Nephrogenic ridge tumors and their syndromes

Simultaneous Clinical Presentation of Renal Cell Carcinoma and Immunoglobulin Light Chain Amyloidosis

A 77-year-old female was admitted to the hospital for an evaluation of congestive heart failure. She gave a history of progressive peripheral edema over eight to 10 months, extending up to the knees bilaterally. Admitting creatinine was 148 mmol/L, serum albumin was 15g/L, and urine protein on quantification was 9.09 g/day. Her immunoglobulin G (IgG) level was 18.4g/L and serum-free kappa level was 92.3 mg/L. The immunofixation of urine revealed monoclonal IgG kappa (1.97 g/d). Her kidney biopsy subsequently confirmed the diagnosis of immunoglobulin light chain (AL) amyloidosis. During the course of investigations, it was incidentally noted that she had a mass on her right kidney, which on biopsy was identified as renal cell carcinoma (RCC). This case deals with the rare situation of AL amyloidosis existing with a solid organ carcinoma and the therapeutic dilemma of treating two unrelated conditions involving the kidneys.

Do patients with a higher body mass index have a greater risk of advanced-stage renal cell carcinoma?

OBJECTIVES

To evaluate whether patients with a higher body mass index (BMI) are at elevated risk of an advanced tumor stage for renal cell carcinoma at diagnosis. A high BMI has recently been proved to be associated with advanced tumor stages for some malignant diseases.

METHODS

From January 1994 to December 2000, 693 operations for renal cell carcinoma were performed in 683 patients at our institution. Ten patients underwent surgery twice for bilateral tumors. Of the 683 patients, 417 were men and 266 women. The mean age at surgery was 62.2 years, and the mean tumor diameter was 5.2 cm. Seventy-eight percent of the patients were asymptomatic at tumor diagnosis. The following parameters were evaluated with regard to a possible correlation to tumor stage and/or tumor diameter: BMI, presence of symptoms, age, sex, hemoglobin, lactate dehydrogenase, erythrocyte sedimentation rate, serum cholesterol, and triglycerides. For statistical analysis, the Spearman rank correlation test was used.

RESULTS

The mean BMI was 26.8 +/- 4.4 (range 16.9 to 44.3). Statistical analysis showed a significant positive correlation between advanced T stage and the presence of symptoms (P <0.0001), erythrocyte sedimentation rate (P <0.0001), lactate dehydrogenase (P = 0.0015), and age (P = 0.046), and an inverse correlation with hemoglobin (P <0.0001) and serum cholesterol (P <0.0001). For all other investigated parameters, including BMI, no significant correlation could be proved.

CONCLUSIONS

Our data indicate that obese patients are not at greater risk of advanced tumor stages of renal cell carcinoma at the time of diagnosis compared with a population of normal weight.

Kidney cancer: current management guidelines

Renal cell carcinoma accounts for 2% of all cancers. Medical progress has improved the outcome of early but not advanced disease. This article highlights the current practice for the management of renal cell carcinoma.

Paraneoplastic elevation of serum alkaline phosphatase in renal cell carcinoma: incidence and implication on prognosis

PURPOSE

We investigated the incidence and prognostic significance of paraneoplastic elevation of serum alkaline phosphatase in patients with renal cell carcinoma.

MATERIALS AND METHODS

Clinical data of 365 pathologically proved renal cell carcinoma cases were reviewed. Serum alkaline phosphatase level greater than 100 units per 1., but without obvious conditions that may cause phosphatase elevation, including metastasis to or disease of liver or bone and pregnancy, was regarded as paraneoplastic serum alkaline phosphatase elevation. Survival was evaluated using the Kaplan-Meier method.

RESULTS

Of 365 patients 77 (21.1%) had paraneoplastic serum alkaline phosphatase elevation. The respective incidence from stage I to IV cases was 9.9% (16 of 161), 31.9% (15 of 47), 34.3% (23 of 67) and 25.6% (23 of 90). Patients with stage I disease had the lowest incidence but there were no statistically significant differences among stages II, III and IV disease. Of 77 patients with elevated serum alkaline phosphatase 48 had additional paraneoplastic manifestations. The disease specific 5-year survival rate in patients with normal serum alkaline phosphatase was significantly better than in patients with isolated phosphatase elevation, which in turn was better than in patients with multiple paraneoplastic syndromes (70.7 versus 50.5 versus 30.8%). Patients with persistent or recurrent elevation of serum alkaline phosphatase after radical nephrectomy had metastatic lesion or local recurrence. In some patients serum alkaline phosphatase returned to normal after nephrectomy but metastasis developed later without recurrent phosphatase elevation.

CONCLUSIONS

Paraneoplastic serum alkaline phosphatase elevation in renal cell carcinoma patients implies an unfavorable prognosis, and additional paraneoplastic syndromes further worsen the prognosis. Recurrent or persistent serum alkaline phosphatase elevation after radical nephrectomy suggests distant metastasis or residual tumor. However, the return of serum alkaline phosphatase to normal does not guarantee cure of the disease. Identification of paraneoplastic serum alkaline phosphatase elevation is valuable in the prediction of outcome and postoperative followup of renal cell carcinoma patients.

Asymptomatic renal abscess: evaluation with gadolinium DTPA-enhanced MRI

Incidental detection of renal mass in a transplant patient is a diagnostic challenge. These patients are at risk for the development of neoplasms and, more commonly, infection with atypical organisms. Symptomatology may be lacking in either, and both conditions may present with similar symptoms. Magnetic resonance imaging (MRI) evaluation with gadolinium DTPA is helpful in the evaluation of asymptomatic renal mass, with enhancement effectively excluding simple and hemorrhagic cysts. Because the MRI appearances of renal cell neoplasm and renal abscess overlap, both must be considered in the differential diagnosis.

