Radical Nephrectomy For Renal Cell Carcinoma Research Articles

MP29-07 INVERSE RELATIONSHIP BETWEEN INSULIN RECEPTOR EXPRESSION AND FAVORABLE OUTCOMES IN PATIENTS WHO UNDERWENT RADICAL NEPHRECTOMY FOR RENAL CELL CARCINOMA

INTRODUCTION AND OBJECTIVES: It has been reported that obesity increases the risk of renal cell carcinoma (RCC). Insulin, which regulates mitogenic effects as well as plasma glucose levels, has been linked with the development of cancer. We investigated the relationship between insulin receptor (IR) expression and favorable outcomes in patients who underwent radical nephrectomy for RCC. METHODS: pT1eT4 tumor specimens from 99 patients with RCC (clear cell, 81; papillary, 8; chromophobe, 4; sarcomatoid, 4; and Xp11.2 translocation, 1) were evaluated for IR expression and insulinlike growth factor 1 (IGF-1) receptor (IGF-1R) protein by immunohistochemistry. Serum insulin, C-peptide, and IGF-1 levels were measured by ELISA. Association between the biomarker expression and serum concentration, prognostic factors, and clinical outcomes were assessed. RESULTS: IR expression was high in 24 (24.3%) tumors, intermediate in 57 (57.5%), and low in 18 (18.2%). IGF-1R expression was high in 28 (28.3%) tumors, intermediate in 54 (54.5%), and low in 17 (17.2%). High IR expression was an independent predictor of favorable progression-free survival (p 1⁄4 0.017, Cox proportional hazards model). Overall survival of patients with RCC and high IR expression was significantly longer than that of patients with low-to-intermediate IR expression (p 1⁄4 0.031, logrank test). Serum insulin, C-peptide, and IGF-1 levels were not associated with favorable prognostic outcomes. CONCLUSIONS: In patients with RCC who underwent radical nephrectomy, high IR expression was an independent predictor of favorable outcome. The findings suggest that insulin signaling may play a role in the RCC progression.

The use of partial nephrectomy: results from a contemporary national prospective multicenter study

Despite benefits in functional renal outcome and favorable oncological efficacy, previous studies show marked underuse of partial nephrectomy (PN). We investigated national utilization of partial and radical nephrectomy (RN) using a contemporary, prospective population-based cohort. Between June and December 2010, 1,237 patients were treated by PN or RN for renal cell carcinoma in 56 French centers. Data were prospectively collected, and statistical analyses were performed. Overall, 667 (53.9 %) and 570 patients (46.1 %) underwent RN and PN, respectively. In case of PN, surgical approach was an open PN in 63.3 % of cases, a laparoscopic PN in 21.0 % of cases and a robot-assisted PN in 15.7 % of cases. PN was used in T1a, T1b, T2 and T3 tumors in 395 (76.7 %), 131 (38.2 %), 29 (14.7 %) and 7 (4.6 %), respectively. Median ischemia time was 16 min [0-60], and mean blood loss was 280.4 ml (±339.9). Tumor characteristics and operative features were significantly different according to the surgical approach. Warm ischemia time was significantly higher in case of laparoscopic or robot-assisted procedure (p < 0.001). There was no statistical significant difference in blood loss and transfusion rate according to surgical approach. Postoperative medical and surgical complications occurred in 8.2 and 10.0 % of PN, respectively, with no significant difference according to surgical approach. Partial nephrectomy for renal cell carcinoma is commonly used in this French centers sample. Mini-invasive approaches represent also a significant part of all partial nephrectomies with no difference in terms of complication rates.

Analysis and validation of tissue biomarkers for renal cell carcinoma using automated high-throughput evaluation of protein expression.

