Mayo Clinic Classification Research Articles

Presurgical pazopanib for renal cell carcinoma with inferior vena caval thrombus: a single-institution study.

The aim of this study was to investigate the clinical benefit of presurgical therapy with pazopanib in renal cell carcinoma (RCC) patients with a tumor thrombus extending to a high level in the vena cava. A retrospective review was performed for seven consecutive patients with RCC and tumor thrombus involving the vena cava above the hepatic vein (level 3-4, Mayo Clinic classification) treated with pazopanib without initial cytoreductive nephrectomy at our institution. The effect of pazopanib was assessed in terms of the primary site response, thrombus diameter, and height (before and after treatment) on computed tomography or MRI. The tumor thrombus level before the induction of pazopanib was 3 in one patient and 4 in the remaining six patients. After pazopanib, shrinkage of the primary site and thrombus diameter and length were observed in all patients except one (with a rhabdoid tumor). The mean decreases of primary tumor diameter, tumor thrombus diameter, and length were 14, 9, and 31 mm, respectively. The tumor thrombus level decreased in three (43%) patients and remained stable in the remaining patient. Our findings suggest that presurgical treatment with pazopanib may shrink the tumor thrombus and decrease the surgical invasiveness in RCC patients with a high-level tumor thrombus.

Influence of image reconstruction parameters on cardiovascular risk reclassification by Computed Tomography Coronary Artery Calcium Score

ObjectiveTo investigate the influence of different CT reconstruction parameters on coronary artery calcium scoring (CACS) values and reclassification of predicted cardiovascular (CV) risk. MethodsCACS was evaluated in 113 patients undergoing ECG-gated 64-slice CT. Reference CACS protocol included standard kernel filter (B35f) with slice thickness/increment of 3/1.5 mm, and field-of-view (FOV) of 150–180 mm. Influence of different image reconstruction algorithms (reconstructed slice thickness/increment 2.0/1.0–1.5/0.8–3.0/2.0–3.0/3.0 mm; slice kernel B30f-B45f; FOV 200–250 mm) on Agatston score was assessed by Bland-Altman plots and concordance correlation coefficient (CCC) analysis. Classification of CV risk was based on the Mayo Clinic classification. ResultsDifferent CACS reconstruction parameters showed overall good accuracy and precision when compared with reference protocol. Protocols with larger FOV, thinner slices and sharper kernels were associated with significant CV risk reclassification. Use of kernel B45f showed a moderate positive correlation with reference CACS protocol (Agatston CCC = 0.67), and yielded significantly higher CACS values (p < .05). Reconstruction parameters using B30f or B45f kernels, 250 mm FOV, or slice thickness/increment of 2.0/1.0 mm or 1.5/0.8 mm, were associated with significant reclassification of CV risk (p < .05). ConclusionsKernel, FOV, slice thickness and increment are major determinants of accuracy and precision of CACS measurement. Despite high agreement and overall good correlation of different reconstruction protocols, thinner slices thickness and increment, and sharper kernels were associated with significant upward reclassification of CV risk. Larger FOV determined both upward and downward reclassification of CV risk.

Updated Canadian Expert Consensus on Assessing Risk of Disease Progression and Pharmacological Management of Autosomal Dominant Polycystic Kidney Disease.

