Transitional cell tumors of the renal pelvis in analgesic abusers

Synchronous/Metachronous Multiple Primary Malignancies: Review of Associated Risk Factors

The incidence of secondary primary malignancy (SPM) has been reported to range from 1.33% to 5.8%, according to the location of the primary cancer and the follow-up duration. The highest occurrence rate of SPM, of 36.6% within 6 months, has been reported in lung cancer. Genitourinary malignancies were reported to be the third-most-common SPM in several reports. However, the incidence of genitourinary malignancy as the first primary cancer associated with SPM has not been reported. Several risk factors are related to the occurrence of SPM, including viral infection chemotherapy, radiation, genetics, smoking, betel quid chewing, and environmental factors. An early survey for SPM is indicated in first primary malignancy patients with these associated factors. In this study, we summarize several risk factors related to the occurrence of SPMs and preventive tests, which may help in their early detection and, consequently, better survival.

A critical review of the acetaminophen preclinical carcinogenicity and tumor promotion data and their implications for its carcinogenic hazard potential

In 2019 the California Office of Environmental Health Hazard Assessment (OEHHA) initiated a review of the carcinogenic hazard potential of acetaminophen, including an assessment of the long-term rodent carcinogenicity and tumor initiation/promotion studies. The objective of the analysis herein was to inform this review process with a weight-of-evidence assessment of these studies and an assessment of the relevance of these models to humans. In most of the 14 studies, there were no increases in the incidences of tumors in any organ system. In the few studies in which an increase in tumor incidence was observed, there were factors such as absence of a dose response and a rodent-specific tumor supporting that these findings are not relevant to human hazard identification. In addition, we performed qualitative analysis and quantitative simulations of the exposures to acetaminophen and its metabolites and its toxicity profile; the data support that the rodent models are toxicologically relevant to humans. The preclinical carcinogenicity results are consistent with the broader weight of evidence assessment and evaluations of multiple international health authorities supporting that acetaminophen is not a carcinogenic hazard.

Historical review of the causes of cancer

In the early 1900s, numerous seminal publications reported that high rates of cancer occurred in certain occupations. During this period, work with infectious agents produced only meager results which seemed irrelevant to humans. Then in the 1980s ground breaking evidence began to emerge that a variety of viruses also cause cancer in humans. There is now sufficient evidence of carcinogenicity in humans for human T-cell lymphotrophic virus, human immunodeficiency virus, hepatitis B virus, hepatitis C virus, human papillomavirus, Epstein-Barr virus, and human herpes virus 8 according to the International Agency for Research on Cancer (IARC). Many other causes of cancer have also been identified by the IARC, which include: Sunlight, tobacco, pharmaceuticals, hormones, alcohol, parasites, fungi, bacteria, salted fish, wood dust, and herbs. The World Cancer Research Fund and the American Institute for Cancer Research have determined additional causes of cancer, which include beta carotene, red meat, processed meats, low fibre diets, not breast feeding, obesity, increased adult height and sedentary lifestyles. In brief, a historical review of the discoveries of the causes of human cancer is presented with extended discussions of the difficulties encountered in identifying viral causes of cancer.

Cancer risk among elderly persons with end-stage renal disease: a population-based case-control study

BACKGROUND

Patients with end-stage renal disease (ESRD) have elevated cancer risk. Cancer risk increases with age, but associations of ESRD with specific malignancies are incompletely studied for older individuals.

METHODS

We conducted a population-based case-control study (1,029,695 cancer and 99,610 controls) among the U.S. elderly using SEER-Medicare linked data. We defined ESRD as presence of dialysis claims in the 3 months prior to selection.

RESULTS

Although ESRD was not associated with excess cancer risk overall (odds ratio 1.02; 95%CI 0.91-1.14), risk was specifically increased for cancers of the stomach (1.45; 1.16-1.81), small intestine (1.92; 1.27-2.92), colon (1.17; 1.00-1.36), liver (1.53; 1.16-2.01), biliary tract (1.78; 1.20-2.65), lung (1.17; 1.02-1.34), cervix (2.12; 1.39-3.23), kidney (2.42; 2.01-2.92), and for multiple myeloma (1.77; 1.40-2.24) and chronic myeloid leukemia (1.74; 1.08-2.80). The association between liver cancer and ESRD was attenuated upon adjustment for hepatitis B and C infection or diabetes mellitus. Multiple myeloma risk was highest with short ESRD duration (p < 0.0001), possibly reflecting reverse causality, while kidney cancer risk showed a borderline rise over time (p = 0.08).

CONCLUSIONS

Among elderly individuals with ESRD, the excess risks for some cancers may reflect immune dysfunction or a high prevalence of other risk factors, such as viral infections or diabetes mellitus. Our results underscore the need for studying biological pathways of carcinogenesis in ESRD.

