Drug-induced granulomatous interstitial nephritis in a pediatric patient

Acute interstitial nephritis (AIN) is a known cause of acute renal failure in children. In most instances, drug therapy is the offending agent. Although granuloma formation has been observed in drug-induced interstitial nephritis, it is not a commonly associated manifestation. This is a case of a 15-year-old white female with Tetralogy of Fallot and pulmonary atresia who developed acute renal failure secondary to drug-induced interstitial nephritis and renal granulomas. In addition to interstitial edema with eosinophils and lymphocytes, her renal biopsy showed interstitial granulomas, immune complexes within tubular basement membranes, and the unusual feature of multinucleated giant cells engulfing tubules. Her acute renal failure resolved after the withdrawal of antibiotics and the initiation of intravenous steroid therapy.     

Risk factors for renal scarring in children and adolescents with lower urinary tract dysfunction

Risk factors for renal scarring in children with lower urinary tract dysfunction (LUTD) were evaluated. The medical records of 120 patients were assessed concerning gender, presence of vesicoureteric reflux (VUR), bladder capacity, detrusor overactivity, residual urine, febrile urinary tract infection (UTI), bacteriuria, constipation, detrusor sphincter incoordination (DSI), high detrusor pressure at maximal cystometric capacity (PMCC), low compliance, and thickness and trabeculation of the bladder wall. Renal scarring was diagnosed by ^99mtechnetium-dimercaptosuccinic acid renal scan (DMSA). Renal scarring was detected in 38 patients (31%). VUR, UTI, decreased bladder capacity, urinary residue, and trabeculated and thick bladder wall were associated with scarring at univariate analysis. Multivariate analysis showed VUR (P < 0.0001) as the independent risk factor for renal scarring. Thickness of the bladder wall was a marginal risk factor (P  = 0.07). Although UTI was not a risk factor, it was associated with VUR (P  = 0.03). In our analysis, VUR was the main risk factor; however, renal scarring was probably due to multifactorial causes, as VUR was associated with UTI.     

Late-onset chylothorax following extrapleural pneumonectomy for mesothelioma

We report a 64-year-old woman treated with surgical intervention for late-onset chylothorax following a pleuropneumonectomy. The patient underwent an extrapleural pneumonectomy for diffuse malignant mesothelioma and was uneventfully discharged on postoperative day 29. Pleural effusion aspirated on postoperative day 9 was dark red. A chest roentgenogram taken at our outpatient clinic revealed a mediastinal shift on postoperative day 56. No bacterial infection was found in the milky effusion. We made a diagnosis of postoperative late-onset chylothorax based on the laboratory data obtained from tests of the pleural fluid. A repeat thoracotomy to ligate the lymphatic duct was performed because conservative management with chest tube drainage and no oral feeding was unsuccessful. The patient was discharged after the operation with a good clinical course.     

Spontaneous Regression of Inflammatory Pseudotumor of the Liver: Report of Three Cases

Inflammatory pseudotumor (IPT) of the liver is a rare benign hepatic lesion that sometimes mimics malignant tumors. An accurate diagnosis of IPT is important to avoid unnecessary surgery. We herein report three cases of IPT of the liver that spontaneously regressed and were successfully diagnosed without a surgical resection. Malignant tumors were initially suspected based on the initial imaging findings, including ultrasonography, computed tomography (CT), and magnetic resonance imaging. In particular, a delayed enhancement in the periphery of the masses was observed on dynamic CT scans, similar to the imaging results for metastatic tumors or intrahepatic cholangiocarcinomas. The serum levels of C-reactive protein were elevated in all three patients (6.6, 3.4, and 1.5 mg/dl), while the serum levels of tumor markers were almost within the normal ranges (carcinoembryonic antigen, <5 ng/ml; carbohydrate antigen 19-9, 201, 3, and 14 U/ml). Serial repeated imaging studies over the course of a month showed the spontaneous regression of the hepatic tumors, thus enabling us to make a diagnosis of IPT without a surgical resection. A percutaneous biopsy confirmed the histology in one case. The regression of tumors on repeated images should play a key role in making an accurate diagnosis of IPT.     

