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Normal Alkaline Phosphatase Levels in Patients With Bone Metastases Due to Renal Cell Carcinoma
732
RENAL TUMORS,RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION
ities equivalent to that of open exploration, but with potentially less morbidity. We present 3 cases in which laparoscopy was used to diagnose and manage urologic patients with an acute abdomen in a postoperative period. METHODS: Three patients underwent laparoscopy between 1 and 14 days postoperatively for an acute abdomen (fever, elevated white blood cell count, and peritoneal signs). The initial procedures included a pubovaginal sling repair with fascia lata, endoscopic placement of a percutaneous gastrostomy tube, and a laparoscopic ureterolithotomy for a distal stone. RESULTS: In each of the 3 patients laparoscopy revealed misplacement or malfunction of a previously placed tube. In all cases, the patient was managed laparoscopically without the need for laparotomy. CONCLUSIONS: These cases demonstrate the feasibility of laparoscopy to provide diagnostic and therapeutic solutions to postoperative urologic patients presenting with an acute abdomen.
Editorial Comment: The acutely ill patient undergoing an emergency surgical procedure is m o r e susceptible to surgical and postoperative complications than a healthy counterpart undergoing an elective procedure. As such, the use of laparoscopy in these patients is appealing. In earlier reports in the general surgery literature the safety and efficacy of this approach h a v e been reported. Indeed, C h u n g et al w e r e able to m a k e an accurate diagnosis in 56 of 57 patients presenting with an acute abdomen (9 had intestinal obstruction and 3 had peritonitis due to fecal soilage) and to treat the underlying cause laparoscopically in 62V0.1 Bauer et al h a v e extended this practice to encompass the seriously ill postoperative urological surgery patient. In their series all 3 patients were effectively diagnosed and treated laparoscopically. Of note, in the early laparoscopic literature intestinal obstruction and peritonitis w e r e considered contraindications to laparoscopy. With the advent of open Hasson cannula access and the realization that laparoscopy results in less systemic stress, even these cases can n o w be safely and effectively approached laparoscopically. Ralph V. Clayman, M.D. 1. Chung, R S., Dim, J. J. and Chari, V.: Efficacy of routine laparoscopy for the acute abdomen. Surg. Endosc., 12: 219,1998.
Recommended Reading: Dussol, B. and Berland, Y.:Urinary kidney stone inhibitors. What is the news? Urol. Int., 60:69, 1998.
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION Normal Alkaline Phosphatase Levels in Patients With Bone Metastases Due to Renal Cell Carcinoma
L. KRITEMAN AND W. H. SANDERS, Division of Urology, Emory University School ofMedicine, Atlanta, Georgia Urology, 51: 397-399,1998 Objectives. To determine the correlation between alkaline phosphatase levels and bone metastases in renal cell carcinoma. Methods. The records of two cohorts, including 539 and 184 patients, with metastatic renal cell carcinoma were renewed. In both groups, metastases were shown on magnetic resonance imaging (MRI), computed tomography (CT),or bone scan. In addition, the second cohort included data concerning pain on presentation. None of the patients in either cohort had any systemic therapy (chemotherapy or immunotherapy); many patients had undergone radical nephrectomy as the primary treatment of the cancer. All radiographic and laboratory information was obtained within a 6-week enrollment period. Normal alkaline phosphatase levels were referenced according t o age and sex, resulting in an upper limit of normal of 111 to 141 U L Results. In the first cohort bone metastases were documented by MRI, CT, and/or bone scans in 164 patients. Alkaline phosphatase levels were less than or equal to 141 U L in 118 patients (72%)and less than or equal to 111 U L in 87 patients (53%).There were 123 patients with bone metastases who had previously undergone a nephrectomy for presumed local disease. Alkaline phosphatase levels were less than or equal to 141 U/L in 91 patients (74%)and less than or equal to 111 U L in 70 patients (57%).In the second cohort 22 of 37 patients (59%)had little to no pain on presentation, and 19 (86%)of that group had normal alkaline phosphatase levels. Conclusions. Alkaline phosphatase is an insensitive indicator of bone metastases. Editorial Comment: T h e authors studied a large group of patients with metastatic renal cell carcinoma and then noted the s e r u m alkaline phosphatase. It w a s relatively common to h a v e
