[Renal cell carcinoma extending into the right atrium. Case report]

We report the clinical case of a 48-year-old woman with advanced renal cell carcinoma, and an inferior vena cava thrombus extending into the right atrium. The patient underwent complete tumor excision with radical nephrectomy and inferior vena cava trombectomy using adjunctive cardiopulmonary bypass and deep hypothermic circulatory arrest. Pathological studies revealed no capsular invasion by the renal cell carcinoma. Eighteen months postoperatively the patient is asymptomatic and on immunosuppressive therapy for suspected metastatic disease. We discuss the morbilidity, mortality and long term survival of patients with similar presentation of renal cell carcinoma based in a review of the published literature. Long term survival after surgical treatment is possible in a patient with localized renal cell carcinoma extending into the right atrium. In patient with localized renal cell carcinoma and inferior vena cava tumor thrombus the cephalad extent of inferior vena caval involvement does not appear to influence the prognosis.

[Non-convulsive status with hemianopsia and ictal headaches: an uncommon manifestation of parieto-occipital epilepsy]

INTRODUCTION

Parieto-occipital epilepsy is uncommon disease that usually occurs with positive symptoms such as illusions, visual hallucinations. The pericital headache, with or without migraine-type characteristics, is common symptoms (amaurosis, hemianopsia) are rare.

CLINICAL CASE

A 21 year-old woman with a previous medical history of Rendu-Osler disease was admitted to the hospital because of migraine-type headache. Examination revealed homonymous hemianopsia which had not been previously observed. During admission, brief episodes of ocular and cephalic deviation to the left were observed. An electroecephalogram showed frequent seizures arising from the right parieto-occipital region. Symptoms disappeared with antiepileptic drug treatment.

CONCLUSION

We report a case of parieto-occipital epilepsy with headache and hemianopsia as ictal symptoms. Differential diagnosis must be done basically with migraine attacks. This type of epilepsy may be underdiagnosed.

Structure and function of the bithorax complex genes of Drosophila

The bithorax complex consists of three genes, Ubx, abd-A and Abd-B, which together specify the characteristic development of parasegments 5 to 13 of Drosophila. These genes are structurally homologous; they are of similar size, are transcribed in the same orientation and they all have a homeobox near the 3' end of their transcription unit. Genetic and molecular analyses of Ubx suggest that the gene contains one transcription unit encoding the protein products and at least three cis-regulatory regions. Two of these, abx and bxd, promote the activity of the Ubx transcription unit to the levels appropriate for parasegments 5 and 6, respectively. A third regulatory element, called Cbx-like, prevents the expression of Ubx anterior to parasegment 5. The gene abd-A is not as well known, but genetic and molecular studies indicate at least one cis-regulatory region downstream of the 3' end of the transcription unit. In the gene Abd-B there are two distinct trans-acting elements, called m and r. The m element is a conventional homeotic function, which specifies the identity of parasegments 10 to 13. The r element is specific for parasegment 14 where it suppresses a number of homeotic functions (including m). Molecular analysis indicates that Abd-B contains two transcription units with a common 3' end which correspond to the m and r elements defined genetically.

Purification, product characterization and kinetic properties of lipoxygenase from olive fruit (Olea europaea L.)

Lipoxygenase from olive fruit was purified to homogeneity for the first time after differential centrifugations and by hydrophobic chromatography. The enzyme had a molecular mass of 98 kDa and exhibited a maximal activity at pH 6. Lipoxygenase had a better affinity for linoleic acid (Km=82.44 microM) than for linolenic acid (Km = 306.26 microM). It is inhibited by linoleate:oxygen oxidoreductase (LOX) inhibitors like nordihydroguaiaretic acid (NDGA) or propyl gallate. The reaction product was 13-hydroperoxy octadecadienoic acid when linoleic acid was used as substrate.

The optimum timing of radical cystectomy for patients with recurrent high-risk superficial bladder tumour

OBJECTIVE

To establish the optimum time of radical cystectomy (RC) for patients with recurrent high-risk superficial bladder tumours after the failure of intravesical therapy.

