A case of angiomyolipoma of the renal sinus

The case of a 63-year-old woman with a relatively rapidly growing angiomyolipoma (AML) originating from the right renal sinus is presented. The tumor had enlarged to more than fivefold in volume (7.4 × 6.7 × 10.1 cm) in the 7 years following its detection (5.6 × 3.4 × 4.6 cm) and had significantly pushed aside the duodenum and the inferior vena cava. The tumor was surgically resected together with the right kidney, and pathological examination revealed AML originating from the renal sinus. An AML involving or originating from the renal sinus is exceedingly rare; only 14 cases have been reported. Rapidly growing AMLs of the renal sinus are difficult to differentiate from liposarcoma because of similar findings in imaging studies. It should be noted that AML of the renal sinus can be a differential diagnosis of retroperitoneal fatty mass. Furthermore, an enlarged AML in the renal sinus may push aside other organs, such as the ileum, pancreas, and major vessels. Clinicians should determine whether these patients should be placed under active surveillance or be treated with invasive measures, such as radical nephrectomy.     

Renal angiomyolipoma in Japanese tuberous sclerosis patients

Purpose

Renal angiomyolipoma (AML) is a benign neoplasm that may grow massive in tuberous sclerosis (TS) patients. The aim of this study was to document the characteristics of renal AML in Japanese TS patients.

Methods

Medical records of 29 TS patients followed up at the authors’ center were reviewed for the presence, size, symptom, and treatment of renal AML.

Results

Twenty-four patients screened for renal AML were subdivided into 4 groups: group 0 (n = 8), no mass; group 1 (n = 5), AML less than 1 cm in diameter; group 2 (n = 4), AML 1 to 4 cm in diameter; group 3 (n = 7), AML greater than 4 cm in diameter. When present, AML always affected both kidneys and were multiple. All patients in groups 1 and 2 were symptom free, and the tumors seemed stable in size. All tumors in group 3 grew progressively causing various symptoms. Total or partial nephrectomy or transarterial embolization was performed in 5 patients with limited success.

Conclusions

AML in TS patients can be stable or aggressive. Pediatric surgeons aware of this problem should be involved in a follow-up program.     

Renal epithelioid angiomyolipoma: a rare variant with unusual behavior

Purpose

To compare the clinical, pathological and oncological outcome of EAML with classic angiomyolipoma (AML).

Methods

A retrospective review of patients’ files with a diagnosis of AML was conducted. Both classic and epithelioid AML were compared as regard the patients’ demographics, mode of presentation, tumor features and follow-up data. The accuracy of preoperative radiological diagnosis of EAML and the postoperative pathological data were evaluated.

Results

Between November 1988 and July 2012, 1,502 renal masses were treated. Forty-two patients (2.8 %) had renal AML of whom 12 patients (28.6 %) had epithelioid morphology. All the patients with EAML were symptomatic on presentation compared to 16.7 % asymptomatic patients with classic AML. Specific diagnosis of EAML was not suggested based on preoperative radiological evaluation. In one patient, there was a venous tumor extension into the right renal vein; another patient had a solitary pulmonary nodule. Pathological data of EAML patients showed wide areas of necrosis (4 patients), atypia (6 patients), increased mitotic figures (2 patients), nuclear anaplasia, enlarged nuclei and prominent nucleoli (3 patients), and multilobulated multinucleated giant cells (5 patients). At a median follow-up period of 12 and 9 months for EAML and classic AML groups, respectively, one patient with EAML had evidence of both local recurrence and distant metastasis 3 months following open radical nephrectomy.

Conclusion

Epithelioid AML is potentially aggressive and usually present as a symptomatic renal mass. It may be misdiagnosed as malignant renal mass on preoperative radiological evaluation.     