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION
normal alkaline phosphatase levels with metastatic disease to bone. These data are impressive because sometimes alkaline phosphatase level is used to decide whether to perform a bone scan. In this case the alkaline phosphates were an insensitive indicator of bone metastases, as the authors conclude. Fray F. Marshall, M.D. Granulocyte-Macrophage-Colony Stimulating Factor in Metastatic Renal Cell Carcinoma. A Phase I1 Trial B. I. RINI,W. M. STADLER, R. T. SPIELBERGER, M. J. RATAINAND N. J. VOGELZANG, Section of Hematology! Oncology, University of Chicago, Chicago, Illinois, and Department of Hematology and Bone Marrow Transplantation, City of Hope Medical Center, Duarte, California Cancer, 8 2 1352-1358, 1998 BACKGROUND. Due to lack of success with standard chemotherapy and only modest success with immunotherapy, metastatic renal cell carcinoma (RCC) is associated with a poor prognosis. Granulocytemacrophage-colony stimulating factor (GM-CSF) is a cytokine with potential antitumor activity, including stimulation of tumor necrosis factor (TNF) and interleukin-1 secretion. It is also a potent growth factor for and activator of antigen-presenting dendritic cells. GM-CSF toxicity may be mediated by TNF, and inhibition of TNF release by pentoxifylline (PTX)may ameliorate these toxic effects. The authors conducted a Phase I1 trial to determine the activity of GM-CSF in metastatic RCC and to study the effect of FTX on GM-CSF toxicity. METHODS. Twenty-four eligible patients with metastatic RCC received 10 p g k g of GM-CSF per day, administered subcutaneously, on a 14-days-on/l4-days-off schedule. Twelve patients received concurrent FTX at a dose of 400 mg administered orally 4 times per day. RESULTS. One patient experienced prolonged stability of disease aRer having progressive disease on entry. Two other patients experienced substantial slowing of their progressive disease while on study. One of these patients had rapidly progressing metastases on other immunotherapy before receiving GM-CSF. Toxicity was not diminished in patients treated with PTX; it included hyperleukocytosis, nausea, vomiting, pain, fever, skin reactions, myalgia, and fatigue. CONCLUSIONS. GM-CSF at the dose and schedule described in this report has minor activity against metastatic RCC, and FTX does not ameliorate its side effects. Editorial Comment: GM-CSF has been used in tumor vaccines for renal cell carcinoma.' A tumor vaccine combines antigen and stimulatory cytokine to produce a specific response. GM-CSFhas not typically been used as a systemic agent for the treatment of metastatic renal cell carcinoma and may not produce specificity of action. Systemic GM-CSF might be used in the future in combination with other forms of treatment but a s a single agent it was not impressive. Fray F. Marshall, M.D. 1. Simons, J. W.,Jaffee, E. M., Weber, C. E., Levitsky, H. I., Nelson, W. G., Carducci, M.A, Lazenby, A. J., Coben, L. K., Finn, C. C., Cliff, S. M., Hauda, K. M., Beck, L. A, Leiferman, K. M., Owens, A. H.,Jr.,
Piantadosi, S., Dranoff, G., Mulligan, R C., Pardoll, D. M. and Marshall, F. F.: Bioactivity of autologous irradiated renal cell carcinoma vaccines generated by ex vivo granulocyte-macrophage colony stimulating factor gene transfer. Cancer Res., 57: 1537, 1997.
Interactive MRI-Guided Radiofrequency Interstitial Thermal Ablation of Abdominal Tumors: Clinical Trial for Evaluation of Safety and Feasibility J. S. LEWIN,C. F. CONNELL, J. L. DUERK, Y.-c. CHUNG, M. E. CLAhfPITT, J. SPISAK,G. S. GAZELLE AND J. R. HAAGA, Departments of Radiology and Biomedical Engineering, University Hospitals of Cleveland and Case Western University, Cleveland, Ohio, and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts JMRI, 8: 40-47, 1998 Permission to Publish Abstract Not Granted
Editorial Comment: In this study interstitid thermal ablation was used under magnetic resonance imaging guidance for the destruction of renal cell carcinoma metastases or local recurrence. There were also 3 metastatic leiomyosarcomas. Tumors less than 6 cc in estimated volume appeared to be more effectively treated, while there was more uncertainty in the treatment of larger tumors. It may have been difficult to create a large enough tumor ablation zone to eradicate larger tumors. Tumor vascularity may also create a heat sink making it more difficult to destroy the tumors. Cryosurgery and other forms of thermal therapy will likely improve in the future. Fray F. Marshall, M.D.
