Acute renal failure due to oxalate ingestion

Analysis of the infiltrant tumours of the bladder diagnosed in our service between 1986-1996 both inclusive, with associated tumour of the upper tract during its evolution. From a total of 262 infiltrant transitional tumours of the bladder and 52 transitional tumours of the upper urinary tract, 8 patients were found to have both types of tumours in association, which accounted for 3.05% of all infiltrant vesical tumours. Mean age of our patients, all male, was 65. The pathological anatomy of the upper tract tumours was: 4 pT1 and 4 pT3. 75% presented relapsing tumours of the bladder, 50% had a background of bladder Cys, 87.5% were multifocal vesical tumours and 100% were larger than 3 cm. In addition, 62% cases were ipsilateral to the tumours of the upper urinary tract. It can therefore be concluded that for tumours of the bladder, multifocality, relapse, presence of vesical Cys and tumour size, are all concurring features when association of these two types of tumours occurs.     

Intestinal obstruction and peritoneal carcinomatosis after endoscopic resection of transitional carcinoma of urinary bladder

Gut involvement in bladder tumours is low, even exceptional in the presence of surface, low-grade neoplasia. The authors explain their experience in the diagnosis and management of a patient treated endoscopically for a vesical surface tumour which subsequently exhibited peritoneal and gut metastatic seeding. The various mechanisms for gut dissemination of vesical neoplasias and the repercussion of their endoscopic management are discussed.     

Laparoscopically assisted colpopoesis using sigmoid colon]

Presentation of one case of scrotal vesical hernia in a 66-year old patient who presented with scrotal mass, micturition difficulty and two-phase micturition that improved when pressure was exerted on the scrotum. Diagnosis was established by physical examination and CUMS. The patient underwent surgery during which a direct inguinal hernia due to paraperitoneal vesical sliding was found. Right herniorrhaphy was performed with Shouldice's technique. Postoperative radiological monitoring showed normal vesical morphology. The pathogeny, classification and treatment, as well as the differential diagnosis uncommonly reported by the authors consulted, are commented.     

Conservative surgery for stage I ovarian carcinoma in women of childbearing age

OBJECTIVE: To assess the results of a policy of tailored conservative surgical management for young women with stage I ovarian carcinomas. DESIGN: Retrospective study. PARTICIPANTS: Ninety-nine women aged 40 years or younger who underwent either primary surgery in our department or were referred after primary surgery performed elsewhere. METHODS: Of the 99 women in our study, 56 underwent fertility-sparing surgery and 43 more radical surgery. Minimal requirements for conservative management were adequate staging and complete information about the therapeutic options. Factors important in the choice of the treatment were, age, wish to preserve fertility, histologic type and grade, and the stage of the tumour. RESULTS: Conservative treatment was conducted in 84% of nulliparous and in 33% of parous women; 62% of grade 1 tumours, 48% of grade 2, and 50% of grade 3 were treated conservatively. With a median follow up of seven years, we observed five recurrences (9%) of carcinoma in women treated conservatively and five (12%) in those treated more radically. Two women (one in each treatment arm) were saved after recurrence. Two recurrences after conservative surgery involved the residual ovary (3.6%). Two women developed borderline tumour in the contralateral ovary and both were treated by surgery. CONCLUSION: After adequate staging and accurate information is given to the patient, conservative treatment may be safe in some women with early ovarian cancer. The risk of recurrence in the contralateral ovary is low. Conservative surgery may be also considered in some Stage I grade 3 tumours and in some women with stage JC tumours.     

Vesicovaginal and vesicocutaneous fistulas: transurethral suture cystorrhaphy as a new closure technique

PURPOSE: We assessed the usefulness of endoscopic treatment of vesical fistulas. MATERIALS AND METHODS: Two bladder fistula patients underwent transurethral surgery in an attempt to close the fistula. RESULTS: Both patients were cured of the fistula, without undergoing an open procedure. CONCLUSIONS: Cystoscopically assisted suture closure of vesical fistulas can be a successful procedure in selected patients. Nontraditional instrumentation and technique allowed for transurethral closure of these fistulas.     

