[Ileocolic intussusception from metastatic renal cell carcinoma]

The lung, the liver, the bone tissue and the brain are the most frequent sites for renal cell carcinoma metastasis. Small bowel metastasis from renal cell carcinoma is rare, with only few cases published. We report the case of ileal metastasis from operated kidney cancer revealed by ileocolic intussusception and causing intestinal obstruction in a 32-year-old woman.

Bladder perforation in a peritoneal dialysis patient

The dysfunction of the catheter in peritoneal dialysis (PD) is a frequent complication. However, perforation of organs are rare, particularly that of the urinary bladder. This requires an early diagnosis and prompt treatment of patients. We report here the case of a 38-year-old woman having end-stage renal disease due to autosomal-dominant polycystic kidney disease treated by PD since November 2000. Three years later, she was treated for Staphylococcal peritonitis. Four months later, she presented with a severe urge to urinate at the time of the fluid exchanges. The biochemical analysis of the fluid from the bladder showed that it was dialysis fluid. Injection of contrast through the catheter demonstrated the presence of a fistula between the bladder and the peritoneal cavity. She underwent cystoscopic closure of the fistulous tract and the PD catheter was removed. Subsequently, the patient was treated by hemodialysis. One month later, a second catheter was implanted surgically after confirming the closure of the fistula. Ten days later, she presented with pain at the catheter site and along the tunnel, which was found to be swollen along its track. The injection of contrast produced swelling of the subcutaneous tunnel but without extravasation of the dye. PD was withdrawn and the patient was put back on hemodialysis. Bladder fistula is a rare complication in PD and diagnosis should be suspected when patient complains of an urge to pass urine during the exchanges, which can be confirmed by contrast study showing presence of dye in the bladder. PD may be possible after the closure of the fistula, but recurrence may occur.

[Cardiac metastasis of renal cell carcinoma, a rare location]

The renal carcinoma is situated in the third rank of the urologic cancers. It is metastatic in a third of the cases, when we made the diagnosis of the cancer. Lungs, bone, the liver, the suprarenal gland and the brain stay metastatic sites of preference. Some metastatic locations are anecdotal and made the object of some publications. We report the case of a cardiac metastasis of renal carcinoma at an old patient 81 years old operated for cardiac tumor.

Short- and long-term outcomes of living donors in Tunisia: a retrospective study

Despite initiatives to increase cadaveric donation, there is still a shortfall in donor organs. Kidneys from living donors now makes a significant contribution to increasing the number of organs available for transplantation in Tunisia. We performed a retrospective study of 405 kidney transplantations, including 321 (79.3%) from living donors performed from June 1986 to December 2007. We obtained information on only 162 (50.4%), namely, 64 men (39.5%) and 98 women (60.5%), whose mean age at the time of donation was 42.3 ± 12.2 years. Twelve (8.22%) perioperative complications occurred: wound infections (n = 4), pneumothorax (n = 4), phlebitis (n = 1), hematomas (n = 2), and urinary infection (n = 1). The mean follow-up period was 117.4 ± 74.4 months. Hypertension occurred in 42 donors (25.9%) with mean values of 134 ± 20 for systolic and 79 ± 10 for diastolic blood pressure. Twelve donors (7.4%) developed proteinuria (mean proteinuria, 0.08 ± 1.25 g/d). Renal insufficiency was found in 28 donors (19.44%), 2 of whom developed chronic renal failure requiring dialysis at intervals of 36 and 84 months. In both cases, we diagnosed a familial form of focal segmental glomerulosclerosis. Two donors (1.2%) died within 10 years after kidney donation due to senility. The relatively favorable outcomes suggest that living-donor kidney transplantation is an acceptable approach, in view of the superior results it yields in recipients. However, efforts to increase the number of cadaveric donors in Tunisia should be made. It is also important to develop a registry of long-term kidney function after kidney donation.

Urothelial carcinoma with plasmocytoid component

Plasmocytoid urothelial carcinoma is a rare subtype of tumour of the urinary bladder. Its clinical and histopathological features have not been well characterized. There are few reports of this type of tumour. We report a case of 65-year-old man who was operated in our department for bladder tumour. The pathological diagnosis was high-grade urothelial carcinoma with plasmocytoid component. The patient died shortly thereafter from liver and bone metastasis.

