Intestinal testis tumor metastasis as a cause of intussusception: a case report

We report on an extraordinary testicular tumour causing intussusception with its intestinal metastases.

Tc-99m dextran scintigraphy in the diagnosis of protein losing enteropathy

Tc-99m dextran scintigraphy was performed on a 16-year-old male patient with protein losing enteropathy. Abnormal leakage of the radiotracer was observed in the right upper lumbar area that moved over time and excreted in the stool which was suggestive of protein loss. It is concluded that Tc-99m dextran is useful in the detection of protein losing enteropathy which is not detected by extensive radiological and endoscopic examination.

Prolonged interferon alpha treatment in children with chronic hepatitis B

Interferon alpha has been used widely to treat hepatitis B virus infection in children. However, the overall initial response rates have been < 50% and several strategies have been attempted to improve this. The aim of this study was to evaluate the safety and efficacy of prolonged interferon alpha treatment in children who did not respond to a previous course of interferon alpha treatment. Twenty-seven children with chronic hepatitis B who had not responded to a 6-month course of interferon alpha 2a (5 MU/m2 body surface) thrice weekly subcutaneously continued to receive interferon alpha at the same dosage for another 6 months without a rest phase. The children were followed for 6 months after completing 12 months of therapy. All of them had HBsAg, HBV-DNA and HBeAg tested on completion of the first course. Six of the 27 (22.2%) cleared both HBV-DNA and HBeAg after completion of therapy and all six had a sustained response. Pre-treatment predictive factors were not significantly associated with treatment response. No adverse effect of interferon was seen during follow-up. We conclude that prolonged interferon treatment is well tolerated and leads to additional benefit.

Glutathione S-transferase M1 gene polymorphism in bladder cancer patients. a marker for invasive bladder cancer?

The glutathione S-transferase M1 (GSTM1) gene is polymorphic in humans, and the deficiency in enzyme activity of GSTM1 is caused by the inherited homozygous absence of the GSTM1 gene, or the "null" genotype (GSTM1, 0/0). The increased risk of bladder cancer has been shown to correspond with this gene defect. No reports, however, have been found in the literature regarding GSTM1 gene deficiency with superficial and invasive bladder cancer. In this study, we examined the association of the GSTM1-null genotype with superficial and invasive bladder cancer. Using a polymerase chain reaction (PCR)-based method, we examined the frequency of the GSTM1 gene defect in Turkish patients with superficial bladder cancer (N = 61), invasive bladder cancer (N = 42), and control subjects (N = 202) who had no history of cancer. The GSTM1 null genotype was observed in 34.7% of the control subjects and in 54.3% of total bladder cancer patients (OR: 2.246; 95% CI: 1.384-3.645, P: 0.00094). In other words, the presence of the GSTM1-null genotype significantly increased the risk of bladder cancer development. Among invasive bladder cancers, the frequency of the GSTM1-null genotype was 64.3% (OR: 0.294, 95% CI: 0.147-0.590, P: 0.0003). This was also significantly higher than control subjects, indicating that patients carrying this genotype were at increased risk for developing invasive bladder cancer. This relationship was not statistically significant in the superficial bladder cancer group (OR: 0.585, 95% CI: 0.327-1.045, P: 0.06). Our results indicate that GSTM1 gene polymorphism should be considered as an important risk modifier in the development of bladder cancer and might be used as a predictive marker for invasive bladder cancer.

Resection of residual masses alone: an alternative in surgical therapy of metastatic testicular germ cell tumors after chemotherapy

OBJECTIVES

The standard approach in postchemotherapy surgery of testicular cancer is retroperitoneal lymph node dissection. However, because of its high rate of morbidity (mainly loss of antegrade ejaculation), various approaches have been suggested. We present our experience in limited postchemotherapy surgery for residual masses.

METHODS

Seventy-five patients underwent resection of residual masses after chemotherapy. After tumor marker levels returned to normal, patients with residual lymph nodes greater than 2 cm in nonseminomatous germ cell tumors and greater than 4 cm in seminomas and any resectable parenchymal lesions were candidates for the limited surgery. We performed 82 operations on 75 patients. The ejaculatory function of the patients after surgery was assessed during their last visit.

