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Diagnostic Urology and Testis Cancer
0022-534 7/92/1476-1684$03.00/0 JOURNAL OF UROLOGY Copyright© 1992 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 147, 1684-1696, June 1992 Printed in U.S.A.
THE
ABSTRACTS DIAGNOSTIC UROLOGY AND TESTIS CANCER Imaging of the Renal Arteries: Value of MR Angiography J. F. DEBATIN, C. E .. SPRITZER, T. M. GRIST, C. BEAM, L. P. SVETKEY, G. E. NEWMAN AND H. D. SOSTMAN, Departments of Radiology and Medicine, Duke University Medical Center, Durham, North Carolina AJR, 157: 981-990, 1991
Abstract Printed in J. Uroi., 147: 1179, 1992
Editorial Comments: The authors have evaluated a new technique-magnetic resonance angiographyand compared it with conventional angiography for renovascular disease. Interpreted independently, this prospective study suggests that magnetic resonance angiography could be of value as a screening technique in patients with renovascular disease. Jerome P. Richie, M.D.
sive glomerular dysfunction nor end-stage renal failure developed over a period of 10 years.
Editorial Comment: This case report of a patient with approximately 20% total functioning renal mass did not show evidence of glomerular dysfunction or end stage renal failure at IO-year followup. Cases such as this and those seen by many urologists refute the clinical significance of glomerular hyperfiltration in patients with a solitary kidney or a portion of a solitary kidney. Jerome P. Richie, M.D. Progressive Renal Toxicity Due to Ifosfamide D. HENEY, J. WHEELDON, P. RUSHWORTH, C. CHAPMAN, I. J. LEWIS AND C. C. BAILEY, Department of Paediatrics and Child Health, St. James's University Hospital and Department of Chemical Pathology, The General Infirmary at Leeds, Leeds, England Arch. Dis. Child., 66: 966-970, 1991
Long-Term Follow-Up of a Human Subject With a Remnant Kidney
A prospective and follow up study of renal tubular and glomerular function in 11 children receiving ifosfamide treatment was conducted. Each child received between four and 14 courses of ifosfamide, given as a continuous infusion of 3 g/m2 over 24 hours for two or three days. Evidence of renal toxicity was seen in all patients. There was a treatment related rise in urinary tubular markers (N-acetyl-glucosaminidase and a 1 microglobulin). Recovery was limited, so that by the fourth course of treatment all values remained abnormal. There was an associated treatment related reduction in plasma phosphate concentration. Urinary albumin also showed a treatment related rise, but with fewer abnormal values. Electrophoresis was used to confirm tubular or glomerular patterns. Glomerular toxicity was less severe and occurred in fewer patients. The follow up study showed persistence of tubular damage in all seven patients examined, and there was evidence of glomerular damage in five of the seven children. Children receiving ifosfamide need to be carefully monitored for renal toxicity both during treatment and at follow up.
E. A. RuTSKY, E. V. DUBOVSKY AND K. A. KIRK, Nephrology Research and Training Center, Division of Nephrology; Departments of Medicine and Biostatistics, and Division of Nuclear Medicine, Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
Editorial Comment: This article emphasizes the need for careful monitoring of children treated with ifosfamide because of the possibility of progressive nephrotoxicity. Jerome P. Richie, M. D.
Magnetic resonance angiography is rapidly evolving to the point that large clinical trials will be needed to determine whether the technique can indeed be substituted for invasive angiography in diagnosing vascular lesions of the kidney. This preliminary study indicates that the technique is being refined at a rapid pace. The procedure obviously will not be a screening test but perhaps it can be used in high risk patients. Additionally, its use in screening potential renal donors will have to be carefully evaluated. Early digital subtraction angiographic studies without central injection often miss the presence of multiple renal arteries, which is a major consideration in evaluating kidneys for renal donation. E. Darracott Vaughan, M.D.
