Nabil K. Bissada

Long-term experience with management of renal cell carcinoma involving the inferior vena cava

OBJECTIVES To evaluate the long-term outcome and prognosis and influence of patient and tumor characteristics and therapeutic interventions on patients with renal cell carcinoma (RCC) extending to the inferior vena cava (IVC). METHODS The data of 75 patients (51 men and 24 women; age range 27 to 92 years) with RCC and involvement of the IVC, including 49 without and 26 with metastatic disease, treated between July 1973 and December 1998 were reviewed. The clinical presentation, laboratory and imaging investigations, extent and level of caval involvement, operative details, and estimated blood loss, as well as the postoperative course, morbidity, and actuarial and disease-free survival were analyzed. RESULTS Seventy-five patients between 27 and 92 years old with RCC involving the IVC were studied. Of the 54 operative patients, 48 had no metastasis and 6 had metastatic disease; 32 had IVC tumor extension to the infrahepatic or low retrohepatic IVC, 7 had high intrahepatic IVC extension, and 15 had right atrial extension. In 7 patients, tumor had invaded the IVC wall. Partial IVC wall excision was done in 4 patients and resection of a complete segment of the IVC in 3 patients. Tube graft to replace a segment of the IVC was used in 2 patients. Patients with intracardiac extension were initially treated with cardiopulmonary bypass. Subsequently, profound hypothermia and circulatory arrest were also used. Three patients died in the postoperative period: two with and one without metastatic disease. The follow-up period ranged between 25 and 144 months. Of the 48 patients without evidence of metastasis at surgery, the perioperative mortality rate was 2%. Twenty-two patients (47%) were alive without evidence of metastases, 4% developed solitary metastasis, and 36% eventually developed multiple metastases. CONCLUSIONS Our long-term experience confirms that of other investigators that nonmetastatic RCC with extension into the IVC is a potentially curable condition provided complete removal can be achieved. The level of extension of the tumor thrombus dictates the surgical techniques used for successful removal of the tumor thrombus. The treatment of patients with caval involvement and metastatic disease at presentation needs to be carefully individualized. Those with extensive multiorgan metastases continued to do poorly irrespective of the therapeutic approach chosen.

Complete Remission of Hormone Refractory Adenocarcinoma of the Prostate in Response to Withdrawal of Diethylstilbestrol

The phenomenon of regression of adenocarcinoma of the prostate after the withdrawal of antiandrogens is well documented. However, to our knowledge we report the first case of durable complete remission of hormone refractory prostate cancer after cessation of diethylstilbestrol. The drug was discontinued because the patient had disease progression while on diethylstilbestrol and withdrawal resulted in durable remission. In more than 3 years of followup since discontinuing diethylstilbestrol there has been no evidence of clinical or biochemical recurrence.

Prognostic and functional significance of thromboxane synthase gene overexpression in invasive bladder cancer.

Thromboxane synthase (TXAS) is one of the enzymes downstream from cyclooxygenase-2 and catalyzes the synthesis of thromboxane A(2) (TXA(2)). TXAS was among the genes we identified based on its overexpression in invasive bladder tumors. TXAS is overexpressed in common forms of bladder tumors: 69 of 97 (71.1%) transitional cell carcinoma (TCC), 38 of 53 (71.6%) squamous cell carcinoma, and 5 of 11 (45.5%) adenocarcinoma relative to nontumor tissue. Overall, 112 of 161 (69.5%) invasive tumors exhibited elevated expression. Significantly, patients with tumors having >4-fold levels of TXAS expression showed significant statistical evidence of lower overall survival expressed by the estimated hazard ratio of 2.74 with P = 0.009 in Coxs regression analysis. TXAS mRNA expression was found to be an independent prognostic marker for patients with bladder cancer. Treatment of bladder cancer cell lines (T24 and TCC-SUP) with TXAS inhibitors and TXA(2) (TP) receptor antagonists reduced cell growth, migration, and invasion, whereas TP agonists stimulated cell migration and invasion. The positive correlation between elevated TXAS expression and shorter patient survival supports a potential role for TXAS-regulated pathways in tumor invasion and metastases and suggests that modulation of the TXAS pathway may offer a novel therapeutic approach.