Adrenal surgery in the pediatric population

Adrenal tumors in children may be benign or malignant. In addition, both benign and malignant tumors may be hormonally active, leading to hypertension, metabolic crises, and endocrinopathies. These tumors may be found incidentally or secondary to signs and symptoms of the aforementioned disorders. Both a metabolic and a radiographic work-up are required before treatment of an adrenal tumor. The primary therapy for most adrenal lesions is surgical, though some are treated medically or require chemotherapy before excision. Laparoscopy has become the surgical approach of choice in both adult and pediatric patients with localized disease. Open surgical approaches remain necessary in patients with extensive locally invasive or metastatic disease.     

Surgical treatment strategies and outcome in patients with breast cancer metastatic to the spine: a review of 87 patients

Aggressive surgical management of spinal metastatic disease can provide improvement of neurological function and significant pain relief. However, there is limited literature analyzing such management as is pertains to individual histopathology of the primary tumor, which may be linked to overall prognosis for the patient. In this study, clinical outcomes were reviewed for patients undergoing spinal surgery for metastatic breast cancer. Respective review was done to identify all patients with breast cancer over an eight-year period at a major cancer center and then to select those with symptomatic spinal metastatic disease who underwent spinal surgery. Pre- and postoperative pain levels (visual analog scale [VAS]), analgesic medication usage, and modifed Frankel grade scores were compared on all patients who underwent surgery. Univariate and multivariate analyses were used to assess risks for complications. A total of 16,977 patients were diagnosed with breast cancer, and 479 patients (2.8%) were diagnosed with spinal metastases from breast cancer. Of these patients, 87 patients (18%) underwent 125 spinal surgeries. Of the 76 patients (87%) who were ambulatory preoperatively, the majority (98%) were still ambulatory. Of the 11 patients (13%) who were nonambulatory preoperatively, four patients were alive at 3 months postoperatively, three of which (75%) regained ambulation. The preoperative median VAS of six was significantly reduced to a median score of two at the time of discharge and at 3, 6, and 12 months postoperatively (P < 0.001 for all time points). A total of 39% of patients experienced complications; 87% were early (within 30 days of surgery), and 13% were late. Early major surgical complications were significantly greater when five or more levels were instrumented. In patients with spinal metastases specifically from breast cancer, aggressive surgical management provides significant pain relief and preservation or improvement of neurological function with an acceptably low rate of complications.     

Prophylactic single-dose prulifloxacin for catheter-associated urinary tract infection after tension-free vaginal tape procedure

The purpose of the study was to evaluate whether antibiotic prophylaxis with a single dose of prulifloxacin after tension-free vaginal tape (TVT) procedure decreases catheter-associated urinary tract infections (UTIs). Patients undergoing TVT procedure receiving a single dose of prulifloxacin (600 mg) 10 h before catheter removal (n = 54) were compared with historical controls who have had no treatment (n = 60). All patients had an indwelling urethral catheter in situ for 24 h. Urine specimens for culture were collected preoperatively, before Foley removal, and 7 days postoperatively in both groups. Main outcome measures were significant bacteriuria and symptomatic UTI at catheter removal and 1 week postoperatively. No patient had a positive urine culture in the prulifloxacin group compared with 14 (23.3%) in the control group at catheter removal (P = 0.0001). Ten out of 14 (71.4%) women with a positive catheter urine culture had a symptomatic UTI. One week after surgery no difference was found in the rate of significant bacteriuria between groups. Our data suggest that a prophylactic single dose of prulifloxacin could help to reduce the rate of symptomatic and asymptomatic UTIs after short-term urethral catheterization in women undergoing TVT procedure.     