Amer. J. Kidney Dis., 18: 509-513, 1991
It has been proposed that once functioning renal mass has
An Assessment of Combined Tumour Markers in Patients with Seminoma: Placental Alkaline Phosphatase (PLAP), Lactate Dehydrogenase (LD) and fJ Human Chorionic Gonadotrophin (fJHCG)
been reduced below a critical level, either as the result of disease, congenital absence of a kidney, or surgical ablation, that hyperfiltration and glomerular hypertension lead to progressive glomerular sclerosis and end-stage renal failure. We A. J. MUNRO, 0. S. NIELSEN, W. DUNCAN, J. STURGEON, M. report the clinical course and renal function of a human subject K. GosPODAROWICZ, A. MALKIN, G. M. THOMAS AND M.A. followed for 10.8 years after extensive renal ablation. FunctionS. JEWETT, Departments of Radiation Oncology and Medicine, ing renal mass was estimated at one fourth to one fifth of Princess Margaret Hospital, and Division of Urology, Univernormal. During the follow-up period, creatinine clearance insity of Toronto and The Wellesley Hospital, Toronto, and creased from 0.27 mL/s (16 mL/min) to 0.88 mL/s (53 mL/ Toronto-Bayview Regional Cancer Centre and Department of min), the total renal plasma flow (all of which was to the left Clinical Biochemistry, Sunnybrook Medical Centre, Ontario, kidney) increased from 62 mL/min to 190 mL/min, and 24Canada, and Departments of Oncology and Experimental Clinhour urine protein excretion increased from 0.09 g to 0.4 g. ical Oncology, Radiumstationen, Aarhus, Denmark Despite probable glomerular hyperfiltration, neither progres- Brit. J. Cancer, 64: 537-542, 1991 1684
1685 We have assessed the tumour markers placental alkaline and human phosphatase (PLAP), lactate dehydrogenase chorionic gonadotrophin (f:IHCG) using 2,000 serum samples from 286 patients with seminoma. The ROC curves show that no one marker performs adequately for the detection of disease either at initial staging or during follow-up. We used a Markov model heuristically to devise strategies, in which marker results were assessed in combination, which might be useful in clinical practice. We found that the best strategy was to consider a test result abnormal only if either the f:IHCG was >6 U 1- 1 or the LD was >400 U 1- 1 and the PLAP level was >60 U 1-1 • This will detect about 50% of patients with disease and the falsepositive rate is 2%. In practical terms this means that PLAP need only be estimated in patients whose f:IHCG is <6 IU 1- 1 and whose LD is >400 U 1-1 •
Editorial Comment: The availability of specific tumor ma:rkers fo:r nonseminomatous germ cell tumm:s has greatly facilitated the management of such patients. Unfortunately, the lack of specific tumor markers has hampered the management of patients with pure seminoma. The authors evaluated 3 tumor markers: 1) placental alkaline phosphatase, 2) lactate dehyd:rogenase and 3) /3 subunit of human chorionic gonadotropin, for the ability to detect :relapse and also positive predictive values in 286 patients with. seminoma. Patients we:re divided randomly into 2 groups: 1 for data generation and l to test the data. Using these techniques the authors identified a mechanism to detect disease in approximately 50% of the patients. Even with the combination of all 3 tumo:r markers, this sensitivity and specificity are too low for everyday practical use in patients with seminoma. Jerome P. Richie, M.D.
ADRENAL, HYPERTENSION, RENAL PHYSIOLOGY AND RENAL FAILURE Recombinant Human Eryth:ropoietin Therapy in the §urgfoal Setting and Applications in Oncology L. T, GOODNOUGH, Departments of Medicine and Pathology, Case vVestern Reserve n.uwrsu,v ,u,,wuu,,.u, Ohio
Amer. J. The development of recombinant human (Epo), along with a sensitive and reriroctwc1ble assay for plasma Epo, has resulted in new potential applications for the treatment of medical and surgical anemias. A series of studies have defined a role for Epo therapy in the perisurgical setting to include the facilitation of autologous blood procurement and to facilitate postoperative erythropoiesis in order to minimize homologous blood transfusion requirements. Other possible applications of Epo therapy include the treatment of medical illnesses. Clinical trials to date have demonstrated that Epo therapy can correct the anemias of renal insufficiency, of rheumatoid arthritis, and of acquired immunodeficiency syndrome (AIDS) patients undergoing antiviral therapy. Clinical trials investigating the application of Epo therapy in the oncologic setting are in progress. These developments herald a new age in transfusion medicine, which includes the use of pharmacologic therapies in blood conservation strategies.
Edito:rfal Comment: Mm·e and mm"e .!,"~'""'""··~, a:ire i'equestin.g au.tologm:rn blood collection before a majo:r op~ eration fo:r use during surgery. A limiting factor is the number of units of blood that can be given, and a frequent problem is a lower than optimal hematocrit wh.e~1 the patient is eventually admitted to the hospital for surge,:y. In. this study patients were given 600 units pe:r kg. body weight erythropoietin twice a week for 21 days, during which time an attempt was made to collect 6 units of blood. Mean blood collection in these patients was 5.4 units versus 4.1 units in the control group, and admission and discharge hematoc:rit values were significantly highe:r in the erythropoietin group. There was no comment concerning any complications :related to e:ryth:ropoietin treatment. Erythropoietin administered alone to increase hematoc:rit without blood donation could be anothe:r option and warrants fu:rthe:r study, although its use would necessitate careful monitoring of the postoperative thromboemholic phenomenon. E. Darracott Vaughan, M,D.
