Surgical Management of Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus

Background. The optimal management of patients with renal cell carcinoma with inferior vena cava tumor thrombus remains unresolved. Traditional approaches have included resection with or without the use of cardiopulmonary bypass. Chemotherapy has played a minor role except for biotherapeutic agents used for metastatic disease.

Methods. From January 1989 to January 1996, 37 patients with renal cell carcinoma and inferior vena cava tumor thrombus underwent surgical resection. The 27 men and 10 women had a median age of 57 years (range, 29 to 78 years). Thirty-six patients presented with symptoms; 21 had hematuria. Distant metastases were present in 12 patients. Tumor thrombi extended to the infrahepatic inferior vena cava (n = 16), the intrahepatic inferior vena cava (n = 16), the suprahepatic inferior vena cava (n = 3), and into the right atrium (n = 2). All tumors were resected by inferior vena cava isolation and, when necessary, extended hepatic mobilization and Pringle maneuver, with primary or patch closure of the vena cavotomy. Cardiopulmonary bypass was necessary in only 2 patients with intraatrial thrombus.

Results. Complications occurred in 11 patients, and 1 patient died 2 days postoperatively of a myocardial infarction (mortality, 2.7%). Twenty patients are alive; overall 2- and 5-year survival rates were 61.7% and 33.6%, respectively. For patients without lymph node or distant metastases (stage IIIa), 2- and 5-year survival rates were 74% and 45%, respectively. The presence of distant metastatic disease (stage IV) at the time of operation did not have a significant adverse effect on survival, as reflected by 2- and 5-year survival rates of 62.5% and 31.3%, respectively. Lymph node metastases (stage IIIc) adversely affected survival as there were no long-term survivors.

Conclusions. Resection of an intracaval tumor thrombus arising from renal cell carcinoma can be performed safely and can result in prolonged survival even in the presence of metastatic disease. In our experience, extracorporeal circulatory support was required only when the tumor thrombus extended into the heart.     

Phospholipid determination in platelets,plasma and red cells of patients with chronic myeloproliferative disorders

Abstract: Red cell phospholipids (PLs) were assessed in 11 patients with essential thrombocythemia and 5 patients with polycythemia vera. Platelet and plasma PLs were also determined in 10 of these patients, and the results were compared with studies performed in 16 healthy volunteers. The amount of platelet PLs in patients was similar to controls (556 ± 90 nmol/10⁹cells, versus 481 ± 91 nmol/10⁹cells), as was the percentage of the main specimens of these compounds, including phosphatidylserine (11.1 ± 0.8%), which is relevant for platelet procoagulant activity. We did not find differences between red cell PLs of patients (300 ± 60 nmol/10⁹cells), versus controls (289 ± 71 nmol/10⁹cells), and the sphingomyelin/phosphatidylcholine ratio in these cells was the same in both groups (0.75 ± 0.1). Finally, we did not detect any alteration in the amount of plasma PLs specimens.     

Fatal attraction: do high-technology treatments for end-stage renal disease benefit Aboriginal patients in central Australia?

The health problems of Aboriginal Australians, like those of many indigenous peoples, resemble those of the developing world, yet they are dealt with using the tools, techniques, and high-technology medical solutions of first-world health. Such approaches ignore the social components of health and illness, including the need for preventive and educative programs at the primary health care level. The example of end-stage renal disease provides a poignant example of the inadequacies of this approach. Central Australian Aboriginal people suffer from a high incidence of kidney disease from numerous causes including non-insulin-dependent diabetes mellitus and glomerulonephritis. The high incidence has led to numbers of people developing end-stage renal disease and moving into the Northern Territory-South Australia renal failure program for dialysis and/or transplantation. In requiring patients to leave their lands, communities and families, this program removes people from the religious and social support network that could ensure a reasonable quality of life in their final years, while offering only marginal extensions of those years. Expensive technology programs are of little benefit and of considerable cost to Aboriginal patients and draw attention away from efforts to reduce the exposure of at-risk Aboriginal people to the factors that facilitate the development of end-stage renal disease.     

Cerebral involvement in children with acute and relapsing inflammatory polyneuropathy

We present two children with seizures and other signs of cerebral involvement at the outset of acute inflammatory demyelinating polyneuropathy, consistent with a diagnosis of encephalomyeloradiculoneuropathy. One child had a recurrence associated with mild central dysfunction and improved during therapy with corticosteroids. Both children recovered completely. Both acute and relapsing inflammatory demyelinating neuropathy may be accompanied by cerebral dysfunction, expanding the clinical spectrum of encephalomyeloradiculoneuropathy.     

Submassive hepatic necrosis associated with the use of progabide: A GABA receptor agonist

Progabide, a recently introduced gamma-aminobutyric acid mimetic, is currently undergoing clinical evaluation for a variety of convulsive disorders. We describe a patient in whom severe hepatic failure developed after four weeks of Progabide therapy. The patient's course was marked by encephalopathy, jaundice, hypoglycemia, markedly elevated serum aminotransferase levels, and prolongation of the prothrombin time. Liver biopsy showed extensive hepatocellular necrosis. The patient recovered slowly after discontinuation of the drug. The finding of eosinophilia and increased serum IgE suggests an immunologically mediated mechanism for the Progabide-induced hepatic injury. Alternatively, the lipophilic moiety of Progabide may interact with hepatocyte cell membrane lipids leading to toxic injury. We conclude that Progabide may occasionally cause severe hepatic injury.     

Effect of age and maturation on sudomotor nerve regeneration in mice

This study demonstrates that regeneration of unmyelinated sudomotor axons in mice becomes progressively slower during aging. Identical lesions were made in mice aged 0, 2, 4, 6, 7, 24 and 60 weeks. The peroneal, sural and saphenous nerves were cut and tied to prevent regeneration. The sciatic nerve was then frozen at the thigh, leaving the hind paw completely denervated. By 7 days, sweat glands (SGs) of the paw had ceased sweating after pilocarpine injection. Subsequent regeneration of sudomotor axons was judged by the rate of return of pilocarpine sensitivity. SGs in the hind paws of normal newborn mice did not sweat at birth. Cholinergic stimulation first activated sweating at 13 days of life. The number of responsive SGs increased progressively to reach the adult level by 30 days. In one-week-old mice, whose sciatic nerve had been sectioned, the SG response to cholinergic stimulation was very delayed in time and reduced in number. Sweat glands of young mice, between 2 and 4 weeks of age, regained cholinergic sensitivity at a faster rate than mature animals and attained normal SG counts. Throughout a broad intermediate range of age in adulthood (7-24 weeks), the rate of sudomotor nerve regeneration was the same, but in older mice (60 weeks) it was slower and less complete.     

Ruptured aneurysm of the sinus of Valsalva. Presentation of 4 cases and review of the literature

We studied four patients with ruptured aneurysms of the sinus of Valsalva. All were men with a mean age of 33 years. The presenting illness was insidious in three and of abrupt onset in one. Physical examination showed a continuous murmur in all. Chest X ray film showed moderate cardiomegaly. Electrocardiogram disclosed left ventricular hypertrophy. Echocardiogram revealed the site of the rupture which was corroborated by aortography. Two aneurysms ruptured to the right ventricle and two to the right atrium. All were corrected by surgery. All patients became asymptomatic.