Use of dynamic two-dimensional transesophageal echocardiography for renal cell carcinoma with cavoatrial tumor thrombus

Previous investigations involving continuous blood pressure (BP) monitoring have shown an important alteration of the 24-hour BP profile in patients with obstructive sleep apnea syndrome (OSAS). We investigated the impact of REM sleep on the 24-hour BP cycle in 16 severe OSAS male patients (mean respiratory disturbance index = 66 +/- 16 events/hour of sleep), with hypertension (mean BP 162 +/- 21/105 +/- 11 mmHg World Health Organization (WHO) protocol). Two successive nights of polysomnography were performed, and arterial BP was monitored continuously during the second 24-hour period after brachial artery cannulation. During the daytime, subjects were kept awake and supine. At 3 p.m. BP was continuously monitored during quiet supine wakefulness for 20 minutes. Systolic, diastolic and mean BP and heart rate (HR) were analyzed and tabulated in mean values of 5 minute segments. Sleep/wake information were correlated with cardiovascular variables. Each uninterrupted REM sleep period was identified and comparison between the period of quiet supine wakefulness and REM sleep HR and BP values was performed. 8 OSAS patients presented a normal drop of the mean arterial BP during the nocturnal REM sleep periods compared to quiet supine wakefulness (mean value = -10.8 +/- 7.3 mmHg) ("dippers") while the other 8 subjects ("REM sleep non dippers"), revealed an elevated mean arterial BP during REM sleep (mean value = 18.9 +/- 10.9 mm Hg). The absence of the normal circadian BP dip seen during the nocturnal sleep period is considered as an indication of vascular risk. The REM sleep non dipping may play a role in this risk.     

Successful preoperative interferon-alpha therapy of renal cell carcinoma with tumor thrombus extending into the inferior vena cava--case report

We report a case of renal cell carcinoma in whom preoperative interferon-alpha therapy was successful in reducing the primary lesion and the tumor thrombus extending into the inferior vena cava. A 67-year-old man was referred to our hospital because of his right renal mass. We made a diagnosis of a right renal tumor with tumor thrombus by imaging examinations. Because his performance status was 3, a radical operation was considered risky. So we started interferon-alpha therapy. Four months after the start of interferon-alpha therapy, the primary lesion and the tumor thrombus reduced in their size, and the clinical response was evaluated as partial response by the response criteria for urological cancer treatment. Because of improving the performance status and reducing the tumor size, radical nephrectomy and tumor thrombectomy could be performed. Pathological examinations revealed that viable renal cell carcinomas were found only in some small parts of the primary lesion, but not in the tumor thrombus. Postoperatively, no recurrence and metastasis of renal cell carcinoma of the patient have been detected in these two and a half years.     

Surgery for hepatocellular carcinoma with tumor thrombus in the right atrium

Three cases of tumor thrombus that originated from a hepatocellular carcinoma in the liver and extended into the right atrium are described. All patients had received both resection of the tumor thrombus and lobectomy of the liver either simultaneously or independently within a short interval. Surgical order and extracorporeal circulation system were varied depending on the thrombus extension. Two of the patients died within 4 months of surgery due to different reasons and the other is doing well at 24 months after surgery.     

Metastasis of renal cell carcinoma to the contralateral renal pelvis

A young woman with syphilids resembling borderline lepromatous (BL) leprosy is being described. This is yet another addition to its already well-documented manifestations. The high prevalence of leprosy and syphilis augments the epidemiological significance of the case.     

Inferior vena cava filter used for unresectable renal cell carcinoma with tumor thrombi

A titanium Greenfield inferior vena cava filter was used for the treatment of 2 patients with unresectable renal cell carcinomas with tumor thrombi to prevent a fatal pulmonary embolism induced by tumor clots released during systemic interferon therapy and embolization of the primary tumor. After treatment, the size of the renal cell carcinomas at the primary site and the tumor thrombi decreased by 50%. There were no fatal pulmonary embolisms or complications related to the filter during the observation period (24 and 25 months) after therapy. This method may be useful in the prevention of a fatal pulmonary embolism induced by embolization and systemic interferon therapy in these patients.     