Hematuria: current strategies

Clinical history and examination are essential in order to correctly guide the sequence of complementary investigations. First-line examinations are urine culture, KUB and ultrasonography, bearing in mind that the two main causes to be investigated are renal stones and tumours. Depending on the results of this first series of examinations, abdominopelvic CT-scan and vesical endoscopy, performed under local anaesthesia as an outpatient procedure, generally establish the aetiological diagnosis. MRI may usefully complete CT data in some cases of renal tumours. Lastly, more invasive techniques such as arteriography, retrograde ureteropyelography and ureteroscopy are much less frequently required for diagnostic purposes.     

Interaction between fluoxetine and haloperidol: pharmacokinetic and clinical implications

INTRODUCTION: The esophageal epidermoid cancer has an important association with aerodigestive tract neoplasms and possibly share the same risk factors. Furthermore, other neoplasms can be associated with esophagus cancer. OBJECTIVE: To analyze retrospectively the patients with esophageal epidermoid cancer (EEC) and associated neoplasms, treated by the Esophagus Stomach and Small Intestine Group of Surgery at Hospital de Clinicas de Porto Alegre from January 1988 to June 1995. PATIENTS AND METHODS: Nineteen (7.28%) of the 261 studied patients had associated neoplasms to the EEC. Ten patients presented synchronic tumours and 9 metachronic ones. The predominant sex was the masculine with 17 cases. The mean age was 62.52 years in the moment of the esophageal cancer diagnostic. RESULTS: The aerodigestive tumours, squamous carcinomas in totality, represented the predominant associated neoplasm histological type in 68.42% of the cases. The most frequent associated aerodigestive tumours site was the respiratory tract (53.8%), followed by the oral cavity and oropharynx (23%) and larynx (23%). In our sample, twelve patients were smokers and 9 were alcohol abusers. In relation to the EEC treatment, surgery was performed in 6 patients. The associated neoplasm was treated with radical surgery in 11 patients and radiotherapy in 5. Surprisingly 4 cases (21%) of gastric adenocarcinoma associated to the EEC were diagnosed, treated with radical surgery in 3 patients. CONCLUSION: The authors call attention to the importance of a criterial staging as well as the follow up in patients with EEC owing to the significant association with others neoplasms, principally with aerodigestive tumours, and discuss the common risk factors possibility: tobacco and alcohol use. Important association with gastric neoplasms were found in this casuistry.     

Paraganglioma of the prostatic urethra. A report of three cases and a review of the literature

OBJECTIVE: To determine the incidence and clinical presentation of prostatic urethral paragangliomas and to compare these findings with paragangliomas occurring in the other sites of the lower urinary tract. PATIENTS AND METHODS: The clinical records of three patients with prostatic urethral paragangliomas were reviewed, as was the histology of each specimen. The tumours were stained immunocytochemically with neuron-specific enolase, chromogranin, S100 protein, protein gene product 9.5, prostate-specific acid phosphatase and prostate-specific antigen. RESULTS: The three tumours occurred in elderly men, two of whom presented with haematuria, one of whom also had a vesical transitional cell carcinoma, and the third patient had obstructive symptoms due to co-existent prostatic hyperplasia. The histological appearances and immunocytochemical findings were consistent with paraganglioma. Treatment consisted of local excision and there were no recurrences or metastases at 5 and 6 years in two patients for whom follow-up was available. CONCLUSION: Urethral paragangliomas are rare tumours arising in elderly men and are hormonally inactive. Although haematuria may be the presenting symptom, it is important to exclude additional more common and possibly more sinister lesions such as transitional cell carcinoma. Local excision appears to be curative.     