Clinical Outcome and Health Ca:re Costs in Renal Revascularization-Percutaneous T:ra:m,lu.minal Renal Angioplasty Versus Rec1:m.structive Surgery H.
WEIBULL, D. BERGQVIST, S. JENDTEG, B. LINDGREN, U. PERSSON, K JONSSON ANDS. E. BERGENTZ, Departments
of Surgery and Radiology, Malmo General Hospital, Lund University, Malmo and Swedish Institute for Health Economics, Lund, Sweden Brit. J. Surg., 78: 620-624, 1991 Abstract Printed in J. Urol., 147: 773, 1992
Editorial Comment: We a1°e beginning to see :reports of long-term folfowup comparing the results of transluminal angioplasty and surgical reconstructi.on. fo this study the median foUowup was 48 months and there were no recurrences of stenosis i:n the operated g:roup compared to a 69% :recurrence :rate hi the angioplasty group. Patients who had :restenosis following angioplasty were treated by either :repeat angioplasty or reconstructive surgery, An interesting :result wa!l the fact that because of :recurrences in tbe angiopla:;;ty giroup there was no significant of cost the te:.:m. E. Darracott Long-Teirm Results Afte:rc Pe:rcutanem.!s T:ransluminal Angioplasty of Atherosclerotic Renal Artery Stenosis-The Importance of Intensive Follow-Up H. WEIBULL, D. BERGQVIST, K. JONSSON, L. HULTHEN, P. MANNHEM AND S.-E. BERGENTZ, Departments of Surgery, Radiology and Endocrinology, Lund University, Malmo General Hospital, Malmo, Sweden
Eur. J. Vase. Surg., 5: 291-301, 1991 The aim of this study was to investigate the long-term results of percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis (PTRA) in patients with renovascular hypertension with or without impending renal insufficiency who were followed up intensively with aggressive reintervention. Diagnostic work-up was based on angiography, pressure
Vol. 147, 1684-1696, June 1992 Printed in U.S.A.
THE
ABSTRACTS DIAGNOSTIC UROLOGY AND TESTIS CANCER Imaging of the Renal Arteries: Value of MR Angiography J. F. DEBATIN, C. E .. SPRITZER, T. M. GRIST, C. BEAM, L. P. SVETKEY, G. E. NEWMAN AND H. D. SOSTMAN, Departments of Radiology and Medicine, Duke University Medical Center, Durham, North Carolina AJR, 157: 981-990, 1991
Abstract Printed in J. Uroi., 147: 1179, 1992
Editorial Comments: The authors have evaluated a new technique-magnetic resonance angiographyand compared it with conventional angiography for renovascular disease. Interpreted independently, this prospective study suggests that magnetic resonance angiography could be of value as a screening technique in patients with renovascular disease. Jerome P. Richie, M.D.
sive glomerular dysfunction nor end-stage renal failure developed over a period of 10 years.
Editorial Comment: This case report of a patient with approximately 20% total functioning renal mass did not show evidence of glomerular dysfunction or end stage renal failure at IO-year followup. Cases such as this and those seen by many urologists refute the clinical significance of glomerular hyperfiltration in patients with a solitary kidney or a portion of a solitary kidney. Jerome P. Richie, M.D. Progressive Renal Toxicity Due to Ifosfamide D. HENEY, J. WHEELDON, P. RUSHWORTH, C. CHAPMAN, I. J. LEWIS AND C. C. BAILEY, Department of Paediatrics and Child Health, St. James's University Hospital and Department of Chemical Pathology, The General Infirmary at Leeds, Leeds, England Arch. Dis. Child., 66: 966-970, 1991
Long-Term Follow-Up of a Human Subject With a Remnant Kidney
A prospective and follow up study of renal tubular and glomerular function in 11 children receiving ifosfamide treatment was conducted. Each child received between four and 14 courses of ifosfamide, given as a continuous infusion of 3 g/m2 over 24 hours for two or three days. Evidence of renal toxicity was seen in all patients. There was a treatment related rise in urinary tubular markers (N-acetyl-glucosaminidase and a 1 microglobulin). Recovery was limited, so that by the fourth course of treatment all values remained abnormal. There was an associated treatment related reduction in plasma phosphate concentration. Urinary albumin also showed a treatment related rise, but with fewer abnormal values. Electrophoresis was used to confirm tubular or glomerular patterns. Glomerular toxicity was less severe and occurred in fewer patients. The follow up study showed persistence of tubular damage in all seven patients examined, and there was evidence of glomerular damage in five of the seven children. Children receiving ifosfamide need to be carefully monitored for renal toxicity both during treatment and at follow up.