PATIENTS AND METHODS

Among 318 patients with transitional cell carcinoma treated with RC and with no neoadjuvant therapy, there were 46 with clinical stage Ta, T1 or Tis refractory to transurethral resection associated with intravesical therapy. These patients had at least one of: (i) high-risk superficial bladder tumours after failure of two consecutive induction courses of intravesical therapy; (ii) superficial bladder tumours with prostatic stromal invasion; (iii) superficial bladder tumours with mucosa/ducts involvement after failure of one course of intravesical therapy; (iv) uncontrolled superficial tumours with transurethral resection associated or not with intravesical therapy. Progression and cause-specific survival of these patients were compared to those with muscle-invasive tumours. Univariate and multivariate analyses of predictive factors for cause-specific survival were also used in patients with superficial tumours. The incidence of significant prognostic factors was compared in both superficial and muscle-invasive tumours, as were the progression pattern and survival.

RESULTS

The progression-free and cause-specific survival of patients with superficial tumours was 54% and 67%, respectively, with no significant difference from those with muscle-invasive tumours. In multivariate analysis, positive lymph-nodes and prostatic stromal invasion were significant and independent variables for survival. The incidence of positive lymph nodes was 15% vs 30% (P < 0.05) and of stromal invasion was 32% vs 1.5% (P < 0.001) in patients with superficial and muscle-invasive tumours, respectively. Accounting for the progression pattern in patients with superficial tumours, extravesical urothelial recurrence prevailed over local or distant recurrences (30% vs 15%), whereas in patients with muscle-invasive tumours the opposite occurred (5% vs 33%, respectively). The cause-specific survival of patients with superficial tumour and prostatic stromal invasion was one of three, and in those who developed extravesical urothelial recurrence was 28.5%.

CONCLUSION

In patients with recurrent high-risk superficial bladder cancer after intravesical therapy, our criteria for RC were inappropriate, and patients had a survival rate similar to those with muscle-invasive tumours. RC might have been used too late, as there was a high incidence of prostatic stromal invasion and extravesical urothelial recurrence after RC. Both events seem to be responsible of the low cause-specific survival. Predictive factors for progression are needed to indicate early RC in patients with recurrent high-risk superficial tumours. From a previous analysis the pathological pattern of the clinical lack of response (T1, G3, bladder carcinoma in situ and prostate involvement) to intravesical therapy evaluated at 3 months might be important for predicting progression, and an early RC at that time might be useful.

Disruption of basement membrane, extracellular matrix metalloproteinases and E-cadherin in renal-cell carcinoma

A retrospective study was performed to determine the prognostic value of Basement Membrane (BM) integrity, Matrix Metalloproteinases (MMPs) and E-Cadherin expression in renal cell carcinoma (RCC).

MATERIALS AND METHODS

An immunohistochemical study on laminin and collagen IV, MMPs 1 and 2, and E-Cadherin was carried out on 71 RCCs. BM fragmentation was considered taking 75% as a cut-off. MMP 1 and MMP2 immunostaining, as well as E-Cadherin was considered taking 25% as a cut-off.

RESULTS

An inverse relationship was seen between E-Cadherin with laminin, collagen IV and MMPs. More than 75% loss of laminin, collagen IV and E-Cadherin, as well as higher expression of MMPs, were associated with symptoms, tumoral size and worse grade. Loss of collagen IV and E-Cadherin were of prognostic value.

CONCLUSION

Both BM and E-Cadherin are good prognostic markers. MMPs patterns show a relationship between BM proteins and E-Cadherin, but evaluation is more time-consuming and provide no better prognostication; consequently they are not useful in routine clinical applications.

Late oncological occurrences following radical cystectomy in patients with bladder cancer

PURPOSE

To evaluate the prognoses and predictive factors of late oncological occurrences and its impact on follow-up strategy in patients with bladder tumours treated with radical cystectomy.

MATERIALS AND METHODS

Late oncological occurrences were considered when they took place after three years from cystectomy or when early recurrence was controlled with therapy and patients developed recurrence again after a three-year disease-free interval. Univariate and multivariate analysis of predictive factors for late oncological occurrences were carried out on 215 patients at risk of late oncological recurrences.

