Contralateral metachronous tumor occurrence is more frequently associated with distant metastases or postoperative intrarenal recurrence in renal cell carcinoma patients

Objective: To analyze the prognosis of patients with sporadic bilateral renal cell carcinoma (RCC). Methods: From January 1979 to December 2007, 984 patients with sporadic RCC underwent surgery at our department. Of these, 53 patients (5.7%) presenting with bilateral RCC were included in this retrospective analysis. Results: Thirty‐one of the 53 bilateral RCC patients had synchronous RCC, and 22 had metachronous RCC. Distant metastases by the time of the bilateral tumor occurrence were found in four patients (13%) in the synchronous group and in 10 patients (48%) in the metachronous group. No difference was found between the two groups in terms of overall survival. In contrast, survival after the second surgery in the metachronous group was significantly lower than that after the first surgery (P < 0.001) in the synchronous group (P = 0.02). In addition, the incidence of local recurrence after partial nephrectomy was higher in the metachronous group (26%) compared to the synchronous group (4%, P = 0.04) or the unilateral RCC patients (0.4%, P < 0.01). Conclusions: Metachronous occurrence of RCC in the contralateral kidney is associated with an unfavorable prognosis, suggesting that metachronous contralateral tumors might be metastasis of the original tumors. A stricter follow‐up schedule is advisable for metachronous bilateral RCC patients.     

Risk of contralateral manifestation in children with unilateral inguinal hernia: should hernia in children be treated contralaterally?

PURPOSE: This study was done to identify risk factors for metachronous manifestation of contralateral inguinal hernia in patients with unilateral inguinal hernia. METHODS: Characteristics of 156 patients with metachronous contralateral hernia were compared with those of 156 patients with unilateral hernia who were ascertained not to have presented with contralateral hernia. RESULTS: There was a tendency for the hernia to be more often on the left side in 88 of 156 patients (56.4%) with contralateral manifestation compared with 70 of 156 patients (44.9%) in the control group (P =.054). The age at hernia repair of the patients with contralateral manifestation, 1 to 120 months (median, 14 months), was significantly younger than the 1 to 149 months (median, 20 months) of the control patients (P =.016). More patients with contralateral manifestation had a family history of inguinal hernia, and the percentage, 24.4%, was significantly higher than the 14.7% in the control group (P =.046). A univariate analysis with the Cox regression models found that hernia on the left side and a positive family history were significantly associated with the metachronous manifestation of contralateral hernia (hazard ratio [HR], 1.40; P =. 037 and HR, 1.59; P =.013, respectively). CONCLUSION: The risk of metachronous manifestation of contralateral hernia is high in patients with left-side hernia and in those with a family history, and the incidence of contralateral hernia is at most 10% in these patients. The authors think that the incidence is still too low to justify routine exploration and surgery for a patent processus vaginalis. Contralateral exploration should therefore be reserved for high-risk patients in whom second anesthesia and surgery have to be avoided.     

Metachronous bilateral renal cell carcinoma: risk assessment, prognosis and relevance of the primary-free interval

PURPOSE: We evaluated the prognosis, risk factors and relevance of the primary-free interval in a large cohort with metachronous bilateral renal cell carcinoma. MATERIALS AND METHODS: We studied 120 patients with metachronous, bilateral renal cell carcinoma who were treated at 12 international academic centers. Logistic regression was performed to evaluate risk factors for contralateral metachronous renal cell carcinoma during followup. Disease specific survival was evaluated with univariate and multivariate analysis. RESULTS: Median age at diagnosis of the first and second renal cell carcinomas was 54 and 62 years, respectively. The most common histological subtype was bilateral clear cell renal cell carcinoma (89% of cases). Familial renal cell carcinoma was found in 14% of patients, von Hippel-Lindau disease was found in 4% and nonfamilial renal cell carcinoma was found in 81%. The 15-year disease specific survival rates for the first and second renal cell carcinomas were 66% and 44%, respectively. Logistic regression revealed von Hippel-Lindau disease, a family history of renal cell carcinoma, multifocal first renal cell carcinoma and young patient age as independent risk factors for contralateral renal cell carcinoma after surgery for unilateral renal cell carcinoma. A longer primary-free interval was associated with a better prognosis. When calculating disease specific survival from the diagnosis of the first renal cell carcinoma, the primary-free interval was an independent prognostic factor. CONCLUSIONS: Long-term survival rates of metachronous, bilateral renal cell carcinoma are moderate. von Hippel-Lindau disease, a family history of renal cell carcinoma, multifocal first renal cell carcinoma and young patient age are independent risk factors for contralateral renal cell carcinoma. These risk factors support close and extended abdominal surveillance following nephrectomy for unilateral renal cell carcinoma. Patients with a longer primary-free interval have a more favorable prognosis.     