A case of adenocarcinoma arising in the vesical diverticulum

A 70-year-old woman presented at our hospital with the chief complaint of gross hematuria and pain on urination. Cystoscopy revealed a broad-based tumor covered with mucus on the right wall of the bladder and therefore a transurethral resection was performed. At surgery the tumor was found to arise from the diverticulum and could not be resected because of the risk of perforation. A histopathological examination disclosed adenocarcinoma including a small region of signet ring cell carcinoma. The tumor was thus diagnosed to be adenocarcinoma originating from the vesical diverticulum and total cystectomy and urinary diversion (ileal conduit) were scheduled. At operation, the carcinoma was found to have infiltrated into the cecum. The operation procedure was therefore changed to partial cystectomy and excision of the cecum in consideration of both the patient's quality of life and her overall prognosis. Although a tumor originating from the vesical diverticulum and adenocarcinoma are both considered to be factors indicating a poor prognosis, no signs of recurrence or metastasis have been detected in this patient at 26 months after the operation.     

Phylloid pigmentary pattern with mosaic trisomy 13

PET is a diagnostic method that creates high resolution, 3 dimensional tomographic images of the distribution of positron emitting radionuclides in the human body. Recent technological developments allow the use of whole-body PET devices in clinical oncology. 18FDG is a glucose analog transported and competitively used with glucose reflecting the increased glucose metabolism into malignant cells. Differential diagnosis between chronic pancreatitis and pancreatic cancer is already a well-documented indication. For initial staging of gastro-esophageal and colorectal tumours, results are preliminary but the clinical impact seems to be rather limited. At present, the major indication of FDG-PET is the detection and staging of colorectal cancer recurrences. FDG-PET allows the differentiation between scared tissue and tumour when structural imaging is often confusing. In the same time, the whole-body imaging capability provides unique information that can modify loco-regional and liver staging. Overall, FDG-PET affects the clinical management of 30 to 40% of these patients. Quantitative assessment of therapeutic response to chemotherapy regimen appears to be one of the most promising applications of FDG-PET. Since the most effective therapy of colorectal cancer are often surgical, the role of chemotherapy in colorectal cancer remains limited to adjuvant therapy and in advanced disease. However, FDG-PET could be of great value in assessing the response of oesophageal carcinomas to chemo-radio therapy, before surgery. In our experience, FDG-PET appears to be the first line diagnostic method in the detection and staging of colorectal recurrence and differential diagnosis of pancreatic tumour versus chronic pancreatitis.     

Tuberculosis in liver transplant patients

Beta human chorionic gonadotrophin levels have been assessed in blood serum of 79 patients with bladder tumours before and seven days after transurethral electroresection (TUR). With the growth grade of anaplasia and staging the mean serum beta HCG level increased. Beta HCG was a good biological marker to differentiate between superficial and deep tumours.     

The accuracy of staging: an important prognostic determinator in stage I ovarian carcinoma. A multivariate analysis

BACKGROUND: Several prognostic factors for stage I ovarian carcinoma have been analyzed. Some of them are biological and clinical in nature, but others such as the thoroughness of the staging procedure, the extent of the surgery and the philosophy of treatment, are defined by the human element. PATIENTS AND METHODS: We reviewed the records of 351 patients with Stage I ovarian cancer who had been treated from 1981 to 1991. For all patients the following information was available: age, size of the tumor, FIGO sub-stage, tumor grade, histologic type, rupture of the tumor, cytology, extent of the staging and of the surgery (hysterectomy and bilateral salpingo-oophorectomy vs. fertility-conserving surgery) and use of adjuvant treatments. The thoroughness of the staging was defined as: optimal staging: total abdominal hysterectomy and bilateral salpingo-oophorectomy or fertility-conserving surgery, peritoneal cytology or washing, omentectomy, multiple peritoneal biopsies, sampling of the retroperitoneal nodes or formal lymphadenectomy, peritoneal staging: all the criteria described above were met with the exception of retroperitoneal sampling, incomplete staging: lack of any of the previously-cited criteria. RESULTS: An optimal staging was performed in 100 patients, a peritoneal staging in 107 and an incomplete staging in 144. Radical surgery was performed in 295 women and fertility-conserving surgery in 56. With a median follow-up of 108 months (range 14-184) 64 patients had recurrence of the tumor. Fifty-three died of the disease, two are currently alive with disease and nine were salvaged by surgery and/or chemotherapy. In a multivariate analysis only the tumor grade and the type of staging were significant independent prognostic factors for both disease-free and overall survival. CONCLUSIONS: As described by other authors, we confirm that tumor grade is the single most important biological prognostic factor in early ovarian carcinoma. The thoroughness of the staging impacts significantly on survival, particularly in poorly differentiated carcinomas. Fertility-sparing surgery is not associated with a worse outcome than standard radical surgery.     