Renal transitional-cell carcinoma in two cats with chronic kidney disease

Two 12-year-old cats were diagnosed with chronic kidney disease (CKD) based on physical examination, clinicopathologic data and, in one case, abdominal ultrasound findings. Approximately 1 year after the initial diagnosis of CKD both cats developed renal transitional cell carcinoma (TCC)--bilateral in one cat. Based on post-mortem examination, one cat had no evidence of metastasis and the other had metastasis to the large intestine, heart and lungs. This is the first report of de novo bilateral renal TCC in a cat, as well as the first report of renal TCC developing in cats with previous history of confirmed CKD.

Non-contrast-enhanced computerized tomography and analgesic-related kidney disease: report of the national analgesic nephropathy study

Previous studies suggested that the non-contrast-enhanced computerized tomography (CT) scan is a highly reliable tool for the diagnosis of analgesic-associated renal disease. However, this issue has not been addressed in the US population. A total of 221 incident patients with ESRD from different regions of the United States underwent a helical CT scan and detailed questioning about drug history. Specific renal anatomic criteria were developed to determine whether a constellation of CT findings (small indented calcified kidneys [SICK]) is linked to analgesic ingestion. For approximating use before the onset of renal disease, only analgesic ingestion at least 9 yr before starting dialysis was considered relevant. Fifteen patients met the criteria for SICK. This represented 7% of the enrolled patients and approximately 1% of the total ESRD population. There was a significant increase in the estimated risk among patients with a history of heavy aspirin ingestion (odds ratio [OR] 7.4 [95% confidence interval (CI) 1.2 to 43] for > or =1 kg lifetime; OR 8.8 [95% CI 1.2 to 66] for > or =0.3 kg/yr). Total analgesic ingestion of > or =0.3 kg/yr also was significantly associated with SICK (OR 8.2; 95% CI 1.5 to 45). These findings were accounted for largely by combination products that contained aspirin and phenacetin (used by three patients with SICK), which are no longer available. In addition, the CT finding of SICK was present only in a minority of heavy analgesic users, yielding a sensitivity of 5 to 26%. Findings of SICK are infrequent in the US ESRD population and do not occur among a sufficient proportion of heavy analgesic users to render the non-contrast-enhanced CT scan a sensitive tool to detect analgesic-associated kidney injury.

Phenacetin acts as a weak genotoxic compound preferentially in the kidney of DNA repair deficient Xpa mice

Chronic use of phenacetin-containing analgesics has been associated with the development of renal cancer. To establish genotoxicity as a possible cause for the carcinogenic effect of phenacetin, we exposed wild type and DNA repair deficient Xpa-/- and Xpa-/-/Trp53+/- mice (further referred as Xpa and Xpa/p53 mice, respectively), carrying a reporter lacZ gene, to 0.75% (w/w) phenacetin mixed in feed. Xpa mice completely lack the nucleotide excision repair pathway, and as such they are sensitive to some classes of genotoxic compounds. Phenacetin exposure induced a significant increase of lacZ mutations in the kidney of both Xpa and Xpa/p53 mice. A minor response was found in liver, whereas no lacZ mutation induction was observed in the spleen of these animals. Interestingly, the observed phenacetin-induced mutant frequencies were higher in male than those found in female mice. This gender difference is probably due to a difference in metabolic rate. Phenacetin-induced mutations mainly consisted of point mutations rather than deletions. The mutational spectra in the kidney of treated WT and Xpa mice were quite similar. Taken together, these results demonstrate that the human carcinogen phenacetin acts as a weak genotoxic agent in an in vivo mouse model system.

Synchronous bilateral ureteral and renal pelvic carcinomas

BACKGROUND

Synchronous bilateral urothelial tumors of the upper urinary tract are very rare. The authors reported baseline and long-term follow-up data for all patients in western Sweden during a 28-year period.

METHODS

The authors performed a clinical and histopathologic study of all patients in western Sweden who were diagnosed with a malignant neoplasm in the renal pelvis or ureter between 1971 and 1998.

RESULTS

Of 936 patients, 15 (1.6%) had synchronous bilateral tumors. The incidence of such tumors decreased in each successive decade. Abuse of phenacetin-containing analgesics by patients also decreased during the study period, as did the incidence of renal papillary necrosis. The median age at diagnosis of bilateral tumors was 68 years, and 80% of the patients were male. Eleven patients had bilateral tumors of the renal pelvis, two had bilateral ureteral tumors, and two had tumors of the renal pelvis and contralateral ureter. Partial renal pelvic, ureteral, or kidney resection on at least one side was possible in eight patients, and four patients were left untreated on at least one side. Only three patients underwent bilateral nephroureterectomy. Twelve patients (80%) had bladder carcinoma diagnosed either before or after diagnosis of the upper tract tumors. The median survival period for the 11 patients who received surgery for their bilateral tumors was 84 months.

CONCLUSIONS

The decreasing incidence of synchronous bilateral upper tract tumors may be related to the prohibition of phenacetin-containing analgesics in the 1960s. Partial resection with preservation of the renal parenchyma was possible in the majority of patients. Survival for patients with bilateral tumors did not differ from that of patients with unilateral tumors.

