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273 PERCUTANEOUS ADRENAL BIOPSY: INDICATIONS, COMPLICATIONS AND DIAGNOSTIC ACCURACY
Percutaneous adrenal biopsy: indications, complications and diagnostic accuracy
273
274
Evaluation of 39 patients operated on Pheochromocytoma regarding to PASS classification Safarik L.1, Novak K.1, Bilek R.2, Zelinka T.3, Widimsky J.3, Dvoracek J.1, Ciprova V.4
Gomha A.M.1, El-Mekresh M.1, Osman Y.1, Taha N.2, Eraky I.1 Urology & Nephrology Center, Urology, Mansoura, Egypt, 2Urology & Nephrology Center, Pathology, Mansoura, Egypt 1
Introduction & Objectives: To critically analyze the role, accuracy as well as safety of percutaneous adrenal biopsy based on a single center experience. Material & Methods: Between 1976 through 2005, 238 patients with 246 adrenal masses were diagnosed in a single institute. Adrenal biopsies were performed in 45 patients (18.9%) because of an equivocal diagnosis, suspicious of malignancy as well as neuroblastoma cases for preoperative chemotherapy. Out of these biopsied masses, definitive histopathology was confirmed in 39 patients. Overall sensitivity was calculated and safety of the procedure was reviewed and reported. Results: Patients included 24 male and 21 female patients with mean age of 19.6 ± 21.2 years (range 6 months – 65 years). Biopsy was carried out CT and US guided in 27 and 18 patients respectively. Five patients were diagnosed to harbor an advanced inoperable (± metastatic) adrenal malignancy proved by biopsy to be neuroblastoma. Another patient was suggested to have a metastatic hepatocellular carcinoma to the adrenal based on the radiological finding and the result of the biopsy. No definitive histopathology was obtained in these 6 patients and were excluded from the final analysis. There were 3 non-representive biopsies that were proved to be neuroblastoma, adrenocortical carcinoma and myelolipoma after surgical excision. The results of the biopsy in the remaining 36 patients were: 21 neuroblastoma, 5 pheochromocytoma, 3 metastatic lesions from primary bladder carcinoma, 2 cortical adenoma, 1 adrenocortical carcinoma, 1 paraganglioma, 1 cystic teratoma, 1 schwannoma, 1 myelolipoma. The biopsies provided accurate diagnosis as proved by definitive histopathology after surgical excision in all but two patients in whom the final diagnosis was established as adrenocortical carcinoma while the biopsy was paraganglioma in one patient and cortical adenoma in the other. Overall sensitivity of percutaneous adrenal biopsy was 87.2 %. Apart from 2 hypertensive episodes following silent pheochromocytoma biopsy that was managed conservatively without serious sequelae, no complications were reported. Conclusions: Percutaneous biopsy is a safe, accurate procedure for the diagnosis of pathologic conditions of the adrenal gland. However, it should be restricted for suspected neuroblastoma cases prior to preoperative chemotherapy and as a last diagnostic aid for suspicious adrenal masses.
275
Effect of FTY720-induced lymphopenia on rat kidney transplants with severe preservation reperfusion injury
Fuller F.1, Naether M.2, Rose F.2, Nieminen-Kelha M.2, Kong L.2, Nolting J.2, Hoff U.2, Linde Y.2, Hegner B.2, Dragun D.2 Charite University Hospital, Campus Mitte, Urology, Berlin, Germany, 2Charite University Hospital, Campus Mitte, Nephrology, Berlin, Germany 1
Introduction & Objectives: In the presence of delayed graft function, conventional immunosuppressants usually aggravate preexisting tubular injury. In animal models the novel immunomodulator FTY720 prolongs renal allograft survival by preventing lymphocyte egress from lymphoid tissue. We tested whether or not FTY720 acts tubulotoxic in kidney transplants with prolonged cold preservation and also studied effects of FTY720 on cultured rat renal tubular cells. Material & Methods: Donor kidneys were cold-stored in UW for 24 hrs prior to transplantation into bilaterally nephrectomized syngeneic rats. Recipients (n = 6 / group) received 0.5 mg/kg/day FTY720 or vehicle via oral gavage. Animals were sacrificed two days post transplantation. Flow cytometry analysis of peripheral blood and lymph nodes was performed to prove biological effects of FTY720. Graft function and histology were assessed. Apoptosis was measured by the TUNEL assay. Immunohistochemistry served for studies on inflammatory cell infiltration, tubular proliferation and dedifferentiation. The effect of phosphorylated FTY720 (0.1 umol/l 10 umol/l) on viability and proliferation of native tubular epithelial cells was assessed in vitro. Results: In recipient animals FTY720 induced peripheral lymphopenia combined with a significant reduction in CD3+ intragraft infiltrates. Serum creatinine levels on days one and two post transplantation were not influenced by FTY720 treatment. Despite severe tubular damage in both experimental groups, there was a trend towards less necrosis and apoptosis in the FTY720 group. Tubular damage in FTY720-treated animals was confined to the outer medulla, while in vehicle-treated animals tubular damage extended to the cortex. Proliferative activity as measured by expression of PCNA antigen, was significantly increased in cortical tubules of FTY720-treated animals (P = 0.01). Expression of vimentin, a marker of tubular cell injury and dedifferentiation, was low in both treatment groups. FTY720 had no effect on renal macrophage infiltration. In vitro, viability and proliferation of cultured tubular epithelial cells was not influenced by FTY720. Conclusions: Unlike calcineurin inhibitors or antiproliferative immunosuppressants, FTY720 has no adverse effect on early graft function and does not enhance tubular damage in rat kidney grafts with severe preservation injury.