Hepatocellular carcinoma with portal vein tumor thrombus: embolization of arterioportal shunts

PURPOSE: To evaluate transcatheter arterial embolization in patients with hepatocellular carcinoma, portal vein tumor thrombus, and arterioportal shunts. MATERIALS AND METHODS: Ten patients with hepatocellular carcinoma, portal vein tumor thrombus, and severe arterioportal shunting were identified; in these patients, portal blood flow before embolization was hepatofugal. Embolization of arterioportal shunts was performed with steel coils that were introduced through a catheter during arteriography. After embolization, changes in portal hemodynamics and clinical signs and performance status of patients were evaluated; survival rates of patients with and patients without severe arterioportal shunting were compared. RESULTS: In all patients after embolization, angiography showed resolution of arterioportal shunting, and portography showed hepatopetal blood flow in the portal vein trunk. After embolization, performance status of five patients with initial scores of 2 or 3 improved. Ascites resolved in four patients and improved in four patients. One patient died of hepatic failure caused by rupture of esophageal varices 7 days after embolization. Median survival was 4.3 months, and the 6-month and 1-year survival rates were 45% and 12%, respectively. There were no significant differences between survival rates in patients with and patients without severe arterioportal shunting. CONCLUSION: Transcatheter arterial embolization of arterioportal shunts is a useful treatment for improving quality of life in patients with hepatocellular carcinoma.     

Surgical analysis for metastatic lung tumor from renal cell carcinoma

Metastatic lung tumor from renal cell carcinoma were studied in 29 cases. Eighteen patients were treated surgically, 11 were treated non-surgically. The overall 5-year survival rate with the patients of pulmonary resection was 53.5%, and that with those of conservative therapy was 0%, and this difference is statistically significant (p < 0.05). There was no significant difference in any characteristics such as sex, age, stage, grade, disease free interval, metastatic pattern and combination with or without interferon therapy. There was no significant difference in surgically treated patients with pulmonary metastasis in terms of any factors such as age, sex, stage, grade, disease free interval, pulmonary metastasis pattern, metastatic number, surgical procedure, combination with or without interferon therapy statistically. Analysis for the surgically treated patients with pulmonary metastasis from renal cell carcinoma shows no significant difference in prognosis with any characteristics. This result shows efficacy of surgery even if for the patients with synchronous bilateral multiple pulmonary metastasis from renal cell carcinoma.     

Epidermal growth factor receptor expression is associated with rapid tumor cell proliferation in renal cell carcinoma

Epidermal growth factor receptor (EGF-r) expression and tumor cell proliferation rate have been proposed as potential prognostic parameters in renal cell carcinoma (RCC). In this study, immunohistochemical stains using antibodies to EGF-r and the cell proliferation marker Ki-67 (MIB-1) were used to study the relationship between EGF-r expression, tumor cell proliferation, and prognosis in 50 non-papillary RCC extending beyond the renal capsule (pT3). A high Ki-67 labeling index (LI) was associated with poor patient prognosis (P < .05). Thirty-eight cases (76%) expressed strong cell membrane immunoreactivity for EGF-r. There was a tendency toward a shortened survival for EGF-r-positive tumors (P = .08). Tumor growth fraction (Ki-67 LI) was significantly higher in EGF-r-positive tumors than in EGF-r-negative tumors (P < .05), suggesting that rapid tumor proliferation might be responsible for the poor prognosis associated with EGF-r-positive RCC.     

Rational diagnosis and surgical therapy of renal cell carcinoma with tumor thrombosis in the vena cava

Cerebral blood flow (CBF) rises when the glucose supply to the brain is limited by hypoglycemia or glucose metabolism is inhibited by pharmacological doses of 2-deoxyglucose (DG). The present studies in unanesthetized rats with insulin-induced hypoglycemia show that the increases in CBF, measured with the [14C]iodoantipyrine method, are relatively small until arterial plasma glucose levels fall to 2.5 to 3.0 mM, at which point CBF rises sharply. A direct effect of insulin on CBF was excluded; insulin administered under euglycemic conditions maintained by glucose injections had no effects on CBF. Insulin administration raised plasma lactate levels and decreased plasma K+ and HCO3- concentrations and arterial pH. These could not, however, be related to the increased CBF because insulin under euglycemic conditions had similar effects without affecting CBF; furthermore, the inhibition of brain glucose metabolism with pharmacological doses (200 mg/kg intravenously) of DG increased CBF, just like insulin hypoglycemia, without altering plasma lactate and K+ levels and arterial blood gas tensions and pH. Nitric oxide also does not appear to mediate the increases in CBF. Chronic blockade of nitric oxide synthase activity by twice daily i.p. injections of NG-nitro-L-arginine methyl ester for 4 days or acutely by a single i.v. injection raised arterial blood pressure and lowered CBF in normoglycemic, hypoglycemic, and DG-treated rats but did not significantly reduce the increases in CBF due to insulin-induced hypoglycemia (arterial plasma glucose levels, 2.5-3 mM) or pharmacological doses of deoxyglucose.     

