Renal Pelvic Urothelial Carcinoma With Invasion Into Renal Medulla Can Be Redefined as pT2 to Improve Correlation With Survival

According to the American Joint Cancer Committee, pT3 renal pelvic carcinoma is defined as tumor invading the renal parenchyma and/or peripelvic fat and is the largest pT category, with notable survival heterogeneity. Anatomical landmarks within the renal pelvis can be difficult to discern. Using glomeruli as a boundary to differentiate renal medulla invasion from renal cortex invasion, this study aimed to compare patient survival of pT3 renal pelvic urothelial carcinoma on the basis of the extent of renal parenchyma invasion and, thereafter, determine whether redefining pT2 and pT3 improves pT correlation with survival. Cases with primary renal pelvic urothelial carcinoma were identified through a review of pathology reports from nephroureterectomies completed at our institution from 2010 to 2019 (n = 145). Tumors were stratified by pT, pN, lymphovascular invasion, and invasion of the renal medulla versus invasion of the renal cortex and/or peripelvic fat. Overall survival between groups was compared using Kaplan-Meier survival models and Cox regression multivariate analysis. pT2 and pT3 tumors had similar 5-year overall survival, with multivariate analysis demonstrating an overlap between hazard ratios (HRs) for pT2 (HR, 2.20; 95% CI, 0.70-6.95) and pT3 (HR, 3.15; 95% CI, 1.63-6.09). pT3 tumors with peripelvic fat and/or renal cortex invasion had a 3.25-fold worse prognosis than pT3 tumors with renal medulla invasion alone. Furthermore, pT2 and pT3 tumors with only renal medulla invasion had similar overall survival, whereas pT3 tumors with peripelvic fat and/or renal cortex invasion had a worse prognosis (P = .00036). Reclassifying pT3 tumors with only renal medulla invasion as pT2 yielded greater separation between survival curves and HR. Thus, we recommend redefining pT2 renal pelvic carcinoma to include renal medulla invasion and restricting pT3 to peripelvic fat and/or renal cortex invasion to improve the prognostic accuracy of pT classification.

The Stratification of Positive Lymph Nodes into pN1 and pN2 for Upper Urinary Tract Carcinoma is not Prognostically Significant

The 3^rd-7^th edition of the American Joint Committee on Cancer had 3 categories for positive lymph nodes (pN1-3) in upper urinary tract carcinoma. The 8^th edition removed pN3, defining pN1 as one lymph node with tumor deposit ≤ 2 cm and pN2 as a node with tumor deposit > 2 cm or metastases in multiple nodes. The aim of this study was to assess if the current pN categories impact survival in renal pelvic and ureteral carcinoma. Nephroureterectomies performed at our institution for primary upper urinary tract carcinoma between 2010-2019 were reviewed. Lymphadenectomy was performed in 73.3% of cases (151/206, median 9 nodes). Eighty-one (53.6%) patients were deceased at last review [pN0, 53 (44.5%); pN1-2, 28 (87.5%)]. There was no difference in overall or recurrence free survival between pN1 and pN2 with 5-year overall survival (95% confidence interval) of pN0, 60.7% (52.0-70.8%); pN1, 15.4% (4.3-35.2%); and pN2, 21.1% (8.8-40.3%). The metastatic deposit size threshold of 2 cm, number of positive lymph nodes, as well as extranodal extension did not correlate with overall or recurrence free survival. As such, pN1 and pN2 were grouped together with a 5-year overall survival of 18.8% (9.12-28.6%). The current stratification of upper urinary tract carcinoma into pN1 and pN2 does not provide prognostic information, and both yield a stage IV classification, regardless of pT or pM category. Therefore, we recommend further simplification of pN classification into one category for regional lymph node metastasis, irrespective of lymph node deposit size or number of positive lymph nodes.

Doxycycline sclerotherapy of cervical spine aneurysmal bone cysts: single-institution 13-year experience

BACKGROUND

Aneurysmal bone cysts (ABCs) are benign, locally aggressive neoplasms that typically affect patients during their first two decades of life. Curettage with or without bone grafting or adjuvants is the current standard treatment; however, other surgical and medical treatments, such as sclerotherapy, have been reported. Treatment options for cervical spine ABCs are more limited because the proximity of ABCs to critical structures leads to greater risk of spontaneous or treatment-related adverse events, including death.

OBJECTIVE

To retrospectively review all children and young adults with cervical spine ABCs treated with doxycycline sclerotherapy at one referral center to assess its viability as a standalone treatment.