Giant renal angiomyolipoma in a case with pulmonary lymphangiomyomatosis

A 27-year-old female with pulmonary lymphangioleiomyomatosis was referred to us because of the right large renal angiomyolipoma (AML), 10 cm in diameter, which was found by abdominal CT during close investigation of her pulmonary disease. About 6 months earlier she had received operation for pneumothorax and the histological examination disclosed pulmonary lymphangioleiomyomatosis (LAM). Clinically she does not have tuberous sclerosis. Partial nephrectomy was performed. The renal tumor arose from the lower part of the kidney with somewhat exophytic growth. She is now followed at outpatient clinic without recurrence of renal AML. Pulmonary LAM often associates with renal AML. Although pulmonary LAM is a progressive disease and has a poor prognosis, because of the risk of the rupture of renal AML, large renal AMLs should be treated. Recently several cases have been reported for whom nephron-sparing surgery was performed. This case is 10th report of LAM, which is associated with AML in Japan.     

Management of renal angiomyolipoma in complex clinical situations.

Renal angiomyolipoma (AML) is associated with complex clinical situations such as tumour in a solitary kidney, bilateral, large or multicentric tumours or those associated with tuberous sclerosis (TS) or pregnancy. Management in these situations may be challenging. Fifteen patients (20 kidneys) were admitted with symptomatic AML over last 10 years. Eleven patients had one or the other complicating factor. Ten patients had a tumour of >10 cm, 4 had TS, 5 had multiple and bilateral tumours, 1 patient was pregnant and 1 had a solitary functioning kidney. With the newer imaging modalities correct diagnosis was possible in 12 cases and renal cell carcinoma (RCC) was suspected in 3 cases. Selective angioembolization (SAE) was done in 3 patients, which successfully controlled bleeding in all. Nephron-sparing surgery (NSS) was performed in 5 patients. Total nephrectomy was done in 4 cases, in 3 due to suspicion of RCC and in 1 due to extensive involvement of the kidney. Three patients with multiple and bilateral tumours were chosen for conservative treatment and none developed recurrence of bleeding on strict follow-up. In a pregnant patient, bleeding was successfully controlled with angioembolization. However, 1 patient with a solitary functioning kidney with large-sized tumour (20 x 18 cm) underwent NSS. In conclusion, the basis of management of AML is preservation of renal tissue, which can be effectively achieved with SAE or NSS. In a solitary functioning kidney, NSS or SAE is the ideal treatment, if feasible. The patients in the TS group are usually more complicated and require life-long follow-up after initial management with NSS or SAE. Pregnant AML patients can be safely managed with SAE. Conservative treatment without any intervention and regular follow-up may be more helpful in some patients with multiple, bilateral extensive tumours.     

Pretransplantation minimal residual disease monitoring by multiparameter flow cytometry predicts outcomes of AML patients receiving allogeneic hematopoietic stem cell transplantation

Background and purposeIs minimal residual disease (MRD) monitoring by multiparameter flow cytometry (MFC) prognostic for acute myeloid leukemia (AML) patients before allogeneic hemopoietic stem cell transplantation (allo-HSCT)? And if so, what level of MRD eradication can be used to help guide the timing of HSCT? Can haplo-HSCT improve the prognosis of AML patients with MRD positive? To figure out these questions, we initiated this retrospective study.Methods96 AML patients were included retrospectively and divided into 5 groups, according to pre-transplantation MRD levels (from 5 × 10⁻² to <1 × 10⁻⁴), to analyze the overall survival (OS), disease-free survival (DFS) and cumulative incidence of relapse (CIR). Secondly, we compared the prognosis of MRD-negative (MRD^neg) and MRD-positive (MRD^pos) AML patients (cutoff value = 1 × 10⁻³) who underwent allo-HSCT, and further analyzed the prognosis of MRD^pos patients after received different transplantation modalities.ResultsIt is found that the 2-year OS and DFS of MRD negative group were better than the MRD positive group, and that the deeper the eradication of MRD before transplantation, the better the prognosis of patients. The CIR in patients received HLA-identical transplantation, was higher in the MRD^pos than in the MRD^neg. Haploid transplantation reduced the CIR disparity between MRD^pos and MRD^neg group. Subsequently, in AML patients who remain MRD positive before HSCT, we show that haplo-HSCT offered a better prognosis than HLA-identical transplantation (MSDT and MUDT).ConclusionIt is suggested that achieving MFC-MRD <10⁻³ (10⁻⁴ or even better) before allo-HSCT could reduce the relapse of AML and improve OS and DFS significantly, while haplo-HSCT may be preferred for patients not achieving MRD negativity.     

