Murat Sade

Prognostic Significance of Microvascular Invasion in Localized Renal Cell Carcinoma

Objectives: The treatment of localized and even advanced renal cell carcinoma (RCC) is radical nephrectomy. However, 30% of these patients progress after radical nephrectomy. Prognostic factors are needed in order to determine the course of disease in patients undergoing radical nephrectomy. The aim of this study is to study the prognostic significance of microvascular invasion (MVI) in patients who had undergone radical nephrectomy for localized RCC.Methods: Between June 1989 and February 1999, pathologic sections of the specimens from 41 patients without metastases, nodal involvement or macroscopic venous involvement were investigated for MVI.Results: MVI was observed in 17% of the patients. MVI was related to the grade of the tumor and tumor size (p = 0.032, p = 0.017). In sarcomatoid–type RCC, MVI was more common than in other histologic types (p = 0.003). After a median follow–up of 48 months, the progression rate was 29% in patients with MVI and 17% without MVI (p = 0.001). Median progression time was 3 months in those with MVI and 41 months with no MVI (p = 0.01). The survival rate decreased from 85 to 70% in patients with MVI during a median follow–up of 48 months (p = 0.031). In multivariate analysis, MVI was not found to be an independent prognostic factor.Conclusion: Although MVI is closely related to progression and prognosis, in multivariate analysis it was not found to be an independent prognostic factor in localized RCC. We conclude that MVI should also be evaluated together with tumor grade in predicting the prognosis of patients with localized RCC.

METALLOTHIONEIN EXPRESSION IN RENAL CELL CARCINOMA: SUBCELLULAR LOCALIZATION AND PROGNOSTIC SIGNIFICANCE

PURPOSE We investigated the immunohistochemical localization of metallothionein (MT) in renal cell carcinoma and determined the potential role of MT expression as a possible prognostic variable for tumor proliferation and progression. MATERIALS AND METHODS Tumor tissue blocks from 70 patients with renal cell carcinoma who underwent radical or partial nephrectomy were investigated. Mean followup plus or minus standard error was 36 +/- 3 months. Immunohistochemical testing was performed by the avidin-streptavidin method using a monoclonal mouse antiMT antibody. MT staining intensity in samples was evaluated semiquantitatively. The subcellular distribution of MT was also determined. Staining characteristics were compared with the clinicopathological results. RESULTS MT immunostaining was found in 39 of 70 tumors (55.7%) and subcellulary MT was localized in the cytoplasm, nucleus and cell membrane. The survival of patients with MT immunostaining was significantly worse than that of those with MT negative results (p = 0.02). A significant relationship of higher tumor grade and MT staining intensity was observed in grades I and III (p = 0.01), and grades II and III (p = 0.02) tumors. No association was found of MT expression and pathological stage. Sarcomatoid tumors showed significantly higher MT expression than clear cell, papillary, granular or chromophobe tumors (p = 0.02, 0.001, 0.01 and 0.01, respectively). MT expression was not an independent prognostic variable. CONCLUSIONS MT over expression seems to be associated with malignant behavior and poor prognosis in renal cell carcinoma. Therefore, MT expression may be considered a useful marker of less differentiated and more aggressive renal cell carcinoma.

Giant angiomyolipoma associated with marked pulmonary lesions suggesting lymphangioleiomyomatosis in a patient with tuberous sclerosis

The association between Tuberous Sclerosis (TS) and Angiomyolipoma (AML) is well known. A patient with TS and giant AML mimicking Renal Cell Carcinoma (RCC), measuring 29 × 18 × 11 cm, weighing 4700 gr is presented. Imaging studies revealed coexistent pulmonary lymphangioleiomyomatosis and concurrent renal and pulmonary involvement is extremely rare in patients in TS. We believe that the growth potential of this hamartomatous lesion may reach to a life threatening size.

Is Magnetic Resonance Imaging Necessary in the Staging of Prostate Cancer

Objective: To evaluate the necessity of using magnetic resonance imaging (MRI) in the staging of patients with clinically localized prostate cancer. Methods: Sixty-one patients with prostate cancer were evaluated with MRI for preoperative staging with a conventional body-coil (Siemens Magnetom, 1.0 Tesla superconducting system). Twenty-nine patients underwent radical prostatectomy for presumed clinically localized disease. Of those, 17 were staged both with MRI and computerized tomography (CT). The remaining patients were staged with CT alone. MRI and CT findings, and the final pathologic staging of patients are reviewed. Results: On pathological examination of the surgical specimens, the tumor was found to extend beyond the prostate in 7 patients (41%). Among the 17 patients who were operated, extraprostatic extension (EPE) was detected accurately in 3 patients with MRI (sensitivity 20%, specificity 92%, accuracy 70.5%). No metastatic lymph nodes were detected on the basis of MRI (sensitivity 0%, specificity 93%, accuracy 88.2%). In 1 patient EPE was correctly identified by CT (sensitivity 14%, specificity 100%, accuracy 64.7%). Conclusion: Neither MRI with conventional body-coild nor CT are sufficient to indicate local extension of disease in clinically localized prostate cancer.

RENAL BOTRYOMYCOSIS MIMICKING RENAL CELL CARCINOMA

Botxyomycosis is characterized by a chronic suppurative lesion with distinctive fungus-like grains similar to sulfur granules in actinomycosis.1 The integumentary and visceral forms are recognized.’ Only 2 of the previously reported 6 renal botryomycosis cases were isolated, which simulated renal cell carcinoma radiologically and clinically, and actinomycosis and mycosis pathologically.2.3 We report on a patient in whom isolated renal botryomycosis was preoperatively diagnosed as renal cell carcinoma and who underwent radical nephrectomy. CASE REPORT A 57-year-old man presented with right renal colic and fever 4 months in duration. He had a 10-year history of type I1 diabetes mellitus and had undergone extracorporeal shock wave lithotripsy elsewhere for right ureteral stones on 2 occasions. Physical examination demonstrated tenderness and pain on palpation of the right lumbar region. Abdominal ultrasonography and computerized tomography of the abdomen revealed a solid 5 cm. mass at the lower pole of the right kidney (fig. 1). Escherichia coli was cultured from the urine. The preoperative diagnosis was renal cell carcinoma and right radical nephrectomy was performed. The mass invaded the perirenal adipose tissue, psoas muscle and liver at surgical exploration, and it was completely resected. Pathological evaluation demonstrated that the mass consisted of confluent abscesses extending into perirenal adipose tissue. Centrally these abscesses contained Gram-negative bacilli surrounded by amorphous eosinophilic material, termed the Splendore-Hoeppli phenomenon (fig. 2). Histochemical stains (Gomori methenamine silver for actinomyces and fungi, and Brown-Hopps tissue gram stain) confirmed the diagnosis of botryomycosis. Postoperatively the patient was treated with 2 gm. cephalosporin daily and convalescence was uneventful.