Charles University, Urology, Prague, Czech Republic, 2Academy of Sciences, Endocrinology, Prague, Czech Republic, 3Charles University, Endocrinology, Prague, Czech Republic, 4Charles University, Pathology, Prague, Czech Republic 1
Introduction & Objectives: Pheochromocytoma Adrenal gland Scaled Score (PASS) has been recently introduced to determine between benign and malignant pheochromocytomas. Following study has been undertaken to assess the possibility of evaluate malignant potential from the levels of blood and urine nephrins. Material & Methods: 41 patients have been referred to surgery due to clinically and laboratory examinations pointing to the diagnosis of pheochromocytoma (Ph). 39 had actually pathologically confirmed Ph, while two were excluded. Urinary epinephrine, norepinephrine and dopamine, as well as blood metanephrine and normethanephrine were determined. Pathologist was asked to state PASS score in all Phs presuming that ≤ 4 is benign, while all above have malignant potential. Results were correlated with Student t-test. Mean follow-up was 49 months. Results: There were 19 men and 22 women, 4 had recurrent disease. Mean weight was 162,52 g (13 – 1200). Seven operations were primarily open (due to recurrent or bulky disease), 34 transperitoneal laparoscopic. There were 6 revisions mainly due to bleeding, one of them laparoscopically. Prevailing nephrine (at least tripled base level): epinephrine in 8, norepinephrin in 10 and dopamine in 8. One was equivocal. Correlation of blood and urine nephrines – see table 1. PASS
≤4
>4
U-epinephrine (nmol/h)
2079,45
1587,7
U-norepinephrine (nmol/h) U-dopamine (nmol/h)
2221,4
2389,9
905,9
547,27
Metanephrine (ng/l)
1062,6
765
Normetanephrine (ng/l) PASS
2127,3 21 (53,8%)
2332,9 18(46,2%)
Highest PAS
p < 0.05
10
Lowest PASS Mean hospital stay
p < 0.05
2 open
13 days
laparoscopy
4,9 days
Thirty patients (77%) were cured only with the surgery with normal nephrine levels and blood pressure, postsurgically, 5 were improved regarding blood pressure control, 2 died due to generalization and 2 with the connection of surgery (long lasting and recurrent disease). Conclusions: Almost half of the operated patients had PASS higher than 4, e.g. presumably malignant. Urinary norepinephrine and blood normetanephrine showed positive correlation with higher PASS score and could be seen as warrant marker in prognosis assessment. So far, only 4 patients have died, all of them with PASS > 4, while 13 likely malignant are still alive with now signs of recurrence, one N/A.