Conservative treatment of renal angiomyolipomas in patients with tuberous sclerosis

AIMS: Renal angiomyolipoma (AML) associated with tuberous sclerosis (TS) presents a treatment dilemma due to multifocal tumors with a potential for significant growth and subsequent hemorrhage. We reviewed the literature and our experience with AML and TS patients to determine the long-term behavior of these lesions. MATERIALS AND METHODS: We reviewed 8 patients (16 renal units) with bilateral renal AMLs and comorbid TS. We evaluated their renal function, renal imaging, and clinical course. Patients were followed for a mean of 11.5 years (range 3.5 - 21 years). RESULTS: The records of 8 patients (7 females, 1 male) with a mean age of 33.1 years (range 21 - 54) were evaluated. The mean serum creatinine of these patients at the time of diagnosis was 0.75 mg/dl (range 0.4 - 1.1). Mean serum creatinine at last follow-up was 0.83 mg/dl (range 0.6 - 1.3). The average size of the largest lesion was 13.9 cm (range: 0.5 - 28). Of the 8 patients, 6 received treatment during the course of their disease, including arterial embolization of 7 renal units in 5 symptomatic patients (2 patients needed 2 embolizations). Partial nephrectomy was performed on 2 renal units in 2 patients, and a total nephrectomy was performed in 1971 on another patient. Currently, all 8 patients have stable renal function; 4 patients are asymptomatic with regards to their lesions, while the other 4 patients report transient flank pain adequately controlled with oral analgesics (2 patients with propoxyphene plus acetaminophen 100/650 mg PO t.i.d. p.r.n., the other 2 patients with ibuprofen 600 mg PO p.r.n.). None of the patients experienced life-threatening hemorrhage or required dialysis. CONCLUSIONS: Our study and a review of the literature have not revealed an obvious or quantitative risk of morbidity or mortality from renal hemorrhage directly related to AMLs of any specific size in TS patients. Due to multiple lesions and distortion of anatomy it can be difficult to distinguish individual lesions for preemptive treatment in asymptomatic patients. If size criteria alone are used, multiple treatments will be required over the course of the patient's life. Also, preemptive treatment exposes patients to iatrogenic morbidity. Consideration should be given to medical management of AMLs in TS patients with asymptomatic, slowly enlarging tumors that maintain features of an AML. Embolization, partial nephrectomy, or other ablative treatments (i.e. cryotherapy and RFA) can be reserved for symptomatic patients.     

INTERFERON-GAMMA AND INTERLEUKIN-2 SUPPRESS THE EXPERIMENTAL METASTASIS OF MOUSE RENAL ADENOCARCINOMA

While cytokines such as interferon-alpha (IFN-α), interferon-gamma (IFN-γ) and interleukin-2 (IL-2) are partially effective in the treatment of metastatic renal cell carcinoma, these cytokines have not been investigated for their ability to suppress the development of metastasis. We investigated whether they suppressed experimental pulmonary metastasis by subline-2 of streptozotocin-induced mouse renal adenocarcinoma (MRAC-PM2). IFN-γ (1 × 10⁴ and 1 × 10⁵ U/mouse) and IL-2 (1 × 10⁴ and 1 × 10⁵ U/mouse) suppressed the experimental pulmonary metastasis of MRAC-PM2 in a dose-dependent manner, but 1 × 10⁵ lU/mouse of IFN-α did not. The combination of 1 × 10⁵ U IFN-γ with 1 × 10⁵ U IL-2 had the most powerful inhibitory effect on pulmonary metastasis without any side-effects. In addition, the combination of 1 × 10⁵ U IFN-γ with 1 × 10⁵ U IL-2 had a synergistic inhibitory effect on the growth of subcutaneous tumors. These results indicate that either IFN-γ or IL-2, or their combination, produce a more favorable effect than IFN-α on the metastatic development of renal adenocarcinoma.     