The objective of this study was to compare the predictive ability of potential tissue biomarkers to known prognostic factors that predict renal cell carcinoma (RCC) recurrence using an automated system of immunohistochemical analysis. After institutional review board approval, a tissue microarray was constructed using tissue from patients who had partial or radical nephrectomy for RCC. Patients with metastatic disease were excluded. Immunohistochemical staining of the tissue microarray for Ki-67, C-reactive protein, carbonic anhydrase 9, and hypoxia-inducible factors 1α and 2α was analyzed using automated image analysis. Univariable and multivariable analyses were performed to evaluate the association of putative biomarkers and known prognostic factors. Of 216 patients who met the entrance criteria, 34 (16%) patients developed metastatic recurrence within a median follow-up interval of 60.9 (interquartile range, 13.9-87.1) months. RCC morphotypes analyzed in this study include clear cell (n = 156), papillary (n = 38), chromophobe (n = 16), and collecting duct/unclassified (n = 6). Univariate analysis identified that only increased Ki-67 was predictive of RCC recurrence among the proteins evaluated, in addition to other known clinicopathological prognostic factors. After multivariate analysis, Ki-67 was identified as an independently predictive risk factor for RCC recurrence (hazard ratio [HR], 3.73 [confidence interval {CI}, 1.60-8.68]). Other independent predictors of RCC recurrence included tumor diameter (HR, 1.20 [CI, 1.02-1.41]) and perinephric fat invasion (HR, 4.49 [CI, 1.11-18.20]). We conclude that Ki-67 positivity is independently predictive of RCC recurrence after surgery in nonmetastatic patients. Automated analysis of tissue protein expression can facilitate a more objective and expedient investigation of tissue biomarkers for RCC.

Contralateral renal cell carcinoma ureteric metastases can arise on tyrosine kinase adjuvant therapy and be effectively treated by endoscopic laser excision and ablation.

Renal cell carcinoma (RCC) uncommonly metastasizes to the ureter and rarely to the contralateral ureter. We describe the presentation of 2 successive contralateral ureteric metastases from RCC in our institution. The first represents the only reported metachronous ureteric deposit on adjuvant sorafenib after laparoscopic radical nephrectomy for RCC. The other presented with a synchronous lesion after radiological work-up. Both lesions were treated with endoscopic excision and laser ablation with preservation of the renal unit and no local recurrence. We report these cases and discuss the literature.

Complications of radical nephrectomy for renal cell carcinoma: a retrospective study comparing transperitoneal and retroperitoneal approaches using a standardized reporting methodology in two Chinese centers

The reporting of complications following transperitoneal and retroperitoneal open radical nephrectomy (RN) is nonstandardized. This study aimed to compare early complications between the two approaches using a standardized reporting methodology in a large contemporary cohort. Between 1996 and 2009, 558 patients underwent open RN for renal cell carcinoma (RCC) in our two centers (424 from Sun Yat-sen University Cancer Center and 134 from the First Affiliated Hospital of Sun Yat-sen University). Records were reviewed for clinicopathologic features and complications. Complications were graded using the Clavien system based on the severity of impact. One hundred and five patients (18.8%) had one or more early complications (168 complications overall). The overall rates of grades I to V complications were 5.6%, 10.8%, 2.2%, 0.4%, and 0.2%, respectively. Patients who underwent transperitoneal RN did not experience more overall or procedure-related complications than those who underwent retroperitoneal RN (P = 0.911 and P = 0.851, respectively). On subgroup analysis, neither grade I/II nor grades III-V complications were significantly different between the transperitonal RN and retroperitoneal RN groups. Multivariate analysis showed that for any grade of complication, age (P = 0.016) and estimated blood loss (P = 0.001) were significant predictors. We concluded that open RN is a safe procedure associated with low rates of serious morbidity and mortality. Compared with retroperitoneal RN, transperitoneal RN was not associated with more complications. Older patient and more blood loss at surgery were independent predictors for higher early postoperative complication rates.

Renal cell carcinoma: currently the most interesting genitourinary malignancy

Renal cell carcinoma: currently the most interesting genitourinary malignancy

Endoscopic Mucosal Resection of a Solitary Metastatic Tumor in the Stomach

Endoscopic mucosal resection (EMR) is increasingly being utilized in the management of early gastric cancer. Metastatic cancer of the stomach is uncommon. We report a case of solitary gastric metastasis from renal cell carcinoma (RCC) that was successfully excised with EMR. A 71-year-old man presented with iron deficiency anemia, he had undergone a radical nephrectomy for RCC 3 years previously. Upper gastrointestinal endoscopy revealed a malignant-appearing 10 × 12 mm polyp in the stomach. Histopathology of the biopsy revealed that it was a metastasis from RCC, confirmed by immunohistochemistry with Vimentin and CAM 5.2 positivity. Computed tomography and bone scanning revealed no other metastases. Simultaneous laparoscopy and upper gastrointestinal endoscopy revealed that the lesion was localized to the gastric mucosa. EMR of the tumor en bloc was performed successfully. Histology confirmed a complete excision. He had an uneventful postoperative course and is well 15 months after surgery, without any tumor recurrence.