733
RENAL TUMORS,RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION
ities equivalent to that of open exploration, but with potentially less morbidity. We present 3 cases in which laparoscopy was used to diagnose and manage urologic patients with an acute abdomen in a postoperative period. METHODS: Three patients underwent laparoscopy between 1 and 14 days postoperatively for an acute abdomen (fever, elevated white blood cell count, and peritoneal signs). The initial procedures included a pubovaginal sling repair with fascia lata, endoscopic placement of a percutaneous gastrostomy tube, and a laparoscopic ureterolithotomy for a distal stone. RESULTS: In each of the 3 patients laparoscopy revealed misplacement or malfunction of a previously placed tube. In all cases, the patient was managed laparoscopically without the need for laparotomy. CONCLUSIONS: These cases demonstrate the feasibility of laparoscopy to provide diagnostic and therapeutic solutions to postoperative urologic patients presenting with an acute abdomen.
Editorial Comment: The acutely ill patient undergoing an emergency surgical procedure is m o r e susceptible to surgical and postoperative complications than a healthy counterpart undergoing an elective procedure. As such, the use of laparoscopy in these patients is appealing. In earlier reports in the general surgery literature the safety and efficacy of this approach h a v e been reported. Indeed, C h u n g et al w e r e able to m a k e an accurate diagnosis in 56 of 57 patients presenting with an acute abdomen (9 had intestinal obstruction and 3 had peritonitis due to fecal soilage) and to treat the underlying cause laparoscopically in 62V0.1 Bauer et al h a v e extended this practice to encompass the seriously ill postoperative urological surgery patient. In their series all 3 patients were effectively diagnosed and treated laparoscopically. Of note, in the early laparoscopic literature intestinal obstruction and peritonitis w e r e considered contraindications to laparoscopy. With the advent of open Hasson cannula access and the realization that laparoscopy results in less systemic stress, even these cases can n o w be safely and effectively approached laparoscopically. Ralph V. Clayman, M.D. 1. Chung, R S., Dim, J. J. and Chari, V.: Efficacy of routine laparoscopy for the acute abdomen. Surg. Endosc., 12: 219,1998.
Recommended Reading: Dussol, B. and Berland, Y.:Urinary kidney stone inhibitors. What is the news? Urol. Int., 60:69, 1998.
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION Normal Alkaline Phosphatase Levels in Patients With Bone Metastases Due to Renal Cell Carcinoma
L. KRITEMAN AND W. H. SANDERS, Division of Urology, Emory University School ofMedicine, Atlanta, Georgia Urology, 51: 397-399,1998 Objectives. To determine the correlation between alkaline phosphatase levels and bone metastases in renal cell carcinoma. Methods. The records of two cohorts, including 539 and 184 patients, with metastatic renal cell carcinoma were renewed. In both groups, metastases were shown on magnetic resonance imaging (MRI), computed tomography (CT),or bone scan. In addition, the second cohort included data concerning pain on presentation. None of the patients in either cohort had any systemic therapy (chemotherapy or immunotherapy); many patients had undergone radical nephrectomy as the primary treatment of the cancer. All radiographic and laboratory information was obtained within a 6-week enrollment period. Normal alkaline phosphatase levels were referenced according t o age and sex, resulting in an upper limit of normal of 111 to 141 U L Results. In the first cohort bone metastases were documented by MRI, CT, and/or bone scans in 164 patients. Alkaline phosphatase levels were less than or equal to 141 U L in 118 patients (72%)and less than or equal to 111 U L in 87 patients (53%).There were 123 patients with bone metastases who had previously undergone a nephrectomy for presumed local disease. Alkaline phosphatase levels were less than or equal to 141 U/L in 91 patients (74%)and less than or equal to 111 U L in 70 patients (57%).In the second cohort 22 of 37 patients (59%)had little to no pain on presentation, and 19 (86%)of that group had normal alkaline phosphatase levels. Conclusions. Alkaline phosphatase is an insensitive indicator of bone metastases. Editorial Comment: T h e authors studied a large group of patients with metastatic renal cell carcinoma and then noted the s e r u m alkaline phosphatase. It w a s relatively common to h a v e
