Delayed Cytoreductive Nephrectomy Following Three Years of Targeted Therapy for Metastatic Renal Cell Carcinoma.

We present a 55-year-old male, with good performance status who was diagnosed with a case of metastatic renal cell carcinoma following a pathologic femur fracture. Despite good performance status, multifocal metastases and poor-prognostic features portended a grim prognosis with predicted overall survival of less than nine months. On initial presentation, he was excluded from cytoreductive nephrectomy based on brain metastasis and interleukin-2 was not pursued as the primary tumor was to be left in situ. The patient was reconsidered for cytoreductive nephrectomy after sustained response to fifth line targeted therapies with shrinkage of tumor burden. The post-operative course was uneventful and the patient was discharged home on postoperative day one. Temsirolimus was resumed one week after surgery and the patient reported returning to his normal activities at the two week follow-up visit. We highlight important clinical features of metastatic renal cell carcinoma, the surgical considerations for cytoreductive nephrectomy and the detailed multidisciplinary care the patient received throughout this case report.

Hepatocellular proliferation and changes in microarchitecture of right lobe allografts in adult transplant recipients.

Imaging studies show complete restoration of liver volume in adult recipients of right lobe allografts within 2-3 weeks of living donor transplantation (LDLT). However, it is not known if this growth is associated with restoration of hepatic microarchitecture. We compared 21 biopsies without significant pathology from LDLT recipients with 23 biopsies from adult recipients of cadaveric donor liver transplantation (CDLT) performed within 3 months of transplantation. The difference in the number of portal tracts per cm was statistically significant (P < .0001) between CDLT (9.08 +/- 1.74) and LDLT recipients within 3 months (6.26 +/- 1.62), as well as after 3 months following transplantation (6.56 +/- 1.44). The coefficient of correlation between length of biopsy specimens and the number of portal tracts in these 3 groups was .94, .93, and .85, respectively. Proliferative activity demonstrated by immunohistochemical staining for MIB-1 was seen predominantly in hepatocytes in both groups; bile ducts only occasionally stained positive. The difference between labeling indices of hepatocytes was statistically significant (P = .00056) between CDLT and LDLT recipients within 3 months of transplantation (.82 +/- .63 and 4.53 +/- 3.72), and between LDLT recipients within 3 weeks and after 3 weeks of transplantation (5.97 +/- 3.78 and 1.80 +/- 1.37, P = .0074). In conclusion, restoration of liver volume following LDLT occurs by proliferation of hepatocytes in the immediate posttransplant period. There is a decrease in number of portal tracts in these volume-restored allografts. Volume restoration is therefore, not accompanied by restoration of hepatic microarchitecture.

Unresectable squamous cell carcinoma of donor origin treated with immunosuppression withdrawal and liver retransplantation.

Posttransplantation allograft malignancy of donor origin is a rare complication after liver transplantation. In the case described, subjective fevers and nonspecific abdominal complaints nearly 6 months following cadaveric liver transplantation in a young woman prompted an evaluation which was remarkable for a large central liver mass. A poorly differentiated squamous cell carcinoma was diagnosed, but was unresectable at exploration. The tumor was confined to the liver. Histocompatibility testing using polymerase chain reaction (PCR) amplification techniques identified both donor and recipient HLA alleles. The patient was treated with chemoembolization, systemic chemotherapy and cessation of immunosuppression. Repeat biopsy 2 months later showed the tumor to be completely necrotic. With decompensated liver disease, she was relisted and retransplanted. More than 2 years later she remains disease-free with complete pathological remission. This is the only reported case of squamous cell carcinoma of donor origin arising in a transplanted liver.

Imprint cytology of metastatic sialoblastoma. A case report.

BACKGROUND: Sialoblastoma is a rare, aggressive and potentially malignant perinatal/congenital tumor that recapitulates the developing salivary gland. There is only 1 brief description of the cytologic findings of metastatic sialoblastoma and 1 poorly documented case of lung metastasis in the literature. CASE: A 75-month-old girl with a history of recurrent sialoblastoma initially diagnosed at 21 months and treated with multiple incomplete surgical excisions, chemotherapy and radiation presented with a solitary lung nodule. Imprint smears and frozen section of the mass were diagnostic of metastatic sialoblastoma. CONCLUSION: Cytologic features of sialoblastoma showed complete concordance with histology and included the presence of variably arranged, tight, solid clusters of atypical-appearing, basaloidlike cells in a background of dispersed epithelial and myoepithelial cells. The clusters contained admixed benign ductal cells and dense, metachromatic, magenta hyaline globular material with smooth, rounded outlines. The differential diagnoses include neoplasms composed of either basaloid cells and/or admixed hyaline matrix material and included pleomorphic adenoma, basal cell adenoma and adenoid cystic carcinoma. All these neoplasms affect patients in the first 2 years of life, whereas sialoblastoma usually occurs in the first 2 decades of life.

Venous hemodynamics in living donor right lobe liver transplantation.

We evaluated the influence of portal and hepatic venous hemodynamics on the immediate and 3-month postoperative function of living donor right lobe grafts. Portal velocity was measured prospectively by ultrasound in 14 consecutive donor/recipient pairs. Velocity was converted to flow with the Moriyasu formula. Measurements were taken in donors in the operating room and in recipients at 1 hour after reperfusion and 3 months after transplant. Recipient liver function tests were measured postoperatively. Prereperfusion and postreperfusion liver biopsies were evaluated and correlated with the hemodynamic and biochemical results. There were 11 male (78.6%) and 3 female donors (mean age, 38.9 +/- 9.8 years) for 10 male (71.4%) and 4 female recipients (mean age, 49.3 +/- 14 years). The mean graft/recipient weight ratio was 1.22 +/- 0.3. The mean right portal vein pressure was 8 +/- 1.8 mm Hg in donors versus 13 +/- 4.7 mm Hg in recipients (P < .05). The mean peak flow velocity (Vmax) in the portal vein in donors was 47.6 +/- 12.8 cm/sec (normal, 44 cm/sec). One hour after graft reperfusion in the recipient, the mean portal Vmax was significantly higher at 94.7 +/- 28.4 cm/sec (P = .004), but by 3 months follow-up, mean portal Vmax had fallen to 58.8 +/- 37.8 (P = .01). Recipient portal vein Vmax highly correlated with portal flow (r = 0.7, P = .01). Increased recipient total bilirubin on postoperative day 2 correlated highly with higher recipient portal flow one hour after transplant (r = 0.6; P =.03). Portal vein velocity/flow dramatically increases after reperfusion, returning to baseline about 3 months after transplant. Evaluation of hepatic and portal venous flow is a relatively easy skill to acquire. Intraoperative ultrasound may enable the surgeon to predict graft dysfunction and possibly, may be used to implement pre-emptive therapies.