Renal cell carcinoma in octogenarians: Comprehensive analysis using the SEER database.

4624 Background: Little data exist about clinical outcomes in octogenarians who undergo surgery for renal cell carcinoma (RCC). The goal of this study was to determine overall and cancer-specific survival, and the use of partial versus radical nephrectomy in elderly patients. Methods: Utilizing the Surveillance, Epidemiology, and End Results (SEER) database, 60,693 patients in the years 1988 and 2005 were identified who underwent either partial or radical nephrectomy for RCC. Patients were separated into two groups—those younger than age 80, and those 80 years of age or older— and were stratified by the aforementioned variables. Chi-squared and Kaplan-Meier analyses were used to determine differences amongst the cohorts in terms of surgical approach and overall and cancer-specific survival. Results: Four-thousand two-hundred twenty seven patients (7.5%) were over the age of 80. Octogenarians were more likely to undergo radical nephrectomy than their younger counterparts (87% versus 92%, p<0.0001). At a median follow-up of 37 months (range 0-215) in patients <80 years, and 27 months (range 0-203) in patients ≥80 years, octogenarians were more likely to die of all causes (HR 2.32, 95% CI 2.22-2.42, p<0.001) than their younger counterparts. Octogenarians were also more likely to die of RCC (HR 1.33, 95% CI 1.23-1.43, p<0.001), but at a lower hazard ratio than for overall mortality. These cancer-specific differences in survival persisted throughout individual pathologic stages, with the exception of pathologic stage pT4 and metastatic disease. Octogenarians who underwent partial nephrectomy were 0.39 times less likely to die of RCC (95% CI 0.26-0.60, p<0.001) than older patients who underwent radical nephrectomy. Conclusions: Octogenarians who undergo partial nephrectomy have improved overall and cancer-specific survival than those who undergo radical nephrectomy, yet they are less likely to undergo partial nephrectomy than their younger counterparts. Octogenarians experience a decreased overall and cancer-specific survival benefit from extirpative surgery than younger patients. This data should be considered when treating the renal mass in the “elderly” patient. No significant financial relationships to disclose.

