Pathology of Renal Cancer and its Metastases

1600

ONCOLOGY AND CHEMOTHERAPY

lymphatic drainage of the right kidney is more extensive, with lymph nodes being found from the bifurcation of the inferior vena cava to well above the renal veins. These nodes surround the vena cava and also include the interaortocaval lymph nodes. The regional lymph nodes on the right side drain directly into the thoracic duct. The author notes that if 25 per cent of the patients with renal cell carcinoma have regional lymph node metastases, and if 25 per cent of these patients can be cured by complete removal of the regional lymph nodes then 10 per cent of the patients will benefit from regional lymphadenectomy. Future development of effective adjuvant therapy will make regional lymphadenectomy even more important. Five to 9 per cent of the patients with renal cell carcinoma have involvement of the inferior vena cava. If this extends above the hepatic veins the author recommends cardiopulmonary bypass, hypothermia and temporary exsanguination. Of his patients 14 have undergone this procedure with 1 postoperative death. One patient is without disease more than 40 months postoperatively and 1 patient has survived for more than 5 years. 4 figures, 13 references Drago K. Montague, M.D. Cleveland, Ohio

Organ-Preserving Surgery for Renal Cell Carcinoma in Patients With a Solitary Kidney or Bilateral Tumors G.

HUBMER AND P. H. PETRITSCH,

Department of Urology,

University of Graz, Graz, Austria Sem. Surg. Oncol., 4: 133-136, 1988 From 1974 to 1986, 238 patients underwent an operation for renal cell carcinoma with 15 of these patients (6.3 per cent) undergoing organ-preserving procedures because of tumor in a solitary kidney or bilateral tumor. A transperitoneal approach was used in all patients, and when the projected renal ischemia time was less than 30 minutes the kidney was protected by giving mannitol before the renal artery was clamped. When the projected renal ischemia time was greater than 30 minutes the kidney was cooled with crushed ice or perfused with cold, hyperosmolar, intracellular electrolyte solution. Whenever possible the tumor was removed with a margin of tissue free of disease. However, in some cases enucleation was necessary. Only 1 extracorporeal procedure was required. Of 10 patients with tumor in a solitary kidney 9 have no evidence of disease. Six patients had bilateral disease (1 underwent bilateral nephrectomy). Of these patients 3 have no evidence of disease and 3 are dead at 4, 5 and 9 years (but only 1 died of metastatic tumor). 2 figures, 3 tables, 10 references Drago K. Montague, M.D. Cleveland, Ohio

Urological Aspects of Surgical Management for Metastatic Renal Cell Cancer

were to lymph nodes in 6 patients, bone in 4, brain in 3 and adrenal glands in 2. Results are presented for 12 of the 15 patients (results are given for only 3 of the 6 with lymph node metastases). The mean survival for 3 patients with lymph node metastases was 24.5 months, with 2 patients dead and 1 alive. The mean survival time for 9 patients with distant metastases was 35 months, with 4 dead and 5 alive (3 free of disease). The authors conclude that patients with renal cell cancer and a solitary metastasis are good candidates for removal of the kidney and metastasis. A tumor-reducing operation should not be performed in the presence of multiple metastases because of the lack of effective adjuvant treatment for renal cell carcinoma. 4 tables, 4 references Drago K. Montague, M.D. Cleveland, Ohio

Orthopaedic Management of Bony Metastases of Renal Cancer N. PONGRACZ, R. ZIMMERMAN AND R. KOTZ, Department of

Orthopaedics, University of Vienna, Vienna, Austria Sem. Surg. Oncol., 4: 139-142, 1988 After the lung and liver, the skeletal system is the third most frequent location for metastases from tumors of the breast, prostate, kidney, thyroid and lung. These metastatic bone lesions cause pain and loss of function. Because patients with bony metastases and renal carcinoma can have long-term survival relief of pain and restoration of function are important. The authors review their experience with 57 patients. In 17 patients no operation was performed and treatment consisted of radiation (4), plaster cast fixation (2), chemotherapy (2), embolization (1) and cordotomy (1). Seven terminally ill patients received analgesic treatment alone. A total of 40 patients underwent 52 operations. Radical removal of the metastasis was done and an endoprosthesis was placed in 7 patients with a solitary bony metastases. In 30 patients bone cement and plates were placed and 15 underwent bone curettage. There was 1 postoperative death and postoperative function was improved in all of the remaining patients. Relief of pain was good to excellent in 46 patients, fair in 4 and poor in 2. In 11 patients the renal tumor had already been removed before bony metastases were discovered. The mean survival time in this group was 30.5 months (range 6 to 70 months). In 29 patients bony metastases were discovered first and led to the discovery of a renal primary tumor. Mean survival in this group was 19 months (range Oto 60 months). 3 figures, 2 tables, 9 references Drago K. Montague, M.D. Cleveland, Ohio

Pathology of Renal Cancer and its Metastases

w.