RESULTS

The histologic features of the resected specimens were necrosis/fibrosis, teratoma, and viable cancer in 33.3%, 45.3%, and 21.3%, respectively. Two patients had a relapse in the retroperitoneum, two in the thorax, and one in the liver. In 3 of these 5 patients, repeated limited resections were performed. At a mean follow-up of 37.4 months (range 3 to 127), 62 patients (82.7%) had no evidence of disease, 8 patients (10.7%) had died, 3 patients were alive with disease, and 2 patients were lost to follow-up. Removal of the residual masses was incomplete in 7 patients (9.3%). Five (45.5%) of 11 patients with viable cancer cells in the specimen had no evidence of disease after complete removal of the residual mass; in the group with incomplete removal, all patients had evidence of disease. The prognosis of patients with incomplete resections and those with viable cancer cells in the specimen was found to be worse than for those with complete resections and those with other histologic findings. Antegrade ejaculation was preserved in 58 (93.6%) of the 62 living patients.

CONCLUSIONS

In the present series, our surgical technique resulted in an excellent antegrade ejaculation rate and a rate of relapse attributable to the surgical technique that was very low (3%). Thus, removal of the residual mass only may be a beneficial option in postchemotherapy surgery.

Comparison of BTA stat and NMP22 tests in the detection of bladder cancer

OBJECTIVE

This study aimed to compare the BTA (bladder tumour antigen) stat and urinary nuclear matrix protein (NMP22) tests in the detection of bladder cancer.

MATERIAL AND METHODS

The office-based qualitative BTA stat and the laboratory-based quantitative NMP22 tests were studied in the same urine samples obtained from 49 patients with a high suspicion of bladder cancer and 20 healthy subjects.

RESULTS

A tumour was identified in 36 patients after the cystoscopy. BTA stat demonstrated a sensitivity of 89%, which was superior to the sensitivity of 66.6% with the NMP22 test in detecting the bladder cancer (p < 0.02). The sensitivities for grade I tumours with BTA stat and NMP22 were 55.5% and 33.3%, respectively. The sensitivity of BTA stat was 100% for tumour categories except for the pTa and grade I tumours. No positive result was observed with both tests among the healthy subjects. The specificities for BTA stat and NMP22 were 78.7% and 69.6%, respectively.

CONCLUSIONS

The BTA stat test was significantly more sensitive than the NMP22 test in the detection of bladder cancer. Although the sensitivity of BTA stat was not sufficient to replace cystoscopy, its ease and low cost may play a role in reducing the number of control cystoscopies, especially in patients with low risk of progression.

Celiac disease in Turkish children: presentation of 104 cases

BACKGROUND

Celiac disease is characterized by life-long gluten intolerance. Clinical features of patients with celiac disease are variable. In the present study, clinical, laboratory and histologic features of 104 patients with celiac disease were evaluated.

METHODS

Intestinal biopsy and serum antigliadin and anti-endomysium antibodies were used for the diagnosis of patients. Mucosal lesions were classified according to the criteria of Marsh. Antigliadin antibodies were measured with a commercial enzyme-linked immunosorbent assay. Anti-endomysium antibodies were analyzed by indirect immunofluorescence with the use of a section of monkey esophagus. Routine hematological and biochemical analyses and measurement of immunoglobulin levels were undertaken.

RESULTS

The mean (+/- SD) patient age was 5.9 +/- 4.1 years (range 10 months-16 years) and the most common symptom was diarrhea (81.7%) followed by abdominal distention, weight loss, anorexia and failure to thrive. Abdominal distention (60.6%), short stature (45.2%) and iron-deficiency anemia were the most common findings. High serum alanine aminotransferase levels were found in 38.3% of patients and these levels became normal after adoption of a gluten-free diet in all but two patients with cirrhosis. Immunoglobulin A, IgG antigliadin antibodies and IgA anti-endomysium antibodies were found in 76, 94 and 90% of patients, respectively. Biopsy of the small intestine revealed that 95, two and seven patients had type 3, type 2, and type 1 lesions, respectively, according to the Marsh classification. There was no statistically significant difference between patients and control groups with regard to antinuclear antibody, antismooth muscle antibody, anti-DNA and anticardiolipin antibodies (IgG and IgM).

CONCLUSIONS

Although classical celiac disease was seen in most patients in the present study, clinical variability of the condition should be kept in mind. In particular, patients with uncommon findings, such as short stature, cryptogenic liver disease and iron-deficiency anemia, should also be screened for celiac disease.

Is scrotal violation per se a risk factor for local relapse and metastases in stage I nonseminomatous testicular cancer?

OBJECTIVES

To determine the risk of local recurrence and relapse in patients with Stage I nonseminomatous testicular cancer with scrotal violation.