721 SURGICAL APPROACH AND THE USE OF LYMPHADENECTOMY AND ADRENALECTOMY FOR PATIENTS WITH RENAL CELL CARCINOMA

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy I1 Apr 2010721 SURGICAL APPROACH AND THE USE OF LYMPHADENECTOMY AND ADRENALECTOMY FOR PATIENTS WITH RENAL CELL CARCINOMA Christopher Filson, David Miller, Julie Ruterbusch, Joanne Colt, Wong-Ho Chow, and Kendra Schwartz Christopher FilsonChristopher Filson Ann Arbor, MI More articles by this author , David MillerDavid Miller Ann Arbor, MI More articles by this author , Julie RuterbuschJulie Ruterbusch Detroit, MI More articles by this author , Joanne ColtJoanne Colt Bethesda, MD More articles by this author , Wong-Ho ChowWong-Ho Chow Bethesda, MD More articles by this author , and Kendra SchwartzKendra Schwartz Detroit, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1209AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There is no standard approach to management of the adrenal gland and regional lymph nodes in patients undergoing radical nephrectomy (RN). We therefore used data from the NCI's United States Kidney Cancer Study (KCS) to evaluate variation in the use of lymphadenectomy and adrenalectomy among patients undergoing RN for renal cell carcinoma (RCC). We specifically assessed the influence of tumor size and surgical approach on use of these adjuncts to RN. METHODS We evaluated patients with RCC enrolled in the KCS, a population-based, case–control study conducted in the metropolitan areas of Detroit and Chicago from 2002-2007. During the study interval, 1,136 patients with RCC consented to both an epidemiological interview and medical record review. We identified patients who underwent open (ORN) or laparoscopic radical nephrectomy (LRN). Next, we used medical records and routinely-collected data from the Detroit SEER registry to determine the proportion of patients who underwent concurrent lymphadenectomy or adrenalectomy. We performed bivariate analyses to evaluate associations between tumor size, surgical approach, and receipt of lymphadenectomy or adrenalectomy. RESULTS We identified 730 patients who underwent ORN (427, 58%) or LRN (303, 42%) for RCC from 2002-2007. Among this group, 11% and 24% underwent lymphadenectomy or adrenalectomy, respectively. Lymphadenectomy was more common among patients treated with an open surgical approach (14.3% vs 5.3%, p<0.01); this difference was most pronounced for cases with tumors between 4-7 cm (15.9% vs 2.9%, p=0.01) (Figure). Patients treated with ORN were also more likely to undergo adrenalectomy, especially among cases with tumors ≤ 4 cm (21.7% vs. 11.4%, p<0.01). CONCLUSIONS Among contemporary patients undergoing RN for RCC, the use of lymphadenectomy and adrenalectomy is relatively uncommon and varies by tumor size and surgical approach. In an era characterized by an increasing number of patients with small tumors, diffusion of minimally-invasive surgical techniques, and emergence of potential systemic adjuvant therapies, our findings highlight several important considerations for urologists interested in optimizing the surgical management of patients with RCC. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e280-e281 Peer Review Report Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Filson Ann Arbor, MI More articles by this author David Miller Ann Arbor, MI More articles by this author Julie Ruterbusch Detroit, MI More articles by this author Joanne Colt Bethesda, MD More articles by this author Wong-Ho Chow Bethesda, MD More articles by this author Kendra Schwartz Detroit, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Metastatic Renal Cell Carcinoma in the Neck: An Unusual Presentation

Metastasis of renal cell carcinoma (RCC) to the head and neck region is infrequent. A rare case of metastatic RCC, presenting as an enlarging neck mass and radiologically mimicking a carotid body tumour clinically and radiographically, presented in a 68-year-old male patient, 18 months after radical nephrectomy for RCC. It is estimated that 14-16% of all patients with renal cell carcinomas have metastases above the clavicle. However, there are no reported cases of metastatic renal cell carcinoma to the neck mimicking a carotid body tumour. Renal cell carcinoma is the third most common neoplasm to metastasize to the head and neck region following breast and lung carcinomas.

Effectiveness of Computed Tomography for Predicting the Nuclear Grade of Renal Cell Carcinoma

Purpose: Nuclear grade is one of the independent prognostic factors for renal cell carcinoma (RCC). We investigated the effectiveness of a preoperative CT scan for predicting the nuclear grade of clear cell RCC. Materials and Methods: We retrospectively reviewed the medical records of patients who underwent surgery for renal lesions between January 2002 and December 2007. We analyzed the pathologic and radiologic reports of 65 patients who underwent radical nephrectomy for RCC and were diagnosed with clear cell RCC. The Hounsfield unit (HU) of the area with maximum enhancement (M) and the total area of the RCC (T) were measured during CT. Ratio values by nuclear grade were calculated by using formulas (M HU/aorta HU, T HU/aorta HU) to eliminate differences between individuals. Results: A total of 65 cases of clear cell RCCs were classified according to Fuhrman nuclear grade. Five cases were grade I, 33 were grade II, 15 were grade III, and 12 were grade IV. There was a significant difference in CT enhancement between each nuclear grade, and lower nuclear grades tended to have an increased ratio of maximum enhancement (p=0.020). Fuhrman nuclear grade was divided into two groups: low (Fuhrman grades I, II) and high (Fuhrman grades III, IV). The ratio of enhancement for the M area was significantly higher in the low Fuhrman nuclear grade group than in the high group (p=0.033). Conclusions: CT enhancement is inversely related to the nuclear grade of clear cell RCC. This study found that measuring the area of maximum enhancement in CT may be a useful method for presuming the pathologic nuclear grade of RCC, especially when the Fuhrman nuclear grade is divided into low and high groups. (Korean J Urol 2009;50:942-946) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Safety and Efficacy of Laparoscopic Radical Nephrectomy with Manual Specimen Morcellation for Stage cT1 Renal-Cell Carcinoma