Humoral hypercalcaemia in renal carcinoma due to parathyroid hormone related protein

Parathyroid hormone related protein (PTHRP) has been implicated in humoral hypercalcaemia of malignancy (HHM). We describe a patient with a renal carcinoma and hypercalcaemia, and for the first time have demonstrated a 4-fold PTHRP concentration gradient across a renal tumour bed. This provides further strong evidence that the primary tumour was the source of the PTHRP. The PTHRP 1-86 content of the tumour tissue was 4.8 ng/g, similar to that previously found in tumours associated with HHM. In PTHRP-secreting tumours, PTHRP may be a useful oncological marker after surgical resection.

Cytoreductive surgery prior to interleukin-2-based therapy in patients with metastatic renal cell carcinoma

From May 1985 to December 1990, 93 patients with the clinical diagnosis of metastatic renal cell carcinoma and their primary tumor in place were evaluated for cytoreductive surgery as preparation for systemic therapy with regimens based on interleukin-2. These patients had typical sites of metastatic disease and manifestations of paraneoplastic syndromes. Patients underwent removal of the primary tumor, as well as debulking when this could be performed safely. Thirty-two percent of patients (30/93) had a second surgical resection in addition to their nephrectomy, frequently because of the large size of the primary tumor and its invasion of adjacent structures. Thirteen percent of patients (12/93) experienced postoperative complications. There were no perioperative mortalities. Forty percent of patients (37/93) who underwent nephrectomy could not be treated with immunotherapy, usually because of progression of disease. A preoperative ECOG status greater than or equal to 2 was the only significant risk factor associated with failure to undergo immunotherapy (P = 0.043). The response rate to immunotherapy in the 56 patients receiving interleukin-2 was 27 percent (4 CR, 11 PR).

An investigation of cellular components released from human renal cancer and foetal kidney xenografts in nude mice (nu/nu) by cross-immunization of hairy littermate relatives

The release of components from human kidney tumour xenografts (GYL) and human foetal kidney explants maintained in nude mice has been studied. The GYL tumour released antigens into the serum which could be detected by the generation of antibodies following cross-immunisation of closely related hairy litter mate (HLM) mice. The production of anti-GYL antibody was monitored by an I125 binding assay using viable GYL tumour cells. In 2/16 hairy litter mate mice, cell surface antibody binding by GYL cells was twice that found with 8 other human tumour cell lines (including 2 other kidney cancer cell lines). Absorption of these antisera with 10(7) GYL tumour cells completely abolished this response, where 50%, 38% and 25% of activity remained following absorption with; a normal kidney cell line, a homogenate of normal kidney and a mixed pool of human tumour cells. Six out of 8 GYL tumour bearing nude mice tested had elevated plasma levels of HCG. Absorption of the HLM antisera with an excess of commercial HCG abrogated I125 binding by only 15%, suggesting that antibody production was not directed primarily against ectopic HCG.

Cancer, chemotherapy and anaesthesia

The main principle in anaesthetic management of cancer patients is caution in dosage because of the possibility of decreased cardiac and respiratory reserve, and possible obscured hepatic and renal impairment. The anaesthetic problems which should be anticipated in cancer patients who are on therapy are discussed and summarised in Table III. An understanding of these problems ensures greater safety during operation and quicker recovery in the postoperative period.

Cholestasis as a paraneoplastic manifestation of carcinoma of the kidney

Two cases of hepatic paraneoplastic manifestations of carcinoma of the kidney are presented. In one, hepatosplenomegaly and abnormal liver function tests resolved following removal of the tumour. In the other, pruritus as a symptom of cholestasis was the presenting feature. Post-operatively a full blown cholestatic syndrome developed. Although their clinical presentations differed they may represent a spectrum of the same disease.

Coagulation factors in renal adenocarcinoma

Coagulation factors, including plasma fibrinogen, serum fibrinogen-fibrin degradation products, platelet counts and prothrombin times, were studied in patients with renal adenocarcinoma. Plasma fibrinogen levels were elevated and correlated with tumor stage, disease activity and therapy. Fibrinogen-fibrin degradation product levels also were elevated, although such elevations did not correlate with other parameters. Platelet count and prothrombin times were normal. Fibrinogen may be a valuable marker of disease activity in patients with renal carcinoma. In addition, since significant intratumoral fibrin deposits have been demonstrated anticoagulants or fibrinolytic agents may enhance cytotoxic therapy and should be considered in adjunctive chemotherapeutic protocols.

Hormones in renal cancer

Plasma renin, erythropoietin and chorionic gonadotropin levels were evaluated in 57 patients with renal adenocarcinoma. Renin elevation, found in 37 per cent, was unrelated to blood pressure levels but was associated with high grade, high stage lesions of mixed histologic cell type and predicted a poor prognosis. Erythropoietin was raised in 63 per cent of patients and was more sensitive than renin in indicating the presence of renal adenocarcinoma. However, it was less specific and did not correlate directly with tumor grade, stage, histologic type, prognosis or hematocrit and hemoglobin levels. None of the patients had elevated chorionic gonadotropin levels. Therefore, we believe that renin and erythropoietin determinations may be of value as biochemical tumor markers in renal adenocarcinoma.