G. HIENERT, D. LATAL AND s. RUMMELHARDT, Department of Urology, University of Vienna, Vienna, Austria

ULRICH, P. BUXBAUM AND J. H. HOLZNER, Institute of Pathological Anatomy, University of Vienna School of Medicine, Vienna, Austria Sem. Surg. Oncol., 4: 143-148, 1988

Sem. Surg. Oncol., 4: 137-138, 1988 A total of 15 patients with renal cell carcinoma underwent nephrectomy and removal of metastatic disease. Removal of metastases was done at a separate operation before nephrectomy in 6 patients and during the nephrectomy in 9. Metastases

Renal epithelial tumors have been shown to derive from the renal tubule except for oncocytoma, which probably originates from the collecting duct. Tumors are divided into adenomas and carcinomas, with the diagnosis of renal adenoma being made if the tumor is less than 2.5 cm. and encapsulated, and

ONCOLOGY AND CHEMOTHERAPY

consists of small, uniform epithelial cells without hemorrhage or necrosis. Most renal cell carcinomas consist of clear or vacuolar cells. Granular cell tumors have a poorer survival rate. The newly defined chromophobe cell type probably has a less malignant potential. Spindle cell carcinomas have a poor prognosis with a median survival of 6 months from diagnosis. There are 3 main patterns of tumor cell arrangement: com pact (solid), tubular or alveolar and papillary. The pattern of growth generally does not correlate with survival. Nuclear grading of atypia is one of the most important indicators of prognosis. The most valuable prognostic guide, however, is the pathological stage at nephrectomy. Opinion is divided as to whether renal vein involvement significantly changes prognosis. The local extent of tumor is an important prognostic indicator in the absence of metastases. However, the presence of metastases is a poor prognostic sign regardless of the extent of local disease. 3 figures, 3 tables, 24 references Drago K. Montague, M.D. Cleveland, Ohio

Bladder Cancer: Pelvic Lymphadenectomy Revisited H. W. HERR, Urologic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York

J. Surg. Oncol., 37: 242-245 (Apr.) 1988 In up to 37 per cent of the patients with bladder cancer the lymph nodes may be the only site of metastasis. Despite this observation cystectomy with radical pelvic lymphadenectomy has produced few cures of this disease. With the advent of effective chemotherapy the results of pelvic lymphadenectomy with other modalities need re-defining. Evaluated in detail are 662 patients treated by cystectomy and bilateral pelvic lymphadenectomy. Of these patients 134 had regional lymph node metastasis. A few patients with micrometastasis are benefited by pelvic lymphadenectomy, so that only 1 to 2 per cent of the over-all group with bladder cancer have a significant survival. The use of methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) produces a 36 per cent complete and a 40 per cent partial clinical response rate in patients with measurable metastatic disease. In 16 patients treated with 4 to 6 cycles of M-VAC cystectomy and lymphadenectomy were performed. Viable tumor was found in lymph nodes and soft tissue. Two additional M-VAC cycles were given and 5 of the 16 patients were free of cancer (median 12 months). The final role of resection of chemotherapy-resistant nodal disease needs further evaluation and documentation. 1 table, 22 references John A. Arcadi, M.D. Whittier, California

Pyridoxine: A Potential Local Antidote for MitomycinC Extravasation R.

RENTSCHLER AND D. WILBUR, Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, California J. Surg. Oncol., 37: 269-271 (Apr.) 1988 Two cases are presented of mitomycin C extravasation treated with intralesional injections of a 100 mg./ml. solution

ofpyridoxine hydrochloride. In case 1 the injection ofpyridoxine into the center of the lesion seen in mitomycin C extravasation was done 1 day after injury. The periphery was injected 5 days later with 3 ml. pyridoxine hydrochloride (100 mg./ml.). Central sparing was noted initially but subsequently the entire area became necrotic. In case 2 the extravasation reaction was noted and treated 4 weeks after the mitomycin C was given and extravasated. The swollen, red, tender, indurated area was injected with 100 mg. pyridoxine in 1 ml. solution. Necrosis did not occur and healing was apparently complete. The authors postulate the good effect of pyridoxal-5-phosphate to be "... forming shift-base complexes with the extravasated Mitomycin-C". Although the injection of pyridoxine was painful its early injection may prevent necrosis after mitomycin C extravasation. 2 figures, 7 references John A. Arcadi, M.D. Whittier, California

Odyssey of a Sailor's Diagnosis Since 1795 AD M. R. SHETTY, Northwest Community Hospital, Arlington Heights, Illinois J. Surg. Oncol., 38: 140-141 (June) 1988 The author reviews the case of an eighteenth century sailor often attributed to being the first reported case of bilateral testicular cancer. He concludes that the patient did not have carcinoma but rather scurvy, since the condition resolved when he was fed lime juice and the wounds were dressed with diluted lemon juice. He suggests that no further references to this patient as a case of testicular cancer be made. 6 references Mark J. Schacht, M.D. Chicago, Illinois

Germ Cell Tumors in Indian Children

s. KHANNA,

N. C. ARYA, I. M. GUPTA, s. GUPTA AND G. D. Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

SINGHAL,

J. Surg. Oncol., 37: 235-238 (Apr.) 1988 From 1962 to 1982, 1,791 Indian children less than 15 years old were seen for tumor and tumor-like lesions. Of the tumors 135 were of germ cell origin. Tumors that had predominantly mature cells were judged to be benign (65.9 per cent) and the remainder had either mostly immature elements or malignant cells (34.1 per cent). The majority of the germ cell tumors were sacrococcygeal (30 per cent), while 21 per cent were in the ovaries, 10 per cent in the testis, 22 per cent in the neck, including the thyroid and orbit, and 4.4 per cent in the retroperitoneum. Although the majority of the germ cell tumors were benign, 100 per cent of the testicular and 80 per cent of the ovarian tumors were malignant. Mean age of the children with benign tumors was 6.3 years and for those with malignant germ cell tumors it was 8.3 years. Factors for the relatively high frequency of malignant tumors, sex distribution and anatomical location compared to other reports are discussed. 2 tables, 14 references John A. Arcadi, M.D. Whittier, California