Functional imaging using DCE-US: Which parameter for the early evaluation of antiangiogenetic therapies?

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Background: The early evaluation of anti-angiogenic treatments is a challenge in oncology. Functional imaging methods based on the measure of tumoral vascularization have been developed using different modalities (CT, MRI, US). We analyzed the response in four studies using different targeted treatments with dynamic contrast enhanced-ultrasonography (DCE-US). Seven parameters characterizing tumoral perfusion were estimated. The objective of the study was to determine which parameter is the most appropriate to confirm earlier the efficacy of treatments. Methods: A total of 823 DCE-US were performed in 117 patients included in 4 following studies (multikinase inhibitor targeting angiogenic-receptor with a cytotoxic or thyrosine-kinase inhibitor targeted angiogenic-receptor and C-kit or monoclonal antibody anti-VEGFR). Each DCE-US was performed using contrast agent (Sonovue, Bracco) with perfusion and quantification softwares (Toshiba) from raw linear data with a high temporal resolution: 4 frames per second during 3 minutes. Seven quantitative parameters of perfusion were estimated: peak intensity (PI) and area under the total curve (AUC), area under the wash-in (AUWI), area under the wash-out (AUWO), time to peak intensity, mean transit time (MTT), wash-in slope. DCE-US were performed before treatment and after D3, D 8, 15, 21 (according each study design) and every 2 months. Patients were classified in good responders and bad responders according the response (RECIST on CT-scan) after 2 cycles or 2 months. Results: Among the 7 parameters, 2 parameters related to the blood volume studies (AUC and AUWO) were always earlier significantly modified (p = 0.04 to p = 0.004). One was never modified: MTT. For the 4 others, it's depending of each study. Conclusions: DCE-US appears as a sensitive tool to evaluate tumoral response to anti-angiogenic drugs. Functional parameters related to the blood volume are more pertinent and represent a key add value to early evaluation of these therapies studies.

No significant financial relationships to disclose.

Interest of DCE-US with quantification to demonstrate the VDA effect on vascularization in patients with advanced solid tumors treated with AVE8062

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Background: To determine the optimal time for the assessment of the perfusion in patients receiving AVE8062 (Vascular Disrupting Agent) at different doses combined with a fixed dose of cisplatin and then to correlate these results with the tumor response. Methods: Patients (pts) with advanced solid tumors, treated with AVE8062 (from 11.5 to 30 mg/m2) in combination with 75 mg/m2 cisplatin given every 3 weeks, were prospectively followed by DCE-US. DCE-US was performed before treatment, at 3 time points (0, 6 and 24 hours (h)) on Day 1 of the first (C1) and second cycle (C2), then every 2 cycles thereafter. Contrast uptake was acquired using VRI perfusion software after SonoVue bolus injection. Time-Intensity Curves (TIC) were determined using linear raw- data from CHI-Q (Toshiba) software. Peak Intensity (PI) representing the blood volume was calculated from automatic modeling of TIC. CT-scans performed before treatment and every 2 cycles were reviewed and tumor response assessed (RECIST). Results: A total of 96 DCE-US were performed in 13 pts, 11 of whom had data for both cycle 1 and cycle 2. Among these 11 patients, 8 presented with a dramatic decrease of PI and 3 with an increase of PI. At cycle 1, mean change from baseline in PI was -36% at 6h and -47% at 24h after AVE8062 infusion. Greater decreases were observed at cycle 2, -70% at 6 h and 78% at 24 h. No pt had a clinical response, but by cycle 2, the 8 pts with a decrease in PI at 24h went on to have stable disease as best response; 3 pts with increased PI 24h after their second treatment all had disease progression as best response. Conclusions: The best timing to observe the effect of AVE8062 on the PI seems to be 24 hours after drug administration at cycle 2. These preliminary results suggest that 24 hr PI at cycle 2 could be useful for determining pts who are more likely to have disease progression as best response to AVE8062. If confirmed, the assessment of PI variation may predict the clinical response to AVE8062. Further studies are needed to assess the possible predictive value of DCE-US on duration of progression-free survival.

No significant financial relationships to disclose.

Cystic nephroma in the adult: pathological aspects and therapeutic implications

Cystic nephroma is a benign renal neoplasm. Since its initial description, there has been much debate regarding its origin. Preoperative diagnosis of Cystic nephroma is difficult to achieve. The differential diagnoses of Cystic nephroma are recently described mixed epithelial and stromal tumours of the kidney and cystic renal cell carcinoma. The Authors report three cases of Cystic nephroma and illustrate the clinical, radiological and histological features of this renal neoplasm.