MATERIALS AND METHODS

We retrospectively reviewed the clinical notes and imaging of 16 patients treated with doxycycline sclerotherapy for pathologically proven cervical spine ABCs at our institution between May 2008 and March 2021. All patients underwent image-guided percutaneous doxycycline sclerotherapy to ablate the ABC and stimulate bone formation. We assessed clinical outcomes through chart review and described post-treatment imaging outcomes using modified Neer scoring.

RESULTS

Of the 16 total children and young adults treated, 2 were lost to follow-up, leaving 14 patients with a median age of 14.5 years. Twelve of these 14 patients were successfully treated with doxycycline sclerotherapy for a success rate of 86%. One patient experienced one treatment-related complication (Society of Interventional Radiology [SIR] adverse event classification D), before ultimately being successfully treated. Doxycycline treatment failed in two patients, who then underwent surgical management. Post-treatment imaging of successfully treated cases had a mean modified Neer score of 1.3, whereas post-treatment imaging in failed cases had a mean score of 3.5.

CONCLUSION

Doxycycline sclerotherapy is a viable standalone treatment for cervical spine ABCs because it is safe and effective while avoiding the morbidity associated with open surgical treatments.

Image-Guided Percutaneous Management of Skull and Spine Giant Cell Tumors: Case Report of 2 Challenging Cases Successfully Treated with Doxycycline Sclerotherapy

Background

A giant cell tumor (GCT) of bone is a benign, locally aggressive tumor that is often challenging to treat. When complete resection is not possible, curettage with or without adjuvants is the most common treatment. The high frequency of local recurrence and risk of injury to adjacent structures can limit this surgical approach, especially with skull and spine lesions.

Case Description

We report 2 cases of axial skeleton GCTs, 1 in the skull of a 58-year-old woman in whom operative management failed, who experienced local recurrence, and 1 in the cervical spine of an 8-year-old girl that grew extracompartmentally to surround her brachial plexus. Both patients were referred to us because of the surgically challenging nature of their tumors. After completion of the same percutaneous doxycycline sclerotherapy protocol previously described for aneurysmal bone cysts (ABCs), both patients were considered cured and were able to return to normal activities without loss of pretreatment function. After 4 and 10 years of follow-up, respectively, there has been no tumor recurrence in either patient.

Conclusions

We successfully treated 2 patients with very challenging axial skeleton GCTs using a percutaneous doxycycline sclerotherapy protocol previously shown to have success with ABCs. We believe that this minimally invasive procedure should be considered a potential alternative treatment for GCTs, especially axial skeleton lesions, which may not be easily approached with standard surgical techniques.

DNA copy number variants: A potentially useful predictor of early onset renal failure in boys with posterior urethral valves

INTRODUCTION

Posterior urethral valves (PUV) are among the most common urological causes of chronic kidney disease (CKD) in childhood. Recently, genomic imbalances have been cited as potential risk factors for altered kidney function and have been associated with CKD. The phenotypic effects of a copy number variant (CNV) in boys with PUV are unknown. Here, it was hypothesised that the progression to early renal failure in PUV patients may be influenced by genetic aberrations.

OBJECTIVE

To assess the relationship between CNVs and renal outcomes.

PATIENTS AND METHODS

Between September 2012 and July 2015, 45 children with PUV were recruited to evaluate the presence of CNVs in their DNA. The patients' medical records were retrospectively reviewed. The criteria for outcomes of renal function included: assessments of the nadir serum creatinine in the first year of life, the estimated glomerular filtration rate at 1 and 5 years, and the requirement for renal replacement.

RESULTS

Thirteen CNVs were identified in 12 boys (29% of the cohort). Microarray analysis revealed two pathogenic CNVs (well-established CNVs known to be associated with genetic disease) and 11 of unknown significance (CNVs with insufficient current available evidence for unequivocal determination of clinical significance), including genes that have been previously implicated in kidney diseases and urogenital disorders. The median follow-up was 10.2 years (range 3-17.5) in the group of patients with CNV compared with 5.8 years (range 1-16.6) in those CNV-. The nadir creatinine values were significantly higher in boys with CNVs than in those without CNVs (57.5 μmol/L (range 23-215) and 28 μmol/L (range 18-155), respectively (P = 0.05) (Figure). Boys CNV+ had a worse prognosis, with a higher incidence of Stage-V CKD compared with the control group (33% with CNVs vs. 9% in CNV-, P = 0.06) at a median age of 22 months (range 8 months-16 years). Four (33%) patients CNV+ underwent renal transplantation.