METHODS

From 1983 to 1998, 75 patients with clinical Stage I nonseminomatous testicular cancer who were initially treated with orchiectomy and surveillance alone were retrospectively reviewed.

RESULTS

Of 75 patients with Stage I nonseminomatous testicular cancer, 13 had scrotal violation. The surgical margins and the spermatic cords were free of tumor in all patients. Five patients (38%) in the scrotal violation group and 17 patients (27%) in the inguinal orchiectomy group experienced relapses. The difference was not significant (P = 0.41). Local recurrence was not observed in either group. All relapses, except one in the standard inguinal orchiectomy group, were treated successfully with chemotherapy and postchemotherapy surgery, if needed. The progression rate and survival were not significantly different between the two groups.

CONCLUSIONS

Scrotal violation without positive surgical margins and tumor spillage does not adversely affect relapse rate and survival. Therefore, scrotal violation per se is not an exclusion criterion for the surveillance-only policy in patients with Stage I nonseminomatous testicular germ cell cancer.

Glycogen storage disease type Ia: frequency and clinical course in Turkish children

The aim of this study was to determine the relative frequency of type Ia in glycogen storage disease (GSD) with prominent liver involvement and to determine its clinical and laboratory findings and prognosis in Turkish children. From 1980 to 1998, 45 out of 100 GSD patients (27 male) with liver involvement had been diagnosed for type Ia. The files were retrospectively evaluated and clinical and laboratory features were documented. In addition to routine laboratory evaluations, urine albumin, calcium excretions, and plasma biotinidase activity were measured. Breast-feeding was continued in all infants. After 6 months of age, uncooked cornstarch was administered to the patients. The relative frequency of type Ia in GSD with liver involvement was 45%. The diagnosis was made in 71% of patients before 2 years of age (median 1 year). Main complaint was abdominal protruding (57.8%), and main physical finding was hepatomegaly (100%). Forty percent of the patients had growth retardation at diagnosis. Among laboratory parameters, hypertriglyceridemia (97.8%) and hypertransaminasemia (95.6%) were the most frequent findings following plasma biotinidase activity, which was elevated in all patients. Microalbuminuria was determined in 52.8% of the patients and hypercalciuria in 23.8%. Histopathological findings of the liver included fibrosis (75.6%), steatosis (37.8%), mosaicism (24.4%) and nuclear hyperglycogenation (15.6%). During follow-up period, the ratio of patients with growth retardation did not change. Transaminases were decreased in 48.7% of the patients. Although triglyceride and cholesterol levels decreased in the majority of the patients, they did not normalise. The prevalence of type Ia in GSD with prominent liver involvement was found higher than the other reports. Microalbuminuria was also higher than the previous reports.

A study of the etiology of idiopathic calcium urolithiasis in children: hypocitruria is the most important risk factor

PURPOSE

To determine the association of metabolic risk factors with pediatric calcium urolithiasis we compared metabolic evaluation data on children with idiopathic calcium stones and those on healthy children.

MATERIALS AND METHODS

Metabolic evaluation was done in 78 calcium stone formers 1 to 15 years old (mean age 7.2) who were free of urinary tract infection, anatomical abnormalities, and metabolic, endocrinological and intestinal disorders, and in 24 healthy children. Evaluation included serum biochemistry, and measurement of daily excretion of urinary calcium, oxalate, urate, phosphorus, citrate and magnesium.

RESULTS

Demographic characteristics, serum parameters, and daily excretion of calcium, urate, phosphorus and magnesium did not differ statistically in the 2 groups. However, urinary oxalate was significantly higher and urinary citrate was significantly lower in stone formers than in controls (p = 0.002 and 0.028, respectively). Hypocitruria and hyperoxaluria were 4.3 and 3-fold more common in stone formers than in controls, respectively. Multivariate analysis using logistic regression showed that hypocitruria was the only significant risk factor for idiopathic calcium stones (p = 0.008).

CONCLUSIONS

Hypocitruria was the most important risk factor in our patients. Hyperoxaluria was also common and accompanied hypocitruria in many stone formers. In contrast to many previous reports, we failed to show that hypercalciuria is an important metabolic defect for idiopathic calcium stones, possibly because our study evaluated a different population.

Acute lymphoblastic leukemia in a child with Wilson disease

Wilson disease is an autosomal recessively inherited disease of copper metabolism and is characterized by liver and central nervous system dysfunction. The heterozygote carrier state rate is about one in 90 persons and the incidence of the disease is about 30 in 1,000,000. Although leukemia is the most common form of childhood malignancies, the probability of the presence of Wilson disease and acute lymphoblastic leukemia in the same patient is very low. We report an unusual case of a child with Wilson disease who developed acute lymphoblastic leukemia in three months.

