Renal cell carcinoma and malignant phase hypertension

Many cross-sectional and follow-up studies of large numbers of patients with hypertension have demonstrated an increased prevalence and mortality from renal cancer. We report the details of three patients with renal cell carcinoma from a series of 254 consecutive patients with malignant phase hypertension, an excess over the expected number reported from several large published series with non-malignant hypertension. In view of this excess we investigated the prevalence of hypertension in a series of 192 consecutive patients who presented with a diagnosis of renal cell carcinoma, in comparison with a local unselected population screening survey. Hypertension was found in 43% of the renal carcinoma patients and 20% of the local population, also a clear excess. The mechanism of the association between renal cancer and malignant and non-malignant hypertension is unclear.

Genetic instability in incidentally discovered and advanced prostate cancer

OBJECTIVE

To investigate the frequency of microsatellite instability, a marker for genetic instability, in incidental and advanced prostate cancers, and to determine the role and prognostic importance of genetic instability in prostate carcinogenesis.

PATIENTS AND METHODS

Microsatellite analysis was performed on 72 prostate cancers, of which 26 were incidentally discovered at transurethral prostatectomy (TURP) for benign disease. They were staged and graded 1-3 according to glandular differentiation. Fresh prostatic tissue was obtained at TURP performed for bladder outlet obstruction, from 43 patients (median age 73 years, range 55-88), with tissue from the remaining 29 (median age 75, range 53-83) patients obtained from pathology archives, having been originally collected at TURP between 1969 and 1986.

RESULTS

Instability was detected in 14 (19%) cancers overall, in eight (31%) of 26 incidental tumours and in six (13%) of 46 clinically apparent tumours. These differences were not statistically different (2P=0.1). The time to progression and survival were similar between men with tumours showing instability and those with no instability.

CONCLUSION

These data suggest that genetic instability is an early event in prostate carcinogenesis, but does not appear to influence prognosis.

Genetic alterations in incidentally diagnosed, transitional zone prostate cancer: a seven year follow-up

PURPOSE

To investigate the frequency and prognostic significance of genetic alterations in incidentally diagnosed, transitional zone prostate cancer.

MATERIALS AND METHODS

Twenty-six incidentally diagnosed, transitional zone cancers were examined by the PCR for genetic alterations on chromosomes 8p and 13q and by immunohistochemistry for alterations of the expression of the cell-cycle regulatory proteins RB1 and p53 and of the cell adhesion molecules E-cadherin and alpha-catenin.

RESULTS

All of the tumors had at least one molecular abnormality (median 2.0 range 1 to 4). Allelic loss on 8p occurred in 37% and on 13q in 50% of informative tumors. Abnormal expression of pRb was found in 67%, of p53 in 33%, of E-cadherin in 36% and of alpha-catenin in 43%. In addition microsatellite instability was found in 23% of tumors. Only loss of expression of alpha-catenin was found to have prognostic importance.

CONCLUSIONS

Genetic alterations were common, but, apart from alpha-catenin, did not appear to be related to tumor progression. The lack of prognostic significance is likely to be due to the multifocal nature of prostate cancer, but may also relate to qualitative differences between transitional zone and peripheral zone prostate cancers.

Cystic renal cell carcinoma: radiological features and clinico-pathological correlation

The radiological appearances of 11 cystic renal cell carcinomas (RCC) presenting over a 13-year-period are reviewed and correlated with their clinicopathological features. The tumours occurred in seven males and four females with a mean age of 59.1 years (range 27-87 years). Their ultrasound features were categorized according to Bosniak [5]. There were six category 3 or 4 cysts (indeterminate or malignant); three category 2 cysts and two category 1 cysts. Computed tomography scans (CT) demonstrated malignant features in all seven patients scanned. Cyst aspiration, intravenous urograms and arteriograms were generally unhelpful. Histological growth patterns of nine tumours were determined and all were staged by Robson's classification: eight were Stage 1, one was Stage 3 and two were Stage 4. Three of four deaths were related to tumour bulk, and the fourth patient died from an unrelated cause. All seven survivors had Stage 1 disease. No correlation existed between different histological subtypes and tumour aggression. Overall, the behaviour of cystic RCCs was similar to those of solid RCCs apart from the high percentage (72.2%) of Stage 1 disease. We conclude that any deviation from a simple cyst on ultrasound should be assessed by CT and/or surgery. Indeterminate lesions on CT including multilocular lesions should be surgically explored.

A comparison of intramuscular ketorolac and pethidine in the alleviation of renal colic

OBJECTIVE

To compare the analgesic efficacy of a single 30 mg intramuscular dose of ketorolac with that of intramuscular pethidine 100 mg, in a double-blind, parallel-group investigation of patients presenting with pain suggestive of renal colic.