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION
normal alkaline phosphatase levels with metastatic disease to bone. These data are impressive because sometimes alkaline phosphatase level is used to decide whether to perform a bone scan. In this case the alkaline phosphates were an insensitive indicator of bone metastases, as the authors conclude. Fray F. Marshall, M.D. Granulocyte-Macrophage-Colony Stimulating Factor in Metastatic Renal Cell Carcinoma. A Phase I1 Trial B. I. RINI,W. M. STADLER, R. T. SPIELBERGER, M. J. RATAINAND N. J. VOGELZANG, Section of Hematology! Oncology, University of Chicago, Chicago, Illinois, and Department of Hematology and Bone Marrow Transplantation, City of Hope Medical Center, Duarte, California Cancer, 8 2 1352-1358, 1998 BACKGROUND. Due to lack of success with standard chemotherapy and only modest success with immunotherapy, metastatic renal cell carcinoma (RCC) is associated with a poor prognosis. Granulocytemacrophage-colony stimulating factor (GM-CSF) is a cytokine with potential antitumor activity, including stimulation of tumor necrosis factor (TNF) and interleukin-1 secretion. It is also a potent growth factor for and activator of antigen-presenting dendritic cells. GM-CSF toxicity may be mediated by TNF, and inhibition of TNF release by pentoxifylline (PTX)may ameliorate these toxic effects. The authors conducted a Phase I1 trial to determine the activity of GM-CSF in metastatic RCC and to study the effect of FTX on GM-CSF toxicity. METHODS. Twenty-four eligible patients with metastatic RCC received 10 p g k g of GM-CSF per day, administered subcutaneously, on a 14-days-on/l4-days-off schedule. Twelve patients received concurrent FTX at a dose of 400 mg administered orally 4 times per day. RESULTS. One patient experienced prolonged stability of disease aRer having progressive disease on entry. Two other patients experienced substantial slowing of their progressive disease while on study. One of these patients had rapidly progressing metastases on other immunotherapy before receiving GM-CSF. Toxicity was not diminished in patients treated with PTX; it included hyperleukocytosis, nausea, vomiting, pain, fever, skin reactions, myalgia, and fatigue. CONCLUSIONS. GM-CSF at the dose and schedule described in this report has minor activity against metastatic RCC, and FTX does not ameliorate its side effects. Editorial Comment: GM-CSF has been used in tumor vaccines for renal cell carcinoma.' A tumor vaccine combines antigen and stimulatory cytokine to produce a specific response. GM-CSFhas not typically been used as a systemic agent for the treatment of metastatic renal cell carcinoma and may not produce specificity of action. Systemic GM-CSF might be used in the future in combination with other forms of treatment but a s a single agent it was not impressive. Fray F. Marshall, M.D. 1. Simons, J. W.,Jaffee, E. M., Weber, C. E., Levitsky, H. I., Nelson, W. G., Carducci, M.A, Lazenby, A. J., Coben, L. K., Finn, C. C., Cliff, S. M., Hauda, K. M., Beck, L. A, Leiferman, K. M., Owens, A. H.,Jr.,
Piantadosi, S., Dranoff, G., Mulligan, R C., Pardoll, D. M. and Marshall, F. F.: Bioactivity of autologous irradiated renal cell carcinoma vaccines generated by ex vivo granulocyte-macrophage colony stimulating factor gene transfer. Cancer Res., 57: 1537, 1997.
Interactive MRI-Guided Radiofrequency Interstitial Thermal Ablation of Abdominal Tumors: Clinical Trial for Evaluation of Safety and Feasibility J. S. LEWIN,C. F. CONNELL, J. L. DUERK, Y.-c. CHUNG, M. E. CLAhfPITT, J. SPISAK,G. S. GAZELLE AND J. R. HAAGA, Departments of Radiology and Biomedical Engineering, University Hospitals of Cleveland and Case Western University, Cleveland, Ohio, and Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts JMRI, 8: 40-47, 1998 Permission to Publish Abstract Not Granted
Editorial Comment: In this study interstitid thermal ablation was used under magnetic resonance imaging guidance for the destruction of renal cell carcinoma metastases or local recurrence. There were also 3 metastatic leiomyosarcomas. Tumors less than 6 cc in estimated volume appeared to be more effectively treated, while there was more uncertainty in the treatment of larger tumors. It may have been difficult to create a large enough tumor ablation zone to eradicate larger tumors. Tumor vascularity may also create a heat sink making it more difficult to destroy the tumors. Cryosurgery and other forms of thermal therapy will likely improve in the future. Fray F. Marshall, M.D.
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