Clinical Spectrum of Adrenal Myelolipoma: Analysis of 8 Tumors in 7 Patients

Adrenal myelolipoma is a rare, benign, and biochemically nonfunctioning tumor. Most patients with adrenal myelolipoma are asymptomatic and the condition is discovered incidentally at autopsy. Review of the literature reveals 70 patients with surgically documented adrenal myelolipoma. We report 7 additional patients with 8 adrenal myelolipomas, of whom 5 underwent surgical removal because of tumor size, unusual imaging features or symptomatology. Of our patients 4 had symptomatic lesions requiring surgical removal, while 1 had an adrenal myelolipoma that was discovered intraoperatively. Of the remaining 2 patients 1 had a small (3 cm.) lesion discovered incidentally on excretory urography and 1 had bilateral adrenal myelolipoma discovered incidentally on computerized tomography.

Isolated lymphoma of genitourinary tract and adrenals

With the routine use of computed tomographic imaging, intrinsic involvement of the genitourinary tract in newly diagnosed non-Hodgkins lymphoma is seen in as many as 10 percent of patients. Incidental discovery of an extranodal, extra-lymphatic lesion in the genitourinary tract without clinical or radiographic evidence of disease elsewhere, however, is an uncommon occurrence. The clinical presentation and imaging findings in 4 patients with initial manifestation of lymphoma isolated to the kidney, ureter, bladder, and adrenals, respectively, are presented. These patients had no evidence of lymphoma elsewhere, and imaging studies mimicked the more common neoplasms affecting these organs.

Ureterosigmoidostomy: Is it a Viable Procedure in the Age of Continent Urinary Diversion and Bladder Substitution?

Between January 1977 and June 1985, 63 patients requiring supravesical diversion underwent ureterosigmoidostomy with an antireflux technique. Of the patients 49 had bladder cancer and 14 had other conditions. Two patients died in the postoperative period. Postoperatively, all patients were instructed to empty the rectum frequently, and received bicarbonate and potassium supplementation. Median followup was 41 months (range 3 to 70). Renal function remained stable in 92% of the patients. Radiographic deterioration occurred in 23% of the renal units, which was severe in 7%. These results indicate that the short and intermediate followup results with ureterosigmoidostomy are comparable to those of an ileal conduit. The method has the added advantage of being a form of continent diversion. We believe that ureterosigmoidostomy remains a viable and convenient alternative in select patients with bladder cancer who are not suitable for other forms of continent diversion or bladder substitution.

Ureteroenteric anastomotic strictures: treatment with Palmaz permanent indwelling stents.

A 70-year-old man with bilateral ureteroenteric anastomotic strictures and recurrent urinary tract sepsis that continued despite bilateral Double-J ureteral stents and nephrostomy tubes was successfully treated with bilateral Palmaz indwelling permanent stents.

Repair of Active Radiation-Induced Vesicovaginal Fistula Using Combined Gastric and Omental Segments Based on the Gastroepiploic Vessels

Combined gastric and omental segments were successfully used to repair an active radiation-induced vesicovaginal fistula. The technique is described.

Characteristics and Use of the in Situ Appendix as a Continent Catheterization Stoma for Continent Urinary Diversion in Adults

Use of the in situ appendix to provide continence was evaluated in 21 adults undergoing continent urinary diversion. The appendix with minimal or no manipulation was used in 20 of the 21 adults to provide the continence mechanism. Our findings indicate that in the majority of adults with no prior appendectomy the unaltered or minimally altered appendix is suitable to provide continence, and that dilating a narrow appendix is safe, effective and compatible with providing an adequate continence mechanism.

FAVORABLE EXPERIENCE WITH A SIMPLE TECHNIQUE TO CREATE A CONCEALED UMBILICAL STOMA

PURPOSE After using different sites for continent urinary diversion stomas the umbilicus became the preferred site. Experience with a simple technique to place the continent diversion stoma at the umbilical site is reported. MATERIALS AND METHODS Cutaneous continent urinary diversion was performed in 95 patients with placement of the stoma at the umbilical site. A triangular skin flap is elevated to the right of the umbilicus, a 1 cm. piece of the umbilical scar is excised and the apex of the skin flap is anastomosed to the spatulated appendix, tapered ileum or gastric tube. RESULTS All patients had satisfactory cosmetic results, 3 required simple revision and 4 needed dilation. These 7 patients as well as all others easily catheterized the urinary pouch. CONCLUSIONS This simple technique results in good cosmesis and it is associated with a minimal need for stomal revision.