276
Renal transplantation in older adults: the impact of recipient age
López López A.I., Cao Avellaneda E., López Cubillana P., Prieto González A., Maluff Torres A., Escudero Bregante F., Pérez Albacete M. Hospital Universitario Virgen de la Arrixaca, Urology, Murcia, Spain Introduction & Objectives: As survival worldwide population has improved over the last few decades, the patients requiring kidney transplantation age, has also increased. On the other hand, organ shortage forces to know the clinical evolution of aged patients with kidney transplantation. Thus, the main aim of this study is to investigate the impact of donor and recipient age in kidney allograft survival.As a second aim we would like to determine if medical and surgical complications were or not similar between both age recipients groups (recipients >60 and <60 years old). Material & Methods: We compiled data from 242 consecutive kidney transplantation, performed in a single institution between January 2001 and December 2005. We performed a descriptive analysis of the main variables considered (donor and receptor age and sex, cause of donor death, cardiovascular risk recipient factors (HTA, Diabetes mellitus and vascular calcifications), recipient time in dialysis, cause of end stage renal disease, number of HLA mismatches etcetera…). Then, we undertook an inferential univariant analysis just comparing groups (receptor and donor older and younger than 60 years old). Finally a predictive model including the main variables in our study has been tried done. Results: Of the 242 patients having received a kidney transplant 45 patients (23 men and 22 women) were >60 years old with a mean age of 64,48 years (IC 95%63.55-65.41).This group of receptor’s donor average age was 43,46 yr (IC 95% 41,90-45,02). The average time in dyalisis was 38.21 months (IC 95% 26.51-49,90). 197 patients (104 men and 77 women) were younger than 60 years old at the time of the transplantation. Their donor’s average age was 38,82 yr (IC 95% 36.59-41.05). No statistically significative differences have been found between both groups (<60 and >60yr) on incidence of fistula (p=0.654), acute vascular surgical complications (p=0.296 arterial thrombosis and p=0.685 venous thrombosis) urinary or surgical wound infection (p= 0.589 and p=0.386), urinary obstruction (p=0.471) or linfocele (p=335). No statistically significative differences had been found either between both groups on primary nonfunction (p=0.605), delayed graft function (defined as the need for HD after kidney transplantation) (p=0.161) or delayed graft function duration (p=0.521). No statistically significative differences have been found between both groups (<60 and >60yr) on renal function (defined by creatinine values) at 3, 6, 12 and 24 months. Using binomial logistic regression analysis, we did not found any relevant predictive model to argue the appearance if different complications in the older recipients. Conclusions: No statistically significative differences have been found on clinical and surgical complications between recipients older and younger 60 years old. This retrospective evaluation confirmed our idea that the old patient should not be excluded a priori from the transplantation option.
Eur Urol Suppl 2007;6(2):91
273
274
Evaluation of 39 patients operated on Pheochromocytoma regarding to PASS classification Safarik L.1, Novak K.1, Bilek R.2, Zelinka T.3, Widimsky J.3, Dvoracek J.1, Ciprova V.4
Gomha A.M.1, El-Mekresh M.1, Osman Y.1, Taha N.2, Eraky I.1 Urology & Nephrology Center, Urology, Mansoura, Egypt, 2Urology & Nephrology Center, Pathology, Mansoura, Egypt 1
Introduction & Objectives: To critically analyze the role, accuracy as well as safety of percutaneous adrenal biopsy based on a single center experience. Material & Methods: Between 1976 through 2005, 238 patients with 246 adrenal masses were diagnosed in a single institute. Adrenal biopsies were performed in 45 patients (18.9%) because of an equivocal diagnosis, suspicious of malignancy as well as neuroblastoma cases for preoperative chemotherapy. Out of these biopsied masses, definitive histopathology was confirmed in 39 patients. Overall sensitivity was calculated and safety of the procedure was reviewed and reported. Results: Patients included 24 male and 21 female patients with mean age of 19.6 ± 21.2 years (range 6 months – 65 years). Biopsy was carried out CT and US guided in 27 and 18 patients respectively. Five patients were diagnosed to harbor an advanced inoperable (± metastatic) adrenal malignancy proved by biopsy to be neuroblastoma. Another patient was suggested to have a metastatic hepatocellular carcinoma to the adrenal based on the radiological finding and the result of the biopsy. No definitive histopathology was obtained in these 6 patients and were excluded from the final analysis. There were 3 non-representive biopsies that were proved to be neuroblastoma, adrenocortical carcinoma and myelolipoma after surgical excision. The results of the biopsy in the remaining 36 patients were: 21 neuroblastoma, 5 pheochromocytoma, 3 metastatic lesions from primary bladder carcinoma, 2 cortical adenoma, 1 adrenocortical carcinoma, 1 paraganglioma, 1 cystic teratoma, 1 schwannoma, 1 myelolipoma. The biopsies provided accurate diagnosis as proved by definitive histopathology after surgical excision in all but two patients in whom the final diagnosis was established as adrenocortical carcinoma while the biopsy was paraganglioma in one patient and cortical adenoma in the other. Overall sensitivity of percutaneous adrenal biopsy was 87.2 %. Apart from 2 hypertensive episodes following silent pheochromocytoma biopsy that was managed conservatively without serious sequelae, no complications were reported. Conclusions: Percutaneous biopsy is a safe, accurate procedure for the diagnosis of pathologic conditions of the adrenal gland. However, it should be restricted for suspected neuroblastoma cases prior to preoperative chemotherapy and as a last diagnostic aid for suspicious adrenal masses.