Specimen morcellation during laparoscopic radical nephrectomy for renal-cell carcinoma is controversial, and supporting literature remains sparse. We seek to evaluate the safety and efficacy of morcellation for specimen removal after laparoscopic radical nephrectomy for management of renal lesions of malignant potential at a single institution. We retrospectively reviewed the records of all patients who underwent laparoscopic radical nephrectomy at Northwestern Memorial and Evanston Hospital from 2001 to 2006. Twenty-two patients were identified who underwent specimen morcellation for extraction after laparoscopic nephrectomy that was performed for enhancing solid or cystic renal masses. Laparoscopic radical nephrectomy was performed on all the patients. Patient age ranged from 36 to 96 years old. All patients were clinical stage T(1)N(0)M(0). The specimen was mechanically morcellated within Cook Lap Sac under direct and laparoscopic vision. Average tumor size after morcellation was 3.0 cm. On histologic review of the morcellated specimen, 18 patients were confirmed to have renal-cell carcinoma, 2 had an oncocytoma, and 2 had benign cysts. One patient with renal-cell carcinoma had a pathologic upgrade to stage T(3b). Average operating time was 268 minutes (range 110 to 389 min). With the exception of the patient who became anephric after nephrectomy, average hospital stay was 2.6 days. A mean clinical and radiographic follow-up of 434 days failed to show any known disease progression or port site recurrence in patients with renal-cell carcinoma. Intracorporeal, mechanical morcellation after laparoscopic radical nephrectomy appears to be safe and effective in clinical stage T1 renal-cell carcinoma. This study adds to current literature that promotes the use of morcellation as an alternative for intact specimen removal in properly selected patients. Further prospective studies are necessary to show long-term oncologic outcomes.

Single-Center Experience of Caval Thrombectomy in Patients With Renal Cell Carcinoma With Tumor Thrombus Extension Into the Inferior Vena Cava

The objective of this study is to describe a single-center experience of caval thrombectomy in patients with renal cell carcinoma (RCC) and tumor thrombus extension into the inferior vena cava (IVC). We retrospectively reviewed 23 patients undergoing radical nephrectomy with caval thrombectomy. Follow-up included an office visit and computed tomography scan. Statistical comparisons were made using 2-sample t tests. Patients' ages ranged from 32 to 83 years (mean, 62 years; 18 male, 5 female). Tumor size ranged from 3 to 21 cm (mean, 8.6 cm). Tumor thrombus staging was based on the Nevus classification: level I (2/23), II (6/23), III (13/26), IV (2/23). Tumor thrombi were removed by means of digital extraction (20), Fogarty embolectomy (2), or endarterectomy (1-caval wall invasion). Lateral venorrhaphy was used for IVC repair in all cases. Hepatic mobilization and suprahepatic clamping were necessary in 14 patients. Clamp times were significantly different between the suprahepatic (SH) and infrahepatic (IH) groups (15 vs 9.4 minutes, P < .012). Mean blood loss was also significantly different (3.2 L vs 2 L, P < .045). In the SH group, 2 patients developed postoperative atrial fibrillation and 2 patients died (respiratory failure; missed enterotomy). The IH group had no perioperative morbidity or mortality. Median followup was 15 months (range, 1-54 months). Follow-up imaging was available for 19/23 patients. Ninety-five percent of patients had a patent IVC (18). One SH patient developed an IVC stenosis/thrombosis 12 months postoperatively with successful thrombolysis and stenting. There was a 16% (3/19) recurrence rate in follow-up, with all patients demonstrating renal vascular invasion and high Fuhrman grade upon final pathologic evaluation. Caval thrombectomy can be performed safely during radical nephrectomy for RCC with tumor thrombus extension. The need for suprahepatic clamping is associated with longer clamp times, increased blood loss, and increased morbidity and mortality. Lateral venorrhaphy with primary repair avoids complicated caval reconstructions and results in high patency rates, despite a not insignificant recurrence rate.