Laparoscopic nephroureterectomy to exclude upper urinary tract malignancy associated with analgesic nephropathy

BACKGROUND AND PURPOSE

Analgesic abuse is a potential cause of end-stage renal disease. Such patients bear an elevated risk of developing malignancies, predominantly transitional-cell carcinoma. We report our experience with laparoscopic nephroureterectomy carried out in patients with analgesic nephropathy to exclude upper urinary tract malignancy. All patients were scheduled to be put on the waiting list for cadaveric renal transplantation.

PATIENTS AND METHODS

Since 1996, nine women and two men with a long-term history of analgesic abuse have undergone laparoscopic nephroureterectomy at our hospital. The median age was 63 years (range 51-70 years). All patients had developed end-stage renal failure secondary to heavy analgesic abuse with a median duration of 14 years (range 7-40 years). The median interval from the beginning of hemodialysis to laparoscopic nephroureterectomy was 36 months (range 6-76 months).

RESULTS

The median operative time was 99 minutes (range 55-170 minutes). There were no conversions to open surgery. Two complications occurred, and three patients required blood transfusions. The median hospital stay lasted 5 days (range 2-12 days), and the median convalescence was 20 days (range 6-44 days). In seven patients, histopathologic examination of the kidney revealed changes attributable to analgesic abuse. None of the patients had a transitional-cell carcinoma, but in two patients, a renal-cell carcinoma stage pT1cN0cM0 grade 2 was detected.

CONCLUSION

Patients with analgesic nephropathy bear an elevated risk for the development of transitional-cell or renal-cell carcinoma. In these patients, laparoscopic nephroureterectomy combines minimally operative invasiveness with a maximum of diagnostic safety.

Regular use of analgesics is a risk factor for renal cell carcinoma

Phenacetin-based analgesics have been linked to the development of renal pelvis cancer and renal cell carcinoma (RCC). The relationship between non-phenacetin types of analgesics and kidney cancer is less clear, although laboratory evidence suggests that these drugs possess carcinogenic potential. A population-based case-control study involving 1204 non-Asian RCC patients aged 25-74 and an equal number of sex-, age- and race-matched neighbourhood controls was conducted in Los Angeles, California, to investigate the relationship between sustained use of analgesics and risk of RCC according to major formulation categories. Detailed information on medical and medication histories, and other lifestyle factors was collected through in-person interviews. Regular use of analgesics was a significant risk factor for RCC in both men and women (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.4-1.9 for both sexes combined). Risks were elevated across all four major classes of analgesics (aspirin, non-steroidal anti-inflammatory agents other than aspirin, acetaminophen and phenacetin). Within each class of analgesics, there was statistically significant increasing risk with increasing level of exposure. Although there was some minor variability by major class of formulation, in general individuals in the highest exposure categories exhibited approximately 2.5-fold increase in risk relative to non- or irregular users of analgesics. Subjects who took one regular-strength (i.e. 325 mg) aspirin a day or less for cardiovascular disease prevention were not at an increased risk of RCC (OR = 0.9, 95% CI = 0.6-1.4).

[Analgesics and laxatives as risk factors for cancer in the efferent urinary tract--results of the Berlin Urothelial Carcinoma Study]

A retrospective case-control study (1990-1995), the Berlin Urothelial Cancer Study (BUS), examined analgesics and laxatives as risks for the induction of urothelial cancer in renal pelvis, ureter and bladder. Especially for renal pelvis cancer could observe substance and dose specific risk of compound analgesics. The analgesic substances Phenacetin, Paracetamol, Acetylsalicylic acid (ASA) and Pyrazolones were assessed. Besides a risk of contact laxatives (chemical or anthranoide ingredients) for urothelial cancer was found, not yet described. The highest risk shows the anthranoide plant Senna. Thus this study confirms the risk of specific analgesic ingredients and found an evidence for a new risk of contact laxatives. As both, analgesics and contact laxatives, are typical OTC--("Over the counter") products, a severe controlling is demanded and for laxatives further studies are needed.

High mortality from urothelial carcinoma despite regular tumor screening in patients with analgesic nephropathy after renal transplantation

Patients with end-stage renal failure due to analgesic nephropathy have an increased risk of developing a urothelial carcinoma. To determine the impact of renal transplantation on the frequency of urothelial carcinomas, we analyzed 2072 patients who underwent 2371 renal transplantation between 1968 and 1993, including 78 (3.8%) with clinically proven analgesic nephropathy. Before and after transplantation a regular tumor screening was performed in patients with analgesic nephropathy by urine cytology and abdominal sonography. In 11 of the 78 patients with analgesic nephropathy (14.1%; age 51-66 years, 40-108 months after initiation of dialysis treatment, 5-77 months after transplantation), a urothelial carcinoma of the native urinary tract, especially the kidneys, was diagnosed. Therapy comprised nephroureterectomy (n = 6), transurethral resection (n = 6) and/or cystectomy (n = 2). Seven patients died due to tumor progression 16.3 (4-33) months postoperatively and one patient died due to a perioperative complication. Despite regular tumor screening after transplantation, the diagnosis of a urothelial carcinoma was made very late, leading to a high tumor-related mortality. As a consequence, we suggest that a bilateral nephroureterectomy should be performed prophylactically in patients with proven analgesic nephropathy. In addition, a cystoscopy with lavage cytology testing of the bladder should be performed twice a year.