275
Effect of FTY720-induced lymphopenia on rat kidney transplants with severe preservation reperfusion injury
Fuller F.1, Naether M.2, Rose F.2, Nieminen-Kelha M.2, Kong L.2, Nolting J.2, Hoff U.2, Linde Y.2, Hegner B.2, Dragun D.2 Charite University Hospital, Campus Mitte, Urology, Berlin, Germany, 2Charite University Hospital, Campus Mitte, Nephrology, Berlin, Germany 1
Introduction & Objectives: In the presence of delayed graft function, conventional immunosuppressants usually aggravate preexisting tubular injury. In animal models the novel immunomodulator FTY720 prolongs renal allograft survival by preventing lymphocyte egress from lymphoid tissue. We tested whether or not FTY720 acts tubulotoxic in kidney transplants with prolonged cold preservation and also studied effects of FTY720 on cultured rat renal tubular cells. Material & Methods: Donor kidneys were cold-stored in UW for 24 hrs prior to transplantation into bilaterally nephrectomized syngeneic rats. Recipients (n = 6 / group) received 0.5 mg/kg/day FTY720 or vehicle via oral gavage. Animals were sacrificed two days post transplantation. Flow cytometry analysis of peripheral blood and lymph nodes was performed to prove biological effects of FTY720. Graft function and histology were assessed. Apoptosis was measured by the TUNEL assay. Immunohistochemistry served for studies on inflammatory cell infiltration, tubular proliferation and dedifferentiation. The effect of phosphorylated FTY720 (0.1 umol/l 10 umol/l) on viability and proliferation of native tubular epithelial cells was assessed in vitro. Results: In recipient animals FTY720 induced peripheral lymphopenia combined with a significant reduction in CD3+ intragraft infiltrates. Serum creatinine levels on days one and two post transplantation were not influenced by FTY720 treatment. Despite severe tubular damage in both experimental groups, there was a trend towards less necrosis and apoptosis in the FTY720 group. Tubular damage in FTY720-treated animals was confined to the outer medulla, while in vehicle-treated animals tubular damage extended to the cortex. Proliferative activity as measured by expression of PCNA antigen, was significantly increased in cortical tubules of FTY720-treated animals (P = 0.01). Expression of vimentin, a marker of tubular cell injury and dedifferentiation, was low in both treatment groups. FTY720 had no effect on renal macrophage infiltration. In vitro, viability and proliferation of cultured tubular epithelial cells was not influenced by FTY720. Conclusions: Unlike calcineurin inhibitors or antiproliferative immunosuppressants, FTY720 has no adverse effect on early graft function and does not enhance tubular damage in rat kidney grafts with severe preservation injury.