Metachronous colorectal cancer

OBJECTIVE: Although the diagnosis of metachronous colorectal cancer have increased, due primarily to improvements in diagnostic modalities, the potential risk factors for these tumours are not well known. We compared the characteristics of patients with metachronous and sporadic primary colorectal cancer to determine risk factors for its occurrence. PATIENTS AND METHODS: We reviewed the records of 5447 patients with colorectal cancer, who had been treated at Asan Medical Centre between July 1989 and January 2004. A metachronous cancer was defined as a secondary colorectal cancer occurring more than 6 months after the index cancer. RESULTS: Metachronous colorectal cancer occurred in 39 (0.7%) patients. Their average age was 53 years, somewhat younger than the average age of sporadic colorectal cancer patients (58 years). In patients with metachronous cancer, the cancer was more likely to be located in the right colon (P < 0.03), and the incidence of synchronous polyps or cancer was significantly higher (P < 0.001). The relative distributions of histological grades and clinicopathological characteristics were similar in index and metachronous cancers. Metachronous cancers were diagnosed more frequently at an early stage. The time interval between index and metachronous cancer ranged from 6 to 215 months (mean 39 months), with 13 (33.3%) patients diagnosed with metachronous cancer after 5 years. CONCLUSION: We found that in patients aged < 50 years, existence of synchronous polyps or cancer influence on the development of metachronous colorectal cancer. Regular follow-up is necessary for early detection, even after 5 years, for these patients.     

Surgical treatment of adrenal metastasis from renal cell carcinoma: a single-centre experience of 45 patients

OBJECTIVE: To report, in a retrospective study, the diagnostic problems and oncological results of surgery in patients with either synchronous or metachronous adrenal metastasis, which are uncommon in renal cancer, at 2-10% of patients. PATIENTS AND METHODS: Of 1179 patients treated for renal cancer between 1987 and 2003, 914 had renal surgery with concomitant ipsilateral adrenalectomy (routinely in 875 and for abnormal findings on computed tomography, CT, in 39) and 15 contralateral adrenalectomy (all after suspicious findings on CT). During the follow-up after renal surgery, another 14 patients had adrenalectomy for CT evidence of an abnormal adrenal gland, contralateral to the previous renal tumour in 12 and bilaterally in two. RESULTS: Of 914 ipsilateral adrenal glands removed during renal surgery, 854 (93.5%) were normal on pathological examination, 28 (3%) had a benign pathology, six (0.8%) were directly infiltrated by the tumour and 26 (2.7%) were metastatic. For both benign and metastatic ipsilateral adrenal pathology, CT had sensitivity, specificity and positive/negative predictive values of 47%, 99%, 73% and 96%, respectively. Of 29 contralateral glands removed because of suspicious CT findings (15 at diagnosis of renal cancer, 14 during the follow-up) there was no abnormality in one (3.4%), a benign pathology in seven (24%) and a metastasis in 21 (72%). Thus there were 32 synchronous (incidence 2.7%; ipsilateral to the renal tumour in 24, contralateral in six and bilateral in two), and 13 metachronous adrenal metastases (incidence 1.0%; contralateral in 11 and bilateral in two). The metachronous metastases were diagnosed at a mean (range) interval of 30.6 (8-73) months after renal surgery. No ipsilateral adrenal metastases were discovered at diagnosis or during the follow-up in the 382 patients with an organ-confined renal tumour of <4 cm in diameter. Twenty-seven patients with an isolated adrenal metastasis (synchronous in 14, metachronous in 13) had statistically significantly (P < 0.001) better survival than the 18 (all synchronous) with multiple sites of metastatic disease. In particular, there was long-term survival (mean 83 months) in 10 patients with an isolated adrenal metastasis. CONCLUSION: Sparing the ipsilateral adrenal is advisable only for organ-confined renal tumours of <4 cm in diameter; clinical local staging of renal cancer is the best predictor of the risk of adrenal metastasis. Conversely, CT had good diagnostic ability for the contralateral adrenal gland, especially during the follow-up. Some patients with isolated adrenal metastasis could be treated by metastasectomy, with long-term survival free of disease and confirming that, even if in a few and unselectable patients, removing all the neoplastic bulk can be curative. Nevertheless, the high rate of relapse underlines the need for an effective systemic therapy, and more so for widespread metastatic disease that currently cannot be cured.     