RESULTS

Among 357 patients treated with cystectomy, 163 (45.6%) relapsed, 149 (41.7%) of them as early recurrence and 17 (4.7%) were considered as late oncological events. This incidence increased up to 8% when patients at risk were considered. Three patients with early recurrence reached a complete response after treatment and relapsed again as late recurrences. Distant metastases and local recurrence represented 78.5% of early recurrence as opposed to 11.7% in late oncological occurrences, whereas, extravesical urothelium recurrences represented 8.6% and 70% respectively (p<0.01). Among patients with late oncological occurrences, nine (53%) were disease-free, seven with urothelial recurrence and two of three with lymph-node recurrence whereas only eight (5.6%) patients with early recurrence were free of tumour (p<0.0001). Multiple tumours, prostate involvement and organ-confined tumours in cystectomy specimen were the independent variables for predicting late oncological occurrences in multivariate analysis.

CONCLUSIONS

Recurrences in the remaining urothelium prevail as the pattern of late oncological occurrences. The prognosis of these events is significantly better than an early recurrence. Patients at risk of late oncological occurrences are those with multiple tumours, prostate involvement and with organ-confined tumours in cystectomy specimen. After three years from cystectomy, the follow-up schedule of these patients be limited to performing an annual CT-scan and urinary cytology to detect essentially upper urinary tract recurrence and extrapelvic lymph-nodal recurrence. Afterwards an annual intravenous urography might replace to CT-scan since lymph-nodal involvement was not detected.

[Trihalomethanes in the drinking water of Carabobo State, Venezuela]

OBJECTIVE

Disinfection of water with chlorine in water treatment plants leads to the formation of trihalomethanes (THMs). These compounds are associated with adverse health effects. The aim of this study was to analyze THM concentrations in the water provided for human consumption in the two main water treatment systems of Carabobo State: the Alejo Zuloaga plant and the Pao-Cachinche reservoir, which form the Central Regional System I (CRS I), and the Lucio Baldo Soules plant and the Pao-La Balsa reservoir, which form the Central Regional System II (CRS II).

METHODS

We analyzed 144 water samples collected in 6 samplings carried out in 2000 and 2001. THM concentrations were determined by gas chromatography using the headspace technique. The concentrations of the following THMs were measured: chloroform (CHCl3), bromoform (CHBr3), chlorodibromomethane (CHBr2Cl) and bromodichloromethane (CHCl2Br).

RESULTS

The concentration of total THMs was between 47.84 g/l and 94.23 g/l. CHCl3 was the most commonly formed compound representing 83% of all THMs in the CRS I and 82% in the CRS II. The concentrations of total THMs in the CRS I, specifically in the Baja and San Diego networks, were significantly higher (p < 0.05) than permissible levels set by the American Environmental Protection Agency (80 g/l) for the sum of all four THMs.

CONCLUSIONS

The results show that in the area studied there is a risk of adverse health effects due to THMs in drinking water, especially in the Baja and San Diego networks.

Extrahepatic synthesis of factor VII in human atherosclerotic vessels

OBJECTIVE

Coagulation is initiated by the interaction of tissue factor (TF) with plasma coagulation factors VII (FVII) and X (FX). TF is highly expressed in atherosclerotic lesions, but little is known about the synthesis of FX or FVII outside of the liver. Previous studies suggested that macrophages synthesize FVII. We therefore hypothesized that macrophages within atherosclerotic lesions may produce FVII, leading to partial activation of the coagulation cascade.

METHODS AND RESULTS

Immunohistochemistry was performed using antibodies against FVII, FX, and TF on normal and atherosclerotic vessels. In atherosclerotic lesions, FVII immunostaining was colocalized with TF in macrophages and spindle-shaped smooth muscle cells. FVII mRNA was also detected in these cells using in situ hybridization, suggesting the local synthesis of FVII in atherosclerosis. Reverse transcriptase-polymerase chain reaction confirmed the presence of FVII mRNA in normal and atherosclerotic vessels as well as smooth muscle cells, fibroblasts, and keratinocytes in vitro.

CONCLUSIONS

The localization of FVII synthesis outside the liver may be indicative of other cellular functions for this coagulation protein. The observed coexpression of TF and FVII may contribute to autocrine signaling via thrombin-independent mechanisms and may represent a novel mechanism contributing to growth in the setting of vascular disease.