Prognostic significance of erythropoietin expression in human renal cell carcinoma: Michael A, Politi E, Havranek E, Corbishley C, Karapanagiotou L, Anderson C, Relph K, Syrigos KN, Pandha H, Department of Oncology, St. George’s Hospital Medical School, London, UK

To investigate, in a retrospective study, the expression of erythropoietin (Epo) in human renal cell carcinoma (RCC) and its correlation with overall survival, as Epo (a hematopoietic cytokine that regulates the production of red blood cells), with its receptor, was recently localized in nonhematopoietic tissues, e.g. liver, uterus, central nervous system, vascular endothelial cells, and solid tumors. We used data from 113 patients who had radical nephrectomy for RCC between 1990 and 2000, taking sections from formalin-fixed and paraffin wax-embedded tissue blocks. The association between Epo staining and the patients’ characteristics was assessed by either χ2 tests (for categorical variables) or two-sample independent t-tests (for continuous variables). Tissue from 37 patients (33%) was positive for cytoplasmic Epo expression; 76 (67%) samples were negative. Univariate hazard ratio analysis confirmed that those with positive Epo staining were more than twice as likely to die as those with negative staining (hazard ratio 2.34, 95% confidence interval 1.27–4.3). This study shows that the expression of Epo in RCC is adversely associated with overall survival. This is the first report of such an association, and might be explained by the loss of von Hippel-Lindau protein function in clear cell RCC. The expression of Epo might have potential use in clinical trials when stratifying high-risk patients for adjuvant therapy after nephrectomy.

Surgical Results of Laparoscopic Radical Nephrectomy according to Tumor Size in Renal Cell Carcinomas

Purpose: Laparoscopic surgery has been generalized for the treatment of localized renal cell carcinoma (RCC). Recently, laparoscopic radical nephrectomy for an RCC over the pT2 stage has gained rapid momentum as an effective surgery for treatment. We evaluated the possibility of the use of laparoscopic surgery for a large RCC, using the surgical results according to tumor size. Materials and Methods: Between June 2003 and June 2007, a total of 46 patients that under underwent a laparoscopic radical nephrectomy for RCC were divided into three groups according to tumor size: group 1 (n=16, tumor size ≤4cm), group 2 (n=15, tumor size 4cm 7cm). The surgical outcomes and perioperative morbidities were evaluated retrospectively, and were compared for each group. Results: The transfusion rate for group 3 patients was higher than for the other groups (group 1: 0%, group 2: 13.3%, group 3: 26,7%). However, the mean operative time (group 1: 154.3 minutes, group 2: 158.4 minutes, group 3: 197.9 minutes), postoperative initiative time to ambulate (group 1: 1.88 days, group 2: 2.00 days, group 3: 1.87 days) postoperative initiative time to diet (group 1: 1.38 days, group 2: 1.53 days, group 3: 1.53 days), total hospital stay (group 1: 7.94 days, group 2: 8.47 days, group 3: 8.20 days) and complication rate (group 1: 12.5%, group 2: 13.3%, group 3: 13.3%) were similar for patients in the three groups. Pathological results indicated that all cases showed a renal cell carcinoma with a negative surgical margin. Conclusions: There were no differences in the operative and postoperative results of the performance of laparoscopic radical nephrectomy according to tumor size, except for the transfusion rate. If the use of the technique and experience accumulate, laparoscopic radical nephrectomy will be feasible for all localized RCC regardless of tumor size. (Korean J Urol 2008;49:203-207) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Tratamento cirúrgico na recidiva retroperitoneal tardia por carcinoma renal de células claras após nefrectomia radical

Late renal cell carcinoma recurrence in the renal fossa is a rare event. This condition occurs in 1 to 2% of radical nephrectomies. We reported a late recurrence at the renal fossa about four and half years after radical nephrectomy due to a renal cell carcinoma (RCC) without metastasis elsewhere. Diagnosis in an outpatient follow-up was made during an abdominal computed tomography and we observed a retroperitoneal mass in the renal fossa. The excision at the recurrence area was made through a subcostal transversal incision without any difficulty. After 6 months from this second procedure, there was no evidence of recurrence. The surgical aggressive treatment for late retroperitoneal RCC recurrence is a good method in this rare situation. Abdominal computed tomography must be done during long periods of follow-up for patients with radical nephrectomy for RCC to search for late retroperitoneal recurrences.