Robot-assisted laparoscopic nephroureterectomy for upper tract urothelial carcinoma (UT-UC)

Upper tract urothelial carcinoma (UT-UC), including tumors evolving from the renal pelvis and ureter, accounts for around 5% of all UCs and 10% of all renal tumor cases. In Taiwan, the incidence of UT-UC is higher than the western countries especially in the female and patients at renal replacement therapy. The standard care of UT-UC is nephroureterectomy with bladder cuff excision. In the past decades, minimally invasive surgery is proved to achieve comparable oncological results as conventional open procedure. Though laparoscopic nephroureterectomy with bladder cuff excision including pure laparoscopic or hand-assisted technique have been very common practice in Taiwan, several institutes have the early experience of robot-assisted nephroureterectomy which is believed to provide 3-D visualization with magnification, better surgical exposure, and safer watertight suture of the cystostomy. In this review, we review the published reports of robot-assisted nephroureterectomy with bladder cuff excision.     

Long-Term Use of Mycophenolate Mofetil is Associated With a Reduction in the Incidence and Risk of Late Rejection

To evaluate the association of long-term continuous (minimum 1 year) mycophenolate mofetil (MMF) vs. azathioprine (AZA) therapy with the incidence of late acute rejection, we analyzed 47 693 primary renal allograft recipients reported to the United States Renal Data System between 1988 and 1998. The primary study endpoint was acute rejection beyond 1 year after transplantation. Univariate Kaplan-Meier analysis and multivariate Cox proportional hazard models were used to investigate the risk of reaching the study endpoints. All multivariate analyses were corrected for potential confounding covariates. Mycophenolate mofetil was associated with a 65% decreased risk of developing late acute rejection as compared to AZA (RR = 0.35, CI 0.27-0.45, p < 0.001). The incidence of acute rejection episodes at 2 and 3 years post-transplantation was significantly lower in the MMF group (0.9% at 2 years, 1.1% at 3 years) than the AZA group (6.1% at 2 years, 9.3% at 3 years). In the primary vs. repeat late rejection analysis, MMF patients exhibited a decreased late acute rejection risk of 72% (RR = 0.28, p < 0.001) and 60%, respectively (RR = 0.40, p < 0.001). In African Americans, the late acute rejection risk was 70% lower in MMF patients than AZA patients (RR = 0.30, p < 0.001). Further study is indicated to determine the optimal duration of MMF therapy after renal allograft transplantation.     

Metabolic syndrome and atherosclerotic events in renal transplant recipients

BACKGROUND: Metabolic syndrome (MS) is a known cardiovascular risk factor in the general population. We explored the influence of MS on the occurrence of atherosclerotic events (AEs) after renal transplantation. METHODS: Three hundred thirty-seven renal transplant recipients were included in the study. Various parameters (e.g., anthropometric and biological) were measured 1 year after transplant. RESULTS: One year after transplant, 32% of the study population met criteria for MS. Older age, male gender, pretransplant high body mass index, and an increase in body mass index>or=5% in the first year after transplant were predictive factors for development of MS at 1 year after transplant. Forty-two patients (12.4%) experienced AEs during the 8 years of follow-up. The cumulated incidence of AEs was greater in patients with MS compared with others without MS (25% vs. 7%; P<0.001). In multivariate analysis, patients with MS at 1 year after transplant had an increased risk of AE (hazard ratio 3.40, 95% confidence interval 1.58-7.32, P=0.002). Older age, low creatinine clearance, high C-reactive protein level, and a past history of cardiovascular disease were other independent risk factors for AE. CONCLUSIONS: Similar to the general population, MS is an independent risk factor for AE after renal transplantation. Relevant preventive measures targeting different aspects of MS would then have a potential impact on prevalence of AE in this population.     