Purpose:The purpose of this article is to update the previously published consensus recommendations from March 2017 discussing the optimal management of adult patients with autosomal dominant polycystic kidney disease (ADPKD). This document focuses on recent developments in genetic testing, renal imaging, assessment of risk regarding disease progression, and pharmacological treatment options for ADPKD.Sources of information:Published literature was searched in PubMed, the Cochrane Library, and Google Scholar to identify the latest evidence related to the treatment and management of ADPKD.Methods:All pertinent articles were reviewed by the authors to determine if a new recommendation was required, or if the previous recommendation needed updating. The consensus recommendations were developed by the authors based on discussion and review of the evidence.Key findings:The genetics of ADPKD are becoming more complex with the identification of new and rarer genetic variants such as GANAB. Magnetic resonance imaging (MRI) and computed tomography (CT) continue to be the main imaging modalities used to evaluate ADPKD. Total kidney volume (TKV) continues to be the most validated and most used measure to assess disease progression. Since the publication of the previous consensus recommendations, the use of the Mayo Clinic Classification for prognostication purposes has been validated in patients with class 1 ADPKD. Recent evidence supports the benefits of a low-osmolar diet and dietary sodium restriction in patients with ADPKD. Evidence from the Replicating Evidence of Preserved Renal Function: an Investigation of Tolvaptan Safety and Efficacy in ADPKD (REPRISE) trial supports the use of ADH (antidiuretic hormone) receptor antagonism in patients with ADPKD 18 to 55 years of age with eGFR (estimated glomerular filtration rate) of 25 to 65 mL/min/1.73 m2 or 56 to 65 years of age with eGFR of 25 to 44 mL/min/1.73 m2 with historical evidence of a decline in eGFR >2.0 mL/min/1.73 m2/year.Limitations:Available literature was limited to English language publications and to publications indexed in PubMed, the Cochrane Library, and Google Scholar.Implications:Advances in the assessment of the risk of disease progression include the validation of the Mayo Clinic Classification for patients with class 1 ADPKD. Advances in the pharmacological management of ADPKD include the expansion of the use of ADH receptor antagonism in patients 18 to 55 years of age with eGFR of 25 to 65 mL/min/1.73 m2 or 56 to 65 years of age with eGFR of 25 to 44 mL/min/1.73 m2 with historical evidence of a decline in eGFR >2.0 mL/min/1.73 m2/year, as per the results of the REPRISE study.

The benefit of preoperative renal artery embolization in patients with renal cell carcinoma and venous tumor thrombus

Objective To evaluate the impact of preoperative renal artery embolization in renal cell carcinoma patients with venous tumor thrombus. Methods A total of 249 RCC patients with venous tumor thrombus underwent radical nephrectomy and thrombectormy in our hospital. Seventy-four patients received preoperative renal artery embolization while other 175 patients did not. The related items were analyzed. The tumor thrombus level was divided into 5 groups with American Mayo clinic classification system. Considering the significant difference in tumor situation and treatment strategies, we took the hepatic vein as a cut-off line, dividing patients into two subgroups, the early and advanced tumor thrombus groups. There were 208 patients in the early tumor thrombus group and 41 patients in the advanced group. The related items were analyzed respectively. Results Patients in the embolization group tended to have larger tumors and higher percentage of advanced tumor thrombus. For all patients, the embolization group had longer operation time [(4.8±2.1)h vs. (4.1±2.2)h , P 0.05). Conclusion Preoperative RAE may be more appropriate for patients with advanced tumor thrombus because of its benefits in reducing operation time, intraoperative blood loss and elevating the operative security. Key words: Renal artery embolization; Renal cell carcinoma; venous tumor thrombus

Critical analysis of olecranon fracture management by pre-contoured locking plates

BackgroundFractures of the proximal ulna are rare and usually managed surgically. Strong fixation of the harware is essential to obtain good outcomes. We report our experience with pre-contoured locking plate fixation of complex olecranon fractures and present a critical appraisal of the outcomes. HypothesisPre-contoured locking plates provide good outcomes, but their clinical tolerance may be limited in some instances. Materials and methodsFrom September 2009 to December 2011, 28 patients were managed using a pre-contoured locking compression plate (LCP®). Among them, 6 were excluded because of missing data, which left 22 patients (11 males and 11 females) with a mean age of 55.7 years, including 12 who were employed. The fracture was on the dominant side in 11 patients. According to the Mayo Clinic classification, 15 fractures were type II and 7 type III. In addition to the ulnar fracture, a radial head fracture was present in 9 patients and a coronoid process fracture in 5 patients. Functional recovery was assessed using the Broberg-Morrey score and Mayo Elbow Performance Score (MEPS). Radiographs were obtained to evaluate the quality of fracture reduction and fracture healing, as well as to look for ossifications and osteoarthritis. ResultsMean follow-up was 20 months. Flexion was 131°, extension loss was 9.5°, pronation was 79°, and supination was 80.5°. The mean Broberg-Morrey score was 96.7 and the mean MEPS score 96.6. Fracture healing occurred in all patients, within a mean of 10.6 weeks. Evidence of early osteoarthritis was found in 6 patients, ossifications in 3 patients, and synostosis in 1 patient. An infection was successfully treated with lavage and antibiotic therapy in 1 patient. The fixation hardware was removed in 6 patients. No prognostic factors were identified. Discussion-conclusionOur hypothesis was confirmed. The outcomes are encouraging and comparable to those reported in the literature. The critical issue is the limited clinical tolerance of the plate with a high rate of posterior impingement requiring plate removal (27%). Rigorous technique is essential during plate implantation. Level of evidenceLevel IV, retrospective study.

