[ENT expert assessment for federal health insurance in North Rhine. A contribution to the internal discussion of quantitative and qualitative optimization of the expert witness process]. / HNO-Begutachtung im MDK Nordrhein. Ein Beitrag zur internen Diskussion über die quantitative und qualitative Optimierung eines Begutachtungsprozesses.

Contribution to an Internal Discussion on Quantitative and Qualitative Optimisation of Expertising Procedures: The medical advisory and expertising Services of the German statutory sickness insurance are according to German social legislation authorised to request supporting documents direct from the treating physicians or hospitals. The consultant medical expertiser for ENT diseases at Cologne worked out the percentage of requests that resulted in "further investigations" and the amount of work involved. A document form was used to record all such requests for a given period. 154 expertising procedures concerning ENT diseases were counted within a period of 5 weeks. 47% of the patients concerned pertained to workers' sickness insurance funds and 29% to guilds sickness insurance funds. Two thirds of all requests were channelled through the statutory sociomedical preconsultant service and one-third were sent by post. 55% of all the requested documents were considered to be "complete" and 45% "incomplete". N = 100 requests were initial and N = 54 were follow-up requests. The answers received were considered satisfactory and final in 62% of the requests, whereas "further inquiries" were considered necessary in n = 58 (38%) of the cases. 80% of the cases in which the requests resulted in satisfactory information, were approved for sickness insurance payment and approximately 20% were rejected. The average period of time that elapsed between a request for more information and the reply and the final expertising given to and passed on to the patient by the statutory insurance body was 2 weeks. In cases where "further inquiries" are considered necessary, three additional working days are usually required in the Cologne ENT diseases area. If the statutory sociomedical preconsultant service procedure could be intensified, this would result in better channelling of requests by the ENT medical and advisory service of the stautory sickness insurance bodies. A more pronounced examination by the statutory sociomedical preconsultant service could minimise the need for additional requests, follow-ups and "further inquiries" and could increase the speed of completion of approved or rejected insurance cases from 14 days to at the most one day or even 0 days. This pilot study was conducted to encourage the local bodies to optimise their work. In the long run good quality of work, patient satifaction and patients' job security will result and will be the corner-stones of modern quality assurance and quality management in North-Rhine Westphalian medical expertising and consultant services in association with the relevant statutory sickness insurance bodies.

Isolated echinococcal cyst of the kidney. Case report and review of the literature.

We report an isolated echinococcal cyst of the kidney as a rare extrahepatic manifestation of the parasitic infestation. The pathogenesis, problems of diagnosis and treatment of renal hydatid disease are reviewed and discussed.

Maximal displacement of the ureter by a liposarcoma.

We describe a patient with displacement of both ureters to the right side caused by a liposarcoma. The left ureter was displaced beyond the right ureter. The risk of intraoperative trauma to the ureter could be minimized by preoperative placement of ureteral stents.

Laparoscopic varicocelectomy: indication, technique and surgical results.

OBJECTIVE: To assess the efficacy of laparoscopic techniques for the operative therapy of varicocele. PATIENTS AND METHODS: Fifty-one patients who underwent laparoscopic varicocelectomy due to subfertility and/or pain between June 1992 and December 1994 were evaluated. RESULTS: In all patients, except one with a remaining slight reflux on post-operative Valsalva's manoeuvre, operative therapy was effective and no major complications occurred. The procedure was minimally invasive, effective and, because the anatomy was readily seen, multiple veins and/or collaterals were easily assessed and the surgery precise. CONCLUSION: The laparoscopic technique is an efficient, minimally invasive operation with optimal results. After a brief period of training the operation can be performed in 15-30 min and is therefore no longer than embolization techniques. Treatment of both sides in one session was not a problem.

Is the transplant-preserving management of renal allograft rupture justified?

OBJECTIVE: To evaluate the transplant-preserving management of renal allograft rupture. PATIENTS AND METHODS: From April 1982 to January 1994 a total of 238 renal transplantations were performed on 227 patients. Eight cases (3.5%) of renal allograft rupture occurred. Transplant nephrectomy was necessary in one patient. Seven patients were surgically treated with collagen foam, fibrin glue and vicryl mesh. RESULTS: In all seven cases treated conservatively, renal salvage and satisfactory graft function was achieved. After a mean follow-up of 52.9 months (range 2-94) the mean creatinine level was 15.6 mg/L (range 11-21). Of these seven patients with renal allograft rupture one returned to haemodialysis 22 months after transplantation and had several episodes of rejection. Almost 4.5 years after renal allograft rupture, the creatinine value in six of the seven patients was only slightly higher than the mean creatinine values of all donor kidney recipients (14.4 +/- 5.5 mg/L). CONCLUSION: There should be an attempt to salvage the transplant after allograft rupture in all cases. Using these transplant-preserving techniques, renal function could be achieved for all patients with allograft rupture.