Prognostic significance of erythropoietin expression in human renal cell carcinoma

To investigate, in a retrospective study, the expression of erythropoietin (Epo) in human renal cell carcinoma (RCC) and its correlation with overall survival, as Epo (an haematopoietic cytokine that regulates the production of red blood cells), with its receptor, was recently localized in non-haematopoietic tissues, e.g. liver, uterus, central nervous system, vascular endothelial cells and solid tumours. We used data from 113 patients who had radical nephrectomy for RCC between 1990 and 2000, taking sections from formalin-fixed and paraffin wax-embedded tissue blocks. The association between Epo staining and the patients' characteristics was assessed by either chi-squared tests (for categorical variables) or two-sample independent t-tests (for continuous variables). Tissue from 37 patients (33%) was positive for cytoplasmic Epo expression; 76 (67%) samples were negative. Univariate hazard ratio analysis confirmed that those with positive Epo staining were more than twice as likely to die as those with negative staining (hazard ratio 2.34, 95% confidence interval 1.27-4.3). This study shows that the expression of Epo in RCC is adversely associated with overall survival. This is the first report of such an association, and might be explained by the loss of Von Hippel-Lindau protein function in clear cell RCC. The expression of Epo might have potential use in clinical trials when stratifying high-risk patients for adjuvant therapy after nephrectomy.

Case Report: Retroperitoneoscopic Radical Nephrectomy for Renal-Cell Carcinoma during Twin Pregnancy

Renal-cell carcinoma (RCC) is rarely reported during pregnancy. Both the open and the laparoscopic approach to nephrectomy have been used effectively and safely in pregnant patients with RCC. We report a unique case of a 52-year-old woman found to have RCC during twin gestation who was treated with retroperitoneoscopic radical nephrectomy, one of the first such cases managed by this approach.

Incidence of adrenal involvement and assessing adrenal function in patients with renal cell carcinoma: Is ipsilateral adrenalectomy indispensable during radical nephrectomy?

To determine the value of ipsilateral adrenalectomy with radical nephrectomy, by investigating the clinical aspects of adrenal involvement and adrenocortical function in patients with renal cell carcinoma (RCC). The demographic, clinical and pathological data of adrenal involvement were reviewed in 247 patients with RCC. To evaluate adrenocortical function, 14 patients (adrenalectomy in eight, adrenal-sparing in six) had a rapid adrenocorticotropic hormone (ACTH) stimulation test before and 2 weeks after surgery. There was adrenal involvement with RCC in seven of the 247 (2.8%) patients (a solitary adrenal metastatic tumour in four and direct extension into the adrenal gland in three). All adrenal involvement was detectable on abdominal computed tomography before surgery, and these patients had a large primary renal tumour of > pT2 and/or distant metastasis. Plasma cortisol levels declined significantly more in response to the rapid ACTH stimulation test in those treated by adrenalectomy than in those with spared adrenal glands at 2 weeks after surgery (P < 0.05), while there was no significant difference between the groups before surgery. These results suggest that unconditional ipsilateral adrenalectomy with radical nephrectomy for RCC should be avoidable, and thus preserve the reserve of adrenocortical function, as preoperative imaging, especially thin-slice multidetector helical computed tomography, can detect adrenal involvement with RCC in most cases. Unilateral adrenalectomy might cause an irreversible impairment of the reserve of adrenocortical function.

Solitary psoas muscle metastasis after radical nephrectomy for renal cell carcinoma

Skeletal muscle is a very rare location for the metastasis of renal cell carcinoma (RCC) and only one case of solitary metastasis to the psoas muscle has been reported. We present a 63-year-old male patient with late recurrence (14 years) after left side radical nephrectomy for RCC. He first visited Chikushi Hospital, Fukuoka University, Japan in January 2000 for a postoperative follow-up because he had shifted residence to the area. Follow-up was by abdominal computed tomography (CT) and chest X-ray. In December 2001, a CT scan showed a 1.5 cm enhanced mass in the right psoas muscle without any other metastasis. The mass was resected that month and histological study showed RCC metastasis.