MP30-16 EARLY UNCLAMPING IN LAPAROSCOPIC PARTIAL NEPHRECTOMY IMPROVES EARLY ESTIMATED GLOMERULAR FILTRATION REDUCTION RATE

The aim of this study was to analyze the impact on survival of microscopic venous wall (renal vein and inferior vena cava) invasion in a series of patients with RCC and venous extension. METHODS: We conducted a retrospective review of 1974 patients with RCC and vena cava thrombus between 1971 and 2012 in 22 of Europe and USA . Kaplan Meier and a multivariate logistic regression analyses were used to assess the impact of microscopic invasion of the renal vein and cava on cancer-specific survival (CSS), We also analyzed other clinicopathological factors as F€ uhrman grade, thrombus level, perirenal fat invasion, sarcomatoid features and tumor necrosis. RESULTS: With a mean follow-up of 42.45 months CSS was 42.7 %. One hundred thirty-one (18.8%) patients had microscopic invasion of the vena cava wall (MIVC) and 295 microscopic invasion of the renal vein wall (MIRV). According to the Mayo Clinic classification, 309 (15.7 %) patients had level I tumor thrombus,, 360 (18.2 %) level II, 213 (10.8 %) level III and 173 (8.8 %) level IV . In the univariate analysis, the MIVC and MIRV (p: 0.015), higher Fuhrman (p < 0.001), perirenal fat invasion (p < 0.001) and presence of multifocal disease ( p < 0.001) were significantly correlated with worse CSS. In multivariable analysis, the MIVC (HR 1.7 CI 1.1-2.5, p: 0.009), Fuhrman grade (HR: 2.1 CI 1.3-3-4, p.0.002) and perirenal fat invasion (HR 2.1 CI 1.4 3-3, p < 0.0001) were confirmed as predictors of CSS. CONCLUSIONS: In addition to other factors known as Fuhrman grade and perirenal fat invasion, the MIVC is an independent prognostic factor of survival in RCC with vena cava thrombus.

Coronary artery calcium score on low-dose computed tomography for lung cancer screening.

To evaluate the feasibility of coronary artery calcium score (CACS) on low-dose non-gated chest CT (ngCCT). Sixty consecutive individuals (30 males; 73 ± 7 years) scheduled for risk stratification by means of unenhanced ECG-triggered cardiac computed tomography (gCCT) underwent additional unenhanced ngCCT. All CT scans were performed on a 64-slice CT scanner (Somatom Sensation 64 Cardiac, Siemens, Germany). CACS was calculated using conventional methods/scores (Volume, Mass, Agatston) as previously described in literature. The CACS value obtained were compared. The Mayo Clinic classification was used to stratify cardiovascular risk based on Agatston CACS. Differences and correlations between the two methods were compared. A P-value < 0.05 was considered significant. Mean CACS values were significantly higher for gCCT as compared to ngCCT (Volume: 418 ± 747 vs 332 ± 597; Mass: 89 ± 151 vs 78 ± 141; Agatston: 481 ± 854 vs 428 ± 776; P < 0.05). The correlation between the two values was always very high (Volume: r = 0.95; Mass: r = 0.97; Agatston: r = 0.98). Of the 6 patients with 0 Agatston score on gCCT, 2 (33%) showed an Agatston score > 0 in the ngCCT. Of the 3 patients with 1-10 Agatston score on gCCT, 1 (33%) showed an Agatston score of 0 in the ngCCT. Overall, 23 (38%) patients were reclassified in a different cardiovascular risk category, mostly (18/23; 78%) shifting to a lower risk in the ngCCT. The estimated radiation dose was significantly higher for gCCT (DLP 115.8 ± 50.7 vs 83.8 ± 16.3; Effective dose 1.6 ± 0.7 mSv vs 1.2 ± 0.2 mSv; P < 0.01). CACS assessment is feasible on ngCCT; the variability of CACS values and the associated re-stratification of patients in cardiovascular risk groups should be taken into account.