PATIENTS AND METHODS

Seventy-six patients (17 women, 15 men; mean age 45.2 years, range 20-80) were allocated by means of a pre-determined randomization schedule to receive ketorolac and 78 patients (20 women, 58 men; mean age 42.1, years range 18-70) to receive pethidine. Data from eight patients in the ketorolac group and six in the pethidine group were excluded from the efficacy analyses because of protocol violations. The severity of each patient's pain was assessed on a four-point verbal rating scale (VRS) and a 10 cm visual analogue scale at pre-dose and at 15 min intervals for the first hour post dosing. The time to first administration of rescue analgesic, up to 24 h following dosing with the study medication, was recorded. Adverse events were elicited by general questioning.

RESULTS

Eighty-eight per cent of patients in each treatment group had improved according to the VRS of pain severity 1 h after dosing; the summed pain intensity differences up to 1 h were statistically significantly different in favour of ketorolac (P < 0.05). Fifty-six per cent of patients who were receiving ketorolac required rescue analgesia during the study period compared with 74% receiving pethidine. The incidences of adverse events were lower in the ketorolac group (28%) than the pethidine group (51%).

CONCLUSION

Ketorolac can be considered a viable alternative to pethidine for the treatment of renal colic.

Phase III randomised study of zoladex versus stilboestrol in the treatment of advanced prostate cancer

An open randomised Phase III trial was conducted of the depot GnRH analogue goserelin (Zoladex) versus stilboestrol (3 mg/day) in patients with advanced or metastatic prostate cancer. The study included 250 patients and the median follow-up was 43 months. In the Zoladex arm the time to first response was achieved earlier and more patients reported an improvement in symptoms. There was no statistically significant difference between the Zoladex and the stilboestrol arms with regard to survival and time to treatment failure. A major reason for treatment failure was the preponderance of adverse events in patients receiving stilboestrol. It is suggested that stilboestrol should no longer be used for prostate cancer when equally effective alternative treatments are available.

The fragmented staghorn calculus: a radiological sign of pyonephrosis

Staghorn calculi may cause several complications, particularly important being the development of pyonephrosis due to long-standing infection. We describe four patients who presented with either a marked systemic illness or a loin mass due to pyonephrosis. In each patient, the plain abdominal radiograph showed a fragmented staghorn calculus, which is suggested as a radiological sign of pyonephrosis and indicative of the need for surgical attention.

Installation and use of a neodymium-YAG laser in a urology department

We report our experience in setting up a urological laser unit. An operating theatre was upgraded to include the required safety features and a neodymium-YAG laser was installed. A preliminary study using cadaver bladders was performed to establish the technique of cystoscopic laser application. We treated 55 bladder tumours in 12 patients by laser coagulation, with total destruction of 54 tumours and no serious complications; 6 patients developed recurrent tumours. Twenty-one patients underwent surgery with the contact laser scalpel. The instrument proved slow but effective, with excellent haemostasis and almost painless wounds. Healing was delayed in 2 cases but there were no wound infections. All wounds healed with good cosmetic scars. The neodymium-YAG laser is an effective means of destroying superficial non-invasive bladder tumours endoscopically and can also be used in conjunction with a laser scalpel for open surgery.

Phase II study of Zoladex depot in advanced prostatic cancer with special reference to criteria of response and survival

Zoladex is a potent decapeptide analogue of luteinising hormone releasing hormone (LHRH). The drug is formulated as a 3.6 mg depot dispersed in a matrix of d,l-lactide-glycolide copolymer, which is totally biodegradable. This formula releases drug continuously for at least 28 days and reliably suppresses serum testosterone into the castrate range. The effect of the depot was studied in 29 patients with locally advanced or metastatic carcinoma of the prostate. Average age at entry was 71 years (range 52-87) and follow-up was from 13.5 to 34.5 months (median 23). Endocrine studies showed that medical castration was maintained in all cases. Three patients experienced bone pain in the first month of treatment and two others had temporary nephrostomies for worsening ureteric obstruction. Subjective improvement was seen in 23/28 cases (82%). There were no complete responses, but partial response was seen in 24/28 (85.7%) using our own criteria, 24/28 (85.7%) using the criteria recommended by the British Prostate Group (BPG) and 15/28 (53.6%) using NPCP criteria. Stable disease was seen in 3/28 patients (10.7%) by our own or BPG criteria, and in 12/28 patients (42.9%) according to NPCP criteria. Progression of disease was measurable in 21 patients (72.4%) whatever criteria were applied; 11/29 (37.9%) have died, giving a median survival of 10 months (range 2.4-26). Following these encouraging results, a multicentre randomised comparative study with stilboestrol 3 mg daily is being undertaken.

Ureteropyelostomy: a simple and effective treatment for symptomatic ureteroureteric reflux

Partial ureteric duplication may cause delayed drainage of urine from the upper tracts because of ureteroureteric "see-saw" reflux. This can be eliminated by the procedure of ureteropyelostomy, in which the partially duplicated ureter is converted into a bifid renal pelvis. This operation leaves a short anastomotic suture line and has a low complication rate. We report seven patients who have undergone ureteropyelostomy for symptomatic ureteroureteric reflux. All remain symptom-free after follow-up for a minimum of 1 year.

