Yoram Dekel

PREDICTING THE SUCCESS OF RETROGRADE STENTING FOR MANAGING URETERAL OBSTRUCTION

PURPOSE Retrograde ureteral stenting is often considered the first line option for relieving ureteral obstruction when temporary drainage is indicated. Several retrospective studies have implied that in cases of extrinsic obstruction retrograde ureteral stenting may fail and, therefore, percutaneous nephrostomy drainage is required. We examined the efficacy of retrograde ureteral stenting for resolving ureteral obstruction and identified clinical and radiological parameters predicting failure. MATERIALS AND METHODS Enrolled in our prospective study were 92 consecutive patients with ureteral obstruction, which was bilateral in 8. Retrograde ureteral stenting was attempted in all cases by the urologist on call. When stent insertion failed, drainage was achieved by percutaneous nephrostomy. Patients were followed at 3-week intervals for 3 months. Each followup visit included a medical interview, blood evaluation, urine culture and ultrasound. Stent malfunction was defined as continuous flank pain manifesting as recurrent episodes of acute renal colic, 1 or more episodes of pyelonephritis, persistent hydronephrosis or elevated creatinine. Preoperative data and outcomes were compared in cases of intrinsic and extrinsic obstruction. Univariate and multivariate analysis was done to identify predictors of the failure of ureteral stent insertion and long-term function. RESULTS The etiology of obstruction was intrinsic in 61% of patients and extrinsic in 39%. Extrinsic obstruction, which was associated with a greater degree of hydronephrosis, was located more distal. Retrograde ureteral stenting was successful in 94% and 73% of patients with intrinsic and extrinsic obstruction, respectively. At the 3-month followup stent function was maintained in all patients with intrinsic obstruction but in only 56.4% with extrinsic obstruction. On multivariate logistic regression the type of obstruction, level of obstruction and degree of hydronephrosis were the only predictors of stent function at 3 months. Stent diameter and preoperative creatinine had no predictive value. CONCLUSIONS Retrograde ureteral stenting is a good solution for most acutely obstructed ureters. In patients with extrinsic ureteral obstruction a more distal level of obstruction and higher degree of hydronephrosis are associated with a greater likelihood of stent failure. These patients may be better served by percutaneous drainage.

Significance of angiogenesis and microvascular invasion in renal cell carcinoma

The aim of this study is to evaluate the relationship between tumor angiogenesis and microvascular invasion, and the subsequent development of metastatic disease in patients undergoing surgery for renal cell carcinoma (RCC). The study group consisted of 102 patients who underwent surgery for RCC between the years 1990 and 1997 in our institute with a mean follow up period of 81.3 months. Paraffin blocks were stained for Factor VIII-related antigen and CD34 which decorate endothelial cells in order to assess angiogenesis and microvascular invasion and their relevance for developing metastatic disease. When Factor VIII-related antigen staining was used we found that the microvessel count correlated with the development of metastatic disease with a mean count of 49.7 for patients with no evidence of disease and a mean count of 95.5 for patients who developed metastatic disease (p<0.05). We also found that microvascular invasion correlated with the development of metastatic disease. It was demonstrated in 55.5% of patients who developed metastatic disease versus 23.8% of patients with no evidence of disease with Factor VIII staining (p<0.05), and in 33.3% and 7.1%, respectively (p<0.05) with CD34 staining. This study suggest that demonstration of intense angiogenesis and microvascular invasion may be a predictor of a more aggressive tumor mandating closer follow up and consideration of adjuvant therapy.

Human DNA topoisomerase‐IIα expression as a prognostic factor for transitional cell carcinoma of the urinary bladder

To investigate the immunohistochemical expression of topoisomerase II‐α (TII‐α, a nuclear enzyme, the expression of which increases rapidly at the end of the S to G2/M phase and declines when mitosis ends) in bladder urothelial neoplasms (transitional cell carcinoma), and its correlation with grade, stage and survival.

Renal cell carcinoma in pregnancy

Renal cell carcinoma is a rarely reported neoplasm in pregnancy. The pregnancy demands special consideration in terms of the diagnostic evaluation and management. Two patients with renal cell carcinoma who presented during the second trimester of pregnancy and underwent radical nephrectomy are reported with a review of published studies. It seems that because the mothers welfare is the primary concern, surgical management need not be delayed.

