Renal cell carcinoma: evaluation of the 1997 TNM system and recommendations for follow-up after surgery.

OBJECTIVE: We evaluated the tumor recurrence pattern after radical or nephron-sparing surgery for localized renal cell carcinoma. Based on this pattern, we suggest a surveillance protocol after surgery. METHODS: The outcome of 200 consecutive patients with localized renal cell carcinoma (RCC) that were operated on between January 1982 and December 1997 was evaluated retrospectively. Radical nephrectomy was performed in 155 patients (77.5%), and nephron-sparing surgery in 45 patients (22.5%). The timing and site of disease recurrence were correlated with parameters of the primary tumor. RESULTS: One hundred and twenty-four patients (62%) had pathological stage T1, 26 (13%) had stage T2, and 50 (25%) had stage T3 (41 stage T3a, 8 stage T3b, and 1 stage T3c). The mean follow-up was 47 months (range 6--169 months). Four patients (3.2%) with stage T1, 6 patients (23%) with T2, and 13 patients (26%) with T3 developed recurrent disease. None of the patients with a stage T1 tumor, smaller than 4 cm, had tumor recurrence. There were no recurrences after nephron-sparing surgery compared to 23 recurrences (14.8%) among patients after radical nephrectomy (p = 0.01). Only 1 patient who underwent pulmonary lobectomy for asymptomatic metastases smaller than 2.5 cm, found by routine chest CT, attained long-term survival. CONCLUSIONS: The prognosis of patients after radical nephrectomy for renal cell carcinoma, smaller than 4 cm, is excellent and they do not need radiological follow-up. Patients with larger T1 tumors, 4--7 cm in diameter, or a higher stage should be followed with CT of the chest and abdomen done every 6 months for 5 years and then annually. Following partial nephrectomy of small renal tumors periodic renal ultrasonography should be done to rule out local recurrence in the operated kidney.

Preoperative thallium scanning, selective coronary revascularization, and long-term survival after carotid endarterectomy.

BACKGROUND AND PURPOSE: Long-term survival in patients after carotid endarterectomy (CEA) is determined mainly by their concomitant cardiac disease. We tested to determine whether preoperative thallium scanning (PTS) and subsequent selective coronary revascularization (CR), by either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG), improve long-term survival after CEA. METHODS: Two hundred twenty-six of 255 consecutive patients (88%) undergoing CEA from 1990 to 1996 had PTS. Those with significant reversible defects on PTS were referred for coronary angiography and possible CR. Patients who had undergone PTS were divided into the following 4 groups: group 1, normal or mild defects on PTS; group 2, moderate-severe fixed and/or reversible defects in patients who did not undergo CR; group 3, patients who had CR secondary to their PTS results; and group 4, patients who had CR in the past that was not related to the PTS. Perioperative data were prospectively recorded, and data on long-term survival and cardiac and neurological complications were collected. RESULTS: Seventy-seven patients (34%) had preoperative coronary angiography, and 42 (19%) had subsequent CR: preoperative PTCA or CABG in 24, combined CEA+CABG in 10, and post-CEA CABG in 8 patients. No deaths resulted from the coronary angiography, CR, or CEA. Six patients had perioperative nonfatal myocardial infarction and 8 had stroke. During the follow-up (40+/-23 months), 47 patients (18%) died, 31 (66%) from cardiac disease and 4 (8.5%) from stroke. Independent predictors of long-term overall mortality were diabetes mellitus, preoperative T-wave inversion on ECG, lower-extremity arterial disease, and history of neurological symptoms [exp(beta)=3. 5, 3.4, 2.5, and 2.4; P=0.0003, 0.0004, 0.01, and 0.04, respectively]. In addition, preoperative moderate-severe thallium defect without CR (group 2) independently predicted long-term cardiac mortality [exp(beta)=2.8; P=0.04]. Patients with preoperative CR (group 3) had long-term survival rate similar to that of group 1 and significantly better than that of group 2 (P=0. 02). CONCLUSIONS: PTS predicts long-term survival, and selective CR based on the thallium results improves the survival rate of patients undergoing CEA.

Accurate anatomical location of war injuries: analysis of the Lebanon war fatal casualties and the proposition of new principles for the design of military personal armour system.