Antiproliferative effects of four different cytokines on renal carcinoma cell lines.

The effect of alpha-Interferon (alpha-IFN), gamma-interferon (gamma-IFN), tumor necrosis factor alpha (TNF-alpha) and interleukin-2 (Il-2) on growth of two renal cancer cell lines (DNT-11, HTB-44) was studied. Cell proliferation was measured by a tetrazolium based microculture assay (MTT) after incubation of tumor cells with different concentrations of these 4 cytokines over 72 hours. TNF-alpha showed no antiproliferative effect when cell line DNT-11 was tested, even at high concentrations of 1.000 ng/ml. Proliferation of the other cell line (HTB-44) was only slightly reduced (15%) at 100 ng/ml; a tenfold increase of TNF concentration could not improve these results. The antiproliferative effect of alpha-IFN was in the range of 22-26%. When gamma-IFN was used, both cell lines showed reduction of proliferation between 26% and 37%, respectively. Kinetic studies revealed that prolongation of incubation time for more than 72 hours was not able to improve these results. Il-2 did not influence cell proliferation of either cell line tested, even at high concentrations, as expected.

Hla-dr expression in tumor-tissue and cell-lines of renal-cell carcinoma.

The expression of MHC class II antigens in renal cell carcinoma may be important for the response to interleukin-2 based immunotherapy. Therefore, we determined the HLA-DR expression in 50 primary tumors, in 45 specimens of non-transformed renal tissue of tumor bearing kidneys and in two newly established cell lines (DNT-11 and DNT-63) derived from metastases by indirect immunofluorescence. The systematic examination of the adjacent normal kidney for the expression of HLA-DR revealed that 33 (73%) specimens were positive, 12 (27%) intermediate, however no negative results were obtained. Of 50 tumor specimens 24 (48%) were regarded as positive and 26 (52%) as negative. There was no correlation between HLA-DR expression and tumor stage or grading, respectively. Both cell lines were HLA-DR negative over a time period of 4 years.

[Value of computerized tomography in detection of lymph node metastases in bladder cancer]. / Die Bedeutung des Computertomogramms zur Erfassung von Lymphknotenmetastasen beim Harnblasenkarzinom.

The accuracy of computed tomography (CT) in staging of pelvic lymph nodes in bladder cancer was investigated in 50 patients. All patients underwent pelvic lymph node dissection and cystectomy. The results of preoperative CT findings were compared with the histopathological findings in the dissected lymph nodes. Normal lymph nodes free of tumour cells were found in 32 patients. In 6 patients, single lymph node involvement was detected, while in 12 patients two or more lymph nodes were found to be positive for tumour infiltration. CT results were confirmed in 38 patients (76%). Specificity of CT was 100%, but the sensitivity of this method was only 33%. Based on these results, it appears that CT evaluation of pelvic lymph nodes in bladder cancer patients should have only a limited impact on decision making in patient management.

Immunohistochemical studies on the expression of HLA class I antigens in renal cell carcinoma: comparison of primary and metastatic tumor tissue.

HLA class I expression was studied in 43 specimens of normal renal tissue, 48 primary renal cell carcinomas (RCCs), and 12 metastases by immunofluorescence, using two different monoclonal antibodies (MoAbs; IOT2c, W6/32). Homogenous staining of all normal renal tissues was observed, as expected. From the panel of 48 renal tumors, 40 had a strong expression of HLA class I antigens when tested with both MoAbs, 7 tumors had only weak expression of HLA class I and were regarded as 'HLA class I negative', and 1 tumor showed homogenous staining when tested with one MoAb (IOT2c) but was negative when the other was used (W6/32). This was the only case in which different results with the two MoAbs were found. Reduced expression of HLA class I antigens was observed in 5/12 metastases, and in 1 metastasis no expression of HLA class I could be seen. The staining chartacteristics of 10 metastases in comparison with the respective primary tumors were as follows: same HLA class I score 7/10; loss of HLA class I 3/10; gain of HLA class I 0/10. In RCC, a complete loss of HLA class I expression is a rare phenomena, which was observed in 0/48 primary tumors and in 1/12 metastases. Reduced expression of HLA class I antigens occurs in about 15% of primary tumors but is more frequent (50%) in metastases; however, if this is relevant for cytotoxicity by T lymphocytes is unknown.

Cell surface expression and serum levels of intercellular adhesion molecule-1 in renal cell carcinoma.