Pharmacokinetic and endocrinological parameters of a slow-release depot preparation of the GnRH analogue ICI 118630 (zoladex) compared with a subcutaneous bolus and continuous subcutaneous infusion of the same drug in patients with prostatic cancer

Seventeen patients with advanced prostatic cancer were treated with the gonadotrophin-releasing hormone analogue DSer (tBU)6 AzaGly 10 GnRH (ICI 118630), either as a constant SC infusion, or in the form of a monthly SC slowrelease depot formulation, in which case patients were randomised to receive one of three doses. Six of these patients also received a 250-microgram SC bolus of ICI 118630, for pharmacokinetic studies, before starting the infusion or the depot. Drug levels were measured using a double-antibody radioimmunoassay. In contrast to the SC infusion, which gave a smooth serum 118630 level profile, drug release from the depot preparation was not constant, levels varying in a predictable manner throughout each 28-day period, reaching a peak proportional to the dose of ICI 118630 received, between days 15 and 18 of each cycle. With all methods of administration there was an initial rise in LH, usually followed by a rise in testosterone, after which the SC infusion and the depot were both effective in reducing serum LH to basal levels and testosterone into the castrate range within 1 month. It is too early to make any assessment of clinical response; however, depot treatment was well tolerated: Four patients experienced an initial flare in bone pain, probably related to the initial rise in testosterone, and twelve patients experienced flushing; one patient with pre-existing hydronephrosis and hydroureter developed renal failure, possibly related to a tumour flare reaction. No patients have experienced cardiovascular side effects or local reaction.

The association of hypertension, the Ask-Upmark kidney and other congenital abnormalities

We report 2 cases of hypertension with segmental renal hypoplasia (Ask-Upmark kidney) and other anomalies in the absence of vesicoureteral reflux. These cases support the view that the Ask-Upmark kidney is a defect of renal development rather than acquired as a consequence of vesicoureteral reflux. In 1 patient the abnormal renal vein renin ratio suggested that the renin-angiotensin system may have had a part in the pathogenesis of the hypertension.

Leiomyosarcoma of the spermatic cord

Leiomyosarcoma of the spermatic cord is extremely rare. We report a case associated with recurrent papillary bladder tumours and benign hyperplasia of the prostate. The use of adjuvant chemotherapy is described for the first time in the management of this condition.

Urodynamic investigation in a district general hospital

In patients with disorders of micturition there is a poor correlation between clinical diagnosis and urodynamic findings. Thirty-three out of 82 patients studied in a Urodynamic Unit had their treatment plan altered as a result of the investigation.

Complete deficiency of adenine phosphoribosyltransferase: a third case presenting as renal stones in a young child

We report a third case of 2, 8-dihydroxyadenine stones in a child with a complete lack of the adenine salvage enzyme--adenine phosphoribosyltransferase (APRT). The propositus, a 20-month-old girl of consanguineous Arab parents, presented with multiple urinary tract infections and supposed 'uric acid' stones in the right renal pelvis and left ureter. Both parents and one brother were heterzygotes for the defect, in keeping with an autosomal recessive mode of inheritance. In contrast with the other purine salvage enzyme disorder of childhood with true uric acid stones (the Lesch-Nyhan syndrome), uric acid excretion was normal in all family members. As in our previous case, treatment with allopurinol, without alkali, has eliminated the urinary excretion of 2, 8-dihydroxyadenine: the stones were removed surgically. 2, 8-Dihydroxyadenine should be considered in any child thought to have uric acid stones and tests made to distinguish the two compounds.

Pre-operative arterial embolisation in renal carcinoma

Nephrectomy for carcinoma is often accompanied by moderate or severe bleeding but this may be reduced by prior occlusion of the renal artery. Embolisation with fresh autologous clot is rendered ineffective by rapid lysis. In vitro experiments showed that the clot could be stabilised by the addition of epsilon amino caproic acid (EACA). By injecting stabilised clot into the renal arterysatisfactory devascularisation of kidney and tumour was achieved in 10 patients.

Preoperative skin preparation: clinical evaluation of depilatory cream

Preoperative hair removal by a depilatory cream was compared with routine shaving. Although the incidence of wound infection was similar in both groups, cream depilation was found to be better. It was effective, atraumatic, non-toxic, and could be self-administered. Furthermore, it could be used safely on granulating wounds and did not support bacterial growth. Depilation was associated with a significant reduction in skin surface bacteria and proved to be cheaper than shaving.

Osteosarcoma of the thyroid gland

A case of osteosarcoma of the thyroid gland in a 61-yr-old woman who died from tracheal compression due to local recurrence 6 wk after operation is presented. The main features of 27 previously reported similar cases, and the problems of histogenesis are discussed.