Charles University, Urology, Prague, Czech Republic, 2Academy of Sciences, Endocrinology, Prague, Czech Republic, 3Charles University, Endocrinology, Prague, Czech Republic, 4Charles University, Pathology, Prague, Czech Republic 1
Introduction & Objectives: Pheochromocytoma Adrenal gland Scaled Score (PASS) has been recently introduced to determine between benign and malignant pheochromocytomas. Following study has been undertaken to assess the possibility of evaluate malignant potential from the levels of blood and urine nephrins. Material & Methods: 41 patients have been referred to surgery due to clinically and laboratory examinations pointing to the diagnosis of pheochromocytoma (Ph). 39 had actually pathologically confirmed Ph, while two were excluded. Urinary epinephrine, norepinephrine and dopamine, as well as blood metanephrine and normethanephrine were determined. Pathologist was asked to state PASS score in all Phs presuming that ≤ 4 is benign, while all above have malignant potential. Results were correlated with Student t-test. Mean follow-up was 49 months. Results: There were 19 men and 22 women, 4 had recurrent disease. Mean weight was 162,52 g (13 – 1200). Seven operations were primarily open (due to recurrent or bulky disease), 34 transperitoneal laparoscopic. There were 6 revisions mainly due to bleeding, one of them laparoscopically. Prevailing nephrine (at least tripled base level): epinephrine in 8, norepinephrin in 10 and dopamine in 8. One was equivocal. Correlation of blood and urine nephrines – see table 1. PASS
≤4
>4
U-epinephrine (nmol/h)
2079,45
1587,7
U-norepinephrine (nmol/h) U-dopamine (nmol/h)
2221,4
2389,9
905,9
547,27
Metanephrine (ng/l)
1062,6
765
Normetanephrine (ng/l) PASS
2127,3 21 (53,8%)
2332,9 18(46,2%)
Highest PAS
p < 0.05
10
Lowest PASS Mean hospital stay
p < 0.05
2 open
13 days
laparoscopy
4,9 days
Thirty patients (77%) were cured only with the surgery with normal nephrine levels and blood pressure, postsurgically, 5 were improved regarding blood pressure control, 2 died due to generalization and 2 with the connection of surgery (long lasting and recurrent disease). Conclusions: Almost half of the operated patients had PASS higher than 4, e.g. presumably malignant. Urinary norepinephrine and blood normetanephrine showed positive correlation with higher PASS score and could be seen as warrant marker in prognosis assessment. So far, only 4 patients have died, all of them with PASS > 4, while 13 likely malignant are still alive with now signs of recurrence, one N/A.
276
Renal transplantation in older adults: the impact of recipient age
López López A.I., Cao Avellaneda E., López Cubillana P., Prieto González A., Maluff Torres A., Escudero Bregante F., Pérez Albacete M. Hospital Universitario Virgen de la Arrixaca, Urology, Murcia, Spain Introduction & Objectives: As survival worldwide population has improved over the last few decades, the patients requiring kidney transplantation age, has also increased. On the other hand, organ shortage forces to know the clinical evolution of aged patients with kidney transplantation. Thus, the main aim of this study is to investigate the impact of donor and recipient age in kidney allograft survival.As a second aim we would like to determine if medical and surgical complications were or not similar between both age recipients groups (recipients >60 and <60 years old). Material & Methods: We compiled data from 242 consecutive kidney transplantation, performed in a single institution between January 2001 and December 2005. We performed a descriptive analysis of the main variables considered (donor and receptor age and sex, cause of donor death, cardiovascular risk recipient factors (HTA, Diabetes mellitus and vascular calcifications), recipient time in dialysis, cause of end stage renal disease, number of HLA mismatches etcetera…). Then, we undertook an inferential univariant analysis just comparing groups (receptor and donor older and younger than 60 years old). Finally a predictive model including the main variables in our study has been tried done. Results: Of the 242 patients having received a kidney transplant 45 patients (23 men and 22 women) were >60 years old with a mean age of 64,48 years (IC 95%63.55-65.41).This group of receptor’s donor average age was 43,46 yr (IC 95% 41,90-45,02). The average time in dyalisis was 38.21 months (IC 95% 26.51-49,90). 197 patients (104 men and 77 women) were younger than 60 years old at the time of the transplantation. Their donor’s average age was 38,82 yr (IC 95% 36.59-41.05). No statistically significative differences have been found between both groups (<60 and >60yr) on incidence of fistula (p=0.654), acute vascular surgical complications (p=0.296 arterial thrombosis and p=0.685 venous thrombosis) urinary or surgical wound infection (p= 0.589 and p=0.386), urinary obstruction (p=0.471) or linfocele (p=335). No statistically significative differences had been found either between both groups on primary nonfunction (p=0.605), delayed graft function (defined as the need for HD after kidney transplantation) (p=0.161) or delayed graft function duration (p=0.521). No statistically significative differences have been found between both groups (<60 and >60yr) on renal function (defined by creatinine values) at 3, 6, 12 and 24 months. Using binomial logistic regression analysis, we did not found any relevant predictive model to argue the appearance if different complications in the older recipients. Conclusions: No statistically significative differences have been found on clinical and surgical complications between recipients older and younger 60 years old. This retrospective evaluation confirmed our idea that the old patient should not be excluded a priori from the transplantation option.
Eur Urol Suppl 2007;6(2):91