Short-term effect of captopril on microalbuminuria in children with glycogen storage disease type Ia

Early signs of renal dysfunction in glycogen storage disease type Ia (GSD Ia) are glomerular hyperfiltration and proteinuria. In a non-randomized study, the effect of captopril on the improvement of proteinuria in GSD Ia patients with microalbuminuria was investigated. A positive effect has been shown for the insulin-dependent diabetes mellitus patients. Microalbuminuria was defined as albumin/creatinine ratio (mg/mmol) more than 2.5 in spot urine. Nineteen (52.7%) out of 36 patients had microalbuminuria, and 8 patients received captopril at a dose of 1 mg/kg per day. Microalbuminuria was evaluated periodically during the follow-up period. Of the captopril-treated patients, one was lost to follow-up. In the remaining 7 patients, urinary albumin excretion normalized in 3 patients (42.9%) and decreased at least by 50% in another 3 patients (42.8%) after 6 months of treatment. One patient, who was the oldest, did not have any benefit. In untreated patients, only two patients had a decrease in microalbuminuria of more than 50%. Patients with microalbuminuria had significantly higher blood lactate (p < 0.05) and plasma triglyceride (p < 0.01) concentrations and significantly lower blood bicarbonate concentration (p < 0.05) than those patients without it. Additionally, the patients with microalbuminuria had been diagnosed earlier than those without microalbuminuria (p < 0.05). Patients with microalbuminuria have more severe clinical and laboratory findings than those without microalbuminuria. Captopril at a dose of 1 mg/kg per day seems to be effective in at least 50% of GSD Ia patients with microalbuminuria.

Clinical experience with BCG alone versus BCG plus epirubicin

BACKGROUND

Bacillus Calmette-Guérin (BCG) and epirubicin have both been shown to be effective in the treatment of superficial bladder cancer. We studied whether the alternating combination of these agents could improve the efficacy with tolerable side-effects in the treatment of high-risk superficial bladder tumors.

METHODS

Forty-one patients with high-risk superficial bladder transitional carcinoma were included in this study. Twenty-one patients were randomized into the BCG group and 20 patients were treated with sequential BCG and epirubicin. The patients were followed for 9-24 months (mean 18 months). Recurrence rates, median time to the first recurrence, progression rate and complications were compared.

RESULTS

Fifteen percent of the patients in the BCG and epirubicin group and 19% of the patients in the BCG alone group developed tumor recurrence. Tumor progression was observed in 4.7% and 10% in the BCG/epirubicin group and the BCG alone group, respectively. Median time to first recurrence was 11 months for the BCG/epirubicin group and 16 months for the BCG group (P > 0.05). Three patients in the BCG/epirubicin treatment group developed serious side-effects, which necessitated antituberculosis treatment.

CONCLUSION

Because the efficacy of combination was no better than the standard treatment and the alternating combination seemed to be related to a higher incidence of side-effects, this study albeit small, does not recommend combination therapy of BCG and epirubicin in high risk patients with superficial bladder cancer.

Bilateral germ cell cancer of the testis: a report of 11 patients with a long-term follow-up

OBJECTIVE

To describe the incidence, clinical characteristics, treatment methods and long-term follow-up of bilateral germ cell tumours of the testis (GCTT) in patients treated at one institution.

PATIENTS AND METHODS

Of 552 patients with GCTT, 11 (2%, mean age 26. 9 years) developed bilateral disease; all 11 underwent radical orchidectomy. Additional treatment was planned according to the histological type and clinical stage of the tumour, and previous treatments. Intramuscular testosterone was administered periodically after total castration. The data on survival, sexual status and treatment complications were reviewed.

RESULTS

Of the 11 patients, seven developed a second tumour metachronously (median interval 87 months) and four had synchronous bilateral GCTT. Cryptorchidism, infertility or atrophic testis was associated with the development of bilateral GCTT in seven of the 11 patients. All synchronous tumours and most of the sequential tumours had identical histology on both sides. Although all sequential tumours presented at an early clinical stage, three of four synchronous bilateral GCTTs presented at an advanced stage. Five patients received platinum-based chemotherapy; three patients underwent post- chemotherapy resection of the retroperitoneal residual mass. Sexual libido and potency were conserved in all patients. No significant morbidity was recorded as being caused by any of these treatments. At a median follow-up of 11. 6 years, all patients were alive with no evidence of cancer.