Renal cell carcinoma with inferior vena caval tumour thrombus: Surgical management and clinical outcomes at a low‐volume centre

AimIn the present study, we discuss the surgical management, complications and clinical outcomes of patients with renal cell carcinoma (RCC) extending into the inferior vena cava (IVC), who were treated with surgical resection at a teaching hospital from 1997 to 2011.Patients and MethodsTwelve patients diagnosed with RCC and IVC tumour thrombus underwent radical nephrectomy and IVC tumour thrombectomy during the study period.ResultsOf the 12 patients (male : female: 1:1), the mean age was 65 years (range: 48–82 years). All had good premorbid performance status and no distant metastasis at the time of operation. Employing the Mayo Clinic classification, the tumour thrombus extension was level I in four cases (33 per cent), level II in four cases (33 per cent), level III in two cases (17 per cent) and level IV in two cases (17 per cent). In one patient, the renal tumour extended into the right atrium and had a solitary right pulmonary artery tumour embolus, which subsequently underwent a simultaneous right pulmonary artery tumour embolectomy. In our series, the mean blood loss in levels I–IV tumour thrombus were 1050 mL, 2075 mL, 4152 mL and 11 500 mL, respectively. Complications occurred in three cases (25 per cent), and one (8.3 per cent) required re‐laparotomy for haemostasis. There was no hospital mortality. The median follow up was 45.5 months (range: 6–125 months). Median disease‐free and overall survivals were 29 and 76 months, respectively. Five‐year disease‐free and overall survivals were 35.5 per cent and 62.5 per cent, respectively.ConclusionRadical nephrectomy and IVC tumour thrombectomy remain a challenging procedure. With detailed perioperative planning and multidisciplinary efforts, surgical resection is the definitive treatment of choice for patients with RCC and IVC tumour thrombus. The perioperative and survival outcomes of the present series were comparable to contemporary series.

Staging lymphadenectomy in renal cell carcinoma must be extended: a sensitivity curve analysis

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: In renal cell carcinoma the role of lymphadenectomy (LND) is still controversial. Moreover, no firm consensus exists regarding the minimum number of lymph nodes that should be removed to obtain a satisfactory staging LND at the time of surgery. Our findings demonstrate that, when clinically indicated, staging LND in renal cell carcinoma should be extended. The removal of 15 lymph nodes might represent the lowest threshold to define a staging LND as adequate. More extended LND should be pursued if unfavourable clinical and pathological characteristics are evident at diagnosis and/or during surgery. To investigate the staging of lymphadenectomy in renal cell carcinoma. No convincing data exist regarding the minimum number of lymph nodes that should be removed at the time of nephrectomy to ensure an accurate staging. Between 1987 and 2011, 850 patients with renal cell carcinoma underwent either partial or radical nephrectomy plus lymph node dissection (LND) at a single tertiary care institution (Tany N0-1Many ). Receiver operating characteristic curve coordinates were used to graph the probability of finding lymph node invasion according to the number of removed lymph nodes. Assuming that the likelihood of finding lymph node invasion according to the number of lymph nodes removed may be affected by patient characteristics, analyses were further stratified for clinical and pathological characteristics. The rate of lymph node metastases strongly correlated with the clinical and pathological characteristics of the patients. Fifteen lymph nodes need to be removed to achieve a 90% probability of detecting at least one metastatic lymph node. Only slight differences were recorded after stratification for clinical nodal status, the presence of metastases at diagnosis and pathological T stage. Finally, 13, 16 and 21 lymph nodes need to be removed to achieve a 90% probability of detecting lymph node invasion, if present, in the low risk (score 0-1), intermediate risk (score 2-3) and high risk (score 4-5) Mayo Clinic classification, respectively. The removal of 15 lymph nodes represents the lowest threshold for considering a staging LND as adequate. More extended LND should be pursued if unfavourable clinical and pathological characteristics are evident at diagnosis and/or during surgery.