Intercellular adhesion molecule-1 (ICAM-1) is the natural ligand of the T-lymphocyte adhesion molecule LFA-1 (lymphocyte-function-associated antigen-1). ICAM-1 is involved in target cell recognition by T-lymphocytes, LAK cells and natural killer cells. The molecule has also been detected on a variety of normal cells and on human tumors. Renal cell carcinoma (RCC) is one of the few tumors that respond to immunotherapy, but clinical results are generally disappointing. We therefore analyzed, by immunohistochemistry, the expression of ICAM-1 in pairs of normal kidneys, RCC, and RCC metastases. Moreover, serum ICAM-1 was determined in RCC patients and compared with surface expression of cell-bound ICAM-1. Strong glomerular expression of ICAM-1 was observed in all specimens of normal kidney examined. Proximal tubuli were weakly stained in the majority of specimens. Of the tumors, 80% stained positive for ICAM-1. Although ICAM-1 was detected on the majority of extrarenal tumor specimens examined, staining was generally weaker in the metastases. Patients without metastases at initial presentation more frequently expressed ICAM-1 in their primary tumors than did patients with metastases. Levels of serum ICAM-1 (sICAM-1) were significantly higher in RCC patients than in controls with non-malignant renal diseases. Patients with an unfavorable prognosis, e.g. with advanced tumor stage or metastasis at initial presentation, had higher levels of sICAM-1 than patients with low-grade and/or low-stage tumors.(ABSTRACT TRUNCATED AT 250 WORDS)

Establishment and characterization of two new human renal cancer cell lines (DNT-11 and DNT-63) derived from metastases.

Two new human cell lines (DNT-11 and DNT-63) derived from renal cell carcinoma metastases were established and characterized. They have been passaged up to 50 times in vitro for more than 4 years. Each line has an epithelial morphology. Cell cycle time of DNT-11 and DNT-63 was 60 hours and 48 hours, respectively. Both cell lines expressed HLA class I antigens, but were found to be negative for HLA class II. DNT-11 and DNT-63 had a hyperdiploid DNA content. They exhibited anchorage independent growth, and the plating efficiency of DNT-11 and DNT-63 was 0.85% and 1.65%, respectively. These two cell lines may provide a useful tool for studying the biology and immunology of metastatic renal cell carcinoma.

Detection of endogenous receptors for carbohydrate ligands in primary and metastatic human renal cell carcinoma.

Frozen sections of primary and metastatic human renal cell carcinoma (RCC) were analyzed for the expression of endogenous binding sites for carbohydrates. Fluorescent neoglycoproteins, carrying chemically linked carbohydrate residues on bovine serum albumin as a carrier protein, were applied to 44 primary tumor specimens. In the majority of specimens, accessible binding sites with specificity for maltose and N-acetylgalactosamine were detected. In specimens of normal kidney no specific binding of carbohydrate ligands was observed under these experimental conditions. Specimens of both the primary tumor and a metastasis were available in 10 cases. When the expression of specific binding sites of primary tumors and metastases was compared, the respective patterns were similar with no clear gain or loss of certain lectins in the metastases. We conclude that binding sites with specificity for maltose and N-acetylgalactosamine are present on human RCC and their corresponding metastases.

Late metastases in seminoma: incidence, localization, and therapeutic implications.

Late metastases of seminoma testis were found in 2 patients thirty and nine years after orchiectomy and radiotherapy. Metastases involved retroperitoneal lymph nodes and lung in 1 case and obstruction of the sigmoid colon and left ureter in the other. Cases of late, atypically localized metastases of seminoma described in the literature are reviewed. Therapy includes surgical removal of the metastases, radiation therapy, and systemic chemotherapy. Therapeutic considerations must include toxicity of preceding radiotherapy.

Expression of HLA class-I antigens on renal cell carcinoma and non-transformed renal tissue.

To determine the HLA class-I antigen expression in renal cell carcinoma, the expression of beta-2-microglobulin (beta 2-m) was analyzed. 20 renal tumor specimens and 20 normal renal tissues were examined for beta 2-m expression by immunofluorescence. Homogenous staining of all normal renal tissues was observed, as expected. From the panel of 20 tumors, 17 also had a strong expression of beta 2-m. Furthermore, two newly established renal cancer cell lines exhibited a normal distribution of beta 2-m at two different passages. From these results we conclude that in most cases malignant transformation in renal cancer is not associated with a loss of HLA class-I antigens. This could be a favorable explanation for the restricted results of interferon-gamma in renal cell carcinoma, the main function of which is probably to enhance major histocompatibility complex class-I expression.