Segmental infarction of the testis: an exceptional complication of diabetes microangiopathy

We report a case of segmental infarction of the testis in a 55-year-old man. Past medical history included 12 years of type II diabetes and hypertension. The patient presented with a 2-month history of testicular pain and was found clinically and sonographically to have a testicular tumour. The pathological examination of the partial orchiectomy specimen revealed segmental infarction of the testicle secondary to diabetes microangiopathy. We propose diabetes microangiopathy as a localization and aetiology of segmental testicular infarction. A possible testicular sparing procedure through an inguinal approach may be considered in cases of testicular masses for which the clinical and imaging findings are suggestive of focal testicular infarction.

Management of penile fractures complicated by urethral rupture

The combination of lesions of the penile urethra and the corpus cavernosum is rare and likely to go unremarked. It worsens the immediate and long-term prognosis and poses a problem of management. Among 312 cases of penile fracture, we performed a retrospective study of a series of 10-case of traumatic corpora cavernosa rupture complicated with urethral rupture, treated in the department of Urology at 'Charles Nicolle' Hospital in Tunis. The median patients' age was 30 years. The most common mechanism was manipulation of an erect penis, found in six cases. Urethral rupture was suspected in all patients given the presence of bloody urethral discharge. No preoperative radiographic investigations were necessary. All patients underwent immediate surgical exploration. The urethral injury was always partial and localized at the level of the corpora tear. Surgical repair of both urethral and corpora tear was done in all patients. The follow up was uneventful. Urethrography at the removal of the transurethral catheter did not visualize contrast extravasation in any patient. No urethral stricture or erectile complaints were noted within a 36-month mean follow-up. Urethral rupture must be suspected in any case of penile fracture presenting with bloody urethral discharge. Standard treatment is immediate surgical repair.

False penile fracture: report of 16 cases

We determined the value of diagnostic and therapeutic approaches of false penile fractures and the outcome of treatment. We retrospectively reviewed 16 cases of presumed penile fracture with a negative surgical exploration. Clinical presentation, technique of treatment and outcome were noted. The mean age was 39 years (17-64). Nine patients were injured during sexual intercourse. All the patients presented with the presumptive diagnosis of penile fracture. False penile fracture was evoked in one patient presenting a new erection. Surgical penile exploration was carried out for all the patients without any radiological explorations. It revealed nonspecific dartos bleeding in 10 cases and avulsed superficial dorsal vein in six cases requiring venous ends ligation. All the patients regained penile appearance and potency. We can hardly distinguish false penile fracture from 'true' penile fracture with certainty either clinically or radiologically, thus, surgical exploration is mostly necessary. The prognosis is excellent.

Primitive neuroectodermal tumor of the kidney with vena caval tumor thrombus: diagnosis and management

Primitive neuroectodermal tumors (PNET) of the kidney are rare and highly aggressive malignancies. We report a case of 28-year-old male with PNET of the kidney with inferior vena caval thrombus. Immunohistochemistry revealed strong positivity for CD99 and weak positivity for vimentin. Neuron-specific enolase (NSE), chromogranin and cytokeratin were negative. Patient underwent nephrectomy and six cycles of polychemotherapy the patient was in partial remission. He underwent two further cycles of high dose chemotherapy and died 9 months after diagnosis due to liver metastases. The diagnosis of renal PNET must be considered in young patients with renal neoplasm, particularly those with advanced disease at presentation. Achieving exact diagnosis has important clinical consequences.

Du diagnostic au traitement de la rupture de la coiffe de hanche : à propos d'un cas

OBJECTIVE

To report a case of spontaneous gluteus medius tear repaired surgically in a 42-year-old woman patient without any other antecedent other than diabetes. PATIENT AND METHODS-RESULTS: Trochanteric pain evolving for 7 months led to scintigraphy objectifying a hyperfixation of the trochanter and ultrasonography showing an inflammatory gluteus medius tendon. These examinations were supplemented by magnetic resonance imaging and tomodensitometry visualising the tendon rupture but no marked fat degeneration of the muscle despite atrophy of this one. Surgical exploration confirmed the presence of a major rupture of the gluteus medius tendon, which was reinserted through an osseous trench. Rehabilitation involved protecting the tendon, by an installation of the member in abduction and passive mobilization from the third postoperative day, with a move to partial support on day 45. The result after 16 months was excellent, the patient returning to work 8 months after the surgery without any residual pain.