Bladder tumour development after urothelial carcinoma of the upper urinary tract is related to primary tumour location

OBJECTIVE: To better define the predictors of bladder tumour development in patients operated for upper urinary tract urothelial cancer (UT-UC). PATIENTS AND METHODS: Surgical specimens from 191 consecutive patients with no history of bladder cancer and operated for UT-UC were chosen for analysis. Bladder tumour development was assessed in relation to UT-UC location, tumour multiplicity, stage and grade, margin status, mode of operation, age and gender. RESULTS: Overall, 51 of 191 (27%) patients developed subsequent bladder tumours, including 25 of 123 (20%) with pelvic, 19 of 47 (40%) with ureteric and seven of 21 (33%) with multifocal tumours (P = 0.04 for all subgroups; P = 0.01 for pelvic vs ureteric). There was no influence of the other variables. The median (mean, range) time to recurrence was 12 (18, 3-64) months. In a multivariate analysis, ureteric tumour location was an independent predictor (P = 0.02; risk ratio, RR, 2.0, 95% confidence interval, CI, 1.1-3.7). After excluding 68 patients with systemic disease progression, bladder tumour development was noted in 39 of 123 (32%), including 18 of 76 (24%) with pelvic, 16 of 34 (47%) with ureteric and five of 13 with multifocal tumours (P = 0.06 for all subgroups; P = 0.02 for pelvic vs ureteric). In a multivariate analysis, ureteric location (P = 0.03; RR 2.1, 95% CI 1.1-4.2) and high tumour grade (P = 0.04; RR 2.2, 95% CI 1.03-4.7) were independent predictors of subsequent bladder tumour development. CONCLUSION: The risk of developing a bladder tumour after surgery for UT-UC is significantly related to ureteric tumour location and high tumour grade. Clinical trials to evaluate a possible reduction of bladder cancer risk by intraoperative ureteric ligation and/or peri-operative topical intravesical chemotherapy instillation are justified.     

Associations with contralateral recurrence following nephrectomy for renal cell carcinoma using a cohort of 2,352 patients

PURPOSE: We determined the incidence of and factors associated with the development of renal cell carcinoma (RCC) in the contralateral kidney after nephrectomy for localized RCC. MATERIALS AND METHODS: Between 1970 and 2000, 2,352 patients with sporadic, localized unilateral RCC and a normal contralateral kidney underwent nephrectomy for RCC. Cancer specific survival rates were estimated using the Kaplan-Meier method. Univariate Cox proportional hazards models were used to determine associations with outcome. RESULTS: Of the 2,352 patients studied 28 (1.2%) had RCC in the contralateral kidney, including 20 with clear cell and 8 with papillary RCC. Mean time from primary surgery to contralateral recurrence was 5.2 years (median 4.8, range 0 to 18) for clear cell RCC compared with 5.6 years (median 1.3, range 0 to 21) for papillary cell RCC. Positive surgical margins (risk ratio 14.23, p = 0.010) and multifocality (risk ratio 5.74, p = 0.019) were significantly associated with contralateral recurrence following nephrectomy for clear cell RCC, while nuclear grade (risk ratio for grades 3/4 vs 1/2, 4.78, p = 0.040) was significantly associated with contralateral recurrence following nephrectomy for papillary RCC. In patients with clear cell RCC estimated cancer specific survival rates 1, 3, and 5 years following contralateral recurrence were 93.8%, 80.2% and 72.9%, respectively. CONCLUSIONS: In patients with localized RCC and a normal contralateral kidney who underwent nephrectomy for RCC positive surgical margins and multifocality were significant predictors of contralateral recurrence for clear cell RCC, while nuclear grade was a significant predictor of contralateral recurrence for papillary RCC.     