DISCUSSION

The role of CNVs in the deterioration of renal function remains unknown. It can be hypothesised that CNVs could be a contributing factor or may serve as an accelerant for the progression to renal failure.

CONCLUSION

The CNVs >100 Kb were significantly associated with early onset renal failure in children with PUV. Prenatal detection of CNV could help to identify foetuses at high risk of severe renal impairment in cases of suspected PUV, especially in cases without oligohydramnios or severe pulmonary hypoplasia. These preliminary results should be confirmed in a larger cohort of patients.

Late presentation of Nipah virus encephalitis and kinetics of the humoral immune response

Nipah virus is a newly discovered paramyxovirus transmitted directly from pigs to humans. During a large encephalitis outbreak in Malaysia and Singapore in 1998-9, most patients presented acutely. A 12 year old child is described who developed encephalitis 4 months after exposure to the virus. She was diagnosed by a new indirect IgG enzyme linked immunosorbent assay (ELISA), which is also described. The late presentation and IgG subclass responses had similarities to subacute sclerosing panencephalitis. Nipah virus should be considered in patients with encephalitis even months after their possible exposure.

Radiofrequency catheter ablation in the treatment of supraventricular tachycardia in the elderly

OBJECTIVES

The purpose of this study was to evaluate the efficacy and safety of radiofrequency catheter ablation for the treatment of supraventricular tachycardias in an elderly (> or = 70 years of age) group of patients.

BACKGROUND

Supraventricular tachycardias are the most common form of cardiac arrhythmia and affect all age groups. Although usually well tolerated in youth, supraventricular tachycardias may be associated with disabling symptoms and have life-threatening potential in the elderly. In addition, antiarrhythmic agents are less well tolerated and may be associated with a higher incidence of toxicity in the elderly.

METHODS

From May 1989 to March 1993, 454 patients underwent a radiofrequency catheter ablation procedure at the University of California, San Francisco, for the treatment of symptomatic supraventricular tachycardia. Sixty-seven of these patients were > or = 70 years of age and constituted the study group. Patients underwent one of the following catheter ablation procedures: complete atrioventricular (AV) junctional ablation for ventricular rate control in patients with atrial fibrillation (37 patients), AV node modification for the treatment of AV node reentrant tachycardia (17 patients), accessory pathway ablation (9 patients), ablation of the "slow zone" to cure atrial flutter (4 patients) and atrial tachycardia ablation (1 patient). One patient underwent ablation for both AV node reentrant tachycardia and atrial flutter.

RESULTS

Success was achieved in 67 (98.5%) of 68 ablation procedures. There were no procedural or early deaths. The overall complication rate was 7.4%, and only one patient (1.5%) had long-term sequelae (permanent cardiac pacing for complete heart block). At a mean (+/- SD) follow-up of 22.1 +/- 12.9 months, 63 (94%) of 67 patients were alive, with no antiarrhythmic agents for the treatment of their presenting arrhythmia.

CONCLUSIONS

In this series radiofrequency catheter ablation appears to be an effective and safe treatment option for elderly patients (> or = 70 years of age) with a variety of symptomatic, drug-resistant supraventricular tachycardias. Because of the high incidence of severe symptoms associated with tachycardic episodes, the expense and the possible severe proarrhythmic problems associated with antiarrhythmic medications in this age group, catheter ablation may be considered an early rather than a "last resort" treatment option.

The effect of protein deficiency on some rat liver lipid metabolic enzymes and CoA

Two groups of male Wistar rats were fed normal (i.e., 18%) and protein-free diets, respectively, for 7 weeks. In vivo incorporation of [1-14C] acetate into palmitic, stearic, oleic, and arachidonic acids by the liver was reduced in the protein-deficient rats. In vitro incubation of liver microsomes with labeled palmitate or linoleate revealed no change in the specific activities of chain elongating or desaturating enzymes. Protein deficiency resulted in a decrease in specific activity of short chain acyl-CoA synthetase and in total CoA, accompanied by the virtual disappearance of acyl-CoA and an increase in free CoA. Furthermore, there was less microsomal fatty acid synthetase and mitochondrial beta-hydroxybutyrate dehydrogenase activity. These results are discussed in relation to fatty acid synthesis and the changes in liver fatty acid composition.