Urologic cancers in uremic patients

From 1981 through 1990, 21 urologic cancer cases were discovered in 21 uremic patients at our hospital. This constituted 55% (11 of 20) of the total malignancies in nondialyzed uremic patients, 41% (nine of 22) of the total in chronic hemodialysis patients, and 50% (one of two) of those in patients on continuous ambulatory peritoneal dialysis. No cases of urologic cancer were found in kidney transplant recipients. When compared with the general population, the standardized incidence ratio of kidney cancer in chronic hemodialysis patients was found to be 24.1 (P < 0.01) and that of bladder cancer was found to be 16.4 (P < 0.01). Multiple underlying renal diseases contributed to the development of the urologic cancer cases, including four analgesic nephropathy-associated transitional cell carcinoma cases, two acquired cystic kidney disease-associated renal cell carcinoma cases, two chronic pyelonephritis-associated (stone and tuberculosis) squamous cell carcinoma cases, and one xanthogranulomatous pyelonephritis-associated transitional cell carcinoma case. Uremia per se may be an important promoting factor. Hematuria (17 of 21 cases) was the most common presenting feature despite the fact that most of the patients were anuric. The clinical diagnosis of renal parenchymal tumors was based on ultrasonography (five of five cases), whereas most urothelial tumors were detected by cystoscopy or retrograde pyelography (14 of 16 cases). The survival rate of the 17 aggressively treated patients was 82% at 2 years and 45% at 5 years. We conclude that uremic patients are at greater risk of developing urologic cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for renal cell carcinoma: results of a population-based case-control study

For a case-control study of risk factors for renal cell carcinoma, a mailed questionnaire was used to collect data on 518 cases and 1,381 population-based controls in Ontario, Canada. Active cigarette smoking increased risk twofold among males (odds ratio estimate [OR] = 2.0, 95 percent confidence interval (CI) = 1.4-2.8) and females (OR = 1.9, CI = 1.3-2.6). Passive smoking appeared to increase risk somewhat among nonsmokers (males: OR = 1.6, CI = 0.5-4.7; females: OR = 1.7, CI = 0.8-3.4). A high Quetelet index (QI) was associated with a twofold increase in risk in both sexes, although this was based on reported weight at age 25 years for males (OR = 1.9, CI = 1.2-3.1) and five years prior to data collection for females (OR = 2.5, CI = 1.4-4.6). Diuretic use was associated with significantly increased risk among females, but not among males. Phenacetin use increased risk, while acetaminophen use was not associated with altered risk, although few subjects used either compound. Multiple urinary tract infections increased risk, but only significantly in females (OR = 1.9, CI = 1.2-2.9). Our data indicate the need for further exploration of passive smoking and diuretics as risk factors, as well as elucidation of mechanisms by which high lifetime QI and frequent urinary-tract infections might increase risk of this cancer.

Epidemiologic study of analgesic abuse: mortality study in 7275 working women (1968-1987)

In a prospective, longitudinal investigation over a period of 20 years in 7275 working women 30 to 49 years old, we examined the effect of the ingestion of analgesics on cause-specific mortality. Evidence of intake of phenacetin and salicylate containing analgesics was obtained at a urine screening in 1967 and was shown to relate to intake between 1968 to 1978. Life table analysis of the effect of phenacetin intake on overall mortality showed significant differences between the groups of women with intake (N = 613) versus no intake (N = 4175): for total [relative risk (RR) = 2.1, P less than 0.001], urorenal (RR = 24.4, P less than 0.001), cardiovascular (RR = 4.5, P less than 0.001), and cancer mortality (RR = 1.9, P less than 0.001). No significant effects on overall or cause-specific mortality were found for salicylate intake. These results make a causal relationship between the amount of analgesic containing phenacetin consumed and the risk of death from urorenal disease likely. Furthermore, the data show an elevated risk for cardiovascular disease and cancer for phenacetin intake. No such relationships are demonstrable for the use of salicylate.

An epidemiologic study of abuse of analgesic drugs. Effects of phenacetin and salicylate on mortality and cardiovascular morbidity (1968 to 1987)

BACKGROUND

Phenacetin abuse is known to produce kidney disease; salicylate use is supposed to prevent cardiovascular disease. We conducted a prospective, longitudinal epidemiologic study to examine the effects of these drugs on cause-specific mortality and on cardiovascular morbidity.

