Management of synchronous renal cell carcinoma and aortic disease.

BACKGROUND: We have noted a significant incidence of renal cell carcinoma (RCC) detected during evaluation for aneurysmal and aortoiliac occlusive disease. The approach to synchronous malignancy and aortic disease (staged versus concurrent resection) is controversial, as is the management of incidental RCC (partial versus radical nephrectomy). PATIENTS AND METHODS: We reviewed our experience with incidental RCC in patients undergoing aortic reconstruction between 1991 and 1994. Ninety-seven patients underwent aortic reconstruction for aneurysmal (72), occlusive (20), or embolic disease (5) during the time frame under review. All were men. Of the 80 preoperative computerized tomographic (CT) scans obtained, 7 (9%) demonstrated renal lesions suspicious for RCC. All lesions were explored and excised by partial or radical nephrectomy before heparinization and completion of the planned aortic procedure. RESULTS: The overall mortality rate was 3%. None of the deaths occurred in patients undergoing combined procedures. Four partial and three radical nephrectomies were performed. Of the 7 renal lesions, 2 were complex cysts and 5 were RCC. Both patients with complex cysts were treated with wedge resection. One patient required surgical drainage of a wound abscess after partial nephrectomy. No significant differences were found between preoperative (1.4 +/- 0.1 mg/dL) and postoperative (1.8 +/- 0.2 mg/dL) creatinine levels following combined procedures. On follow-up CT scans done at 6-month intervals (mean follow-up 24 months), no evidence exists of recurrence, metastasis, or graft infection. CONCLUSIONS: This patient population demonstrated an unexpectedly high prevalence of incidental RCC (5 or 80 CTs, 6%). No increase in mortality was found when RCC and aortic disease were treated at the same operation. While partial nephrectomy was associated with one wound infection in this series, it is an effective treatment for small incidental RCC and may avoid unnecessary nephrectomy in patients with benign disease. Base on the high incidence of RCC in this population, we recommend exploration of all suspicious lesions. Nephrectomy can be performed safely in the same setting as aortic reconstruction. Because underlying renal dysfunction is not uncommon in patients with aneurysmal and aortoiliac occlusive disease, nephron-sparing surgery should be considered.

Influence of end-stage renal disease and renal transplantation on serum prostate-specific antigen.

OBJECTIVE: To evaluate the effect of dialysis and kidney transplantation on serum prostate-specific antigen (PSA) levels, and to compare these results with those from normal age-matched controls. In addition, to evaluate the efficacy of PSA and digital rectal examination (DRE) for detection of prostate cancer in patients on dialysis and following kidney transplantation. PATIENTS AND METHODS: Between January 1990 and July 1993 all men in the transplant programme over the age of 40 years who were undergoing pre-transplant evaluation or post-transplant follow-up underwent a yearly DRE and PSA evaluation. Twelve patients were evaluated pre-transplant and 70 patients were evaluated post-transplant. A total of 136 PSA levels were obtained (1.7 per patient). Patients with suspicious findings underwent further evaluation with transrectal ultrasound and biopsies if indicated. Controls were patients without known prostate cancer who had been evaluated in a Prostate Cancer Awareness Clinic. RESULTS: The average PSA values in the study groups were unaffected by either dialysis or transplantation when compared with age-matched controls. In addition, 12 patients who had been on dialysis at the time of their initial evaluation and who subsequently underwent transplantation did not show any difference in their average PSA values pre- or post-transplant. Three patients (4%) were found to have prostate cancer and two underwent radical retropubic prostatectomy. They are free of disease 24 and 36 months post-operatively and neither has experienced any decline in renal function. Immunosuppression was not modified. CONCLUSION: Transplantation and dialytic therapy do not appear to affect clinical serum PSA levels. PSA and DRE appear to be equally valid for detection of prostate cancer in patients on dialysis and post-transplant when compared with the general population. Finally, radical prostatectomy appears to be a safe and feasible treatment option in this group of patients.

Expression of insulin-like growth factor I (IGF-I) in nevi and melanomas.

Expression of IGF-I mRNA and protein was evaluated in pigmented lesions by in situ hybridization and immunohistochemistry. An IGF-I cDNA clone (phigf1) was subcloned into pBluescript KS II-. Both sense and antisense 35S riboprobes were prepared and used for in situ hybridization on formalin-fixed, paraffin-embedded specimens. Control hybridizations with a beta-actin probe were also performed. Grains were counted in 787-microns2 melanocytic areas of sections hybridized with the antisense IGF-I probe. Seven common nevi contained a mean of 218 grains; nine dysplastic nevi, a mean of 463 grains; eight early primary melanomas, a mean of 402 grains; five advanced primary melanomas, a mean of 217 grains; and nine metastatic melanomas, a mean of 194 grains. The differences between common and dysplastic nevus, common nevus and early melanoma, early and advanced primary melanoma, and early primary melanoma and metastatic melanoma were statistically significant. Keratinocytes also expressed abundant IGF-I message. IGF-I protein was demonstrable by immunohistochemistry in melanocytes and keratinocytes. These results suggest that progression-associated variation occurs in the net expression of IGF-I mRNA in melanocytic tumors.

Immunohistochemical localization of cytokines in nevi.

Eight common nevi and 11 dysplastic nevi were evaluated for the presence of basic fibroblast growth factor, platelet-derived growth factor, transforming growth factor-alpha, interleukin-1-alpha, and interleukin-1-beta by immunohistochemical labelling with highly specific monoclonal antibodies. Basic fibroblast growth factor was abundant in the nevus cells and keratinocytes of nevi. Dysplastic nevus cells on average stained less intensely for basic fibroblast growth factor than did common nevus cells. In both types of nevi, basic fibroblast growth factor was identified in the basement membranes at the dermoepidermal junction and surrounding nevus cell nests and individual nevus cells. Labelling of nevus cells for transforming growth factor-alpha was variable, while there was moderate labelling for platelet-derived growth factor and light labelling for interleukin-1-alpha. Only two nevi, both dysplastic, stained (very faintly) for interleukin-1-beta. It is possible that these cytokines, especially basic fibroblast growth factor, act in autocrine fashion to maintain nevocellular growth and may also contribute to the epidermal hyperplasia and fibrosis frequently observed in nevi.