Malignant tumours of the parotid gland: a 12-year review

Malignant parotid tumours are uncommon and present a significant management challenge. Fifty-one such patients (25 male, 26 female, median age 64 years) operated on in the Newcastle Plastic Surgery Unit between 1983 and 1994 were retrospectively evaluated. Preoperative investigations included FNA cytology (n = 20), and for staging CT and/or MRI scans (n = 21). Of the 35 primary tumours 32 were epithelial and three lymphomatous. Metastatic tumours were squamous cell carcinoma (7), melanoma (6), renal cell carcinoma (2) and sebaceous carcinoma (1). FNA cytology correctly diagnosed malignancy with an 88% sensitivity (false negatives = 2). A total or radical parotidectomy was required in 60% of patients, the rest undergoing superficial parotidectomy. In continuity neck dissection was undertaken in 23 (45%) cases. Postparotidectomy reconstruction included 10 free, 3 myocutaneous, and 4 local transposition/rotation flaps. Thirty-seven patients (73%) received postoperative radiotherapy. Seventy-two per cent of patients are alive after a mean follow-up of 42 months. The crude 5- and 10-year survival rates were 68% and 49% respectively while the loco-regional control rate (Kaplan-Meier method) at 10 years was 79%. Fifteen patients (30%) have permanent facial palsy. It is concluded that radical surgery with appropriate reconstruction followed by planned postoperative adjuvant radiotherapy gives effective control of malignant parotid tumours.     

Prolonged survival follows resection of oesophageal SCC downstaged by prior chemoradiotherapy

BACKGROUND: The poor survival rate of surgically treated patients with oesophageal cancer has not improved substantially over the last 25 years, but combined modality therapy has shown early promising results. METHODS: A prospective study was undertaken to determine the effect of pre-operative synchronous chemoradiotherapy followed by oesophagectomy in 53 patients with squamous cell carcinoma (SCC) of the oesophagus. The patient group was unselected, other than by fitness for surgery. RESULTS: In 25% of patients, complete pathological regression of the tumour was achieved. All but one of the patients in this subgroup had T2 tumours on pre-operative clinical staging and two had evidence of lymph node involvement, but postoperative pathological examination revealed that pre-operative chemoradiotherapy had downstaged their disease to T0N0. There was no hospital mortality in this subgroup and the actuarial 7 year survival was 69%. CONCLUSIONS: For squamous oesophageal tumours deep to the submucosa this is an extremely good survival. For the present, this form of therapy for SCC of the oesophagus appears capable of achieving results comparable to, or better than, those reported for 3-field lymphadenectomy.     

Intrahepatic vein fetal blood sampling: current role in prenatal diagnosis

We present our experience with the use of ultrasonography in the assessment of suspected primary or recurrent bone tumours of the appendicular skeleton and pelvis in 73 patients. Ultrasound can effectively assess the extraosseous component of malignant and aggressive benign lesions and those tumours arising from the surface of the bone. Periosteal reaction, cortical destruction, pathological fracture, matrix mineralization, fluid-fluid levels and involvement of the neurovascular bundle are all identified. Despite this, we could not identify any advantage of ultrasound compared to plain radiography or magnetic resonance imaging in diagnosis and local staging. However, ultrasound was found to be of great value in guiding percutaneous needle biopsy.     