METHODS

In 1968 we evaluated a study group of 623 healthy women 30 to 49 years old who had evidence of a regular intake of phenacetin, as measured by urinary excretion of its metabolites, and a matched control group of 621 women. Salicylate excretion was also measured. All subjects were examined over a period of 20 years.

RESULTS

Life-table analyses of mortality during the 20 years, with adjustment for the year of birth, cigarette smoking, and length of follow-up, revealed significant differences between the groups in overall mortality (study group vs. control group, 74 vs. 27 deaths; relative risk, 2.2; 95 percent confidence interval, 1.5 to 3.3), deaths due to urologic or renal disease (relative risk, 16.1; 95 percent confidence interval, 3.9 to 66.1), deaths due to cancer (relative risk, 1.9; 95 percent confidence interval, 1.1 to 3.3), and deaths due to cardiovascular disease (relative risk, 2.9; 95 percent confidence interval, 1.5 to 5.5). The relative risk of cardiovascular disease (fatal or nonfatal myocardial infarction, heart failure, or stroke) was 1.8, and the 95 percent confidence interval 1.3 to 2.6. The odds ratio for the incidence of hypertension was 1.6, and the 95 percent confidence interval 1.2 to 2.1. The effects of phenacetin on morbidity and mortality, with adjustment for base-line salicylate excretion, were similar. In contrast, salicylate use had no effect on either mortality or morbidity.

CONCLUSIONS

Regular use of analgesic drugs containing phenacetin is associated with an increased risk of hypertension and mortality and morbidity due to cardiovascular disease, as well as an increased risk of mortality due to cancer and urologic or renal disease. The use of salicylates carries no such risk.

The cytogenetics of renal tumors. Where do we stand, where do we go?

In this review an attempt is made to give an overview of the present status of cytogenetic research in tumors of the kidney. The results of numerous studies in renal cell carcinoma and adenoma, transitional cell carcinoma, and renal oncocytoma are presented, and the findings from the literature, together with 52 current observations, are analyzed and evaluated with respect to their significance for the understanding of renal malignancies.

Epidemiology and mechanistic basis of analgesic-associated nephropathy

End-stage renal failure (ESRF) due to analgesic nephropathy is still a common clinical condition in several countries, but the prevalence in dialysis patients shows large geographical differences. The frequency of ESRF of unknown aetiology is the inverse of that linked to analgesic abuse, and data suggest that the occurrence of analgesic nephropathy may be underestimated. The study of analgesic nephropathy is difficult because the earliest damage to the kidney is a renal papillary necrosis (RPN), which cannot easily be diagnosed. Continued analgesic abuse generally leads to a progressive secondary cortical degeneration which is easier to diagnose. If analgesic abuse is stopped at an early enough stage in nephropathy, clinical symptoms stabilize or improve, and ESRF may be averted. A high incidence of upper urothelial carcinoma (UUC) is also observed in individuals with a history of analgesic abuse, but it is still not clear if the two have a related pathogenesis. Study of the mechanism of RPN in animals administered analgesics and nonsteroidal antiinflammatory drugs (NSAID) has been difficult owing to their extrarenal toxicity. Several model compounds cause identical clinical changes and have as their selective target the renal medullary interstitial cells; subsequently, other changes (including cortical and glomerular degeneration) develop as a secondary cascade. A number of mechanisms have been proposed to explain RPN (e.g., counter-current concentrating mechanism, ischaemic injury, altered prostaglandin metabolism, immunological changes), but peroxidative metabolism of papillotoxic chemicals within the interstitial cells seems to be the most likely cause. Analgesic abuse is a costly socioeconomic condition for which there is currently no clinical treatment. If it is diagnosed early enough, severe renal degeneration can be prevented. Additional epidemiological information is needed to establish the causative role of analgesics and other chemicals, in order to determine the relative risk of each. Additional animal experiments are needed in order to clarify the molecular pathogenesis of RPN and UUC, to differentiate the stages in progression to ESRF and to develop more sensitive and selective diagnostic criteria.

Primary tumors of the renal pelvis: evaluation of clinical and pathological features in a consecutive series of 10 years

We operated on 36 patients for primary carcinoma of the renal pelvis between 1975 and 1984. The patients were evaluated for etiological factors, symptoms, diagnostic modalities, treatment, histological type and grade of dedifferentiation, presence of invasion, abnormalities in the urothelium adjacent to the tumor, abnormalities in the epithelium of the collecting tubules and patient survival. No etiological factors were found. The main symptom was hematuria. Diagnosis was made by excretory urography with tomography. Urine cytology examination was of no help in the diagnosis. The survival was high in patients with low grade tumors, tumors without invasion and tumors without coexisting atypia in the adjacent urothelium but it was poor in those with high grade tumors, tumors with invasion and tumors with atypia of the adjacent urothelium.