Open and laparoscopic inguinal hernia repair in children: A regional experience

PurposeThe optimal approach for pediatric inguinal hernia repair continues to be debated. We conducted a regional retrospective study to assess rates of recurrence and metachronous hernias after open repair (OPEN) and laparoscopic repair (LAP)MethodsA retrospective cohort study was conducted at two children's hospitals that serve a region of approximately 4 million people. All patients < 14 years old undergoing OPEN or LAP by pediatric surgeons during a 5-year period (2011 – 2015) were analyzed after a minimum follow up of 4 years. Cox proportional regression was used to compare the effect of surgical approach on hernia recurrence and metachronous contralateral hernias.ResultsA total of 1,952 patients, 587 female (30%) and 1365 male (70%), had 2305 hernias repaired. Median post operative follow up time was 6.6 years (range 4–9 years). OPEN and LAP were performed for 1827 (79%) and 478 (21%) hernias, respectively. There were no significant differences in rate of prematurity, age at repair, or frequency of emergent repair. LAP was associated with a lower incidence of metachronous contralateral hernias compared to OPEN (1.4% vs 3.8%, p = 0.047), and a higher incidence of recurrence (9% vs 0.9%, p < 0.001). After adjusting for confounders, LAP had a higher rate of recurrence than OPEN (hazard ratio 10.4, 95% CI 6–18.1).The recurrence rate did not decrease over the study period (p = 0.731).ConclusionLaparoscopic inguinal hernia repair in children resulted in a modest decrease in the incidence of metachronous hernias, at the cost of a significant increase in recurrence.Type of StudyRetrospective Comparative Study.Level of evidenceLevel III.     

Systematic review of the risk of developing a metachronous contralateral inguinal hernia in children

BACKGROUND: This study aims to establish the risk of developing a metachronous contralateral inguinal hernia (MCIH) following open repair of a unilateral inguinal hernia in children. METHODS: A systematic review was performed using a defined search strategy. Studies in which children undergoing open repair of a unilateral inguinal hernia without contralateral exploration and who were followed up for MCIH development were included. RESULTS: Of 5937 titles and abstracts screened, 154 full-text articles were identified for review; 49 papers were analysed with data on 22,846 children. The incidence of MCIH was 7.2 per cent overall, 6.9 per cent in boys and 7.3 per cent in girls (P = 0.381). Children with a left-sided inguinal hernia had a significantly higher risk of developing a MCIH than those with a right-sided hernia (10.2 versus 6.3 per cent respectively; P < 0.001). CONCLUSION: Overall, in both boys and girls, 14 contralateral explorations are required to prevent one metachronous hernia. The risk of developing a MCIH appears unchanged in early childhood, with a slight reduction after 12 years of age. Children with a left-sided hernia have the greatest risk of developing a contralateral hernia, but ten explorations are still required to prevent one metachronous hernia. Most MCIHs occur in the first 5 years after unilateral inguinal hernia repair.     

Contralateral recurrence and prognostic factors in familial non-BRCA1/2-associated breast cancer

BACKGROUND: A higher incidence of contralateral breast cancer and ipsilateral recurrence has been reported in familial breast cancer than in sporadic cancer. This study investigated the influence of contralateral cancer and tumour stage on survival in patients with familial non-BRCA1/BRCA2-associated breast cancer. METHODS: The incidences of contralateral breast cancer, ipsilateral recurrence, distant disease-free and overall survival were assessed in 327 patients from families with three or more breast and/or ovarian cancers, but no BRCA1 or BRCA2 gene mutation (familial non-BRCA1/2), and in 327 control subjects with sporadic breast cancer, matched for year and age at detection. RESULTS: Mean follow-up was 7.3 years for patients with familial-non-BRCA1/2 cancers and 6.5 years for patients with sporadic breast cancer. Tumours were stage T1 or lower in 62.1 per cent of familial non-BRCA1/2 cancers versus 49.9 per cent in sporadic breast cancers (P = 0.003), and node negative in 55.8 versus 52.1 per cent, respectively (P = 0.477). After 10 years the incidence of metachronous contralateral breast cancer was 6.4 per cent for familial non-BRCA1/2 tumours versus 5.4 per cent for sporadic cancers. The rate of ipsilateral recurrence was not significantly increased (17.0 versus 14.2 per cent, respectively, at 10 years; P = 0.132). Tumour size (hazard ratio (HR) 1.02 per mm increase, P = 0.016) and node status (HR 2.6 for three or more involved nodes versus node negative, P = 0.017) were independent predictors of overall survival in the familial non-BRCA1/2 group, and in the whole group, whereas contralateral breast cancer (HR 0.7, P = 0.503) and risk-reducing contralateral mastectomy (HR 0.4, P = 0.163) were not. CONCLUSION: Stage at detection was a key determinant of prognosis in familial non-BRCA1/2 breast cancer, whereas contralateral cancer was not. Risk-reducing contralateral mastectomy did not significantly improve survival, but early detection can. Decisions on breast-conserving treatment can be made on the same grounds in patients with familial and sporadic breast cancer.     