Conservative elective treatment of upper urinary tract tumors: a multivariate analysis of prognostic factors for recurrence and progression

PURPOSE

We evaluate the safety and efficacy of conservative elective treatment of upper urinary tract tumors, and determine predictive factors for recurrence and progression to optimize indications of this type of treatment.

MATERIALS AND METHODS

Since 1984 we have performed a prospective study of conservative treatment of single, low grade and stage, less than 3 cm. upper tract tumors. The study includes 54 patients with a normal contralateral kidney who had been followed for more than 36 months. Open conservative surgery was performed in 31 cases and endourological surgery in 23. Minimum followup was 36 months, maximum 210 and mean 84.8. Univariate and multivariate analyses of recurrence and progression were performed in relation to age, sex, association with a bladder tumor, bladder tumor stage and grade, sequence of bladder tumor in relation to upper urinary tract tumor, number of previous bladder tumor recurrences, association with bladder carcinoma in situ, upper urinary tract tumor grade, stage, location, size and therapy, and upper urinary tract cytology.

RESULTS

Of the 54 patients 19 (35%) had recurrence, which was bilateral recurrence in 4, and progression occurred in 9 (16%). At the end of analysis 44 (62.9%) patients were disease-free and alive at a mean time of 92.88 months, 13 (24%) died disease-free at a mean of 72.7 months and 7 (12.9%) died of disease at a mean of 97.85 months. Cause specific mortality occurred in 7 (12.9% cases). Among the 54 initially conservatively treated units 42 (77.7%) kidneys were ultimately preserved. On univariate and multivariate analysis tumor location in the renal pelvis and association with a previous multi-recurrent bladder tumor were variables significantly related to recurrence and progression, as well as bilateral recurrence.

CONCLUSIONS

Conservative treatment is an optional approach for select upper urinary tract tumors. The strongest risk factors for recurrence and progression were association with a previous multi-recurrent bladder tumor and tumor location in the renal pelvis but these conditions were also the strongest risk factors for bilateral recurrence. Conservative treatment can also be recommended in these cases but only with compliant patients and close followup.

Conservative elective treatment of upper urinary tract tumors: a multivariate analysis of prognostic factors for recurrence and progression

PURPOSE

We evaluate the safety and efficacy of conservative elective treatment of upper urinary tract tumors, and determine predictive factors for recurrence and progression to optimize indications of this type of treatment.

MATERIALS AND METHODS

Since 1984 we have performed a prospective study of conservative treatment of single, low grade and stage, less than 3 cm. upper tract tumors. The study includes 54 patients with a normal contralateral kidney who had been followed for more than 36 months. Open conservative surgery was performed in 31 cases and endourological surgery in 23. Minimum followup was 36 months, maximum 210 and mean 84.8. Univariate and multivariate analyses of recurrence and progression were performed in relation to age, sex, association with a bladder tumor, bladder tumor stage and grade, sequence of bladder tumor in relation to upper urinary tract tumor, number of previous bladder tumor recurrences, association with bladder carcinoma in situ, upper urinary tract tumor grade, stage, location, size and therapy, and upper urinary tract cytology.

RESULTS

Of the 54 patients 19 (35%) had recurrence, which was bilateral recurrence in 4, and progression occurred in 9 (16%). At the end of analysis 44 (62.9%) patients were disease-free and alive at a mean time of 92.88 months, 13 (24%) died disease-free at a mean of 72.7 months and 7 (12.9%) died of disease at a mean of 97.85 months. Cause specific mortality occurred in 7 (12.9% cases). Among the 54 initially conservatively treated units 42 (77.7%) kidneys were ultimately preserved. On univariate and multivariate analysis tumor location in the renal pelvis and association with a previous multi-recurrent bladder tumor were variables significantly related to recurrence and progression, as well as bilateral recurrence.

CONCLUSIONS

Conservative treatment is an optional approach for select upper urinary tract tumors. The strongest risk factors for recurrence and progression were association with a previous multi-recurrent bladder tumor and tumor location in the renal pelvis but these conditions were also the strongest risk factors for bilateral recurrence. Conservative treatment can also be recommended in these cases but only with compliant patients and close followup.