Genotoxicity of analgesic compounds assessed by an in vitro micronucleus assay

Several analgesic compounds and mixtures of analgesics were examined for both cytotoxicity and ability to induce chromosomal damage in the normal rat-kidney cell line NRK-49F. Chromosomal damage was assessed using an in vitro micronucleus assay. Of all the compounds tested, only N-hydroxyparacetamol caused a high degree of cell death at the concentrations used. 4 analgesic compounds were found to be inducers of micronuclei in NRK cells; in order of decreasing potency these were: N-hydroxyparacetamol, N-hydroxyphenacetin, caffeine and paracetamol. An aspirin, phenacetin, caffeine mixture (APC) failed to induce micronuclei above the background level, and a paracetamol-codeine combination did not increase the level of micronuclei induction above that induced by paracetamol alone. This report suggests paracetamol and some related compounds are capable of inducing chromosomal damage in mammalian cells in vitro, which is consistent with recent reports of a possible paracetamol-DNA interaction.

Transitional cell tumors of the renal pelvis and ureter associated with capillarosclerosis indicating analgesic abuse

An association between transitional cell tumors (TCT) and abuse of compound analgesics has been established during the past two decades. Recently thickening of basement membranes around subepithelial capillaries, known as capillarosclerosis, has been reported as a change in the urinary tract pathognomonic for a long-standing abuse of compound analgesics. Therefore the authors reviewed pathologic and clinical data in 59 patients treated for TCT of the renal pelvis or ureter. Capillarosclerosis was found in nine cases (15%) of the TCT group but not in any of the cases selected as controls. Capillarosclerosis is suggested as a valuable marker, which always should be looked for in bladder biopsy specimens. Whenever present it should arouse suspicion of analgesic abuse, and the associated increased risk for developing TCT of the renal pelvis or ureter should be borne in mind.

Analgesic-associated nephropathy

Although the question of whether or not analgesic abuse leads to a certain type of nephropathy has been investigated since 1953, no conclusive answer has been forthcoming. Epidemiologic investigations on the correlation between analgesic abuse and renal function as well as experimental animal studies have given contradictory results concerning the possibility of analgesic-associated kidney damage. However, studies on the correlation between analgesic abuse and papillary necrosis have demonstrated that this lesion coincides in 69% of the cases with an analgesic history. Follow-up studies of patients with analgesic nephropathy have shown that renal function deteriorates in 60% of the patients with continued abuse and that it stabilizes in 80% of the patients after cessation of abuse. Studies on the legislative restriction of phenacetin/acetaminophen, carried out mostly in Scandinavian countries since 1965, show a 50%-90% decline in signs of analgesic nephropathy (papillary necrosis) following a reduction in the sale of these drugs. The prevalence of analgesic abuse may be underestimated, since up to 80% of the abusers tend to deny their analgesic intake. Obviously, only a small percentage of analgesic abusers (approximately 1%) finally develop nephropathy. Even though the results of epidemiologic and experimental studies are contradictory, the results of investigations on papillary necrosis and on legislative prevention as well as of patient follow-ups tend to indicate a correlation between analgesic abuse and a well-defined type of nephropathy.

Risk of second malignancy after cancers of the renal parenchyma, renal pelvis, and ureter

Risk of second primary malignancy was assessed in a population-based survey of persons who developed cancers of the renal parenchyma, renal pelvis, or ureter in Connecticut during the period 1935-1982. Among 4176 patients with a first primary tumor of the renal parenchyma, a second cancer was reported in 219 (5%), yielding a small but significantly elevated relative risk (RR) of 1.2, which reflects excesses for cancers of the bladder, kidney, and lymphatic-hematopoietic system. Among 939 patients with a first primary tumor of the renal pelvis or ureter, a second cancer was reported in 155 (17%), associated with a significantly elevated RR of 2.7. This resulted mainly from a 21-fold increase in risk for bladder cancer, although significant excesses were also found for lung and prostate cancers, and metachronous cancers of the renal pelvis and ureter. These associations seem to reflect the multicentric behavior of tumors arising in the urinary tract, the role of cigarette smoking, and host factors yet to be defined, and some degree of heightened medical surveillance and detection of tumors, especially in the same organ system.

Heavy phenacetin use and bladder cancer in women aged 20 to 49 years

We investigated the use of analgesics containing phenacetin or acetaminophen in 173 young women with urinary bladder cancer and 173 matched controls. The cases, who were 20 to 49 years old at the time of diagnosis of cancer, were 6.5 times more likely to report regular use of analgesics containing phenacetin at least one year before diagnosis than were their matched controls (odds ratio, 6.5; 95 per cent confidence interval, 1.5 to 59.2). Among the 15 women (13 cases and 2 controls) reporting regular use of phenacetin-containing drugs, 8 of the cases and 1 of the controls reported daily use for over one year (P = 0.04). Excessive use of analgesics containing acetaminophen was not reported. The increased risk of bladder cancer in young women who regularly used phenacetin-containing products remained present after adjustments for all other identified risk factors.