CONCLUSIONS

All patients with unilateral GCTT have an increased risk of developing a contralateral testicular tumour, even decades after diagnosis. Management should be adapted to each patient. As all patients in this series survived in the long-term, developing a second germ cell cancer does not necessarily predict a poor prognosis.

Induction of mycobacteremia by intravesical bacillus Calmette-Guerin instillation in an experimental animal model and detection with polymerase chain reaction

PURPOSE

The aim of this study was to detect mycobacteremia by polymerase chain reaction (PCR), induced by the instillation of bacillus Calmette-Guerin (BCG) to guinea pig bladder. We also investigated the peak time and the effect of the dose of BCG in injured and non-injured bladder. The sensitivities of routine culture and PCR were also compared.

MATERIALS AND METHODS

Five different doses (0, 0.069, 0.69, 6.9 and 69 mg.) of BCG were instilled into 5 injured and 5 non-injured bladders. Blood samples were collected at 0, 5, 15, 30 and 60 minutes following instillation for routine culture and PCR for each dose. A total of 50 female guinea pigs were used.

RESULTS

Three of 5 samples (60%) obtained 30 minutes after the instillation of 69 mg. BCG into injured bladders were PCR positive. Furthermore, 4 of 5 samples (80%) were PCR positive when samples were obtained at the 60th minute following instillation. All the other samples were negative for PCR and routine culture. All the routine tuberculosis culture results were negative, including those which were PCR positive.

CONCLUSIONS

Mycobacteremia was detected only in injured bladders and with high doses of BCG. PCR is a highly sensitive and rapid diagnostic method for detection of mycobacteremia.

Bladder cancer

There is a need for the development of reliable tumor markers in bladder cancer. A number of studies this past year focused on the evaluation of urinary markers that hold promise as noninvasive adjuncts to traditional diagnostic or surveillance techniques, principally urinary cytology and cystoscopy. Tests for bladder tumor antigen, NMP22, and fibrin degradation products, as well as the Immunocyt test, are commercially available. Other urinary marker tests discussed in this review include telomerase, cytokeratins, and vascular endothelial growth factor. Although these tests in many instances have improved sensitivity in detecting bladder cancer compared with urinary cytology, none have become widely accepted in routine clinical practice. Nonetheless, with further refinement and prospective validation in multicenter trials, markers such as these may provide information that would permit tailoring on an individual basis the type of as well as interval of surveillance examinations. Furthermore, they may also provide information allowing the appropriate selection of therapy based on predicted response. In addition to urinary markers, intense research efforts have also focused on developing clinically useful molecular prognostic markers. A number of cell-cycle regulatory proteins, including p53 and p21, have received much attention in this regard. Emerging data suggests that it may soon be possible to determine the molecular phenotype of both superficial and invasive bladder cancers, thereby providing information regarding tumor behavior on an individual basis. As with urinary markers, however, no molecular markers have been incorporated as yet into day-to-day patient care. Assurances of reproducibility, standardization, and prospective validation studies are urgently needed. It is only through this type of rigorous evaluation that the level of confidence sufficient to base treatment decisions on marker status will be attained.

Proposal for changes in cystoscopic follow-up of patients with low-grade pTa bladder tumor

OBJECTIVES

The cystoscopic follow-up of superficial bladder cancer accounts for a considerable workload for urologists and is also an invasive procedure with high costs. There is a potential benefit both to the urologist and the patient if unnecessary cystoscopies can be avoided.

METHODS

The recurrence and progression rates of 120 patients with pTa G1 or G2 and small (<4 cm) transitional cell carcinoma were evaluated retrospectively.

RESULTS

The recurrence rate was 6.5% (8/120) at 3 months. The recurrence rates at 6 and 9 months were 6.7 (8/119) and 3.6% (4/112), respectively. However, when the third month (first check) was clear, the recurrence rates at 6- and 9-month cystoscopy were 4.3 (5/116) and 2.7% (3/111), respectively. The recurrence rate at 12 months was 8% (8/99). For G1 tumors, the recurrence rates at 3, 6, 9 and 12 months were 6 (5/84), 5 (5/83), 2.5 (2/80) and 7% (5/71), respectively. The same results for G2 tumors were 8 (3/36), 8 (3/36), 6 (2/32) and 10.5% (3/28), respectively. The progression rate for the first year was lower than 1%. The difference between G1 and G2 tumors according to recurrence rate within the first year was not statistically significant (p>0. 05).