Bilateral massive renal angiomyolipoma concurrent with oncocytoma in tuberous sclerosis complex associated with pulmonary lymphangioleiomyomatosis

We describe a patient with tuberous sclerosis complex and massive bilateral renal angiomyolipomas (AMLs) in association with pulmonary lymphangioleiomatosis, who experienced hemorrhagic shock because of rupture of the left renal AML. She was treated with transarterial embolization, followed by bilateral nephrectomy. The total tumor burden weighed 5800 g, making it the largest AML by weight in published reports. The histopathologic examination revealed concurrent oncocytomas with AMLs in the right kidney, indicating a possible shared mechanism in the pathogenesis of these two disorders. This case also represents a rare, but significant, overlap between renal AML, pulmonary lymphangioleiomatosis, and tuberous sclerosis complex.     

Results of endoscopic transsphenoidal pituitary surgery in 40 patients with a growth hormone-secreting macroadenoma

Objective  

Transsphenoidal pituitary surgery (TS) is the primary treatment of choice for patients with acromegaly. Macroadenomas (>1 cm) are more difficult to resect than microadenomas (remission rate ± 50% compared to ± 90%). Besides the conventional microscopic TS, the more recently introduced endoscopic technique is nowadays frequently used. However, no large series reporting on its results have yet been published. We evaluated the outcome of endoscopic TS in 40 patients with a growth hormone (GH)-secreting macroadenoma treated in our hospital between 1998 and 2007.     

Sekundärer Spontanpneumothorax bei tuberöser Sklerose

Secondary pneumothorax occurs as a symptom of an underlying pulmonary disease. We report the case of an 18-year-old woman with tuberous sclerosis (Bourneville's disease) and recurrent pneumothoraces. Clinical outcome was favorable 6 months after bilateral videothoracoscopic pleurectomy. The complete triad of tuberous sclerosis (TS) (mental retardation, seizures, adenoma sebacium) is not always present in those who develop pulmonary involvement. When TS involves the lung it is clinically and pathologically indistinguishable from lymphangioleiomyomatosis (LAM). The very rare pulmonary involvement of TS and LAM are problems primarily of women in childbearing age. A pneumothorax can be the first symptom of TS or LAM.     

'Tactile sensation': a new clinical sign during fine needle aspiration of breast lumps.

The tactile sensation (TS) felt during fine needle aspiration (FNA) of symptomatic breast abnormalities was recorded prospectively in 169 patients. TS was classified as malignant (if ''gritty''), or benign (if ''rubbery'', ''soft'' or ''fibrous''). This assessment was compared with fine needle aspiration cytology (FNAC) and the final diagnosis, to evaluate the clinical utility of TS. A ''gritty'' TS was recorded in 55/59 cancers and 22/110 benign lesions (sensitivity 93.2%, specificity 80%). Comparison of TS and FNAC in 69 patients with definitive histopathology revealed complementary results (TS, sensitivity 88.9%, specificity 48.5%; FNAC, sensitivity 55.6%, specificity 100%). Combining the sensitivity of TS with that of FNAC increased the overall sensitivity to 97.2%. Recording TS during FNA of symptomatic breast lumps enhances diagnosis, and alerts the clinician to the possibility of an underlying carcinoma when FNAC fails to confirm malignancy.     

Flexibility of the thoracic curve and three-dimensional thoracic kyphosis can predict pulmonary function in nonoperatively treated adult patients with adolescent idiopathic scoliosis

BackgroundAlthough several radiographic predictors for pulmonary function in adolescent patients have been reported, those in adult patients remain unclear. Therefore, we aimed to investigate the associations between spinal deformity and pulmonary function in nonoperatively treated adult patients with adolescent idiopathic scoliosis (AIS).MethodsOf 319 patients treated nonoperatively for AIS, 90 (average age, 40.0 ± 6.5 years) underwent both full-length standing radiographs and pulmonary function test. Standard two-dimensional (2-D) radiographic measurements were performed. Three-dimensional thoracic kyphosis (3-D TK) was calculated from 2-D standing radiograph data using a validated formula: 3-D TK (°) = 18.1 + 0.81 × (2-D TK) + 0.54 × (Cobb angle of thoracic curve). 3-D TK was defined as the sum of segmental kyphosis between T5 and T12, which eliminates the overestimation of TK in 2-D measurements due to rotational deformity. Bivariable correlation analysis, followed by a stepwise multiple linear regression analysis, was performed.ResultsThe average Cobb angle of the thoracic curve at the time of survey was 49.4° ± 14.6° with flexibility of 37.5% ± 18.2%. Thoracic curve magnitude, flexibility, apical vertebral rotation and translation, and 3-D TK were significantly correlated with percent-predicted forced vital capacity (%FVC) and expiratory volume in 1 s (%FEV1.0). Stepwise multiple regression analysis showed that curve flexibility and 3-D TK were significant, independent predictors of %FVC (R² = 0.358) and %FEV1.0 (R² = 0.335), curve flexibility having a greater impact (standardized coefficient > 0.45) than 3-D TK (<0.32).ConclusionsOur results indicate that nonoperatively treated patients with AIS should be recommended to maintain flexibility of the thoracic curve to prevent future pulmonary impairment. Moreover, 3-D TK is another independent predictor of pulmonary function, which suggests that segmental sagittal alignment is a component of deformity correction to focus on.     