Chemically induced renal papillary necrosis and upper urothelial carcinoma. Part 1

In the past, renal papillary necrosis (RPN) has been commonly associated with long-term abusive analgesic intake, but over recent years a wide variety of industrially and therapeutically used chemicals have been shown to induce this lesion experimentally or in man. Destruction of the renal papilla may result in: (1) secondary degenerative cortical changes which precede chronic renal failure or (2) a rapidly metastasizing upper urothelial carcinoma, which has a very poor prognosis. This article will briefly review the published data on the morphology, function, and biochemistry of the normal renal medulla and the pathology associated with RPN, together with the secondary changes which give rise to cortical degeneration or epithelial carcinoma. It will then examine in detail those chemicals which have been reported to cause RPN in an attempt to delineate structure-activity relationships. Finally, the many different theories that have been proposed to explain the pathophysiology of RPN will be examined and an hypothesis will be put forward to explain the primary pathogenesis of the lesion and its secondary consequences.

Chemically induced renal papillary necrosis and upper urothelial carcinoma. Part 2

In the past, renal papillary necrosis (RPN) has been commonly associated with long-term abusive analgesic intake, but over recent years a wide variety of industrially and therapeutically used chemicals have been shown to induce this lesion experimentally or in man. Destruction of the renal papilla may result in: (1) secondary degenerative cortical changes which precede chronic renal failure or (2) a rapidly metastasizing upper urothelial carcinoma, which has a very poor prognosis. This article will briefly review the published data on the morphology, function, and biochemistry of the normal renal medulla and the pathology associated with RPN, together with the secondary changes which give rise to cortical degeneration or epithelial carcinoma. It will then examine in detail those chemicals which have been reported to cause RPN in an attempt to delineate structure-activity relationships. Finally, the many different theories that have been proposed to explain the pathophysiology of RPN will be examined and an hypothesis will be put forward to explain the primary pathogenesis of the lesion and its secondary consequences.

Multiple primary tumors in association with prostatic cancer

One hundred forty-six patients with clinically nonmetastatic carcinoma of the prostate were treated at Columbia-Presbyterian Medical Center from 1964 through 1976. Of these 146 patients, 24 (16.4%) had developed at least one additional primary cancer. This review contrasts the 122 patients who had a single primary prostate cancer only with the 24 patients who had additional primary carcinomas with respect to age, racial distribution, clinical stage, and prostate cancer histology including Gleason's score, patterns of failure of prostate cancer, and survival data. Local failure and distant failure were less in the multiple primary group. Patients with high Gleason's scores appear to be at greater risk for second primaries. Five-year observed survival (by actuarial life table method) for the single prostate primary group was 76.5%, and 5-year observed survival of the prostate multiple primary group where prostate cancer appeared first was 71%.

Renal effects of antipyretic analgesics

Most antipyretic analgesics can cause acute nephrotoxic effects, including acute tubular necrosis, acute interstitial nephritis, glomerular toxicity, and functional changes, such as "salicyl edema," following large doses of sodium salicylate. Most functional changes are related to acute suppression of prostaglandin synthesis, "the acute prostaglandin-effect," and have been primarily noted with the use of indomethacin. The association between prolonged and excessive consumption of compound analgesics and the development of renal disease and renal failure, characterized by renal papillary necrosis, is now well established. Studies in several countries have shown that the incidence of analgesic nephropathy as an indication for dialysis and transplantation corresponds to the per capita consumption of phenacetin in compound analgesics. Analgesic nephropathy, which is part of a wider clinical syndrome, the analgesic syndrome, is uncommon following the use of single analgesics. Analgesic nephropathy and the analgesic syndrome are discussed in detail, including the development of uroepithelial tumors.

Analgesics and tobacco as risk factors for cancer of the ureter and renal pelvis

In a case-control study of 36 men with cancer of the ureter and 307 male controls with the same age distribution tobacco smoking conferred a relative risk for this cancer of 2.9, whereas consumption of analgesics of any kind did not increase the risk. The relative risk for cancer of the renal pelvis, determined for 29 men, was 2.4 for tobacco and 6.0 for phenacetin-containing analgesics. Analgesics containing no phenacetin conferred no increased risk for cancer at this site. Data for 13 women with ureteral cancer, 5 of whom had taken phenacetin, are presented but not analyzed.

Phenacetin-containing analgesics and cancer of the bladder or renal pelvis in women

In a case-control investigation of 154 women with cancer of the bladder and 440 female population controls spanning the same age range, the relative risk for this cancer was 2.6 in consumers of phenacetin-containing analgesics and 2.7 in tobacco smokers. The relative risks for cancer of the renal pelvis, determined for 31 cases, were 5.4 with phenacetin and 4.7 with tobacco. Increasing consumption of either agent increased the risk for cancer at each of the two sites, while a synergistic rather than purely additive effect was apparent when both phenacetin-containing analgesics and tobacco had been taken. Consumption of analgesic preparations which contained no phenacetin did not increase the risk of developing cancer at either site. The evidence indicates that phenacetin is a clinically important carcinogen for the lower as well as for the upper urinary tract.