982 STAGING LYMPHADENECTOMY IN RENAL CELL CARCINOMA MUST BE EXTENDED: A SENSITIVITY CURVE ANALYSES

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging III1 Apr 2012982 STAGING LYMPHADENECTOMY IN RENAL CELL CARCINOMA MUST BE EXTENDED: A SENSITIVITY CURVE ANALYSES Umberto Capitanio, Rayan Matloob, Firas Abdollah, Nazareno Suardi, Fabio Castiglione, Ettore Di Trapani, Dario Di Trapani, Cristina Carenzi, Marco Roscigno, Massimo Freschi, Francesco Montorsi, and Roberto Bertini Umberto CapitanioUmberto Capitanio Milan, Italy More articles by this author , Rayan MatloobRayan Matloob Milan, Italy More articles by this author , Firas AbdollahFiras Abdollah Milan, Italy More articles by this author , Nazareno SuardiNazareno Suardi Milan, Italy More articles by this author , Fabio CastiglioneFabio Castiglione Milan, Italy More articles by this author , Ettore Di TrapaniEttore Di Trapani Milan, Italy More articles by this author , Dario Di TrapaniDario Di Trapani Milan, Italy More articles by this author , Cristina CarenziCristina Carenzi Milan, Italy More articles by this author , Marco RoscignoMarco Roscigno Milan, Italy More articles by this author , Massimo FreschiMassimo Freschi Milan, Italy More articles by this author , Francesco MontorsiFrancesco Montorsi Milan, Italy More articles by this author , and Roberto BertiniRoberto Bertini Milan, Italy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1082AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In renal cell carcinoma (RCC) the role of lymphadenectomy (LND) is still controversial. Moreover, no convincing data exist regarding the minimum number of lymph nodes that should be removed at the time of nephrectomy. METHODS Between 1987 and 2011, 850 RCC patients underwent either partial or radical nephrectomy plus LND at a single tertiary care institution (TanyN0-1Many). The receiver operating characteristic curve coordinates were used to graph the probability of finding lymph node invasion (LNI) according to the number of removed lymph nodes. Assuming that the likelihood of finding LNI according to the number of lymph nodes removed may be affected by patients' characteristics, analyses were further stratified for clinical nodal status, presence of metastases at diagnosis, pathological T stage and LNI risk according to the Mayo Clinic LNI risk score. RESULTS The rate of lymph node metastases strongly correlated with clinical and pathological characteristics of the patients. Fifteen lymph nodes need to be removed to achieve a 90% probability of detecting at least one metastatic lymph node. Only slightly differences were recorded after stratification for clinical nodal status, presence of metastases at diagnosis and pathological T stage. Finally, 13, 16 and 21 lymph nodes need to be removed to achieve a 90% probability of detecting LNI, if present, in low (score 0-1), intermediate (score 2-3) and high risk (score 4-5) Mayo Clinic classification, respectively. CONCLUSIONS The removal of 15 lymph nodes represents the lowest threshold for the extent of LND at radical nephrectomy. More extended LND should be pursued if unfavourable clinical and pathological characteristics are evident at diagnosis and/or during surgery. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e399-e400 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Umberto Capitanio Milan, Italy More articles by this author Rayan Matloob Milan, Italy More articles by this author Firas Abdollah Milan, Italy More articles by this author Nazareno Suardi Milan, Italy More articles by this author Fabio Castiglione Milan, Italy More articles by this author Ettore Di Trapani Milan, Italy More articles by this author Dario Di Trapani Milan, Italy More articles by this author Cristina Carenzi Milan, Italy More articles by this author Marco Roscigno Milan, Italy More articles by this author Massimo Freschi Milan, Italy More articles by this author Francesco Montorsi Milan, Italy More articles by this author Roberto Bertini Milan, Italy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Carpal instabilities: Classification and diagnosis

