Robert Carachi

A meta-analysis of the risk of boys with isolated cryptorchidism developing testicular cancer in later life

Background Significant variability exists for the relative risk (RR) of testicular malignancy in isolated cryptorchidism. Objective To perform a meta-analysis to clarify the true magnitude of this risk, allowing clinicians to better counsel patients and their families. Setting Secondary research conducted by undergraduate researchers, clinical academics and a clinical statistician. Design, data sources, and methods A search of the English literature was performed for studies relating to testicular cancer and cryptorchidism, published between 1 January 1980 and 31 December 2010, using Embase and Medline databases. 735 papers were identified and analysed by four authors independently in accordance with our inclusion and exclusion criteria. Studies reporting an association between cryptorchidism and subsequent development of testicular malignancy were included. Genetic syndromes or other conditions which predisposed to the development of cryptorchidism were excluded. Pooled estimates and 95% CIs for the RRs were calculated. Results Nine case–control studies and three cohort studies were selected. The case–control studies included 2281 cases and 4811 controls. Cohort studies included 2 177 941 boys, with a total of 345 boys developing testicular cancer (total length of follow-up was 58 270 679 person-years). The pooled RR was 2.90 (95% CI 2.21 to 3.82) with significant heterogeneity (p<0.00001; I2=89%). Conclusion Boys with isolated cryptorchidism are three times more likely to develop testicular cancer. The limitations of this study must be acknowledged, in particular, possible publication bias and the lack of high-quality evidence focusing on the risk of malignancy in boys with isolated cryptorchidism.

A new bioprosthesis in large abdominal wall defects

A collagen-coated Vicryl mesh bioprosthesis was used to repair a 4 x 4 cm full-thickness abdominal wall defect, created in experimental rats. The tensile strength of the repair at 6 months reached 70% of the original abdominal wall. Implant collagen could not be differentiated from host collagen after 2 weeks. The increase in collagen content of the repair was responsible for the increasing tensile strength of the wound with time. All histological sections showed good tolerance of the implant. These results support the use of collagen Vicryl membrane to repair large abdominal wall defects. Clinical trials are indicated.

Keratinocyte regulation of TGF‐β and connective tissue growth factor expression: A role in suppression of scar tissue formation

Allogeneic keratinocytes applied to large full‐thickness wounds promote healing while suppressing scar tissue formation. This effect may be mediated in part by their effect on the levels of transforming growth factor‐βs (TGF‐βs) and connective tissue growth factor (CTGF) in the wound and subsequent modulation of fibroblast activity. We have examined the levels of TGF‐β and CTGF produced by keratinocytes and fibroblasts, and the effect of keratinocyte‐conditioned medium using monolayer and living skin‐equivalent cultures. Keratinocyte monolayers did not release any detectable TGF‐β1, but released moderate levels of TGF‐β2 into culture medium, and stained strongly for TGF‐β1, but only weakly for TGF‐β2. Fibroblasts released large amounts of TGF‐β1, no TGF‐β2, and stained strongly for TGF‐β1. Neither cell type released TGF‐β3, but both stained strongly for TGF‐β3. Keratinocyte‐conditioned medium suppressed the levels of TGF‐βs and CTGF associated with the fibroblasts compared with fibroblasts incubated in Dulbeccos minimal essential medium and fibroblast‐conditioned medium. In living skin equivalents, keratinocytes stained very strongly for TGF‐β1 and CTGF, moderately strongly for TGF‐β3, and only weakly for TGF‐β2. Fibroblasts stained strongly for TGF‐β1 and 3 and CTGF. These observations suggest that keratinocytes may affect the TGF‐β profile in such a way as to suppress the formation of scar tissue.

Inactive renin: A tumor marker in nephroblastoma

Renin-containing cells have been identified in nephroblastoma. A prospective study of eight children with nephroblastoma has demonstrated abnormally high levels of total renin. The increase in total renin was due to increased levels of inactive renin (prorenin), rather than the active renin. These high levels decreased to normal after operation. The plasma level of inactive renin could be a useful biochemical tumor marker in nephroblastoma.