Bladder cancer etiology. A different perspective

The descriptive epidemiologic features of bladder cancer and lung cancer in Los Angeles County were studied for the period 1972-1976, using data from the Los Angeles County/University of Southern California Cancer Surveillance Program. The incidence pattern for bladder cancer was found to differ markedly from the pattern observed for lung cancer. As expected, the descriptive pattern for lung cancer closely paralleled the known epidemiology of cigarette smoking; in addition, it was consistent with the expected pattern of an occupationally linked disease. In contrast, the pattern observed for bladder cancer indicated that factors other than cigarette smoking and occupational exposures may be etiologically important. The available descriptive epidemiology of coffee consumption, unlike that of cigarette smoking, is consistent with the pattern of bladder cancer occurrence in Los Angeles. Available analytic studies on the association of bladder cancer and coffee consumption are consistent with a causal relationship.

Transitional cell carcinoma of the kidney

This paper presents 14 personal patients with transitional cell carcinoma of the kidney who were managed over a period of 13 years. Emphasis is placed on the diagnostic features, the great variety of radiological appearances of this neoplasm and the value of preoperative cytological examination of urine. In three patients the tumour started in the mucosa of peripheral calyces, and did not involve the surgical renal pelvis; this added to the diagnostic difficulty, and led to delay in diagnosis and treatment in one patient. The possibility that this tumour may be more common in Australia because of the high incidence of analgesic nephropathy is raised.

Chronic antigenic stimulation from the graft as a possible oncogenic factor after renal transplant

In the period 1956-1976, 3 649 kidney transplantations were performed on 3 040 patients in Scandinavia. In the same period 67 primary malignant tumours were detected in these patients. In comparisons using age and sex-specific incidence in a background population, the observed tumour incidence was significantly higher than expected. Analyses were made in regard to a number of factors with potential influence on oncogenesis. The interval from transplantation to appearance of tumour was significantly longer in the recipients of grafts from living relatives than in cadaver kidney recipients. Significant correlation of tumour incidence was found with HLA mismatch in recipients of necrokidneys. Chronic interstitial nephritis as underlying kidney disease and blood transfusion showed correlation with tumour incidence. From these observations the hypothesis is proposed that a chronic antigen effect is a dominant factor among the numerous possible oncogenic mechanisms in patients with transplants.

Phenacetin abuse and malignant tumors. An autopsy study covering 25 years (1953-1977)

The findings presented in this study are based on 29.226 autopsies performed (between 1953 and 1977) at Basel University on adult inhabitants of Basel, from which 409 urinary tract tumors (UTT) and 513 phenacetin abusers (PA) were discovered. There were 44 (8.6%) PA with UTT which, when compared with the control group (1.27%), represents a statistically significant increased incidence. Of the 50 UTT in PA, 52% occurred in the bladder, 6% in the ureter, and 42% in the renal pelvis. The induction time for tumors of the urinary bladder was about 27 years, and for tumors of the renal pelvis about 20 years. The commonest tumors arising in PA were invasive solid and non-invasive papillary urothelial carcinomas. PA with UTT died earlier than nonabusers but had metastases as frequently as nonabusers. Analgesic nephropathy was not always an accompanying disease. The daily dose of g/phenacetin in tumor patients in general, and in patients with tumors of the urinary bladder in particular, was about 1 g lower than in patients with analgesic nephropathy (without tumors) and in those with tumors of the renal pelvis. Thus, for the localization of the tumors, the daily dose seems to be more important than the total dose. Our investigation proved that not only tumors of the renal pelvis, but also of the ureter and the urinary bladder, are significantly more frequent in PA than in nonabusers. It is suspected that despite restriction of the over-the-counter sale of phenacetin-containing analgesics and even after stopping any analgesic abuse, UTT will further increase due to the longer induction time. Routine cytological screening tests of the urine are recommended for all known PA. A prescription for all phenacetin- and paracetamol-containing analgesics is necessary.

Urothelial abnormalities in the obstructed bladder

Bladder mucosa from patients undergoing prostatectomy was examined histologically for evidence of pre-malignant change. The mucosal appearances were compared with tissue taken from control patients without bladder outlet obstruction. The appearances in patients with uncomplicated obstruction and in control patients were found to be similar and dysplastic change was uncommon. However, dysplasia was found relatively frequently in patients with bladder outlet obstruction complicated by the presence of infection, catheters or stones. In all, 10 out of 74 patients were found to have dysplasia and 7 of these agreed to have a further cystoscopy and biopsy taken at an interval of between 10 and 28 months after the first examination. Persistent dysplasia was found in all 7 cases and in 3 of these it had progressed from mild to moderate in severity. The significance of these findings is discussed.