Survival analysis of clear cell renal carcinoma according to the Charlson comorbidity index.

PURPOSE: We assessed the convenience of elective surgery for clear cell renal carcinoma with regard to overall survival in accordance with established comorbidity criteria. MATERIAL AND METHODS: This retrospective study included all patients with a histological diagnosis of clear cell renal carcinoma diagnosed between July 1, 1983 and June 1, 2006 in a population of 200,000 inhabitants. All tumors were classified in stages according to the classification of the American Joint Committee on Cancer based on the 2002 UICC TNM classification. Comorbidity in each patient was assessed by the Charlson comorbidity index. Study variables were gender, age, smoking, Charlson index, Charlson index 2 or less and greater than 2, tumor stage, localized stage and locally advanced or metastatic stage. The chi-square or Fisher exact test, or ANOVA was used to analyze the groups, as applicable. Survival associated with each tumor stage and comorbidity group was evaluated by the Kaplan-Meier test. Similarly a binary logistical regression model was used to assess survival after 1, 5 and 10 years. No minimum followup was established for including a patient in the analysis. SPSS, version 12.0 for Windows software was used for statistical analysis with a probability of the null hypothesis of lower than 0.05 considered significant. RESULTS: A total of 232 renal masses were diagnosed during the study period, of which 192 (82.7%) were useful for the study. There were no significant differences between the genders in age (p = 0.486), stage (p = 0.659) and Charlson index (p = 0.463). Median followup was 1,416 days. Of the 192 patients 33 (17.2%), 28 (14.6%), 32 (16.7%), 29 (15.1%), 32 (16.7%) and 38 (19.8%) showed a Charlson index of 1 to 5 or greater, respectively. Stage was I to IV in 29 (15.1%), 69 (35.9%), 40 (20.8%) and 47 cases (24.5%), respectively. It proved impossible to determine tumor stage in 4 cases (2.1%). There were 72 deaths (37.5%), including 25 (34.7%) from intercurrent disease and 45 (62.5%) from clear cell renal carcinoma. The cause of death could not be determined in 2 cases (2.8%). Survival analysis revealed significant differences in overall survival according to stage (p <0.001) and Charlson index (p = 0.02), between localized stages and locally advanced or metastatic stages (p <0.001) and between patients with a Charlson index of 2 or less vs greater than 2 (p <0.001), particularly in those with local stage (p <0.001) but not in those with locally advanced or metastatic stage (p >0.05). In the logistical regression model tumor stage and the comorbidity index were prognostic factors after 1 year (B exponential 2.4 and 1.3, respectively, p <0.05), after 5 years (B exponential 1.6 and 1.3, p <0.05) and after 10 years (B exponential 1.5 and 1.4, respectively, p <0.05). The first was of greatest importance for short-term survival. CONCLUSIONS: Patients with localized clear cell renal carcinoma and a comorbidity index of greater than 2 may choose observation as treatment for the condition.

Análisis de la donación renal efectiva por muerte encefálica en un hospital de nivel 2 de la comunidad de Madrid en un período de 10 años / Analysis of effective renal donation from brain-dead donors in a level II hospital over 10 years