E. A. RuTSKY, E. V. DUBOVSKY AND K. A. KIRK, Nephrology Research and Training Center, Division of Nephrology; Departments of Medicine and Biostatistics, and Division of Nuclear Medicine, Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
Editorial Comment: This article emphasizes the need for careful monitoring of children treated with ifosfamide because of the possibility of progressive nephrotoxicity. Jerome P. Richie, M. D.
Magnetic resonance angiography is rapidly evolving to the point that large clinical trials will be needed to determine whether the technique can indeed be substituted for invasive angiography in diagnosing vascular lesions of the kidney. This preliminary study indicates that the technique is being refined at a rapid pace. The procedure obviously will not be a screening test but perhaps it can be used in high risk patients. Additionally, its use in screening potential renal donors will have to be carefully evaluated. Early digital subtraction angiographic studies without central injection often miss the presence of multiple renal arteries, which is a major consideration in evaluating kidneys for renal donation. E. Darracott Vaughan, M.D.
Amer. J. Kidney Dis., 18: 509-513, 1991
It has been proposed that once functioning renal mass has
An Assessment of Combined Tumour Markers in Patients with Seminoma: Placental Alkaline Phosphatase (PLAP), Lactate Dehydrogenase (LD) and fJ Human Chorionic Gonadotrophin (fJHCG)
been reduced below a critical level, either as the result of disease, congenital absence of a kidney, or surgical ablation, that hyperfiltration and glomerular hypertension lead to progressive glomerular sclerosis and end-stage renal failure. We A. J. MUNRO, 0. S. NIELSEN, W. DUNCAN, J. STURGEON, M. report the clinical course and renal function of a human subject K. GosPODAROWICZ, A. MALKIN, G. M. THOMAS AND M.A. followed for 10.8 years after extensive renal ablation. FunctionS. JEWETT, Departments of Radiation Oncology and Medicine, ing renal mass was estimated at one fourth to one fifth of Princess Margaret Hospital, and Division of Urology, Univernormal. During the follow-up period, creatinine clearance insity of Toronto and The Wellesley Hospital, Toronto, and creased from 0.27 mL/s (16 mL/min) to 0.88 mL/s (53 mL/ Toronto-Bayview Regional Cancer Centre and Department of min), the total renal plasma flow (all of which was to the left Clinical Biochemistry, Sunnybrook Medical Centre, Ontario, kidney) increased from 62 mL/min to 190 mL/min, and 24Canada, and Departments of Oncology and Experimental Clinhour urine protein excretion increased from 0.09 g to 0.4 g. ical Oncology, Radiumstationen, Aarhus, Denmark Despite probable glomerular hyperfiltration, neither progres- Brit. J. Cancer, 64: 537-542, 1991 1684
1685 We have assessed the tumour markers placental alkaline and human phosphatase (PLAP), lactate dehydrogenase chorionic gonadotrophin (f:IHCG) using 2,000 serum samples from 286 patients with seminoma. The ROC curves show that no one marker performs adequately for the detection of disease either at initial staging or during follow-up. We used a Markov model heuristically to devise strategies, in which marker results were assessed in combination, which might be useful in clinical practice. We found that the best strategy was to consider a test result abnormal only if either the f:IHCG was >6 U 1- 1 or the LD was >400 U 1- 1 and the PLAP level was >60 U 1-1 • This will detect about 50% of patients with disease and the falsepositive rate is 2%. In practical terms this means that PLAP need only be estimated in patients whose f:IHCG is <6 IU 1- 1 and whose LD is >400 U 1-1 •
Editorial Comment: The availability of specific tumor ma:rkers fo:r nonseminomatous germ cell tumm:s has greatly facilitated the management of such patients. Unfortunately, the lack of specific tumor markers has hampered the management of patients with pure seminoma. The authors evaluated 3 tumor markers: 1) placental alkaline phosphatase, 2) lactate dehyd:rogenase and 3) /3 subunit of human chorionic gonadotropin, for the ability to detect :relapse and also positive predictive values in 286 patients with. seminoma. Patients we:re divided randomly into 2 groups: 1 for data generation and l to test the data. Using these techniques the authors identified a mechanism to detect disease in approximately 50% of the patients. Even with the combination of all 3 tumo:r markers, this sensitivity and specificity are too low for everyday practical use in patients with seminoma. Jerome P. Richie, M.D.