Substantial Early Loss of Induced Pluripotent Stem Cells Following Transplantation in Myocardial Infarction

The limited success of cardiac stem cell therapy has lately generated discussion regarding its effectiveness. We hypothesized that immediate cell loss after intramyocardial injection significantly obscures the regenerative potential of stem cell therapy. Therefore, our aim was to assess the distribution and quantity of induced pluripotent stem cells after intramyocardial delivery using in vivo bioluminescence analysis. In this context, we wanted to investigate if the injection of different cell concentrations would exert influence on cardiac cell retention. Murine‐induced pluripotent stem cells were transfected for luciferase reporter gene expression and transplanted into infarcted myocardium in mice after left anterior descending coronary artery ligation. Cells were delivered constantly in aqueous media (15 μL) in different cell concentrations (group A, n = 10, 5.0 × 10⁵ cells; group B, n = 10, 1.0 × 10⁶ cells). Grafts were detected using bioluminescence imaging. Organ explants were imaged 10 min after injection to quantify early cardiac retention and cell biodistribution. Bioluminescence imaging showed a massive early displacement from the injection site to the pulmonary circulation, leading to lung accumulation. Mean cell counts of explanted organs in group A were 7.51 × 10⁴ ± 4.09 × 10³ (heart), 6.44 × 10⁴ ± 2.48 × 10³ (left lung), and 8.06 × 10⁵ ± 3.61 × 10³ (right lung). Respective cell counts in group B explants were 1.69 × 10⁵ ± 7.69 × 10⁴ (heart), 2.11 × 10⁵ ± 4.58 × 10³ (left lung), and 3.25 × 10⁵ ± 9.35 × 10³ (right lung). Applying bioluminescence imaging, we could unveil and quantify massive early cardiac stem cell loss and pulmonary cell accumulation following intramyocardial injection. Increased injection concentrations led to much higher intracardiac cell counts; however, pulmonary biodistribution of transplanted cells still persisted. Therefore, we recommend applying tissue engineering techniques for cardiac stem cell transplantations in order to improve cardiac retention and limit biodistribution.     

Management of renal angiomyolipoma: a report of 53 cases

OBJECTIVE: To evaluate the clinical, therapeutic and prognostic aspects of renal angiomyolipoma (AML) in patients either monitored by clinical and radiological follow-up or treated by surgical therapy. PATIENTS AND METHODS: Fifty-three patients with renal AML were divided in two groups; 33 patients in group 1 were monitored by annual clinical and ultrasonographic follow-up and 20 in group 2 were treated with surgical therapy. Two patients had tuberous sclerosis (TS) with synchronous bilateral and multiple lesions. Apart from the patients with TS, there were 38 lesions in group 1 and 25 in group 2. The mean (range) follow-up of group 1 was 60.2 (12-164) months. RESULTS: In group 1, the diagnosis was most often incidental, after ultrasonography performed for symptoms unrelated to AML. In group 2, the suspicion of a malignant renal lesion, and spontaneous tumour rupture with bleeding and perirenal haematoma, were the main indications for surgical treatment. The mean lesion diameter was significantly greater in group 2 (5.4 cm) and in symptomatic patients (8.1 cm). In group 1, 92% of renal AMLs showed no radiographic changes, serious complications or new renal or extrarenal lesions during the follow-up. Only three lesions grew, after 22, 85 and 164 months, respectively. Of the 20 patients in group 2, 14 underwent conservative surgery. CONCLUSION: Small (<4 cm) isolated AMLs, detected incidentally, showed a low risk of developing during long-term follow-up. Such patients may be followed conservatively by ultrasonography every 2 years. Spontaneous perinephric haemorrhage is related to the size of the lesion. When surgery is indicated (by symptoms or diagnostic doubt), a conservative procedure can be performed in most of cases.     