OBJETIVOS: Las características epidemiológicas del donante en muerte encefálica se han modificado a lo largo del tiempo sin un incremento significativo en la tasa de explantes efectuados. Evaluar si las características epidemiológicas (sexo, edad y causa de exitus) del donante en muerte encefálica se han modificado a lo largo del tiempo. Evaluar si la tasa de explantes efectivos se ajustan a un estándar de calidad. MÉTODOS: En este estudio retrospectivo se incluyeron todos los pacientes con donación renal (una o dos unidades renales) en el período comprendido entre el 1 de enero de 1995 y el 31 de diciembre de 2005, en un hospital de Nivel 2 con Unidad de Cuidados Intensivos, pero sin Neurocirugía y sin ser centro de referencia de politraumatismos severos, en un área sanitaria de la Comunidad de Madrid (Móstoles, 200.000 habitantes). Se evaluó la causa de éxitus, la edad, serología para VHB o VHC, así como la donación conjunta de otros órganos (hígado, páncreas, intestino, corazón, pulmón y tejidos). Además se evaluarán las diferencias entre dos periodos de tiempo consecutivos: 1995-1999 y 2000-2005. Para el análisis estadístico se aplicará el Test T para muestras independientes, considerándose como significativo un error alfa inferior a 0.05, median- te el Software SPSS v13.0 (Chicago, Illinois, USA) para Windows. Para el ajuste de la tasa de explantes se utilizará como indicador de calidad un mínimo de un 0,2 % del total de exitus intrahospitalario. RESULTADOS: Durante todo el periodo a estudio hubo 4314 exitus en todo el ámbito hospitalario. Se realizaron 46 extracciones renales con una edad media de 58.1 años (error estándar de la media -eem- de 14.25). En el primer periodo (1995-1999) se produjeron 20 donaciones con una edad media de 52.8 años (eem 12.13) y en el segundo periodo (2000-2005) se produjeron 26 donaciones con una edad media de 62.23 (eem 14.49) años. No obstante no existieron diferencias estadísticamente significativas entre ambos grupos (p=0.273). En total 8 pacientes fueron VHB positivos (17.4 %) y 4 (8.7 %) VHC positivo. En el 80.4 % de los pacientes la causa de muerte encefálica fue una hemorragia cerebral (37 pacientes), el 15.2 % por en- cefalopatía hipóxica (7 pacientes), un paciente falleció por embolia grasa tras accidente de tráfico y otra por púrpura trombótica. No existieron diferencias en cuanto a la causa de exitus entre ambos periodos (p>0.05). Se realizó extracción hepática en el 74 % de los pacientes, cardiaca y pulmonar en el 6,5 %, pancreática en el 4,3 % y de tejido en el 50 %. La tasa de donación fue de un 1,05 %. CONCLUSIONES: 1. Existe una tendencia al alza en la edad del donante en muerte encefálica, aunque sin significación estadística, probablemente debido al tamaño muestral. 2. Las tasas de detección de donantes en muerte encefálica se encuentra por encima de los estándares de calidad. No obstante, se deberían establecer programas formativos a nivel hospitalario para la detección de estos pacientes y mejorar los resultados obtenidos (AU)

OBJECTIVES: The epidemiological characteristics of brain-dead donors have changed with time without a significant increase in the rate of explants performed. The objective of this article is to evaluate if the epidemiological characteristics (sex, age, and death cause) have changed with time, and To evaluate if the rate of effective explants is adjusted to a quality standard. METHODS: All patients who became renal donors (one or two renal units) between January 1st 1995 and December 31st 2005 in a level II hospital with intensive care unit but without neurosurgery, which is not a re- ference center for severe polytrauma patients, within a health-care area of the Autonomic Community of Madrid (Mostoles, 200.000 inhabitants), were included in this retrospective study. Cause of death, age, HBV and HCV serologies, as well as multiorgan donation (liver, pancreas, bowel, heart, lungs, and tissues). Additionally, the differences between two consecutive periods of time will be analyzed: 1995-1999 and 2000-2005. SPSS v 13.0 software (Chicano, Illinois, USA) was used for the statistical analysis; the T test for independent samples was applied, considering an alpha error inferior to 0.05 for significance. A minimum of 0.2% of the total number of hospital deaths was considered as quality indicator for the adjustment of donation rate. RESULTS: Over the whole study period there were 4314 deaths in the hospital. Forty-six renal harvestings were performed with a mean donor age of 58.1 yr. (mean standard error (SE)14.25) . In the first study period (1995-1999) there were 20 donations with a donor mean age of 52.8 yr. (SE 12.13), and there were 26 donations in the second period (2000-2005) with a mean age of 62.23 yr. (SE 14.49) . Nevertheless, the- re were no statistically significant differences between both groups (p = 2.273). A total of eight patients were HBV positive (17.4%) and four (8.7%) HCV positive. In 80.4% of the patients the cause of brain death was brain hemorrhage (37 patients),15.2% hypoxic encephalopathy (7 patients), one patient died due to fat embolism after motor vehicle accident, and another one from thrombotic purpura. There were no differences in death cause between both periods (p> 2.05). Hepatic extraction was performed in 74% of the patients, heart and lung in 6.5%, pancreas in 4.3%, and tissues in 50%. Donation rate was 1.05%. CONCLUSIONS: 1. There is a trend to higher brain- dead-donor age, although it is not statistically significant, probably due to sample size. 2. The rate of brain-dead donor detection is over quality standards. Nevertheless, training programs to detect these patients and improve results should be established at the hospital level (AU)