CONCLUSIONS

This study supports the proposal that for patients with small and welldifferentiated pTa tumors at diagnosis, if the first control cystoscopy is clear, it is appropriate to perform the second check cystoscopy 1 year from initial resection and subsequent controls yearly. One should note that the study group included the most suitable patients for cystoscopic follow-up according to size and multiplicity of the tumor. This change in policy is further supported by the fact that progression occured in less than 1% in this group of patients.

Factors involved in diagnostic delay of testicular cancer

In testicular cancer, which is one of the highly curable cancers, the beneficial effect of early diagnosis on survival has been well accepted for years. This study was planned to determine the probable factors involved in diagnostic delay of testicular cancer. A total of 140 patients with testicular cancer were included in this study. We attempted to find a relationship between the mode of presentation, stage of the tumour, patients' socioeconomic status and the delay in diagnosis. Majority of patients presented with scrotal pain (49.3%). No significant correlation was found between the mode of presentation and stage of the disease (p>0.05). The median time of delay in diagnosis was 5.4 months. The stage at presentation was not influenced by the delay in diagnosis. Similarly the annual income and the educational level of the patients had no significant impact on the delay in diagnosis. No effect of delay in diagnosis on the stage at presentation could be demonstrated in our study. Our results indicate that in this country people are not thoroughly educated about the importance of routine self-examination of the testes. It must also be emphasized that painful testicular masses need to be evaluated carefully to rule out malignancy.

Multicentricity in renal cell carcinoma

OBJECTIVE

To find the incidence of multicentric renal cell carcinoma and its possible relationship to the other clinical and pathologic findings.

METHODS

A total of 40 patients with renal cell carcinoma underwent radical nephrectomy between March 1994 and January 1996 at Hacettepe University, School of Medicine, Department of Urology. All of the materials were examined grossly and histologically by the same pathologist.

RESULTS

Among 40 kidneys 4 had satellite carcinoma (10%), 3 of them had been shown by preoperative imaging techniques, 1 was found histopathologically.

CONCLUSION

If preoperative imaging techniques do not show additional lesion in the kidney besides the small early stage primary in incidentally discovered patients, the incidence of satellite renal cell carcinoma is low enough to justify nephron sparing surgery.

Marsupialization for bilateral pararenal lymphatic cysts

A case of bilateral pararenal lymphatic cysts associated with hypertension is described. The cysts surrounded the renal parenchyma and were located underneath the renal capsule. No vascular pathology explaining the cause of hypertension was diagnosed by radiological techniques. Hypertension improved following bilateral marsupialization.

Wilson's disease with hepatic presentation in childhood

OBJECTIVE

To evaluate clinical, laboratory findings, treatment and long-term follow-up of children with Wilson's disease with hepatic presentation.

DESIGN

Retrospective study with a median follow-up period of 9 years.

SETTING

University medical center.

SUBJECTS

Thirty-four children with hepatic involvement, ranging in age from three to fifteen years, were diagnosed as Wilson's disease over an eighteen year period.

METHODS

The diagnosis was based on the presence of family history and Kayser-Fleischer rings, low serum ceruloplasmin levels and increased urinary and hepatic copper concentrations.

RESULTS

Four patients had also neurological manifestations. Eight patients were diagnosed as fulminating hepatic failure resulting in death in a few days. The most common symptoms were abdominal distension and abdominal pain. Hepatomegaly was the predominant physical finding and serum transaminases were elevated in most of the patients. Twenty patients had cirrhosis and six had chronic hepatitis histopathologically. All patients with fulminating hepatic failure had hyperbilirubinemia with normal alkaline phosphatase and higher aspartate aminotransferase than alanine aminotransferase. Patients were treated with D-penicillamine and zinc sulphate. Three patients underwent liver transplantation. Four more patients besides patients with fulminating hepatic failure died due to end stage liver disease. Twenty-two patients were followed for median 9 years. Four patients with poor compliance progressed to decompensated cirrhosis and the others were stable.

CONCLUSIONS

Liver disease with unknown origin with positive family history and parental consanguinity should imply Wilson's disease strongly.