In this study we present a new approach to the design of the military personal armour system (MPAS). This approach is based on a computerized analysis of the exact anatomical location of 405 penetrating war injuries (290 shrapnel and 115 bullet injuries) in 164 soldiers killed in the Lebanon war. All the penetrating injuries (hits) were plotted on a computerized image of the human body. About 90 per cent of all hits were to the front of the body; 55 per cent of all hits were to the left side. About 45 per cent of all hits were to the torso, which is slightly more than the torso's proportion of total body-surface area (36 per cent). Of all hits to the torso, 64 per cent of the shrapnel hits and 73.3 per cent of the bullet hits were limited to the front mid torso (T4 to T9). The head at the level of the helmet received 9 per cent of all hits, most of which were over the frontal bones (72.4 per cent). The body part with the greatest density of penetrating injuries was the face, with 22.2 per cent of all penetrating wounds, and in particular the mid face, from the level of the lips to the level of the zygomatic bones, was especially vulnerable, sustaining 10 per cent of all the penetrating wounds. These findings suggest several possible modifications in the standard MPAS: an additional protective device over the front mid torso may be incorporated; the face may be protected by a transparent and lightweight face-shield; a horizontal margin added to the standard helmet may protect the upper face from missiles from above; a chin cover may protect the lower face.

Extracorporeal shock wave lithotripsy for treatment of ureterolithiasis in patients with cystinuria.

Ten of 42 patients with cystinuria admitted for extracorporeal shock wave lithotripsy (ESWL) treatment had ureterolithiasis. Of these, 3 had bilateral stones, 2 had only 1 functioning kidney, and 2 had stones in both the kidney and ureter on the same side. Only 1 patient was on medical treatment at the time of referral. After initiation of medical treatment for cystinuria, 2 patients were discharged without further intervention, 1 was discharged after placement of a ureteric stent and 10 were treated with ESWL. After an average of 1.5 ESWL treatment sessions per ureter, 8 patients became stone-free and in the remaining 2, ureteroscopy was required to complete the treatment. Problems associated with the ESWL treatment of cystine stones are discussed. It was concluded that ESWL is the treatment of choice for ureterolithiasis in patients with cystinuria because it is effective and is the least invasive procedure even in patients with cystinuria.

Reactive oxygen species generated by human neutrophils inhibit sperm motility: protective effect of seminal plasma and scavengers.

OBJECTIVE: To investigate whether activated poly-morphonuclear neutrophils (PMN) can affect sperm motility and to assess the capacity of seminal plasma and of scavengers of reactive oxygen species to prevent any loss of motility. DESIGN: Blood PMN were isolated, and their capacity to generate reactive oxygen species was investigated. The effect of activated PMN was tested on the motility of Percoll-washed spermatozoa in the presence and absence of reactive oxygen species scavengers or seminal plasma (whole or fractionated). PARTICIPANTS: Fertile volunteers and patients attending the Infertility Clinic at the Royal Victoria Hospital. RESULTS: The production of reactive oxygen species by activated PMN occurred in the 1st hour after stimulation and was linearly correlated with the concentration of PMN. Percoll-washed spermatozoa had reduced motility in the presence of PMN, and the drop in motility was more severe as the concentration of PMN was increased. Catalase and dimethylsulfoxide reduced the toxic effect of PMN on sperm motility, whereas superoxide dismutase was without effect. Seminal plasma (50%, vol/vol) allowed a highly variable protective effect against the loss of sperm motility that appeared to originate predominantly from the low molecular weight (< 10 kd) fraction but also from the high molecular weight (> 12 kd) fraction of seminal plasma. CONCLUSION: These data suggest that [1] the presence of PMN, even at 0.6 x 10(6) cells/mL, in semen can be hazardous for spermatozoa, [2] H2O2 and .OH are responsible for the loss of motility, and [3H] seminal plasma confers a variable protection due to high and low molecular weight factors.

Determination of neutrophil concentration in semen by measurement of superoxide radical formation.

OBJECTIVE: To develop an assay that measures the concentration of functional neutrophils in human semen. DESIGN: Human blood neutrophils were first isolated to establish linearity and proportionality for the determination of functional neutrophil concentration. Thereafter blood neutrophils in seminal plasma and neutrophils in semen of patients were measured. SETTING: Blood and human samples were obtained from clinics of the Royal Victoria Hospital. PATIENTS, PARTICIPANTS: Blood from normal men or from patients presenting with chest pain or trauma were used. Semen samples were also obtained from healthy fertile donors or from unselected patients attending the infertility clinic. MAIN OUTCOME MEASURES: Active neutrophil concentration in semen by a colorimetric assay. RESULTS: The assay developed is based on the reduction of nitroblue tetrazolium of pale yellow color to blue formazan by the superoxide anions produced by stimulated neutrophils. The intensity of the derived blue color is proportional to the concentration of active neutrophils. This assay is simple, requires only 10 minutes of preparation time, and detects neutrophil concentrations greater than 0.5 x 10(6) neutrophils/mL of semen, independent of sperm concentration.