[Will the climate change affect the mortality from prostate cancer?]. / Afectara el cambio climatico a la mortalidad por cancer de prostata?

UNLABELLED: The global heating of the atmosphere, as well as the increase of the exposition to sunlight, will be associated with a decrease of the mortality from prostate cancer, due to an increase of the plasmatic levels of vitamin D. OBJECTIVES: To evaluate if climatological factors (temperature, rainfall, and number of sunlight hours per year) may influence the mortality associated with prostate cancer over a five-year period. METHODS: In this ecology type study we will evaluate the trends of prostate tumors associated mortality in the period between January 1st 1998 and December 31st 2002, in the geographic area of Spain (17 Autonomic communities-CA-and 2 Autonomic cities- Ceuta and Melilla-, 43 million inhabitants). Demographic and mortality data were obtained from the National Institute of Statistics (INE) and climatological data about temperature and rainfall were obtained from the National Institute of Meteorology (INM). The provinces were classified using the climatic index of Martonne (defined as the quotient between annual rainfall and mean annual temperature plus 10). Areas with a quotient below 5 ml/m2/o C are considered extremely arid zones; between 5 and 15 ml/m2/o C are considered arid zones, between 15 and 20 ml/m2/o C semiarid zones; between 20 and 30 ml/m2/o C subhumid zones; between 30 and 60 ml/m2/o C humid zones; and over 60 ml/m2/o C superhumid zones. We compared mortality rates between different climatic areas using the Jonckheere-Terpstra test for six independent samples following the index of Martonne. All calculations were performed using the SPSS v 13.0 for Windows software. A logistic regression model was performed to identify climate factors associated with prostate cancer mortality. A likeliness of the null hypotheses inferior to 0.05 was considered significant. RESULTS: Prostate cancer mortality presented statistically significant differences, being higher in provinces with higher Martonne index (p < 0.001) and lower in areas with a greater number of sunlight hours per year (p = 0.041). The adjusted mortality rate associated with extreme aridity regions and was 21.51 cases/100,000 males year, whereas in humid zones it was 35.87 cases/100,000 males years. CONCLUSIONS: Mortality associated with prostate cancer is significantly superior in regions with less exposition to the sunlight. The climate change may lead to a modification of the main epidemiologic patterns, and it may be associated with a modification of cancer mortality rates. Nevertheless, these results should be taken with caution and should be confirmed by prospective studies.

¿Afectará el cambio climático a la mortalidad por cáncer de próstata? / Will the climate change affect the mortality from prostate cancer?

