Prolonged survival in a patient with choroidal metastases from urothelial bladder cancer

Choroidal metastases secondary to urothelial carcinoma are extremely rare and are usually associated with an extremely poor prognosis. We present a case of an 88-year-old man with newly diagnosed urothelial carcinoma of the bladder who presented with acute loss of vision before commencing definitive concurrent chemoradiotherapy to the bladder. Ophthalmological examination demonstrated bilateral choroidal metastases. He received palliative radiotherapy to the orbits and completed his planned radiotherapy to the bladder. He remained disease-free at last follow-up 4 years after the completion of treatment. We review the literature particularly with regard to diagnosis and management of choroidal metastases. Choroidal metastases should be considered in a patient with a history of urothelial cancer presenting with new onset of eye symptoms.     

Syringobulbia - Prolonged survival

Summary A patient, suffering from syringomyelia for 34 years and syringobulbia for 27 years, has been under our care for the past 10 years. The symptoms and neurological signs were typical, both developed or rapidly became worse after a minor injury. On three occasions the patient was almost completely disable because of sensory and motor dysfunctions; and, without exceptions, his misery was relieved by surgical drainage of the syrinx.Branch of Surgical Neurology, National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, Maryland 20014.     

Indolent nonseminomatous germ cell tumor of testis. Prolonged survival of patient with persistent metastatic disease

The complete response rate of disseminated nonseminomatous germ cell tumors (NSGCT) of the testes with current aggressive chemotherapy and surgical resection of residual disease is between 70 and 80 per cent. Those patients who do not attain complete response tend to have short survivals. A case is presented of a forty-one-year-old white man who has had nearly continuous evidence of metastatic embryonal carcinoma for more than eleven years. Although NSGCTs are characterized by rapid proliferation, early metastasis, high response rate to chemotherapy, and rapid death if uncontrolled, this case demonstrates an indolent form of disease with poor response to chemotherapy and yet prolonged survival in spite of uncontrolled disease. This is the first reported case of indolent metastatic germ cell neoplasm with survival of more than ten years.     

Prolonged survival with a remnant kidney

Surgical ablation of five-sixths renal mass in Munich-Wistar rats fed a high protein diet leads to focal sclerosis in the remnant kidney and progressive renal failure. Experimental data suggest that this injury results from intraglomerular hypertension and/or chronic glomerular hyperfiltration. Data in humans largely are limited to patients with unilateral renal agenesis or uninephrectomy, either for unilateral renal disease or for kidney transplant donation. Isolated case reports have documented focal sclerosis and progressive renal failure in two patients with a remnant kidney. To obtain data in humans with a remnant kidney, we surveyed more than 800 urologists and nephrologists in the United States and abroad. Criteria for inclusion in the study were (1) surgical resection (in one or more operations) resulting in the presence of a remnant kidney; and (2) an adequate period of follow-up, defined as 5 years or greater. A total of 13 patients were identified (from 13 different centers). Twelve patients had renal cancer and one had tuberculosis. Six patients were observed for 10 or more years postoperatively and all have stable serum creatinine levels of less than 270 mumol/L (3.0 mg/dL); two of these six patients are now more than 25 and 30 years postoperation. The other seven patients, observed for 5 to 7 years, have serum creatinine levels less than 270 mumol/L (3 mg/dL), while one has an increasing serum creatinine level. The two longest surviving patients both have undergone successful pregnancy with no overall change in serum creatinine. These observations demonstrate that it is possible for humans to survive more than 30 years with a stable serum creatinine, despite the presence of only a remnant kidney.     

Prolonged donor ischemic time does not adversely affect long-term survival in adult patients undergoing cardiac transplantation

OBJECTIVE: With liberalization of donor eligibility criteria, organs are being harvested from remote locations, increasing donor ischemic times. Although several studies have evaluated the effects of prolonged donor ischemic times on short-term survival and graft function, few have addressed concerns regarding long-term survival. METHODS: Over the last 11 years, 819 consecutive adults underwent cardiac transplantation at Columbia Presbyterian Medical Center. Recipients were separated into the following 4 groups based on donor ischemic time: <150 minutes, 150 to 200 minutes, 200 to 250 minutes, and >250 minutes. Statistical analysis included Kaplan-Meier survival and Cox proportional hazard models to identify predictors of long-term survival. RESULTS: Donor ischemic time was 120.1 +/- 21.1 minutes for group 1 (n = 321), 174.1 +/- 14.7 minutes for group 2 (n = 264), 221.7 +/- 14.6 minutes for group 3 (n = 154), and 295.5 +/- 37.1 minutes for group 4 (n = 80) (P <.001). There were no significant differences in recipient age, donor age, etiology of heart failure, United Network for Organ Sharing status, or history of previous cardiac surgery among the groups (P = NS). Prolonged donor ischemic time did not adversely affect long-term survival, with actuarial survival at 1, 5, and 10 years of 86.9%, 75.2%, and 56.4% for group 1; 86.2%, 76.9%, and 50.9% for group 2; 86.4%, 71.0%, and 43.7% for group 3; and 86.7%, 70.1%, and 50.9% for group 4 (P =.867). There was no significant difference in freedom from transplant coronary artery disease among the 4 groups (P =.474). CONCLUSIONS: Prolonged donor ischemic time is not a risk factor for decreased long-term survival. Procurement of hearts with prolonged donor ischemic time is justified in the setting of an increasing recipient pool with a fixed donor population.     