Cruciferous vegetables in relation to renal cell carcinoma

In the general population and in patients with essential hypertension the presence of left ventricular hypertrophy is a powerful predictor of cardiovascular events, independent of blood pressure and other cardiovascular risk factors. The prevalence of left ventricular hypertrophy increases with age and with the severity of renal impairment. Left ventricular hypertrophy is also a sensitive indicator of vascular structural changes in both large and small arteries. The possibility of reversing left ventricular hypertrophy therefore represents a major therapeutic goal for the treatment of hypertensive patients. Several studies examining the characteristics of left ventricular hypertrophy in the elderly, the interrelations between cardiac and vascular hypertrophy, the possibility of reversing left ventricular hypertrophy and its consequent prognostic value will be reported and commented on in the present review.     

Immunotherapy of renal cell carcinoma

Immunologic approaches to the therapy of metastatic renal cell carcinoma have provided moderate improvement in response rates for a disease that is extremely resistant to all forms of treatment. This article reviews recent clinical efforts using immunotherapy for renal cell carcinoma, including the adoptive transfer of cytotoxic killer cells and/or the use of biologic response modifiers, such as interferon and interleukin-2.     

Prevalence, morphology and biology of renal cell carcinoma in von Hippel-Lindau disease compared to sporadic renal cell carcinoma

PURPOSE: Renal cell carcinoma occurs as a sporadic tumor but may be part of the autosomal dominant von Hippel-Lindau disease, characterized by retinal and central nervous system hemangioblastoma, pheochromocytoma, pancreatic cysts and renal cell carcinoma. We determine the prevalence of von Hippel-Lindau disease in a series of unselected renal cell carcinoma cases by molecular genetic analysis, and compare sporadic to von Hippel-Lindau renal cell carcinoma with respect to morphology and biology. MATERIALS AND METHODS: We established registers comprising 63 subjects with von Hippel-Lindau renal cell carcinoma, belonging to 30 distinct families (register A), and 460 unselected patients operated on for renal cell carcinoma in an 11-year period (register B). Molecular genetic analysis of the von Hippel-Lindau gene was performed for living patients of register A, representing 80% of von Hippel-Lindau families, and register B, 62% living patients, to identify von Hippel-Lindau germline mutations. In addition, register B was evaluated by a questionnaire (95% response) for familial occurrence of von Hippel-Lindau disease. RESULTS: The prevalence of von Hippel-Lindau renal cell carcinoma was 1.6% in 189 consenting unselected renal cell carcinoma patients. Risk factors for occult germline von Hippel-Lindau gene mutations in register B included familial renal cell carcinoma in 3 of 3 patients (100%), multifocal or bilateral renal cell carcinoma in 1 of 10 (10%) and age younger than 50 years at diagnosis in 1 of 33 (3%). Compared to sporadic von Hippel-Lindau renal cell carcinoma was characterized by an occurrence 25 years earlier, association with renal cysts, multifocal and bilateral tumors, cystic organization and low grade histology, and a better 10-year survival (p < 0.001 each). In von Hippel-Lindau disease metastases occurred only in tumors larger than 7 cm. CONCLUSIONS: von Hippel-Lindau differs from sporadic renal cell carcinoma in morphology and biology. Our data provide arguments for planning surgery for von Hippel-Lindau renal cell carcinoma and should stimulate future investigations.     

Cytokine levels in cystic renal masses associated with renal cell carcinoma

PURPOSE: We compared cytokine levels in fluid from renal cysts with and without renal cell carcinoma. MATERIALS AND METHODS: Fluid was aspirated from 18 renal cysts without (benign) and 21 with renal cell carcinoma (malignant). Serum from patients with renal cell carcinoma and healthy controls was collected and cytokines were measured by enzyme-linked immunosorbent assay. RESULTS: Interleukin-6 (IL-6) and basic fibroblast growth factor concentrations were higher in malignant than benign cysts or serum (p <0.006). Epidermal growth factor levels were significantly higher in malignant cysts and serum than in benign cysts (p <0.01). IL-6 levels in malignant cysts positively correlated with the erythrocyte sedimentation rate (R=0.80) and C-reactive protein (R=0.86), and they were higher in grade 3 than in grade 2 tumors. Basic fibroblast growth factor levels were significantly higher in malignant cysts associated with hypervascular than hypovascular tumors (p=0.029). CONCLUSIONS: Cytokine levels in aspirated fluid may help to identify malignant renal cysts and indicate the characteristics of coexisting tumors.     