Isoflurane inhibits endothelium-mediated nitric oxide relaxing pathways in the isolated perfused rabbit lung

Purpose

The role of volatile anaesthetics on nitric oxide (NO)-dependent relaxation is unclear in the pulmonary circulation. We examined the effects of isoflurane on NO-dependent relaxation in isolated perfused rabbit lungs.

Methods

Eighteen rabbit lungs were perfused in a constant-flow recirculation manner. In study I (n= 12), acetylcholme (ACh, 4 × 10^?10 ? 10^?8 M) or nitroglycenne (NTG, 6 × 10^?10?10^?8 M) was cumulatively injected into the pulmonary artery in the absence or presence of isoflurane (1, 2 MAC). In study 2 (n=6), ACh was injected as in study I in the presence or absence of Nω-nitro-L-arginine methyl ester (L-NAME, 100 μM), an NO synthesis blocker. In all experiments, indomethacin was administered to prevent formation of vasoactive prostanoid metabolites, and the pulmonary vessels were preconstricted with prostaglandin F2α (PGF2α) infused before ACh or NTG injection. The ACh-or NTG-induced relaxation was expressed as % decrease in PGF2α preconstriction.

Results

Isoflurane at 2 MAC attenuated the dose-dependent relaxation to ACh at doses of 4 × 10^?9 M and 4 × 10^?8 M from 27.8 ± 4.3% and 38.8 ± 5.3% to 17.0 ± 3.5% and 25.5 ± 4.9%, respectively (P < 0.05). Isoflurane did not change the dose-dependent relaxation to NTG and L-NAME abolished the ACh-induced relaxation.

Conclusion

Isoflurane inhibited NO-dependent relaxation in the pulmonary circulation at a site distal to the endothelial cell receptor-mediated responses but proximal to guanylate cyclase activation of vascular smooth muscle. Acetylcholine-induced relaxation in isolated perfused rabbit lungs was regulated primarily by NO.     

Preoperative opioid use and the outcome of thoracoscopic splanchnicectomy in chronic pancreatitis: a systematic review

Background

Thoracoscopic splanchnicectomy (TS) is a minimally invasive intervention to relieve pain in patients with chronic pancreatitis (CP) with equivocal results. Preoperative opioid use seems to impair TS outcome but this has not been investigated in a systematic matter.

Methods

We searched PubMed, EMBASE, and The Cochrane Library for studies on the outcome of TS in CP patients. Studies with ≥5 patients and a follow-up of ≥12 months were included. Success was defined as the proportion of patients free of opioids or who had a reduction of ≥4 points on a pain scale. The effect of opioid use on the success rate of TS was analyzed by uni- and multivariate regression.

Results

Sixteen studies with 484 patients were included in our review. The mean (±SD) age of the patients was 44 ± 4.3 years and 66 % were male. Median follow-up period was 21 months (IQR 14–35). Median preoperative opioid use was 85 % (IQR 54–100 %). After TS, a median of 49 % (IQR 22–75 %) of patients were free of opioids at end of follow-up. The median success rate was 62 % (IQR 48–86 %). Mean success rate in studies in which ≤50 % of the patients used opioids preoperatively was 81 % (SD ± 21) compared to 60 % (SD ± 15) for other studies (p = 0.049). Higher age, male gender, and lower rates of preoperative opioid use were associated with a higher success rate (p = 0.003, 0.047, and 0.017, respectively). Multivariate regression, including age, gender, preoperative opioid use, and duration of follow-up, identified age and preoperative opioid use as independent predictors of success after TS (both p = 0.002).

Conclusion

Preoperative opioid use is associated with a worse outcome after TS in CP patients. To optimize outcome, use of TS may be considered at an earlier stage in the treatment of patients with CP before prolonged opioid therapy.     

