Idiopathic bilateral adrenal haemorrhage related to acute adrenal insufficiency.

A 54-year-old woman presented with sudden epigastralgia and left back pain. She had no significant history. Laboratory data showed mild inflammation and no liver or renal dysfunction. Abdominal CT showed left adrenal enlargement and haemorrhage. Hydrocortisone therapy was started to prevent adrenal insufficiency before laboratory findings for ACTH (adrenocorticotropic hormone) and cortisol levels. On the second hospital day, abdominal CT showed additional right adrenal enlargement and haemorrhage. The serum cortisol level suggested adrenal insufficiency. No specific findings were detected by bilateral adrenal angiography. 6 to 12 months later, abdominal CT showed decreased bilateral adrenal haemorrhage. This case illustrates the importance of prompt diagnosis and treatment of acute adrenal insufficiency, and shows sequential changes in the size of bilateral adrenal haemorrhage. Rapid corticosteroid replacement is important if acute adrenal insufficiency is suspected. In a case with unilateral adrenal haemorrhage, the possibility of additional adrenal haemorrhage on the opposite side should also be considered.

Effects of direct injection of dehydrated ethanol on PC3 human prostate cancer cells in nude mice: preliminary study.

OBJECTIVES: The effect of direct local injection of dehydrated ethanol on hormone-independent prostatic carcinoma cells (PC3 cells) implanted in nude mice was investigated. METHODS: PC3 tumors were implanted subcutaneously into 30 nude mice. Three weeks later, dehydrated ethanol was injected directly into the tumors. Twenty-three animals received an injection of ethanol at a volume of 40 microL, 80 microL, or 160 microL, and were divided into a low-dose group (n = 11) and a high-dose group (n = 12) on the basis of the ethanol/tumor volume ratio (<30% versus> or =30%). The control group (n = 7) was injected with 40 microL of physiological saline. The tumor volume before treatment was 324.9 +/- 110.9 mm(3) and was assessed as well as 1 day, 4 days, 1 week, 2 weeks, and 3 weeks after injection. Then the changes of tumor volume were compared between the two ethanol groups (low-dose group and high-dose group) and the control group. Histological examination was performed for up to 3 weeks after injection. RESULTS: Assessment of tumor volume showed that the ethanol/tumor volume ratio was 16.1 +/- 5.3% in the low-dose group (n = 5) and 51.8 +/- 20.3% in the high-dose group (n = 6). Tumor growth was significantly inhibited after 1 and 2 weeks in the ethanol groups compared with the control group (n = 3). After 3 weeks, there was a tendency for tumor regrowth in the low-dose group, but growth inhibition was maintained in the high-dose group. Histological examination showed tumor degeneration and necrosis with feeding vessel obstruction in the acute phase. CONCLUSIONS: Local injection of dehydrated ethanol regressed tumors of prostatic carcinoma cells in nude mice, with the degeneration of tumor cells and occlusion of feeding vessels.

[Clinico-pathological investigation of upper urinary tract tumors in patients with normal renal function and in patients with end stage renal disease].

AIMS: To clinically investigate upper urinary tract tumors in end stage renal disease (ESRD) patients. PATIENTS AND METHODS: Between 1988 and 2003, a study was made of 153 patients who underwent surgical treatment for upper urinary tract tumors in the Department of Urology, Tokyo Women's Medical University. Of these, 10 had ESRD while 143 had normal renal function. Comparisons were made of the following variables between the two groups: patient's background, clinical findings, surgical procedures, pathological findings, prognosis, depth of tumor cell invasion, tumor grades, postoperative survival rates, cancer-specific survival rates, and complications. RESULTS: Ten ESRD patients with upper urinary tract tumors were comprised of 5 males and 5 females with a median age of 59 (40-71) years and an average hemodialysis period of 71 (0-279) months. Macroscopic hematuria appeared in seven cases (70%) at the onset, and tumors occurred at the renal pelvis in nine cases (90%). As to the T stage, seven cases (70%) were pT2 or more and all 10 cases (100%) exhibited grade 2 or higher in ESRD patients, yielding no significant differences with the cases of normal renal function. In addition, there was no significant difference in both groups with respect to postoperative survival rates and cancer-specific survival rates in cases with curative resection. CONCLUSION: Although upper urinary tract tumors had been considered to exhibit higher grades and stages of malignancy in ESRD cases than in those with normal renal function, the present results showed that the clinico-pathological features are similar in both patients groups. Given that there was no significant difference in postoperative survival rates and cancer-specific survival rates, radical surgery should be also indicated, if possible, for the ESRD patients with upper urinary tract tumors as well as the patients with normal renal function.

Retroperitoneoscopic adrenalectomy: lateral versus posterior approach.

