Pure primary choriocarcinoma of the urinary bladder with long-term survival

Choriocarcinoma was diagnosed in a 77-year-old woman with an acute massive, painless hematuria. One year after anterior pelvic exenteration and ileal conduit, the beta-human chorionic gonadotropin level increased to 934 mIU/mL without any sign of tumor progression. After six courses of chemotherapy (vincristine, actinomycin, and cyclophosphamide), the beta-human chorionic gonadotropin levels returned to normal. To our knowledge, this is the fourth case of pure choriocarcinoma in the bladder, with the longest survival time of 33 months so far.     

Acute bacterial meningitis

In the past 10 years the epidemiology of bacterial meningitis has changed, with a decreased incidence of meningitis caused by Haemophilus influenzae and an increasing incidence of meningitis caused by penicillin- and cephalosporin-resistant strains of Streptococcus pneumoniae. Meningococcal meningitis has become an increasing threat to college students. Successful outcome from meningitis requires not only eradication of the bacterial pathogen but also management of the neurological complications of raised intracranial pressure, stroke, and seizure activity. In this article, the pathophysiology, etiology, clinical presentation, differential diagnosis, and management of acute bacterial meningitis are reviewed. The present recommendations for the use of dexamethasone in the treatment of this infection, the use of chemoprophylaxis, and the indications for vaccinations are included.     

Perioperative morbidity and renal function in young and elderly patients undergoing elective nephron‐sparing surgery or radical nephrectomy for renal tumours larger than 4 cm

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? The incidence of renal tumours is rising constantly. Patients in the 6th or 7th decade of life are mainly affected. Nephron‐sparing surgery (NSS) has become the gold standard for the treatment of patients presenting with renal tumors ≤4 cm and is recommended for cT1b lesions in experienced centers. Little is known about the functional outcome of elderly patients presenting with renal tumours larger than 4 cm and being treated by NSS in comparison to radical nephrectomy (RN). Here we could show that NSS can be performed safely with considerable perioperative morbidity and a better functional outcome according to renal function without lacking oncological control.

OBJECTIVE

To analyse renal function, perioperative morbidity and overall survival (OS) in patients aged <55 years compared with patients aged >65 years treated by radical nephrectomy (RN) or elective nephron‐sparing surgery (NSS) for renal tumours >4 cm.

PATIENTS AND METHODS

From our database, we identified 829 patients with renal tumours >4 cm treated by either RN (n= 641) or NSS (n= 188) at our institution between 1981 and 2007. After excluding patients with imperative indication and metastases, we identified retrospectively 81 patients aged <55 years (young patients) and 85 patients aged >65 years (elderly patients) treated for renal tumours >4 cm. In all, 36 and 33 patients underwent NSS and 45 and 52 patients underwent RN in the young and elderly group, respectively. Preoperative and periodically postoperative serum creatinin values were used to estimate glomerular filtration rate (GFR). Chronic kidney disease (CKD) was defined as GFR <60 mL/min/1.73 m². Clinical characteristics, complications and renal function were compared between age groups and surgical approaches, and OS was estimated using the Kaplan–Meier method.

RESULTS

The median (range) tumour size in young patients was larger compared with that of elderly patients, i.e. 6 (4.2–14.0) cm vs 5 (4.2–16.0) cm, with P < 0.001 considered to be statistically significant. The complication rates did not differ between the age groups (P= 0.656) or between NSS and RN in young (P= 0.095) or elderly patients (P= 0.277). Chronic kidney disease after RN or NSS occurred in 31.1% and 15.5% for young patients, respectively and in 50.9% and 24.2% in elderly patients, respectively, until last available follow‐up which was obtained after a median (range) of 5.69 (0.1–19.2) years for young patients and 5.48 (0.8–18.1) years for elderly patients. Overall survival did not significantly differ between NSS vs RN in young (P= 0.655) and elderly patients (P= 0.058).

CONCLUSION

Our findings suggest that performing NSS for tumours >4 cm when feasible in young and carefully selected elderly patients is more beneficial for maintaining long‐term renal function. Regardless of age, patients undergoing RN for renal tumours >4 cm developed more new onsets of CKD than patients treated by elective NSS. The complication rate did not differ between the age groups or between types of surgery.