Intraoperative Evaluation of Sentinel Lymph Nodes for Metastatic Melanoma by Imprint Cytology

Background Sentinel lymph node biopsy (SLN) has revolutionized nodal staging. Accurate intraoperative evaluation of SLN permits a single procedure, with lymphadenectomy being performed during the initial operative procedure when the SLN is positive. There is a paucity of literature on intraoperative imprint cytology (IIC) evaluation of the SLN in melanoma. The purpose of this article is to present an update to our experience with IIC for SLN in melanoma. Methods Melanoma patients had SLNs examined by IIC. SLNs were bisected, and imprints were made from each half. Imprints were stained with hematoxylin and eosin and with Diff-Quik. Paraffin-embedded sections were examined with multiple hematoxylin and eosin–stained sections from the SLNs in conjunction with immunohistochemical staining for S-100, Melan-A, and HMB-45 proteins. Results Metastases were identified in 40 (17%) of 229 patients. Of these, 13 patients were detected by IIC (sensitivity, 33%). The negative predictive value was 88%. No false-positive results were identified (specificity, 100%). The positive predictive value was 100%. The accuracy of IIC was 78%. The sensitivity for detecting macrometastases (>2 mm) was better than that for detecting micrometastases (≤2 mm): 62% vs. 16% (P < .01). Patients with positive SLNs by IIC had lymphadenectomy under the same anesthetic. A total of 533 nonsentinel lymph nodes were identified in 42 patients. Only two patients (8%) had positive nonsentinel lymph nodes after a negative IIC. Conclusions IIC is a viable alternative to frozen sectioning when intraoperative evaluation is desired. IIC is significantly more sensitive for macrometastases. IIC evaluation of SLNs in melanoma makes a single operative procedure possible for a significant proportion of patients with regional nodal metastases. Presented at the Society of Surgical Oncology, San Diego, California, March 24, 2006.     

Biliary Obstruction in Gall Bladder Cancer Is Not Sine Qua Non of Inoperability

Background The presence of biliary obstruction in patients with gallbladder cancer (GBC) is generally viewed as an indicator of advanced disease, inoperability and poor prognosis. Methods Data was collected from patients with GBC with obstructive jaundice who underwent resection during the period January 2001 to October 2003. Systematic analysis of prospective data was undertaken; patients were analyzed for resectability, post-operative morbidity, mortality and disease-free survival. Results During this period 14 patients with GBC with biliary obstruction underwent resection with curative intent. In these jaundiced patients, the resectability rate was 27.45% (14 of 51). In the jaundiced group the mortality was 7.14% the morbidity rate 50%, the mean disease free survival was 23.46 months (median 26 months and range of 2 to 62 months). Seven patients (50%) survived more than two years. Conclusion Biliary obstruction in gall bladder cancer is not sine qua non of inoperability and resection results in meaningful prolongation of survival.     

Metallothionein in bladder cancer: correlation of overexpression with poor outcome after chemotherapy

We examined metallothionein (MT) expression in bladder cancer and its relationship to clinicopathologic factors, survival data, and outcome of chemotherapy. In 97 patients who underwent radical cystectomy for bladder cancer, 34 of whom received cisplatin-based chemotherapy, MT expression was evaluated immunohistochemically. Results were correlated with histopathologic data, survival rates, and outcome of chemotherapy. MT overexpresison was present in 33 patients (34.0%): strong in 7 (7.2%) and focal in 26 (26.8%). Overexpression was an independent prognostic factor and was significantly associated with poor survival. Patients undergoing chemotherapy showed worse survival if their tumours were MT-positive than if they were MT-negative. MT overexpression predicts unfavorable survival in bladder cancer patients. In those treated with cisplatin chemotherapy, survival is significantly poorer if tumours express MT. Our results show that MT overexpression may mediate resistance to alkylating agents. Therefore, further studies are warranted to define those patients who need a more aggressive therapy.