El calentamiento global de la atmósfera, así como el incremento de la exposición a la luz solar, se asociará a un descenso de la mortalidad unida al cáncer de próstata, debido a un incremento de los niveles plasmáticos de Vitamina D. OBJETIVOS: Evaluar si los factores climatológicos (temperaturas, precipitación y número de horas de luz solar al año) influyen sobre la mortalidad asociada al cáncer de próstata a lo largo de un período de cinco años. METODOS: En este estudio de tipo ecológico se evaluaron las tendencias de mortalidad asociada a los tumores de próstata en el período comprendido entre el 1 de Enero de 1998 y el 31 de Diciembre de 2002, en el área geográfica de España (17 Comunidades Autónomas -CCAA- y dos Ciudades Autónomas -Ceuta y Melilla-, 43.000.000 habitantes). Los datos demográficos y de mortalidad se obtuvieron del Instituto Nacional de Estadística (INE) y los datos climatológico de temperaturas y precipitaciones se obtuvieron del Instituto Nacional de Meteorología (INM). Se clasificaron las diferentes provincias mediante el índice climático de Martonne (definido como el cociente entre las precipitaciones anuales y la temperatura media anual mas 10). Se consideraron zonas de aridez extrema aquellas cuyo cociente sea inferior a 5 ml/m2/ºC, zonas áridas aquellas cuyo cociente se encuentre entre 5 y 15 ml/m2/ºC, zonas semiáridas aquellas que se encuentren entre 15 y 20 ml/m2/ºC, subhúmedas entre 20 y 30 ml/m2/ºC, húmedas entre 30 y 60 y pérhúmedas cuando sean superiores a 60 ml/m2/ºC. Se valoraron las diferentes tasas de mortalidad entre las distintas áreas climáticas mediante el test de Jonckheere-Terpstra para 6 muestras independientes según el Índice de Martonne. Todos los cálculos se realizarán mediante el software SPSS v13.0 para Windows. Se realizó un modelo de regresión logística para identificar factores climáticos asociados a la mortalidad por cáncer de próstata. Se consideró significativo una verosimilitud de la hipótesis nula inferior a 0,05. RESULTADOSLa mortalidad por cáncer de próstata presentó diferencias estadísticamente significativas siendo superior en las provincias con índice de Martonne más elevado (p< 0,001) y menor en las áreas con mayor numero de horas de sol al año (p=0,041). La tasa de mortalidad ajustada asociada a las áreas de aridez extrema fue de 21,51 casos/100.000 varones y año, mientras que en las zonas húmedas fue de 35,87 casos/100,000 varones y año. CONCLUSIONES: La mortalidad asociada al cáncer de próstata es significativamente superior en las regiones con menor exposición solar. El cambio climático puede conducir a una modificación en los patrones epidemiológicos, pudiendo asociarse a una modificación de las tasas de mortalidad por cáncer. No obstante, estos resultados hay que tomarlos con precaución y deben ser confirmados por estudios prospectivos (AU)

The global heating of the atmosphere, as well as the increase of the exposition to sunlight, will be associated with a decrease of the mortality from prostate cancer, due to an increase of the plasmatic levels of vitamin D. OBJECTIVES: To evaluate if climatological factors (temperature, rainfall, and number of sunlight hours per year) may influence the mortality associated with prostate cancer over a five-year period. METHODS: In this ecology type study we will evaluate the trends of prostate tumors associated mortality in the period between January 1st 1998 and December 31st 2002, in the geographic area of Spain (17 Autonomic communities-CA-and 2 Autonomic cities- Ceuta and Melilla-, 43 million inhabitants). Demographic and mortality data were obtained from the National Institute of Statistics (INE) and climatological data about temperature and rainfall were obtained from the National Institute of Meteorology (INM). The provinces were classified using the climatic index of Martonne (defined as the quotient between annual rainfall and mean annual temperature plus 10). Areas with a quotient below 5 ml/m2/o C are considered extremely arid zones; between 5 and 15 ml/m2/o C are considered arid zones, between 15 and 20 ml/m2/o C semiarid zones; between 20 and 30 ml/m2/o C subhumid zones; between 30 and 60 ml/m2/o C humid zones; and over 60 ml/m2/o C superhumid zones. We compared mortality rates between different climatic areas using the Jonckheere-Terpstra test for six independent samples following the index of Martonne. All calculations were performed using the SPSS v 13.0 for Windows software. A logistic regression model was performed to identify climate factors associated with prostate cancer mortality. A likeliness of the null hypotheses inferior to 0.05 was considered significant. RESULTS: Prostate cancer mortality presented statistically significant differences, being higher in provinces with higher Martonne index (p < 0.001) and lower in areas with a greater number of sunlight hours per year (p = 0.041). The adjusted mortality rate associated with extreme aridity regions and was 21.51 cases/100,000 males year, whereas in humid zones it was 35.87 cases/100,000 males years. CONCLUSIONS: Mortality associated with prostate cancer is significantly superior in regions with less exposition to the sunlight. The climate change may lead to a modification of the main epidemiologic patterns, and it may be associated with a modification of cancer mortality rates. Nevertheless, these results should be taken with caution and should be confirmed by prospective studies

[Analysis of effective renal donation from brain-dead donors in a level II hospital over 10 years]. / Análisis de la donación renal efectiva por muerte encefálica en un Hospital de Nivel 2 de la Comunidad de Madrid en un periodo de 10 años.