[Survival after recurrent left ventricular free wall rupture, with an atypical occurrence after post-infarction exercise test]

Left ventricular free wall rupture is an unusual but highly lethal complication of acute myocardial infarction. We report on the extremely rare occurrence of a patient surviving two episodes of free wall rupture within a seven-month period. The first event happened in the course of an exercise testing after a seemingly uncomplicated inferior acute myocardial infarction; the second, seven months after the first, as a pseudoaneurysm in the setting of a new inferior wall infarction. Surgical repair was successful in both instances, with patient remaining asymptomatic in follow-up.

Essential oil composition and antimicrobial activity of three Zingiberaceae from S.Tomé e Príncipe

The essential oil composition of three Zingiberaceae widely used as medicinal aromatic plants from S. Tomé and Príncipe: Aframomum danielli (Hook. f.) K. Schum., Curcuma longa L. and Zingiber officinale Rosc. was studied. Two samples of the essential oils from fruit of A. danielli and from rhizomes of the other two species, were obtained by hydrodistillation and analyzed by GC, GC-MS, and (13)C-NMR. The essential oil from fruits of A. danielli has been studied for the first time and was characterised by its high content of monoterpenes, with 1,8-cineole (25.5 - 34.4 %) the major constituent, followed by beta-pinene (14.1 - 15.2 %) and alpha-terpineol (9.9 - 12.1 %). Essential oils from the rhizomes of C. longa contained a lower content of ar-turmerone (4.0 - 12.8 %) than those reported in the literature for C. longa from other origins (24.7 - 31.4 %), whereas the results for Z. officinale essential oils were in accordance with the literature data. The essential oils of A. danielli and Z. officinale showed antimicrobial activity against all Gram-positive and Gram-negative bacteria tested, as well as against yeasts and filamentous fungi, using the agar diffusion method.

Composition and chemical polymorphism of the essential oils from Piper lanceaefolium

Essential oils obtained by hydrodistillation from leaves and spikes of Piper lanceaefolium H.B.K. of Costa Rica were analysed by GC-FID, GC-MS and 13C-NMR methods. Main constituents found in the oil from leaves were sesquiterpene hydrocarbons - especially beta-caryophyllene and germacrene D - and phenylpropanoids, of which elemicin and parsley apiol were the major ones. The volatile oil from spikes showed monoterpene hydrocarbons, namely alpha- and beta-pinene, and the same phenylpropanoids as in the oil from leaves as the major constituents. Results obtained in the analysis by GC-FID and GC-MS of the essential oils from individual plants of different geographic origin were submitted to chemometric cluster analysis and principal component analysis, showing the presence of three different types of oils (i) parsley apiol/elemicin, (ii) elemicin/parsley apiol/dill apiol, and (iii) parsley apiol/dill apiol.

Specific tracheal migration is mediated by complementary expression of cell surface proteins

Migration of the Drosophila tracheal cells relies on cues provided by nearby cells; however, little is known about how these signals specify a migratory path. Here we investigate the role of cell surface proteins in the definition of such a pathway. We have found that the PS1 integrin is required in the tracheal cells of the visceral branch, whereas the PS2 integrin is required in the visceral mesoderm; both integrins are necessary for the spreading of the visceral branch over its substratum. This is the first identification of a cell surface molecule with expression restricted to a subset of tracheal cells that all migrate in a given direction. We have also found that expression of PS1 in the visceral branch is regulated by the genes that direct tracheal cell migration, showing that integrin expression is part of the cell-fate program that they specify. These results support a model in which signal transduction determines the tracheal migratory pathways by regulating the expression of cell surface proteins, which in turn interact with surface molecules on the surrounding cell population.

Chemical composition of the essential oil from the leaves of Piper fulvescens, a plant traditionally used in Paraguay

The essential oil from the leaves of the aromatic aniseed smelling plant Piper fulvescens, obtained by hydrodistillation, was investigated by GC and GC-MS, as well as by 13C-NMR after fractionation of the oil by column chromatography. A total of 37 constituents, representing 78.2% of the oil were identified. The main compounds were trans-anethole (26.4%) and ishwarane (12.1%), an unusual sesquiterpene hydrocarbon.