Cytoreductive nephrectomy in the elderly patient: the M. D. Anderson Cancer Center experience

PURPOSE: Cytoreductive nephrectomy as part of a multidisciplinary approach may be considered in patients with metastatic renal cell carcinoma. The benefit in the elderly population (75 years or older) is unclear. We reviewed our experience to help determine if it is of benefit in this patient population. MATERIALS AND METHODS: Of 404 patients undergoing cytoreductive nephrectomy from 1995 and 2005 we identified 24 elderly patients. Outcomes in these elderly patients were analyzed and compared to outcomes in the remaining 380 who were younger than 75 years. RESULTS: Median age in the elderly and younger groups was 77.5 and 57.0 years, respectively. Performance status, sex distribution, and tumor histology, stage, grade and size were comparable. Estimated blood loss, transfusion rates, surgical times and hospital stay were similar in the 2 groups. There were 5 perioperative deaths (21%) in elderly patients compared to 4 (1.1%) in younger patients (p<0.01). Estimated blood loss, units transfused and surgical time were greater in the patients who died perioperatively (p<0.05). Median survival was 16.6 months in the elderly group, which did not differ statistically from the 13.7 months in the younger group. CONCLUSIONS: Cytoreductive nephrectomy in the elderly population can be associated with the potential for significant morbidity and mortality. Despite this and as part of a multidisciplinary approach it may provide potential survival as well as other benefits, which may justify it in highly select and highly motivated patients who are 75 years or older. However, it must be performed carefully with realistic expectations on behalf of the patient and urologist.     

质性个案研究：医疗卫生专业人员实用策略

在医疗卫生专业领域,我们熟悉临床个案这一概念。关注临床个案是大多数临床实践的核心。质性个案研究方法被用于教育学、商贸学、社会学等多种学科。质性个案研究的一个显著标志就是它能抓住单个     

Cytofluorometric determination of nuclear DNA content in gallbladder epithelium of patients with biliary stones.

Cytofluorometric determination of nuclear DNA content in fresh gallbladder epithelium of 11 patients with biliary stones were performed to assess the histological correlations and to evaluate the ploidy pattern affected by inflammation or regenerative proliferating benign epithelium associated with non-neoplastic or neoplastic diseases. 27% of the patients were classified to have pure cholesterol stones, 54% were classified to have mixed stones and 19% were classified to have black stones. All of the specimens show suggestion of chronic cholecystitis without any metaplastic or neoplastic change. The bile culture shows free of bacteria in all of the cases. Cytofluorometric nuclear DNA ploidy analysis shows 64% diploidy and 36% low ploidy patterns of histograms. It can be concluded that the low ploidy pattern which could lead to false positive diagnosis of aneuploidy and may be associated with regenerative proliferating benign epithelium with severe inflammatory changes.     

Glutathione, glutathione S-transferase, and transmembrane transport of glutathione conjugate in human neutrophil leukocytes

Glutathione (GSH) conjugation is important in the detoxification of carcinogens and other exogenous electrophilic drugs and chemicals. The conjugation is catalyzed by GSH S-transferase. Neutrophil GSH content was 12.3 +/- 2.5 (mean +/- SD) nmol/10(7) cells, and transferase activity of cytosol preparations was 0.187 +/- 0.035 nmol/min/mg protein with 1-chloro-2,4-dinitrobenzene (CDNB) as substrate. Maximal activity was found at a pH of 7.0 and a temperature of 40 degrees C. Apparent Km of transferase was 1.25 +/- 0.18 mmol/L CDNB, and apparent Vmax was 0.621 +/- 0.22 nmol/min/mg. GSH-CDNB conjugate was quantitated by HPLC in cells and in medium after CDNB exposure. Transport of conjugate from cells to medium increased with CDNB concentration to 50 mumol/L, and kinetic data showed two saturable transport mechanisms with apparent Km of 5.90 mumol/L and 0.265 mumol/L, respectively. Cellular GSH content fell rapidly with CDNB concentration greater than 2.5 mumol/L, and was depleted in a 10-minute incubation at a concentration of greater than 50 mumol/L CDNB. Neutrophils have a significant content of GSH and a significant amount of transferase activity, and transport of GSH conjugate involves two distinct saturable pathways. GSH depletion can be accomplished with a relatively low concentration of an exogenous chemical and could impair the ability of the cells to carry out their phagocytic functions.     

The role of FISH and cytology in upper urinary tract surveillance after radical cystectomy for bladder cancer

ObjectivesCytology and fluorescence in situ hybridization (FISH) (Urovysion) assay are often used during upper urinary tract surveillance in patients following radical cystectomy with urinary diversion, without much available data regarding efficacy in this population. Here, we evaluate the value of FISH and cytology in detecting upper tract recurrence in the face of a urinary diversion.Materials and methodsA review of our cystectomy database revealed 270 patients who had at least one FISH and/or cytology assay performed during surveillance after radical cystectomy. Workup included upper tract imaging in all patients and upper tract endoscopy as indicated. A total of 163 FISH assays and 474 urinary cytology examinations were included in the analysis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of FISH and cytology were assessed.ResultsTen patients (3.4%) developed upper tract recurrence after a median follow-up time of 31 months (2–202). All but 1 patient presented either with gross hematuria or positive finding on imaging; 6 had positive FISH and cytology, and 2 had positive cytology only (no FISH done). For detection of upper tract recurrence, sensitivity, specificity, PPV, and NPV of cytology were 80.0%, 85.6%, 10.7%, and 99.5%, respectively; and that for FISH were 85.7%, 86.5%, 23.1%, and 99.2%, respectively.ConclusionsThe FISH assay and urinary cytology both demonstrate high rates of false positivity and are useful mainly for their negative predictive ability in patients with a urinary diversion. Unless prospective trials show otherwise, both—or at least the more expensive test—can be omitted from surveillance strategies.     

Recurrent seminomas: Clinical features and biologic implications

ObjectivesCertain patients with seminoma and clinically atypical phenotypes—visceral metastases, elevated levels of β human chorionic gonadotropin (βHCG), and/or recurrent disease—have a poor prognosis. The primary goal of this pilot study was to characterize the clinical characteristics and treatment profile of these rare patients. We also wished to test whether these tumors expressed any specific biomarkers that might distinguish them as a unique subtype of seminoma.Materials and methodsWe retrospectively identified 25 patients with a history of seminoma plus visceral metastases, βHCG levels >200 mU/ml, and/or recurrent disease. We reviewed these patients' histories for treatment efficacy and clinical outcome. Tissue samples were available from 6 of those patients, and we studied them for expression of the markers OCT 3/4, PLAP, CD30, TRA-1-60, c-kit, and gp200. We compared our results with the expression of those markers in tissue samples from mixed seminoma/embryonal carcinomas and classic seminomas.ResultsOur analysis suggested that certain chemotherapeutic regimens (such as ifosfamide, paclitaxel, and cisplatin) are efficacious for the treatment of patients with these atypical seminomas. Further, specimens from the atypical seminomas generally had staining profiles that resembled those of classic seminomas and the seminoma components in mixed germ-cell tumors, but the profiles differed from those of the embryonal carcinoma components in the same mixed germ-cell tumors.ConclusionsAlthough these atypical seminomas tend to be resistant to chemotherapy, they may still respond to certain chemotherapeutic regimens. Our pilot immunohistochemical study also suggested that the unique phenotypes associated with these atypical seminomas do not result from any relationship with embryonal carcinomas. More study is needed to confirm these initial findings.