OBJECTIVES: The epidemiological characteristics of brain-dead donors have changed with time without a significant increase in the rate of explants performed. The objective of this article is to evaluate if the epidemiological characteristics (sex, age, and death cause) have changed with time, and To evaluate if the rate of effective explants is adjusted to a quality standard. METHODS: All patients who became renal donors (one or two renal units) between January 1st 1995 and December 31st 2005 in a level II hospital with intensive care unit but without neurosurgery, which is not a reference center for severe polytrauma patients, within a health-care area of the Autonomic Community of Madrid (Mostoles, 200.000 inhabitants), were included in this retrospective study. Cause of death, age, HBV and HCV serologies, as well as multiorgan donation (liver, pancreas, bowel, heart, lungs, and tissues). Additionally, the differences between two consecutive periods of time will be analyzed: 1995-1999 and 2000-2005. SPSS v 13.0 software (Chicano, Illinois, USA) was used for the statistical analysis; the T test for independent samples was applied, considering an alpha error inferior to 0.05 for significance. A minimum of 0.2% of the total number of hospital deaths was considered as quality indicator for the adjustment of donation rate. RESULTS: Over the whole study period there were 4314 deaths in the hospital. Forty-six renal harvestings were performed with a mean donor age of 58.1 yr. (mean standard error (SE)14.25). In the first study period (1995-1999) there were 20 donations with a donor mean age of 52.8 yr. (SE 12.13), and there were 26 donations in the second period (2000-2005) with a mean age of 62.23 yr. (SE 14.49). Nevertheless, there were no statistically significant differences between both groups (p = 2.273). A total of eight patients were HBV positive (17.4%) and four (8.7%) HCV positive. In 80.4% of the patients the cause of brain death was brain hemorrhage (37 patients), 15.2% hypoxic encephalopathy (7 patients), one patient died due to fat embolism after motor vehicle accident, and another one from thrombotic purpura. There were no differences in death cause between both periods (p> 2.05). Hepatic extraction was performed in 74% of the patients, heart and lung in 6.5%, pancreas in 4.3%, and tissues in 50%. Donation rate was 7.05%. CONCLUSIONS: 1. There is a trend to higher brain-dead-donor age, although it is not statistically significant, probably due to sample size. 2. The rate of brain-dead donor detection is over quality standards. Nevertheless, training programs to detect these patients and improve results should be established at the hospital level.

[Encrusted pyelitis in patients with urinary diversion]. / Pielitis incrustante en pacientes con derivación urinaria.

OBJECTIVE: This is a case of Encrusted Pyelitis (EP) caused by Corynebacterium urealyticum (CU) in a patient who had undergone a cystectomy and Bricker type urinary diversion 28 months beforehand. METHODS/RESULTS: After the immediate post-operative period no urinary catheterisation or any other urological procedure was performed on the patient. Before surgery, the patient presented non functional of the right kidney, secondary to a lithiasic obstructive uropathy. Clinical symptoms were deteriorated renal function, anuria, haematuria, pyrexia and left lumbar pain. It was suspected that the patient had this pathology and this was fundamental in diagnosis. Helicoid CT was the principal method used to show calcification plaques on the wall of the left renal pelvis, and selective culture of CU confirmed the diagnosis. Early commencement of treatment with vancomycin at an initial dosage of 500 mg/12 hours, and subsequent adjustment of dosage according to blood drug levels, achieved negative urine culture within a fortnight. Oral acidification was effected using acetohidroxamic acid 125 mg/12 hours, and it was continued until CT confirmed the disappearance or considerable reduction of the pyelic calcification plaques. CONCLUSION: The presence of EP in patients with urinary diversion is a matter worthy of consideration, even in patients who have not undergone recent urological procedures. Awareness of risk factors and early commencement of effective treatment may improve the prognosis of these patients.