CONCLUSION

The spontaneous rupture of the gluteus medius, often ignored, can occur in young subjects and induce limited function, often well corrected by reinsertion surgery.

[Contribution of cell cycle and DNA content study by flow cytometry in the prognosis of superficial bladder cancer: Tunisian experience]

Clinico-pathological study of superficial bladder cancer (pTa/pT1) informs about prognostic factors such as the size of the tumor, its uni or multifocal character, its grade and stage. Presently, these factors constitute the basis of therapeutic decision but do not allow to foresee the prognosis with certainty. Many technics have contributed to a better knowledge of such tumors; however, they have not allowed to fully master prognostic uncertainties. During the last decades, cell cycle and DNA content study by flow cytometry has been developping, bringing an additional prognostic element to various types of tumors. We have decided to study the impact of this technique to the assessment of the prognosis of superficial bladder tumors. The study concerned 65 patients presenting superficial bladder tumors (pTa/ pT1), with a follow-up of at least two years in case of not recurrence and in case of recurrence, having had a second resection with analysis of sections. Flow cytometry was applied to formol-fixed and paraffin-embedded endoscopic resection material of initial tumors by simple-labelling of DNA with propidium iodide. Following cytometric study, 35 (54%) of tumors were aneuploid and 30 (46 %) were diploid. For the diploid ones, S-phase mean value was 14.94% (from 2.72% to 33.43%); and G2M mean value was 8.3 (from 1% to 18%). The presence of an DNA- aneuploid peak had a predictive value of recurrence and progression in stage, with relative risks of 12 and 6.85 respectively. It was also correlated with the histological grade and stage. On the other hand, S-phase and G2M values had no prognostic significance.

Résultats de l’ostéosynthèse par vissage sans greffe osseuse des fractures articulaires du calcaneus

PURPOSE OF THE STUDY

The prognosis of calcaneal joint fractures is less favorable than fractures without joint involvement. Surgical treatment is frequently recommended. The type of fixation and the usefulness of a bone graft remain subjects of debate. The purpose of this work was to present the functional and anatomic results obtained with simple screw fixation without bone grafting in a retrospective series of 35 displaced joint fractures of the calcaneus.

MATERIAL AND METHODS

The series included 31 patients (four bilateral fractures), 86% men. Mean age was 36 years (17-60 years). Using the Duparc classification, there were 12% type III fractures and 88% type IV fractures. Horizontal joint impaction was observed in 36% of patients, vertical impaction in 8%, and mixted impaction in 56%. The mean Bohler angle was 2 degrees (range -25 degrees to 15 degrees ). According to the Utheza classification, 70% of the fractures had two sagittal fracture lines, 16.5% one sagittal fracture line, and 13.5% comminutive fractures. Incongruency of the subtalar joint was noted in 70%, with a conflict with the lateral malleolus in 50%. Mean time to surgery was 12 days (7-30 days). The sub- and retromalleolar approach was used to achieve simple screw fixation. Bone grafts were not used. Mean follow-up was two years (range 12-38 months).

RESULTS

There were no serious complications. Functional outcome was analyzed with the Kitaoka scale, mean score 74.3 +/- 1.1 (range 46-98), with 16% excellent outcome, 56% good outcome, 25.2% fair outcome, and 2.5% poor outcome. There was a correlation between functional outcome and age, etiology, and type of fracture. Anatomic results were assessed with the Babin scale and were very good in 24%, good in 8%, fair in 28%, and poor in 40%. Secondary loss of the initial heightening of the joint surface was noted in 48% of the cases, 3 degrees on average.

DISCUSSION

This series confirms the value of surgical treatment compared with conservative treatment. Compared with plate fixation, screw fixation exposes the patient to less risk of skin and infectious problems. Simple screwing generally provides satisfactory results with acceptable stability. In light of the present results, adjunction of a bone graft would not be necessary since the loss of correction of the joint surface height was often minimal.

CONCLUSION

Screw fixation of calcaneal joint fractures is a reliable technique. Adjunction of a bone graft does not appear to be necessary.