Interferon-alpha treatment for chronic hepatitis C in children

Interferon-alpha therapy has been proven efficient in chronic hepatitis C infection. Although it has been used as a standard therapy in adults, there are limited data on benefits of interferon treatment in children. We conducted a study of recombinant interferon-alpha therapy in 10 children with chronic hepatitis C. They had high aminotransferase values and positive antibodies to hepatitis C virus and HCV-RNA for at leas six months. Interferon-alpha was given at a dosage of 5 million units/m2 body surface three times a week for six months. At the end of therapy, five (50%) of the patients had complete response and two partial response. Three patients were nonresponders. Eight of the patients could be followed up for six months after stopping therapy, at which point one of the four complete responders and a partial responder relapsed. One of the three nonresponders had complete response at 12 months. Eventually, four (50%) of eight patients were complete responders. All of the nonresponders were the patients with previous malignant diseases. These findings suggest that interferon-alpha has beneficial effects in children with chronic hepatitis C, and a six month therapy seems to be reasonable. Patients with underlying malignant disease are not good candidates for interferon treatment.

Comparison of standard and high dosage recombinant interferon alpha 2b for treatment of children with chronic hepatitis B infection

BACKGROUND

Interferon is currently the most useful therapeutic agent for chronic viral hepatitis. The aim of this study was to compare the efficacy of standard and high dosages of interferon in children with chronic hepatitis B virus (HBV) infection.

METHODS

Thirty children with chronic hepatitis B infection were randomly assigned to receive 5 million units/m2 body surface area (Group I) or 10 million units/m2 body surface area (Group II) recombinant interferon alpha 2b three times weekly for 6 months. Patients were followed for at least 6 months (range, 6 to 18; median, 9 months) after the end of therapy, by physical and serologic examination every 3 months.

RESULTS

Clearance of HBV DNA occurred in 4 (27%) patients from Group I and 9 (60%) patients from Group II at the end of therapy. Hepatitis B e antigen (HbeAg) clearance was 7% (1 patient) and 53% (8 patients) in the two groups, respectively (P < 0.05). HBV DNA was undetectable in 40 and 60% of the children at the 12th month of randomization in Groups I and II, respectively. HBeAg/antibody to HBeAg seroconversion was found in 33% (5 patients) who received standard dosage and 60% (9 patients) in the high dosage group. Sustained complete response (normal alanine aminotransferase, negative HBeAg and HBV DNA at 12th month) was obtained in 5 and 9 patients respectively from groups I and II (P > 0.05). Only mean baseline serum alanine amino-transferase concentrations were predictive of response to interferon.

CONCLUSIONS

A 6-month course of interferon alpha 2b in children with chronic HBV disease was well-tolerated by most patients. Sustained suppression of HBV was obtained in 60% of patients with high dosage interferon and in 33% of the patients receiving standard dosage. Although these results were not statistically significant, studies with more patients are needed to ascertain whether high dosage improves the response rate.

Propranolol for primary and secondary prophylaxis of variceal bleeding in children with cirrhosis

Variceal bleeding due to portal hypertension is a frequent and severe complication of cirrhosis in children as in adults. The prophylactic approach is important for these high mortality bleedings, both for the first and for recurrent attacks. Variceal bleeding/rebleeding rates were evaluated in sixty patients with cirrhosis who received 1-2 mg/kg/day propranolol p.o. for 1-14 years. According to Child-Pugh classification, 33 patients were Class A, 22 Class B, and five Class C. Patients were divided into two groups according to whether they had variceal bleeding before starting propranolol treatment (secondary prevention; 15 patients) or not (primary prevention; 45 patients). Seven (15.6%) of 45 patients experienced bleeding on propranolol therapy in the primary prevention group, while eight (53.3%) of 15 patients bled in the secondary prevention group (p < 0.01). Propranolol was found effective in primary and secondary prevention in Class A patients, while it was effective only for primary prevention in Class B and C patients. Propranolol administration is useful for preventing first and recurrent variceal bleeding in Class A cirrhotic patients. In Class B and C cirrhotic patients, it is effective only for preventing the first bleeding episode.

Ursodeoxycholic acid treatment in children with Byler disease

BACKGROUND

There have been a few reports of patients with Byler disease and the best medical treatment is not known. The aim of the present study is to show the effect of ursodeoxycholic acid (UDCA) on clinical, laboratory and histologic findings in children with Byler disease.

METHODS

Nine children aged between 1.5 and 9 years with Byler disease were administered UDCA orally at doses of 15-20 mg/kg per day. They were followed for at least 12 months. Clinical, laboratory and histologic outcomes were evaluated after 12 months of treatment.