Increasing incidence of all stages of kidney cancer in the last 2 decades in the United States: an analysis of surveillance, epidemiology and end results program data.

PURPOSE: Since the 1980s with the increased use of abdominal imaging, such as computerized abdominal tomography, renal cancer has commonly been diagnosed as an incidental mass. We analyzed the renal cancer incidence from 1973 to 1998 in the Surveillance, Epidemiology and End Results program by historic staging of localized, regional or distant disease to evaluate possible stage migration due to increased abdominal imaging. MATERIALS AND METHODS: We used renal cancer data from the Surveillance, Epidemiology and End Results 9 registries, public use, August 2000 submission (National Cancer Institute, Bethesda, Maryland), which represents approximately 14% of the United States population. We analyzed the age adjusted renal cancer incidence from 1973 to 1998 using the 1990 American standard million population. We compared the incidence of the 3 stages of renal cancer from 1973 to 1985 and 1986 to 1998 by the chi-square test and used joinpoint regression analysis to determine whether there was a significant change in the intragroup or intergroup incidence rate with time. RESULTS: During 1973 to 1985 the rate of localized, regional and distant renal cancer was 45%, 23% and 32% compared with 54%, 21% and 25%, respectively, from 1986 to 1998 (p = 0.45). However, the plot of incidence rate versus diagnosis year by stage showed an increasing trend in the 3 stage groups. The annual percent change in the localized, regional and distant groups was 3.7 (95% confidence interval [CI] 3.2 to 4.2), 1.9 (95% CI 1.2 to 2.6) and 0.68 (95% CI 0.1 to 1.3) per 100,000 population, respectively (p <0.05). The 3 groups also had significantly different growth rates (p <0.01). CONCLUSIONS: There was no significant difference in stage at presentation of renal cancer diagnosed in 1973 to 1985 compared with that diagnosed in 1986 to 1998. While the lack of a decrease in distant disease despite the increased detection of regional and localized renal cancer implies that a proportion of innocuous renal cancer cases may be detected by increased abdominal imaging, the increased incidence of renal cancer in all 3 categories indicates that other factors may also be contributing to the increasing incidence of renal cancer.     

The influence of various maintenance immunosuppressive drugs on lymphocele formation and treatment after kidney transplantation

PURPOSE: We compared the incidence of lymphocele formation and treatment in kidney transplant recipients given 3 immunosuppressive drug regimens. MATERIALS AND METHODS: Consecutive series of adult kidney only recipients, including group 1-152 who received sirolimus/mycophenolate mofetil (MMF)/prednisone (P), group 2-168 who received cyclosporine/MMF/P and group 3-193 who received cyclosporine/azathioprine/P, were analyzed for post-transplantation lymphocele formation. All available records and imaging studies were reviewed, such as ultrasound, computerized tomography, magnetic resonance imaging etc, for peritransplant fluid collections greater than 2.5 cm. Demographic characteristics and the risk factors for lymphocele were compared in these 513 recipients using univariate and multivariate analysis. RESULTS: The overall incidence of lymphocele formation was 174 of 513 cases (33.9%) and the incidence of treated lymphoceles was 81 of 513 (15.7%). In groups 1 to 3 the incidence was 45.5%, 33.9% and 24.7%, respectively. These differences were significantly higher in group 1 vs groups 2 or 3 (p = 0.014) but they were not significantly different between groups 2 and 3. Similarly the incidence of treated lymphoceles was 23%, 12.5% and 12.9%, respectively. Findings were again statistically higher in group 1 vs groups 2 and 3 (p = 0.003) but not statistically significant between groups 2 and 3. A greater number of group 1 patients required surgical interventions compared with those in groups 2 and 3 (13.8% vs 4.7% and 4.8%, respectively, p = 0.019). In addition, acute rejection (p = 0.001) and body mass index greater than 32 (p = 0.02) were significant risk factors on multivariate analysis. CONCLUSIONS: The combination of sirolimus/MMF/P, obesity with a body mass index of greater than 30 kg/m and acute rejection are independent risk factors for lymphocele formation and treatment after kidney transplantation. Patients should be counseled and consideration should be given to prophylactic measures in this higher risk renal transplant population.     