Childhood phaeochromocytoma and paraganglioma: 100% incidence of genetic mutations and 100% survival

INTRODUCTION The aim is to identify the incidence of genetic mutations and outcome of children presenting with phaeochromocytoma/paraganglioma (PGL) to a single paediatric surgical service to determine the need for genetic counselling in associated kindreds. METHODS A retrospective case note review was undertaken of all cases treated between 1998 and 2008 with particular reference to presentation, management, and predisposing genetic conditions. RESULTS Seven cases (4 male, 3 female) were identified (median age, 13 years; interquartile range, 9-16). Three cases had a family history of phaeochromocytoma/PGL. All presented with neurologic symptoms related to hypertension, including headaches (n = 5), hemiparesis (n = 2), facial palsy, and hemianopia. All underwent surgical resection. Five patients had meta-iodobenzylguanidine (MIBG) therapy for apparently malignant features. All cases were found to have a predisposing genetic mutation: von Hippel-Lindau (n = 3), succinate dehydrogenase mutations (n = 3), and multiple endocrine neoplasia (n = 1). All patients are alive after a median follow-up of 5 (interquartile range, 2-7) years. CONCLUSIONS All 7 cases had a familial genetic mutation identified, and none arose de novo. We advocate genetic counselling for all families of children diagnosed with phaeochromocytoma/PGL with lifelong surveillance tailored to the underlying syndrome because of the increased risk of synchronous and metachronous tumours associated with these genetic syndromes.

Collagen-coated Vicryl mesh is not a suitable material for repair of diaphragmatic defects

Encouraged by the results in abdominal wall defects, the authors used the collagen-coated Vicryl mesh (CCVM) in repair of diaphragmatic defects in two patients. In a patient with recurrent diaphragmatic hernia, CCVM was used to reinforce the anterior abdominal muscle flap. The hernia recurred after 8 months. In another patient, it was used to repair a large diaphragmatic defect. This patient had a recurrence of the hernia in 10 weeks. The results suggestthat CCVM is not a good material for repairing the diaphragmatic defect. However, it can be used to reinforce other types of repairs.

Neonatal tumours: Glasgow 1955-86.

Fifty one neonatal tumours were diagnosed in Glasgow over a 32 year period. The most common tumours were teratomas (n=19), others being renal tumours (n=9), soft tissue sarcomas (n=8), neuroblastomas (n=7), and others (n=8). Of the total, 31% were malignant. Neonatal tumours pose difficult problems of management, and because of their comparative rarity and the great potential for cure we recommend that all centres dealing with such patients should contribute to and benefit from a Neonatal Tumour Registry.

Separation of renal fragments by a urinoma after renal trauma: percutaneous drainage accelerates healing

Background. Two boys suffered blunt abdominal trauma resulting in renal injury. In both cases the damaged kidney was fractured through its mid-portion, and the upper and lower fragments of the kidney became widely separated by a urinoma. Materials and methods. US-guided drainage of the urinoma resulted in immediate apposition of the renal fragments. The drains were left on free drainage by gravity for 1 week before removal. Results. The urinomas did not reaccumulate and follow-up DMSA scans showed good residual function. Conclusion. We suggest that drainage of urinomas that separate renal fragments should be considered since this may accelerate healing and help preserve renal function.

Colour Doppler imaging of the acute paediatric scrotum

The differentiation of the causes of acute scrotal pathology by clinical means alone is prone to inaccuracy, resulting in inappropriate surgical exploration. Colour Doppler imaging (CDI) provides the facility to assess blood flow. Torsion of the testis impedes blood flow, whereas it is enhanced or normal in inflammatory pathology. We have investigated 40 cases of acute scrotal disease by means of CDI in which the radiologist performing the test was unaware of the preliminary clinical diagnosis. The clinical diagnostic accuracy was 60%, whereas the diagnostic accuracy of CDI was 82%. CDI provides an effective means of enhancing diagnostic accuracy.

Neonatal tumours: a single-centre experience

Abstract.Solid tumours are uncommon in the neonatal period. We present our experience of managing neonatal tumours in a tertiary reference centre to study the incidence, pathology and types, efficacy of treatment, and impact of antenatal diagnosis on the management in our practice in a retrospective study of case-notes and pathology reports. Eighty-three neonates with solid tumours were seen over a 45-year period (1955–1999); 62 (74%) presented at birth. Only 11 were diagnosed antenatally. Teratomas were the commonest type (n = 33, 40%) followed by neuroblastomas (NB) (14), renal (13), soft-tissue (10), hepatic (4), and miscellaneous tumours (2). Twenty-three (28%) were malignant, 50% of these being NBs. Surgery remains the mainstay of treatment. Chemotherapy has also become safer. Therapeutic complications were responsible for 50% of deaths before 1986; from 1986 onwards, there has been no therapy-related mortality. Only one-third of the recent cases were diagnosed antenatally. Counseling the family and in-utero transfer is the best option. In our limited series, there was no significant difference in management and outcome in the antenatally-diagnosed cases. The small numbers of neonatal tumours seen by individual centres underline the need for an international effort to optimise therapy and improve understanding of these tumours.