Impact of imaging and thrombus level in management of renal cell carcinoma extending to veins.

OBJECTIVES: To evaluate the role of newer imaging modalities in the diagnosis and evaluation of management according to extent of renal vein (RV) or inferior vena cava (IVC) thrombi in patients with renal cell carcinoma. MATERIAL AND METHODS: Fifty-nine patients with renal cell carcinoma and tumor thrombus extension into the RV or IVC were studied. Diagnosis was based on contrast-enhanced CT, magnetic resonance imaging or color-Doppler ultrasonography. Surgical treatment was contemplated in 42 suitable patients and complete resection could be done in all but 3 cases. RESULTS: There were 48 males and 11 females with mean age of 51.8 years. Isolated RV involvement was seen in 27 cases whereas IVC extension was present in 32 cases. The thrombus extent was infrahepatic in 62.5% (20/32) patients with IVC extension. With the newer imaging modalities like contrast-enhanced CT, color-Doppler ultrasound and/or magnetic resonance imaging, correct diagnosis of the extent of the thrombus was possible in 95% of the patients. The accuracy of color-Doppler ultrasound was same as magnetic resonance imaging in the evaluation of the extent of the thrombus. In the present series a median follow-up of 4 years revealed a high incidence of local and distant recurrences and decreased survival in patients presenting with advanced disease, who had venous wall invasion. CONCLUSIONS: The extent of RV or IVC thrombi can be accurately diagnosed with contrast-enhanced CT scan and in case of doubt color-Doppler ultrasound is a good alternative to magnetic resonance imaging. Management can be planned according to the level of the tumor thrombus. Invasion of the venous wall was found to be a bad prognostic factor affecting survival.

Prognostic significance of p53 nuclear overexpression in patients of muscle invasive urinary bladder carcinoma treated with cystectomy.

INTRODUCTION: The objective of the study was to determine the pattern of p53 expression in patients with muscle invasive bladder cancer treated with cystectomy and to assess the prognostic value of p53 expression in this group of patients. MATERIALS AND METHODS: We retrospectively analyzed data of 100 patients who underwent cystectomy for invasive transitional cell carcinoma of the urinary bladder. These patients were seen at 3-monthly intervals during the first 2 years, 6-monthly in the third year, and yearly thereafter. Immunohistochemical analysis for p53 was done on paraffin-fixed tissues with DO-7 antibodies. The tumours with >30% cells staining for p53 proteins were considered p53 positive. RESULTS: There were 95 males and 5 females with a mean age of 54 years. Two patients died in the perioperative period and were excluded from analysis. Over a median follow-up period of 2 years (range 3 months to 10 years) 62 patients are alive without disease while 36 had relapse and of these, 31 have died. The p53 expression was significantly related to stage and grade of the tumour. p53-negative tumours were more likely to be organ confined and of lower grade as compared to p53-positive tumours. The stage of tumour was significantly related to outcome but grade and p53 immunohistochemistry did not provide any prognostic information. CONCLUSIONS: p53 immunostaining was positive in 57% of muscle invasive urinary bladder tumours. The p53 positivity correlated well with the stage and grade of the disease, whereas it has no additional prognostic value.

Fertility preserving radical cystectomy in a young female with malignant mesenchymal tumour of urinary bladder.

Fertility preserving radical cystectomy has been reported in young males with leiomyosarcoma and transitional cell carcinoma but not in females. We present a case of 19-year-old lady with mesenchymal tumour of urinary bladder with myogenic differentiation who was managed with fertility preserving radical cystectomy. As the patient was just 19-year-old a consensus was made to preserve the internal genitalia (both the ovaries and uterus) in order to restore the fertility. Immunohistochemistry was compatible with mesenchymal tumour with myogenic differentiation. Adjuvant chemotherapy (Ifosfamide, CDDP and Etocid) was given. Patient is doing well at a follow-up of 6 months.

Is there a need for pelvic CT scan in cases of renal cell carcinoma?

OBJECTIVES: To determine the necessity of pelvic computed tomography (CT) in patients of renal cell carcinoma (RCC). MATERIALS AND METHODS: We reviewed the records of 400 patients of RCC, who underwent treatment at our institution between January 1988 and February 2001. These patients were evaluated pre-operatively with ultrasonograms (USG) and contrast enhanced CT scan of the abdomen and pelvis. USG or CT scans of these cases were reviewed for presence of pathology in the pelvis, which were classified into 3 categories viz; benign and likely to be insignificant, benign and likely to be significant; and malignant. RESULTS: Of the 400 cases, 114 were stage I, 68 were stage II, 99 were stage III and 119 were stage IV. In all patients, tumour was identified in the kidney on preoperative CT scan. Fourteen patients (3.5%) had an abnormality on pelvic CT. Five (1.25%) had category 1, three (0.75%) had category 2 and six (1.5%) had category 3 abnormality on pelvic CT. However, all these abnormalities in pelvis were detected prior to CT by other investigations (USG or plain x-ray). Of the six cases with malignant findings, two had superficial bladder cancer, one had RCC in a pelvic kidney and three had bone metastases in the pelvis. CONCLUSIONS: Pelvic CT does not offer additional information in the vast majority of cases with RCC and should be performed selectively. Thus the cost of diagnostic imaging in RCC can be reduced.

Post-ESWL, clinically insignificant residual stones: reality or myth?

OBJECTIVES: To assess the significance of asymptomatic residual stone fragments of less than 4 mm (clinically insignificant residual fragments [CIRFs]) after extracorporeal shock wave lithotripsy (ESWL). METHODS: Eighty-one patients were followed up for 6 to 60 months (mean 15) after ESWL to determine the fate of the CIRFs. RESULTS: Of the 81 patients, 6 were lost to follow-up, leaving 75 patients. During follow-up, fragments passed spontaneously in 18 patients, remained stable in 13 patients, and became clinically significant in 44 patients who developed one or more complications. For the latter patients, repeated ESWL was done in 16, percutaneous nephrolithotomy in 3, and ureteroscopic stone removal in 4 patients. The remaining 21 patients were treated conservatively with analgesics. We found that 53% of the CIRFs located in the pelvis passed spontaneously, and most of the CIRFs in caliceal location became clinically significant. Also, as the stone burden and number of stone fragments increased, the risk of CIRFs becoming clinically significant increased. The outcome was the same whether a metabolic abnormality was present or not, provided the patient received appropriate treatment. The clearance rate was highest in the first 6 months. Finally, as the duration of follow-up increased, the rate of complications increased. CONCLUSIONS: Patients with residual stones after ESWL require close follow-up and timely adjuvant therapy. As the number and size of residual fragments increased, the risk of complications increased. A pelvic location was a favorable factor for spontaneous passage. Metabolic defects, if treated adequately, did not increase the regrowth rate. Although the complete clearance rate of CIRFs with repeated ESWL was lower than for the operative interventions, most patients improved with this modality.

Peyronie's disease: an unusual presentation with butterfly shaped calcified plaques.

Peyronie's disease is characterized by the formation of a fibrotic plaque in the tunica albugenia of the penis. Two patients with calcified butterfly shaped plaques involving the ventrolateral aspect of the penis are described. These patients were managed by plaque excision and dermal grafting with excellent post-operative results.