Mycophenolate mofetil vs. azathioprine is associated with decreased acute rejection, late acute rejection, and risk for cardiovascular death in renal transplant recipients with pre-transplant diabetes

Outcomes specifically in mycophenolate mofetil (MMF)-treated diabetic renal transplant patients have not been previously reported. This study compared acute rejection (AR), late acute rejection (LAR), patient survival [and specifically death from cardiovascular (CV), infectious and malignant causes], incidence of post-transplant malignancies, and graft loss in MMF- or azathioprine (AZA)-treated renal transplant patients with pre-transplant diabetes. Outcomes were compared between MMF- (n = 14 144) and AZA- (n = 3001) treated diabetic patients using the Scientific Registry of Transplant Recipients data on all U.S. adult renal transplants performed between 1995 and 2002. Statistical analyses included Kaplan-Meier survival analysis, Cox multivariable regression and chi-square tests. MMF patients had less AR compared with AZA-treated patients (23.5% vs. 28.3%, p < 0.001) and less risk for LAR over 4 yr [hazard ratio (HR): 0.64, 95% CI 0.44, 0.92; p = 0.02]. While time to any-cause death did not differ between the groups, MMF treatment was associated with a 20% decreased risk of CV death (HR: 0.80, 95% CI 0.67, 0.97; p = 0.020) compared with AZA treatment. MMF patients also had a lower incidence of malignancies than AZA patients (2.2% vs. 3.7%, p < 0.001). These results suggest treatment with MMF compared with treatment with AZA in diabetic transplant patients is associated with less AR, less risk of LAR, a decreased risk of CV death, and a lower incidence of malignancies.     

Epidemiology and management of liver metastases from colorectal cancer

OBJECTIVE/BACKGROUND: Little is known about the epidemiology and the management of liver metastases from colorectal cancer at a population level. The aim of this population-based study was to report on the incidence, treatment, and prognosis of synchronous and metachronous liver metastases. METHODS: Data were obtained from the population-based cancer registry of Burgundy (France). RESULTS: The proportion of patients with synchronous liver metastases was 14.5%. Age-standardized incidence rates were 7.6 per 100,000 in males, 3.7 per 100,000 in females. The 5-year cumulative metachronous liver metastasis rate was 14.5%. It was 3.7% for TNM stage I tumors, 13.3% for stage II, and 30.4% for stage III (P < 0.001). The risk of liver metastasis was also associated to gross features. Resection for cure was performed in 6.3% of synchronous liver metastases and 16.9% of metachronous liver metastases. Age, presence of another site of recurrence, and period of diagnosis were independent factors associated with the performance of a resection for cure. The 1- and 5-year survival rates were 34.8% and 3.3% for synchronous liver metastases. Their corresponding rates were, respectively, 37.6% and 6.1% for metachronous liver metastases. CONCLUSION: Liver metastases from colorectal cancer remain a substantial problem. More effective treatments and mass screening represent promising approaches to decrease this problem.     

Vascular complications after live donor renal transplantation: study of risk factors and effects on graft and patient survival