One-stage bilateral pulmonary resections for pulmonary metastases

Objective

We analyze the safety and efficacy of one-stage bilateral pulmonary resections for pulmonary metastases via a bilateral approach.

Methods

We retrospectively analyzed 154 cases with pathologically verified pulmonary metastases which underwent curative pulmonary resection. Intraoperative and perioperative variables were evaluated.

Results

One hundred and thirty cases underwent unilateral pulmonary metastasectomy (group U), and the other 24 cases with bilateral pulmonary metastases underwent one-stage bilateral pulmonary resections (group B). Operation time in group B was significantly longer than in group U (354 ± 132 vs. 203 ± 110 min; p < 0.001), but was not longer than double that in group U (407 ± 219 min; p = 0.540). Operative blood loss was not significantly greater in group B than group U (113 ± 158 vs. 76 ± 138 ml; p = 0.069). Neither duration of postoperative hospital stay nor incidence of postoperative complications differed between the two groups. Hospitalization costs in group B were significantly greater than in group U (257 ± 120 × 10⁴ vs. 168 ± 69.2 × 10⁴ yen; p < 0.001), but they were significantly less than double those in group U (336 ± 138 × 10⁴ yen; p < 0.001).

Conclusions

We consider one-stage bilateral pulmonary metastasectomy to be safe for bilateral pulmonary metastases. Moreover, it may offer an economic benefit by avoiding the expenses associated with a two-stage operation.     

Thymidylate Synthase as a Prognostic Biomarker for Locally Advanced Rectal Cancer after multimodal Treatment

Purpose

For years, 5-fluorouracil (5-FU) has been the backbone of radiochemotherapy (RCT) of locally advanced rectal cancer. Its main target, thymidylate synthase (TS), is speculated to be an important biomarker for response prediction and long-term prognosis. In this study, we analyzed TS expression in the rectal cancer tissue of 208 patients to evaluate its predictive/prognostic potential.

Methods

All patients included were diagnosed with locally advanced adenocarcinoma of the rectum (UICC II and III) and were treated within randomized clinical trials of the German Rectal Cancer Study Group. Preoperative RCT (50.4 Gy and concomitant either 5-FU or 5-FU and oxaliplatin) was administered in 167 patients followed by surgical resection with total mesorectal excision (TME). Another 41 patients received postoperative RCT. TS levels and further clinicopathological parameters were assessed in univariate and multivariate analyses. Additionally, a TS gene polymorphism was analyzed with respect to the intratumoral protein levels.

Results

Low TS expression in pretreatment biopsies correlated with impaired patient survival (p = 0.015). Analysis of a 28-bp repeat revealed a correlation between the *3/*3 genotype and high TS expression in pretherapeutic biopsies. In this study, a correlation of TS expression and grade of RCT-induced tumor regression was not found. Histopathological examination confirmed a complete tumor remission in 16 patients (9.6%). Analyses of the resection specimen indicated an unfavorable prognosis for patients with low intratumoral TS expression in case of detected lymph node metastases (p = 0.04).

Conclusions

TS can serve as a prognostic biomarker indicating an unfavorable prognosis for patients with low TS expression.     

Renal angiomyolipoma with epithelioid sarcomatous transformation and metastases: demonstration of the same genetic defects in the primary and metastatic lesions

Angiomyolipoma (AML) is a benign neoplasm that occurs either sporadically or in patients with tuberous sclerosis complex (TSC) and shows frequent allelic losses at chromosome arm 16p. It has been suggested recently that the melanogenesis marker-positive perivascular epithelioid cell (PEC) has been found consistently in AML. The authors report a 50-year-old woman without evidence of TSC affected by classic renal AML containing an area composed of atypical epithelioid cells with the same morphoimmunophenotypic characters of PEC. After 7 years from surgical removal of the lesion, the patient developed a local recurrence and successive lung and abdominal metastases that showed morphologic and immunohistochemical features overlapping those of the epithelioid area of the previously removed AML. Genetic analysis showed that the classic AML and its epithelioid area as well as the pulmonary and abdominal metastases shared the same allelic loss on chromosome arm 16p. Based on these findings, the authors view this case as evidence of a malignant transformation of a classic AML with morphologic, immunophenotypic, and genetic demonstration of its clonal origin.