Antigen loss variants of a murine renal cell carcinoma: implications for tumor vaccination

Chronic graft-versus-host disease (GvHD) in mice is a model resembling glomerulonephritis in human systemic lupus erythematosus. In the present study congenic mouse strains were used to investigate the pathogenetic role of (1) donor T cell subset chimerism and (2) donor thymocytes in this model. In GvHD employing minor lymphocyte-stimulating-1 (Mls-1)-compatible donors and recipients, full-blown immune complex glomerulonephritis was associated with a low-donor CD8(+) T cell chimerism. Injection of lymphocytes from Mls-1-negative donors (Mls-1(b)) into Mls-1-positive recipients (Mls-1(a)) induces a type of GvHD characterized by rapid self-limitation accompanied by the immediate inhibition of donor T cell chimerism and the absence of glomerulonephritis. However, omission of thymocytes from the donor inoculate does result in glomerular depositions containing immunoglobulins. These results suggest that donor CD8(+) T cell chimerism is associated with attenuation of immune complex glomerulonephritis, whereas Mls-1-incompatible donor T cell precursors prevent the disease.     

Resection of metastatic renal cell carcinoma

PURPOSE: Resection of solitary metastases from renal cell carcinoma (RCC) is associated with a 5-year survival rate of 35% to 50%. Selection criteria are not well defined. PATIENTS AND METHODS: We retrospectively analyzed our experience with 278 patients with recurrent RCC from 1980 to 1993. RESULTS: One hundred forty-one of 278 patients underwent a curative metastectomy for their first recurrence (44% 5-year overall survival [OS] rate), 70 patients underwent noncurative surgery (14% 5-year OS rate), and 67 patients were treated nonsurgically (11% 5-year OS rate). Favorable features for survival were a disease-free interval (DFI) greater than 12 months versus 12 months or less (55% v 9% 5-year OS rate; P < .0001), solitary versus multiple sites of metastases (54% v 29% 5-year OS rate; P < .001), and age younger than 60 years (49% v 35% 5-year OS rate; P < .05). Among 94 patients with a solitary metastasis, lung (n = 50; 54% 5-year OS rate) was more favorable than brain (n = 11; 18% 5-year OS rate; P < .05). Survival rates after curative resection of second and third metastases were not different compared with initial metastectomy (46% and 44%, respectively, v 43% 5-year OS rates; P = nonsignificant). Favorable predictors of survival by multivariate analysis included a single site of first recurrence, curative resection of first metastasis, a long DFI, a solitary site of first metastasis, and a metachronous presentation with recurrence. CONCLUSION: Selected patients with recurrent RCC who can undergo a curative resection of their disease have a good opportunity for long-term survival, particularly those with a single site of recurrence and/or a long DFI.     

Thoracoscopic excision of an uncertain intramural esophagus tumor (granular cell tumor/Abrikossoff tumor)

A granular cell tumor is one of the rare tumors of the esophagus. We present the case of a 65-year-old male patient, who was admitted to our hospital for an elective cholecystectomy. In the routine diagnostic gastroscopy an intramural tumor in the distal esophagus was incidentally found. Repeated endoscopic biopsies did not reveal the histologic diagnosis, although endoscopic ultrasound invasion to the tunica muscularis could not be excluded. After indicating the operative therapy, the tumor was removed through a thoracoscopic approach. The histologic specimen showed a granular cell tumor of the esophagus (tumor of Abrikossoff). Since the tumor grade was unknown, our therapy seemed to be justified because of the low risk involved in minimally invasive operative procedures. There has been much discussion and controversy in the literature on this subject, including the potential for malignancy and the correct therapy regime, with a general shift to conservative or minimally invasive treatment. The case is discussed with a review of the literature.     

Treatment of renal cell carcinoma with escalating doses of alpha-interferon

Forty-one patients with advanced renal cell cancer started treatment with recombinant alpha-interferon intramuscularly, beginning at a dose of 5 x 10(6) U x 3/week, progressively increasing doses every week, from 5 x 10(6) U x 3/week to 10 x 10(6) U x 3/week, to the highest dose of 15 x 10(6) U x 3/week. No complete response was achieved, partial response was achieved in 6 (13%) patients with a median duration of 45.2 (13-134) weeks. The majority of side effects from interferon treatment evaluated according to WHO classification were seen during the first 2 months and they were fever (after interferon administration) in 95% patients, chills (51%), flu like syndrome (65%), fatigue (87%), anorexia (80%), worsening in performance status (56%), nausea and vomiting (19%), weight loss (> 10% during therapy) (26%), leukopenia (14%), anemia (75%), neurological symptoms (43%), psychological symptoms (19%) and dyspnea (9%). The results are similar to other studies and toxicity was only moderate.     

Spontaneous regression of brain metastasis secondary to renal cell carcinoma

Spontaneous regression of malignant tumors is a rare event. A case involving brain metastasis from renal cell carcinoma (RCC) is presented. Nine years after the diagnosis of metastasis the patient is alive without evidence of recurrence. We have only found three previous RCC cases in the literature involving spontaneous regression of brain metastasis (4, 16, 17).