Pielitis incrustante en pacientes con derivación urinaria / Encrusted pyelitis in patients with urinary diversion

OBJETIVO: Presentamos un caso de pielitis incrustante (PI) ocasionada por Corynebacterium urealyticum (CU) sobre paciente cistectomizado hace 28 meses y al que se le realizó una derivación urinaria tipo Bricker. MÉTODO/RESULTADOS: Desde el postoperatorio inmediato, no había sido sometido a cateterismo urinario ni a ninguna otra manipulación urológica. El sujeto presentaba con anterioridad a la cirugía, anulación funcional del riñón derecho secundario a uropatía obstructiva litiásica. El deterioro de la función renal, anuria, hematuria, fiebre y dolor lumbar izquierdo fue la clínica de presentación. La sospecha de esta entidad fue primordial para su diagnóstico. La TC helicoidal fue el método principal para mostrar las placas de calcificación en la pared de la pelvis renal izquierda, siendo el cultivo selectivo para CU el método diagnóstico de confirmación. La instauración precoz de tratamiento con vancomicina a una dosis inicial de 500 mg/ 12 horas y ajustando posteriormente su dosificación según los niveles de fármaco en sangre, logró una negativización del urocultivo en 15 días. Se llevó a cabo acidificación oral con ácido acetohidroxámico a dosis de 125 mg/ 12 horas, y se mantuvo su administración hasta la constatación mediante TC de la desaparición o reducción considerable de las placas de calcificación piélicas. CONCLUSIÓN: La existencia de PI en pacientes portadores de derivaciones urinarias es un hecho a tener en cuenta, incluso en aquellos pacientes que no han sufrido manipulaciones urológicas recientes. El conocimiento de los factores de riesgo y la instauración precoz de un tratamiento eficaz puede mejorar el pronóstico de estos sujetos (AU)

Nefroma mesoblástico del adulto: aportación de un nuevo caso / A case of adult mesoblastic nephroma

OBJETIVO: Presentamos un nuevo caso de nefroma mesoblástico en el adulto, describiendo la presentación clínica, tratamiento realizado, diagnóstico histológico y evolución de la paciente. METODOS/RESULTADOS: Se trata de una paciente de 68 años, diagnosticada mediante ecografía de masa renal, a la que se realizó una nefrectomía radical. El diagnóstico anatomopatológico fue de nefroma mesoblástico. La paciente no ha presentado recidiva tras Fig. 3: Infiltrado inflamatorio constituido por numerosas células espumosas (xantomatosas), acompañadas por linfocitos y células plasmáticas (hematoxilina-eosina. X400). un seguimiento de 3 años. CONCLUSIONES: El nefroma mesoblástico en el adulto tiene un comportamiento benigno, siendo excepcional la recidiva después de la cirugía (AU)

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Tumor testicular fundido / "Burned out" testicular tumor

OBJETIVO: En este artículo revisamos los distintos aspectos relacionados con el tumor testicular fundido o fenómeno de "autoquemadura".MÉTODO: Se han revisado los artículos publicados hasta la actualidad referentes a esta entidad clínica. Para ello hemos recurrido a una búsqueda informatizada (MEDLINE 1980-1999), y se han revisado citas bibliográficas utilizadas en los artículos seleccionados. RESULTADOS: El fenómeno de "autoquemadura" supone la regresión de un foco de tumor testicular tras la producción de metástasis a distancia, sin conocerse su causa. A pesar de esto, podemos identificar lesiones histológicas características, como son la presencia de una lesión compuesta de tejido colágeno, con células neoplásicas dispersas en su interior. El diagnóstico se realiza mediante el estudio anatomopatológico de la pieza de orquiectomía, debiendo llevarse a cabo ésta en pacientes con tumor germinal extragonadal que presentan alteraciones en la exploración física o en la ecografía. CONCLUSIONES: La presencia de un tumor testicular fundido debe tenerse en cuenta en pacientes con tumores germinales extragonadales, debiendo realizarse una cuidadosa exploración física y ecografía testicular. La orquiectomía puede mejorar el pronóstico de estos tumores, ya que la quimioterapia puede no ser efectiva (AU)