Prolonged survival of xenografts after organ culture

Recent reports demonstrate that culture of thyroid allografts before transplantation results in prolonged and sometimes indefinite survival. The loss of passenger leukocytes during organ culture was discussed as a possible reason for these findings. Recent data from a genetically defined system in the mouse demonstrated that passenger leukocytes play an important role in providing a helper stimulus which potentiates the generation of cytotoxic T cells to serologically defined determinants. To ascertain whether this mechanism also is involved in a xenogeneic system, cultured Wistar thyroids were transplanted to DBA/2 mice. The experimental system used was described first by Lafferty and co-workers. Thyroid function was determined by 125-iodine uptake of the graft and by histology. Fresh Wistar thyroids were rejected after a short period of good function on the sixth day after transplantation. Culturing for 10 days resulted in a prolonged graft function up to the fifteenth day. However, if the thyroids were kept in culture for 27 days, no functional signs of rejection could be detected on the twenty-fifth day after transplantation by iodine uptake. The iodine uptake ratio was 47.1 (control group on day 6 was 2.4). Injection of 10(5) fresh donor cells at the time of transplantation reversed the effect of long-term organ culture.     

Prolonged survival in a patient with hepatic malignant melanoma treated by intra-arterial bleomycin and oral hydroxyurea

A case is reported of hepatic metastasis of malignant melanoma six years after enucleation of the right eye in an elderly patient. A fourteen month objective response to the administration of intra-arterial bleomycin and oral hydroxyurea is presented. The response rate that can be expected in large numbers of patients must await further study.     

Prolonged kidney allograft survival with promethazine.

The effects of promethazine hydrochloride have been investigated in a rabbit kidney allograft model. The drug was ineffective on its own, but if added to a protocol that induced partial suppression of rejection in 50% of recipients, its effect was dramatic. Allograft survival was prolonged from a control mean of 10.3 days to a mean of 26.3 days. One animal survived 2 1/2 months, and no other drug than promethazine was given after day 6. Promethazine and 6-methylprednisolone alone also prolonged allograft survival, but the results were significantly better if the recipient had been exposed to donor blood before grafting. The results suggest that promethazine is a useful adjuvant immunosuppressive drug. It could be beneficial in man.     

Prolonged allogeneic islet graft survival by protoporphyrins

Transplantation of islets of Langerhans in patients with type 1 diabetes allows for improved metabolic control and insulin independence. The need for chronic immunosuppression limits this procedure to selected patients with brittle diabetes. Definition of therapeutic strategies allowing permanent engraftment without the need for chronic immunosuppression could overcome such limitations. We tested the effect of the use of protoporphyrins (CoPP and FePP), powerful inducers of the cytoprotective protein heme-oxygenase 1 (HO-1), on allogeneic islet graft survival. Chemically induced diabetic C57BL/6 mice received DBA/2 islets. Treatment consisted in peritransplant administration of CoPP or saline. Islets were either cultured in the presence of FePP or vehicle before implant. Short-course administration of CoPP led to long-term islet allograft survival in a sizable proportion of recipients. Long-term graft-bearing animals rejected third-party islets while accepting a second set donor-specific graft permanently, without additional treatment. Preconditioning of islets with FePP by itself led to improved graft survival in untreated recipients, and provided additional advantage in CoPP-treated recipients, resulting in an increased proportion of long-term surviving grafts. Preconditioning of the graft with protoporphyrins prior to implant resulted in reduction of class II expression. Administration of protoporphyrins to the recipients of allogeneic islets also resulted in transient powerful immunosuppression with reduced lymphocyte proliferative responses, increased proportion of regulatory cells (CD4+CD25+), decreased mononuclear cell infiltrating the graft, paralleled by a systemic upregulation of HO-1 expression. All these mechanisms may have contributed to the induction of donor-specific hyporesponsiveness in a proportion of the protoporphyrin-treated animals.     

Lazarus sign and extensor posturing in a brain-dead patient. Case report

A man was declared brain dead after having sustained a gunshot wound to the head. All clinical criteria for the diagnosis of brain death were met. The electroencephalogram was isoelectric, and four-vessel angiography demonstrated the absence of cerebral blood flow. However, stereotypic spontaneous movements were observed which persisted for several hours. The possible mechanism is discussed and a short review of the literature is given.