Classification of carpal instability is difficult. The most common and the most accepted one is the Mayo Clinic classification, which defines Carpal instability, dissociative (CID), Carpal instability, non-dissociative (CIND), Carpal instability, combined (CIC) and Carpal instability, adaptive (CIA). Diagnostic tools are clinical examination, standard Rx, dynamic Rx, CT, NMR, arthrography and scintigraphy. Today arthroscopy is the gold standard.

Localized scleroderma: A series of 52 patients

Background Localized scleroderma also called morphea is a skin disorder of undetermined cause. The widely recognized Mayo Clinic Classification identifies 5 main morphea types: plaque, generalized, bullous, linear and deep. Whether each of these distinct types has a particular clinical course or is associated with some patient-related features is still unclear. Methods We report here a retrospective series of patients with localized scleroderma with an attempt to identify features related to the type of lesion involved. The medical records of all patients with a diagnosis of localized scleroderma were reviewed by skilled practitioners. Lesions were classified according to the Mayo Clinic Classification. The relationship between each lesion type and various clinical features was tested by non-parametrical methods. Results The sample of 52 patients included 43 females and 9 males. Median age at onset was 30 y (range 1–76). Frequencies of patients according to morphea types were: plaque morphea 41 (78.8%) (including morphea en plaque 30 (57.7%) and atrophoderma of Pasini–Pierini 11 (21.1%)), linear scleroderma 14 (26.9%). Nine patients (17.3%) had both types of localized scleroderma. Median age at onset was lower in patients with linear scleroderma (8 y (range 3–44)) than in others (36 y (range 1–77)) ( p = 0.0003). Head involvement was more common in patients with linear scleroderma (37.5%) than in other subtypes (11.1%) ( p = 0.05). Atrophoderma of Pasini–Pierini was never located at the head. Systemic symptoms, antinuclear antibodies and the rheumatic factor were not associated with localized scleroderma types or subtypes. Conclusion These results suggest that morphea types, in adults are not associated with distinct patient features except for age at disease onset (lower) and the localization on the head (more frequent), in patients with lesions of the linear type.

A prospective analysis of 142 carotid endarterectomies for occlusive vascular disease, 1979-1985.

Carotid endarterectomy may carry a substantial risk of morbidity and mortality from major stroke, thus offsetting any statistical benefit in reduction of future stroke. Because of the disturbing ranges in the incidence of stroke morbidity and mortality reported from the several institutional series studying carotid endarterectomy, the authors undertook a prospective review of 142 consecutive carotid endarterectomies performed for symptomatic atherosclerotic occlusive vascular disease on the neurosurgical service. The University of Alabama Hospital. Preoperative risk assessment was performed in each case according to the Mayo Clinic classification system. The overall mortality rate was 1.4% and the major stroke morbidity rate was 0.7%, for a combined major morbidity and mortality rate of 2.1%. The incidence of minor neurological morbidity was 1.4%. There was no morbidity or mortality in the Grade I and II (low-risk) patient groups. This low combined major morbidity and mortality rate of 2.1% for carotid endarterectomy causes the surgical stroke-free survival curve to intersect the medical stroke-free survival curve at an earlier point in time, and thus demonstrates the greater reduction in risk of stroke which accrues over time for the surgically treated patient.