Combined intravesical hyperthermia and mitomycin chemotherapy: a preliminary in vivo study

Summary.  Previous clinical studies of the combination of local intravesical hyperthermia with cytostatic drugs for the treatment of Superficial Transitional Cell Carcinoma of the urinary bladder (STCCB) showed encouraging results both in reducing recurrence rate to 20–30% within 2 years and in ablative success rate of 79%. Our objectives were to evaluate bladder tissue and adjacent organs during and following hyperthermia treatment. An intravesical catheter equipped with a radio‐frequency antenna (Synergo® SB‐TS 101.1 System) was used for hyperthermia and intravesical chemotherapy (mitomycin C) was instilled in vivo for 60 min in two anaesthetized sheep. Thirteen to fifteen thermocouples were sewn surgically on the internal and external surfaces of the bladder wall and on adjacent organs to monitor the temperature during the treatment. We expected the intravesical temperature to be under 46 °C and the external layers below 45 °C. The bladder was filled with 50 mL of chemotherapeutic solution (400 µg/mL of mitomycin C in distilled water). The sheep were sacrificed at the end of the treatment. Three other sheep, which underwent thoracic surgery, served as control group. Histological changes in both groups showed foci of oedema and haemorrhage with inflammation in the lamina propria and serosa. Foci of desquamation of the epithelium were noticed in the treated sheep. Histological analysis of the treated group showed no significant differences from the control group. The control group showed similar changes, some less pronounced. The combined treatment of hyperthermia with mitomycin C did not cause major damage to the urinary bladder or adjacent organs. All changes were superficial and reversible, and the control group showed similar changes, some less pronounced. Although this is an experimental model based on one single session treatment, rather than repeated treatments, it suggests that the approach may be useful in future studies both in models and man.

The spectrum of laryngeal neoplasia: the pathologist's view.

Several types of neoplastic change with different prognostic implications typically involve the laryngeal squamous epithelium. The purpose of this review is to examine the spectrum of these changes, as well as their relationship to benign squamous epithelial proliferative states. Since these pathological changes are apt to occur in regions where the epithelial lining is typically squamous, it is important to recognize that the epithelium of the larynx varies from stratified squamous to respiratory-type, depending on the location. The lingual (anterior) surface of the epiglottis is lined by a stratified squamous type, while the laryngeal (posterior) surface is stratified squamous merging into respiratory-type. In the larynx, the supraglottic and infraglottic portions are a respiratory-type, which contrasts with the stratified squamous epithelium of the glottis. This typical distribution does show some degree of variability in those patches of squamous epithelium and is frequently seen within the respiratory-type epithelial regions. The junction between the two epithelial types may be abrupt or separated by a transitional zone.

Unusual splenic metastasis from renal cell carcinoma. A case report and review of the literature.

This is a short report on a splenic metastasis from renal cell carcinoma. Previously, the patient had renal carcinoma removed by nephrectomy. The diagnosis of metastasis was based on morphology and immunohistochemistry. It is certainly true that splenic metastases from renal cell carcinoma are rare. Nevertheless, they have been well described in the literature. A giant cell reaction to tumor is noted in a number of cancers and mainly represents an unusual phenotype.

The expression of DCC protein in female breast cancer

AbstractBackground. The deleted in colorectal cancer (DCC) gene has been shown to be frequently deleted or its expression reduced or absent in glioblastomas, colorectal, gastro-intestinal, pancreatic and prostatic tumors. In the present study, we investigated the expression of DCC in surgical specimen from 75 patients with primary breast cancer. Methods. The expression of the DCC, estrogen receptors (ER), and progesterone receptors (PR) was studied in 75 surgical specimens of primary breast cancer using an immunohistochemical method. To evaluate the outcomes of the breast cancer patients, we followed up the patients during minimum of 10 years. Results. Reduced or loss of expression of DCC was identified in 45 out of 75 samples. There were significant differences between cases without metastasis or local recurrences versus these with metastasis or local recurrences (p = 0.006), and between patients alive with no evidence of malignancy versus those with recurrence or dead of disease (p = 0.005). There were no significant differences between the DCC status and age, sex, tumor location, stage, grade, or proportion of patients who received adjuvant therapy. Conclusions. These findings suggest that a decrease in DCC expression may influence the prognosis of breast carcinoma patients.

Talc Inhalation is a Life-Threatening Condition

A case of rapidly progressive disease and pulmonary hypertension due to chronic cosmetic talc inhalation is presented. Although an uncommon cause of pulmonary hypertension, talc, especially through intravenous administration, should be included in the etiology of parenchymal pulmonary hypertension. In our case talc inhalation was inadvertent, causing fulminant disease leading to the patient’s death. To our knowledge, this is the first case of inadvertent talc inhalation causing death in adult patient.

DCC protein expression in clear cell renal cell carcinoma.

To investigate whether the expression of protein from the ‘deleted in colorectal cancer’ (DCC) gene, which predicts a poor outcome for patients with colorectal carcinoma, can also serve as a prognostic factor in renal cell carcinoma (RCC).