RESULTS

Seven children presented in the first 6 months of life with itching and/or jaundice. Gamma-glutamyl transpeptidase and cholesterol levels were normal in all patients, despite severe cholestasis. With UDCA therapy, pruritus disappeared/diminished in four (44.4%) patients. The mean serum concentrations of alanine aminotransferase, aspartate aminotransferase (AST), total and conjugated bilirubin decreased, although it was significant only for AST (P = 0.01). Before treatment, all biopsy materials showed cellular/canalicular cholestasis and fibrosis. After UDCA therapy cholestasis was ameliorated. Two patients died during follow up.

CONCLUSIONS

The results suggest that administration of UDCA leads to clinical and biochemical improvement in children with Byler disease. The UDCA ameliorates symptoms partially, improves the life quality of patients and may be given for as long as the disease continues.

Nonoliguric renal failure after transurethral resection of prostate

PURPOSE

To define the relation of nonoliguric renal failure to transurethral resection of the prostate (TURP), its clinical importance, and predictive factors.

PATIENTS AND METHODS

The files of 439 patients who had undergone TURP at Hacettepe University School of Medicine, Department of Urology, between January 1991 and 1994 were analyzed. The patients were divided into three groups according to postoperative serum creatinine concentration and the presence of clinical signs and symptoms of TUR syndrome (Group I: patients with preoperative and postoperative creatinine in the normal range; Group II: patients suffering nonoliguric renal failure; and Group III: patients with TUR syndrome). The data of the groups were compared in terms of factors influencing nonoliguric renal failure.

RESULTS

The mean postoperative concentrations of sodium, blood urea nitrogen, creatinine, and albumin in Groups II and III were statistically different from those in Group I (P < 0.001). There was a moderate relation between hyponatremia and the occurrence of nonoliguric renal failure (r(s) = -0.56). Capsule perforation increased the risk of nonoliguric renal failure 10.6 fold. All of the patients were managed by a conservative approach, and none of the patients died or progressed to end-stage renal disease. They were all discharged with a mean hospitalization period of 7 days and normal renal function tests.

CONCLUSION

Nonoliguric renal failure was thought to be an early step in the pathophysiology of TUR syndrome with acute renal failure. It is an asymptomatic clinical picture that is undiagnosed unless laboratory examinations are performed. A conservative therapeutic approach is enough.

Cholesteryl ester storage disease: case report during childhood

Cholesteryl ester storage disease (CESD) is rare and characterized by accumulation of cholesteryl esters and triglycerides in many tissues due to the deficiency of lysosomal acid lipase. We report a 3(1/2)-year-old child with CESD. The diagnosis was indicated by liver biopsy and confirmed by reduced acid lipase activity in leukocytes.

Hepatitis as the presenting symptom of childhood systemic lupus erythematosus

We report in this article a girl with an initial diagnosis of autoimmune hepatitis who developed full-blown systemic lupus erythematosus (SLE) at her two-years follow-up. She was formerly considered as HBV-related chronic active hepatitis but due to the persistence of elevated liver enzymes, the reversal of the albumin and globulin ratio and abnormal HBV serology, she was later diagnosed as autoimmune hepatitis. With the clinical findings of arthritis, arthralgia and malar rash and supported by results of laboratory tests, she was diagnosed as a case of unusual SLE presenting with autoimmune hepatitis. We conclude, therefore, that each patient with a diagnosis of autoimmune hepatitis in childhood who exhibits abnormal HBV serology must be evaluated for a possible diagnosis of SLE.

Skeletal muscle metastasis from carcinoma of the bladder

Metastasis to skeletal muscle from carcinoma of the bladder is extremely rare. To the best of our knowledge, there is no reported case in the English literature. In this report, we describe a 41-year-old man with bladder carcinoma with metastasis to the right deltoid muscle.

Prognostic factors and the role of nephrectomy in metastatic renal cell carcinoma

The objective of this study is to evaluate the prognostic factors and the role of nephrectomy in metastatic renal cell carcinoma. We reviewed 62 cases of metastatic renal cell carcinoma to document the factors influencing survival and to evaluate the role of nephrectomy. Sex and age of patients, size of primary tumor, site and number of metastases, nephrectomy, cell type and grade of tumor and medical treatment were analyzed as prognostic factors. Age and sex, cell type and type of medical treatment cannot be considered reliable predicting factors. However, improved survival was correlated with tumor size < or = 7 cm in diameter, low grade histology, metastasis limited to single organ and removal of the primary tumor. When these parameters were analyzed in a multivariate model, the presence of nephrectomy was the sole significant parameter. We therefore suggest that nephrectomy should be considered in all patients with metastatic renal cell carcinoma, as long as the morbidity of the operation is acceptable.