ADRENAL, HYPERTENSION, RENAL PHYSIOLOGY AND RENAL FAILURE Recombinant Human Eryth:ropoietin Therapy in the §urgfoal Setting and Applications in Oncology L. T, GOODNOUGH, Departments of Medicine and Pathology, Case vVestern Reserve n.uwrsu,v ,u,,wuu,,.u, Ohio
Amer. J. The development of recombinant human (Epo), along with a sensitive and reriroctwc1ble assay for plasma Epo, has resulted in new potential applications for the treatment of medical and surgical anemias. A series of studies have defined a role for Epo therapy in the perisurgical setting to include the facilitation of autologous blood procurement and to facilitate postoperative erythropoiesis in order to minimize homologous blood transfusion requirements. Other possible applications of Epo therapy include the treatment of medical illnesses. Clinical trials to date have demonstrated that Epo therapy can correct the anemias of renal insufficiency, of rheumatoid arthritis, and of acquired immunodeficiency syndrome (AIDS) patients undergoing antiviral therapy. Clinical trials investigating the application of Epo therapy in the oncologic setting are in progress. These developments herald a new age in transfusion medicine, which includes the use of pharmacologic therapies in blood conservation strategies.
Edito:rfal Comment: Mm·e and mm"e .!,"~'""'""··~, a:ire i'equestin.g au.tologm:rn blood collection before a majo:r op~ eration fo:r use during surgery. A limiting factor is the number of units of blood that can be given, and a frequent problem is a lower than optimal hematocrit wh.e~1 the patient is eventually admitted to the hospital for surge,:y. In. this study patients were given 600 units pe:r kg. body weight erythropoietin twice a week for 21 days, during which time an attempt was made to collect 6 units of blood. Mean blood collection in these patients was 5.4 units versus 4.1 units in the control group, and admission and discharge hematoc:rit values were significantly highe:r in the erythropoietin group. There was no comment concerning any complications :related to e:ryth:ropoietin treatment. Erythropoietin administered alone to increase hematoc:rit without blood donation could be anothe:r option and warrants fu:rthe:r study, although its use would necessitate careful monitoring of the postoperative thromboemholic phenomenon. E. Darracott Vaughan, M,D.
Clinical Outcome and Health Ca:re Costs in Renal Revascularization-Percutaneous T:ra:m,lu.minal Renal Angioplasty Versus Rec1:m.structive Surgery H.
WEIBULL, D. BERGQVIST, S. JENDTEG, B. LINDGREN, U. PERSSON, K JONSSON ANDS. E. BERGENTZ, Departments
of Surgery and Radiology, Malmo General Hospital, Lund University, Malmo and Swedish Institute for Health Economics, Lund, Sweden Brit. J. Surg., 78: 620-624, 1991 Abstract Printed in J. Urol., 147: 773, 1992
Editorial Comment: We a1°e beginning to see :reports of long-term folfowup comparing the results of transluminal angioplasty and surgical reconstructi.on. fo this study the median foUowup was 48 months and there were no recurrences of stenosis i:n the operated g:roup compared to a 69% :recurrence :rate hi the angioplasty group. Patients who had :restenosis following angioplasty were treated by either :repeat angioplasty or reconstructive surgery, An interesting :result wa!l the fact that because of :recurrences in tbe angiopla:;;ty giroup there was no significant of cost the te:.:m. E. Darracott Long-Teirm Results Afte:rc Pe:rcutanem.!s T:ransluminal Angioplasty of Atherosclerotic Renal Artery Stenosis-The Importance of Intensive Follow-Up H. WEIBULL, D. BERGQVIST, K. JONSSON, L. HULTHEN, P. MANNHEM AND S.-E. BERGENTZ, Departments of Surgery, Radiology and Endocrinology, Lund University, Malmo General Hospital, Malmo, Sweden
Eur. J. Vase. Surg., 5: 291-301, 1991 The aim of this study was to investigate the long-term results of percutaneous transluminal angioplasty of atherosclerotic renal artery stenosis (PTRA) in patients with renovascular hypertension with or without impending renal insufficiency who were followed up intensively with aggressive reintervention. Diagnostic work-up was based on angiography, pressure