PURPOSE: We used a lateral or posterior approach to perform retroperitoneoscopic adrenalectomy for adrenal tumors and compared the results to determine which approach is more advantageous. PATIENTS AND METHODS: We removed 42 adrenal tumors from 42 patients by retroperitoneoscopic surgery. We used the posterior approach in 17 cases and the lateral approach in 25 cases. We compared the operating time, complications, and surgical advantages for the two approaches. RESULTS: The mean operating time was significantly shorter with the lateral approach, 141 +/- 64 minutes v 225 +/- 88 minutes for the posterior approach (P = 0.0019), which we believe reflects the technical advantages of the lateral approach. Complications included one case of pneumothorax and an instance of pulmonary edema in a patient with chronic renal failure using the lateral approach and one occurrence each of pneumothorax and bleeding using the posterior approach. Retroperitoneoscopic adrenalectomy could not be performed in 1 of 25 cases (4.0%) using the lateral approach and in 3 of 17 cases (17.6%) using the posterior approach. CONCLUSION: Our series suggests that the lateral approach is preferable to the posterior approach for retroperitoneoscopic adrenalectomy.

Spoke-wheel-like enhancement as an important imaging finding of chromophobe cell renal carcinoma: a retrospective analysis on computed tomography and magnetic resonance imaging studies.

AIM: Little information has been reported with regard to the radiological features of chromophobe cell renal carcinomas (CCRC). The aim of the present study was to identify imaging characteristics which lead to the histological diagnosis of CCRC. METHODS: The imaging findings of computed tomography (CT) and magnetic resonance imaging (MRI) were retrospectively analyzed in 11 patients with CCRC operated on at Tokyo Women's Medical University, Tokyo, Japan. RESULTS: None of the factors studied were significant in distinguishing the two variants, typical and eosinophilic variants. Enhanced CT scans showed a spoke-wheel-like enhancement with a central scar in 3 patients (27%). The radiological patterns were classified into two groups. Seven patients (64%) showed pattern 1 in which: (i) a hypodense to isodense enhancement compared to the renal medulla in the corticomedullary phase during dynamic CT; (ii) an isodense mass compared to the renal medulla in unenhanced CT scan; and (iii) a lobulated appearance were typically observed. Four patients (36%) showed pattern 2 that seemed to be similar to the features of clear cell carcinoma, having an alveolar structure including a hyperdense enhancement in the corticomedullary phase and an inhomogeneous appearance. A spoke-wheel-like enhancement was observed only in patients with pattern 1, and was more clearly demonstrated in larger tumors. CONCLUSIONS: The CT and MRI findings in CCRC patients were not uniform, but it was noted that a spoke-wheel-like enhancement with a central stellate scar, which might have been mistaken for oncocytoma, was one of important findings of CCRC. Tumors demonstrating a spoke-wheel-like enhancement with a central scar should be carefully managed, because they could be malignant.

Impact of arterial occlusion during partial nephrectomy on residual renal function: an evaluation with (99m)technetium-dimercaptosuccinic acid scintigraphy.

BACKGROUND: Partial nephrectomy (PNx) has been performed with temporary renal arterial occlusion and in situ renal hypothermia (conventional PNx). However, the impact of temporary renal arterial occlusion on residual renal function has not been well assessed. To address this question, we performed renal scintigraphy with (99m)technetium-dimercaptosuccinic acid (DMSA) for the quantitative measurement of postoperative residual renal function after conventional PNx and partial nephrectomy without arterial occlusion (non-clamping PNx). METHODS: Thirty-four patients underwent postoperative DMSA scintigraphy after PNx for renal cell carcinoma. No obvious difference in preoperative renal function between the diseased kidney and the contralateral kidney was found in any of the patients. Of these patients, 24 underwent conventional PNx, and 10 underwent non-clamping PNx. Residual renal function was evaluated using the relative DMSA uptake of the operated kidney. RESULTS: The relative DMSA uptake of the operated kidney was 39.9 +/- 7.3% (25.1-58.8) after conventional PNx compared to 34.8 +/- 8.9% (13.5-45.5) after non-clamping PNx. This difference was not statistically significant (P = 0.15). Total ischemic time during conventional PNx had no adverse influence on the residual renal function. In the analysis of the other determinant factors influencing residual renal function, tumor size was the only significant factor that inversely correlated with the relative DMSA uptake. CONCLUSION: Our results showed that arterial clamping during PNx has no negative impact on the functional residual capacity as long as insitu renal hypothermia is adequately performed.

Nephron-sparing tumorectomy for a large benign renal mass: a case of massive bilateral renal angiomyolipomas associated with tuberous sclerosis.

A case of massive bilateral angiomyolipomas (AML) associated with tuberous sclerosis in a 33-year-old woman is reported. She was hospitalized because she had been experiencing abdominal fullness and epigastralgia. Several imaging studies revealed massive bilateral renal tumors and she was diagnosed as having renal AML associated with tuberous sclerosis. Left nephrectomy was carried out after renal arterial embolization for intratumor hemorrhage. Two years after left nephrectomy, nephron-sparing surgery (tumorectomy) for right AML was done because of an increase in the size of the right renal AML and she hoped for a future pregnancy. The left kidney with AML weighed 5700 g and the right AML weighed 1700 g. Postoperative serous creatinine did not differ from that before operation and an increase in the size of the residual tumor was not observed 8 months after operation. We consider that tumorectomy is an effective therapy in patients with a very large tumor involving a solitary kidney.