We evaluated the incidence and management of vascular complications after live donor renal transplantation. Possible risk factors and their effects on patient and graft survival were also assessed. MATERIALS AND METHODS: A total of 1,200 consecutive live donor renal transplants were performed in 1,152 patients at a single institution. The incidence of different types of vascular complications were determined and correlated with relevant risk factors. The impact on patient and graft survival was also studied. RESULTS: There were 34 vascular complications (2.8%). Stenotic or thrombotic complications were recorded in 11 cases (0.9%), including renal artery stenosis in 5 (0.4%), renal artery thrombosis in 5 (0.4%) and renal vein thrombosis in 1 (0.1%). Hemorrhagic complications were observed in 23 patients (1.9%). Although no risk factors could be identified that were related to stenotic or thrombotic complications, grafts with multiple renal arteries were significantly associated with hemorrhagic complications (p = 0.04). Stenotic and thrombotic complications as well as hemorrhagic complications were significantly associated with subsequent biopsy proved acute tubular necrosis (p <0.001). The mean 5-year patient and graft survival rates +/- SD for those with vascular complications were 71.9% +/- 1.9% and 41.6% +/- 8.9% compared with 86.3% +/- 1.1% and 76.8% +/- 1.4% for the remainder of our transplant population, respectively (p <0.001). The deleterious impact on survival was not only observed in recipients with thrombotic or stenotic crises, but also in those with hemorrhagic sequelae. CONCLUSIONS: Hemorrhagic crises are as serious as the stenotic and thrombotic complications affecting patient and graft survival. Because they are a significant factor in the development of hemorrhagic complications, grafts with multiple renal arteries should be managed critically.     

Analysis of the United Network for Organ Sharing database comparing renal allografts and patient survival in combined liver-kidney transplantation with the contralateral allografts in kidney alone or kidney-pancreas transplantation

BACKGROUND: Combined liver-kidney transplantation (LKT) is the accepted treatment for patients with liver failure and irreversible renal insufficiency. Controversy exists as to whether simultaneous LKT with organs from the same donor confers immunologic and graft survival benefit to the kidney allograft. This study compares the outcomes of simultaneous LKT with the contralateral kidneys used for kidney alone transplantation (KAT) or combined pancreas-kidney transplantation (PKT) to understand the factors that account for the differences in survival. METHODS: From October 1987 to October 2001, LKTs with organs from 899 cadaver donors were reported to the United Network for Organ Sharing; 800 contralateral kidneys from these donors were used in 628 KAT and 172 PKT recipients. These 800 paired control patients were the basis of this analysis. RESULTS: Graft and patient survival rates were lower among LKT recipients compared with KAT (P<0.001) and PKT recipients (P<0.001), because of a higher patient mortality rate during the first 3 months posttransplant. Among human leukocyte antigen-mismatched transplants, LKT recipients demonstrated the highest 1-year rejection-free survival rate (LKT 70%, KAT 61%, and PKT 57% ) (P=0.005 vs. KAT, P=0.005 vs. PKT). There was a lower incidence of renal graft loss resulting from chronic rejection among LKT recipients (LKT 2% vs. KAT 8% vs. PKT 6%, P<0.0001). CONCLUSIONS: Patients undergoing LKT exhibit a higher rate of mortality during the first year posttransplant compared with patients undergoing KAT and KPT. Analysis of the data indicates an allograft-enhancing effect of liver transplantation on the renal allograft.     

术前影像诊断肾癌的肾脏良性病变发生率及预测因素分析

目的:研究在中国患者中术前影像学诊断肾癌行肾脏部分切除手术或根治性肾切除手术的肾脏良性占位病变发生率,并分析其预测因素。方法:回顾性分析从2003年1月～2010年9月共1 531例术前影像学诊断为肾癌并行肾脏部分切除手术或根治性肾切除手术患者的临床资料,多因素回归分析术后病理检查证实为良性患者的临床病理资料。结果:在1 531例患者中,共有81例(5.3%)为良性,其中包括错构瘤52例(3.4%),嗜酸细胞腺瘤12例(0.8%),复杂性囊肿6例(0.3%),其他类型11例(0.7%)。单因素分析显示女性、肿瘤最大径较小、年龄较小、囊性占位病变为临床表现者,病理检查证实为良性的可能性大。多因素回归分析显示,女性(OR,3.13;95%CI,1.95～5.04;P<0.001)、肿瘤最大径较小(OR,0.75;95%CI,0.66～0.85;P<0.001)、年龄较小(OR,0.94;95%CI,0.92～0.96;P<0.001)是良性占位病变的独立预测因素,而囊性占位病变不是显著性预测因素。结论:在中国患者中,术前影像学检查诊断为肾癌术后病理检查证实为良性病变的发生率为5.3%,较国外同类研究明显偏低。良性占位病变中最常见的类型为错构瘤,而欧美同类研究中为嗜酸细胞腺瘤。女性、年龄较小、肿瘤最大径较小是良性占位病变的独立预测因素。