Colorectal hydrosonography in diagnosis of tumorous and inflammatory diseases of the large intestine

PURPOSE: Evaluation as to whether diagnosis of large bowel disease and TNM staging of colorectal carcinoma are possible by colorectal hydrosonography (HUS). METHOD: 52 patients with suspected neoplastic or inflammatory large bowel disease, underwent HUS. Before performing abdominal ultrasound, the colon was filled with fluid. Morphological alterations of the bowel wall were judged benign or malignant. Colorectal carcinomas were classified according to the TNM system. RESULTS: Laparotomy was performed in 46 of 52 patients. Correlation with surgery and histopathology showed that 77% of morphologic alterations of the colonic wall were detected by HUS. While benign lesions of the colonic wall occasionally mimicked malignant disease, colonic carcinomas were reliably diagnosed by HUS, because destruction and invasion of the bowel wall was visible. Carcinomas of the lower part of the rectum, however, were missed in most cases. Accuracy to determine the infiltration depth of colorectal carcinomas was 89%, but hydrosonographic N-staging was unreliable. Inflammatory disease of the large bowel as well as changes complicating the inflammatory bowel disease were accurately diagnosed by HUS. CONCLUSION: In selected patients, colorectal HUS is suited for diagnosis and staging of colonic tumours. It also helps to evaluate inflammatory bowel disease, because small and large bowel can be reliably distinguished from each other and the degree of stenosis of inflamed colonic segments becomes visible. Furthermore, HUS increases the visibility of fistulas.     

Somatostatin receptor scintigraphy of carcinoid tumours using the [111In-DTPA-D-Phe1]-octreotide

Somatostatin-receptor scintigraphy using the 111In-labelled somatostatin-analogue octreotide ([111In-DTPA-D-Phe1]-octreotide) was performed in 40 patients with carcinoid tumours. In 31/40 patients, this scintigraphy proved positive compared with the 33/40 patients whose tumours were disclosed on CT scans. In addition, 18 previously unidentified lesions were detected with this scintigraphy. Two of these lesions represented previously undetectable primary tumours. It is concluded that somatostatin receptor scintigraphy using [111In-DTPA-D-Phe1]-octreotide has a future role in the staging of patients with carcinoid disease.     

Staging and surgery in testicular cancer

Both staging and surgery in testicular cancer are thoroughly analysed. Extensive experiences from various authors are reported and compared. The essentials for staging are suggested and a new detailed stage grouping is proposed. The role of surgery in diagnosis, staging and therapy is examined. It is stressed that in non-seminomas, retroperitoneal lymph node dissection is not only a staging procedure, but it may be also a curative operation in several cases of patients with lymph node metastases and a prospective randomized clinical trial is advocated in order to clarify the usefulness of adjunctive chemotherapy in these cases. Surgery is also useful as adjuvant to chemotherapy in several patients with advanced non-seminomas and it is underlined that it should be undertaken early, after only 2 or 3 cycles of chemotherapy, in order to avoid the strong fibrosis that often occurs after long-term chemotherapy and which makes surgical dissection very difficult or even impossible. Lastly, even if extensive, surgery seems to be a safe procedure in these young patients.     

Adenoacanthoma of the endometrium: a separate entity or a histological curiosity?

In a series of 42 patients with endometrial adenoacanthoma and of 53 with adenocarcinoma, age at the time of diagnosis, age at the onset of the menopause, gravidity, pathological staging, and survival were compared to see if there was any significant difference, apart from morphology, between the two tumours. No significant differences could be established, and it was concluded that adenoacanthoma should be regarded as a histological variant of adenocarcinoma and not as a separate entity.     

Rare pancreatic tumours in children (other than nesidioblastosis)

BACKGROUND: The rarity of pancreatic tumours other than nesidioblastosis in children is such that the experience of any one surgeon or institution is small. As a consequence, there is limited information on the appropriate management and outcome of these tumours. For this reason a review was conducted of the experience of a large paediatric surgical institution. METHODS: During a 23-year period, six patients with pancreatic tumours other than nesidioblastosis were treated at the Royal Children's Hospital, Melbourne. RESULTS: Despite the varied modes of presentation and surgery undertaken, all six patients with surgery alone, with follow-up from 1 to 18 years. Two of the tumours were malignant; the remaining four being islet cell adenomata. No form of adjuvant treatment (chemotherapy or radiotherapy) was used. CONCLUSION: These rare paediatric tumours appear to have a good prognosis, even when malignant, and respond well to radical surgical ablation. Adjuvant therapy appears to be unnecessary.