at Taipei Veterans General Hospital. Methods: Between September 2003 and March 2006, 185 laparoscopic urologic operations were performed, consisting of 70 nephrectomies (36 radical, 17 partial, 11 simple, 6 donor), 28 adrenalectomies, 28 nephroureterectomies, 22 radical prostatectomies, 17 ureterolithotomies, 6 radical cystectomies, 5 pyeloplasties, 2 renal cyst unroofings, 2 nephropexies and 5 other operations. We reviewed the database of the patients to evaluate the complications and analyze factors related to laparoscopic surgeries. Results: A total of 25 patients had 26 complications (14.1%, major in 4, minor in 22). The complications were categorized into intraoperative and postoperative complications in 10 and 16 patients, respectively. The mortality rate was 0%. The conversion rate was 0.54% (1 patient). The re‐operation rate was 1.08% (2 patients). The most common intraoperative complication was vascular injury (5 patients). The incidence of complication was related to the difficulty level of operation. No statistically significant differences were found between complication rate and patient age, patient body mass index or the American Society of Anesthesiologist score. Conclusion: The complications of laparoscopic urologic surgeries are strongly correlated with the operative difficulties. In spite of elevated complication rates in difficult surgeries, the major complication rate in this study was very low. As the laparoscopic surgeries in urology involve more and more technique‐dependent difficult fields, documentation and analysis of experience of complications is important for the development of this surgical modality.

Evolutionary magnetic resonance appearance of renal cell carcinoma after percutaneous cryoablation

Objective: To determine the evolutionary MRI appearance of renal cell carcinoma (RCC) following cryoablation. Methods: For this institution review board-approved study, we recruited patients with biopsy-proven RCC and treated them with percutaneous cryoablation between November 2009 and October 2014. Two radiologists retrospectively reviewed the pre-procedural and follow-up MRI. The findings included tumour sizes, signal intensities on T1 weighted imaging (T1WI), T2 weighted imaging (T2WI), diffusion-weighted imaging, apparent diffusion coefficient (ADC) map and contrast enhancement patterns. The ADC values of the tumours before and after treatment were measured. Results: A total of 26 patients were enrolled. The ablated tumours exhibited predominantly high signals on T1WI at 1–9-month follow-up (47.1% strong hyperintense at 3 months) and subsequently returned to being isointense. In T2WI, the signals of the ablated tumours were highly variable during the first 3 months and became strikingly hypointense after 6 months (58.3% strong hypointense at 6 months). Diffusion restriction was prominent during the first 3 months (lowest ADC: 0.62 ± 0.29 × 10−3 mm2 s−1 at 1 month). Contrast enhancement persisted up to 6 months after the procedure. The residual enhancement gradually increased in the dynamic scan and was most prominent in the delay phase. Conclusion: The MRI of the cryoablated renal tumour follows a typical evolutionary pattern. Advances in knowledge: Familiarity of practitioners with the normal post-cryoablation change of RCC on MRI can enable the early detection and prevention of tumour recurrence.

Percutaneous computed tomography-guided cryoablation for renal tumor: Experience in 30 cases

Background Percutaneous cryoablation is a minimally invasive alternative for surgical resection of a renal tumor. We report our experience with applying computed tomography‐guided cryoablation in renal tumors, focusing on the technique, safety, and treatment response. Methods We retrospectively reviewed the medical records of patients who received cryoablation from October 2009 to August 2013 for renal tumor diagnosed by imaging studies performed at Taipei Veterans General Hospital, Taipei, Taiwan. Patient comorbidities and tumor morphology, technical success rate, tumor control rate, renal function change, and complications were recorded. Results A total of 30 patients (32 tumors) were treated, comprising 30 renal cell carcinomas and two angiomyolipomas. The mean age of the patients was 73.7 years (range, 34–89 years). The patients were referred for percutaneous cryoablation arising from old age, medical comorbidities, or preexisting malignancy. The mean follow‐up period was 15.2 months (range, from 32 days to 47.4 months). According to the Clavien–Dindo classification, surgical complications included one Grade III, four Grade II, and two Grade I complications. The mean decrease in hemoglobin was 0.77 g/dL (range, from +1.1 g/dL to −3 g/dL). The mean hospital stay after cryoablation was 2.2 days (range, 1–10 days). Incomplete ablation was noted in two patients and local tumor recurrence in two patients. One of them received repeated cryoablation and achieved successful local control. Of the 22 renal cell carcinoma patients with follow‐up period > 6 months, 19 patients achieved successful local tumor control (86.4%). The percentage change of glomerular filtration rate before and 3–6 months after the procedure was +1.9%, which was statistically nonsignificant (p = 0.94). Conclusion Computed tomography‐guided percutaneous cryoablation is a safe and effective technique for treating renal tumors with excellent renal function preservation.

Impact of warm ischemia time on the change of split renal function after minimally invasive partial nephrectomy in Taiwanese patients

Background Nephron‐sparing surgery has become the standard treatment for T1 renal tumors. However, relevant data on the Taiwanese population are lacking, and most of the current literature uses global instead of split renal function (SRF) for postoperative renal function follow‐up. We evaluated the postoperative renal function after minimally invasive partial nephrectomy in Taiwanese patients. Methods We retrospectively reviewed our database from April 2004 to July 2012 and enrolled patients who received laparoscopic partial nephrectomy (LPN) or robot‐assisted partial nephrectomy (RPN). The estimated glomerular filtration rate (eGFR) and SRF were calculated as representatives of renal function. The preoperative and 6‐ and 12‐month postoperative renal functions were assessed. Freidman test was used to evaluate pre‐ and postoperative renal function changes; Wilcoxon test was used for comparing the renal function of each period. Results The 6‐ and 12‐month postoperative SRF values were decreased compared with the preoperative values. Multivariate analysis revealed that older age was related to a lower postoperative eGFR, and a longer warm ischemia time was related to a decreased postoperative SRF. Patients with a warm ischemia time of >30 minutes were correlated with a larger mean tumor size, higher “preoperative aspects and dimensions used for an anatomical” score, greater amount of blood loss during the operation, longer postoperative hospital stay, and lower postoperative SRF compared with patients with a warm ischemia time of <30 minutes. Patients in the RPN group had shorter warm ischemia time and higher 6‐month postoperative SRF compared with patients in the LPN group. Conclusion SRF is more sensitive for postoperative follow‐up than eGFR. Longer warm ischemia time is associated with poorer postoperative renal function. RPN is a safe and feasible alternative to LPN.